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Objective: To develop a follow-up algorithm for urinary stone patients after definitive treatment., Materials and Methods: The panel performed a systematic review on follow-up of urinary stone patients after treatment (PROSPERO: CRD42020205739). Given the lack of comparative studies we critically evaluated the literature and reached a consensus on the follow-up scheme., Results: A total of 76 studies were included in the analysis, including 17 RCTs. In the stone-free general population group, 71-100% of patients are stone-free at 12 months while 29-94% remain stone-free at 36 months. We propose counselling these patients on imaging versus discharge after the first year. The stone-free rate in high-risk patients not receiving targeted medical therapy is < 40% at 36 months, a fact that supports imaging, metabolic, and treatment monitoring follow-up once a year. Patients with residual fragments ≤ 4 mm have a spontaneous expulsion rate of 18-47% and a growth rate of 10-41% at 12 months, supporting annual imaging follow-up. Patients with residual fragments > 4 mm should be considered for surgical re-intervention based on the low spontaneous expulsion rate (13% at 1 year) and high risk of recurrence. Plain film KUB and/or kidney ultrasonography based on clinicians' preference and stone characteristics is the preferred imaging follow-up. Computed tomography should be considered if patient is symptomatic or intervention is planned., Conclusions: Based on evidence from the systematic review we propose, for the first time, a follow-up algorithm for patients after surgical stone treatment balancing the risks of stone recurrence against the burden of radiation from imaging studies., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Context: Endourological procedures frequently require fluoroscopic guidance, which results in harmful radiation exposure to patients and staff. One clinician-controlled method for decreasing exposure to ionising radiation in patients with urolithiasis is to avoid the use of intraoperative fluoroscopy during stone intervention procedures., Objective: To comparatively assess the benefits and risks of "fluoroscopy-free" and fluoroscopic endourological interventions in patients with urolithiasis., Evidence Acquisition: A systematic review of the literature from 1970 to 2022 was performed using the MEDLINE/PubMed, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov. Primary outcomes assessed were complications and the stone-free rate (SFR). Studies reporting data on ureteroscopy and percutaneous nephrolithotomy (PCNL) were eligible for inclusion. Secondary outcomes were operative duration, hospital length of stay, conversion from a fluoroscopy-free to a fluoroscopic procedure, and requirement for an auxiliary procedure to achieve stone clearance., Evidence Synthesis: In total, 24 studies (12 randomised and 12 observational) out of 834 abstracts screened were eligible for analysis. There were 4564 patients with urolithiasis in total, of whom 2309 underwent a fluoroscopy-free procedure and 2255 underwent a comparative fluoroscopic procedure for treatment of urolithiasis. Pooled analysis of all procedures revealed no significant difference between the groups in SFR (p = 0.84), operative duration (p = 0.11), or length of stay (p = 0.13). Complication rates were significantly higher in the fluoroscopy group (p = 0.009). The incidence of conversion from a fluoroscopy-free to a fluoroscopic procedure was 2.84%. Similar results were noted in subanalyses for ureteroscopy (n = 2647) and PCNL (n = 1917). When only randomised studies were analysed (n = 12), the overall complication rate was significantly in the fluoroscopy group (p < 0.001)., Conclusions: For carefully selected patients with urolithiasis, fluoroscopy-free and fluoroscopic endourological procedures have comparable stone-free and complication rates when performed by experienced urologists. In addition, the conversion rate from a fluoroscopy-free to a fluoroscopic endourological procedure is low at 2.84%. These findings are important for clinicians and patients, as the detrimental health effects of ionising radiation are negated with fluoroscopy-free procedures., Patient Summary: We compared treatments for kidney stones with and without the use of radiation. We found that kidney stone procedures without the use of radiation can be safely performed by experienced urologists in patients with normal kidney anatomy. These findings are important, as they indicate that the harmful effects of radiation can be avoided during kidney stone surgery., (Copyright © 2023. Published by Elsevier B.V.)

Purpose: Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children., Methods: MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data., Results: Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1]., Conclusion: SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Context: No algorithm exists for structured follow-up of urolithiasis patients., Objective: To provide a discharge time point during follow-up of urolithiasis patients after treatment., Evidence Acquisition: We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library, clinicaltrials.gov, and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Fifty studies were eligible., Evidence Synthesis: From a pooled analysis of 5467 stone-free patients, we estimated that for a safety margin of 80% for remaining stone free, patients should be followed up using imaging, for at least 2 yr (radiopaque stones) or 3 yr (radiolucent stones) before being discharged. Patients should be discharged after 5 yr of no recurrence with a safety margin of 90%. Regarding residual disease, patients with fragments ≤4 mm could be offered surveillance up to 4 yr since intervention rates range between 17% and 29%, disease progression between 9% and 34%, and spontaneous passage between 21% and 34% at 49 mo. Patients with larger residual fragments should be offered further definitive intervention since intervention rates are high (24-100%). Insufficient data exist for high-risk patients, but the current literature dictates that patients who are adherent to targeted medical treatment seem to experience less stone growth or regrowth of residual fragments, and may be discharged after 36-48 mo of nonprogressive disease on imaging., Conclusions: This systematic review and meta-analysis indicates that stone-free patients with radiopaque or radiolucent stones should be followed up to 2 or 3 yr, respectively. In patients with residual fragments ≤4 mm, surveillance or intervention can be advised according to patient preferences and characteristics, while for those with larger residual fragments, reintervention should be scheduled., Patient Summary: Here, we review the literature regarding follow-up of urolithiasis patients. Patients who have no stones after treatment should be seen up to 2-3 yr, those with large fragments should be reoperated, and those with small fragments could be offered surveillance with imaging., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objectives: Ureteroscopy is one of the commonest procedures performed to manage urolithiasis. Flexible ureteroscopy has been traditionally based on reusable, fiber-optic ureteroscopes. Technology advancements permitted the development of single-use scopes with digital image. The aim of this study is to compare efficacy and safety between a reusable, fiberoptic ureteroscope with a single-use, digital scope., Patients and Methods: We collected data based on chart review from a prospectively collected database on a tertiary, high-volume hospital in Greece. Baseline, perioperative and postoperative data were gathered and analyzed. Chi-square and Fisher's exact test was used to compare qualitative data and unpaired t-test for continuous data, with a statistical significance set at a = 0.05., Results: 40 patients underwent flexible ureteroscopy with a single- use digital scope, while 37 with the reusable scope. The two groups were matched regarding baseline characteristics and stone-related parameters. After data analysis, a shorter operative time in favor of single-use flexible ureteroscope was detected (45 vs 65 min, p = 0.001), while safety was also in favor of this type of scope with a significantly higher immediate stonefree rate (70% vs 43%, p = 0.005). Overall complications did not differ between the two groups, although a lower sepsis rate was detected in patients treated with single-use scope., Conclusions: Our findings indicate that single-use, digital ureteroscopes are a viable alternative for flexible ureteroscopy and management of urolithiasis, especially in centers with deficient facilities for sterilization and ensured funds for more expensive reusable scopes.

Introduction: Fluoroscopy-guided endourology procedures require proper radiation protection to minimize radiation risk. This multicenter study aimed at investigating radiation protection practice and related radiation exposure of operating team members. Materials and Methods: Six endourology centers from the South-Eastern European Group for Urolithiasis Research answered questionnaires and collected data of 315 procedures performed within a 3-months period, with simultaneous measurement of dose to staff and dose area product (DAP) to patient. A pair of calibrated personal dosimeters, one for body and one for eye-lens dose, was worn by all key staff members. Dosimeters were centrally calibrated, measured, and analyzed. Results: The annual workload ranged from 173 to 865 procedures per center. Practice of personal dose monitoring and use of radiation protection shielding was found to be inconsistent. Lead aprons and thyroid collars were used by all, whereas protective eyewear was used in only half of centers. Due to the regular use of protective aprons, the whole-body dose of all 44 monitored staff members was safely below the regulatory dose limits. Eye-lens dose of 17 (14 urologists and 3 assisting staff) was above the dosimeter detection level, and dose per procedure varied from <10 to 63 μSv. The highest annual eye-lens dose of 13.5 mSv was found for the surgeon in the busiest department by using an over-the-couch X-ray tube without a ceiling suspended screen. Working closer to patient body with no protection resulted in a six-time higher eye-lens dose per DAP for a surgeon compared with others in the same center. Lower eye-dose per procedure was associated with lower DAP to patient and with the use of an under-the-couch tube, lower fluoroscopy pulse rate, collimation, fluoroscopy time, and acquired images. Conclusion s: The study results call for the need to establish standard protocols about use of fluoroscopy during endourology procedures and to increase radiation protection knowledge and awareness of surgical staff.

Purpose of Review: Surgical management is the cornerstone of urolithiasis treatment, but high recurrence rates and associated complications necessitate the existence of medical treatment options, aiming at dissolution of kidney stones and prevention of recurrence. The purpose of this review is to present the most recent knowledge existing in scientific literature, regarding dissolution therapy and ways of monitoring nephrolithiasis patients., Recent Findings: A number of laboratory studies have been performed testing experimental treatments (tolvaptan, chlorthalidone, atorvastatin, a-lipoic acid, glucosaminoglycans, plant extracts), to reduce kidney stone formation and cellular damage and showed encouraging results. Uric acid stones is the main target of dissolution therapy, but until last years, existing level of evidence was low. A number of prospective and randomized studies, proved the efficacy and safety of oral chemolysis for radiolucent stones and associated prognostic features of success. Tolvaptan and a-Lipoic acid were also tested in patients with cystinuria and resulted in reduction of recurrence. Finally, some new diagnostic markers are suggested as tests for the monitoring of urolithiasis patients, with satisfying accuracy and discriminative ability., Summary: Medical dissolution therapy for nephrolithiasis is an effective option, especially for patients with radiolucent/uric acid stones. In the future, we need clinical trials to confirm the encouraging results of pilot studies testing several agents for patients with cystinuria., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Urolithiasis is a clinical condition showing increasing trends, especially among European and other developed countries. The European Association of Urology (EAU), in close collaboration with experts in the field, publishes a yearly updated clinical guideline, in order to provide practicing urologists around Europe and the rest of the world a tool for optimizing patient care and decision-making. The methodological approach for developing this guide is quite rigorous and follows rigorous scientific standards. The challenges that a urologist faces are increasing; therefore, during meticulous literature search, the EAU Urolithiasis Panel identifies gaps in knowledge and conducts systematic reviews, in order to provide answers or to propose ideas for designing future research. This way, a new section was published last year, regarding diagnosis and management of bladder stones, with more systematic reviews on the way. The aim of this study is to analyze current structure and goals of the EAU Urolithiasis Panel, along with future ambitions and challenges. PATIENT SUMMARY: Increasing trends in kidney stone disease along with developments in technology necessitate systematic organization of information for urologists in order to be able to follow diagnostic and therapeutic algorithms for optimizing patient care. The role of the European Association of Urology Urolithiasis Guideline Panel is to provide such a tool by development of urolithiasis guidelines on an annual basis., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: The objective of this study isto present the content of existing Guidelines on medical management of urinary stone disease., Materials and Methods: A search for current Guidelines from national and international urological Associations was performed in Societe International d'Urologie and American Urological Association websites, along with a search in Pubmed/MEDLINE until 30/06/2020. Two authors performed an independent search and data extraction regarding medical management of acute renal colic, medical expulsive treatment, dietary modifications and pharmaceutical interventions for prevention of stone disease recurrence. Quality of Guidelines was assessed by the two reviewers using the AGREE II instrument., Results: Literature search revealed 82 Associations, while eight of them provide recommendations/Guidelines on medical management of stone disease. Non-steroidalanti-inflammatory drugs or paracetamol are the most common 1st line treatment proposed for acute pain management, with opiates following next. Use of a-blockers is also indicated by most Guidelines for facilitating expulsion of distal ureteral stones 5-10 mm, after shockwave or laser lithotripsy or for alleviating stent-related symptoms. Adequate fluid in take, normal dietary calcium consumption and sodium restriction with varying daily limits, are universal dietary modifications from urological Associations on prevention of stone disease. Thiazidesand alkaline citrates are proposed usually for calciumoxalate stone formers with differences in grading of the recommendations, while urinary alkalization with allopurinol or febuxostat as a second line treatment is acommon treatment algorithm for urate stones, but with differences in target urine pH. European and American Urological Association Guidelines, along with National Institute for Health and Care Excellence recommendations were the most highly rated based on AGREE II., Conclusions: Despite methodological heterogeneity and subjective rating of recommendations, an acceptable degree of consensus was noted on Guidelines regarding medical management of stone disease.

Fluoroscopy is increasingly used to guide minimally invasive endourological procedures and optimised protocols are needed to minimise radiation exposure while achieving best treatment results. This multi-center study of radiation exposure of patients was conducted by the South-Eastern European Group for Urolithiasis Research (SEGUR), in cooperation with the International Atomic Energy Agency. Seven clinical centers from the SEGUR group collected data for 325 procedures performed within a three-months period, including standard percutaneous nephrolithotomy (PCNL), mini PCNL, retrograde intrarenal surgery (RIRS), semirigid ureterorenoscopy (URS) and flexible URS. Data included: air kerma area product ( P KA ), air kerma at the patient entrance reference point ( K a,r ), fluoroscopy time (FT), number of radiographic images ( N ) and fluoroscopy pulse rate, as well as total procedure duration, size and location of stones. Data were centrally analysed and statistically compared. Median P KA values per center varied 2-fold for RIRS (0.80-1.79 Gy cm 2 ), 7.1 fold for mini-PCNL (1.39-9.90 Gy cm 2 ), 7.3 fold for PCNL (2.40-17.50 Gy cm 2 ), 19 fold (0.13-2.51 Gy cm 2 ) for semi-rigid URS and 29-fold for flexible URS (0.10-2.90 Gy cm 2 ). Lower P KA and K a,r were associated with use of lower FT, N and lower fluoroscopy pulse rate. FT varied from 0.1 to 14 min, a small fraction of the total procedure time, ranging from 10 to 225 min. Higher N was associated with higher P KA and K a,r . Higher median P KA in PCNL was associated with the use of supine compared to prone position. No correlation was found between the concrement size and procedure duration, FT, P KA or K a,r . Dose values for RIRS were significantly lower compared to PCNL. The maximum K a,r value of 377 mGy was under the threshold for radiation induced skin erythema. The study demonstrated a potential for patient dose reduction by lowering FT and N , using pulsed fluoroscopy and beam collimation., (© 2020 Society for Radiological Protection. Published on behalf of SRP by IOP Publishing Limited. All rights reserved.)

The purpose of this study is to collect information on the bacterial resistance to antibiotics of bacteria isolated from urine cultures of patients treated for upper urinary tract calculi. Data of patients with urinary tract infection and urolithiasis were retrospectively reviewed to collect information on age, gender, stone size, location, hydronephrosis, procedure of stone removal and antibiotic treatment, identification and susceptibility of pathogens, symptoms, and infectious complications. A total of 912 patients from 11 centers in 7 countries (Bulgaria, Greece, Italy, North Macedonia, Spain, and Turkey) were studied. Mean age was 54 ± 16 years and M/F ratio 322/590. Out of 946 microbial isolates, the most common were E. coli, Gram-positive, KES group (Klebsiella, Enterobacter, Serratia), Proteus spp., and P. aeruginosa. Carbapenems, piperacillin/tazobactam and amikacin showed low resistance rates to E. coli (2.5%, 7%, and 3.6%) and Proteus spp. (7.7%, 16%, and 7.4%), but higher rates were observed with Klebsiella spp., P. aeruginosa, and Gram-positive. Fosfomycin had resistance rates less than 10% to E. coli, 23% to KES group, and 19% to Gram-positive. Amoxicillin/clavulanate, cephalosporins, quinolones, and TMP/SMX showed high resistance rates to most bacterial strains. High rates of antibiotic resistance were observed in patients candidate to stone treatment from South-Eastern Europe. The empirical use of antibiotics with low resistance rates should be reserved to the most serious cases to avoid the increase of multidrug resistant bacteria. Basing on our results, carbapenems, piperacillin/tazobactam, and amikacin may be a possible option for empiric treatment of urinary stone patients showing systemic symptoms.

Purpose of Review: Equipment used in endourology is constantly evolving due to increasing incidence of urolithiasis. Suctioning has been used mainly in PCNL in conjunction with ultrasonic and ballistic devices for stone removal. Recently technological advances permitted the use of suctioning in more endourological techniques. This review aims to summarize the literature regarding these advancements and analyze the upcoming results., Recent Findings: Several centers have conducted experimental and clinical studies on suctioning use during PCNL, mPCNL, and ureteroscopy and concluded that it is an effective and safe adjustment that improves stone-free rates and limits complication rates after these procedures. Suctioning use during common endourological procedures led to improved safety and efficacy among several indications. Due to the observational nature and small sample size of many studies, larger RCTs are needed to make safe conclusions.

Purpose of Review: Active stone removal has been entirely revolutionized in the past decades. Smaller instruments, scope and laser technology advancements and novel lithotripter modalities have entirely changed the way urological surgeons treat stones. Nevertheless novel technologies may lead to different and difficult to manage complications. Accurate knowledge of indications, limitations and technical details of these novel modalities can significantly decrease complication rates. The purpose of this review is to provide the most recently acquired knowledge to decrease patient's morbidity after active stone removal., Recent Findings: Complications of active stone removal are well known for many years, nevertheless novel technologies in stone management can substantially differentiate their rates. Minimal invasive techniques are becoming even more minimal which reflects on the complications., Summary: Mastering the novel techniques in active stone removal and knowing their inherent limitations, in association with the recognition of predisposing factors and preventing measures have led to a highly acceptable low complication rate. Further refinements and technical improvement will reduce even more the complication incidence in the future.