Clinical applications of the IAU guideline on retrograde intrarenal surgery
Bibliographic record
Abstract
Kidney stones represent one of the most common human medical conditions. Surgical management of stone disease has undergone immense change in the last 40 years based on advances in technology and operative techniques. Currently, the vast majority of stones can be managed by shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) or a combination of these modalities [1]. Accumulated experience has demonstrated that both stone factors (size, location, composition) and patient factors (body mass index, renal anatomy, and presence of obstruction with or without infection) are crucial to consider for a well-planned stone removal that will result in high stone-free rates with minimal or no complications. Due to its effectiveness, PCNL has been the preferred approach for stones >2 cm in an intrarenal location [2]. The procedure carries a certain level of invasiveness, however, with violation of the renal parenchyma and the possibility of significant bleeding or injury to adjacent organs. This has encouraged endourologists to explore less invasive alternatives, most notably a retrograde approach with flexible ureteroscopy (fURS) and laser lithotripsy with or without concurrent removal of stone fragments using a variety of retrieval devices [3, 4]. fURS for <2 cm stones located above the iliac vessels has demonstrated superior stone-free rates in a single procedure when compared to SWL. PCNL is still recommended by both the AUA and European Association of Urology guidelines as the first-line approach for stones in an intrarenal location which are >2 cm in size [5, 6]. However, recent years have seen an expanded role for fURS to include larger stones, particularly in patients with other comorbidities such as obesity, musculoskeletal conditions precluding positioning for PCNL or in those on anticoagulants for a variety of associated medical disorders [7-10]. Improvements in endoscope technology, availability of high-powered holmium lasers with variable pulse parameters, new technologies such as the thulium fibre laser and advancements in ancillary devices, such as ureteric access sheaths with suction capabilities, have all facilitated this global trend towards the increased use of fURS. It remains to be seen, by way of well-conducted randomized prospective trials, whether results with fURS in a standard patient with a >2 cm intrarenal stone will provide the same stone-free rates in a single procedure and with low rates of sepsis compared to the well-documented results with PCNL. Currently available guidelines have generally focused at a high level on indications, contraindications and patient selection for deployment of the various surgical approaches to kidney stone patients. The International Alliance on Urolithiasis guidelines on retrograde intrarenal surgery, in addition to covering these overarching considerations, also provide many practical recommendations on the step-by-step approach to retrograde intrarenal surgery for urolithiasis. The guidelines will thus be immediately applicable to daily practice and very helpful to both trainees and practising urologists alike. The field of surgical stone management continues to evolve very rapidly. The International Alliance of Urolithiasis plans to review the guidelines every 2 years and I would encourage them to keep up the great work. Stay tuned! Patent and Royalties Cook Percutaneous Stone Basket.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.009 | 0.026 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.004 | 0.003 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.003 | 0.003 |
| Research integrity | 0.005 | 0.005 |
| Insufficient payload (model declined to judge) | 0.008 | 0.006 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".