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Introduction: The novel coronavirus disease (COVID-19) pandemic has had a significant impact on the care of patients with urolithiasis. Recommendations and prioritization of endourologic surgical procedures vary among regions, and a comprehensive overall international directive is needed. We used the Delphi method to obtain international consensus on managing urolithiasis patients during the pandemic. Methods: A three-round Delphi process was used to elicit expert consensus (53 global key opinion leaders within the Endourological Society from 36 countries) on an extensive survey on management of endourologic patients in a pandemic. Questions addressed general management, inpatient and outpatient procedures, clinic visits, follow-up care, and best practices for suspension and resumption of routine care. Results: Consensus was achieved in 64/84 (76%) questions. Key consensus findings included the following: consultations should be delivered remotely when possible. Invasive surgical procedures for urolithiasis patients should be reserved for high-risk situations (infection, renal failure, etc.). To prevent aerosolization, spinal anesthesia is preferred over general, whenever feasible. Treatment of asymptomatic renal stones should be deferred. Primary definitive treatment of obstructing or symptomatic stones (both renal and ureteral) is preferred over temporizing drainage. Extracorporeal shockwave lithotripsy should be continued for obstructive ureteral stones. There was consensus on treatment modalities and drainage strategies depending on location and size of the stone. Conclusion: International endourologist members of the Endourological Society participated in this Delphi initiative to provide expert consensus on management of urolithiasis during a pandemic. These results can be applied currently and during a future pandemic. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and efficacy of emergency ureteroscopy (URS) compared with elective URS. Methods: We conducted a retrospective analysis of patients who underwent URS for isolated ureteral stones in a single center from October 2001 to February 2014. Our patient cohort was divided into two groups: an emergency URS group (Group A), which consisted of patients who underwent URS within the first 24 h of admission, and an elective or planned URS group (Group B). The URS success rate was defined as being the incidence of successful stone fragmentation and whether there was resolution of renal obstruction. Results: A total of 2957 patients' medical records were available for analysis. Of these, 704 (21%) comprised of emergency cases and the remaining 2253 (79%) were elective cases. Patients in Group A were younger, had a smaller BMIs, and had smaller stone sizes (p < 0.001). The URS success rate was found to be 97% in Group A and 96% in Group B (p = 0.35). Intraoperative or postoperative complication rates were not found to vary significantly between the groups (8% vs 7%, respectively, p = 0.50). The incidence of ureteral stenting was nearly twice as high if URS was performed during night hours (85% vs 45%, p < 0.001). However, ureteral stenting was more prevalent in Group B compared to Group A patients (57% vs 25%, p < 0.001), possibly as a result of the number of pre-stented patients (73%). Conclusions: Emergency URS is an effective and safe option for patients with renal colic. Younger patients without pre-existing obesity and with stone sizes up to 8 mm located in the distal ureter might be a better match for emergency URS. [ABSTRACT FROM AUTHOR]

Background: With webinars looking to be the mainstay post-pandemic, it is important to demonstrate whether webinars are, indeed, effective educational tools for professional training and skill acquisition. We aim at demonstrating, via a global survey, the efficacy of webinars on percutaneous nephrolithotomy (PCNL) and how this knowledge transforms clinical practice. Methods: A structured online survey covering the following sections: (1) Demographics, (2) PCNL techniques, and (3) PCNL equipment was circulated. The target study population were practicing urologists and residents. Categorical data were presented with counts and percentages, and they were compared by using Chi-square test. Continuous data were analyzed with non-parametric methods. Respondents were dichotomized according to attendance of webinar type, attendees of dedicated PCNL webinars (Group A), or attendees of endourological webinars that discussed some aspects of PCNL (Group B). Results: A total of 303 respondents from 38 countries participated. Overall, 91.7% (n = 278) were in Group A and 8.3% (n = 25) were in Group B; 77.9% were younger than 50 years, whereas 51.8% had more than 10 years of urology experience. In group A, urologists of all ages, in academic institutions and private practitioners, significantly benefited in gaining knowledge about the merits of newer devices and the role of suction-assisted devices in modern PCNL. The majority of group A also reflected that by attending a dedicated PCNL-based webinar they benefited in learning newer positions for PCNL access, especially supine, and how to effectively use laser as energy devices for lithotripsy. In Group B, the only area of benefit was in lasing techniques and the use of newer lasers such as the thulium fibre laser. Conclusion: Our survey positively validates the two proposed hypothesis, that is, webinars as a medium of education do benefit practicing urologists in knowledge and the clinical practice domains. Age, experience, or place of practice is no barrier to adopting newer mediums of education such as webinars. [ABSTRACT FROM AUTHOR]

Objective: To develop a tool, both simple and reliable, for postoperative percutaneous nephrolithotomy (PCNL) stone-free failure prediction. Materials and methods: We analysed a sample of 116 patients, who underwent conventional PCNL from 2011 to 2014. Cases with residual stones ⩽ 4 mm in size were regarded as clinically insignificant and ‘stone-free’. Results: According to the low-dose computed tomography (CT) scan performed within 24 hours after operation, the patients were stratified as follows: 72 stone-free and 44 with residual stones. Among the analysed variables, three were derived as most important for prediction purposes: an additional stone in a calyx with an acute angle (⩽ 45°), represented by ‘A’; an additional stone in a long calyx (⩾ 10 mm) with a narrow infundibulum (⩽ 8mm), represented by ‘C’; and a stone size that is > 24 mm, represented by ‘S’. These were abbreviated as the ‘ACS’ score. Depending on the absence or presence of each of these three variables, a score of 0 or 1 was assigned. If the ACS score is 0, then the probability of being a stone-free patient was about 88%; however, when the ACS score is 3, then the probability of being stone free was just 8%. Conclusion: Use of the ACS score seemed to be a simple and reliable tool for PCNL stone-free failure prediction. [ABSTRACT FROM AUTHOR]

Purpose: Traditionally, bilateral urolithiasis treatment involved staged interventions due to safety concerns. Recent studies have shown that same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) is effective, with acceptable complication rates. However, there's no clear data on the optimum laser for the procedure. This study aimed to assess outcomes of SSB-RIRS comparing thulium fiber laser (TFL) and high-power holmium:yttrium-aluminum-garnet (Ho:YAG) laser in a multicenter real-world practice., Materials and Methods: Retrospective analysis was conducted on patients undergoing SSB-RIRS from January 2015 to June 2022 across 21 centers worldwide. Three months perioperative and postoperative outcomes were recorded, focusing on complications and stone-free rates (SFR)., Results: A total of 733 patients were included, with 415 in group 1 (Ho:YAG) and 318 in group 2 (TFL). Both groups have similar demographic and stone characteristics. Group 1 had more incidence of symptomatic pain or hematuria (26.5% vs. 10.4%). Operation and lasing times were comparable. The use of baskets was higher in group 1 (47.2% vs. 18.9%, p<0.001). Postoperative complications and length of hospital stay were similar. Group 2 had a higher overall SFR. Multivariate regression analysis indicated that age, presence of stone at the lower pole, and stone diameter were associated with lower odds of being stone-free bilaterally, while TFL was associated with higher odds., Conclusions: Our study shows that urologists use both lasers equally for SSB-RIRS. Reintervention rates are low, safety profiles are comparable, and single-stage bilateral SFR may be better in certain cases. Bilateral lower pole and large-volume stones have higher chances of residual fragments., Competing Interests: The authors have nothing to disclose., (© The Korean Urological Association.)

Purpose: To assess the incidence of the most common intra- and early postoperative complications following RIRS in a large series of patients with kidney stones., Methods: We conducted a retrospective analysis of patients with kidney stones who underwent RIRS across 21 centers from January 2018 to August 2021, as part of the Global Multicenter Flexible Ureteroscopy Outcome (FLEXOR) Registry., Results: Among 6669 patients undergoing RIRS, 4.5% experienced intraoperative pelvicalyceal system bleeding without necessitating blood transfusion. Only 0.1% of patients, required a blood transfusion. The second most frequent intraoperative complication was ureteric injury due to the ureteral access sheath requiring stenting (1.8% of patients). Postoperatively, the most prevalent early complications were fever/infections requiring antibiotics (6.3%), blood transfusions (5.5%), and sepsis necessitating intensive care unit admission (1.3%). In cases of ureteric injury, a notably higher percentage of patients exhibited multiple stones and stone(s) in the lower pole, and these cases were correlated with prolonged lasing and overall surgical time. Hematuria requiring a blood transfusion was associated with an increased prevalence of larger median maximum stone diameters, particularly among patients with stones exceeding 20 mm. Furthermore, these cases exhibited a significant prolongation in surgical time. Sepsis necessitating admission to the intensive care unit was more prevalent among the elderly, concomitant with a significantly larger median maximum stone diameter., Conclusions: Our analysis showed that RIRS has a good safety profile but bleeding requiring transfusions, ureteric injury, fever, and sepsis are still the most common complications despite advancements in technology., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Background: Retrograde Intrarenal Surgery (RIRS) is recommended as an alternative to percutaneous nephrolithotomy for stones up to 2 cm. Pre-stenting before RIRS remains controversial with various studies differing in outcomes and recommendations. We aim to understand how pre-stenting influences surgical outcomes., Methods: A number of 6579 patients from the TOWER group registry were divided into pre-stented (group 1) and non-pre-stented groups (group 2). Patients aged ≥18 years old, with normal calyceal anatomy were enrolled. Patients with ureteric stones, anomalous kidneys, bilateral stones, planned for ECIRS were excluded., Results: Patients are homogeneously distributed in both groups (3112 vs. 3467). The predominant indication for pre-stenting was symptom relief. Overall stone size was comparable, whilst group 1 had a significantly more multiple (1419 vs. 1283, P<0.001) and lower-pole (LP) stones (1503 vs. 1411, P<0.001). The mean operative time for group 2 was significantly longer (68.17 vs. 58.92, P<0.001). Stone size, LP stones, age, recurrence and multiple stones are contributing factors for residual fragments at the multivariable analysis. The incidence of postoperative day 1 fever and sepsis was significantly higher in group 2, indicating that pre-stenting is associated with a lower risk of post-RIRS infection and a lower overall complications rate (13.62% vs. 15.89%) (P<0.001)., Conclusions: RIRS without pre-stenting can be considered safe without significant morbidity. Multiple, lower-pole and large stone is a significant contributor towards residual fragments. Patients who were not pre-stented had significantly higher but low-grade complications, especially for lower pole and large volume stones. While we do not advocate routine pre-stenting, a tailored approach for these patients should include proper counselling regarding pre-stenting.

Objective: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS)., Materials and Methods: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement., Results: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories., Conclusion: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS., (© 2022 The Authors. BJU International published by John Wiley & Sons Ltd on behalf of BJU International.)

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.)