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Background: With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments and outline future directions and recommendations to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists.Methods: This study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy, RIRS, laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data were consolidated for analysis.Results: A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analyzed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS.Conclusion: Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.

Introduction: Flexible ureterorenoscopy (fURS) is one of the best solutions for treatment of renal calculi

Purpose We evaluated a new single-use digital flexible cystoscope with an integrated grasper designed for double-J stent removal, Isiris (TM), addressing success rate, image quality, deflection, maneuverability and grasper functionality. Methods In September 2015, a prospective cohort study was conducted in six tertiary European reference centers. All consecutive patients included underwent double-J stent removal and were 18 years or older. Success rate was defined by complete stent removal. Image quality, deflection, maneuverability and grasper functionality were rated with a Likert scale. Results A total of 83 procedures were performed. 82% of procedures were performed in the endoscopy room, while the others were in the operating room since a consecutive endourological intervention was planned. The median duration of stent implantation was 28 days [14; 60]. In five patients, stent removal was not possible. Four patients had an incrusted double-J stent, and in one patient, the stent migrated into the ureter. After unsuccessful attempts of stent removal with conventional flexible cystoscope and grasper, the five patients had to be scheduled for an ureterorenoscopy procedure to remove the stent. In the other 78 patients, all double-J stents were removed successfully. Image quality, deflection, maneuverability and grasper functionality were rated as "very good" in 72.3, 78.3, 72.3 and 73.5%, respectively. Conclusion This multicenter clinical evaluation of Isiris (TM) displayed good image quality, active deflection, maneuverability and grasper functionality. Further evaluation of stent removal outcomes, cost analysis and microbiology will help to delineate the possible place of Isiris (TM) in the current practice.

International audience; Cystinuria is an autosomal recessive inherited aminoaciduria leading to nephrolithiasis. Although its prevalence is lower than other renal stone diseases, cystinuria requires an appropriate and specific support. Extracorporeal lithotripsy is relatively inefficient against cystine stones, thus limiting treatment options. The high risk of recurrence and the frequent evolution toward chronic kidney disease need stringent preventive measures based upon an abundant alkaline diuresis and sometimes therapeutic agents forming soluble mixed disulphides with cystine moieties. A close monitoring of diuresis volume, urinary pH and crystalluria prevents recurrence.

The use of a ureteral access sheath (UAS) during flexible retrograde intrarenal surgery (RIRS) has become increasingly popular. Our aim was to evaluate the accessibility of a new UAS device, allowing the transformation of the working guidewire into a safety guidewire. A prospective, multicenter study was conducted between January and February 2010 in six European tertiary reference centers. Patients needing flexible RIRS were eligible to participate in the study. In all cases, insertion of the Re-Trace (TM) (12/14Fr, Coloplast, Denmark) was attempted at the beginning of the procedure. Insertion success was defined as placement of the UAS in the lumbar ureter with successful disengagement of the working guidewire, which turned into a safety guidewire. Influence of gender and pre-stenting status was analyzed by univariate analysis. 137 UASs were used in 75 male and 62 female patients. 25.5 % of ureters were pre-stented: men were 2.17 more often pre-stented than women. The overall Re-Trace (TM) insertion rate was 82.5 %. Success rate was not significantly different between men and women (77.3 vs. 88.7 %, respectively, p = 0.11). Pre-stenting status did not significantly influence the success rate (p = 0.31). When analyzing the combined influence of pre-stenting status and gender, the worst success rates seemed to be obtained in men without pre-stenting, but no significant differences were found between groups. Re-Trace (TM) UAS showed good overall insertion rates. This evaluation validated the new concept of guidewire disengagement: A single wire automatically switches from working to safety role.

Geomagnetic storms are an important aspect of space weather and can result in significant impacts on space- and ground-based assets. The majority of strong storms are associated with the passage of interplanetary coronal mass ejections (ICMEs) in the near-Earth environment. In many cases, these ICMEs can be traced back unambiguously to a specific coronal mass ejection (CME) and solar activity on the frontside of the Sun. Hence, predicting the arrival of ICMEs at Earth from routine observations of CMEs and solar activity currently makes a major contribution to the forecasting of geomagnetic storms. However, it is clear that some ICMEs, which may also cause enhanced geomagnetic activity, cannot be traced back to an observed CME, or, if the CME is identified, its origin may be elusive or ambiguous in coronal images. Such CMEs have been termed \"stealth CMEs.\" In this review, we focus on these \"problem\" geomagnetic storms in the sense that the solar/CME precursors are enigmatic and stealthy. We start by reviewing evidence for stealth CMEs discussed in past studies. We then identify several moderate to strong geomagnetic storms (minimum Dst < -50 nT) in solar cycle 24 for which the related solar sources and/or CMEs are unclear and apparently stealthy. We discuss the solar and in situ circumstances of these events and identify several scenarios that may account for their elusive solar signatures. These range from observational limitations (e.g., a coronagraph near Earth may not detect an incoming CME if it is diffuse and not wide enough) to the possibility that there is a class of mass ejections from the Sun that have only weak or hard-to-observe coronal signatures. In particular, some of these sources are only clearly revealed by considering the evolution of coronal structures over longer time intervals than is usually considered. We also review a variety of numerical modelling approaches...

Bladder neck suspension or colpo-suspension can be performed via retropubic or percutaneous transvaginal approaches. A higher success rate is observed for retropubic procedures. One of the hypotheses proposed, but not yet verified, is that the retropubic approach allows better quality vaginal fixation than the percutaneous approach.The objective of this study was to compare the biomechanical properties of vaginal fixation according to the Burch procedure and according to a percutaneous technique (Vesica; Boston Scientific).We performed bladder neck suspension according to the Burch technique (2 points) on the left and according to the Vesica percutaneous technique on the right, on 6 fresh cadavers (mean age 8-5 years), using the same suture material. Vaginal fixations were subsequently excised. The depth of penetration into the vagina was measured and a computerized traction test (Lloyd Instruments, France) was performed on these fixations. The maximum force of traction before rupture was measured.No significant difference was demonstrated for any of the measurements.Vaginal fixation of bladder neck suspension performed according to the Burch technique or via a percutaneous technique (Vesica) present equivalent biomechanical properties.

Background: Bilateral kidney stones are commonly treated in staged procedures. Objective: To evaluate outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones. Design, setting, and participants: Data from adults who underwent bilateral RIRS in 21 centers were retrospectively reviewed (from January 2015 to June 2022). The inclusion criteria were unilateral/bilateral symptomatic bilateral stone(s) of any size/location in both kidneys and bilateral stones on follow-up with symptom/stone progression. Stone-free rate (SFR) was defined as absence of any fragment >3 mm at 3 mo. Outcome measurements and statistical analysis: Continuous variables are presented as medians and 25–75th percentiles. A multivariable logistic regression analysis was performed to evaluate independent predictors of sepsis and bilateral SFR. Results and limitations: A total of 1250 patients were included. The median age was 48.0 (36–61) yr. Of the patients, 58.2% were prestented. The median stone diameter was 10 mm on both sides. Multiple stones were present in 45.3% and 47.9% of the left and right kidneys, respectively. Surgery was stopped in 6.8% of cases. The median surgical time was 75.0 (55–90) min. Complications were transient fever (10.7%), fever/infection needing prolonged stay (5.5%), sepsis (2%), and blood transfusion (1.3%). Bilateral and unilateral SFRs were 73.0% and 17.4%, respectively. Female (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.18–7.49, p = 0.02), no antibiotic prophylaxis (OR 5.99, 95% CI 2.28–15.73, p < 0.001), kidney anomalies (OR 5.91, 95% CI 1.96–17.94, p < 0.001), surgical time ≥100 min (OR 2.86, 95% CI 1.12–7.31, p = 0.03) were factors associated with sepsis. Female (OR 1.88, 95% CI 1.35–2.62, p < 0.001), bilateral prestenting (OR 2.16, 95% CI 1.16–7.66, p = 0.04), and the use of high-power holmium:YAG laser (OR 1.63, 95% CI 1.14–2.34, p < 0.01) and thulium fiber laser (OR 2.50, 95% CI 1.32–4.74, p < 0.01) were predictors of bilateral SFR. Limitations were retrospective study and no cost analysis. Conclusions: SSB-RIRS is an effective treatment with an acceptable complication rate in selected patients with kidney stones. Patient summary: In this large multicenter study, we looked at outcomes after same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) for renal stones in a large cohort. We found that SSB-RIRS was associated with acceptable morbidity and good stone clearance after a single session.

Despite the worldwide spread of Ho:YAG lasers in urology departments, the physical principles behind their functioning may still seem obscure to many urologists. Moreover, a new laser source, the thulium fiber laser (TFL), was recently approved for stone lithotripsy. Here we describe the concepts of peak power and pulse modulation for laser lithotripsy, analyzing both Ho:YAG lasers and TFLs. Different pulse modalities are available for Ho:YAG lasers—long and short pulses and Moses technology—each with a different pulse shape and peak power. Lower peak power and a more rectangular pulse shape provide higher ablation efficiency and lower stone retropulsion. These characteristics are perfectly embodied by TFL, which shows the most effective ablation efficiency in laboratory studies. A long pulse is the most effective modality for Ho:YAG lasers. Moses technology, despite its promising rationale, is not superior to long-pulse mode. Clinical studies are needed in order to confirm these laboratory data. Patient summary: Laser lithotripsy is one of the main options for the treatment of urinary stones. The peak power and pulse modulation influence the choice of the optimal laser mode for the treatment of urinary stones. Thulium fiber lasers have shown the most favorable dusting profile in terms of both peak power and pulse modality in laboratory studies, but clinical evidence is still lacking. Peak power and pulse modulation influence choice of the optimal laser mode for the treatment of urinary stones. Thulium fiber lasers show the best profile in terms of both peak power and pulse modulation, although clinical studies are still awaited.

To evaluate the cancer detection rate (CDR) of an early repeated flexible ureteroscopy (2nd-look-URS) and its impact on the conservative management of patients affected with upper urinary tract urothelial carcinoma (UTUC). Clinical and surgical data from 41 patients with UTUC who underwent 2nd-look-URS within 60 days of their first URS with concomitant laser tumour photoablation at a single tertiary care referral centre from 2009 to 2013 were retrospectively analyzed. Radical nephroureterectomy was offered during follow-up in case of massive tumour recurrence (defined as a tumour not completely removable only with a conservative approach). Descriptive statistics tested the impact of 2nd-look-URS outcomes on subsequent endoscopic evaluation. Kaplan–Meier curves assessed massive tumour recurrence-free survival (mRFS) rates according to the presence of a tumour at 2nd-look-URS. Cox regression analyses identified predictors of mRFS. CDR at 2nd-look-URS was 51.2 %. CDRs at third URS were 81.3 and 41.2 % in patients with a positive and a negative 2nd-look-URS, respectively (p = 0.02). At a mean (median) follow-up of 34.6 (27.6) months, mRFS rates were 88 and 48 % in patients with negative and positive 2nd-look-URS, respectively (log rank = 0.015). Tumour grade at first URS and 2nd-look-URS outcomes achieved predictor status for mRFS (HR 6.1, 95 % CI 1.42–26.27 and HR 5.39, 95 % CI 1.18–24.66, respectively, all p ≤ 0.03). 2nd-look-URS-related CDR in conservatively treated UTUC patients was 51.2 %. 2nd-look-URS outcomes affected the findings of both subsequent endoscopic evaluation and mRFS. Further studies are needed to confirm the benefits of this approach in terms of patient outcomes.

Objectifs Evaluer les resultats oncologiques du second-look precoce par ureteroscopie souple (URSS) chez les patients traites endoscopiquement pour tumeur urotheliale de la voie excretrice superieure (TVEUS). Etudier l’interet de ce second-look sur les resultats de l’evaluation endoscopique suivante et le risque de progression tumoral. Methodes Etude retrospective monocentrique incluant 41 patients suivis pour TVEUS et ayant eu un second-look dans les soixante jours suivants un traitement endoscopique therapeutique. Le suivi etait ensuite base sur les recommandations europeennes. Une nephro-ureterectomie totale (NUT) etait proposee en cas de progression locale tumorale, definie par une recidive tumorale majeure. L’interet du second-look precoce sur l’evaluation endoscopique suivante a ete analyse par statistiques descriptives. La survie sans progression (SSP) selon le grade tumoral a l’URSS initiale et la presence de recidive tumorale au second-look endoscopique etait etudiee par la methode de Kaplan-Meier. L’identification de facteurs predictifs de SSP etait realisee selon le modele de Cox. Resultats La recidive etait de 51,2 % au second-look. Lors du controle endoscopique suivant le second-look, la recidive etait de 81,3 % chez les patients avec second-look positif et 41,2 % si second-look negatif (p = 0,02). Neuf patients avaient une progression locale apres une periode moyenne de 18,4 mois et ont eu une NUT. Apres un suivi moyen de 34,6 mois, nous avons identifie que le grade tumoral a l’URSS initiale et la recidive au second-look etaient associes a la SSP (79 % et 32 % en cas de bas et haut grade respectivement a la premiere URSS ; 88 % et 48 % chez les patients sans et avec recidive au second-look, p Conclusion Ces donnees montrent que la recidive tumorale lors du second-look precoce etait de 51,2 %. Les resultats du second-look influencent les resultats endoscopiques ulterieurs et le risque de NUT. Le second-look precoce pourrait aider a caracteriser l’agressivite tumorale en cas d’absence d’histologie initiale mais ceci doit etre evalue par d’autres etudes ( Fig. 1 , Fig. 2 ).

Purpose To analyse and report the practice, outcomes and lessons learnt from a global series of retrograde intrarenal surgery (RIRS) in a paediatric multicentre series. Methods A retrospective review of anonymized pooled data gathered globally from 8 centres in paediatric patients ( 10 years (Group C). Overall, post-operative complication rate was 13.7%. Chi-square comparisons were used for categorical variables; analysis of variance (ANOVA) or Kruskal-Wallis tests were used for continuous variables. Results 314 patients were analysed. The mean age was 9.54 +/- 4.76 years. Groups A, B and C had 67 (21.3%), 83 (26.4%) and 164 (52.2%) patients, respectively. Mean stone size was 10.7 +/- 4.62 mm. Pre-stenting was performed in 155 (49.4%) of patients, ureteral access sheaths (UAS) was used in 54.5% of patients with majority (71%) utilizing holmium laser for stone fragmentation. All complications were minor (Clavien-Dindo grade 1 and 2). SFR was 75.5%. Conclusions RIRS is acceptable as a first-line intervention in the paediatric population with reasonable efficacy and low morbidity. Complications are slightly higher in patients < 5 years of age, which should be taken into account while counselling patients.