Introduction: In the current economic climate with continuous expenditure reviews and financial constraints, clinicians should remain conscious of making cost-effective choices on consumables and medications. In this survey, we evaluated the cost awareness amongst UK urologists. This is an observational study in which urology clinicians were asked to estimate the cost of 10 commonly used medications and consumables in urology by completing a questionnaire. Methodology: The survey was primarily conducted at the BAUS Annual Meeting 2017 with subsequent responders at local hospitals and urological courses. The costs of consumables and medications were verified with the relevant companies and the 73rd edition of the British National Formulary. Result: There were 139 responders from across the UK (46 consultants, 64 training registrars, 13 trust grades doctors and 16 senior house officers (SHOs)). In total, 16 and 60% of all estimates were within ± 25% and ± 100% of the true cost of the items respectively. Approximately 97.1, 95.7 and 97.1% overestimated the cost of a 14Ch urethral catheter, Ciprofloxacin and Sildenafil, respectively; while 78.4 and 84.9% of responders underestimated the cost of a JJ ureteric stent and Solifenacin, respectively. On multivariate analysis, SHOs significantly overestimated the cost of urethral catheters, suprapubic catheterization kits and JJ ureteric stents compared to other clinician grades. Conclusion: Cost awareness among UK urologists is poor. Expensive items (e.g. JJ ureteric stent, Solifenacin) tend to be underestimated while inexpensive items (e.g. catheter, Ciprofloxacin, Sildenafil) tend to be overestimated. This lack of appreciation of value may have an impact on drug and consumable expenditure. Level of Evidence: Level 3
Abstract Background Machine (ML) and Deep learning (DL) are subsets of artificial intelligence that use data to build algorithms. These can be used to predict specific outcomes. To date there have been a few small studies on post-PCNL outcomes. Objective We aimed to build and internally validate ML/DL models for post-PCNL transfusion and infection using a comprehensive national database. Design Machine Learning study using prospective national database. Eight machine learning models for 11 outcomes using 43 predictors. Models were ‘complete-case’ analyses. Setting National database Participants Patients undergoing PCNL in the UK between 2014-2019. Outcome Measurements Diagnostic accuracy statistics including overall accuracy, area-under-the-curve (AUC), sensitivity and specificity. Results and Limitations 4412 patients were included, with 3088 in the training set and 1324 in the test set. The models predicted need for transfusion and post-operative infection with a very high degree of accuracy (99%) and high AUC (0.99-1.00). Unfortunately, the remainder of the outcomes did not achieve the same high levels. These two outcomes were therefore included in the provisional web-based application: https://endourology.shinyapps.io/PCNL_Prediction_tool/ Conclusions This is the largest machine learning study on post-PCNL outcomes to date. These models can predict the need for post-PCNL transfusion and post-PCNL infection at an individual level with excellent accuracy. Further work will be done on model tuning and external validation. Patient Summary We used a national database of people having a major kidney stone operation (PCNL). Using this data, we built and tested 8 machine learning models for 11 different outcomes from the operation. Using this method, we can give individual predictions for the likely need for a blood transfusion and development of an infection. We have developed an app to allow surgeons to calculate an individual patient’s risk prior to surgery.
Since its introduction in the early 1980s, extracorporeal shockwave lithotripsy (ESWL) has proven to be a minimally invasive and efficient procedure for the management of renal calculi. It is currently one of the most recommended treatments for small- and medium-sized stones (<20 mm) in most guidelines internationally. The recent coronavirus disease 2019 (COVID-19) outbreak could lead to a further increase in ESWL use as it avoids a general anesthetic and its potential complications in patients with COVID-19 infection. Most publications exhibit ESWL stone-free rates (SFRs) of 70%-80%; however, this is often not the case in many centers, with multiple factors affecting the efficacy of the intervention. Various stone and patient factors have been shown to influence the ESWL success. Stone position, density and size, skin-to-stone distance, and body-mass index contribute to SFRs. Modifications in the lithotripter design and revisions in the technique have also improved the SFRs over the years, with slower shock rates, power-ramping protocols, combined real-time ultrasound, and fluoroscopy imaging technology, all enhancing the efficacy. The adjuvant use of pharmacological agents, such as alpha-blockers, potassium citrate, and the emerging microbubble technology, has also been investigated and shown promising results. Arguably, the most significant determinant of the success of ESWL in a particular unit is how the lithotripsy service is set up and monitored. Careful patient selection, dedicated personnel, and post-treatment imaging review are essential for the optimization of ESWL. Through an analysis of the published studies, this review aimed to explore the measures that contribute to an effectual lithotripsy service in depth.
Congenital anomalies of the kidney and urinary tract (CAKUT) represent a wide range of disorders that result from developmental abnormalities of the kidneys, urinary collecting tract, and lower urinary tract. There has been extensive development in approaches to the management of stones in normal kidneys with the advent of retrograde intra-renal surgeries (RIRS)/ureteroscopies, extracorporeal shock wave lithotripsy (ESWL) percutaneous nephrolithotomy (PCNL), and minimally invasive surgery (laparoscopy/robotics). However, the management of stones in CAKUT is not straightforward and is often challenging for urologists. There are no clear guidelines available to help navigate stone management in such patients.The aim of this literature review was to focus on stone management in anomalous kidneys. Most common abnormalities were considered. The studies were very heterogeneous with different approaches. The methodology involved evaluating studies looking into individual surgical approaches to the management of stones in these anomalous kidneys as well as looking at different approaches to stone management, in particular renal abnormality.We found RIRS is a feasible approach in most stones with sizes <20 mm and PCNL holds the upper hand in stones more than 20 mm. However, ESWL, laparoscopy, and robotics have their places in managing some of these cases.We concluded that stones in anomalous kidneys can be challenging but can be managed safely. There is no straightforward answer to the right technique but rather the right planning based on the anatomy of the kidney in terms of vascularity and drainage, stone size and density, and expertise available.
Clinicians are faced with multiple diagnostic and treatment challenges when managing pregnant women with urolithiasis. Anatomical and physiological changes during pregnancy have to be taken into account whilst simultaneously considering both the expectant mother and the foetus. Ultrasonography remains the first-choice imaging modality, notwithstanding its potentially poor diagnostic accuracy. There is currently no consensus on second-line investigation for suspected urolithiasis. Low-dose non-contrast CT is highly sensitive, but the long-term effects of ionizing radiation on the foetus remain unknown. As far as treatment is concerned, expectant therapy is the primary option for management in the majority of cases. Percutaneous nephrostomy or ureteric stent placements are safe temporizing measures in relieving an acutely obstructed system and should be expedited in the presence of sepsis. Studies have shown ureteroscopy to be safe and effective during pregnancy with no significant risk to the foetus. It is important for the clinician to explain clearly the risks associated with the investigation and management options to the pregnant patient, including an acknowledgement that some of these remain unquantified, or even unknown.
INTRODUCTION:The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise.Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients.MATERIAL AND METHODS: The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia.The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM).RESULTS: 221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries).In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice.Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists.12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists.Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)].CONCLUSIONS: Treatment of paediatric stones can vary according to country and legislations.Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular.In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.
Background: Intractable loin pain is a debilitating condition with a significant impact on the patient's quality of life. Loin pain haematuria syndrome (LPHS) is a disease of exclusion and can be of two subtypes, Primary or Type 2 and secondary or Type 1. The type 1 LPHS could be a result of congenital anomalies, or acquired due infections, trauma, or surgery. Management of these patients can be pharmacological, nerve blocks, renal denervation, auto-transplantation and nephrectomy. Laparoscopic renal denervation (LRDN) has emerged as a minimally invasive surgical procedure, with acceptable results. Materials and Methods: All patients who underwent laparoscopic renal denervation in our unit from 2007 to 2022 by a single surgeon were included in this study. The indications for surgical intervention were loin pain refractory to medical therapy in the absence of any physical causes of pain. All patients were assessed by a multidisciplinary team, involving a urologist, a nephrologist, a pain consultant, and a pain psychologist. Baseline and postoperative pain scores of the patients were obtained. The patients underwent splanchnic or coeliac nerve blocks under local anaesthesia and were reviewed in the outpatient clinic post-procedure. If there were an improvement in the pain control and pain scores, they were offered LRDN. During the surgery, the renal vessels and proximal ureter were stripped from the neuronal and lymphatic tissues. Results: The 20 patients included in the study underwent 23 procedures. All patients were female. The mean age was 44 years, and the median follow up was 24 months. The median operating time was 90 minutes, excluding anaesthetic time. There were no significant adverse events other than one patient needed antibiotics for chest infection. There was significant improvement of pain scores with the mean pain scores falling to 2.47 postoperatively from 8.40. Fifty percent of patients had complete resolution of pain, while 30% had significant reduction in use of pain medication. Patients with primary LPHS did not have significant improvement in their pain scores, and one of these patients required auto-transplantation of her kidney.
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