Plenary Session: Challenges and nightmares in endourology
Beyond the latest devices and techniques, urologists who perform endourological procedures need to be prepared to deal with patients who are using anticoagulation therapy, especially when short-term discontinuation is not an option. These new drugs are more frequently being prescribed and can be an additional challenge for operations where blood loss is a risk. According to current guidelines, ureteroscopy is a low-risk intervention and can still be performed if drug-specific antidotes are available and a proper management algorithm needs to be in place.
These were the conclusions of the opening talk by Mr. Niall Davis (Dublin, IE) of the Plenary Session “Help… Challenges and nightmares in endourology” on the third day of the 40th Annual EAU Congress in Madrid. The session was chaired by Profs. Matthew Bultitude (London, GB) and Olivier Traxer (Paris, FR) and featured debates, state-of-the-art lectures and the AUA lecture, which was delivered by AUA President Dr. Stephen Nakada (Madison, WI, US).
Dr. Nakada gave an overview of key RCTs in endourology in the last 25 years. He noted that while some endourological topics had since then become hopelessly superseded (thanks to advances in PROMs), others were still bones of contention a quarter of a century on, for instance Dr. Nakada’s own Perc vs Stent trial published in Journal of Urology in 1998. This very trial was quoted by two speakers in the session who came before Dr. Nakada. (article continues below photo)
Prof. Bultitude, Dr. Nakada and Prof. Traxer. Dr. Nakada received a special commendation to celebrate the ties between the EAU and the American Urological Association.
A 2001 trial by the LPS group compared URS (using fiberoptic scopes) and SWL for lower pole caliceal calculi 1cm or less. Notably, it took the participation of 19 centres to come up with 67 patients to randomise. In general, Dr. Nakada noted that over the past quarter of a century, trends in endourology favour rapid drainage of the kidney (whether that’s by the urologist or the radiologist), and QoL metrics and patient-reported outcomes have taken a great leap forward since the 1990s. Non-contrast CT has emerged as the best imaging modality for stones, and a form of high-powered laser has become an indispensable tool for the endourologist.
Operative time
The Plenary Session continued with a debate on 15mm upper ureteric stones in adults, comparing antegrade and retrograde approaches, and a State-of-the-Art lecture by Prof. Bhaskar Somani (Southampton, GB) on the safe length of operative time for ureteroscopy.
Prof. Somani introduced the “Quadrifecta of RIRS”, the four main factors that influence operating time for retrograde intrarenal surgery: suction, which facilitates the removal of debris; irrigation, which ensures better visibility for the surgeon; intrarenal pressure, which can cause several problems if it’s too high; and finally intrarenal temperature, which can injure the mucosa with laser-related heat.
With different margins given by different sources, Prof. Somani concluded that “as short as possible” was best, with any procedure over 60 minutes already increasing the risk of complications. Over 90 minutes definitely leads to risk of sepsis and high-grade complications. For large stones, the procedure should be staged, suction devices should be used and the surgical team should be experienced.
When concluding the Plenary Session, Prof. Traxer took the opportunity to introduce the audience to the recently founded EAU Section of Endourology, a merger of the former urolithiasis and uro-technology sections EULIS and ESUT. The Endourology Section will have its first event, ICE25 this autumn in Rome, Italy.