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Purpose: The aim of the study was to evaluate illumination properties in an in-vitro kidney calyx model in saline., Design and Methods: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed closed pink kidney calyx model, submerged in saline. A spectrometer was used for illuminance and color temperature measurements at different openings located at center (direct light), 45° (direct and indirect light) and 90°(indirect light) to the axis of the scope., Results: Maximum illuminance was at the center opening for all scopes (range: 284 to 12,058 lx at 50% brightness and 454 to 11,871 lx at 100% brightness settings). The scope with the highest center illuminance (Flex-Xc) was 26 times superior to the scope with the lowest illuminance (Pusen 7.5Fr) at 100% brightness setting. For each scope, there was a peripheral illuminance drop ranging from - 43 to - 92% at 50% brightness and - 43% to - 88% at 100% brightness settings, respectively (all p < 0.01). Highest drop was for the P7 and the Pusen 9.2F. All scopes had illuminance skew, except the V3. All scopes had a warm color temperature., Conclusion: Illumination properties vary between ureteroscopes in an enclosed cavity in saline, and differs at center vs 45° and 90° positions within scopes. Peripheral illuminance drop can be as high as - 92%, which is undesirable. This may affect the choice of ureteroscope and light brightness settings used in surgery by urologists., (© 2024. The Author(s).)

Purpose: To date, no study has evaluated effects of varying brightness settings on image quality from flexible ureteroscopes submerged in saline. The aim was to evaluate blackout and whiteout occurrences in an in-vitro kidney calyx model., Material and Methods: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed enclosed pink in-vitro kidney calyx model submerged in saline. Endoscopic images were captured with ureteroscope tip placed at 5 mm,10 mm and 20 mm distances. The complete range of brightness settings and video capture modes were evaluated for each scope. Distribution of brightness on a grayscale histogram of images was analyzed (scale range 0 to 255). Blackout and whiteout were defined as median histogram ranges from 0 to 35 and 220 to 255, respectively (monitor image too dark or too bright for the human eye, respectively)., Results: Blackout occurred with the P7, Pusen 7.5F, 9.2F and WiScope at all distances, and V3 at 20 mm - with lowest brightness settings. Whiteout occurred with Flex-X2s, V3 and P7 at 5 mm and 10 mm, as well as with V3 and P7 at 20 mm - mostly with highest brightness settings. The Flex-Xc had neither blackout nor whiteout at all settings and distances., Conclusion: Blackout or whiteout of images is an undesirable property that was found for several scopes, possibly impacting diagnostic and therapeutic purposes during ureteroscopy. These observations form a guide to impact a urologist's choice of instruments and settings., (© 2024. The Author(s).)

Purpose: During endoscopic stone surgery, Holmium:YAG (Ho:YAG) and Thulium Fiber Laser (TFL) technologies allow to pulverize urinary stones into fine particles, ie DUST. Yet, currently there is no consensus on the exact definition of DUST. This review aimed to define stone DUST and Clinically Insignificant Residual Fragments (CIRF)., Methods: Embase, MEDLINE (PubMed) and Cochrane databases were searched for both in vitro and in vivo articles relating to DUST and CIRF definitions, in November 2023, using keyword combinations: "dust", "stones", "urinary calculi", "urolithiasis", "residual fragments", "dusting", "fragments", "lasers" and "clinical insignificant residual fragments"., Results: DUST relates to the fine pulverization of urinary stones, defined in vitro as particles spontaneously floating with a sedimentation duration ≥ 2 sec and suited for aspiration through a 3.6Fr-working channel (WC) of a flexible ureteroscope (FURS). Generally, an upper size limit of 250 µm seems to agree with the definition of DUST. Ho:YAG with and without "Moses Technology", TFL and the recent pulsed-Thulium:YAG (pTm:YAG) can produce DUST, but no perioperative technology can currently measure DUST size. The TFL and pTm:YAG achieve better dusting compared to Ho:YAG. CIRF relates to residual fragments (RF) that are not associated with imminent stone-related events: loin pain, acute renal colic, medical or interventional retreatment. CIRF size definition has decreased from older studies based on Shock Wave Lithotripsy (SWL) (≤ 4 mm) to more recent studies based on FURS (≤ 2 mm) and Percutaneous Nephrolithotomy(PCNL) (≤ 4 mm). RF ≤ 2 mm are associated with lower stone recurrence, regrowth and clinical events rates. While CIRF should be evaluated postoperatively using Non-Contrast Computed Tomography(NCCT), there is no consensus on the best diagnostic modality to assess the presence and quantity of DUST., Conclusion: DUST and CIRF refer to independent entities. DUST is defined in vitro by a stone particle size criteria of 250 µm, translating clinically as particles able to be fully aspirated through a 3.6Fr-WC without blockage. CIRF relates to ≤ 2 RF on postoperative NCCT., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Urothelial carcinoma (UC) affecting the urinary tract is recognized as one of the prevalent types of cancer, ranking fifth in terms of incidence. However, it is important to note that upper tract urothelial carcinoma (UTUC), in comparison to bladder cancer, is relatively uncommon and represents a minority of UC cases, accounting for ∼5% to 10%. It is worth emphasizing that as much as 60% of UTUC cases are invasive at the time of diagnosis, in contrast to 25% of bladder cancer cases. These statistics highlight the urgent need for well-designed, multidisciplinary strategies to guide optimal management for this vulnerable patient population, aiming to control treatment variability and minimize the risks associated with undertreatment and overtreatment. Methods: In this study, we present a comparative analysis of the contemporary guidelines on UTUC management from the European Association of Urology (EAU) and the American Urological Association/Society of Urologic Oncology (AUA/SUO) released in 2023. Our objective is to contrast the different guidelines and examine the evidence on which their recommendations are based. Results: By thoroughly reviewing the guidelines from both organizations, we observed substantial agreement on the management of UTUC. However, we also identified noticeable differences among these guidelines, leading to a wide range of recommendations. These disparities might stem from variations in clinical practices, regional preferences, and the availability of resources. It is crucial to acknowledge that both the EAU and AUA/SUO base their guidelines on the latest scientific evidence and expert consensus within their respective regions. Conclusions: These findings underscore the importance of ongoing collaboration, knowledge exchange, and harmonization of guidelines to improve the standard of care for UTUC globally. Future research should focus on identifying areas of consensus and bridging the gaps between different international guidelines to enhance the management outcomes for this challenging disease.

Purpose: This study aimed to evaluate the ability of Kidney Stone Calculator (KSC), a flexible ureteroscopy surgical planning software, to predict the lithotripsy duration with both holmium:YAG (Ho:YAG) and thulium fiber laser (TFL)., Methods: A multicenter prospective study was conducted from January 2020 to April 2023. Patients with kidney or ureteral stones confirmed at non-contrast computed tomography and treated by flexible ureteroscopy with laser lithotripsy were enrolled. "Kidney Stone Calculator" provided stone volume and subsequent lithotripsy duration estimation using three-dimensional segmentation of the stone on computed tomography and the graphical user interface for laser settings. The primary endpoint was the quantitative and qualitative comparison between estimated and effective lithotripsy durations. Secondary endpoints included subgroup analysis (Ho:YAG-TFL) of differences between estimated and effective lithotripsy durations and intraoperative outcomes. Multivariate analysis assessed the association between pre- and intraoperative variables and these differences according to laser source., Results: 89 patients were included in this study, 43 and 46 in Ho:YAG and TFL groups, respectively. No significant difference was found between estimated and effective lithotripsy durations (27.37 vs 28.36 min, p = 0.43) with a significant correlation (r =  + 0.89, p < 0.001). Among groups, this difference did not differ (p = 0.68 and 0.07, respectively), with a higher correlation between estimated and effective lithotripsy durations for TFL compared to Ho:YAG (r =  + 0.95, p < 0.001 vs r =  + 0.81, p < 0.001, respectively). At multivariate analysis, the difference was correlated with preoperative (volume > 2000 mm 3 (Ho:YAG), 500-750 mm 3 SV and calyceal diverticulum (TFL)), operative (fragmentation setting (p > 0.001), and basket utilization (p = 0.05) (Ho:YAG)) variables., Conclusion: KSC is a reliable tool for predicting the lithotripsy duration estimation during flexible ureteroscopy for both Ho:YAG and TFL. However, some variables not including laser source may lead to underestimating this estimation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Objective: Data regarding open conversion (OC) during minimally invasive surgery (MIS) for renal tumors are reported from big databases, without precise description of the reason and management of OC. The objective of this study was to describe the rate, reasons, and perioperative outcomes of OC in a cohort of patients who underwent MIS for renal tumor initially. The secondary objective was to find the factors associated with OC., Methods: Between 2008 and 2022, of the 8566 patients included in the UroCCR project prospective database (NCT03293563), who underwent laparoscopic or robot-assisted minimally invasive partial (MIPN) or radical (MIRN) nephrectomy, 163 experienced OC. Each center was contacted to enlighten the context of OC: "emergency OC" implied an immediate life-threatening situation not reasonably manageable with MIS, otherwise "elective OC". To evaluate the predictive factors of OC, a 2:1 paired cohort on the UroCCR database was used., Key Findings and Limitations: The incidence rate of OC was 1.9% for all cases of MIS, 2.9% for MIRN, and 1.4% for MIPN. OC procedures were mostly elective (82.2%). The main reason for OC was a failure to progress due to anatomical difficulties (42.9%). Five patients (3.1%) died within 90 d after surgery. Increased body mass index (BMI; odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, p  = 0.009) and cT stage (OR: 2.22, 95% CI: 1.24-4.25, p  = 0.008) were independent predictive factors of OC., Conclusions and Clinical Implications: In MIS for renal tumors, OC was a rare event (1.9%), caused by various situations, leading to impaired perioperative outcomes. Emergency OC occurred once every 300 procedures. Increased BMI and cT stage were independent predictive factors of OC., Patient Summary: The incidence rate of open conversion (OC) in minimally invasive surgery for renal tumors is low. Only 20% of OC procedures occur in case of emergency, and others are caused by various situations. Increased body mass index and cT stage were independent predictive factors of OC., (© 2024 The Author(s).)

Purpose: Artifacts from poor ureteroscopes' light design with shadowing and dark areas in the field of view have been reported. The aim was to quantify effects of light obstruction in a kidney calyx model., Methods: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using an enclosed 3D-printed pink in vitro kidney calyx model submerged in saline, where the field of light was intentionally partially obstructed alternatively at 12, 3, 6, and 9 o'clock. A color spectrometer was used for illuminance measurements at a 45° opening position in the background of the model., Results: Overall and mean background illuminance for each obstructive situation were significantly different between scopes for both 50% and 100% brightness settings (ANOVA p < 0.001). At 50% brightness setting, almost all scopes had their highest and lowest background illuminance with the 6 o'clock and 3 o'clock obstructive situation, respectively. At 100% brightness setting, these became 6 o'clock and 12 o'clock obstructive situations. Considering each obstructive situation individually, the Flex-Xc was consistently the scope with highest background illuminance and the Pusen 7.5F the lowest. Background illuminance for each obstructive situation varied significantly for each scope individually, with the greatest range of variability for Pusen 7.5F and V3., Conclusions: Illuminance performance of ureteroscopes within an obstructed calyx model differ significantly for various obstructive situations. Urologists should be aware of this to help guide their choice of ureteroscope., (© 2024. The Author(s).)

Angiosarcoma is a rare malignancy derived from endothelial cells, which behaves aggressively. Primary angiosarcoma of the kidney is even rarer, and its clinical and radiological presentations do not differ from clear cells renal cell carcinoma (ccRCC). Management protocols are not standardized, although nephrectomy is usually performed. Subsequent treatments (chemotherapy, radiotherapy, and lately, targeted therapies) vary considerably. Herein, we report the case of a middle-aged patient harboring primary angiosarcoma of the left kidney and discuss its presentation and management in light of current guidelines. The case is described for its rarity and masquerading nature., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Introduction: Both Holmium:yttrium-aluminium-garnet (Ho:YAG) laser and Thulium Fiber Laser (TFL) can effectively treat all urinary stone types. This in vitro study evaluated the ablation volume per pulse (AVP) and required energy needed to ablate 1mm 3 (RE, J/mm 3 ) of various stone types at different laser settings with TFL., Methods: 272-µm core-diameter laser fibers (Boston Scientific © ) were connected to a 50 Watts TFL generator (IPG ® ). An experimental setup immerged human stones of calcium oxalate monohydrate (COM), uric acid (UA), and cystine (CYS) with a single pulse lasing emission (0.5/0.8/1 J), in contact mode. Stones were dried out before three-dimensional scanning to measure AVP and deduce from the pulse energy (PE) and AVP the RE. A direct comparison with known Ho:YAG's AVP and RE was then carried out., Results: AVP for COM stones was significantly greater than those for CYS stones and similar to UA stones (p = 0.02 and p = 0.06, respectively). If AVP increased with PE against COM and UA stones, AVP decreased against CYS stones. 1 J PE resulted in a threefold lower RE compared with other PE for COM stones. On the contrary, RE for CYS increased with PE, whereas PE did not had influence on RE for UA. TFL was associated with greater AVP for COM, but lower for UA and CYS stones compared to Ho:YAG laser., Conclusion: This in vitro study firstly describes the ablation volume per pulse and required energy to treat a cubic millimeter of three frequent human stone types, and suggest TFL could not be suited for cystine. Therefore, stone composition could be considered when choosing the laser source for lithotripsy., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To provide a technological description of the new pulsed solid-state Thulium:YAG laser (Tm:YAG). In addition, current available literature on Tm:YAG lithotripsy is also reviewed., Materials and Methods: Medline, Scopus, Embase, and Web of Science databases were used to search for Tm:YAG operating mode articles., Results: Tm:YAG technology works with a laser cavity with thulium-doped YAG crystal, pumped by laser diodes. Laser beam operates at 2013 nm, with an adjustable peak power (≥ 1000 W) and the minimal fiber laser diameter is of 200 µm. It has an intermediate water absorption coefficient and peak power-pulse duration. Various pulse modulations are proposed, aiming to minimize stone retropulsion. Multiple comparative in vitro studies suggest that Tm:YAG's ability to fragment stones is similar to the one of the Ho:YAG laser; on the contrary, its ability to dust all stone types is similar to the one of the TFL, with a low retropulsion. A single in vivo study assessed Tm:YAG lithotripsy feasibility., Conclusions: The new pulsed solid-state thulium:YAG laser could represent a safe and effective compromise between Ho:YAG laser and TFL for endoscopic lithotripsy, either in retrograde intra-renal surgeries or in percutaneous nephrolithotomy., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The novel pulsed thulium:yttrium-aluminum-garnet (p-Tm:YAG) laser was recently introduced. Current studies present promising p-Tm:YAG ablation efficiency, although all are based on non-human stone models or with unknown stone composition. The present study aimed to evaluate p-Tm:YAG ablation efficiency for stone dust from human urinary stones of known compositions., Methods: Calcium oxalate monohydrate (COM) and uric acid (UA) stones were subjected to lithotripsy in vitro using a p-Tm:YAG laser generator (Thulio®, Dornier MedTech GmbH, Germany). 200 J was applied at 0.1 J × 100 Hz, 0.4 J × 25 Hz or 2.0 J × 5 Hz (average 10W). Ablated stone dust mass was calculated from weight difference between pre-lithotripsy stone and post-lithotripsy fragments > 250 µm. Estimated ablated volume was calculated using prior known stone densities (COM: 2.04 mg/mm 3 , UA: 1.55 mg/mm 3 )., Results: Mean ablation mass efficiency was 0.04, 0.06, 0.07 mg/J (COM) and 0.04, 0.05, 0.06 mg/J (UA) for each laser setting, respectively. This translated to 0.021, 0.029, 0.034 mm 3 /J (COM) and 0.026, 0.030, 0.039 mm 3 /J (UA). Mean energy consumption was 26, 18, 17 J/mg (COM) and 32, 23, 17 J/mg (UA). This translated to 53, 37, 34 J/mm 3 (COM) and 50, 36, 26 J/mm 3 (UA). There were no statistically significant differences for laser settings or stone types (all p > 0.05)., Conclusion: To our knowledge, this is the first study showing ablation efficiency of the p-Tm:YAG laser for stone dust from human urinary stones of known compositions. The p-Tm:YAG seems to ablate COM and UA equally well, with no statistically significant differences between differing laser settings., (© 2023. The Author(s).)

Background and Objective: We aimed to evaluate the concordance between the pre-settings ranges of thulium fibre laser (TFL) (Coloplast TFL Drive, Denmark) with easy-to-use graphical user interface and the laser settings used by a high-volume endo-urologist during surgical procedures., Materials and Methods: In October 2022, we prospectively collected data of 67 patients who underwent TFL Drive (Coloplast, Denmark) for the management of urinary stones. Urothelial tumour (upper tract urinary cancer (UTUC) and bladder) 200 and 150 μm laser fibres were used for procedures. Stones characteristics (size and density) tumours and stenosis localizations, laser-on time (LOT), and laser settings were recorded. We also assessed the ablation speed (mm 3 /s), laser power (W), and Joules/mm 3 values for each lithotripsy., Results: A total 67 patients took part in the study. Median age was 52 (15-81) years. 55 (82%), 8 (12%), and 4 (6%) patients presented urinary stones, urothelial tumour, and stenosis, respectively. Median stone volume was 438 (36-6027) mm 3 and median density was 988 (376-2000) HU. Median pulse energy was 0.6 (0.3-1.2), 0.8 (0.5-1) and 1 J for urinary stones, urothelial tumour and stenosis respectably. Endoscopically stone-free rate was 89%. Graphical user interface and surgeon accordance with the safety range were observed in 93.2%, 100% and 100% for urinary stones, UTUC and stenosis, respectively., Conclusion: During endoscopic procedures for urinary stones treatment, it is frequently needed to change laser parameters. These new TFL and GUI technology parameters remained in the pre-set security range in 94.1% of procedures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Flexible ureteroscopy (fURS) is steadily gaining popularity in the management of renal calculi, including those located in the lower pole (LP). Due to difficulty in accessing to the LP of kidney in minority of cases with fURS and reports of lower stone-free rate (SFR), it is still considered as a challenge in selected cases. The purpose of the review was to analyze the various aspects of fURS for LP stones., Methods: An extensive review of the recent literature was done including different factors such as anatomy, preoperative stenting, stone size, flexible scopes, types of lasers, laser fibers, suction, relocation, stone-free rates, and complications., Results: The significance of various lower pole anatomical measurements remain a subject of debate and requires standardization. Recent improvements in fURS such as single-use digital scopes with better vision and flexibility, high power laser, thulium fiber laser, smaller laser fiber, and accessories have significantly contributed to make flexible ureteroscopy  more effective and safer in the management of LP stone. The utilization of thulium fiber lasers in conjunction with various suction devices is being recognized and can significantly improve SFR., Conclusions: With the significant advancement of various aspects of fURS, this treatment modality has shown remarkable efficacy and gaining widespread acceptance in management of LP kidney stones. These developments have made the fURS of LP stones less challenging., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The management of urolithiasis has undergone significant advancements with the introduction of pulsed lasers, particularly the holmium:yttrium-aluminum-garnet (Ho:YAG) laser, which is currently considered the gold standard in endourology. However, the Ho:YAG laser has certain limitations, such as the inability to support small laser fibers (150 μm) and the requirement of a heavy water cooling system, making it challenging to transfer between operating rooms. These limitations have led to the emergence of new laser technologies, including the thulium fiber laser (TFL) and the thulium:yttrium-aluminum-garnet laser (Tm:YAG), as potential alternatives to the Ho:YAG laser., Methods: In this review, we aimed to evaluate the effectiveness and safety of TFL, Ho:YAG, and Tm:YAG lasers in real-life scenarios by comparing clinical trial data with laboratory findings. A literature review was conducted, and relevant in vitro studies and clinical trials until March 2023 were analyzed., Results: The findings indicate that TFL has demonstrated high ablation efficiency for stones of any composition, size, and location, superior the capabilities of Ho:YAG lasers. TFL has shown superior dusting and fragmentation abilities, lower retropulsion, and increased patient safety. The laser parameters, such as ablation efficiency, speed, operative time, dust quality, retropulsion, visibility, temperature safety, and stone-free rate, were compared between laboratory studies and clinical outcomes., Conclusion: Although the number of studies on TFL is limited, the available evidence suggests that TFL represents a significant advancement in laser technology for lithotripsy. However, further research is needed to fully explore the implications and limitations of TFL and Tm:YAG lasers., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To evaluate whether stone dust can be obtained from all prevailing stone composition types using the novel pulsed thulium:YAG (p-Tm:YAG), including analysis of stone particle size after lithotripsy., Methods: Human urinary stones of 7 different compositions were subjected to in vitro lithotripsy using a p-Tm:YAG laser with 270 µm silica core fibers (Thulio ® , Dornier MedTech GmbH ® , Wessling, Germany). A cumulative energy of 1000 J was applied to each stone using one of three laser settings: 0.1 J × 100 Hz, 0.4 J × 25 Hz and 2.0 J × 5 Hz (average power 10 W). After lithotripsy, larger remnant fragments were separated from stone dust using a previously described method depending on the floating ability of dust particles. Fragments and dust samples were then passed through laboratory sieves to evaluate stone particle count according to a semiquantitative analysis relying on a previous definition of stone dust (i.e., stone particles ≤ 250 µm)., Results: The p-Tm:YAG laser was able to produce stone dust from lithotripsy up to measured smallest mesh size of 63 µm in all seven stone composition types. Notably, all dust samples from all seven stone types and with all three laser settings had high counts of particles in the size range agreeing with the definition stone dust, i.e., ≤ 250 µm., Conclusion: This is the first study in the literature proving the p-Tm:YAG laser capable of dusting all prevailing human urinary stone compositions, with production of dust particles ≤ 250 µm. These findings are pivotal for the broader future implementation of the p-Tm:YAG in clinical routine., (© 2023. The Author(s).)

Background: An accurate estimation of the stone burden is the key factor for predicting retrograde intra-renal surgical outcomes. Volumetric calculations better stratify stone burden than linear measurements. We developed a free software to assess the stone volume and estimate the lithotrity duration according to 3D-segmented stone volumes, namely the Kidney Stone Calculator (KSC). The present study aimed to validate the KSC's reproducibility in clinical cases evaluating its inter-observer and intra-observer correlations., Methods: Fifty patients that harbored renal stones were retrospectively selected from a prospective cohort. For each patient, three urologists with different experience levels in stone management made five measurements of the stone volume on non-contrast-enhanced computed tomography (NCCT) images using the KSC., Results: the overall inter-observer correlation (Kendall's concordance coefficient) was 0.99 ( p < 0.0001). All three paired analyses of the inter-observer reproducibility were superior to 0.8. The intra-observer variation coefficients varied from 4% to 6%, and Kendall's intra-observer concordance coefficient was found to be superior to 0.98 ( p < 0.0001) for each participant. Subgroup analyses showed that the segmentation of complex stones seems to be less reproductible., Conclusions: The Kidney Stone Calculator is a reliable tool for the stone burden estimation. Its extension for calculating the lithotrity duration is of major interest and could help the practitioner in surgical planning., Competing Interests: The authors declare that they have no conflicts of interest to disclose other than the following: Olivier Traxer is a consultant for the Boston Scientific Corporation, Coloplast, Quanta System, Rocamed, Wolf, Court Medical, B-Braun, and IPG. Steeve Doizi is a consultant for the Boston Scientific Corporation and Coloplast. Frederic Panthier is a consultant for Dornier.

Introduction: Holmium:yttrium-aluminium-garnet (Ho:YAG) and thulium fiber (TFL) lasers are currently the two laser sources recommended for endocorporeal laser lithotripsy (ELL). Recently, the pulsed-thulium:YAG (Tm:YAG) laser was also proposed for ELL, as an answer to both Ho:YAG and TFL limitations. We aimed to evaluate the efficiency, safety, and laser settings of Tm:YAG laser in ELL during retrograde intrarenal surgery (RIRS)., Methods: A prospective study of the first 25 patients with ureteral and renal stones who underwent RIRS using the Thulio (pulsed-Tm:YAG, Dornier©, Germany) was performed in a single center. 272 µm laser fibers were used. Stone size, stone density, laser-on time (LOT) and laser settings were recorded. We also assessed the ablation speed (mm 3 /s), Joules/mm 3  and laser power (W) values for each procedure. Postoperative results, such as stone-free rate (SFR) and zero fragments rate (ZFR) were also recorded., Results: A total of 25 patients were analyzed (Table 1). The median (IQR) age was 55 (44-72) years old. Median (IQR) stone volume was 2849 (916-9153)mm 3 . Median (IQR) stone density was 1000 (600-1174)HU. Median (IQR) pulse energy, pulse rate and total power were 0.6 (0.6-0,8)J, 15(15-20)Hz and 12(9-16)W, respectively. All procedures used "Captive Fragmenting" pulse modulation (Table 2). The median (IQR) J/mm 3  was 14,8 (6-21). The median (IQR) ablation rate was 0,75 (0,46-2)mm 3 /s. One postoperative complications occurred (streinstrasse). SFR and ZFR were 95% and 55%, respectively., Conclusion: The pulsed-Tm:YAG laser is a safe and effective laser source for lithotripsy during RIRS, using low pulse energy and low pulse frequency., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Thulium lasers (TLs), namely the Thulium fiber laser (TFL) and the Thulium:YAG (Tm:YAG), are being increasingly adopted for the conservative treatment of upper urinary tract urothelial carcinoma (UTUC). However, to date, the real clinical impact of TLs on UTUC management remains not well-characterized. We performed a review of the literature to summarize the current evidence on TLs for UTUC treatment., Materials and Methods: We performed a systematic review in January 2023 using the Embase and Medline online databases, according to the PRISMA recommendations and using the PICO criteria. Outcomes of interest were: (i) to assess the safety and feasibility of TLs in the treatment of UTUC, and (ii) to evaluate the oncological outcomes in terms of tumor recurrence and conservative treatment failure. Moreover, we described TL characteristics and its interaction with soft tissue., Results: a total of 458 articles were screened, and six full texts including 273 patients were identified. All the included studies were retrospective series. Mean patient age ranged from 66 to 73 years. The indication of a conservative treatment was elective and imperative in 21.7-85% and 15-76% of cases, respectively. Laser power settings varied from 5 to 50 W. No intraoperative complications were reported, and all the procedures were successfully performed. The tumor recurrence rate was 17.7-44%, and the indication to radical nephroureterectomy was 3.7-44% during a follow-up of 6-50 months. Most of the postoperative complications were mild and transient, and ureteral strictures were reported in two studies. Major limitations were the retrospective nature of the studies, the small sample sizes, and the short follow-up., Conclusions: TL is an effective and safe technology for endoscopic UTUC treatment. However, current available literature lacks prospective and multicentric studies with large population sizes and long-term follow-up.

Purpose of Review: Retrograde intra renal surgery (RIRS) with laser lithotripsy represents the gold-standard to treat renal stones up to 20 mm. Controlling intraoperative parameters such as intrarenal pressure (IRP) and temperature (IRT) is mandatory to avoid complications. This article reviews advances in IRP and IRT over the last 2 years., Recent Findings: We conducted a PubMed/Embase search and reviewed publications that include temperature and pressure during RIRS. Thirty-four articles have been published which met the inclusion criteria. Regarding IRP, a consensus has emerged to control IRP during RIRS, in order to avoid (barotraumatic and septic) complications. Several monitoring devices are under evaluation but none of them are clinically approved for RIRS. Ureteral access sheath, low irrigation pressure and occupied working channel help to maintain a low IRP. Robotic systems and suction devices would improve IRP intraoperative management and monitoring. IRT determinants are the irrigation flow and laser settings. Low power settings(<20 W) with minimal irrigation flow (5-10 ml/min) are sufficient to maintain low IRT and allows continuous laser activation., Summary: Recent evidence suggests that IRP and IRT are closely related. IRP depends on inflow and outflow rates. Continuous monitoring would help to avoid surgical and infectious complications. IRT depends on the laser settings and the irrigation flow., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this review is to summarize the existing suction systems in flexible ureteroscopy (fURS) and to evaluate their effectiveness and safety., Methods: A narrative review was performed using the Pubmed and Web of Science Core Collection (WoSCC) databases. Additionally, we conducted a search on the Twitter platform. Studies including suctions systems in fURS were included. Editorials, letters and studies reporting intervention with semirigid ureteroscopy, PCNL and mPCNL were excluded., Results: A total of 12 studies were included in this review. These studies comprised one in vitro study, one ex vivo study, one experimental study and eight cohort studies. The Pubmed and WoSCC searches identified three suction techniques (Irrigation/Suctioning system with control of pressure, suction ureteral access sheath (sUAS) and direct in scope suction (DISS)), and the Twitter search identified four of them. The overall results showed that suction is an effective and safe technique that improves stone-free rates, reduces operative time and limits complication rates after fURS., Conclusions: The use of suctioning during common endourological procedures has been shown to improve safety and efficacy in several indications. However, randomized controlled trials are needed to confirm this.

Purpose: End-to-end (ETE) pyeloureterostomy is an alternative to ureteroneocystostomy for urinary anastomosis during kidney transplantation (KT). In preemptive KT from living donors (PKT-LD), end-to-side (ETS) uretero-ureteral anastomosis could have the benefits of pyeloureterostomy without ligation of the native kidney ureter. This study aimed to compare ETS to ETE uretero-ureteral anastomosis in PKT-LD., Methods: A monocentric retrospective 8-year study included all consecutive cases of PKT-LD, excluding ureteroneocystomy anastomosis and homolateral nephrectomy. Two groups were compared: ETS and ETE. Perioperative data on graft function and urological complications were collected., Results: One hundred and six patients were included: 48 patients in the ETS group and 58 patients in the ETE group. Median follow-up was 37.5 months [17.3; 57.5]. The estimated glomerular filtration rate at postoperative day ten and 3 months was similar in both groups. The overall complication rate was 16%, with no significant difference between the 2 groups. There was one ureteral stenosis in each group. None of the patients in the ETS group presented urinary fistula, whereas it occurred in one (1.7%) in the ETE group. Back pain due to native kidney obstruction occurred in 5 patients in the ETE group (8.6%), but not in the ETS group., Conclusion: In preemptive kidney transplantation from living donors, urinary anastomosis can safely be performed as an end-to-side uretero-ureteral anastomosis, with low urological complications. It could prevent symptoms and complications due to native kidney obstruction., Level of Evidence: IV., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate using an inanimate model the thermal injury and laser efficiency on high frequency, high energy, and its combination in hands of junior and experienced urologists during holmium YAG (Ho:YAG) and Thulium fiber laser (TFL) lithotripsy. Methods: A Cyber: Ho 150 WTM and Fiber Dust TFL (Quanta System) with 200 μm core-diameter laser fibers (LF) were used in a saline in vitro ureteral model. Each participant (five junior and five experienced urologists) performed 32 sessions of 5-minute lasering (125 mm 3 phantom BegoStones™), comparing four modes (3 J/5 Hz [1.5 W], 0.3 J/20 Hz [6 W], 1.2 J/5 Hz [6 W], and 1.2 J/20 Hz [24 W]). Transparent tip and cleaved LF, and digital and fiberoptic ureteroscopes were also compared. Ureteral damage was classified in a scale (0-5) according to the burns and holes seen in the ureteral model's surface. Results: High-power (HP) setting (24 W) was associated with higher delivered energy and higher ablation rates (ARs) in both lasers ( p  < 0.001). For the same power setting (6 W), there was no difference in delivered energy or stone ARs. Regardless the settings, a higher AR was observed with TFL than with Ho:YAG (0.5Δ mg/s ± 0.33 vs 0.39 Δmg/s ± 0.31, p  = 0.002) laser. Higher mean AR was found with cleaved tip vs transparent tip ( p  = 0.03) in TFL. For both lasers, higher ureteral damage was observed in the 24 W group ( p  = 0.006) and in the junior urologists ( p  = 0.03). Between 6 W groups, different types of lesions were found and junior urologist have more lesions when high frequency was used, for both Ho:YAG ( p  = 0.05) and TFL ( p  = 0.04). Conclusion: More stone ARs and reduced operative time are observed in HP settings; however, more ureteral thermic-related damage is produced. When comparing the same power, higher energy or frequency does not modify the AR. Nonetheless, more ureteral thermic-related thermal damage is observed in high-frequency settings in unexperienced hands.

Introduction and Objectives: The thulium fiber (Tm-F) laser is currently studied as an alternative to the holmium: yttrium-aluminum-garnet (Ho:YAG) laser, the gold standard for endocorporeal laser lithotripsy. We aimed to evaluate the ex vivo effects of an accidental Tm-F laser exposure on bovine eyes and to test the protective action of different eyeglasses in preventing eye lesions in case of an accident. Methods: A 50-W TFL generator (IPG Photonics ® , Russia) with a wavelength of 1940 nm and 200-μm core diameter fibers (CDFs) were used. The laser fiber tip was pointed perpendicularly at different distances (0, 1, 3, 5, 8, and 10 cm, respectively) to the pupil center of the bovine eye. The Tm-F laser was activated for 1 or 3 seconds at three different settings (0.5 J-20 Hz, 1 J-10 Hz, and 2 J-10 Hz, respectively). The experiment was repeated using laser safety glasses and eyeglasses. After lasering, eye samples were immersed in a 0.5% fluorescein serum (Faure-Ciba-Geigy ® , Switzerland), then rinsed with saline. White and blue light examination looked for localized epithelial burns (LEBs), extended epithelial burns (EEBs), superficial corneal ulcerations (SCUs), and deep corneal ulcerations (DCUs). Results: A total of 68 bovine eyes were used. Despite the laser settings, both DCU (contact) and SCU (1 cm) developed without eye protection for 1 and 3 seconds of lasering. At the 3-cm fiber-eye distance, only burning lesions were observed. Over 5 cm, no lesion was found. At contact or 1-cm fiber-eye distance, pulse energy did not change the lesion grade, but at 3 cm, high pulse energy led to higher grade corneal lesions (0.5 J-10 Hz:LEB; 1 J-10 Hz:EEB). Despite the fiber-eye distance, no corneal lesions were reported in the laser safety glass or eyeglass group for 1 second of laser exposure. Conclusions: Our study highlights the risk of eye damage caused by Tm-F. Without proper eye protection, the Tm-F laser can cause corneal lesions up to 5 cm in distance with 1 second of exposure despite laser settings. Only dedicated protective eyeglasses are effective for long exposures.

Objectives: To assess the effect of various factors on laser fiber tip degradation with the thulium fiber laser (Tm-fiber): fiber stripping, adjustable laser settings (energy, frequency, peak power), and stone density. Methods: Two hundred seventy-three micrometer fibers were used with a 50W Tm-fiber. First, we assessed the evolution of power transmission with stripped and unstripped fibers submerged in saline. The laser was continuously activated for 5 minutes. The influence of each laser parameter (energy, frequency, and peak power) on fiber degradation was assessed by loss of power transmission and reduction of tip length. Second, we assessed the evolution of power transmission after 150 seconds of lithotripsy in a quasicontact mode against soft and hard BegoStones. The influence of lithotripsy with different laser settings on fiber degradation was assessed by loss of power transmission. Results: Power transmission was close to 100% with stripped fibers, while a power gain appeared for unstripped fibers after 5 minutes of laser emission. Thus, only stripped laser fibers were used during the second series of experiments. Regardless of laser settings, there was a constant loss of measured power transmission after lithotripsy with a significant difference between soft and hard stones, p  < 0.0001. Power transmission was 67% and 78% against hard and soft stones, respectively. While there was no influence of peak power on power output against hard stones, there was a significant one against soft stones. Conclusions: The main determinant of loss of power transmission during lithotripsy in contact mode with Tm-fiber is the stone density. Higher loss of power transmission occurs against hard stones than soft stones. All peak powers may be used against hard stones without a difference, while high peak power appears as an additional factor of power loss against soft stones, but this decrease will not the reach the one obtained with hard stones.

Purpose: Robot-assisted partial nephrectomy (RAPN) for posterior renal tumors may be performed through anterior (transperitoneal) or posterior (retroperitoneal) approach depending on surgeon's expertise. We propose herein a surgical artifice using daVinci Xi system to combine advantages of both approaches., Materials and Methods: From November 2019 to November 2020, patients with posterior renal mass, candidate for RAPN were prospectively included after informed consent. After positioning patient in lateral position, daVinci Xi system was docked on tumor side, to initiate transperitoneal procedure. Posterolateral dissection of perinephric space along fascia retrorenalis was conducted until psoas major muscle was exposed. Three additional robotic ports were then inserted in lumbar space, and RAPN was resumed after rotating daVinci Xi boom. Demographics, tumor characteristics, perioperative outcomes, estimated glomerular filtration rate (eGFR) and follow-up data were analyzed., Results: Ten consecutive patients underwent RAPN with the modified technique. All cases were performed robotically, without modification of port placement. Median (range) tumor diameter was 37 (21-48mm) with median RENAL score of 8 (4-10) Median operative time and warm ischemia time were respectively 128min (70-180min) and 19min (14-22). One patient had a Clavien-Dindo grade II complication. At median follow-up of 13 months (6-18), all patients had eGFR comparable to baseline., Conclusions: We report the feasibility and safety of a new hybrid posterior transperitoneal approach for RAPN using daVinci Xi system. Limitations include the absence of RENAL score>10 and pT2 tumors. Greater experience is needed to assess learning curve for surgeons untrained to robotic lomboscopy., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Objective: To assess the fiber-tissue interaction through ablation, coagulation, and carbonization characteristics of the Ho:YAG laser and super pulsed thulium fiber laser (TFL) in a nonperfused porcine kidney model. To assess the degradation of laser fibers during soft tissue treatment. Methods: A 50 W TFL generator was compared with a 120 W Ho:YAG laser. The laser settings that can be set identically between the two lasers (pulse energy and frequency), and clinically relevant for prostate laser enucleation, were identified and used for tissue incisions on fresh nonfrozen porcine kidneys. For each parameter, the short, medium, and long pulse durations for the Ho:YAG generator and the different peak powers 150, 250, and 500 W for the TFL generator were also tested. Laser incisions were performed with 550 μm stripped laser fiber fixed on a robotic arm at a distance of 0.1 mm with the tissue surface and at a constant speed of 10 mm/s. Histologic analysis was then performed, evaluating incision shape, incision depth and width, axial coagulation depth, and presence of carbonization. Degradation of the laser fiber was defined as reduction of laser fiber tip length after laser activation. Results: Incision depths and areas of coagulation were greater with the Ho:YAG laser than those with the TFL. Although no carbonization zone was found with the Ho:YAG laser, this was constant with the TFL. Although a fiber tip degradation was constantly observed with Ho:YAG laser, except in the case of a long pulse duration and low pulse energy (0.2 J), this was not the case with TFL. Conclusion: TFL appears to be an efficient alternative to Ho:YAG laser for soft tissue surgery. The histologic analysis found greater tissue penetration with the Ho:YAG laser and different coagulation properties between the two lasers. These results need to be investigated in vivo to assess the clinical impact of these differences and find the optimal settings for laser prostate enucleation.

Background: Endocorporeal laser lithotripsy (EL) during flexible ureteroscopy (URS-f) often uses "dusting" settings with "painting" technique. The displacement velocity of the laser fiber (LF) at the stone surface remains unknown and could improve EL's ablation rates. This in vitro study aimed to define the optimal displacement velocity (ODV) for both holmium:yttrium-aluminium-garnet (Ho:YAG) and thulium fiber laser (Tm-Fiber)., Methods: A 50W-TFL (IRE Polus ® , Moscow, Russia) and a 30W-MH1-Ho:YAG laser (Rocamed ® , Signes, Provence-Alpes-Côte d'Azur, France), were used with 272 µm-Core-Diameter LF (Sureflex, Boston Scientific © , San Jose, CA, USA), comparing three TFL modes, "fine dusting" (FD: 0.05-0.15 J/100-600 Hz); "dusting" (D: 0.5 J/30-60 Hz); "fragmentation" (Fr: 1 J/15-30 Hz) and two Ho:YAG modes (D: 0.5 J/20 Hz, Fr: 1 J/15 Hz). An experimental setup consisting of immerged cubes of calcium oxalate monohydrate (COM) stone phantoms (Begostone Plus, Bego © , Lincoln, RI, USA) was used with a 2 s' laser operation time. LF were in contact with the stones, static or with a displacement of 5, 10 or 20 mm. Experiments were repeated four times. Stones were dried and µ-scanned. Ablation volumes (mm 3 ) were measured by 3D-segmentation., Results: ODV was higher in dusting compared to fragmentation mode during Ho:YAG lithotripsy (10 mm/s vs. 5 mm/s, respectively). With Tm-Fiber, dusting and fragmentation OVDs were similar (5 mm/s). Tm-Fiber ODV was lower than Ho:YAGs in dusting settings (5 mm/s vs. 10 mm/s, respectively). Without LF displacement, ablation volumes were at least two-fold higher with Tm-Fiber compared to Ho:YAG. Despite the LF-DV, we report a 1.5 to 5-fold higher ablation volume with Tm-Fiber compared to Ho:YAG., Conclusions: In dusting mode, the ODV Tm-Fiber is lower compared to ODV Ho:YAG , translating to a potential easier Tm-Fiber utilization for "painting" dusting technique. The ODV determinants remain unknown. Dynamic ablation volumes are higher to static ones, regardless of the laser source, settings or LF displacement velocity.

Objectives: The Thulium Fiber Laser (TFL) is studied as an alternative to the holmium:yttrium-aluminium-garnet (Ho:YAG) laser for lithotripsy, with the advantage of an induced bubble stream (IBS). This in vitro study compared the TFL's IBS with 150- and 272 μm-core-diameter laser fiber (CDF) and in four irrigant fluids. Methods: A TFL of 50 W (IPG Photonics © ) and 150 and 272 μm-CDF (Boston Scientific © ) were used, comparing nine energies (in the range from 0.025 to 4 J). An experimental setup consisted of a vertically disposed fiber in a cuvette filled with saline, iodinated contrast agent (IOA), human urine, or deionized water (DW) at ambient temperature. High-speed imaging of three consecutive IBS was performed to determine the influence of energy on their maximum length (ML; μm), width (MW; μm), and duration (MD; μs). Fibers were cleaved with ceramic scissors between each experience. Results: The IBS had higher ML and MW and MD with 150CDF than 272CDF. Maximum pulse rate for 150CDF and 272CDF was 2182 and 2000 Hz, respectively. Every maximum power was higher than the technological limit of TFL (>50 W). At equal energy density, 150CDF was associated with lower dimensions and durations. The IBS had higher maximum dimensions in IOA compared with saline solution (SS). Compared with DW and urine, IBS in IOA were longer beyond 500 mJ. Over 25 mJ, IBS were thinner in DW, urine, and SS. The IBS in DW, urine, and SS had similar maximum dimensions. The IBS's duration was higher in IOA compared with DW, urine, and SS, meaning a lower theoretical maximum pulse rate and power in IOA. Conclusion: Lasering with 150CDF fits with lower pulse energies-higher pulse rates settings than 272CDF, such as fine dusting mode. In IOA, Induced Bubbles Streams present higher dimensions and durations than in other studied fluids, related to its higher viscosity. Safety distance and pulse rate should be increased and decreased, respectively.

Introduction: Kidney Stone Calculator (KSC) is a free, three-dimensional (3D) planning software for flexible ureteroscopy(fURS) with Holmium:YAG(Ho:YAG) endocorporeal lithotripsy (EL). KSC provides the stone volume (SV) and expected duration of lithotripsy (ExDL) estimations based on non-enhanced-CT scan (NECT) DICOM series. We aimed to provide a preclinical and clinical evaluation of KSC., Patients and Methods: A preclinical evaluation measured the SV by three operators (resident, endourology expert and research engineer) among 17 NECT cases. Between January and March 2020, a multicentric, prospective, observational double-blind clinical evaluation was conducted in patients presenting with renal stones treated with Ho:YAG-EL during fURS and preoperative NECT. Demographic and surgical data were collected. The primary endpoint was a significant median difference between ExDL and EffectiveDL (EfDL). Second, efficiency (J/mm 3 ) and efficacy (mm 3 /min) ratios were calculated., Results: The preclinical evaluation showed no significant difference in the SV measurements among operators (p > 0.05). Pearson and Kendall coefficients of 0.99 and 0.98, respectively, were found. Twenty-six patients were included in the clinical evaluation, with a median age of 55 years. In 66% of cases, there was a single stone located in the lower pole, with a density > 1000 Hounsfield Unit observed in 42% and 85% of cases. A 14% [Q1-Q3 (5.4-24.8); p = 0.36] median difference between ExDL and EfDL was noted, which was greater in the case of lower pole stones with no possible relocation (p = 0.008). Median values of 17.6 J/mm 3 and 0.4 (0.32-0.56) mm 3 /s EL were also noted., Conclusions: Kidney Stone Calculator is a reproducible and accurate software that allows for an estimation of the stone burden and provides an ExDL for URSf. Defining the influencing factors of EL will improve its ExDL., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: To compare the risk of laser fiber fracture between Ho:YAG laser and Thulium Fiber Laser (TFL) with different laser fiber diameters, laser settings, and fiber bending radii., Methods: Lengths of 200, 272, and 365 μm single use fibers were used with a 30 W Ho:YAG laser and a 50 W Super Pulsed TFL. Laser fibers of 150 µm length were also tested with the TFL only. Five different increasingly smaller bend radii were tested: 1, 0.9, 0.75, 0.6, and 0.45 cm. A total of 13 different laser settings were tested for the Ho:YAG laser: six fragmentation settings with a short pulse duration, and seven dusting settings with a long pulse duration. A total of 33 different laser settings were tested for the TFL. Three laser settings were common two both lasers: 0.5 J × 12 Hz, 0.8 J × 8 Hz, 2 J × 3 Hz. The laser was activated for 5 min or until fiber fracture. Each measurement was performed ten times., Results: While fiber failures occurred with all fiber diameters with Ho:YAG laser, none were reported with TFL. Identified risk factors of fiber fracture with the Ho:YAG laser were short pulse and high energy for the 365 µm fibers ( p = 0.041), but not for the 200 and 272 µm fibers ( p = 1 and p = 0.43, respectively). High frequency was not a risk factor of fiber fracture. Fiber diameter also seemed to be a risk factor of fracture. The 200 µm fibers broke more frequently than the 272 and 365 µm ones ( p = 0.039). There was a trend for a higher number of fractures with the 365 µm fibers compared to the 272 µm ones, these occurring at a larger bend radius, but this difference was not significant., Conclusion: TFL appears to be a safer laser regarding the risk of fiber fracture than Ho:YAG when used with fibers in a deflected position.

Endocorporeal laser lithotripsy (ELL) is currently the gold standard for the treatment of renal stones during retrograde intra-renal surgery (RIRS). The newly-authorised thulium fibre laser (Tm-Fibre) in now evaluated as a holmium:yttrium-aluminium-garnet (Ho:YAG) laser alternative, which is the most well-known laser source for ELL. This update aimed to present the fundamentals of pulsed lasers for EEL [technology, period, pulse characteristic (rate, duration, energy, shape), peak power, average power], and the available lithotripsy modes for both Tm-Fibre and Ho:YAG lasers., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Holmium:YAG(Ho:YAG) is currently the standard for lithotripsy. Superpulsed Thulium Fiber Laser(TFL) has been evaluated as an alternative for lithotripsy, using laser fibers with core-diameters(CDF) down to 50 µm and additional available settings suitable for "dusting" technique. This in-vitro study compared ablation rates, fissures and fragments' size with 150µmCDF or 272µmCDF with different laser settings using TFL and Ho:YAG., Methods: 150CDF and 272CDF were compared using three settings for TFL "fine dusting"(FD:0.15 J/100 Hz); "dusting"(D:0.5 J/30 Hz); "fragmentation"(Fr:1 J/15 Hz) and Ho:YAG(D and Fr). An experimental setup consisting of immerged 10 mm cubes of artificial hard(H) or soft(S) stone phantoms was used with a 20 s' lasing time and a spiral trajectory, in contact mode. Fragments (acquired through sieves) and stones were observed under optical microscopy before three-dimensional scanning to measure fragments and fissures(DOF) mean diameters and ablation volumes., Results: Ablation volumes in with 150CDF-TFL and 272CDF-TFL were higher than those for 272CDF-Ho:YAG in both "dusting" (twofold and threefold) and "fragmentation"(1,5-fold and twofold). "Fine dusting" ablation rates with 150CDF-TFL and 272CDF-TFL were respectively at least 1,5-fold and twofold higher than those for 272CDF-Ho:YAG in "dusting". 150CDF produced significantly smaller DOF than 272CDF in all settings against S and H except in fragmentation. 150CDF produced lower fragments' diameter than 272CDF in all settings except dusting., Conclusion: These preliminary studies demonstrate that at equal settings and CDF, TFL ablation rates are at least two-fold higher than those with Ho:YAG. 150CDF produces smaller fissures and fragments (that meets the definition of "dusting" lithotripsy) than 272CDF and higher ablation volumes than Ho:YAG.

Objectives: To estimate the total energy needed to ablate 1mm 3 of stone volume (Joules/mm 3 ) during flexible ureteroscopic lithotripsy using a low-power Ho:YAG laser device, as a proxy of lithotripsy efficacy., Patients and Methods: We selected 30 patients submitted to flexible ureteroscopy for renal stones whose volume was bigger than 500 mm 3 . A 35 W Ho:YAG laser (Dornier Medilas H Solvo 35, Germany) was used for every procedure with a 272 µm laser fiber. We recorded laser parameters, the total energy delivered by the laser fiber, the time from the first laser pulse until the last one (lithotripsy time), and the active laser time as provided by the machine. We then estimated J/mm 3 values and determinants, along with ablation speed (mm 3 /s), and laser activity (ratio between laser active time and lithotripsy time)., Results: Median (IQR) stone volume and stone density were respectively 1599 (630-3502) mm 3 and 1040 (753-1275) Hounsfield units (HU). In terms of laser parameters, median (IQR) energy and frequency were 0.6 (0.4-0.8) J and 15 (15-18) Hz. Median (IQR) total delivered energy and lithotripsy time were 37,050 (13,375-57,680) J and 68 (36-88) min, respectively. Median (IQR) J/mm 3 and ablation speed were, respectively, 19 (14-24) J/mm 3 and 0.7 (0.4-0.9) mm 3 /s. The laser was active during 84% (70-95%) of the total lithotripsy time. HU density > 1000 was associated with reduced efficacy., Conclusions: It is possible to perform laser lithotripsy using a low-power laser device with a virtually continuous laser activity. The estimation of the pre-operative parameters as well as the J/mm 3 values are fundamental for a proper pre-operatory planning.

Introduction: Holmium:yttrium-aluminium-garnet (Ho:YAG) is currently the gold standard for lithotripsy for the treatment of all known urinary stone types. Stone composition and volume are major determinants of the lithotripsy. This in vitro study evaluated the required energy to ablate 1 mm 3 of various stone types with different laser settings using Ho:YAG., Methods: 272 µm core-diameter laser fibers (Boston Scientific © ) were connected to a 30 Watt MH1 Ho:YAG generator (Rocamed®). An experimental setup consisting of immerged human stones of calcium oxalate monohydrate (COM), uric acid (UA) or cystine (Cys) was used with a single pulse lasing emission (0.6/0.8/1 J), in contact mode. Stones were dried out before three-dimensional scanning to measure ablation volume per pulse (AVP) and required energy to treat 1 mm 3 (RE)., Results: All settings considered, ablation volumes per pulse (AVP) for COM were significantly lower than those for UA and Cys (p = 0.002 and p = 0.03, respectively), whereas AVP for Cys was significantly lower than those for UA (p = 0.03). The mean REs at 0.6 J pulse energy (PE) for COM, Cys and UA were 34, 8.5 and 3.2 J, respectively The mean REs at 1 J PE for COM, Cys and UA were 14.7, 6.4 and 2 J, respectively. At 0.6 J PE, RE for COM was more than tenfold and fivefold higher than those for UA and Cys, respectively., Conclusion: This in vitro study shows for the first time a volumetric evaluation of Ho:YAG efficiency by the ablation volume per pulse on human stone samples, according to various pulse energies. The REs for COM, UA and Cys should be considered in clinical practice.

Purpose: To report the functional outcomes, perioperative morbidity and surgical learning curve key points using "en bloc" greenlight enucleation of prostate (EB-GreenLEP) for patients with refractory lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH)., Methods: Between December, 2015 and May, 2018, all consecutive patients with refractory LUTS due to BPH in our institution were included and underwent EB-GreenLEP by a single surgeon. Perioperative data, complications and functional outcomes at 1-, 6- and 12-month follow-ups were collected and retrospectively analyzed., Results: One hundred patients were included whose median age was 69 years. The median prostate volume (PV) was 84 mL and median enucleated PV was 45.5 mL. Mean irrigation, catheterization and hospitalization times were 1.3, 1.4 and 1.6 days, respectively. Average follow-up was 9.3 months. A single high-grade Clavien-Dindo complication occurred. No urinary retention was reported. Two conversions to conventional resection of the prostate were noted. Three patients had postoperative urinary incontinence at 6 months, only one at 1 year (1%). At 1, 6 and 12 months, there was a significant improvement in IPSS score, QoL and Q max . Enucleation and energy efficiency ratios were shorter after the 30th procedure. We demonstrated a linear correlation between enucleation time and PV (r = 0.53, p < 0.0001)., Conclusion: Our study shows that the mid-term functional results of EB-GreenLEP are comparable to other laser sources for the endoscopic enucleation of the prostate but with a shorter learning curve. We showed that, with (a) low rates of complications and a short hospital stay, EB-GreenLEP can manage medium-size glands (60-90 mL).

To date, transurethral resection of bladder tumor (TURBT) remains the gold standard of staging urothelial cancer of the bladder and treating non-muscle invasive bladder cancer (NMIBC). The primary goal of the procedure includes a proper diagnosis, correct staging, and removal all lesions. Herein, we discuss major contemporary surgical and technical aspects of including en bloc resection, bipolar and laser resection as well as quality control of TURBT., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

An accessory renal artery (ARA) represents an anatomic variation which can challenge endovascular aortic aneurysm repair (EVAR). The aim of this review was to summarize the current knowledge on postoperative outcomes following ARA coverage during EVAR. We performed a systematic literature review. The MEDLINE database was searched on September 2017, and 8 relevant studies were included. The frequency of ARA in patients undergoing EVAR varied between 9.5% and 16.2%, and the frequency of ARA coverage varied between 5.2% and 9.4%. Four reports did not observe any significant changes on postoperative renal function, whereas 1 study reported an early transient increase in creatinine after ARA coverage. The occurrence of renal infarct varied from 20% to 84%. Five studies did not observe endoleaks related to ARA coverage, whereas one reported the occurrence of type II endoleaks in 3 of 18 patients who had ARA coverage. No significant change in blood pressure, mortality, and mean length of hospital stay was observed. The ARA coverage can potentially have renal and vascular consequences, but none of them were critical. Further studies may be useful to identify preoperative criteria that may help to choose the most appropriate surgical approach before ARA coverage.

Pelvi-ureteric junction obstruction corresponds to an impairment of urinary transport that can lead to renal dysfunction if not treated. Several mechanisms can cause the obstruction of the ureter including intrinsic factors or extrinsic factors such as the presence of crossing vessels. The treatment of the disease relies on surgical approaches, pyeloplasty being the standard reference. The technique consists in removing the pathologic ureteric segment and renal pelvis and transposing associated crossing vessels if present. The vascular anatomy of the pelvi-ureteric junction is complex and varies among individuals, and this can impact on the disease development and its surgical treatment. In this review, we summarize current knowledge on vascular anatomic variations in the pelvi-ureteric junction. Based on anatomic characteristics, we discuss implications for surgical approaches during pyeloplasty and vessel transposition.