Kim J. et al., 2023: A systematic review of postoperative outcomes of kidney stone surgery and meta-analysis of outcomes of percutaneous nephrolithotomy in individuals with spinal cord injury.

Tuesday, 09 January 2024

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Division of Urology, Department of Surgery, McMaster University, Hamilton, ON, Canada.
Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
Division of Urology, Department of Surgery, McMaster University, Hamilton, ON, Canada.
McMaster Institute of Urology, St. Joseph's Hospital, Hamilton, ON, Canada.

Abstract

Study design: Systematic review and meta-analysis.

Objectives: To evaluate outcomes of surgical treatment for nephrolithiasis in individuals with spinal cord injury (SCI).

Methods: We systematically reviewed the Ovid MEDLINE, Embase, CENTRAL, and Web of Science databases for studies examining outcomes of kidney stone procedures in individuals with SCI. Our primary outcomes were stone-free rate (SFR) and complications as categorized by Clavien-Dindo classification. A meta-analysis of comparative studies was performed to assess differences in SFR and complication rate between individuals with and without SCI following PCNL.

Results: A total of 27 retrospective and observational articles were included. Interventions for kidney stones included PCNL, shockwave lithotripsy (SWL), and ureteroscopy. Pooled SFR in individuals with SCI was 54%, for SWL, 74% for PCNL, and 36% for ureteroscopy. Meta-analyses found that there was higher rate of grades I (OR 9.54; 95% CI, 3.06 to 29.79), II (OR 3.38; 95% CI, 1.85 to 6.18), and III-V (OR 2.38; 95% CI, 1.35 to 4.19) complications in individuals with SCI compared to non-SCI individuals following PCNL. The rate of infectious complications was also higher in individuals with SCI (OR 6.15; 95% CI, 1.86 to 20.39). However, there was no difference in SFR (OR 0.64; 95% CI, 0.15 to 2.64) between groups.

Conclusions: Individuals with SCI are at higher risk of minor, major, and infectious complications following PCNL compared to non-SCI individuals. There was no significant difference between groups in SFR following PCNL, suggesting that PCNL is an effective surgery for kidney stones in individuals with SCI.

Spinal Cord. 2023 Sep;61(9):469-476. doi: 10.1038/s41393-023-00927-w. Epub 2023 Aug 18. PMID: 37596394.

Comments 1

Hans-Göran Tiselius on Tuesday, 09 January 2024 08:45

In this systematic review and meta-analysis the authors have compared the results of SWL, PCNL and URS for treatment of patients with spinal cord injury. This group of patients, undoubtedly, is a challenge to the urologic surgeon. The problems might differ from one patient to another. This specific problem is exemplified in the current report, in which only 14 out of 27 studies gave information on the stone size. Nevertheless, it is stated that in 68% of the stones in which stone composition had been analyzed, the result showed struvite. It is well-known that urinary tract infection is a major problem in this group of patients.

The indications for PCNL and URS are not known in detail but is assumed to follow the general recommendations, and the overall stone-free rates were as follows:
PCNL 74%
SWL 54%
URS 36%

It is of note that 34% of the stones had staghorn morphology. This observation clearly reflects the presence of bacteriuria with urease-producing micro-organisms, but that information is not consistently available in the different reports.
The author comment is that it is difficult to compare staghorn stone treatment in SCI-patients with that in the general population. Although such data are missing it is rather clear that in the general population there has been a shift from struvite to calcium oxalate in terms of composition of staghorn stones.
The conclusion made by the authors was that “…further prospective and randomized comparative studies…are required to better characterize postoperative outcome in this population”. Such an approach certainly can give some additional information, but even more important is improved methodology aiming at better stone-free rates, reduced infection complications and effective recurrence prevention.

Infection stones composed of struvite are soluble in acid solutions such as Renacidin [1, 2] and although percutaneous chemolysis by many is considered as inconvenient for patients in general. It might be well worth the efforts in SCI patients. Together with stone disintegration to increase the contact surface area of the stone material both stone-free rate and recurrence prevention can be improved. Long-term recurrence prevention with acidification needs to be studied in a large group of SCI-patients treated for recurrence of infection stones with long-term follow-up.
It is important to be active in development of improved treatment methods to obtain stone-free collecting systems and to give patients sufficiently effective medication to counteract new stone formation. It is not enough to continue along the current road to only show the results of modern methods for stone removal by and end-less series of systematic reviews. What we need are better methods to remove stones and to hinder new stones to form.

References
1. Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I.
Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis.
Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989

2. Tiselius HG, Chaussy CG.
Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective.
Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review.

Hans-Göran Tiselius

The indications for PCNL and URS are not known in detail but is assumed to follow the general recommendations, and the overall stone-free rates were as follows:
PCNL	74%
SWL	54%
URS	36%

It is of note that 34% of the stones had staghorn morphology. This observation clearly reflects the presence of bacteriuria with urease-producing micro-organisms, but that information is not consistently available in the different reports.
The author comment is that it is difficult to compare staghorn stone treatment in SCI-patients with that in the general population. Although such data are missing it is rather clear that in the general population there has been a shift from struvite to calcium oxalate in terms of composition of staghorn stones.
The conclusion made by the authors was that “…further prospective and randomized comparative studies…are required to better characterize postoperative outcome in this population”. Such an approach certainly can give some additional information, but even more important is improved methodology aiming at better stone-free rates, reduced infection complications and effective recurrence prevention.

Infection stones composed of struvite are soluble in acid solutions such as Renacidin [1, 2] and although percutaneous chemolysis by many is considered as inconvenient for patients in general. It might be well worth the efforts  in SCI patients. Together with stone disintegration to increase the contact surface area of the stone material both stone-free rate and recurrence prevention can be improved. Long-term recurrence prevention with acidification needs to be studied in a large group of SCI-patients treated for recurrence of infection stones with long-term follow-up.
It is important to be active in development of improved treatment methods to obtain stone-free collecting systems and to give patients sufficiently effective medication to counteract new stone formation. It is not enough to continue along the current road to only show the results of modern methods for stone removal by and end-less series of systematic reviews. What we need are better methods to remove stones and to hinder new stones to form.

References
1. Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I.
Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis.
Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989

2. Tiselius HG, Chaussy CG.
Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective.
Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review.

Hans-Göran Tiselius

In this systematic review and meta-analysis the authors have compared the results of SWL, PCNL and URS for treatment of patients with spinal cord injury. This group of patients, undoubtedly, is a challenge to the urologic surgeon. The problems might differ from one patient to another. This specific problem is exemplified in the current report, in which only 14 out of 27 studies gave information on the stone size. Nevertheless, it is stated that in 68% of the stones in which stone composition had been analyzed, the result showed struvite. It is well-known that urinary tract infection is a major problem in this group of patients. The indications for PCNL and URS are not known in detail but is assumed to follow the general recommendations, and the overall stone-free rates were as follows: PCNL 74% SWL 54% URS 36% It is of note that 34% of the stones had staghorn morphology. This observation clearly reflects the presence of bacteriuria with urease-producing micro-organisms, but that information is not consistently available in the different reports. The author comment is that it is difficult to compare staghorn stone treatment in SCI-patients with that in the general population. Although such data are missing it is rather clear that in the general population there has been a shift from struvite to calcium oxalate in terms of composition of staghorn stones. The conclusion made by the authors was that “…further prospective and randomized comparative studies…are required to better characterize postoperative outcome in this population”. Such an approach certainly can give some additional information, but even more important is improved methodology aiming at better stone-free rates, reduced infection complications and effective recurrence prevention. Infection stones composed of struvite are soluble in acid solutions such as Renacidin [1, 2] and although percutaneous chemolysis by many is considered as inconvenient for patients in general. It might be well worth the efforts in SCI patients. Together with stone disintegration to increase the contact surface area of the stone material both stone-free rate and recurrence prevention can be improved. Long-term recurrence prevention with acidification needs to be studied in a large group of SCI-patients treated for recurrence of infection stones with long-term follow-up. It is important to be active in development of improved treatment methods to obtain stone-free collecting systems and to give patients sufficiently effective medication to counteract new stone formation. It is not enough to continue along the current road to only show the results of modern methods for stone removal by and end-less series of systematic reviews. What we need are better methods to remove stones and to hinder new stones to form. References 1. Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989 2. Tiselius HG, Chaussy CG. Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective. Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review. Hans-Göran Tiselius

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