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Stones: prevention, young patients and the prospects of remote training

Urologists should be doing their part to help their patients prevent stone formation, whether in lifestyle coaching, referring to other specialists or by diligently analysing the removed stones. These were some of the recommendations discussed at EAU21 today.

The final of seven plenary sessions at EAU21 took place on Day 5 of the virtual congress, bringing together stone experts from across the continent for an interesting live session. The session was chaired from the studio by Prof. Thomas Knoll (DE) and Prof. Selçuk Silay (TR), joined by Prof. Evangelos Liatsikos (GR) remotely.

The session was marked by several “quick fire” presentations that offered different solutions for hypothetical cases (involving a 5-year-old child and a young woman). Every presenter was on hand for a group discussion afterwards, also taking questions from the audience on the considerations that the specialists deal with in their own patients.

Preventing stone formation: a task for surgeons?

The session started with two presentations on the prevention of urinary stones, examining the current and upcoming medical options, but also on the (mixed) success of dietary measures. Dr. Wagner (CH) recommended efforts to coach patients to change their diet for the better, praising it as a helpful and inexpensive way to reduce stone recurrence.

Dr. Ferraro (IT) briefly summarised the traditional medical options available to urologists (citrate, thiazides, allopurinol/febyxostat), but also pointed to lumasiran: a recently approved new drug for primary hyperoxalura. In trial results published in the New England Journal of Medicine earlier this year, Garrelfs et al. found a 54% drop in urinary oxilate excretion compared to placebo. Prof. Knoll considered these results “encouraging news after not much progress in the past 20-30 years.”

After the presentations, discussion turned to the role of the surgeon: not just removing stones, but perhaps also playing a role in prevention? Prof. Silay was of the opinion that surgeons, too, should do their part in encouraging prevention, referring patients to dieticians or more specialised care from nephrologists.

Lifestyle change could only count on low compliance from the patients, with Dr. Ferraro estimating that perhaps only a third of patients made the recommended changes to prevent future stone formation. A metabolic examination might reveal that only a very specific change is necessary, improving compliance, instead of more general and wide-ranging dietary advice.

The prospects of surgical remote learning

Amid case discussions that weighed the benefits and drawbacks of ESWL, PNL or flexible URS was an update on technique and training. Prof. Olivier Traxer (FR) summarised his personal experiences of remote training over the past fifteen months.

“With the events of 2020, we have had to rethink education,” said Traxer. “Social media has allowed us to get in touch and spread information, but of course there is little in the way of quality control. The industry has started developing webinars and educational platforms, but we must of course admit that there is a certain amount of bias there.”

“International societies like the EAU and the European School of Urology perhaps did the most to replace physical meetings, creating evidence-based webinars and learning tracks. This year’s Annual Congress [EAU21] is an excellent example of what we are now able to do, to teach surgical theory. Things like stone composition recognition, can easily be done from home.”

“The fact remains however that we are surgeons and we have so far not been able to replace in-person, hands-on teaching. We need feeling and feedback from our tools. While this is so far irreplaceable, a mix of hands-on and remote training is certainly a future for us.”

Profs. Knoll and Liatsikos joined in discussing these realities with Prof. Traxer. Perhaps remote “coaching” of more experienced surgeons with a live feed of the procedure (similar to moderation during live surgery sessions) is an option, but only if the surgeon already has a degree of skill. There are also many legal ramifications that need to be examined for this to be considered.

  • You can watch back the entire 7th Plenary Session through the EAU21 Congress Platform’s On Demand feature. The session will be uploaded over the course of the day and remain there and accredited until October 12th.