Clinical Scorecard: Predicting Surgical Outcomes of Flexible Ureteroscopy in Patients with Renal Anomalies: An Explainable AI Approach from EAU Endourology

At a Glance

Key Highlights

• fURS is a safe and feasible treatment for urolithiasis in patients with renal anomalies, with stone-free rates up to 76% and low major complication rates (2.4%).
• Explainable AI models, including decision trees and SHAP analysis, can predict surgical outcomes and identify key preoperative predictors in complex anatomical cases.
• No standardized guidelines exist specifically for URS outcomes in congenital renal anomalies; clinical decisions rely heavily on experience and intraoperative judgment.

Guideline-Based Recommendations

Diagnosis

• Use preoperative plain or contrast-enhanced CT scan to evaluate renal anatomy and stone characteristics.
• Confirm congenital renal anomalies prior to surgery.
• Perform urine analysis to exclude infection before proceeding with surgery.

Management

• Flexible ureteroscopy combined with laser lithotripsy is recommended as a safe first-line treatment option.
• Consider alternative treatments such as percutaneous nephrolithotomy or shock wave lithotripsy based on anatomy and stone burden.
• Obtain informed consent and provide specialist counseling before surgery.

Monitoring & Follow-up

• Assess intraoperative parameters including operative time, haematuria, and presence of residual fragments.
• Perform 3-month follow-up CT-KUB to evaluate stone-free status (absence of residual fragments or fragments < 2 mm).
• Monitor for postoperative complications such as sepsis and need for reintervention.

Risks

• Increased risk of intraoperative complications due to anatomical variations.
• Potential for procedure abandonment if access is not feasible.
• Postoperative sepsis requiring prolonged intravenous antibiotics in a subset of patients.

Patient & Prescribing Data

569 adult patients with congenital renal anomalies undergoing fURS for urolithiasis

Majority female (73.46%), mean age 44.5 years; most had multiple, small (<20 mm), and soft stones; horseshoe kidney was the most common anomaly (50.62%). Stone-free rate at 3 months was 72.06%, with 9.3% postoperative sepsis and 2.8% procedure abandonment.

Clinical Best Practices

• Preoperative imaging and stone characterization are essential for procedural planning in anomalous kidneys.
• Ensure sterile urine prior to surgery to minimize infection risk.
• Utilize explainable AI tools to support clinical decision-making and predict surgical outcomes.
• Monitor intraoperative haematuria closely as it may limit vision and impact procedure success.
• Plan for follow-up imaging at 3 months to confirm stone clearance and guide further management.

References

• EAU Guidelines on Urolithiasis and Endourology
• Study on fURS outcomes in congenital renal anomalies
• Explainable AI in clinical decision making