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Background: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration (LCBDE) have proved to be safe and effective ways of managing common bile duct (CBD) stones. Clearance of large or impacted CBD stones by routine endoscopic maneuvers can be challenging, often requiring more invasive techniques such as open CBD exploration, which increases morbidity. This report presents a novel approach to managing impacted CBD stones using laparoscopic transcystic common bile duct exploration and holmium laser lithotripsy with favorable outcomes.Methods: This retrospective review analyzes five patients who underwent laparoscopic cholecystectomy with intraoperative management of impacted CBD stones via LCBDE and holmium laser lithotripsy. The technique is described, and outcomes are measured. Data via chart review and use of intraoperative video were obtained with institutional review board approval.Results: Stone clearance from the CBD was achieved for all the patients. The median age of the patients was 39 years. The diameters of the CBDs ranged from 10 to 20 mm, and the median number of stones was one. No mortality was associated with this procedure, and the median hospital stay was 2 days.Conclusions: Laparoscopic CBD exploration via a transcystic approach together with holmium laser lithotripsy is a safe and effective way to clear large solitary or impacted CBD stones. This technique also avoids choledochotomy and may be used in concert with other methods such as ERCP, percutaneous cholangioscopy, and open exploration. [ABSTRACT FROM AUTHOR]

Objectives: To analyse the presentation, management and long-term outcomes of renal transplant patients who formed kidney stones in their allograft. The secondary aim was to identify risk factors for stone formation in this cohort., Materials and Methods: Patient information from an institutional renal transplant database was used to identify individuals who both did and did not form kidney stones following renal transplantation. Computerized tomography (CT) imaging was used to make the diagnosis of kidney stones and measure stone size. Age- and gender-matched controls never forming a stone in their allograft were used for comparative analysis to identify risk factors for stone formation in transplant patients., Results: A total of 8835 transplant patients were included in the study, of which 128 (1.4%) formed a kidney stone in their allograft after surgery. The mean time to kidney stone identification was 6.2 years, and the mean number of stones formed was 1.7, with a mean maximum size dimension on a CT scan of 5.7 mm per stone. A total of 26 patients were subjected to stone-removing procedures, the most common being ureteroscopy (42.3%). The primary intervention failed in eight patients requiring a secondary intervention, and percutaneous nephrolithotomy (PCNL) had the lowest success rate (60%). A total of 164 controls were identified. In comparison to controls, stone formers had lower serum calcium ( p  = 0.008), lower estimated glomerular filtration rates ( p  = 0.019), higher lymphocyte counts ( p  = 0.021) and greater rate of urinary tract infection ( p  = 0.003). Graft failure rates were the same ( p  = 0.524), but time to graft failure was significantly longer in stone patients compared with controls ( p  = 0.008)., Conclusions: The rate of stone formation is low in transplant patients. Success rates for stone treatment vary based on the surgery selected, with PCNL being the worst. Graft survival rates were equivocal, but survival time was better in stone patients. Our analysis calls for further investigation of this important topic., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). BJUI Compass published by John Wiley & Sons Ltd on behalf of BJU International Company.)

Introduction:  Baclofen, a clinically available GABA B receptor agonist, produces nonopioid analgesia in multiple models of pain but has had limited studies related to perioperative pain control. The present study seeks to study effects of baclofen on postoperative pain measures and opioid use in adult patients subjected to percutaneous nephrolithotomy (PCNL)., Methods: Using a placebo-controlled, double-blind methodology, a single 10 mg oral dose of baclofen or placebo was given prior to a surgery in 34 patients undergoing PCNL. Standardized intraoperative and postoperative protocols related to opioid use were followed. Use of postoperative opioids in the post-anesthesia care unit and for the first 24 hours following surgery were recorded as were pain scores and other medication use., Results: There was a significant positive correlation in the use of postoperative opioids in patients who had a preceding history of opioid use. However, there were no significant differences in opioid use which could be attributed to baclofen. There were also no differences in postoperative vital signs, side effects or other medication use., Conclusions:  Analgesic benefits of preoperative baclofen were not observed at the dose employed. Safety of the drug was observed., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. University of Alabama at Birmingham Institutional Review Board for Human Studies issued approval IRB-300002466. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mandabach et al.)

Introduction: The study aim was to analyze the presentation, management, and follow-up of renal transplant patients developing bladder calculi., Methods: Patients who underwent renal transplant with postoperative follow-up at our institution were retrospectively analyzed (1984-2023) to assess for the development of posttransplant bladder stones. All bladder stones were identified by computerized tomography imaging and stone size was measured using this imaging modality., Results: The prevalence of bladder calculi post-renal transplantation during the study window was 0.22% (N = 20/8,835) with a median time to bladder stone diagnosis of 13 years posttransplant. Of all bladder stone patients, 6 (30%) received deceased donor and 14 (70%) living donor transplants. There were 11 patients with known bladder stone composition available; the most common being calcium oxalate (N = 6). Eleven (55%) patients had clinical signs or symptoms (most commonly microhematuria). Fourteen of the bladder stone cohort patients (70%) underwent treatment including cystolitholapaxy in 12 subjects. Of these 14 patients, 9 (64%) were found to have nonabsorbable suture used for their ureteroneocystostomy closure., Conclusions: The prevalence of bladder stones post-renal transplant is low. The utilization of nonabsorbable suture for ureteral implantation was the main risk factor identified in our series. This technique is no longer used at our institution. Other factors contributing to bladder stone formation in this population warrant identification., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Enteric hyperoxaluria is a medical condition characterized by elevated urinary oxalate excretion due to increased gastrointestinal oxalate absorption. Causative features include fat malabsorption and/or increased intestinal permeability to oxalate. Enteric hyperoxaluria has long been known to cause nephrolithiasis and nephrocalcinosis, and, more recently, an association with CKD and kidney failure has been shown. Currently, there are no US Food and Drug Administration-approved therapies for enteric hyperoxaluria, and it is unclear what end points should be used to evaluate the efficacy of new drugs and biologics for this condition. This study represents work of a multidisciplinary group convened by the Kidney Health Initiative to review the evidence supporting potential end points for clinical trials in enteric hyperoxaluria. A potential clinical outcome is symptomatic kidney stone events. Potential surrogate end points include ( 1 ) an irreversible loss of kidney function as a surrogate for progression to kidney failure, ( 2 ) asymptomatic kidney stone growth/new stone formation observed on imaging as a surrogate for symptomatic kidney stone events, ( 3 ) urinary oxalate and urinary calcium oxalate supersaturation as surrogates for the development of symptomatic kidney stone events, and ( 4) plasma oxalate as a surrogate for the development of the clinical manifestations of systemic oxalosis. Unfortunately, because of gaps in the data, this Kidney Health Initiative workgroup was unable to provide definitive recommendations. Work is underway to obtain robust information that can be used to inform trial design and medical product development in this space., (Copyright © 2023 by the American Society of Nephrology.)

Enteric hyperoxaluria is a distinct entity that can occur as a result of a diverse set of gastrointestinal disorders that promote fat malabsorption. This, in turn, leads to excess absorption of dietary oxalate and increased urinary oxalate excretion. Hyperoxaluria increases the risk of kidney stones and, in more severe cases, CKD and even kidney failure. The prevalence of enteric hyperoxaluria has increased over recent decades, largely because of the increased use of malabsorptive bariatric surgical procedures for medically complicated obesity. This systematic review of enteric hyperoxaluria was completed as part of a Kidney Health Initiative-sponsored project to describe enteric hyperoxaluria pathophysiology, causes, outcomes, and therapies. Current therapeutic options are limited to correcting the underlying gastrointestinal disorder, intensive dietary modifications, and use of calcium salts to bind oxalate in the gut. Evidence for the effect of these treatments on clinically significant outcomes, including kidney stone events or CKD, is currently lacking. Thus, further research is needed to better define the precise factors that influence risk of adverse outcomes, the long-term efficacy of available treatment strategies, and to develop new therapeutic approaches., (Copyright © 2021 by the American Society of Nephrology.)

The Primary Hyperoxalurias (PH) are rare disorders of metabolism leading to excessive endogenous synthesis of oxalate and recurring calcium oxalate kidney stones. Alanine glyoxylate aminotransferase (AGT), deficient in PH type 1, is a key enzyme in limiting glyoxylate oxidation to oxalate. The affinity of AGT for its co-substrate, alanine, is low suggesting that its metabolic activity could be sub-optimal in vivo. To test this hypothesis, we examined the effect of L-alanine supplementation on oxalate synthesis in cell culture and in mouse models of Primary Hyperoxaluria Type 1 (Agxt KO), Type 2 (Grhpr KO) and in wild-type mice. Our results demonstrated that increasing L-alanine in cells decreased synthesis of oxalate and increased viability of cells expressing GO and AGT when incubated with glycolate. In both wild type and Grhpr KO male and female mice, supplementation with 10% dietary L-alanine significantly decreased urinary oxalate excretion ~30% compared to baseline levels. This study demonstrates that increasing the availability of L-alanine can increase the metabolic efficiency of AGT and reduce oxalate synthesis., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose of Review: The review of potential therapies in the treatment of hyperoxaluria is timely, given the current excitement with clinical trials and the mounting evidence of the importance of oxalate in both kidney stone and chronic kidney disease., Recent Findings: Given the significant contribution of both endogenous and dietary oxalate to urinary oxalate excretions, it is not surprising therapeutic targets are being studied in both pathways. This article covers the existing data on endogenous and dietary oxalate and the current targets in these pathways., Summary: In the near future, there will likely be therapies targeting both endogenous and dietary oxalate, especially in subsets of kidney stone formers.

Numerous studies have investigated risk factors for the development of postoperative infection in percutaneous nephrolithotomy (PCNL) patients. Herein, we describe our meta-analysis of the risk factors for the prediction of post-PCNL infectious complications. We searched electronic databases using a combination of the terms percutaneous nephrolithotomy, risk factors, infection , and sepsis . The primary outcome was post-PCNL infection as defined by fever >38°C or sepsis as defined by the Sepsis Consensus Definition Committee. Risk factors for infection in each study were identified and included for analysis if present in at least two studies. We used quantitative effect sizes in odds ratio to assess each endpoint. After application of criteria, 24 studies were found, of which 12 were prospective and 12 were retrospective. Of the prospective studies, preoperative urine culture, renal pelvis culture, stone culture, number of access points, hydronephrosis, perioperative blood transfusion, and struvite stone composition were found to be significantly associated with postoperative infection. Of the 12 retrospective studies, preoperative urine culture, stone cultures, number of access points, blood transfusion, stone size, and staghorn formation were associated with infection. Preoperative urine culture, stone culture, number of access points, and need for blood transfusion were consistently found to be significant factors. This indicates that the presence of bacteria in the urine/stone preoperatively as well as the amount of trauma the kidney sustains during the procedure are major predictors of postoperative infection.

Purpose: The aim of this review was to provide current best evidence for evaluation, dietary, and medical management of patients with urolithiasis., Methods: Literature addressing evaluation, dietary, and medical management of urolithiasis was searched. Papers were analyzed and rated according to level of evidence (LOE), whereupon a synthesis of the evidence was made. Grade of recommendation (GOR) was judged from individual clinical experience and knowledge of the evidence according to the Oxford Centre for Evidence-based Medicine., Results: It is obvious that different stone diseases influence the life of stone-forming individuals very differently, and that evaluation and medical management should be personalized according to risk of recurrence, severity of stone disease, presence of associated medical conditions, and patient's motivation. With regard to evaluation, dietary and medical management of patients with urolithiasis evidence from the literature suggest that selective metabolic evaluation may lead to rational dietary and medical management. Statements based on LOE and GOR are provided to guide clinical practice., Conclusion: The provided evidence for evaluation of patients with urolithiasis aims at defining patients at high risk for recurrent/complicated stone disease. Based on this approach, evidence-based dietary and medical management regimes are suggested.

Purpose: This Guideline is intended to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones. The summary presented herein represents Part I of the two-part series dedicated to Surgical Management of Stones: American Urological Association/Endourological Society Guideline. Please refer to Part II for an in-depth discussion of patients presenting with ureteral or renal stones., Materials and Methods: A systematic review of the literature (search dates 1/1/1985 to 5/31/2015) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the Guideline statements. Evidence-based statements of Strong, Moderate, or Conditional Recommendation were developed based on benefits and risks/burdens to patients. Additional directives are provided as Clinical Principles and Expert Opinions when insufficient evidence existed., Results: The Panel identified 12 adult Index Patients to represent the most common cases seen in clinical practice. Three additional Index Patients were also created to describe pediatric and pregnant patients with such stones. With these patients in mind, Guideline statements were developed to aid the clinician in identifying optimal management., Conclusions: Proper treatment selection, which is directed by patient- and stone-specific factors, remains the greatest predictor of successful treatment outcomes. This Guideline is intended for use in conjunction with the individual patient's treatment goals. In all cases, patient preferences and personal goals should be considered when choosing a management strategy., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To compare outcomes of ureteric and renal stone treatment with ureteroscopy (URS) in patients with or without the placement of a preoperative JJ stent., Patients and Methods: The Clinical Research Office of the Endourological Society (CROES) URS Global Study collected prospective data for 1 year on consecutive patients with ureteric or renal stones treated with URS at 114 centres around the world. Patients that had had preoperative JJ stent placement were compared with those that did not. Inverse-probability-weighted regression adjustment (IPWRA) was used to examine the effect of preoperative JJ stent placement on the stone-free rate (SFR), length of hospital stay (LOHS), operative duration, and complications (rate and severity)., Results: Of 8 189 patients with ureteric stones, there were 978 (11.9%) and 7 133 patients with and without a preoperative JJ stent, respectively. Of the 1 622 patients with renal stones, 590 (36.4%) had preoperative stenting and 1 002 did not. For renal stone treatment, preoperative stent placement increased the SFR and operative time, and there was a borderline significant decrease in intraoperative complications. For ureteric stone treatment, preoperative stent placement was associated with longer operative duration and decreased LOHS, but there was no difference in the SFR and complications. One major limitation of the study was that the reason for JJ stent placement was not identified preoperatively., Conclusions: The placement of a preoperative JJ stent increases SFRs and decreases complications in patients with renal stones but not in those with ureteric stones., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Postoperative sepsis is the most common cause of mortality after percutaneous nephrolithotomy (PCNL) procedures. Studies investigating the use of antibiotics in PCNL patients have shown that prophylactic antibiotic regimens can reduce the rate of postoperative infectious complications. In addition, several studies have identified risk factors for sepsis development that can help guide antibiotic treatment and perioperative care overall. This has led the American Urological Association to recommend antibiotic prophylaxis for PCNL as a best practice policy statement. However, despite prophylaxis, postoperative sepsis has continued to remain the leading cause of mortality in PCNL patients. In addition, multiple antibiotic protocols exist within the guideline realms. This review assesses the development and role of antibiotic prophylaxis for PCNL procedures.

Background: The traditional endourology fellowship model includes advanced training in minimally invasive surgery (MIS) for both benign disease/kidney stones and oncology. We have anecdotally observed, however, that many former endourology fellows subspecialize within their practices. Recently the fellowship paradigm, accredited by the Endourological Society (EUS), has been modified to allow for emphasis on benign disease/kidney stones or laparoscopy/robotic surgery, which is heavily weighted toward oncology. In this study, we sought to assess the practice patterns of former endourology fellows to evaluate various fellowship models., Methods: Email addresses for 320 of the 327 endourology fellowship graduates between 2001 and 2010 identified by the EUS were obtained. These were cross-referenced with the American Urological Association (AUA) member database to maximize the yield of valid addresses. A 20-question electronic survey (SurveyMonkey Inc., Palo Alto, CA) was sent to this group. Eleven addresses were invalid and 24 recipients opted out of the survey., Results: Responses were received from 121 of 285 former fellows with active email addresses who did not opt out of the survey (42.5%). Of these respondents, 86% completed fellowships in North America and 71% completed 1-year fellowships. Among respondents in academic practice (46%), 44% reported a "mixed" benign and oncology-based practice, compared to 68% of nonacademic practitioners (P=0.009). Among academic practitioners, 33% practice predominantly MIS for benign disease, and 24% practice predominantly MIS for oncology, versus 23.1% (P=0.3) and 9% (P=0.04), respectively, of nonacademic practitioners. Most fellows had stability of clinical interests (benign v malignant disease) before and after their fellowship., Conclusion: Fellowship-trained endourologists who work in an academic setting are more likely to have a subspecialized practice. A subset of private practice endourologists also have focused practices in benign disease. While the traditional fellowship model will be useful for some graduates, subspecialized tracks may improve the efficiency of the training model.

Background and Purpose: There exist no global standards for defining patient outcomes in renal stone surgery. The objective of this study was to evaluate the quality of reporting of outcomes in studies investigating percutaneous nephrolithotomy (PCNL) and to propose standardized consensus definitions for common outcomes., Methods: We performed a literature search in PubMed for randomized controlled studies that investigated PCNL between 2002 and 2012. All outcomes reported were analyzed for each study. Each article was examined to identify the definition of each reported patient outcome. Various aspects of patient outcomes were presented to a panel of 85 experts in a Delphi process consisting of three rounds. The experts were asked to select options that they believed would best describe each outcome. Finally, we composed recommendations for definition of the most common outcomes reported in PCNL studies., Results: Eighty-three RCTs were included in the review of patient outcomes. Stone-free rate (55, 63.9%), length of stay (47, 56.6%), complication rate (44, 53.0%), and changes in hemoglobin (40, 48.2%) were the most frequently reported outcomes in randomized controlled trials of PCNL. Only 24/53 (45.3%) studies had a formal definition of stone-free status. Only 31/40 (77.5%) studies, which reported change in hemoglobin, had a unit of measurement; however, 22/40 (55.0%) did not report the timing of postoperative hemoglobin measurement. A set of recommendations for defining patient outcomes in PCNL is presented for the 15 most commonly reported outcomes in PCNL., Conclusions: Wide variations and underspecification exist in the definition and reporting of outcomes in PCNL. We propose recommendations for the definition of outcomes based on a review of the literature and expert opinion. Standardization of outcome definition and reporting will improve the quality of urologic research.

Background: Relationships between race/ethnicity, recipient medical insurance, and living donor kidney transplantation (LKT) are incompletely described., Methods: Associations between medical insurance and LKT were assessed in 447 recipients at a southeastern US transplant center. Primary and secondary payers were included in the analyses., Results: A total of 387 deceased donor transplantations and 60 LKTs were performed in 246 (55%) European American (EA), 175 (39.2%) African American (AA), 15 (3.4%) Asian, and 11 (2.5%) Hispanic recipients. Among recipients, 182 (40.8%) were privately insured, 125 (28%) had Medicaid, and the remainder had Medicare, Medicare supplements, or Medicare replacement policies. A higher proportion of patients with private insurance, relative to those without private insurance, received LKT (22% vs. 7.6%, p < 0.0001). Among ethnic groups, LKT with, vs. without, private insurance was 27.5% vs. 12.4% in EAs (p = 0.0028) and 14.3% vs. 0.9% in AAs (p = 0.0005). Medicaid recipients (n = 125) were less likely to receive LKT than those without Medicaid (4.8% vs. 16.8%, p = 0.0003). Among the 69 AA recipients with Medicaid, none received LKT (0 Medicaid vs. 9.5% without Medicaid, p = 0.0065)., Conclusions: Recipient insurance status is associated with LKT, positively with private insurance and negatively with Medicaid. AAs were impacted to a greater extent, potentially contributing to lower rates of LKT., (© 2013 John Wiley & Sons A/S.)