#13 Click here to see the previous editions February 25, 2023
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Hello and welcome to the Stone News by Devicare, where we discuss every 2 months the most recent and relevant studies in stone disease.

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Dear Stone Fans. Welcome to the winter issue of Stone News.

As new laser technologies have emerged achieving micro-dust, new techniques to evaluate stone composition from dust have been described. This will be very important in a near future as aspiration methods will be included in our armamentarium. In this same line, the second article evaluates in-scope suction discussing one of the most needed tools in endourology. Finally, we will look to radiomics in urolithiasis, a new term we need to be familiar with as AI will be a main character of our system. We have three great papers to discuss from latest literature regarding stone disease, please enjoy.

img Thulium Fiber Laser's Dust for Stone Composition Analysis: Is It Enough? A Pilot Study A.Sierra et al. J Endoruol Nov 2022
Haas CR, et al J Urol. 2023
img 2'
https://pubmed.ncbi.nlm.nih.gov/36621994/ img

Many studies have shown how good thulium laser fiber (TFL) is. A better and faster ablation than Ho:YAG has been shown in in-vitro and in-vivo studies. Even a RCT showed that TFL was quicker and achieved better stone free rates than a 30W Ho:YAG. Nonetheless, this is the first comparison of TFL and high power Ho:YAG laser with pulsed modulation.

In this RCT, 108 patient underwent flexible ureteroscopy for kidney stones of less than 2 cm. The patients were divided into two groups with similar demographics and stone characteristics. The study compared the use of TFL and Ho:YAG and pulsed modulation, using both similar settings, meaning similar total power (because, as we know, proper setting may differ between lasers).

The study did not show significant differences regarding OR time or stone free rates with KUB (not even in a subgroup analysis comparing high- and low-density stones, size or location). True SFR (zero fragments left) was 67 and 68%. Also, complications were minor and similar in both groups. The interesting conclusion of this study is that urologists may use either platform to perform an effective ureteroscopy.

img A. Duration of Follow-up and Timing of Discharge from Imaging Follow-up, in Adult Patients with Urolithiasis After Surgical or Medical Intervention: A Systematic Review and Meta-analysis from the European Association of Urology Guideline Panel on Urolithiasis.
Tzelves L et al. Eur Urol Focus. 2023
img 3'
https://pubmed.ncbi.nlm.nih.gov/35851252/ img

One of the most common questions from patients and endourologists is how long we must follow-up our patients. The main problem is that stone disease is a very complex illness that takes into consideration many variables as patients characteristics and stone characteristics. Having 7 stone types and 23 subtypes, we cannot expect to follow or patients equally.

For this, the EAU urolithiasis guidelines performed a systematic review and meta-analysis in order to have the best evidence available to recommend an easy, yet accurate, follow-up flow chart. The main evaluation was done after treatment and three main groups were identified. Fist, the best scenario: stone free, low risk patients, that needed to be followed for 5 years with KUB or KUB US to have a 90% “safety margin”. Patients with residuals stones of less than 4 mm were recommended to be followed for 4 years or to perform a reintervention.

For this patients, medical treatment could be an option before retreatment. Patients with residuals of more than 4 mm, a reintervention was recommended as stone events are likely to happen. Finally, high risk patients had their own recommendations and follow up for 4 years and consider discharge if no progression continuing treatment. Those that are not in medical treatment should be followed for 10 years. We could add that in general during follow up proper alkalinization or urine acidification should be advice depending on the stone type.

This flow chart gives us a pretty good idea of how to follow-up our patients according to their risk of stone events while decreasing the burden of the health system.

img Attitudes of urologists on metabolic evaluation for urolithiasis: outcomes of a global survey from 57 countries.
Karagöz MA, et al. Urolithiasis. 2022
img 3'
https://pubmed.ncbi.nlm.nih.gov/36169664/ img

Stone disease is an illness that has an important impact on patients’ quality of live. Metabolic evaluations and medical treatment are important tools that we have to help them to avoid recurrences and stone events. But how often metabolic evaluations are performed in real practice? To answer this question a survey was performed asking 305 urologists from 57 countries regarding metabolic evaluation, medical treatment and follow-up in their own practice.

Urologists had a mean of 12 years on practice. Curiously only 34% of participants performs metabolic evaluations in first time stone formers, but 85% acknowledge that is important. Also, only 15% used guideline recommendations in all their patients.

Reasons for not doing those evaluations included being unsure of their efficacy, not feeling confident on performing the test and patient related. As for stone analysis, 27% stills perform chemical analysis (and as we know it is an inaccurate tool). The importance of this paper is to know that there are many things in terms of education to be done for our community to encourage urologists to perform proper and confident evaluations.

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