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Editorial: Can artificial intelligence optimize case selection for hemi‐gland ablation?

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The victory of ‘AlphaGo’ over humans in Go, one of the most complex games with more than 10170 board configurations, has yielded tremendous attention worldwide [1]. The later version, ‘AlphaGo Zero’, has brought artificial intelligence (AI) to the next level by demonstrating an absolute superiority, winning 100‐0 against the champion‐defeating AlphaGo [2]. It is exciting, and perhaps shocking, to realize what AI can achieve.

In this issue of BJUI, the study by Zhou et al. [3] is the first to utilize AI to optimize case selection for hemi‐gland ablation. In this study, classification and regression tree (CART) analysis, which is a form of supervised machine‐learning algorithm, was used to identify laterality of prostate cancer. In the conventional approach, case selection was based on biopsy results and MRI findings. For the CART model, in addition to the common clinical variables (i.e. age, PSA, prostate volume, biopsy and MRI results), biopsy coordinate‐derived spatial features were also used as model inputs. The model output was the probability of unilateral clinically significant prostate cancer considered suitable for hemi‐gland ablation. Whole‐mount prostatectomy specimens were used as the standard of reference. The CART model correctly identified laterality in 80% of the cases, compared to 73% with the conventional approach. The positive predictive value of the CART model was 83%, compared to 53% with the conventional approach. The superiority of the CART model has been demonstrated, and the area under curve was 0.82.

Artifical intelligence has been widely adopted in the field of Urology [4]. For prostate cancer detection in particular, our group evaluated the diagnostic performances of four machine‐learning models based on clinical variables in a biopsy cohort of 1625 men [5]. The machine‐learning models achieved excellent performances in detecting clinically significant prostate cancer, with an accuracy of up to 95.3%. Algohary et al. [6] constructed three machine‐learning models to identify the presence of clinically significant prostate cancer based on MRI radiomic features in patients who underwent active surveillance. When compared with the Prostate Imaging–Reporting and Data System (PI‐RADS) scoring system, the machine‐learning models were able to improve overall accuracy by 30–80%.

Fehr et al. [7] developed an automated system to classify Gleason scores based on MRI images. The automated system could distinguish between Gleason scores of 6 and 7 or above cancers with an accuracy of up to 93%. The differentiation between Gleason score 3+4 and 4+3 disease also yielded an accuracy of up to 93%. Importantly, the performance of AI and machine‐learning models is highly dependent on the quality and accuracy of the data being input. In terms of prostate cancer detection, either mapping biopsy or whole‐mount prostatectomy specimens should be considered to represent the ‘ground truth’.

There are a number of challenges in implementing AI in clinical practice. First, decision‐making in healthcare requires logical deduction and explanation. The data processing in AI, however, is often described as a ‘black box’. Taking AlphaGo as an example, some ‘moves’ were considered incomprehensible even by world‐class players. Second, although results from AI are promising, there is in general a lack of regulations and standards to assess its safety, efficacy and validity. Liability issues can be problematic in case of medical mishaps. Third, doctors are human. Conflict of interest does exist, and how we can utilize AI in a complementary rather than a competitive manner is a challenging obstacle to overcome.

Nevertheless, AI has huge potential in improving healthcare. Collaborative effort is needed globally to develop and optimize AI systems, and to increase its acceptability and practicality upon implementation. Future studies answering clinically important questions using appropriate standards of reference will be of paramount importance in paving the way for the AI era in urology.

by Jeremy Yuen‐Chun Teoh, Edmund Chiong and Chi‐Fai Ng

References

  1. Silver D, Huang A, Maddison CJ et al. Mastering the game of Go with deep neural networks and tree search. Nature 2016; 529: 484– 9
  2. Silver D, Schrittwieser J, Simonyan K et al. Mastering the game of Go without human knowledge. Nature 2017; 550: 354– 9
  3. Zhou SR, Priester AM, Jayadevan R et al. Using spatial tracking with magnetic resonance imaging/ultrasound‐guided biopsy to identify unilateral prostate cancer. BJU Int 2020; 125: 399– 406
  4. Chen J, Remulla D, Nguyen JH et al. Current status of artificial intelligence applications in urology and their potential to influence clinical practice. BJU Int 2019; 124: 567– 77
  5. Wang G, Teoh JY, Choi KS. Diagnosis of prostate cancer in a Chinese population by using machine learning methods. Conf Proc IEEE Eng Med Biol Soc 2018; 2018: 1– 4
  6. Algohary A, Viswanath S, Shiradkar R et al. Radiomic features on MRI enable risk categorization of prostate cancer patients on active surveillance: Preliminary findings. J Magn Reson Imaging 2018; 48: 818– 28
  7. Fehr D, Veeraraghavan H, Wibmer A et al. Automatic classification of prostate cancer Gleason scores from multiparametric magnetic resonance images. Proc Natl Acad Sci USA 2015; 112: E6265– 73

 

Article of the week: Update on the guideline of guidelines: non‐muscle‐invasive bladder cancer

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to this post, there is also a video produced by the authors. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Update on the guideline of guidelines: non‐muscle‐invasive bladder cancer

Jacob Taylor , Ezequiel Becher and Gary D. Steinberg

Department of Urology, NYU Langone Health, New York, NY, USA

Read the full article

Abstract

Non‐muscle‐invasive bladder cancer (NMIBC) is the most common form of bladder cancer, with frequent recurrences and risk of progression. Risk‐stratified treatment and surveillance protocols are often used to guide management. In 2017, BJUI reviewed guidelines on NMIBC from four major organizations: the American Urological Association/Society of Urological Oncology, the European Association of Urology, the National Comprehensive Cancer Network, and the National Institute for Health and Care Excellence. The present update will review major changes in the guidelines and broadly summarize new recommendations for treatment of NMIBC in an era of bacillus Calmette‐Guérin shortage and immense novel therapy development.

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Video: Update on the guideline of guidelines: non‐muscle‐invasive bladder cancer

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Update on the guideline of guidelines: non‐muscle‐invasive bladder cancer

Read the full article

Abstract

Non‐muscle‐invasive bladder cancer (NMIBC) is the most common form of bladder cancer, with frequent recurrences and risk of progression. Risk‐stratified treatment and surveillance protocols are often used to guide management. In 2017, BJUI reviewed guidelines on NMIBC from four major organizations: the American Urological Association/Society of Urological Oncology, the European Association of Urology, the National Comprehensive Cancer Network, and the National Institute for Health and Care Excellence. The present update will review major changes in the guidelines and broadly summarize new recommendations for treatment of NMIBC in an era of bacillus Calmette‐Guérin shortage and immense novel therapy development.

View more videos

Article of the week: Use of 68Ga-PSMA/PET for detecting lymph node metastases in primary and recurrent PCa and location of recurrence after radical prostatectomy: an overview of the current literature

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, we recommend this one. 

Use of gallium‐68 prostate‐specific membrane antigen positron‐emission tomography for detecting lymph node metastases in primary and recurrent prostate cancer and location of recurrence after radical prostatectomy: an overview of the current literature

Henk B. Luiting*, Pim J. van Leeuwen†, Martijn B. Busstra*, Tessa Brabander‡, Henk G. van der Poel†, Maarten L. Donswijk§, André N. Vis, Louise Emmett**††, Phillip D. Stricker‡‡§§¶¶ and Monique J. Roobol*

*Department of Urology, Erasmus University Medical Centre, Rotterdam, †Department of Urology, Netherlands Cancer Institute, Amsterdam, ‡Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, §Department of Nuclear Medicine, Netherlands Cancer Institute, Department of Urology, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands, **Department of Nuclear Medicine, St Vincent’s Hospital, ††University of New South Wales, Sydney, ‡‡St. Vincent’s Prostate Cancer Centre, §§Garvan Institute of Medical Research, Kinghorn Cancer Centre, Darlinghurst and ¶¶St Vincent’s Clinical School, UNSW, Sydney, NSW, Australia

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Abstract

Objectives

To review the literature to determine the sensitivity and specificity of gallium‐68 prostate‐specific membrane antigen (68Ga‐PSMA) positron‐emission tomography (PET) for detecting pelvic lymph node metastases in patients with primary prostate cancer (PCa), and the positive predictive value in patients with biochemical recurrence (BCR) after initial curative treatment, and, in addition, to determine the detection rate and management impact of 68Ga‐PSMA PET in patients with BCR after radical prostatectomy (RP).

Materials and Methods

We performed a comprehensive literature search. Search terms used in MEDLINE, EMBASE and Science Direct were ‘(PSMA, 68Ga‐PSMA, 68Gallium‐PSMA, Ga‐68‐PSMA or prostate‐specific membrane antigen)’ and ‘(histology, lymph node, staging, sensitivity, specificity, positive predictive value, recurrence, recurrent or detection)’. Relevant abstracts were reviewed and full‐text articles obtained where possible. References to and from obtained articles were searched to identify further relevant articles.

Fig. 1. Axial and sagittal plane gallium‐68 prostate‐specific membrane antigen positron‐emission tomography /CT images of two patients with locoregional lymph node recurrence after initial curative treatment. The metastasis in patient A is located in the obturator area and the metastasis in patient B is located in the presacral area.

Results

Nine retrospective and two prospective studies described the sensitivity and specificity of 68Ga‐PSMA PET for detecting pelvic lymph node metastases before initial treatment, which ranged from 33.3% to 100% and 80% to 100%, respectively. In eight retrospective studies, the positive predictive value of 68Ga‐PSMA PET in patients with BCR before salvage lymph node dissection ranged from 70% to 100%. The detection rate of 68Ga‐PSMA PET in patients with BCR after RP in the PSA subgroups <0.2 ng/mL, 0.2–0.49 ng/mL and 0.5 to <1.0 ng/mL ranged from 11.3% to 50.0%, 20.0% to 72.7% and 25.0% to 87.5%, respectively.

Conclusion

The review results showed that 68Ga‐PSMA PET had a high specificity for the detection of pelvic lymph node metastases in primary PCa. Furthermore, 68Ga‐PSMA PET had a very high positive predictive value in detecting lymph node metastases in patients with BCR. By contrast, sensitivity was only moderate; therefore, based on the currently available literature, 68Ga‐PSMA PET cannot yet replace pelvic lymph node dissection to exclude lymph node metastases. In the salvage phase, 68Ga‐PSMA PET had both a high detection rate and impact on radiotherapy planning in early BCR after RP.

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Article of the month: Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

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Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a video prepared by the authors; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, we recommend this one. 

Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

William K. Gray*, Jamie Day*, Tim W. R. Briggs* and Simon Harrison*†

*Getting it Right First Time Programme, NHS England and NHS Improvement, London, UK and †Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK

Read the full article

Abstract

Objectives

To investigate volume–outcome relationships in nephrectomy and cystectomy for cancer.

Materials and Methods

Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in England. Data were included for a 5‐year period (April 2013–March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot‐assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors.

Results

Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high‐volume surgeons, although the volume measure and threshold used were important.

Conclusions

We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower‐volume centres, rather than further centralization.

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Editorial: All for one, one for all: is centralisation the way to go?

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The need to centralise complex surgical procedures in large centres remains at the core of many health policy discussions. Much of the debate is focussed on three main aspects: (i) outcomes, (ii) costs and (iii) accessibility. Gray et al. [1] recently noted that increasing centralisation may be unnecessary for invasive procedures such as nephrectomy and cystectomy. Specifically, they noted almost no difference in outcomes of high‐volume centralised centres and those with lower throughput. Their findings go against most of the current literature on the volume–outcomes relationship, which generally reports a correlation between a hospital’s volume of procedures and improved healthcare outcomes. One could ask what factors specific to their analysis could explain the different observations. For one, the healthcare system in the UK may (and likely) operate in ways different from other European and USA‐based healthcare systems, from which most of the current data are derived. Healthcare in the UK may already be organised in such a way that further centralisation may not improve outcomes, which the authors allude to in their conclusions. Differences in methodology may explain their findings, e.g. their use of multilevel modelling, testing specific incremental volume cutoffs, etc. Outcome selection may play a role as well; length of stay and re‐admissions may vary more according to organisational factors rather than individual surgeon expertise.

Regardless of their findings, we would argue that there are other tangible benefits to centralisation, which extend well beyond ‘better outcomes’. For instance, the management of the modern oncological, and urological, patient is critically dependent on a multidisciplinary team. The inherent multidisciplinary nature of large centres facilitates patients receiving their entire course of treatment at the same place. This enhances the continuity and efficiency of care, both of which are undoubtedly hampered in small peripheral centres that ultimately depend on referrals to larger facilities for advanced care for the most complex patients.

This ties into yet another major advantage of centralised centres, which is the ease of access to research. For instance, our affiliated cancer centre runs >1100 active clinical trials, 42 of which pertain to advanced urological diseases. Such trials provide access to otherwise unavailable therapies and enhance the production, diffusion, and application of knowledge.

In touting the many benefits of centralisation, one would imagine it comes at a significant cost. While this may have been true in the past, recent data comparing the higher‐volume teaching hospitals to lower‐volume non‐teaching centres suggest that centralisation actually decreases the 30‐day hospital costs and have similar costs at 90 days compared with non‐teaching hospitals [2]. Similar trends were also seen with radical cystectomies [3] and prostatectomies [4], showing that with the major urological procedures, centralisation is cost‐effective with at least the same outcomes as compared to peripheral centres.

A common objection to centralisation is that it forces many patients to travel long distances and that this in turn could introduce or worsen discrepancies in accessibility to care. If true, this would have profound social and economic consequences for disadvantaged groups, as well as particularly fragile patients. Many centralised centres have developed approaches to ease the burdens of travelling from afar and, if patients can make the journey, the data suggest a survival advantage over those who are treated at peripheral centres. To this end, Vetterlein et al. [5] stratified >700 000 patients by risk class and demonstrated an overall survival benefit in those with all stages of prostate cancer. In the not‐too‐distant future, patient follow‐up can be shifted almost entirely to telemedicine, which can further alleviate travel burdens.

Our aim is not to promote a system of oncological care based solely at centralised hubs. However, to suggest that all care should be distributed equally across all centres seems unrealistic and may have devastating consequences, particularly for those with advanced disease. We strongly advocate the treatment of complex disease at high‐volume, centralised centres and suggest better use of an impartial classification of what constitutes a ‘complex’ disease. Therefore, one answer to this problem is broadly represented by the redistribution of the different surgical procedures amongst the hospitals.

by Daniele Modonutti, Venkat M. Ramakrishnan and Quoc‐Dien Trinh

 

References

  1. Gray WK, Day J, Briggs TW, Harrison S. Understanding volume‐outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme. BJU Int 2020; 125: 234– 43
  2. Burke LG, Khullar D, Zheng J, Frakt AB, Orav EJ, Jha AK. Comparison of costs of care for medicare patients hospitalized in teaching and nonteaching hospitals. JAMA Netw Open 2019; 2: e195229
  3. Leow JJ, Reese S, Trinh QD et al. Impact of surgeon volume on the morbidity and costs of radical cystectomy in the USA: a contemporary population‐based analysis. BJU Int 2015; 115: 713– 21
  4. Gershman B, Meier SK, Jeffery MM et al. Redefining and contextualizing the hospital volume‐outcome relationship for robot‐assisted radical prostatectomy: implications for centralization of care. J Urol 2017; 198: 92– 9
  5. Vetterlein MW, Löppenberg B, Karabon P et al. Impact of travel distance to the treatment facility on overall mortality in US patients with prostate cancer. Cancer 2017; 123: 3241– 52

 

 

 

Video: Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

/by

Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme

Read the full article

Abstract

Objectives

To investigate volume–outcome relationships in nephrectomy and cystectomy for cancer.

Materials and Methods

Data were extracted from the UK Hospital Episodes Statistics database, which records data on all National Health Service (NHS) hospital admissions in the England. Data were included for a 5‐year period (April 2013–March 2018 inclusive) and data on emergency and paediatric admissions were excluded. Data were extracted on the NHS trust and surgeon undertaking the procedure, the surgical technique used (open, laparoscopic or robot‐assisted) and length of hospital stay during the procedure. This dataset was supplemented by data on mortality from the UK Office for National Statistics. A number of volume thresholds and volume measures were investigated. Multilevel modelling was used to adjust for hierarchy and confounding factors.

Results

Data were available for 18 107 nephrectomy and 6762 cystectomy procedures for cancer. There was little evidence of trust or surgeon volume influencing readmission rates or mortality. There was some evidence of shorter length of hospital stay for high‐volume surgeons, although the volume measure and threshold used were important.

Conclusions

We found little evidence that further centralization of nephrectomy or cystectomy for cancer surgery will improve the patient outcomes investigated. It may be that length of stay can be optimized though training and support for lower‐volume centres, rather than further centralization.

View more videos

Article of the week: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a visual abstract prepared by a trainee urologist; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, we recommend this one. 

Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

Manuel Armas-Phan*, David T. Tzou*†, David B. Bayne*, Scott V. Wiener*, Marshall L. Stoller* and Thomas Chi*

*Department of Urology, University of California, San Francisco, CA and †Division of Urology, University of Arizona, Tucson, AZ, USA

Read the full article

Abstract

Objectives

To compare clinical outcomes in patients who underwent percutaneous nephrolithotomy (PCNL) with renal tract dilatation performed under fluoroscopic guidance vs renal tract dilatation with ultrasound guidance.

Patients and Methods

We conducted a prospective observational cohort study, enrolling successive patients undergoing PCNL between July 2015 and March 2018. Included in this retrospective analysis were cases where the renal puncture was successfully obtained with ultrasound guidance. Cases were then grouped according to whether fluoroscopy was used to guide renal tract dilatation or not. All statistical analyses were performed using Stata version 15.1 including univariate (Fisher’s exact test, Welch’s t‐test) and multivariate analyses (binomial logistic regression, ordinal logistic regression, and linear regression).

Results

A total of 176 patients underwent PCNL with successful ultrasonography‐guided renal puncture, of whom 38 and 138 underwent renal tract dilatation with fluoroscopic vs ultrasound guidance, respectively. There were no statistically significant differences in patient age, gender, body mass index (BMI), preoperative hydronephrosis, stone burden, procedure laterality, number of dilated tracts, and calyceal puncture location between the two groups. Among ultrasound tract dilatations, a higher proportion of patients were placed in the modified dorsal lithotomy position as opposed to prone, and a significantly shorter operating time was observed. Only modified dorsal lithotomy position remained statistically significant after multivariate regression. There were no statistically significant differences in postoperative stone clearance, complication rate, or intra‐operative estimated blood loss. A 5‐unit increase in a patient’s BMI was associated with 30% greater odds of increasingly severe Clavien–Dindo complications. A 5‐mm decrease in the preoperative stone burden was associated with 20% greater odds of stone‐free status. No variables predicted estimated blood loss with statistical significance.

Conclusions

Renal tract dilatation can be safely performed in the absence of fluoroscopic guidance. Compared to using fluoroscopy, the present study demonstrated that ultrasonography‐guided dilatations can be safely performed without higher complication or bleeding rates. This can be done using a variety of surgical positions, and future studies centred on improving dilatation techniques could be of impactful clinical value.

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Editorial: Zero‐radiation stone treatment

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In this month’s BJUI, Armas‐Phan et al. [1] report on a prospective observational trial of fluoroscopic vs ultrasound (US)‐guided tract dilatation during percutaneous nephrolithotomy (PCNL). A total of 176 patients underwent successful initial US‐only guided puncture; of these patients, 138 had US‐only dilatation, while in 38 fluoroscopy was required. The authors found no difference in patient factors (e.g. age, gender, body mass index [BMI]) or stone factors (hydronephrosis, stone burden, number of tracts or puncture location). On multivariate analysis, US dilatation was more likely to be performed in the modified dorsal lithotomy position (compared to prone), but there was no significant difference in important outcomes such as stone clearance, complication rates or blood loss.

Whilst only reporting on access (and not necessarily dilatation), the Clinical Research Office of the Endourological Society PCNL Global Study shows us that worldwide fluoroscopic access is by far the most common (88.3% of cases) [2] and there are relatively few reports of US‐guided dilatation in the literature. The technique does produce technical challenges as the surgeon needs to confidently identify the depth of the dilators or balloon and be sure of its location relative to calyceal anatomy. Whilst dilating short is not usually a problem as simply re‐dilating can be done, dilating too far carries serious risk of perforation of the pelvicalyceal system and vascular injury. The authors’ described technique does rely on good kidney and guidewire visualisation, and if this is not possible then fluoroscopy is used instead. Thus, even in this series with experts at this technique, 38 (22%) underwent fluoroscopic dilatation after US‐guided puncture, and of the 138 with intended US dilatation, seven (5%) were converted to fluoroscopy. Furthermore, 115 patients never entered this series as they underwent initial fluoroscopic‐guided puncture. Thus, it is important to realise that this is a series of select patients being treated by expert enthusiasts of this technique and fluoroscopy should be available in the operating theatre, as it is not possible to do this technique for all patients. In particular, obesity limits the visualisation under US and the authors have previously shown that renal access drops from 76.9% of normal‐weight patients (BMI <25 kg/m2) to 45.6% for those classified as obese (BMI >30 kg/m2) [3]. An alternative strategy to avoid radiation is to use endoscopic combined intrarenal surgery (ECIRS), as the depth of dilatation can be monitored by direct visualisation via the flexible ureteroscope.

Patients and healthcare professionals are increasingly aware of the risks posed by ionising radiation. Ferrandino et al. [4] analysed radiation exposure of patients presenting with acute stone episodes in an American setting. The mean dose was a staggering 29.7 mSv and 20% of patients received >50 mSV. There is also awareness of risk to the operating staff from endourological procedures and although doses are relatively low [5], these can accumulate during a lifetime of operating, with risks of not only malignancy but also cataract formation [6]. Whilst I am sure we all wear protective lead gowns in the operating theatre, how many people wear lead glasses? A recent study showed that, at typical workload, the annual dose to the lens of the eye was 29 mSv in interventional endourology [7].

As urologists, we should all be aware of these risks and follow the ALARA (As Low As Reasonably Achievable) principals of keeping doses to a minimum. Thus, this paper [1] is particularly welcome and shows zero‐radiation procedures can be safely performed. The authors now attempt this technique for all PCNL procedures and achieve US‐only puncture and dilatation in over half of their patients. Hopefully, this paper will inspire us all to look at reducing or eliminating radiation usage in our stone procedures and this will be good for patients and surgeons alike.

by Matt Bultitude

 

References

  1. Armas‐Phan M, Tzou DT, Bayne DB et al. Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy. BJUI 2019; 125: 284-91
  2. De La Rosette J, Assimos D, Desai M et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11– 7
  3. Usawachintachit M, Masic S, Chang H, Allen I, Chi T. Ultrasound guidance to assist percutaneous nephrolithotomy reduces radiation exposure in obese patients. Urology 2016; 98: 32– 8
  4. Ferrandino MN, Bagrodia A, Pierre SA et al. Radiation exposure in the acute and short‐term management of urolithiasis at 2 academic centers. J Urol 2009; 181: 668– 72
  5. Galonnier F, Traxer O, Rosec M et al. Surgical staff radiation protection during fluoroscopy‐guided urologic interventions. J Endourol 2016; 30: 638– 43
  6. Hartmann J, Distler F, Baumuller M et al. Risk of radiation‐induced cataracts: investigation of radiation exposure to the eye lens during endourologic procedures. J Endourol 2018; 32: 897– 903
  7. Hristova‐Popova J, Zagorska A, Saltirov I et al. Risk of radiation exposure to medical staff involved in interventional endourology. Radiat Prot Dosimetry 2015; 165: 268– 71

 

 

Visual abstract: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

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