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PurposeOur aim is to evaluate the safety and efficacy of endoscopic combined intrarenal surgery compared to percutaneous nephrolithotomy to guide practitioners and inform guidelines.Materials and methodsA detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001 and 2021.ResultsFour nonrandomized comparative studies and one RCT were identified, yielding five studies with a total of 546 patients (ECIRS/mini-ECIRS, n = 277; PCNL/mini-PCNL, n = 269). Subjects in these five studies met the predefined inclusion criteria established by two reviewers (J.E.A. and R.L.S.) and were therefore eligible for analysis. The results demonstrated that ECIRS was associated with a higher SFR (OR: 4.20; 95% CI: 2.79, 6.33; p < 0.00001), fewer complications (OR: 0.63; 95% CI: 0.41, 0.97; p=0.04), and a shorter hospital stay (WMD: -1.27; 95% CI: -1.55, -0.98; p < 0.00001) when compared to PCNL. There were no statistically significant differences in blood transfusions (OR: 0.45; 95% CI: 0.12, 1.68; p=0.24), operative time (SMD: -1.05; 95% CI: -2.42, 0.31; p=0.13), or blood loss (SMD: -1.10; 95% CI: -2.46, 0.26; p=0.11) between ECIRS and PCNL.ConclusionsECIRS may be a more suitable approach for the surgical management of large and complex kidney stones currently indicating PCNL due to its superior efficacy with comparable surgical time and complication rate, though it is thought that a lack of resources and properly trained personnel may preclude ECIRS from becoming the standard. It is our impression that ECIRS may become the preferred technique in the endourologic community corresponding to the evolutionary sequence of percutaneous stone surgery.

BackgroundTo compare head to head two end-engaging nitinol stone retrieval devices available to urologists, in terms of durability, versatility and efficacy.MethodsFor durability testing, 30 NGage and Dakota baskets were cycled 20 times between grasping and releasing synthetic stone models and evaluated for damage or device failure. For versatility and efficacy testing, baskets were assessed in their ability to capture and release stone models from 1 to 11 mm. Each stone was raised above the capture site and the basket was opened to passively release the stone. If the stone did not release, the basket handle was shaken and the OpenSure feature employed if needed. Manual release was used as a last resort.ResultsDurability-the Cook NGage demonstrated a statistically significant increased rate of visible device breakdown (P=0.0046) in 8 of 30 (26.7%) devices vs. 0 of 30 Dakota devices, with mean damage at 13.5 cycles. Versatility and efficacy-both 8 mm baskets successfully captured stones from 1-8 mm. The Dakota more effectively released 7-8 mm stones (P

Introduction: Recent retrospective literature suggests that the quick sequential organ failure assessment (qSOFA) scoring tool is a potentially superior tool over use of the systemic inflammatory response syndrome (SIRS) criteria to predict septic shock after percutaneous nephrolithotomy (PCNL) surgery. Here we examine use of qSOFA and SIRS to predict septic shock within data series collected prospectively on PCNL patients as part of a greater study of infectious complications. Materials and Methods: We performed a secondary analysis of two prospective multicenter studies including PCNL patients across nine institutions. Clinical signs informing SIRS and qSOFA scores were collected no later than postoperative day 1. The primary outcome was sensitivity and specificity of SIRS and qSOFA (high-risk score of greater-or-equal to two points) in predicting admission to the intensive care unit (ICU) for vasopressor support. Results: A total of 218 cases at 9 institutions were analyzed. One patient required vasopressor support in the ICU. The sensitivity/specificity was 100%/72.4% (McNemar's test p < 0.001) for SIRS and was 100%/90.8% (McNemar's test p < 0.001) for qSOFA. Conclusion: Although positive predictive value for both qSOFA and SIRS in prediction of post-PCNL septic shock is low, prospectively collected data demonstrate use of qSOFA may offer greater specificity than SIRS criteria when predicting post-PCNL septic shock. [ABSTRACT FROM AUTHOR]

Introduction. Bladder neck abscesses are rare urologic pathologies with very few cases published in modern literature. This report explores a case of a bladder neck mass incidentally found on computed tomography (CT) imaging in a patient with an iliopsoas abscess. Case Presentation. We present a case of a 60-year-old woman who was recently treated for sepsis secondary to an iliopsoas abscess in July of 2022. A CT scan revealed an indeterminate structure in the posterior inferior left paramedian bladder wall. During a cystoscopy with transurethral resection of the mass, an abscess was uncovered and evacuated. A postoperative Foley catheter was left in place, and the patient recovered without any complications. Conclusion. At the time of publication, the patient feels well and denies pain or lower urinary tract symptoms. Although bladder abscesses are exceptionally rare, incidental findings during cystoscopy may warrant further investigation in patients with comorbid abscesses. [ABSTRACT FROM AUTHOR]

Purpose: Our aim is to evaluate the safety and efficacy of endoscopic combined intrarenal surgery compared to percutaneous nephrolithotomy to guide practitioners and inform guidelines.Materials and Methods: A detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001 and 2021.Results: Four nonrandomized comparative studies and one RCT were identified, yielding five studies with a total of 546 patients (ECIRS/mini-ECIRS, n = 277; PCNL/mini-PCNL, n = 269). Subjects in these five studies met the predefined inclusion criteria established by two reviewers (J.E.A. and R.L.S.) and were therefore eligible for analysis. The results demonstrated that ECIRS was associated with a higher SFR (OR: 4.20; 95% CI: 2.79, 6.33; p < 0.00001), fewer complications (OR: 0.63; 95% CI: 0.41, 0.97; p=0.04), and a shorter hospital stay (WMD: -1.27; 95% CI: -1.55, -0.98; p < 0.00001) when compared to PCNL. There were no statistically significant differences in blood transfusions (OR: 0.45; 95% CI: 0.12, 1.68; p=0.24), operative time (SMD: -1.05; 95% CI: -2.42, 0.31; p=0.13), or blood loss (SMD: -1.10; 95% CI: -2.46, 0.26; p=0.11) between ECIRS and PCNL.Conclusions: ECIRS may be a more suitable approach for the surgical management of large and complex kidney stones currently indicating PCNL due to its superior efficacy with comparable surgical time and complication rate, though it is thought that a lack of resources and properly trained personnel may preclude ECIRS from becoming the standard. It is our impression that ECIRS may become the preferred technique in the endourologic community corresponding to the evolutionary sequence of percutaneous stone surgery. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous nephrolithotomy (PCNL) is an effective procedure for removal of large kidney stones; however, PCNL has traditionally been reserved for inpatient surgery. Certain cases are being performed entirely at an ambulatory surgery center (ASC), known as ambulatory PCNL (aPCNL). Materials and Methods: Five hundred consecutive PCNL procedures performed at a free-standing ASC between April 2015 and February 2019 were analyzed. Patient demographics, stone characteristics, operative characteristics, and postoperative data, including transfer to hospitals, 30-day readmissions, and complications > Clavien I, were recorded. Results: The mean age of patients undergoing PCNL at the ASC was 57 (range: 16–86) and body mass index 30 (16–49). American Society of Anesthesiologists (ASA) compositions are as follows: ASA 1 (6.5%), ASA 2 (56.2%), ASA 3 (37.2%), and ASA 4 (0. 1%). The mean stone burden was 30 mm (5–140). Standard tract dilation (24–30F) comprised 77% of cases. Ninety-two percent of cases were performed with a single tract, and 99% of cases had a ureteral stent as the only form of drainage (tubeless PCNL). The mean operative time was 104 minutes (32–305), and postanesthesia care unit time was 97 minutes (37–247). The predicted stone-free rate was 84%. Twelve patients (2.4%) required transfer to hospital, and the 30-day readmission rate was 4.2%. Conclusion: aPCNL is a safe and feasible procedure if performed by a high volume endourologist, even within the confines of a free-standing ASC. It is our opinion that the utilization of endoscopic combined intrarenal surgery facilitates high stone-free rates with minimal morbidity and low readmission rates. The institutional review board number is WIRB # 20171472. [ABSTRACT FROM AUTHOR]

Introduction: Current American Urological Association (AUA) Best Practice Statement recommends antibiotic prophylaxis for cystoscopy with manipulation, including stent removal; although no Level 1b trials explicitly address prophylaxis for stent removal. We sought to determine the efficacy of prophylactic antibiotics to prevent infectious complications after stent removal. Materials and Methods: Following institutional review board approval, patients undergoing removal of ureteral stent placed during stone surgery were recruited from July 2016 to March 2019. Patients were recruited at the time of stent removal and randomized to treatment (single dose 500 mg oral ciprofloxacin) or control group (no antibiotics). Telephone contact was attempted within 14 days of stent removal to assess for urinary tract infection (UTI) symptoms, antibiotic prescriptions, or Emergency Department visits. Primary outcome was UTI within 1 month of stent removal – defined by irritative voiding symptoms, fever or abdominal pain associated with positive urine culture (Ucx) (>100k colony-forming units/mL). Results: Seventy-seven patients were enrolled, with 58 meeting final inclusion criteria for the analysis (33 treatment, 25 controls). No differences were seen with clinical and demographic variables, except a higher body mass index in the treatment group (P = 0.007). Positive Ucx rate before stone surgery (16.7% vs. 11.8%, P = 0.819) and at the time of stent removal (16.0% vs. 11.1%, P = 0.648) was not significantly different in treatment versus control groups, respectively. Primary outcome: No patients in either cohort developed symptomatic culture-diagnosed UTI within 1 month of stent removal. Of patients with documented phone follow-up (treatment n = 29, control n = 22), only one patient (control) reported any positive response on phone survey. Conclusions: We found a low infectious complication rate regardless of antibiotic prophylaxis use during cystoscopic stent removal. The necessity of antibiotics during routine cystoscopic stent removal warrants possible reevaluation of the AUA best practice statement. [ABSTRACT FROM AUTHOR]

Introduction: Outpatient percutaneous nephrolithotomy (PCNL) has been described for highly selected patients. We sought to assess the safety and feasibility of outpatient PCNL in a tertiary referral stone center without strict patient selection criteria.Materials and Methods: We reviewed all PCNLs performed at our institution from September 2015 to October 2016. Of the 97 eligible cases, 60 patients underwent planned outpatient PCNL. Primary outcome was complication rate, and secondary outcome determined predictor variables of inpatient admission. Results: Thirty-seven inpatient and 60 planned outpatient (one bilateral) PCNLs were performed with 65% and 44% American Society of Anesthesiologists (ASA) score ≥3, respectively. The 30-day overall complication rate for the inpatient and planned outpatient groups was 27% and 20%, respectively (p = 0.43) [70% and 92% Clavien grades I–II]. Emergency department presentation within 30 days was 19% and 18% (p = 0.94), and unplanned hospital readmission rate was 3% and 10% (p = 0.05). The 37 inpatient PCNL patients had larger total stone burden than outpatient cases (40.7 vs 25.8 mm, p = 0.0014); more often required two or more punctures into the kidney during the procedure (73% vs 45%, p = 0.025); and more often had supracostal access (20% vs 7%, p = 0.05). For the outpatient PCNL cohort, 72% patients were discharged same day, 28% were observed overnight for refractory symptoms or social reasons. Outpatient cohort radiographic stone-free rate by CT (no stones) was 67%. Conclusion: Outpatient PCNL has been safely and effectively performed within our institution in moderate-sized stones almost regardless of comorbidity status. We suggest that this approach is a potential algorithmic change in centers with sufficient case volume. [ABSTRACT FROM AUTHOR]

Purpose: Accurate measurement of pH is necessary to guide medical management of nephrolithiasis. Urinary dipsticks offer a convenient method to measure pH, but prior studies have only assessed the accuracy of a single, spot dipstick. Given the known diurnal variation in pH, a single dipstick pH is unlikely to reflect the average daily urinary pH. Our goal was to determine whether multiple dipstick pH readings would be reliably comparable to pH from a 24-hour urine analysis. Materials and Methods: Kidney stone patients undergoing a 24-hour urine collection were enrolled and took images of dipsticks from their first 3 voids concurrently with the 24-hour collection. Images were sent to and read by a study investigator. The individual and mean pH from the dipsticks were compared to the 24-hour urine pH and considered to be accurate if the dipstick readings were within 0.5 of the 24-hour urine pH. The Bland-Altman test of agreement was used to further compare dipstick pH relative to 24-hour urine pH. Results: Fifty-nine percent of patients had mean urinary pH values within 0.5 pH units of their 24-hour urine pH. Bland-Altman analysis showed a mean difference between dipstick pH and 24-hour urine pH of -0.22, with an upper limit of agreement of 1.02 (95% confidence interval [CI], 0.45-1.59) and a lower limit of agreement of -1.47 (95% CI, -2.04 to -0.90). Conclusions: We concluded that urinary dipstick based pH measurement lacks the precision required to guide medical management of nephrolithiasis and physicians should use 24-hour urine analysis to base their metabolic therapy. [ABSTRACT FROM AUTHOR]

Background: Limited studies have reported on radiation risks of increased ionizing radiation exposure to medical personnel in the urologic community. Fluoroscopy is readily used in many urologic surgical procedures. The aim of this study was to determine radiation exposure to all operating room personnel during percutaneous nephrolithotomy (PNL), commonly performed for large renal or complex stones. Materials and Methods: We prospectively collected personnel exposure data for all PNL cases at two academic institutions. This was collected using the Instadose™ dosimeter and reported both continuously and categorically as high and low dose using a 10 mrem dose threshold, the approximate amount of radiation received from one single chest X-ray. Predictors of increased radiation exposure were determined using multivariate analysis. Results: A total of 91 PNL cases in 66 patients were reviewed. Median surgery duration and fluoroscopy time were 142 (38-368) min and 263 (19-1809) sec, respectively. Median attending urologist, urology resident, anesthesia, and nurse radiation exposure per case was 4 (0-111), 4 (0-21), 0 (0-5), and 0 (0-5) mrem, respectively. On univariate analysis, stone area, partial or staghorn calculi, surgery duration, and fluoroscopy time were associated with high attending urologist and resident radiation exposure. Preexisting access that was utilized was negatively associated with resident radiation exposure. However, on multivariate analysis, only fluoroscopy duration remained significant for attending urologist radiation exposure. Conclusion: Increased stone burden, partial or staghorn calculi, surgery and fluoroscopy duration, and absence of preexisting access were associated with high provider radiation exposure. Radiation safety awareness is essential to minimize exposure and to protect the patient and all providers from potential radiation injury. [ABSTRACT FROM AUTHOR]

Having benign paroxysmal positional vertigo (BPPV) puts patients at a significantly higher risk of falling. It is poorly recognised and diagnosis is frequently delayed. BPPV has been studied in outpatient settings, but there have been no studies looking at the prevalence in patients admitted with falls. This study aims to establish how common BPPV is in these patients. For a 4-month period, patients admitted on an unselected medical take were screened for an admission precipitated by a fall. Patients who consented were assessed for BPPV using the Dix-Hallpike manoeuvre. Patients who tested positive were treated using the Epley manoeuvre. The assessments were carried out by specialist physiotherapists who were experienced at assessing and diagnosing patients with peripheral vestibular disorders. Out of the 111 patients initially identified, 37 (33%) were considered to be appropriate and consented to be part of the study. Of these, 20 patients (54%) had a positive Dix-Hallpike manoeuvre. Of the patients included in the study, over half tested positive for BPPV. This merits further study. Potentially, there is a proportion of patients admitted with falls who have an easily treatable contributing factor that is not being identified with standard practice. [ABSTRACT FROM AUTHOR]

Objective: The objective was to demonstrate that percutaneous nephrolithotomy (PCNL) can be safely performed with a tubeless or totally tubeless drainage technique. Introduction: Standard PCNL includes nephrostomy tube placement designed to drain the kidney and operative tract at the conclusion of the procedure. Modern technique trend is tubeless PCNL and totally tubeless PCNL, which are performed without standard nephrostomy drainage. We aim to reinforce current literature in demonstrating that PCNL can be safely performed using a tubeless technique. With compounded supportive data, we can help generate a trend toward a more cost-effective procedure with improved pain profiles and patient satisfaction, as previously shown with the tubeless technique. Methods: Retrospective analysis of 165 patients who underwent PCNL treatment was performed. Of this group, 127 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 38 patients. Patient's postoperative stone size and burden as well as complication profiles were analyzed. Largest stone size and total stone burden was similar between the groups. Results: Patient characteristics and demographic information were compared and no significant statistical difference was identified between the groups. Complication rates between the groups were compared and no statistical difference was noted. A total of 23 patients had at least one postoperative complication. Conclusion: Tubeless and totally tubeless PCNL demonstrates equivalent outcomes in the properly selected patient group when compared to PCNL performed with a nephrostomy tube. Although this is not the first study to demonstrate this, a large majority of urologists continue standard nephrostomy placement after PCNL. More studies are needed that demonstrate safety of this practice to shift the pendulum of care. Thus, tubeless and totally tubeless PCNL can be performed safely and effectively, which has previously been shown to improve cost, patient pain profiles, and length of hospitalization. [ABSTRACT FROM AUTHOR]

Objective: The objective was to present a straightforward, step-by-step reproducible technique for placement of a guide-wire into any type of urethral catheter, thereby offering a means of access similar to that of a council-tip in a situation that may require a different type of catheter guided over a wire. Materials and Methods: Using a shielded intravenous catheter inserted into the eyelet of a urinary catheter and through the distal tip, a "counsel-tip" can be created in any size or type of catheter. Once transurethral bladder access has been achieved with a hydrophilic guide-wire, this technique will allow unrestricted use of catheters placed over a wire facilitating guided catheterization. Results: Urethral catheters of different types and sizes are easily advanced into the bladder with wire-guidance; catheterization is improved in the setting of difficult urethral catheterization (DUC). Cost analysis demonstrates benefit overuse of traditional council-tip catheter. Conclusion: Placing urinary catheters over a wire is standard practice for urologists, however, use of this technique gives the freedom of performing wire-guided catheterization in more situations than a council-tip allows. This technique facilitates successful transurethral catheterization over wire in the setting of DUC for all catheter types and styles aiding in urologic management of patients at a cost benefit to the health care system. [ABSTRACT FROM AUTHOR]

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract. [ABSTRACT FROM AUTHOR]

Objective: To determine stone clearance rates using endoscopic combined intrarenal surgery (ECIRS) and assess the accuracy of intraoperative prediction of stone-free (SF) status compared to postoperative CT scan.Methods: A single institution, prospectively maintained database of ECIRS was queried for procedures performed 8/2017 to 1/2018. Retrograde access was performed using a ureteral sheath and flexible ureteroscope. Percutaneous nephrolithotomy was performed through a 30fr or 18fr sheath in prone position. Residual stone status was estimated at the end of each procedure and was verified with postoperative CT scan. SF was defined as no single stone >2mm3 on CT.Results: One hundred and ten procedures were reviewed. Average age was 58.9 ± 12.6 years (range 26-87) and 69 (63%) were male. The mean stone size was 33.3 ± 23.5 mm (range 4-140 mm). Ninty-three patients (84.5%) were endoscopically estimated to be SF, of which 84 (90% of predicted SF cohort, 76% of total cohort) were confirmed SF via CT scan. The sensitivity for estimating SF status with ECIRS was 65.4% (95%CI 44.3%-82.8%), specificity was 100% (95%CI 95.7%-100.0%) and accuracy was 91.8% (95%CI 85.0%-96.2%). SF patients had significantly smaller stones than those with residual fragments (28.5 ± 2.1 vs 48.4 ± 5.7mm, P <.0001). On logistic regression, the factors associated with residual stones were preoperative stone burden (OR 1.03 per mm, 95%CI 1.01-1.05, P = .0004) and fluoroscopy time (OR 1.01 per minute, 95%CI 1.0-1.02, P = .0081).Conclusion: ECIRS accurately predicts clinical SF status and may obviate the need for additional CT scans. Consistent with prior studies, the primary determinant of residual stone after percutaneous nephrolithotomy is initial stone size. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to evaluate the novel use of a 1.9 mm Trilogy lithotripter probe with varying locations and composition of renal stones., Methods: We prospectively enrolled patients to undergo mini percutaneous nephrolithotomy (mPCNL) procedures using the 1.9 mm (instead of the standard 1.5 mm) Trilogy probe from August 2021 to April 2022. Several adjunctive irrigation measures compensated for reduced flow with the larger probe. Primary outcome was treatment efficiency. Patient demographics, preoperative demographics, and comorbidities, as well as real-time surgical data were extracted. Statistical analysis was performed using Kruskal-Wallis tests to compare stone type and location., Results: A total of 110 patients were included in this study. The median total treatment time was 6.8 minutes, median lithotripsy time was 3.3 minutes, median stone treatment efficiency was 0.34 mm/min, and treatment efficacy was 50.4 (lithotripter time/treatment time). Overall median lithotripter efficiency was 104.6 mm 3 /min. Treatment efficiency was similar among stone composition (p=0.245) and location (p=0.263). Lithotripter 3D and 1D efficiency was also similar among stone composition (p=0.637 and p=0.766, respectively). Lithotripter 1D efficiency was nearly twice as fast in the lower pole compared to other stone locations (p=0.010). Overall broken probe rate for this procedure was 12%, mostly at the beginning, suggesting a learning curve. Five patients had minor complications, including one patient that required admission to the hospital for postoperative pain management., Conclusions: The 1.9 mm Trilogy lithotripter can be effective in mPCNL procedures with the use of easily implementable adjunctive irrigation techniques, decreasing the gap between lithotripsy time and total treatment time.

Introduction: Although antibiotic therapy has been the mainstay of prophylaxis and treatment of urinary tract infections (UTIs), antibacterial resistance has led to increased incidence of infections and healthcare spending in both community-acquired and nosocomial UTIs. This has led to an active exploration of alternative remedies for both the prophylaxis and treatment of UTIs, especially in women with recurrent urinary tract infections. Probiotic supplementation is one novel intervention that has been studied as a prophylactic measure in patients with UTIs. The current systematic review and meta-analysis was conducted to evaluate the efficacy of probiotics for prophylaxis in UTIs in premenopausal women., Methods: Detailed search strategies for each electronic database were developed for PubMed, EMBASE, and Scopus to identify relevant literature published between 2001-2021. RevMan 5.3 statistical software was used to analyze data in studies. The random-effects model was used for pooling the data. The risk of bias and study quality were assessed using Cochrane Collaboration's tool for assessing risk of bias in included studies. The scope of focus for this review was premenopausal adult women with a history of one or more UTI. The intervention consisted of a probiotic regimen for which the goal was to enhance the defensive microflora of the urogenital tract. Studies comparing a probiotic regimen to a placebo regimen were included. These studies' primary outcome was the proportion of women with at least one symptomatic bacterial UTI in each group (i.e., UTI recurrence rate) in the 12-month period following probiotic intervention. This study extends the work of researchers who systematically investigated the scientific literature on probiotics in the prevention of urinary tract infections with a particular focus on premenopausal women., Results: After screening, three parallel-group randomized-controlled trials (RCTs) were included. We estimated the overall pooled data of these three studies with a total of 284 participants to have met the predefined inclusion criteria and were therefore included in this review. The results demonstrated that probiotics did not have a significant effect in the prophylaxis of UTIs. (Risk Ratio (RR): 0.59 confidence interval (CI): 0.26, 1.33), Heterogeneity: Chi² = 6.63, df = 2 ( p = 0.04); I² =70%, Test for overall effect: Z = 1.27 ( p = 0.20).  Conclusions : Probiotics did not demonstrate a significant benefit in reducing UTI recurrence compared to placebo in premenopausal women. However, more conclusive data is needed to determine the effect that probiotics have on strengthening the urogenital microbial barrier against pathogenic bacteria and protecting against UTI recurrence., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Abdullatif et al.)

Purpose: Postoperative infectious related complications are not uncommon after percutaneous nephrolithotomy. Previously, we noted that 7 days of antibiotics did not decrease sepsis rates compared to just perioperative antibiotics in a low risk percutaneous nephrolithotomy population. This study aimed to compare the same regimens in individuals at moderate to high risk for sepsis undergoing percutaneous nephrolithotomy., Materials and Methods: Patients were prospectively randomized in this multi-institutional study to either 2 days or 7 days of preoperative antibiotics. Enrolled patients had stones requiring percutaneous nephrolithotomy and had either a positive preoperative urine culture or existing indwelling urinary drainage tube. Primary outcome was difference in sepsis rates between the groups. Secondary outcomes included rate of nonseptic bacteriuria, stone-free rate and length of stay., Results: A total of 123 patients at 7 institutions were analyzed. There was no difference in sepsis rates between groups on univariate analysis. Similarly, there were no differences in nonseptic bacteriuria, stone-free rate and length of stay. On multivariate analysis, 2 days of antibiotics increased the risk of sepsis compared to 7 days of antibiotics (OR 3.1, 95% CI 1.1-8.9, p=0.031). Patients receiving antibiotics for 2 days had higher rates of staghorn calculus than the 7-day group (58% vs 32%, p=0.006) but post hoc subanalysis did not demonstrate increased sepsis in the staghorn only group., Conclusions: Giving 7 days of preoperative antibiotics vs 2 days decreases the risk of sepsis in moderate to high risk percutaneous nephrolithotomy patients. Future guidelines should consider infectious risk stratification for percutaneous nephrolithotomy antibiotic recommendations.

The aim of this paper was to evaluate the current technology and designs of flexible ureterorenoscopes. We will review contemporary fiberoptic and digital ureteroscopes, including a discussion on ureteroscope damage and repair, and lastly present the projected future of flexible ureterorenoscopy. Ureterorenoscopy has evolved dramatically over the past several decades, which has led to landscape reshaping of stone disease treatment and upper tract pathology. Advancements in tip control, miniaturization of scopes, introduction of a digital chip on the tip, disposable devices to augment surgery, surgical experience/familiarity and most recently single use scopes are all independent factors that have increased flexible ureterorenoscopy adoption and success. We therefore detail the aforementioned and provide a view of future innovations. A review of literature from 1980 to 2016 was performed by the two authors focusing on literature that details flexible ureterorenoscopy. Technology has significantly impacted the minimally invasive endourologic management of the urinary system. This review summarizes current literature on advances and modern technical achievements. We include a focus on new perspectives and future outlook in the field of managing upper urinary tract pathology with modern technologies. The advancements in flexible ureterorenoscopy are impressive and yet the challenges of this technology are equally daunting. Obstacles to overcome include improving durability, decreasing cost, further miniaturizing scopes size, and determining the role of single use scopes. Ongoing developments in other technology fields (such as virtual 3D imaging, wireless capsular endoscopy, robotics) continue to create both opportunities to improve the procedure but also threaten to replace ureterorenoscopy over time. This is an exciting time because of past achievements and future innovations in ureterorenoscopy.

Background: The 2008 American Urological Association (AUA) Best Practice Statement on antimicrobial prophylaxis states that prophylaxis is not warranted for subjects with normal risk profile undergoing cystourethroscopy unless manipulation such as ureteral stent removal is performed. To date no studies have specifically assessed the need for antimicrobial prophylaxis during cystoscopic ureteral stent removal. We sought to determine the risk of infectious complications following cystoscopic stent removal with and without antimicrobial prophylaxis., Methods: A retrospective review identified 70 subjects who underwent cystoscopic ureteral stent removal following kidney stone treatment, under the care of two separate urologists with differing practice patterns. Each cohort consisted of 35 subjects: with and without prophylactic antibiotics. Clinical variables assessed included demographics, type of stone intervention, prior urinary tract infection (UTI) history, immunocompromising comorbidities, antimicrobial class at time of stone intervention, and antimicrobial administration at cystoscopic stent removal. The primary outcome assessed was development of symptomatic UTI within 4 weeks after stent removal., Results: Overall, 35 patients (50%) received antimicrobial prophylaxis at the time of stent removal and 35 (50%) did not receive antimicrobial prophylaxis, with no demographic or clinical differences between cohorts. Two patients in the antimicrobial cohort (6%) developed a UTI and none of the patients who did not receive antimicrobial prophylaxis developed a UTI (P=0.15)., Conclusions: In our cohort study antimicrobial prophylaxis at the time of cystoscopic stent removal did not appear to provide a significant benefit in UTI prevention. Prospective studies would assist in validating these findings., Competing Interests: The authors have no conflicts of interest to declare.

Rheumatoid arthritis (RA) is a chronic inflammatory disease that often results in significant morbidity, mortality and disability. Over the past 20 years a better understanding of the pathogenesis of RA has led to the development of new approaches to disease treatment. The recent introduction of biological agents has changed the treatment paradigm for RA. The success of early biological therapies including TNF-alpha and IL-1 antagonists has spurred interest in the development of additional novel targets in the treatment of RA. Biological therapies approved for other indications, such as rituximab, are now being evaluated for the treatment of rheumatic diseases such as RA. A co-stimulatory blocker, abatacept, is also in pivotal Phase III trials. This article reviews evolving pharmacological therapies in RA with an emphasis on the newer approaches to treatment including inhibition of cognate signalling and T- and B-cell targets.