Abstract
CROES COUNCIL
Chairman
Jean de la Rosette, MD
Amsterdam (The Netherlands)
Adrian Joyce, MS
Leeds (UK)
Stavros Gravas, MD
Larissa (Greece)
Margaret Pearle, MD
Dallas, TX (USA)
Dean Assimos, MD
Wake Forest, NC (USA)
Ying-Hao Sun, MD
Shanghai (China)
Tadashi Matsuda, MD
Osaka (Japan)
John Denstedt, MD
London (Canada)
Sonja van Rees Vellinga
Amsterdam (The Netherlands)
Mission
Through worldwide collaboration, CROES seeks to assess, using evidence based scientific methodology, the various aspects of clinical endourology.
Vision
By applying rigorous scientific evaluation to the field of clinical endourology, CROES will enable all urologic surgeons to bring to their patients the most effective and efficient care possible.
Projects
• Global PCNL study
• Global URS study
• Global GreenLight™ Laser study
• Global Renal Mass study
• Global NBI study
Contact
For more information please contact Sonja van Rees Vellinga (
CLINICAL RESEARCH OFFICE OF THE ENDOUROLOGY SOCIETY GLOBAL STUDIES: IS RESEARCH A WASTE OF MONEY AND TIME?
Andreas Skolarikos, MD, PhD, FEBU
Research is one of the most important activities to achieve scientific progress. Although it is an easy process on a theoretical basis, practically it is a laborious process, and full commitment and dedication are of paramount importance. Currently, given that the financial challenges have a major influence in daily practice, the need to stress the valid purpose of research is crucial. Conducting research provides a deeper understanding of several scientific topics within the specialty of each physician. Furthermore, it helps physicians of a particular specialty to understand better the scientific work of other colleagues.
The Clinical Research Office of the Endourological Society (CROES) was created a few years ago based on the idea of some enlightened friends, well known for their love and dedication to urologic clinical practice and research. No one would have believed that in such a short period, the CROES council would have managed to achieve something that was missing in medicine worldwide: To mingle together the experience and the everyday practice of a whole surgical specialty. I cannot recall such an achievement all these years that I am practicing medicine and surgery.
Needless to say, such an endeavor was important from the beginning. Global databases including almost 6000 percutaneous nephrolithotomies and 12,000 ureteroscopies (URSs) provide the urologic community the framework to advance knowledge for the good of our patients, to create diagnostic and therapeutic algorithms, and to properly inform our patients about the outcome of these procedures. It is also the best way for every one of us to compare these results with the average results urologists can achieve globally. In my view, this is an unique opportunity to realize how far away or close individual practices are from what is really happening all over the world and one of the best ways for every one of us to improve his own outcomes. Furthermore, for the urologic community and the Endourological Society, it is also a unique opportunity to compare urologic practice among different institutions and healthcare systems. In fact, that may increase the Society's interest and effort to “educate,” “train,” and “promote” best clinical practice to those colleagues who fall into the “left” portion of the “outliers.”
The CROES URS global study
To become more practical, between January 2010 and October 2012, 11,885 patients underwent URS at 114 centers in 32 countries. What is the piece of information one can extract only by reading the descriptive statistics of such a database? URS is most commonly applied to urinary stones located in different portions of the ureter; however, 25% of the patients treated had kidney stones. Semirigid URS prevailed, although flexible URS was used in 25% of the cases. Fragmentation was performed principally using a laser device (49%) or a pneumatic device (30.3%). Interestingly, no disintegration device was used in 17.9% of the cases. Overall, a high stone-free rate (85.6%) was achieved. The vast majority of the patients did not receive any further treatment for renal or ureteral stones (89.4%). Ureteral stents were inserted postoperatively in 81.4% of the patients.
Ninety-four percent of the patients underwent an uneventful procedure, while the most frequent complication was fever (1.8%), although 82.2% of the patients have received antibiotics for the procedure. There was a low incidence of significant bleeding (1.4%), perforation (1.0%), and failure to complete the operation (1.6%). 1 We do not believe that there is better evidence to use for consultation with our patients for URS.
When patients with ureteral stones were treated, the stone-free rate varied based on the location of the stone. 2 Stone-free rates were 94.2% for distal ureter locations, 89.4% for midureter locations, 84.5% for proximal ureter locations, and 76.6% for multiple locations. There was a significantly lower stone-free rate with stones >10 mm, regardless of location. For the proximal ureter, failure and re-treatment rates were significantly higher for semirigid URS than for flexible URS. Although the stone-free rates between the two modalities did not differ, I cannot see a better reason or encouragement for those who do not currently use the flexible instruments to surmount any indicative, technical, or financial obstacles and include them in their armamentarium. Again the complication rate was low, ranging between 2.5% and 4.6%, with the highest incidence reported for multiple stone locations. Readmissions were needed mostly because of ureteral stent discomfort and flank pain or re-treatment either for residual stones or removal of stents.
What is new?
One could argue concerning what new has been added in the literature with the CROES URS Global Study. First of all, these findings, as already mentioned, coming from such a huge database, strengthen the current available evidence. Furthermore, new knowledge has emerged. In patients who had a low stone burden, operative time was longer for patients who had multiple locations than for those who had single stones in any of the other locations. As stone burden increased, operative times changed such that times for patients with multiple locations were lower than for proximal and midureteral stone locations but equivalent to distal ureteral stones. With higher stone burdens, it was likely that multiple stones in several locations were smaller and less challenging to reach, whereas proximal and midureter stones might have been larger and more difficult to reach, making operative times longer for the equivalent stone burden. This observation has not been reported previously.
Furthermore, some findings of the current study differ from those that have emerged from large data sets reported, for example, from the American Urological Association (AUA) guidelines on the management of ureteral calculi in 2007. More specifically, in the CROES database, the subanalysis of proximal stones revealed similar stone-free rates when semirigid (83.8%) or flexible (85.5%) ureteroscopes were used. This finding is in contrast to the AUA guidelines report that showed superior stone-free rates for flexible URS (87% vs 77%). 3 These contradictory results clearly indicate the need for a prospective head-to-head comparison of the two modalities.
One could also argue concerning how the data coming from CROES database have been validated. For those who do not know just because they have not been actively involved in the enrollment of patients, all centers had the obligation to abide with the rules set by the CROES Audit Committee, 4 for which they have been checked on. Because only the first two publications have been released from the URS Global Study, we are looking forward to reading the several multivariate and subgroup analyses that follow to enlighten our knowledge for one of the most common urologic procedures. I am confident that the forthcoming results will trigger the design and completion of Level 1 evidence studies for various topics in the field of URS.
Finally, we may safely conclude that research is not a waste of money and time. To the contrary, it is a long-term investment by many altruistic colleges worldwide aiming to provide the ultimate and best possible quality of care to their patients.