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Objective: The Triple D scoring system is defined as novel and simple nomogram using the main parameters (skin-to-stone distance, stone density, and volume) to indicate most appropriate patients for extracorporeal shockwave lithotripsy (SWL). We aimed to evaluate the accuracy of the Triple D scoring system in predicting SWL success rates., Patients and Methods: In two tertiary academic centers, charts were retrospectively analyzed of patients who had, between January 2014 and May 2016, been treated by SWL for radiopaque kidney stones. A total of 200 patients were enrolled into the study. Parameters were calculated for each of the three specified variables. Since one point was assigned for any parameter that was less than the cutoff value, Triple D scores ranged from 0 (worst) to 3 (best)., Results: Stone-free status was achieved in 115 patients (57.5%), and 85 patients had one or more residual fragments (42.5%). Differences in stone characteristics, including stone location, density, and volume, were statistically significant in patients whether SWL achieved stone-free status or not (p < 0.001, p < 0.001, and p < 0.001, respectively). Triple D scores were significantly higher in patients treated with SWL compared with patients in whom SWL failed (p < 0.001). Triple D scores of 0, 1, 2, and 3 correlated with stone-free rates of 41.7%, 33.7%, 69.4%, and 97%, respectively. The multivariate analyses revealed that Triple D score and stone location were identified as independent factors affecting SWL success (p < 0.001 and p = 0.008, respectively). The mean number of SWL sessions was significantly higher in patients with SWL failure (p = 0.003)., Conclusion: Our study externally validates that the Triple D scoring system is associated with SWL success in the treatment of renal and ureteral stones. Further studies are warranted to assess clinical usefulness and the accuracy of this nomogram in different patient groups.

Objective: To assess and compare the applicability of the Resorlu-Unsal Stone Score (RUSS) and the Modified Seoul National University Renal Stone Complexity (S-ReSC) score for flexible ureterorenoscopy (f-URS)., Patients and Methods: We retrospectively analyzed the hospital files of 719 patients who had been treated with f-URS for kidney stone at two referral centers between July 2012 and December 2015. The RUSS and Modified S-ReSC scores were calculated by the same surgeon for each patient by using imaging methods and were compared as to their predictive capability for postoperative success., Results: A total of 339 patients (168 men and 171 women) with a mean age of 46.5 ± 16.1 (range:1-86) years and a mean body mass index of 27.1 ± 4.1 (range: 12.8-38.5) were included in the study. The mean stone size was 14.4 ± 5.4 (4-40) mm, and the mean stone surface area was 145.3 ± 76.8 (20-658) mm 2 . The overall stone-free rate was 70.1%. The mean scores were 0.5 ± 0.7 and 1.8 ± 1.1 for the RUSS and Modified S-ReSC, respectively. In the logistic regression analysis, musculoskeletal deformity, stone size, and the RUSS were identified as independent predictive factors affecting stone-free status (p: 0, p: 0.014, p: 0.048, respectively). Among these parameters, the RUSS had the highest predictive capability (area under curve value 0.65, [95% confidence interval 589, 721])., Conclusions: Stone size, presence of musculoskeletal abnormalities, and the RUSS score are important factors affecting SF status after f-URS. Despite the RUSS being an independent predictive factor for SF status, more comprehensive systems with higher predictive capability are needed for clinical usage and academic reporting.

Introduction and Objectives: To compare the outcomes of these minimally invasive procedures in this patient population., Patients and Methods: The database of our institution has been retrospectively reviewed, and medical records of urolithiasis patients with a solitary kidney who underwent flexible ureteroscopy (F-URS) or extracorporeal shock wave lithotripsy (SWL) between January 2009 and December 2012 were examined. Retreatment rates, complications, changes in estimated glomerular filtration rates (eGFRs), chronic kidney disease (CKD) stages, and stone-free rates were compared between the two groups., Results: Stones of 48 patients (mean age: 48.8±15.4, range: 14-76) with solitary kidneys were treated with SWL (n=30, 62.5%) or F-URS (n=18, 37.5%). Patient demographics and stone related parameters were similar. The most common stone location was the pelvis in the SWL group (36.6%), whereas it was the pelvis and a calix in the F-URS group (38.8%). Complications and success rates were similar in both groups, however, patients in the SWL group needed more sessions to achieve stone clearance (2.2±0.89 vs 1.06±0.24, p=0.0001). Preoperative and postoperative eGFR and CKD stage changes were also similar., Conclusion: Both SWL and F-URS are effective and safe techniques, which can be used for the treatment of stones in patients with solitary kidneys. However, patients treated with SWL need more sessions to achieve stone clearance.

Purpose: To compare sulbactam-ampicillin and cefuroxime antibiotics for prophylaxis of percutaneous nephrolithotomy (PCNL) and to find out the optimal regimen for antibiotic maintenance to prevent systemic inflammatory response syndrome (SIRS)., Patients and Methods: Between February 2010 and March 2011, a total of 198 patients in whom PCNL was performed were prospectively randomized into two main groups regarding the type of prophylactic antibiotic (group1: sulbactam-ampicillin, group 2: cefuroxime). Each group was further randomized according to duration of antibiotic maintenance (a: single dose prophylaxis, b: additional dose 12 hours after prophylaxis, c: beginning with prophylactic dose until the nephrostomy tube removal). Seven patients in whom purulent urine was obtained through the access needle were excluded from the study. Groups were compared in terms of stone- and operation-related factors as well as preoperative urine cultures, access cultures, stone cultures, postoperative urine cultures, and presence of SIRS., Results: A total of 191 patients (group 1: 95, group 2: 96) were evaluated. Mean patient age, body mass index, stone size, and perioperative outcomes were similar. Positive culture rates did not differ between groups. SIRS was observed in 13 (43.3%) patients in group 1 and 17 patients (56.7%) in group 2 (P=0.44). The relation between duration of antibiotic maintenance and SIRS development was not different in each group (P=0.95 for group 1, P: 0.39 for group 2). Urosepsis was observed in two patients, and one patient died because of septic shock., Conclusions: Sulbactam-ampicillin and cefuroxime antibiotics can be used safely for prophylaxis of PCNL. Single dose administration is sufficient.

Purpose: The aim of our study was to evaluate the outcomes of retrograde intrarenal surgery (RIRS) in elderly patients with stones of moderate size., Patients and Methods: Between September 2008 and June 2011, a total of 28 patients over 65 years of age with single renal stones that measured 1.5 to 3 cm were treated with RIRS. The outcomes of these patients were compared with those of the patients who underwent percutaneous nephrolithotomy (PCNL) using matched-pair analysis (1:1 scenario). The matching parameters were the size and location of the stone as well as age, sex, body mass index, degree of hydronephrosis, presence of previous shockwave lithotripsy, and open surgery. SPSS version 16 was used for statistical analysis., Results: Stone-free rates after a single procedure were achieved in 82.1% of patients for the RIRS and 92.8% of patients for the PCNL group. The second flexible ureterorenoscopy procedure was performed for five patients in the RIRS group. Finally, stone-free rates during the third month of the follow-up period were 92.8% in the RIRS group and 96.4% in the PCNL group. The mean operative time per patient was 64.5 ± 20.9 minutes in the RIRS group after a total of 33 procedures, while it was 40.7 ± 10.7 minutes in the PCNL groups (P<0.0001). The overall complication rates for the RIRS and PCNL groups were 7.1% and 10.7%, respectively. Blood transfusions were needed in two patients in the PCNL group. Hospitalization time was significantly shorter in the RIRS group (26.5 ± 10.6 h per patient vs 60.0 ± 28.8 h; P<0.0001). In both groups, stones were most frequently composed of calcium oxalate (68.4% in the RIRS group and 77.7% in the PCNL group)., Conclusion: RIRS has a low complication rate and represents a safe and effective treatment alternative in selected geriatric patients with kidney stones of moderate size.

Background and Purpose: Operative time is an important perioperative factor and is related to postoperative complications and procedural cost-effectiveness. There are few studies, however, investigating factors that affect operative time during percutaneous nephrolithotomy (PCNL). In this study, patient and kidney stone-related factors that influence operative time were analyzed., Materials and Methods: Clinical records from 1897 patients with renal calculi who underwent PCNL were retrospectively reviewed, and these patients were divided into two groups based on their median operative time (group 1: ≤60 min; group 2: >60 min). Multivariate analyses as well as univariate analyses including chi-square, Fisher exact and Mann Whitney U tests were used to investigate the effects of independent variables on operative time, including patient and kidney stone-related factors such as age, sex, body mass index, history of ipsilateral open surgery, shockwave lithotripsy, presence of hydronephrosis, stone burden, stone type and opacity, and surgical experience., Results: The mean operative time was 64.9±27.6 minutes (range 10-220 min). Univariate analyses determined that a history of open surgery, presence of hydronephrosis, stone type and size, and surgical experience correlated with operative time (P<0.05 for all). Multivariate analyses revealed that presence of hydronephrosis (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.17-1.78, P=0.002), stone type (OR: 2.12, 95% CI: 1.69-2.70, P<0.0001), stone burden (OR: 2.44, 95% CI: 1.85-3.12, P<0.0001), and surgical experience (OR: 0.56, 95% CI: 0.46-0.70, P<0.0001) were significant independent factors in influencing operative time., Conclusions: Presence of hydronephrosis, renal stone size and type significantly affect the operative time during PCNL. The duration of the operation was also observed to decrease with increased surgical experience.

Background and Purpose: Clinically insignificant residual fragments (CIRFs), defined as asymptomatic, noninfectious, ≤4  mm fragments, are sometimes observed after percutaneous nephrolithotomy (PCNL). Because the natural history of these fragments is unclear, we investigated the medium-term outcome of these fragments., Patients and Methods: During a 3-year period, 430 patients underwent PCNL. Overall stone-free rate was 74.5%, and CIRFs were encountered in 22% of cases 3 months after surgery. A total of 38 patients who had CIRFs immediately after PCNL with at least 24 months of follow-up were included in the study. All patients were subjected to periodic follow-up with detailed history, clinical examination, and radiographic follow-up. Serum biochemistry together with urine metabolic evaluation was also performed., Results: The median follow-up was 28.4±5.3 months (range 24-38  mos). Ten (26.3%) patients had a symptomatic episode that necessitated medical therapy during follow-up while others remained asymptomatic. Radiologic assessment showed an increase in the size of the fragments in 8 (21.1%) patients, while the size of the fragments was stable or decreased in 27 (71.1%) cases. Three (7.9%) patients had spontaneous stone passage. Metabolic evaluation revealed abnormalities in 10 (26.3%) patients. Stone analysis revealed magnesium ammonium phosphate in three of eight patients who had an increase in residual fragment size. Also, only two of these eight patients had a metabolic abnormality (one hypocitraturia and one hypercalciuria)., Conclusion: Medium-term follow-up of CIRFs after PCNL revealed that progression within 2 years is relatively common. Increase in fragment size is common in patients with struvite stones, and presence of risk factors on 24-hour urine metabolic analysis does not seem to predict growth of observed fragments.

Purpose: To investigate variables that affect bleeding during percutaneous nephrolithotomy (PCNL), focusing on the experience of a single surgeon., Patients and Methods: The records of 649 PCNL procedures that were performed by the same surgeon were reviewed retrospectively. The effect of surgical experience; patient and stone-related factors, including age, sex, hypertension, and diabetes, serum creatinine level, history of ipsilateral renal procedures, stone surface area and type, degree of hydronephrosis, preoperative hemoglobin level; operative factors, such as the calix of puncture, number of accesses, operative time; and intraoperative complications, such as pelvicaliceal system perforation on bleeding (described as decrease in hemoglobin level and need for blood transfusion), were investigated. For statistical assessment, univariate analyses and multivariate stepwise regression analyses were used., Results: A 92.3% success rate was achieved after one session PCNL. The overall blood transfusion rate was 10.8%. The number of accesses, stone type, diabetes, preoperative hemoglobin level, and operative time were the most important factors for blood transfusion requirement. In the receiver operating characteristic curve, the best cutoff point of operative time was 58 minutes for the blood transfusion requirement. Multivariate stepwise regression analyses showed that there was an association between diabetes, operative time, number of accesses, and stone type with the decrease in hemoglobin levels. No correlation between surgical experience and decrease in hemoglobin level as well as blood transfusion necessity was found., Conclusions: Depending on the results achieved by a single surgeon, multiple access tracts, staghorn calculi, presence of diabetes, and prolonged operative time, but not surgical experience, significantly increased blood loss during PCNL.

Purpose: We aimed to compare the outcomes of patients who were treated using digital and fiberoptic flexible ureterorenoscopy (urs) for kidney stones., Patients and Methods: Between September 2008 and December 2009, a total of 76 patients who were treated with either a conventional fiberoptic flexible ureterorenoscope (FFU) (n = 34) or digital flexible ureterorenoscope (DFU) (n = 42) were compared. All procedures were performed by the same surgeon. Preoperative, operative, and postoperative data were retrospectively analyzed., Results: The mean stone size was 95.2 ± 61.3 mm(2) in the FFU group while it was 93.5 ± 57.1 mm(2) in DFU group (P > 0.05). The initial assessment of the entire pyelocaliceal system was possible in 33 of 34 (97%) cases in the FFU group and in 38 of 42 cases (90.4%) in the DFU group (P > 0.05). The mean operative time was significantly longer in the FFU group (54.4 ± 14.8 minutes vs 44.8 ± 17.9 minutes, P = 0.001). Flexible URS time was 46.5 ± 13.4 minutes in the FFU group while it was 38.3 ± 17.4 minutes in the DFU group (P = 0.001). Mean fragmented stone size per minute was 2.43 ± 0.81 mm(2)/min in the DFU group and 1.96 ± 0.80 mm(2)/min in the FFU group; this was statistically significant (P = 0.01). The overall stone-free rate 1 month after the procedure was 88.2% in the FFU group and 85.7% in the DFU group (P > 0.05). The average number of uses for FFU and DFU before repair necessity was 17 and 21, respectively., Conclusion: Although the DFU have more limited maneuverability, comparable success rates can be achieved with both conventional and digital instruments. On the other hand, the DFU significantly reduced the operative time compared with the conventional one.

Purpose: To analyze the early outcome after single tract vs multiple tracts percutaneous nephrolithotomy (PCNL) in the management of staghorn calculi., Patients and Methods: The records of 413 patients with staghorn calculi (223 [54%] had complete and 190 [46%] had partial) who underwent PCNL were reviewed retrospectively. A total of 244 (59%) patients were managed by single access (group 1); meanwhile, multiple accesses were necessary in 169 (41%) patients (group 2). Both groups were compared in terms of perioperative findings and postoperative outcomes. Patients and stone-related factors affecting the number of accesses performed were analyzed., Results: The mean number of percutaneous accesses was 2.42 +/- 0.74 (range 2-6) in group 2. Mean durations of fluoroscopy screening time and operative time were significantly longer in group 2 (P = 0.002, P < 0.0001, respectively). Supracostal access was necessary in 30.7% in group 2 and in 6.9% in group 1 (P = 0.001). Success was achieved in 70.1% in group 1 and in 81.1% for group 2 after one session of PCNL (P = 0.012). The most common complication was bleeding for both groups, and it was higher in group 2 (P < 0.0001). The mean preoperative and postoperative creatinine concentrations were 1.03 mg/dL and 1.08 mg/dL in group 1, and 0.9 mg/dL and 1.03 mg/dL in group 2, respectively. The mean changes in creatinine values were not statistically significant between the groups (P = 0.16)., Conclusions: The impact of PCNL using either single or multiple access tracts on renal function is similar and of a temporary nature. PCNL with multiple accesses is a highly successful alternative with considerable complication rates in the management of staghorn calculi.

Objectives: Prolonged urine leakage (PUL) from the percutaneous tract after percutaneous nephrolithotomy is a major complication that necessitates the placement of a urethral Double-J stent. We analyzed the characteristics of patients who had this complication to find out its risk factors., Patients and Methods: During a 6-year period, 1407 standard percutaneous nephrolithotomy procedures were performed at our institution. Medical charts were reviewed focusing on the patients who required Double-J placement because of PUL from the percutaneous tract for more than 24 hours after removal of the nephrostomy tube. A total of 81 patients in whom a Double-J stent was placed because of ureteropelvic injury or pelvicaliceal extravasation or as a part of percutaneous endopyelotomy were excluded from the study. Factors that are considered to have an impact on this untoward event were analyzed and compared., Results: Double-J stent was placed in a total of 57 (4.3%) patients who were found to have PUL. Stone size was significantly larger in the stented group (10.0 +/- 5.6 cm(2) vs. 7.8 +/- 5.3 cm(2)). The stones were classified as complex in 68.4% of patients in the stented group and in 53.4% of patients in the nonstented group, and this difference was also statistically significant. Stone-free rate was significantly higher in the nonstented group (p < 0.05). Residual stone and additional treatment rates were statistically higher in the stented group (p < 0.05). Access number and location as well as per-operative bleeding were not predictive factors for PUL development., Conclusion: The necessity for Double-J placement due to PUL from the percutaneous tract, diminishes with increase in stone-free rates. Stone size and stone complexity are other predictive factors for PUL development.

Purpose: Percutaneous nephrolithotomy (PNL) is established in urology practice with routine use of fluoroscopic guidance. Herein, we retrospectively evaluated the potential factors affecting the fluoroscopic screening time (FST) during PNL., Materials and Methods: A total of 282 patients with documented FST in detail during PNL performed by one surgeon were enrolled in this study. In all cases, PNL was performed on patients in prone position under C-armed fluoroscopy unit. The correlation between the FST and patient and also stone factors, including body mass index (BMI), previous open renal surgery, characteristics and size of the stone, and presence of hydronephrosis, as well as procedural factors such as percutaneous access number and location and operation time were analyzed., Results: The mean age of the patients was 43 +/- 14.7 (range: 18-67) years. The mean operation time was 78.9 +/- 22.0 (range: 45-150) minutes, and the mean FST was 10.19 +/- 6.3 (range: 3-50) minutes. The mean stone size was 8.46 +/- 5.11 cm(2) (range: 2-30). The FST was significantly prolonged in patients with increased stone burden (p = 0.001) and necessitating multiple accesses procedures (p = 0.007). However, BMI of the patient, stone configuration, degree of hydronephrosis, history of open renal surgery, and access location did not have an impact on FST (p > 0.05)., Conclusion: In patients with large stones necessitating multiple accesses, FST is significantly prolonged; therefore, they have to be managed by experienced surgeons to diminish the radiation exposure. However, BMI, stone configuration, presence of hydronephrosis, history of open renal surgery, and access location did not have effect on FST in our study.