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To evaluate S-phase fraction as a predictor of invasiveness and cancer-specific survival in upper tract urothelial carcinoma (UTUC).One hundred and fifteen patients having undergone radical nephroureterectomy were analysed with histology in radical nephroureterectomy specimens as reference test and S-phase fraction as index test. Ploidy and S-phase were determined using flow cytometry. Differences in S-phase fraction were calculated between stages, grades (WHO 1999 and 2004 classifications), ploidy and patients that died of UTUC and those who did not. Five- and 10-year-cancer-specific survivals were calculated. Areas under the ROC curve (AUCs) of S-phase fraction in relation to tumour stage and to death from UTUC were measured. Multiple Cox regression was performed.Independent prognostic markers of death from UTUC were S-phase fraction and stage. Correlation between S-phase fraction and risk of dying from UTUC was strong, with a 17% greater risk of death from UTUC with every 1% increase in S-phase fraction, hazard ratio = 1.17, 95% CI = 1.10-1.25,S-phase fraction was a good test for predicting both invasiveness and cancer-specific survival. Using both WHO 1999 and 2004 classifications, rather than one system alone, had a higher predictive value of cancer-specific survival.

Purpose To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. Methods A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. Results and conclusions Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

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.

Purpose: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm 2/min) and using the 3D calculated stone volume (526.7 mm 3/min). Methods: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1–10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1–10 scale (10 = extremely effective). Results: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13–84 years). Mean stone clearance rate was 65.55 mm 2/min or 945 mm 3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien–Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. Conclusions: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

Purpose The aim of this prospective study was to identify the tumour characteristics that are associated with invasiveness and those that are relevant for disease-specific survival (DSS) in upper tract urothelial carcinoma, UTUC. Methods From a prospective consecutive cohort of patients with suspicion of UTUC, those who were diagnosed with UTUC using URS prior to rNU between 2005 and 2012 were included. Tumour characteristics were analysed for prediction of invasiveness and association with DSS. Stages were categorised as superficial (pTa-1 and CIS only) or invasive (≥ pT2). Tumours were graded according to WHO 1999 classification. DSS was analysed regarding possible association with stage, grade, size, multifocality, location, ploidy and rate of proliferation. Associations were tested using Fisher’s exact test, Pearson Chi-square or Cox’s regression. Kaplan–Meier survival curves were constructed. Results Forty-five consecutive patients were included, and 43 of them were included in the final analyses because their rNU specimens were available for reassessment. The only tumour characteristics that were significantly associated with stage were tumour grade (P

OBJECTIVES To investigate gene alterations as diagnostic and prognostic markers in upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS Patients with UTUC who underwent nephroureterectomy between 2005 and 2012 were followed until November 2020. DNA was extracted from paraffin-embedded tumour tissue. Next-generation sequencing using a 388-gene panel was performed. First a blinded analysis using principal component analysis and hierarchical clustering was used to search for patterns of mutations. Then a comparative analysis using analysis of variance (ANOVA) was used to search for mutations enriched in groups of various grades, stages, and survival. In addition, careful manual annotation was used to identify pathogenic mutations over-represented in tumours of high grade/stage and/or poor survival. RESULTS A total of 39 patients were included. All tumour stages and grades were represented in the cohort. The median follow-up was 10.6 years. In all, 11 patients died from UTUC during the follow-up. Tumour mutational burden showed a statistically significant correlation with stage, grade, and stage + grade. Grade 1, Grade 2, and Grade 3 tumours had different mutational patterns. Patients who died from UTUC had pathogenic mutations in specific genes e.g. tumour protein p53 (TP53) and HRas proto-oncogene, GTPase (HRAS). Patients with Ta Grade 1 tumours with a known pathogenic fibroblast growth factor receptor 3 (FGFR3) mutation did not die from UTUC. CONCLUSION The genetic analysis was highly concordant with histopathological features and added prognostic information in some cases. Thus, results from genomic profiling may contribute to the choice of treatment and follow-up regimens in the future.

INTRODUCTION AND OBJECTIVE:PCNL requires a lithotrite to efficiently break and remove stones. We set out to determine the efficacy and safety of a new lithotrite, the EMS Lithoclast Trilogy, in the...

PurposeRetrograde intrarenal surgery (RIRS) is an effective and safe therapeutic option in the treatment of renal stones&upper tract urothelial carcinoma. High frequency jet ventilation (HFJV) is a lung ventilation mode offering a substantial reduction of renal movement. In our pilot study, we evaluated a HFJV ventilatory protocol in endoscopic treatment of renal stones.Materials and methods15 consecutive cases of the treatment of renal stones larger than 7mm have been included in our study, with exclusion of patients suffering from severe pulmonary disease. Total intravenous anesthesia has been chosen with intraprocedural HFJV. The intraoperative gas exchange parameters, as well as eventual postoperative respiratory adverse events were taken note of. A laser stone disintegration has been performed in all procedures, including a three-month postoperative follow-up.ResultsMean duration of HFJV procedure was 56,3 min (35-110), Et CO2(end tidal ; carbon dioxide concentration measured at the end of expiration,the normal values of which are 4-6%) before HFJV - 4,81 % (4,1-5,8) and after HFJV 5,22 % (3,9-7,2) respectively. No signs of respiratory impairment were detected. The operative time ranged between 20- 102 min. The renal movement reduction with HFJV was of significantly noticeable by the surgeon. Three patients were readmitted to the hospital; one of them due to a urinary tract infection. No perioperative pulmonary complications were reported. ConclusionHFJV is a safe, feasible method that can be used in RIRS and can significantly enhance the efficacy of the procedure. However, further evaluation of the method is needed.

The aims of this study were to determine the accuracy and reliability of cytology, histopathology and ploidy of specimens obtained at ureterorenoscopy, to evaluate the importance of how samples are collected and to determine whether cytology is an alternative to histology of biopsies.This prospective study investigated the accuracy of grading of endoscopically taken cytology and histopathology samples from 45 consecutive patients by comparing these with subsequent nephroureterectomy specimens. Histopathology grading was done according to WHO 1999 and 2004 classifications. Ploidy was determined using photospectrometry.Forty-five patients were included. Both cytology and histopathology identified almost all cancers (91% and 94%, respectively) in collected samples. In cytology as well as in histopathology, agreement in grade between barbotage and nephroureterectomy specimens was statistically significant for both 1999 and 2004 WHO classifications. All cancers in the endoscopic biopsies were identified as pathological, although the grading was not correct in all cases. A statistically significant correlation was found between grade and ploidy in grade 1 and grade 3 nephroureterectomy specimens.Specimens collected at ureterorenoscopy (biopsies for histology, barbotages for cytology and analysis of ploidy) proved to be relevant and useful. Barbotage cytology identified 91% of all cancers, a high rate compared to techniques used in other studies, and was also sensitive in detecting low-grade tumours. Barbotage cytology and biopsy histology were equally efficient in detecting cancer. The authors recommend that both barbotage and biopsy be performed in addition to complete ureterorenoscopy. Moreover, if there is no visible lesion, cytology is the only reliable option.

In the original publication of the article, we inadvertently left the author Kay Thomas of the submission

Purpose To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). Methods A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled “Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy” held in Copenhagen, Denmark, in September 2019. Results New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). Conclusion Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

PURPOSE: To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers.METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018.RESULTS: Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice.CONCLUSIONS: Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Purpose:\ud \ud To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC).\ud Methods:\ud \ud In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6–7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence.\ud Results:\ud \ud Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette–Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0–3M0 disease.\ud Conclusions:\ud \ud Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease.

Introduction Ureteric strictures are well-documented complications related to surgery or radiation therapy. Minimally invasive treatment using endoscopic dilatation or laser incision is the standard practice. There are no existing guidelines on which techniques to use in the treatment of different stricture types and a paucity of data regarding long-term results. Purpose Our study aimed to retrospectively assess the long-term efficacy of minimally invasive treatment in benign and malignant ureteric strictures. Materials and methods Over a 5-year period, 2007–2012, we analyzed the data of 59 consecutive patients undergoing minimally invasive treatment for symptomatic ureteric strictures. We excluded 16 patients from final analysis due to failed access or loss to follow-up. All patients but one were treated with antegrade, retrograde balloon or catheter dilatations. Successful outcome was defined as an asymptomatic, completely catheter free patient, with stable renal function. Results 43 patients were eligible for retrospective final analysis. The largest proportion of strictures occurred following surgery combined with radiotherapy 8/43 (19%). Preoperative decompression was required in 30/43 (70%). We identified 32/43 (75%) balloon dilatations, 10/43 (23%) catheter dilatations and 1/43 (2%) laser incision. Overall success rate was 31/43 (72%). All 6 recurrences occurred within 36 months, 4 within the first 12 months. 3/6 patients were successfully re-dilated. Conclusion Minimally invasive treatment is a worthwhile alternative in strictures due to previous radiation and/or surgical treatment of malignancies. Most recurrences occurred within the first year. However, late recurrences arise; therefore, patients should be subject to long-term follow-up. Moreover, re-dilatation may be required.

WOS: 000457123100013 PubMed ID: 30680241 Introduction We assessed the clinical performance of a new digital single-use flexible ureteroscope (UscopePU3022). Material and methods A prospective cohort study was carried out across 11 centers (July-Oct. 2017). The UscopePU3022 was assessed regarding ease of insertion; deflection, image quality, maneuverability and overall performance using either a visual analog* or Likert scale. Results A total of 56 procedures were performed in 11 centers (16 surgeons) with the indication being renal stones in 83%. The median score for ease of scope insertion was 10 (3-10). Intraoperative maneuverability was rated as 'good' in 38% and 'very good' in 52%. Visual quality was rated as 'poor or bad' in 18%, 'fair' in 37% and 'good very good' in 43%. Two scopes failed intraoperatively (4%). Preoperative and postoperative median upward and downward deflection was 270 degrees. Compared to standard flexible ureteroscopy (f-URS) maneuverability was rated as 'equivalent' in 30% and 'better' in 60%; visual quality was 'worse' in 38% and 'equivalent or better' in 62%; limb fatigue scores were 'better' in 86%; and overall performance was 'worse' in 55% and 'equivalent or better' in 45%. Conclusions UscopeTM3022 performed well with regards to maneuverability, deflection and limb fatigue and appears to be at least non-inferior to standard f-URS with regards to these parameters. Poor image quality is a concern for UscopePU3022 with it receiving a low overall performance rating when compared to standard f-URS. Despite this it scored highly when investigators were asked if they would use it in their practice if it was cost-effective to do so.

ObjectiveTo investigate diagnostic accuracy of multiphase computed tomography urography (MCTU) and visual assessment at ureterorenoscopy (URS) for detection of upper tract urothelial carcinoma (UTUC).Patients and MethodsConsecutive patients referred to our tertiary care centre were included in a prospective study covering the period 2005 to 2012. The patients underwent initial imaging and URS with focal samples taken. Cytopathological results served as reference standard.ResultsWe investigated 174 renal units (RUs; renal pelvis and adjacent ureter) in 148 patients. UTUC was found in 104 RUs. MCTU had an accuracy of 0.74, sensitivity of 0.89, specificity of 0.51, positive predictive value of 0.73, and negative predictive value of 0.75; corresponding values for URS were 0.84, 0.84, 0.85, 0.89, and 0.78, respectively. MCTU had significantly higher sensitivity and accuracy compared with other imaging techniques (PConclusionBoth MCTU and URS are important tools in the diagnostic evaluation of UTUC although neither of those techniques achieves 100% accuracy. MCTU should be chosen as the radiographical method if there are no contraindications and URS should always be combined with focal cytology and biopsies of suspicious lesions. To enhance diagnostic precision both MCTU and URS with focal samples should be included in the diagnostic procedure. The present results add impact to current diagnostic guidelines.

INTRODUCTION: Semirigid and flexible ureterorenoscopy (URS) procedures are safe and efficient treatment options for urolithiasis of all localizations. Sometimes, a Double-J stent is placed in preparation of definitive treatment. The aim of our study was to evaluate the influence of prestenting on the outcome of URS.PATIENTS AND METHODS: We retrospectively analyzed 565 patients of our prospective, multicenter multinational database who underwent URS for renal or ureteral stones from June 2011 to December 2013. Demographic and stone-related data, surgery time, stone clearance, and complications were evaluated. Statistical analysis was performed comparing the prestented and nonstented groups.RESULTS: Demographic data, stone size, and localization were comparable in both groups. Three hundred twenty-three patients were prestented and 242 nonstented. Overall, prestenting had significant influence on the stone-free rate (SFR) (86% prestented vs 74% not prestented, p = 0.0003) and complication rate (6.5% vs 14.5%, p = 0.003), but not on surgery time (55 ± 36 minutes vs 61 ± 35 minutes, p = 0.071). Subgrouped, this was also true for renal stones (83% vs 60%, p = 0.0001, odds ratio [OR] 3.15; confidence interval, CI [1.77, 5.62]/8.7% vs 19.4%, p = 0.02, 0.39 [CI 0.19, 0.83]). For ureteral stones, there was no significant influence on SFR (94% vs 90%, p = 0.4, OR 1.63 [CI 0.63, 4.22]), but significantly more complications (3.1% vs 10.7%, p = 0.02, OR 0.27 [CI 0.08, 0.86]) in the nonstented group.CONCLUSION: Prestenting positively affects safety and efficacy of URS. This is more pronounced in the treatment of kidney stones compared with ureteral stones. Although the SFR for ureteral stones is comparable without prestenting, the complication rate is higher.

Introduction: There is a need for alternative training in endourology. Computerised simulators have been introduced but have, so far, not been compared to real surgery. Bench models have proved to be comparable to real surgery when performing standard procedures in the upper urinary tract. Objective: To validate training on bench models as a tool to improve dexterity in semi-rigid ureteroscopy. Methods: Urology residents were tested when performing semi-rigid ureteroscopy on a bench model (Mediskills), before and after training. All standard equipment and instruments, including fluoroscopy, were available. For the test procedure we used a task-specific checklist and a global score (maximum score 10+9=19). After base line assessment, the participants practised under supervision. After training they were reassessed, using the same procedure as previously. Results: The performance was significantly better after the training. Results before/after were: 5.1/9.2, 2.6/7.8 and 7.7/17.2 for task-specific checklist, global score and total score respectively. All residents felt more familiar with the instruments and the procedure after the training. Conclusion: Training on bench models for ureteroscopy enhanced the manual dexterity as well as familiarity with the method and is recommendable before operating on patients.

Purpose: Percutaneous nephrolithotripsy is an essential procedure for treating complex urinary calculi. To achieve optimal access to a large and complicated stone, an upper calyx puncture is often preferable. However, when performing a puncture above the 12th rib there is risk of an increased number of complications. In this retrospective study, we assessed the kind and frequency of complications after sub- and supracostal punctures of the collecting system of the kidney. Material and Methods: Between 1996 and 2001, 85 patients were treated with percutaneous nephrolithotripsy. In 63 patients a subcostal track, below the 12th rib was established. Puncture was performed under ultrasonic or fluoroscopic guidance in 61 patients and CT-guided in 2 patients. In 17 patients a supracostal puncture, above the 12th rib, was performed under CT guidance and in 5 patients with US or fluoroscopic guidance. Result: The main difference regarding preoperative complications was the number of patients complaining of respiratory correlated pain, 7 (32%) in the supracostal puncture group compared with 3 (5%) in the subcostal puncture group. No significant difference regarding peroperative complications was found. Postoperatively, there were 2 major bleedings, one in each group, which had to be treated with arterial embolization. In the supracostal puncture group there were 2 patients with pleural effusion and 2 patients with pneumothorax. Conclusion: The complication rate was slightly higher after supracostal puncture as compared with a subcostal approach, especially regarding respiratory correlated pain. When performing a supracostal puncture there is an increased risk that the track passes through the pleural space, which might explain the difference in the panorama of complications.

PURPOSE: The use of a ureteral access sheath (UAS) during flexible retrograde intrarenal surgery (RIRS) has become increasingly popular. Our aim was to evaluate the accessibility of a new UAS device, allowing the transformation of the working guidewire into a safety guidewire.METHODS: A prospective, multicenter study was conducted between January and February 2010 in six European tertiary reference centers. Patients needing flexible RIRS were eligible to participate in the study. In all cases, insertion of the Re-Trace™ (12/14Fr, Coloplast, Denmark) was attempted at the beginning of the procedure. Insertion success was defined as placement of the UAS in the lumbar ureter with successful disengagement of the working guidewire, which turned into a safety guidewire. Influence of gender and pre-stenting status was analyzed by univariate analysis.RESULTS: 137 UASs were used in 75 male and 62 female patients. 25.5% of ureters were pre-stented: men were 2.17 more often pre-stented than women. The overall Re-Trace™ insertion rate was 82.5%. Success rate was not significantly different between men and women (77.3 vs. 88.7%, respectively, p = 0.11). Pre-stenting status did not significantly influence the success rate (p = 0.31). When analyzing the combined influence of pre-stenting status and gender, the worst success rates seemed to be obtained in men without pre-stenting, but no significant differences were found between groups.CONCLUSIONS: Re-Trace™ UAS showed good overall insertion rates. This evaluation validated the new concept of guidewire disengagement: A single wire automatically switches from working to safety role.

The present chapter deals with the technical aspects of percutaneous management of ureteral stenosis and upper urinary tract (UUT) tumours, where the preoperative investigations are usefully integrated by the preliminary retrograde endoscopic assessment of ureteral and pyelocalyceal features allowed by ECIRS in the Galdakao-modified supine Valdivia position. Antegrade treatment details are also given, as well as follow-up advices, according to the current guidelines.

PURPOSE: To assess efficacy and safety of prone- and supine percutaneous nephrolithotomy (PCNL) for the treatment of lower pole kidney stones.METHODS: Data from patients affected by lower pole kidney stones and treated with PCNL between December 2005 and August 2010 were collected retrospectively by seven referral centres. Variables analysed included patient demographics, clinical and surgical characteristics, stone-free rates (SFR) and complications. Statistical analysis was conducted to compare the differences for SFRs and complication rates between prone- and supine PCNL.RESULTS: One hundred seventeen patients underwent PCNL (mean stone size: 19.5 mm) for stones harboured only in the lower renal pole (single stone: 53.6%; multiple stones: 46.4%). A higher proportion of patients with ASA score ≥ 3 and harbouring multiple lower pole stones were treated with supine PCNL (5.8 vs. 23.1%; p = 0.0001, and 25 vs. 81.5%; p = 0.0001, respectively, for prone- and supine PCNL). One-month SFR was 88.9%; an auxiliary procedure was needed in 6 patients; the 3-month SFR was 90.2%. There were 9 post-operative major complications (7.7%). No differences were observed in terms of 1- and 3-month SFRs (90.4 vs. 87.7%; p = 0.64; 92.3 vs. 89.2%; p = 0.4) and complication rates (7.6 vs. 7.7%; p = 0.83) when comparing prone- versus supine PCNL, respectively.CONCLUSIONS: The results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, regardless the position used. Supine PCNL was more frequently offered in case of patients at higher ASA score and in case of multiple lower pole stones.

Introduction Lower pole kidney stones represent at time a challenge for the urologist. The gold standard treatment for intrarenal stones 2 cm is Percutaneous Nephrolithotomy (PCNL). The success rate of ESWL, however, decreases when it is employed for lower pole stones, and this is particularly true in the presence of narrow calices or acute infundibular angles. Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones

PURPOSE: To investigate prospectively the benefits of three-dimensional stereolithographic biomodeling produced from CT data as an aid to achieving optimal access for percutaneous nephrolithotripsy (PCNL). PATIENTS AND METHODS: Eight patients with complex urinary calculi were selected. Multislice CT scans of the kidney in native and excretory phases were acquired with the patient in the prone position to simulate the position during surgery. Contiguous reconstructed slices were produced from the data volume. The data of interest were processed to transform them into a format acceptable for production of a biomodel. Exact plastic replicas of the pelvicaliceal system and the calculi were created and used for morphologic assessment, preoperative planning, patient education, and surgical navigation. RESULTS: The survey results were based on subjective opinions rather than objective data. The biomodels enhanced the ability to visualize a patient's unique anatomy before surgery. This aided the planning and rehearsal of endourologic procedures. CONCLUSION: Although this study is only a preliminary investigation, we postulate that biomodeling has the advantage of allowing imaging data to be displayed in a physical form. In difficult cases, this technique may improve treatment, operative planning, and communication with colleagues and patients. The limitations of the technology include the manufacturing time and cost, but more accurate puncture-site selection may reduce costs by saving operating time.

Objective: Open surgery is increasingly replaced by endoscopic techniques. In urology, endoscopic procedures of the upper urinary tract are still evolving. The surgical techniques imply high accuracy and are difficult to teach since they are "one man" procedures. Training on bench models has essentially given promising results in general surgery but has never been validated for advanced endourology. In this study, ureteroscopy on a bench model was compared to the same procedure on patients. Material and Method: Fourteen urologists, trainees and consultants, were scored using a task-specific check list and a global score when performing rigid ureteroscopy on patients and on a bench model from Mediskills. The participants had not seen the check lists before the performance and the scoring was carried out by the same person in all cases. Results: The urologists performed equally on patients and the model and they all considered the procedure on the model similar to real surgery. There was no statistical difference in the score between consultants and trainees but those urologists (five consultants and three senior registrars) who were sub-specialised in endourology scored significantly higher than the others on both patients and the model. Conclusions: Bench models are comparable to real surgery for, at least basic, endoscopic procedures in the upper urinary tract. The models are also useful for making the trainees familiar with the operating instruments.

Although some authors have proposed that the favorable impact of transurethral microwave thermotherapy (TUMT) for benign prostatic hyperplasia has only a placebo effect, this idea is inconsistent with the findings of a number of sham-controlled clinical trials. Histologic and immunohistochemical studies have shown that the nerve fibers in the periurethral tissue are damaged or ablated by TUMT, and it appears that the heat affects the innervation of the smooth muscle cells. Among the nerves damaged are the sensory neurons of the posterior urethra, and this change might reduce the excitatory signals from the urethrodetrusor facilitating reflexes. Necrosis and apoptosis within a limited area also have been described. Thus, there is likely more than one basis for the therapeutic effect of TUMT.

Results of transurethral microwave thermotherapy for benign prostatic hyperplasia were good after 1 year in 68% of 66 cases. Despite good correlation between subjective assessment of results and improvement in urodynamic parameters, no predictive factors for probably successful outcome could be identified. Diminution in frequency of micturition (diurnal from 8.8 to 6.8 times, nocturnal from 3.0 to 1.6 times), increased flow rates (Q max from 8.8 to 14.2 ml/s) and reduction of detrusor pressures during voiding (Pdet max from 86.9 to 75.0 cm H2O) were significant, but the change in residual volume (from 52 to 37 ml) was of lesser degree (all mean values). Transurethral microwave thermotherapy can be tried for relief of moderate obstruction when transurethral prostatic resection involves risk, or the patient himself requests noninvasive treatment.

Thirty-seven patients with clinically localized prostate cancer of all grades were treated by suprapubic digitally guided implantation of 125I seeds. The median age at the time of diagnosis was 68 years. The mean follow-up period was 62 +/- 19 months. At last follow-up 18 patients were clinically free of disease; 11 deaths occurred: 9 from prostate cancer and 2 from another disease. Complications occurred in 24 patients most commonly urgency and proctitis, attributable to the treatment. Four patients had severe late rectal complications, and 2 patients died of sepsis secondary to rectal fistulae. Digitally directed retropubic implantation of 125I appears inferior to other treatments of clinically confined prostate cancer both regarding outcome as well as complication rate.

For evaluation of the upper urinary tract, intravenous urography has for many years been the method of choice. In recent years, different imaging protocols have been suggested. In this article different strategies for the evaluation of microscopic haematuria, with a focus on the advantages and disadvantages of different imaging modalities, will be discussed.