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Purpose: To analyze the bibliometric publication trend on the application of "Artificial Intelligence (AI) and its subsets (Machine Learning-ML, Virtual reality-VR, Radiomics) in Urolithiasis" over 3 decades. We looked at the publication trends associated with AI and stone disease, including both clinical and surgical applications, and training in endourology. Methods: Through a MeshTerms research on PubMed, we performed a comprehensive review from 1994-2023 for all published articles on "AI, ML, VR, and Radiomics." Articles were then divided into three categories as follows: A-Clinical (Nonsurgical), B-Clinical (Surgical), and C-Training articles, and articles were then assigned to following three periods: Period-1 (1994-2003), Period-2 (2004-2013), and Period-3 (2014-2023). Results: A total of 343 articles were noted (Groups A-129, B-163, and C-51), and trends increased from Period-1 to Period-2 at 123% ( p = 0.009) and to period-3 at 453% ( p = 0.003). This increase from Period-2 to Period-3 for groups A, B, and C was 476% ( p = 0.019), 616% (0.001), and 185% ( p < 0.001), respectively. Group A articles included rise in articles on "stone characteristics" (+2100%; p = 0.011), "renal function" ( p = 0.002), "stone diagnosis" (+192%), "prediction of stone passage" (+400%), and "quality of life" (+1000%). Group B articles included rise in articles on "URS" (+2650%, p = 0.008), "PCNL"(+600%, p = 0.001), and "SWL" (+650%, p = 0.018). Articles on "Targeting" (+453%, p < 0.001), "Outcomes" (+850%, p = 0.013), and "Technological Innovation" ( p = 0.0311) had rising trends. Group C articles included rise in articles on "PCNL" (+300%, p = 0.039) and "URS" (+188%, p = 0.003). Conclusion: Publications on AI and its subset areas for urolithiasis have seen an exponential increase over the last decade, with an increase in surgical and nonsurgical clinical areas, as well as in training. Future AI related growth in the field of endourology and urolithiasis is likely to improve training, patient centered decision-making, and clinical outcomes.

Introduction: Artificial intelligence and machine learning are the new frontier in urology; they can assist the diagnostic work-up and in prognostication bring superior to the existing nomograms. Infectious events and in particular the septic risk, are one of the most common and in some cases life threatening complication in patients with urolithiasis. We performed a scoping review to provide an overview of the current application of AI in prediction the infectious complications in patients affected by urolithiasis., Evidence Acquisition: A systematic scoping review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) guidelines by screening Medline, PubMed, and Embase to detect pertinent studies., Evidence Synthesis: A total of 467 articles were found, of which nine met the inclusion criteria and were considered. All studies are retrospective and published between 2021 and 2023. Only two studies performed an external validation of the described models. The main event considered is urosepsis in four articles, urinary tract infection in two articles and diagnosis of infection stones in three articles. Different AI models were trained, each of which exploited several types and numbers of variables. All studies reveal good performance. Random forest and artificial neural networks seem to have higher AUC, specificity and sensibility and perform better than the traditional statistical analysis., Conclusions: Further prospective and multi-institutional studies with external validation are needed to better clarify which variables and AI models should be integrated in our clinical practice to predict infectious events.

Introduction: There is a gap in the available literature and guidelines concerning the optimal approach for treating allograft stones, which currently include external shockwave lithotripsy, ureteroscopy and laser lithotripsy, or percutaneous nephrolithotomy. The objective of this systematic review was to evaluate the safety and effectiveness of URS as a treatment option for patients in this scenario., Evidence Acquisition: A comprehensive search of the literature was conducted until August 2023. Only original articles written in English were considered for inclusion. This review has been registered in PROSPERO (registration number CRD42023451154)., Evidence Synthesis: Eleven articles were included (122 patients). The mean age was 46.9±9.5 years, with a male-to-female ratio of 62:49. The preferred ureteral reimplantation technique was the Lich-Gregoire. The mean onset time was 48.24 months. Acute kidney injury, urinary tract infections and fever were the most frequent clinical presentations (18.3% each), followed by hematuria (10%). The mean stone size measured 9.84 mm (±2.42 mm). Flexible URS was preferred over semirigid URS. The stone-free rate stood at 83.35%, while the overall complication rate was 13.93%, with six (4.9%) major complications reported. Stones were mainly composed of calcium oxalate (42.6%) or uric acid (14.8%). Over an average follow-up period of 30.2 months, the recurrence rate was 2.46%. No significant changes in renal function or allograft loss were reported., Conclusions: URS remains an efficient choice for addressing de-novo allograft urolithiasis, offering the advantage of treating urinary stones with a good SFR and a low incidence of complications. Procedures should be performed in an Endourology referral center.

Introduction and Objective: Renal transplantation is the treatment for end-stage renal disease that offers better quality of life and survival. Among the possible complications that might affect allografts, urolithiasis might have severe consequences, causing acute kidney injury (AKI) or septic events in immunocompromised patients. Allograft stones might be treated with percutaneous nephrolithotomy (PCNL). The aim of this Cochrane style review was to assess the safety and efficacy of PCNL in patients with renal transplant. Methods: A comprehensive search in the literature was performed including articles between July 1982 and June 2023, with only English original articles selected for this review. Results: The final review encompassed nine articles (108 patients). The mean age was 46.4 ± 8.7 years, with a male:female ratio of 54:44. The average time from transplantation to urolithiasis onset was 47.54 ± 23.9 months. Predominant symptoms upon presentation were AKI (32.3%), followed by urinary tract infection and fever (24.2%), and oliguria (12.9%). The mean stone size was 20.1 ± 7.3 mm, with stones located in the calices or pelvis (41%), ureteropelvic junction (23.1%), or proximal ureter (28.2%). PCNL (22F-30F) was more frequently performed than mini-PCNLs (16F-20F) (52.4% vs 47.6%). Puncture was guided by ultrasound (42.9%), fluoroscopy (14.3%), or both (42.9%). The stone-free rate (SFR) and complication rates were 92.95% (range: 77%-100%) and 5.5%, respectively, with only one major complication reported. Postoperatively, a ureteral stent and nephrostomy were commonly placed in 47%, with four patients needing a second look PCNL. During an average follow-up of 32.5 months, the recurrence rate was 3.7% (4/108), and the mean creatinine level was 1.37 ± 0.28 mg/dL. Conclusions: PCNL remains a safe and effective option in de novo allograft urolithiasis, allowing to treat large stones in one-step surgery. A good SFR is achieved with a low risk of minor complications. These patients should be treated in an endourology center in conjunction with the renal or transplant team.

Purpose: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications., Methods: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified., Results: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely., Conclusions: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Radiation exposure is affected by C-arm fluoroscopy device positioning during percutaneous renal puncture. Our aim was to compare the exposure of surgeon's lens, hand and chest with a fluoroscopy protocol replicated in different C-arm positions., Materials and Methods: A standardized fluoroscopy protocol was created using water-equivalent solid phantoms to replicate a surgeon and patient. 111 mGy radiation (360 s) was applied in standard fluoroscopy mode (91 kVp, 2.7 mA/mAs). Dosimeters were placed on lens, chest and hand of surgeon and patient phantom models. 7 different C-arm positions were created: 0°, mediolateral (ML) +90°, ML -90°, ML +30°, ML -15°, craniocaudal (CC) +30°, CC +15°. Measurements were evaluated separately for different positions., Results: The highest radiation exposure was measured on patient dosimeter (2.97 mSv). The highest exposure on surgeon was recorded on finger dosimeter in all C-arm positions; highest dose was recorded in ML +90° position (2.88 mSv). In finger dosimeters, lowest exposure was recorded in 0° position (0.51 mSv). The lowest exposure of all positions was measured in chest dosimeter in ML -90° position (0.24 mSv)., Conclusions: In positions where X-ray generator of the C-arm was facing towards the surgeon, radiation exposure measured in all dosimeters was higher compared to positions where the generator was facing away. The hand radiation exposure in all positions was higher than chest and lens. Special care must be taken to avoid facing the X-ray generator tube and hands should be as well-protected as chest and eyes with special protective gear., Competing Interests: The authors have nothing to disclose., (© The Korean Urological Association.)

Purpose of Review: Double J ureteric stents (DJs) are useful aids for urinary drainage in case of stones or tumour causing ureteric obstruction. Prolonged dwelling time such as when forgotten can lead to encrustation. Our aim was to perform a literature review to evaluate outcomes associated with endourological management of encrusted stents (ES)., Recent Findings: There now exist validated tools which can aid in grading the severity of encrustation and aid operative planning such as the total number of surgeries that may be required. Evaluation of different treatment strategies remains under reported. Removal of encrusted stent is a challenging problem, and it typically requires a multimodal endourological approach., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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.)

Purpose of Review: With advancements in surgical technology along with procedural techniques, this article throws light on the latest developments and applications of artificial intelligence (AI), extended reality, 3D (three-dimensional) printing and robotics in percutaneous nephrolithotomy (PCNL)., Recent Findings: This review highlights the applications of AI in PCNL over the past 2 years. Mostly studies have been reported on development of machine learning (ML) based predicting models and identification of stone composition using deep learning convolutional neural network (DL-CNN). But owing to the complexity of the models and lack of generalizability, it is still not incorporated in the routine clinical practice. Extended reality based simulation and training models have enabled trainees to enhance their skills and shorten the learning curve. Similar advantages have been reported with the use of 3D printed models when used to train young and novice endourologists to improve their skills in percutaneous access (PCA). Applications of robotics in PCNL look promising but are still in nascent stages., Summary: Future research on PCNL should focus more on generalizability and adaptability of technological advancements in terms of training and improvement of patient outcomes., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS., Materials and Methods: After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided., Results: A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications., Conclusion: The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS., (© 2022 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

Context: While kidney stone disease is common and ureteroscopy (URS) is perceived as minimally invasive, there is mortality associated with treatment., Objective: The aim of this review was to ascertain the number of mortalities from URS for stone disease over the past three decades, identify relevant patient risk factors and predictors of mortality, and summarise the key recommendations so that similar instances can be avoided, and lessons can be learnt., Evidence Acquisition: A systematic literature search was conducted following Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) methodology for English-language article reporting on data from 1990 to December 2020. Data collated from each study included patient and stone characteristics, number of mortalities, and cause of death., Evidence Synthesis: Fifteen studies met our inclusion criteria and revealed a total of 72 mortalities from ten countries. The age range of reported patients varied from 21 to 89 yr, with over 60% being above 65 yr of age and 97% with some comorbidity. Based on available data, death reports in females were three times more than those in males. The stone size ranged from 10 to 38 mm. Treatment of larger stones corresponded to a longer operative time, with procedural duration varying from 30 to 120 min. Of the reported causes of mortality in 42 patients, the aetiology was sepsis in over half of the patients, with other causes being cardiac-related, respiratory-related, multiorgan failure, and haemorrhagic complications., Conclusions: Although the reported URS mortality rate seems to be low, there has been a rise in deaths over the past decade. Efforts must be made to have preoperative urine culture, and reduce operative time and stage procedures in patients with a large stone burden. Care must be taken in patients with robust preoperative assessment, intraoperative techniques, and postoperative monitoring for early detection of complications with interdisciplinary management of complex cases., Patient Summary: We reviewed the risk factors associated with postureteroscopy mortality and ways to minimise this. Evidence shows that although reported mortality remains low, there seems to be an increase in mortality in the past decade and urologists must remain vigilant of this., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Ureteric stents are an important tool in urology and have a wide range of indications. While they offer a number of advantages, limitations remain despite modern advancements. These include discomfort, migration and encrustation. Standard removal is via cystoscopy but in the paediatric setting this mandates general anaesthetic, which holds disadvantages. Alternative removal methods include use of extraction strings and magnetic retrieval devices, which can be performed in the outpatient setting. This systematic review evaluates the safety and efficacy of different non-cystoscopic methods for stent removal in the paediatric setting., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To look at the bibliometric publication trends on 'Urolithiasis' and aspects of treatment and training associated with it over a period of 16 years from 2000 to 2015. To this end, we conducted this study to look at the publication trends associated with urolithiasis, including the use of simulation, laser technology, and all types of interventions for it., Materials and Methods: We performed a systematic review of the literature using PubMed over the last 16 years, from January 2000 to December 2015 for all published papers on 'Urolithiasis'. While there were no language restrictions, English language articles and all non-English language papers with published English abstracts were also included. Case reports, animal and laboratory studies, and those studies that did not have a published abstract were excluded from our analysis. We also analyzed the data in two time periods, period-1 (2000-2007) and period-2 (2008-2015)., Results: During the last 16 years, a total of 5343 papers were published on 'Urolithiasis', including 4787 in English language and 556 in non-English language. This included papers on URS (n = 1200), PCNL (n = 1715), SWL (n = 887), open stone surgery (n = 87), laparoscopic stone surgery (n = 209), pyelolithotomy (n = 35), simulation in Endourology (n = 82), and use of laser for stone surgery (n = 406). When comparing the two time periods, during period 2, the change was +171% (p = 0.007), +279% (p < 0.001), and -17% (p = 0.2) for URS, PCNL, and SWL, respectively. While there was a rise in laparoscopic surgery (+116%), it decreased for open stone surgery (-11%) and pyelolithotomy (-47%). A total of 82 papers have been published on simulation for stone surgery including 48 papers for URS (67% rise in period-2, p = 0.007), and 34 papers for PCNL (480% rise in period-2, p < 0.001). A rising trend for the use of laser was also seen in period 2 (increase of 126%, p < 0.02, from 124 papers to 281 papers)., Conclusions: Published papers on intervention for Urolithiasis have risen over the last 16 years. While there has been a steep rise of URS and minimally invasive PCNL techniques, SWL and open surgery have shown a slight decline over this period. A similar increase has also been seen for the use of simulation and lasers in Endourology.

Background: Patients with urolithiasis have access to a wide range of efficacious therapeutic surgical options, including shockwave lithotripsy (SWL), retrograde ureteric or intrarenal surgery with semi-rigid and flexible ureteroscopes (URS or fURS) and percutaneous nephrolithotomy (PCNL). In recent years, there have been many peer-reviewed publications evaluating new techniques and new equipment, such as pulse-modulated Holmium:YAG and thulium fibre lasers. However, when reviewing this extensive literature, it becomes apparent that there is no consensus on what constitutes a 'successful' stone treatment outcome. Objectives: The purpose of this article is to review the existing measures of 'success' after the ureteroscopic treatment of urolithiasis and to promote a standardised and holistic approach to reporting outcomes in clinical trials. Methods: Our narrative review focussed on studies examining measures of success in urolithiasis treatment published within the last 10 years. Conclusions: Due to markedly different reported outcome measures of treatments for urolithiasis, comparing results between studies can be difficult. In addition to measuring clinical outcomes, there is an increasing acknowledgement of the importance of patient-reported outcome measures (PROMs) in determining treatment success, and the need to consider the cost-effectiveness and environmental sustainability of various treatments. We suggest that all future studies on this common urological condition should incorporate holistic and tranpsarent outcome measures. Level of evidence: Not applicable [ABSTRACT FROM AUTHOR]

Background: In vitro studies have shown that the holmium Modulated Optics Enhancement Systems (MOSES) technology can lead to an increase in the efficacy of lithotripsy and a reduction of retropulsion, but clinical evidence comparing it to non-MOSES technology is still scarce. We did a comparison of ureteoroscopy and laser stone fragmentation (URSL) between Holmium:YAG laser with MOSES versus non-MOSES technologies. Methods: Patient data and outcomes were prospectively collected and analyzed regarding patient demographics, stone parameters, and clinical outcomes. Patients undergoing URSL with standard holmium laser without MOSES technology (Group 1) were compared to holmium laser with MOSES (Group 2) using the same clinical laser settings (0.4–1 J, 20–40 Hz) with dusting and pop-dusting technique. The independent t -test, Mann–Whitney U test, and Chi-squared test were used, with a p -value of < 0.05 as significant. Given the different sizes of the cohorts, we performed a propensity score 1:1 matched analysis. Results: A total of 206 patients (1:1 matched) with a male:female ratio of 94:112 and a median age of 56 (range: 39–68) years were analyzed. Groups 1 and 2 were matched for ureteric stones (27.7% and 22.3%, p = 0.42), pre-stenting (37% and 35%, p = 0.66), the mean number of stones (1.76 ± 1.3) and (1.82 ± 1.4, p = 0.73), and ureteral access sheath use (37% and 35%, p = 0.77) respectively. While there was no significant statistical difference in clinical outcomes, the stone size was slightly larger in Group 2, 14.8 ± 10.8 mm vs 11.7 ± 8.0 mm, for a lower operative time 42.7 ± 30.6 min versus 48.5 ± 25 min, lower perioperative complication rates 3.9% versus 4.9% and a higher stone-free rate 90.3% versus 87.4%. Conclusion: While the use of MOSES technology was slightly beneficial for the treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high-quality randomized studies to show if there is a true difference in these outcomes. Plain language summary: We compare the outcomes of ureteroscopy and laser stone fragmentation (URSL), using Holmium:YAG laser with MOSES vs Non-MOSES technology: It is a prospective single-centre propensity score-matched analysis using similar laser settings It is a single-centre propensity score-matched analysis using similar laser settings. While the use of MOSES technology was slightly beneficial for treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high quality randomized studies to show if there is a true difference in these outcomes. [ABSTRACT FROM AUTHOR]

Background/aim: Management of asymptomatic kidney stones is an ongoing debate with follow-up and treatment guidelines based on low-level evidence. Our aim was to evaluate current management of asymptomatic urinary stones. Materials and methods: A 70-question survey was designed in collaboration with European Association of Urology, Young Academic Urologists, Section of Uro-Technology and Section of Urolithiasis groups and distributed. Responders filled out hypothetical scenarios from 2 perspectives, either as treating physicians, or as patients themselves. Results: A total of 212 (40.01%) responses were obtained. Median responder age was 39 years. 75% of responders were interested in urolithiasis". 82.5% had never experienced a renal colic, 89.6% had never undergone urolithiasis treatment. Overall, as the kidney stone scenarios got more complicated, the invasiveness of the treatment preference increased. As "the physician", responders preferred the conservative option in all situations more than they would choose as "the patient". For ureteral stones, conservative approach was most preferred for small stones and ureteroscopy became more preferred as the stone size increased. For smaller kidney stones, the most preferred follow-up schedule was 4-6 monthly, whereas for larger and complicated stones it was 0-3 monthly from both perspectives respectively. For all ureteral stone scenarios, 0-4 weekly follow-up was mostly preferred. Interestingly, having had a renal colic was an independent predictor of an interventional approach, whereas having had an intervention was an independent predictor of a conservative approach. Conclusion: Current treatment and follow-up patterns of asymptomatic urinary stones are in agreement with international guidelines on symptomatic stones. In most of the urolithiasis situations urologists chose a conservative approach for their patients compared to what they would prefer for themselves. Conversely, urologists, in the scenarios as "the patient", would like to have a more frequent follow-up schedule for their stones compared to how they would follow-up their patients. [ABSTRACT FROM AUTHOR]

Advances in laser technology and surgical telescopic systems have propelled retrograde intrarenal surgery (RIRS) to the forefront as a viable alternative to percutaneous nephrolithotomy (PCNL). Currently, RIRS is being increasingly utilized as a treatment option, even for kidney stones larger than 2 cm. In this narrative review, we aimed to take a snapshot of current practice in renal stone treatment and the latest technological and technical developments and to evaluate the efficacy of RIRS in larger renal stones. With low complication rates and acceptable stone-free rates, RIRS offers patients a less invasive option with favorable outcomes. There are insufficient data comparing PCNL with RIRS using a new-generation high-power laser and suctioning ureteral access sheath (UAS). Further studies with novel lasers and UAS could provide superiority in terms of RIRS. It is crucial to take into account various patient-specific considerations, such as stone location and burden, when deciding on the appropriate treatment approach. [ABSTRACT FROM AUTHOR]

Introduction Kidney stone disease (KSD) has a lifetime prevalence of up to 14% in the United Kingdom. Primary and secondary prevention of KSD via dietary intervention is a low-cost public health intervention and remains the best preventative strategy against urolithiasis. Material and methods This prospective study was conducted on kidney stone patients attending a stone clinic at our tertiary endourology centre. Patients were taken through a questionnaire, which was completed in the clinic by a trained specialist endourology nurse. Results A total of 259 patients completed the questionnaire. 141 (54.4%) had an active stone during the clinic visit with the remaining 118 (45.6%) with a history of stone treatment. Regarding barriers to fluid intake, 43 (16.6%) patients did not have a habit of drinking water or felt too bloated, 36 (13.9%) did not like the taste, 17 (6.6%) were not thirsty, 10 (3.9%) of patients were too busy. Of those who answered, 108 (46.8%) patients did not believe there was a link between fluid intake and stone formation. A belief of a link between fluid intake and stone formation significantly predicted fluid intake (p = 0.024) with people who did believe in this drinking less water. Conclusions There are numerous perceived barriers to adequate fluid intake, with almost half of all patients not believing that there is a link between fluid intake and stone formation. This misunderstanding may predict a lower fluid intake. More attention should therefore be focussed on patient education and primary prevention aspects to avoid kidney stone recurrence. [ABSTRACT FROM AUTHOR]

Aim: To assess and compare the outcomes associated with ureteroscopy and laser fragmentation (URSL) for extremes of age group (≤10 and ≥80 years). Methods: Retrospective consecutive data were collected from two European centres for all paediatric patients ≤10 undergoing URSL over a 15-year period (group 1). It was compared to consecutive data for all patients ≥80 years (group 2). Data were collected for patient demographics, stone characteristics, operative details, and clinical outcomes. Results: A total of 168 patients had 201 URSL procedures during this time (74 and 94 patients in groups 1 and 2 respectively). The mean age and stone sizes were 6.1 years and 85 years, and 9.7 mm and 13 mm for groups 1 and 2 respectively. While the SFR was slightly higher in group 2 (92.5% versus 87.8%, p = 0.301), post-operative stent rate was also significantly higher in the geriatric population (75.9% versus 41.2%, p = 0.0001). There was also no significant difference in pre-operative stenting (p = 0.886), ureteric access sheath use (UAS) (p = 0.220) and post-operative complications. Group 1 had an intervention rate of 1.3/patient as compared to 1.1/patient in group 2. The overall complications were 7.2% and 15.3% in groups 1 and 2 respectively (0.069), with 1 Clavien IV complication related to post-operative sepsis and brief ICU admission in group 2. Conclusion: The paediatric population had a marginally higher incidence of repeat procedure, but the overall SFR and complications were similar, and post-operative stent insertion rates were much better compared to geriatric patients. URSL is a safe procedure in the extremes of age groups with no difference in the overall outcomes between the two groups. [ABSTRACT FROM AUTHOR]

Ureteral stents are useful devices in urological surgery. The main objective of a ureteric stent is to allow passage of urine and reduce early or late complications related to obstruction in the urinary tract. Despite their widespread use, there is a general lack of knowledge and awareness in stent composition and indication of application. We represented a synthesis of our extensive research over materials, coatings and shapes available on the market and then analyzed the main characteristics and peculiarities of ureteral stents. We have also focused our attention over the side effects and complication that must be considered when placing a ureteral stent. Encrustation, microbial colonization, stent-related symptoms and patient's history must always be evaluated when there is the need for a ureteral stent. The perfect stent should have many characteristics including easy insertion and removal, easy manipulation, resistance to encrustation and migration, lack of complications, biocompatibility, radio-opacity, biodurability, affordability (cost-effectiveness), tolerability and optimal flow characteristics. Nevertheless, further research and studies need to be done to provide more information about stent composition and efficacy in vivo. In this narrative review, we covered the basic information and main characteristics of ureteral stents, in order to help clinicians choose the appropriate device needed for a given situation. [ABSTRACT FROM AUTHOR]

Introduction: We wanted to analyze the trend of publications in a period of 30years from 1994 to 2023, on the application of ‘artificial intelligence (AI), machine learning (ML), virtual reality (VR), and radiomics in percutaneous nephrolithotomy (PCNL)’. We conducted this study by looking at published papers associated with AI and PCNL procedures, including simulation training, with preoperative and intraoperative applications. Materials and Methods: Although MeSH terms research on the PubMed database, we performed a comprehensive review of the literature from 1994 to 2023 for all published papers on ‘AI, ML, VR, and radiomics’ in ‘PCNL’, with papers in all languages included. Papers were divided into three 10-year periods: Period 1 (1994–2003), Period 2 (2004–2013), and Period 3 (2014–2023). Results: Over a 30-year timeframe, 143 papers have been published on the subject with 116 (81%) published in the last decade, with a relative increase from Period 2 to Period 3 of +427% (p=0.0027). There was a gradual increase in areas such as automated diagnosis of larger stones, automated intraoperative needle targeting, and VR simulators in surgical planning and training. This increase was most marked in Period 3 with automated targeting with 52 papers (45%), followed by the application of AI, ML, and radiomics in predicting operative outcomes (22%, n=26) and VR for simulation (18%, n=21). Papers on technological innovations in PCNL (n=9), intelligent construction of personalized protocols (n=6), and automated diagnosis (n=2) accounted for 15% of publications. A rise in automated targeting for PCNL and PCNL training between Period 2 and Period 3 was +247% (p=0.0055) and +200% (p=0.0161), respectively. Conclusion: An interest in the application of AI in PCNL procedures has increased in the last 30years, and a steep rise has been witnessed in the last 10years. As new technologies are developed, their application in devices for training and automated systems for precise renal puncture and outcome prediction seems to play a leading role in modern-day AI-based publication trends on PCNL. [ABSTRACT FROM AUTHOR]

Ureteral access sheaths (UASs) are part of urologist's armamentarium when performing retrograde intrarenal surgery (RIRS). Recently, the world of RIRS has changed dramatically with the development of three game-changers: thulium fiber laser (TFL), smaller size single use digital flexible ureterosopes and intraoperative intrarenal pressure (IRP) measurement devices. We aimed to clarify the impact of UASs on IRP, complications and SFRs and put its indications in perspective of these three major technological improvements. A systematic review of the literature using the Medline, Scopus and Web of Science databases was performed by two authors and relevant studies were selected according to PRISMA guidelines. Recent studies showed that using a UAS lowers IRP and intrarenal temperature by increasing irrigation outflow during RIRS. Data on the impact of a UAS on SFRs, postoperative pain, risk of infectious complications, risk of ureteral strictures and risk of bladder recurrence of urothelial carcinoma after diagnostic RIRS were inconclusive. Prestenting for at least one week resulted in ureteral enlargement, while the influence of pre-operative administration of alpha-blockers was unclear. Since TFL, smaller single use digital ureteroscopes and devices with integrated pressure-measuring and aspiration technology seemed to increase SFRs and decrease pressure and temperature related complications, indications on the use of a UAS may decrease in the near future. [ABSTRACT FROM AUTHOR]

Background: Although paediatric ureteroscopy is widely performed, there is still a lack of data and outcomes in early childhood. In this two-centre study, we compared the outcomes of ureteroscopy for stone disease management in early and late childhood and provide outcomes for the same. Methods: Data was retrospectively collected on consecutive patients from two tertiary paediatric endo-urology European centres over a 15-year period (2006–2021). Patients were split into two groups, namely, early childhood (age ⩽ 9 years) and late childhood (age 9 to ⩽16 years). Outcomes including stone-free rate (SFR) and complications were compared between these two groups. Results: A total of 148 patients underwent 184 procedures (1.2 procedure/patient) during the study period (66 in early childhood and 82 in late childhood). The mean age in early and late childhood groups were 5.6 and 13.3 years, and a male: female ratio of 1.6:1 and 1.1:1, respectively. The SFR and complications in early and late childhood groups were 87.8% and 90.2% (p = 0.64) and 5.7% and 4.1%, respectively. Conclusion: Paediatric ureteroscopy and laser stone fragmentation achieves good results in both early and late childhood with comparable SFRs, although the complications and need for second procedure were marginally higher in the early childhood group. Our study would set up a new benchmark for patient counselling in future, and perhaps this needs to be reflected in the paediatric urolithiasis guidelines. [ABSTRACT FROM AUTHOR]

Introduction: Ureteroscopy and laser stone fragmentation [flexible ureteroscopy and laser lithotripsy (FURSL)] has risen over the last two decades. Laser technology has also evolved over the time, shifting from low- to high-power lasers with the addition of MOSES technology that allows for 'dusting and pop-dusting' of stones. The aim of the study was to look at the outcomes of FURSL in lower pole stones (LPS) using low- and high-power lasers. Patient and Methods: In this study, we compared the outcomes of low-power holmium laser (group A, 20 W) and high-power holmium laser (group B, including both 60 W MOSES integrated system and 100 W lasers) for all patients with LPS treated with laser lithotripsy. Data were collected for patient demographics, stone location, size, pre- and postoperative stent, length of stay, complications and stone free rate (SFR). Results: A total of 284 patients who underwent FURSL procedure for LPS were analysed (168 group A, 116 group B). Outcomes showed that compared with group A, group B had a higher SFR (91.6% versus 96.5%, p = 0.13) and shorter operative time (52 versus 38 min, p < 0.001). The median length of stay was <24 h in all groups (day-case procedures). The complication rate was comparable between the two groups but with more infectious complications (n = 7) noted in group A compared with group B (n = 3) (p = 0.53). Conclusion: Compared with low-power laser, the use of high-power laser for LPS significantly reduced the use of ureteral access sheath (UAS), postoperative stent and procedural time. Although non-statistically significant, the SFR was higher in the high-power group even for relatively larger stone sizes, which was also reflected in a reduction of sepsis-related complication rates with these lasers. [ABSTRACT FROM AUTHOR]

Urological organizations publish detailed evidence-based guidelines to support the urologists in the management of urolithiasis. Our objective was to provide clear guidance on the management of urolithiasis, compare the American Urological Association (AUA) and European Association of Urologists (EAU) guidelines, and present an algorithm for different clinical scenarios. The latest AUA and EAU guidelines on urolithiasis were evaluated for the level of evidence and grade of recommendation. All recommendations on management of urolithiasis (surgical and medical management) were reviewed and included. Both the organizations provide guidance for initial patient assessment, imaging requirements, and therapeutic options, including surgical intervention and medical therapy. In addition, these guidelines provide advice for managing specific patient groups, including pediatric patients and pregnant patients. Although there is a general concordance between both the groups, differences exist particularly for recommended modality of surgical intervention depending on stone location and size. Although both the guidelines were broadly similar, we also highlighted the variations in the level of evidence and grade of recommendation. Although these guidelines provide a valuable evidence-based framework to support the management of urinary tract stones, their implementation must be tailored to individual patient needs and available resources. [ABSTRACT FROM AUTHOR]

Objective: The incidence of kidney stone disease (KSD) is rising worldwide; hence, more focus must be directed toward its etiology and risk factors. Increasing fluid intake is recommended as the most ideal prevention; yet, there is inconsistent evidence surrounding optimum volumes and types of fluid that affect stone formation. This review aimed to analyze the published literature on fluid intake and types of fluid consumed and their impact on KSD prevention. Material and methods: Papers were acquired from databases: MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane Library. Included English language studies that involved adults consuming beverages along with a standardized diet in relation to KSD. Those failing to control dietary factors were excluded. Results: After an initial search of 1099 papers, 9 (541 participants) were included in the final review. Six varieties of water and ten different types of juices were investigated. Higher fluid intake was associated with increased urine output and reduced stone formation. Water with high calcium content seemingly increased the rate of calcium oxalate (CaOx) stone formation. The relative supersaturation of CaOx in urine was decreased with grapefruit, apple, orange juices, and sodas, whereas cranberry juice increased it. Plum juice and the energy drink Gatorade had no effect on stone formation. Conclusion: Fluids low in calcium seem to reduce the risk of KSD. Certain varieties of fluid, such as grapefruit, apple, and orange juices reduce urine CaOx saturation, with a subsequent reduction in stone formation. Findings from this review could contribute to primary prevention for those at risk of KSD. [ABSTRACT FROM AUTHOR]

Objective: Laser technology in urology is currently used for both stone lithotripsy and prostate enucleation. Thulium fiber laser (TFL) is a novel laser, with initial studies showing potential benefits over other lasers both in terms of its effectiveness and safety profile. Material and methods: In the first part of this review, a descriptive analysis of the theoretical concepts behind TFL was performed. This part focused on the physics and laser parameters as applied to the clinical practice. These were interpreted in the context of other lasers, namely, the Holmium:YAG laser to highlight the theoretical advantages as well as potential pitfalls offered by the TFL. In the second part of the review, a narrative synthesis of in-vitro studies regarding TFL and its modifications is performed assessing stonerelated parameters, namely, ablation rate, operative time retropulsion, and safety. Results: TFL achieved high ablation rates in most studies and performed better than Holmium:YAG laser across a range of different settings and ablation modes when the two lasers were compared. Moreover, its ability to use low pulse energy ensures minimal stone retropulsion with the retropulsion threshold estimated to be 2-4 times higher than that of Holmium:YAG laser. From a safety viewpoint, TFL poses no additional risks than other lasers, although it does potentially lead to slightly higher temperatures in the surrounding tissues during lithotripsy. Conclusion: The unique properties of TFL have made it an attractive alternative to conventional laser techniques currently used in urology. Clinical studies are required before its application can become more widespread. [ABSTRACT FROM AUTHOR]

Introduction: The role and long-term follow-up of ureteroscopy and laser stone treatment (URSL) in patients with chronic kidney disease (CKD) is unclear. Given conflicting results and a lack of robust data, we looked at the results of URSL in patients with CKD. Methods: Over a 6.5-year period (March 2012–July 2018), prospective outcomes were recorded for consecutive patients who underwent URSL for ureteral or renal stones. The inclusion criteria were all patients with CKD II–V. Renal function was checked preoperatively and at a minimum of 6 months postprocedure. Data were collected and analyzed for patient and stone demographics, procedural and postoperative details, and complications. Results: Over the study period, 277 patients with preoperative CKD stage II–V were included with a male:female ratio of 188:89 and a mean age of 66.6 years. The mean preoperative estimated glomerular filtration rate (eGFR) (mL/minute) was 63 (range: 14–89, ±18) with 167 (60.2%) CKD II, 70 (25.2%) CKD IIIa, 27 (9.7%) CKD IIIb, 10 (3.6%) CKD IV, and 3 (1%) CKD V patients. The mean single stone size was 9.6 mm (range: 3–37 mm, ±5.2) and 35.3% had multiple stones. The stone was located in the ureter for 112 patients, kidney for 137 patients, with 28 patients who had stones in both ureter and kidneys. A pre- and postoperative stent was present in 34.3% to 60% and 82.6% to 100% of patients, respectively, with an access sheath used in 103 (37.8%). The mean operative time was 44.5 minutes, with a stone-free rate of 91.6%. Postoperatively the mean eGFR improved to 68 (±20) (p < 0.002). Complications occurred in 22 (7.9%) patients of which 18 were Clavien I/II and 4 were Clavien III/IV complications. Conclusion: URSL is safe and effective in patients with CKD with most patients discharged the same day of surgery. For majority of patients with both ureteral and renal stones, the renal function either stayed stable or improved after ureteroscopy on a long-term follow-up irrespective of their underlying CKD status. [ABSTRACT FROM AUTHOR]

Introduction: Urolithiasis in solitary kidney (SK) presents significant management dilemma as any insult to the kidney or its drainage can lead to significant morbidity. The treatment options include shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS). Our aim was to conduct a systematic review of literature on all available endourologic techniques reporting on the management of stones in an SK. Materials and Methods: We conducted a systematic review according to the Cochrane and PRISMA checklist for all English-language articles from inception to December 2018. All studies with a minimum of 10 patients that reported on endourologic management (SWL, PCNL, or URS) were included. Data were extracted for patient and stone demographics, outcomes including stone-free rate (SFR), adverse events, and renal function. Results: After an initial search of 553 articles, 27 were included for the final review (10 PCNL, 1 mini-PCNL, 9 URS, 1 SWL, and 6 comparative studies). The choice of treatment seemed to be based on stone size, with PCNL, URS, and SWL offered for mean stone sizes between 25–50, 10–28, and 12–15 mm, respectively. PCNL, URS, and SWL were reported in 1445, 792, and 186 patients, respectively, with a final SFR of 67%–97.7%, 43%–100%, and 73%–80% and a complication rate of 26.4%, 15%, and 16.7% across the three groups. The renal function deterioration was reported in 4/16 PCNL studies and in 1/15 URS studies, while it remained unaffected in the SWL study. Conclusions: Our review shows a rise of endourologic techniques in the management of stones in SK. Although PCNL was used for larger stones, it had a higher risk of major complications, including blood transfusion. While a good SFR was obtained for patients irrespective of the treatment modality, the selected intervention needs to be balanced with its safety profile and the need for ancillary procedures. [ABSTRACT FROM AUTHOR]

Background: We aimed to evaluate operative time with the outcomes of ureteroscopy (URS) and investigate the relationship between these factors, and assess if longer operative times were associated with a higher risk of complications. Methods: We retrospectively audited consecutive cases of URS done between March 2012 and June 2018. Data were collected for operative times, patient demographics, stone parameters, stent insertions, use of ureteric access sheath, length of stay, stone-free rate (SFR) and complications. Statistical analysis was performed using IBM SPSS version 24. Results: Over 6.5 years, 736 patients with a male:female ratio of 1.8:1 and a mean age of 54.7 years (range: 2-91 years), underwent 860 URS and stone treatment procedures. The mean operative time was 43.5 min (range: 8-160 min), with a stone size of 12.3 mm (range: 3-100 mm) and access sheath was used in 35.8%. The initial and final SFR was 86% and 92.5%, respectively, and 85.6% (n = 736) patients were discharged the same day of procedure. Treatment of multiple renal stones, ureteric and renal stones, large stones, use of access sheath and post-operative stent were all associated with longer operative times (p <0.001). Patients who were stone free and those having day-case procedures had shorter operative times (p <0.001). There were 27 (3.2%) Clavien I/II complications and 8 (0.9%) Clavien ≥III complications. Clavien score ≥III (p = 0.028) and infectious complications (p <0.001) had significantly longer operative times. Conclusion: Patients with shorter operative times have a higher chance of being discharged home the same day without a post-operative stent. Higher operative times are associated with high-grade, especially infection-related, complications. [ABSTRACT FROM AUTHOR]

Objective To ascertain the publication trends of interventions for paediatric kidney stone disease (KSD) we conducted a systematic review of literature over the last 16 years. Patients and methods With a rise of paediatric KSD and related interventions, a systematic review using PubMed was done over the last 16 years for all published papers on ‘Paediatric stone disease intervention – ureteroscopy (URS), shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), open stone surgery, and laparoscopic stone surgery’. The search was limited to English language articles with a published abstract, whilst case reports, animal and laboratory studies, were excluded. We also analysed the data in two time periods, period-1 (2000–2007) and period-2 (2008–2015). Results During the last 16-years, 339 papers were published on paediatric stone disease intervention on PubMed. This included papers on URS (95), PCNL (97), SWL (102), open stone surgery (34) and laparoscopic stone surgery (11). During period-1 and period-2 there were 30 and 65 papers on URS, 16 and 81 papers on PCNL, 33 and 60 papers on SWL, nine and 25 papers on open surgery, respectively. When comparing the two periods, there were 92 published papers for all interventions in period-1 and this had risen almost threefold to 247 papers in period-2. Conclusions Our systematic review shows that intervention for KSD in the paediatric age group has risen over the last 8 years. Whilst URS, SWL, open surgery and laparoscopic surgery have all doubled, PCNL has risen fivefold reflecting an increase in the new minimally invasive PCNL techniques. [ABSTRACT FROM AUTHOR]

Purpose of Review: The incidence of urinary stone disease among the paediatric population is increasing. Whilst there has been a rise in the number of original studies published on ureteroscopy (URS) in children, critical review still remains under-reported. Recent Findings: A Cochrane style systematic review was performed to identify all original articles on URS (minimum of 25 cases) for stone disease in paediatric patients between Jan. 1996 and Dec. 2016. Based on the number of reported cases, centres were divided into medium (25-49 cases) and high (≥ 50 cases) volume studies. Thirty-four studies (2758 children) satisfied our search criteria and were included in this review. The mean stone size was 8.6 mm with an overall stone-free rate (SFR) of 90.4% (range 58-100). Medium-volume centres reported a mean SFR of 94.1% (range 87.5-100), whilst high-volume centres reported a mean SFR of 88.1% (range 58-98.5). Mean number of sessions to achieve stone-free status in medium-volume and high-volume groups was 1.1 and 1.2 procedures/patient respectively. The overall complication rate was 11.1% (327/2994). Breakdown by Clavien grade was as follows: Clavien I 69% and Clavien II/III 31%. There were no Clavien IV/V complications, and no mortality was recorded across any of the studies. The overall failure to access rate was 2.5% (76/2944). Medium-volume and high-volume studies had overall complication rates of 6.9% (37/530) and 12.1% (287/2222) respectively, but there was no significant difference in major or minor complications between these two groups. Summary: Ureteroscopy is a safe and effective treatment for paediatric stone disease. Medium-volume centres can achieve equally high SFRs and safety profiles as high-volume centres. Despite the rarity of paediatric stone disease, our findings might increase the uptake of paediatric URS procedures. [ABSTRACT FROM AUTHOR]

Introduction: With the rise in the use of ureteroscopy and laser stone lithotripsy (URSL), a proportionate increase in the risk of post-procedural urosepsis has also been observed. The aims of our paper were to analyse the predictors for severe urosepsis using a machine learning model (ML) in patients that needed intensive care unit (ICU) admission and to make comparisons with a matched cohort. Methods: A retrospective study was conducted across nine high-volume endourology European centres for all patients who underwent URSL and subsequently needed ICU admission for urosepsis (Group A). This was matched by patients with URSL without urosepsis (Group B). Statistical analysis was performed with 'R statistical software' using the 'randomforests' package. The data were segregated at random into a 70% training set and a 30% test set using the 'sample' command. A random forests ML model was then built with n = 300 trees, with the test set used for internal validation. Diagnostic accuracy statistics were generated using the 'caret' package. Results: A total of 114 patients were included (57 in each group) with a mean age of 60 ± 16 years and a male:female ratio of 1:1.19. The ML model correctly predicted risk of sepsis in 14/17 (82%) cases (Group A) and predicted those without urosepsis for 12/15 (80%) controls (Group B), whilst overall it also discriminated between the two groups predicting both those with and without sepsis. Our model accuracy was 81.3% (95%, CI: 63.7–92.8%), sensitivity = 0.80, specificity = 0.82 and area under the curve = 0.89. Predictive values most commonly accounting for nodal points in the trees were a large proximal stone location, long stent time, large stone size and long operative time. Conclusion: Urosepsis after endourological procedures remains one of the main reasons for ICU admission. Risk factors for urosepsis are reasonably accurately predicted by our innovative ML model. Focusing on these risk factors can allow one to create predictive strategies to minimise post-operative morbidity. [ABSTRACT FROM AUTHOR]