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Objective: To compare the efficacy and postoperative infection rate of super mini percutaneous nephrolithotomy (SMP) and flexible ureteroscopic lithotripsy (FURL) in patients with diabetic nephrolithiasis and to explore the risk factors associated with postoperative infection following these two procedures. Methods: The medical history and surgery details of 252 patients with diabetic nephrolithiasis who underwent lithotripsy in our hospital between January 2018 and May 2023, including 144 SMP and 108 FURL, were reviewed and compared. Perioperative outcomes were compared between the two groups. Logistic regression was performed to identify the significant risk factors for infection after each procedure. Results: SMP achieved a higher stone-free rate (SFR) on postoperative day 1 and postoperative day 30 compared with FURL ( p < 0.05). The mean operative time was shorter in SMP ( p < 0.01). FURL was associated with less hemoglobin drop ( p < 0.01) and shorter length of stay ( p < 0.01). The incident rate of systemic inflammatory response syndrome (SIRS) was higher after SMP (p = 0.019), while the incident rate of urinary tract infection (UTI) was higher after FURL ( p = 0.021). Overall postoperative infection and sepsis rates were similar between the two procedures. Logistic regression analysis revealed that gender odds ratio [OR]: 0.225, 95% confidence interval [CI]: 0.079-0.639), HbA1c (OR: 3.516, 95% CI: 1.841-6.716), and operation time (OR: 1.037, 95% CI: 1.008-1.066) were independent risk factors for infection after FURL, while operation time (OR: 1.063, 95% CI: 1.022-1.106) and HbA1c (OR: 7.443, 95% CI: 2.956-18.742) significantly predicted SMP-associated infections. Conclusion: In diabetic patients, SMP demonstrated higher SFR and shorter operation time, whereas FURL was associated with less bleeding and shorter hospitalization. SMP had a higher incident rate of SIRS and FURL had a higher incident rate of UTI. Elevated HbA1c and prolonged operative duration increased infection risk after both procedures, while female gender was an additional risk factor for FURL-related infections.

Objective: To prospectively capture patient-reported outcomes to assess the recovery profile of ureteroscopy (URS)., Materials and Methods: Adults undergoing URS for renal/ureteral stones were eligible for inclusion (11/2020-8/2022). Patients prospectively completed PROMIS - Pain Intensity, - Pain Interference, and - Ability to participate in social roles and activities in-person preoperatively (POD 0) and via email on POD 1, 7, 14, and 30. Scores are reported as T-scores (normalized to U.S. population, mean=50) with a change of 5 (0.5 SD) considered clinically significant., Results: One hundred and seventy-eight participants enrolled at POD 0 (POD 1 =87, POD 7 =83, POD 14 =70, POD30 =67). There was a worsening of quality of life from day 0 to day 1 and day 0 to 7. All dimensions then improved with an increase in scores from day 0 to day 14 and day 0 to day 30. On multivariable analysis, the presence of a preoperative ureteral stent (OR 0.14) and use of semirigid URS (OR 0.33) were associated with a reduced odds for severe pain interference at day 1. The use of semirigid URS (OR 0.20) was associated with a reduced odds for severe worsening in the ability to participate in social roles at day 1., Conclusion: Ability to participate in social roles declines immediately postoperatively, while pain intensity and interference sharply increase. There is a gradual improvement until POD 30. Findings suggest preoperative stents may influence postoperative recovery. Results offer meaningful insight to assist in counseling and setting expectation for patients postoperatively., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: This study aimed to evaluate the learning curve associated with the adoption of US guided PCNL and demonstrate that it can be carried out safely with results comparable to those obtained using standard PCNL., Methods: Prospective study with 65 patients who underwent PCNL between 2019 and 2020. all procedures were performed in supine position and an initial attempt to gain access to the kidney using US was made., Results: Mean procedure duration was 69.5 ± 27.8 min. Fluoroscopy was used with a mean dose of 276.68 ± 560.71 (cGycm 3 ) and mean fluoroscopy time 40.25 ± 77.69 (s). Throughout the study there was a steady decrease in the use of fluoroscopy and amount of radiation to gain access to the kidney to only 25% at the study end. 76.5% of the patients were stone free at follow-up. Complication rate was 9.2%., Conclusions: Fluoroless US guided PCNL is safe, feasible and reproducible procedure., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Pediatric nephrolithiasis is increasing in incidence and presents differently compared to adults. We report a case of nephrolithiasis in a pediatric patient, presenting with complaints of emesis, anuria, hematuria, and abdominal distension, leading to a diagnosis of bilateral obstructing cystine stones requiring bilateral percutaneous nephrolithotomy. Pediatric patients with anuria should be evaluated for bilateral nephrolithiasis as an etiology. Calculous anuria requires prompt recognition of the pathologic process and relief of the obstruction with close follow-up and supportive care until definitive stone management. Bilateral percutaneous nephrolithotomy can provide definitive surgical intervention without significant morbidity., Competing Interests: Declaration of Competing Interest Jimena Cubillos, MD: Authorship Stipend – Merck Manual. The other authors have no conflict of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The incidence of stone disease has increased significantly in the past 30 years, with a reported prevalence of 11% of the U.S. population in 2022, up from 9% in 2012 and 5.2% in 1994.1 While prevention is a vital aspect of management, many patients present with symptomatic urolithiasis requiring surgical management. Emerging advances in endoscopy and technology has led to a dynamic shift in the surgical management of stone disease. This paper will serve as a comprehensive review to inform urologic and non-urologic medical professionals alike, as well as the layperson, on the surgical treatment of nephrolithiasis, starting from the initial evaluation, laboratory and radiographic studies, and various surgical options. Additionally, the nuances of managing the pediatric and pregnant patient with nephrolithiasis will be explored. Using the most up-to-date urologic data, our aim is to provide a comprehensive resource for readers who interact with patients experiencing acute episodes of urolithiasis.

Even though primary hyperparathyroidism (PHPT) is a common endocrine disorder, due to better and more regular screening, the usual presentation is only seen in less than 15% of cases of PHPT. The authors present the case of a young female patient with a previous medical history of depression and nephrolithiasis, with one year of bone pain, that had become progressively worse and disabling. In the initial work-up, several lytic bone lesions and moderate hypercalcemia were found, leading to admission of the patient in the Internal Medicine ward for investigation and treatment. The ensuing investigation revealed PHPT due to hyperfunctioning parathyroid adenoma. The patient underwent a parathyroidectomy and at the follow-up assessment two months after discharge, she reported no symptoms and a computer tomography scan showed regression of the lytic lesions. This case is a reminder that severe symptomatic PHPT, a rare form in developed countries nowadays, still exists, and even though it is a medical condition, collaboration with surgical specialties is necessary to ensure the best possible treatment and prognosis.

Introduction and Objectives: Pediatric patients with limited lower extremity mobility may be at increased risk of developing nephrolithiasis due to bone mineral metabolic derangements. This study sought to assess whether nephrolithiasis management and related outcomes differ between ambulatory versus non-ambulatory pediatric patients., Methods: This was a retrospective review of ambulatory and non-ambulatory pediatric patients with nephrolithiasis from 2010 to 2021 from a single tertiary care center. Demographics, surgical history, stone compositions, and 24-h urine data were reviewed. Adjusted logistic and linear regression models were utilized to assess whether mobility status was associated with nephrolithiasis-related management and outcomes, including: age at first stone; requiring surgical intervention for stones; number of surgeries; stone compositions; urine culture results; and completion of 24-h urine studies., Results: Among 339 pediatric patients with nephrolithiasis, 67 (19.8%) were non-ambulatory. In adjusted analyses, non-ambulatory patients had 3.24 times greater odds of requiring surgical intervention for stones (95% CI: 1.93-6.84; p < 0.0001); among those who required surgery, non-ambulatory patients required an average of 0.82 more surgical interventions (95% CI: 0.35-1.30; p = 0.0008) than ambulatory patients. Additionally, non-ambulatory patients had 5.28 times greater odds of having a positive urine culture at the time of surgery (95% CI: 2.35-14.08; p = 0.0001) and were significantly less likely to undergo 24-h urine studies (OR: 0.35; 95% CI: 0.15-0.83; p = 0.02). Stone composition significantly varied by mobility status, with non-ambulatory patients being significantly more likely to form calcium apatite (OR: 5.1; 95% CI: 2.18-11.93; p = 0.0002) or struvite (OR 3.72; 95% CI: 1.18-11.74; p = 0.03) stones, and significantly less likely to form calcium oxalate stones (OR: 0.19; 95 CI: 0.08-0.47; p = 0.0003). Among all patients, age at first stone occurred at a median age of 13.4 years (IQR: 8.2-16.4) and did not significantly differ by mobility status (p = 0.92)., Conclusions: Patients with limited mobility required surgery for nephrolithiasis at significantly higher rates and had different stone compositions than ambulatory patients. Obtaining a 24-h urine study in patients with comorbidities affecting ambulation was uncommon, compared to ambulatory patients. Similarly to ambulatory patients, pediatric patients with limited mobility who develop nephrolithiasis tend to first present with stones in early adolescence., Competing Interests: Conflicts of interest The authors have no relevant conflicts of interest to disclose., (Copyright © 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: The acute care surgery model has led to improved outcomes for emergent surgical conditions, but similar models of care have not been implemented in urology. Our department implemented an acute care urology (ACU) service in 2015, and the service evolved in 2018. We aimed to evaluate the impact of the ACU model on the management of nephrolithiasis. Materials and Methods: We conducted a retrospective review of all patients with urology consults in the emergency department for nephrolithiasis, who required surgical intervention from 2013 to 2019. Patients were divided into three cohorts based on date of consultation: Pre-ACU (2013-2014), Phase 1 (2015-2017), and Phase 2 (2018-2019). Results: We identified 733 patients with nephrolithiasis requiring intervention (162 pre-ACU, 334 Phase 1, and 237 Phase 2). Before ACU implementation, median time from consult to definitive intervention was 36 days. After ACU implementation, median time to intervention decreased to 22 days in Phase 1 ( p  < 0.001) and 15 days in Phase 2 ( p  < 0.001). On multivariable Cox regression, the hazard of definitive intervention improved in Phase 1 (hazard ratio [HR] 1.90, p  < 0.001) and in Phase 2 (HR 1.80, p  < 0.001). Rates of primary definitive intervention without initial decompression and loss to follow-up were also significantly improved, compared to the pre-ACU cohort. Conclusions: Implementation of a structured ACU service was associated with improved time to treatment for patients with acute nephrolithiasis, as well as increased primary definitive intervention and improved follow-up care. This model of care has potential to improve patient outcomes for nephrolithiasis and other acute urological conditions.

Background: Nephrolithiasis is a classic indication for parathyroidectomy in primary hyperparathyroidism patients; however, the effects of parathyroidectomy on nephrolithiasis recurrence are not well studied. The aim was to determine effect of parathyroidectomy on time to first nephrolithiasis recurrence and recurrence rate per patient-years., Methods: A retrospective cohort study of patients diagnosed with primary hyperparathyroidism and at least one episode of nephrolithiasis was performed. The patients were divided into observation, presurgery, and postsurgery groups. Endpoints were time to first recurrence of nephrolithiasis and average recurrence rate per patient-years., Results: The cohort was comprised of 1,252 patients. In addition, 334 (27%) patients underwent parathyroidectomy and 918 (73%) were observed. The surgical and nonsurgical groups differed significantly in age, sex, Charlson, calcium, and primary hyperparathyroidism level. Overall recurrence rate was 31.3%. The 5-, 10-, and 15-year recurrence-free survival rates were 74.4%, 56.3%, 49.5%, respectively (presurgery), 82.4%, 70.9%, 62.8%, respectively (postsurgery; P < .0001), and 86.3%, 77.7%, and 70.6%, respectively (observation). The presurgery group had an increased risk of first recurrence compared with the observation group (hazard ratio 1.89; 95% confidence interval, 1.44-2.47). The average recurrence rates among all surgical patients who recurred were 1 event per 4.3 patient-years presurgery versus 1 event per 6.7 patient-years postsurgery (P = .0001)., Conclusion: Recurrent nephrolithiasis is a significant problem in patients with primary hyperparathyroidism. Parathyroidectomy prolongs the time to first recurrence and decreases the number of re-recurrences over time but does not eliminate recurrences. Observation may also be a reasonable approach in selected patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Residual fragments following retrograde intrarenal surgery can lead to future stone episodes. The lower pole of the kidney presents a unique challenge as it is the most difficult location for retrograde intrarenal surgery. We investigated a modified patient position to increase stone-free rate by analyzing presence of residual fragments. We randomized patients into standard position and the T-Tilt position (15° Trendelenburg and 15° airplane away from the surgical side kidney)., Materials and Methods: In this prospective, randomized study, patients were randomized into the standard or T-Tilt position. Demographics, comorbidities and operative parameters were collected. Stone-free rate was determined with renal ultrasound and x-ray at 1-month followup. Postoperative complications were recorded up to 1 month. Variables were compared using Kruskal-Wallis test for continuous variables and chi-square test for categorical variables., Results: A total of 138 patients were analyzed: 75 standard patients and 63 T-Tilt patients. The groups had similar patient and stone factors. The most common stone position was the lower pole (68.0% standard, 74.6% T-Tilt). Stone-free rates were significantly different: standard position was 76.7% and T-Tilt position was 92.1% (p=0.015). Stone-free rates for isolated lower pole stones were significantly different as well: standard position was 68.2% and T-Tilt position was 95.6% (p <0.001). Clavien-Dindo scores did not differ significantly (p=0.262)., Conclusions: The T-Tilt patient position was associated with higher stone-free rates. It is an atraumatic, cost-effective technique. These results suggest that modifying patient positioning during retrograde intrarenal surgery improves stone-free rates.

Objective: To evaluate the effects of location of the tip of percutaneous sheath and nephroscope in the collecting system together with active aspiration on the Intrapelvic pressure measurements (IPP) during miniaturized percutaneous nephrolithotomy (miniPNL)., Materials and Methods: The data of 20 patients underwent miniPNL in supine position was collected prospectively. IPP measurements were done with an 8 Fr urodynamic pressure measurement catheter in 4 different settings with respect to location of tip of sheath and nephroscope. All 4 settings were repeated with active aspiration. Totally measurements were done and compared in 8 different settings for 90 seconds in each patient., Results: Highest mean IPP measurements were recorded in setting II (35.3 ± 11.8 cm H2O) where the sheath was located in the calyx and the tip of the nephroscope was in the renal pelvis. When active aspiration was applied, the mean pressure measurements were significantly lower than the counterpart settings without aspiration (all P values <.0001). When the active aspiration was applied, intrarenal pressure measurements did not exceed 40 cm H2O in any settings in any of the patients., Conclusion: Location of the tip of the sheath and the nephroscope has significant effect on IPP measurements. Active aspiration significantly lowers the IPP and keeps it <40 cm H2O. Endourologists should be aware of possible alterations in IPP during miniPNL and active aspiration should be kept in mind as an effective solution to decrease the risk of complications related to high IPP., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We evaluated the risk factors for the requirement of surgical intervention in infants with nephrolithiasis., Methods: The medical records of 122 (156 kidney units (KU)) infants were reviewed. The clinical features, stone characteristics, changes in stone status, and treatment protocols were noted. The stone status of the KU was categorized into 3 groups according to the change in size between the first and last ultrasound: resolution, unchanged, and growth., Results: The median age was 8 months (r: 2-12). The median length of follow-up was 16 months (r: 10-36). Resolution was detected in 94 KUs (60%). Stone growth was detected in 39 KUs (25%), and stone size was unchanged in 23 KUs (15%). Surgical intervention was required in 26 patients (17%). A history of intensive care unit (ICU) follow-up and a stone size > 5 mm at time of diagnosis were defined as independent risk factors for stone growth (p = 0.005, < 0.001, respectively). The surgical intervention rate was higher in stones > 5 mm and stones with pelvic localization (p = 0.018, 0.021, respectively). Stone resolution was higher in patients with stone size ≤ 5 mm (p = 0.018)., Conclusion: A stone size > 5 mm at the time of diagnosis and a history of ICU follow-up are independent risk factors for stone growth. Pelvic localization of stones and stones > 5 mm are associated with an increased risk of surgical intervention.

Objective: To investigate gender-associated differences in the presentation, course, and outcomes of primary hyperparathyroidism (PHPT)., Study Design: A retrospective institutional cohort., Methods: The database of a tertiary endocrine institute was retrospectively screened for patients treated for PHPT in 2010-2018. Clinical, biochemical, and imaging data were collected. Presentation, management, and outcome variables were compared by gender and by age at diagnosis (<50/≥50 years)., Results: The cohort included 182 women and 161 men diagnosed with PHPT at age 57.6 ± 12.8 and followed for 6.3 ± 5.5 years. There were no gender differences in age at detection of hypercalcemia and basal levels of serum and urinary calcium, serum PTH, and serum 25-hydroxyvitamin D. Men had a higher prevalence of nephrolithiasis (33 % vs 21 %, p = 0.01). Women had a higher frequency of osteoporosis (65 % vs 45 %, p < 0.001), and a lower mean lumbar spine T-score at PHPT diagnosis. At last follow-up, women had worse bone mineral density (BMD) results in all measured sites (lumbar spine, femoral neck, distal radius) and more fractures (34 % vs 20 %, p = 0.004), despite more frequent and longer pharmacological treatment of osteoporosis. On analysis by age, all these gender-associated differences were statistically significant only in patients diagnosed at age ≥50 years. Parathyroidectomy was performed in 52 % of women and 42 % of men (p = 0.06)., Conclusion: The main differences between male and female patients with PHPT are the higher prevalence, more intensive pharmacological treatment, and worse outcomes of osteoporosis in women. Tailoring the optimal medical and/or surgical treatment for fracture prevention in patients with PHPT remains a major challenge, especially in older women., (Copyright © 2020 Elsevier B.V. All rights reserved.)

The aim of this work was to determine which part of a double-J ureteral stent (DJ stents) showed the highest tendency to crystal, calculi, and biofilm deposition after ureterorenoscopic-lithotripsy procedure (URS-L) to treat calcium oxalate stones. Additionally, the mechanical strength and the stiffness of DJ stents were evaluated before and after exposure to urine. Obtained results indicated that the proximal (renal pelvis) and distal (urinary bladder) part is the most susceptible for post-URS-L fragments and urea salt deposition. Both, the outer and inner surfaces of the DJ ureteral stents were completely covered even after 7 days of implantation. Encrustation of DJ stents during a 31-day period results in reducing the Young's modulus by 27-30%, which confirms the loss of DJ stent elasticity and increased probability of cracks or interruption. Performed analysis pointed to the need to use an antibacterial coating in the above-mentioned part of the ureteral stent to prolong its usage time and to prevent urinary tract infection.

Introduction: The primary aim of this study is to compare the efficacy and safety of retrograde intrarenal surgery (RIRS) among the children and adults with similar stone burdens and locations. Also, the secondary aim of this study is to identify the factors affecting the stone-free rates (SFRs) of RIRS., Methods: We retrospectively compared perioperative results, SFRs, and complication rates (CRs) between pediatric (group 1, n: 55) and adult (group 2, n: 220) age groups diagnosed with kidney stones and treated by flexible ureterorenoscopy using the same instruments. Furthermore, multivariate analysis was performed to determine the factors affecting the SFR., Results: A total of 275 patients (pediatric group: 55; adult group: 220) were included in this study. The mean age of pediatric and adult groups was 7.2 ± 5.3 and 43.9 ± 15.1, respectively. The mean stone size was 13.9 ± 6.6 mm in the pediatric group compared to 14.8 ± 6.7 mm in the adult group (p = 0.35). Stone localizations and number were similar. JJ stenting for passive dilatation and use of UAS were higher in the pediatric group (p = 0.002; p = 0.017). However, postoperative double pigtail stenting rate was higher in the adult group (p < 0.001). Total CR was 13.8% and mostly Clavien I-II, and no difference was observed between the 2 groups (p = 0.541). The SFRs between the groups were similar (pediatric group: 81.8%; adult group: 78.2%; p = 0.554). On multivariate analysis, stone size (p < 0.001) and lower calyx stone (p < 0.001) were the negative predictive factors for SFR., Conclusion: There are small technical differences between pediatric patients and adult patients in our study, but RIRS in children is as safe and efficient as it is in adults., (© 2021 S. Karger AG, Basel.)

Candida species are the commensal organisms of human mucosa and opportunistically cause the diseases in susceptible persons. This study aimed to determine the prevalence and virulence of different Candida spp. among nephrolithiatic patients and their association with complicated UTI (cUTI). A total of 164 urine samples were collected from surgical units of two tertiary care hospitals (Poly Clinic and Pakistan Institute of Medical Sciences Hospital, Islamabad). From 74 kidney stone patients, 77 isolates of Candida spp. were confirmed through standard microbiological and molecular characterization. C. albicans was the predominant species with 51 isolates (66.2%) followed by 26 (33.8%) of C. non-albicans. The nephrolithiatic patients suffering from cUTI were more prone to be infected with Candida (P=0.047). Among all isolates, 83% (64) of the Candida isolates were biofilm formers, 80% (60) showed the esterase production and 64.9% (50) showed phospholipase production. Candida isolates positive for various virulence factors were more prevalently isolated from both catheterized and recurrent UTI patients. Among Candida spp., 16.9% (13) isolates showed resistance to fluconazole and 19.5% (15) against voriconazole and 11 isolates were resistant for both tested antifungals. Candida isolated from cUTI cases showed comparatively enhanced virulence attributes and antifungal resistance, suggesting that these factors might have role in development of cUTI in nephrolithiatic patients. Hence, this work highlights the high prevalence of both C. albicans and non albicans spp. in nephrolithiatic patients. So, there is need to administer evidence based antifungal therapy rather than empirical therapy to reduce the cUTI in nephrolithiatic patients., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To present our simplified biplanar fluoroscopic puncture technique, its reduction in the fluoroscopic screening time as well as outcomes and the initial experience for percutaneous nephrolithotomy., Methods: We performed a retrospective review of 136 patients operated with our simplified 0-90° puncture technique for percutaneous nephrolithotomy between 2015 and 2018. All patients were classified by stone complexity with Guy´s nephrolithometric stone score. The stone-free rate was evaluated by nonenhanced computerized tomography, and residual stones were defined as fragments ≥2 mm. Complications were divided according to the Clavien-Dindo classification., Results: One hundred and thirty-six patients were operated with our puncture technique; 121 patients were performed in supine and 15 in the prone position. Fifty-one were men, and 85 were women with an overall mean age of 44.36 ± 13.23 years. The overall stone-free rate was 62.5%, and 83.8 % after an ancillary procedure. The mean fluoroscopy screening time was 69.47 ± 7.1 and 6 ± 4.1 seconds for the total surgical procedure and the percutaneous puncture, respectively. Complications were present in 25.7%, and no grade IV and V complications were present., Conclusion: Our first case series with the 0-90° simplified fluoroscopic puncture technique shows a similar stone-free rate and safety profile but a low fluoroscopic screening time compared to the most common previously reported fluoroscopic puncture techniques non-focused on low radiation protocols. Further studies are required to evaluate the reproducibility, external validation, and the learning curve of our simplified 0-90° technique., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Transparently reported, high-quality randomized controlled trials (RCTs) play a critical role in guiding evidence based clinical practice and informing evidence-based guidelines in patients with nephrolithiasis. Prior studies have found reporting quality to be low. We performed this study to assess whether the reporting of RCTs has improved over time. Materials and Methods: This study was governed by an a priori protocol. We performed a systematic literature search for RCTs analyzing nephrolithiasis treatment. Selection of eligible studies and data abstraction were performed by two of three reviewers independently and in duplicate. We developed and pilot tested a data extraction checklist based on the Consolidated Standards of Reporting Trials (CONSORT) criteria on a scale of 0 to 25. Our primary outcome measure was the mean CONSORT score. We performed statistical hypothesis testing to compare scores between 2002-2006, 2007-2011, and 2012-2017. Results: A total of 203 studies (2002-06: 38; 2007-11: 64; 2012-17: 101) met inclusion criteria. The most common procedure types studied were percutaneous nephrolithotomy (35.1%), shockwave lithotripsy (25.4%), and ureteroscopy (22.9%). Asia contributed an increasing proportion of studies (25.6%, 44.6%, and 74.3%, respectively) in these three time periods. The main journals of publication were the Journal of Endourology (23.9%), the Journal of Urology (19.5%), and Urology (8.3%). The mean ± standard error of the CONSORT summary scores was 11.4 ± 0.4, (2002 to 2006), 12.1 ± 0.3, (2007 to 2011), and 13.3 ± 0.4 ( p  = 0.003) reflecting an increase by 1.92 (95% confidence interval: 0.86 - 2.98). Conclusions: The number of RCTs investigating the use of urologic devices to treat stone disease has substantially increased overtime. There has been a small improvement in reporting quality; however, this remains suboptimal overall. Increased efforts to promote the transparent reporting of RCTs in endourology are warranted.

Purpose of Review: To investigate the application of artificial intelligence in the management of nephrolithiasis., Recent Findings: Although rising, the number of publications on artificial intelligence for the management of urinary stone disease is still low. Most publications focus on diagnostic tools and prediction of outcomes after clinical interventions. Artificial intelligence can, however, play a major role in development of surgical skills and automated data extraction to support clinical research., Summary: The combination of artificial intelligence with new technological developments in the field of endourology will create new possibilities in the management of urinary stones. The implication of artificial intelligence can lead to better patient selection, higher success rates, and furthermore improve patient safety.

Objective: to evaluate the nephroprotective effect of lercanidipine, its effect on the dynamics of creatinine clearance and blood cytokine levels in patients with nephrolithiasis with obstructive uropathy during renal drainage., Material and Methods: 66 patients were included in the study with concretions of the pelvic segment and the presence of obstruction according to instrumental methods of examination. In order to prevent the occurrence of infectious complications before lithotripsy patients the first stage was performed installation of nephrostomic drainage, followed by antibacterial, anti-inflammatory therapy. Patients were divided into 2 groups: the first (33 patients) received standard therapy, the second (33 people) additionally received lercanidipine at a dose of 10 mg per day for 1 month. Determined the concentration of IL-8, VEGF, MCP-1, G-CSF and GM-CSF in the blood serum by the method of solid-phase ELISA. The glomerular filtration rate was calculated using the CKD-EPI formula. All studies were performed at the preoperative stage, on 7, 14, 21 and 28 days after renal drainage., Results: In the appointment of lercanidipine, there was a more rapid decrease in levels of IL-8, VEGF, MS-1, GM-CSF in serum (21 days), and an improvement in renal function, compared with the group that did not receive nephroprotective therapy., Conclusion: The administration of lercanidipine may contribute to a more rapid recovery of renal function and normalization of blood cytokine levels. This drug can be used in the complex treatment of patients with nephrolithiasis with obstructive uropathy.

Objective: To identify the clinical and demographic predictors of repeat stone surgery., Materials and Methods: We retrospectively analysed 1496 consecutive patients, aged > 18 years, who underwent stone surgery at our institution in the period from January 2009 to May 2017 and who had at least 12 months of postoperative follow-up. We defined surgical recurrence as repeat surgery on the same renal unit or on the opposite renal unit if the original imaging did not demonstrate significant stones on that side. Characteristics associated with the risk of surgical recurrence in univariate Cox regression analysis were entered into a multivariate model., Results: Most patients underwent ureteroscopy and laser lithotripsy (83.0%). Approximately 60% of the patients had a personal history of stone disease and 50% were obese. Over a mean (median; interquartile range) follow-up of 4.1  (3.9; 2.4-5.9) years, 24.5% of patients had surgical recurrence, with 82% of repeat surgeries performed for symptomatic nephrolithiasis. The factors associated with increased risk of surgical recurrence in the multivariate model were: age <60 years, female gender, malabsorptive gastrointestinal disease, diabetes, recurrent urinary tract infections, personal history of nephrolithiasis, renal stones and bilateral nephrolithiasis. The hazard ratios for these variables ranged within an interval of <0.5 (from 1.30 to 1.71)., Conclusion: We identified eight demographic and clinical factors associated with increased risk of repeat renal stone surgery. These factors could be combined as a numerical count that allows stratification of patients into low-, intermediate- and high-risk subgroups., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Introduction: The surgical management of nephrolithiasis can be challenging due to multiple appropriate and feasible approaches. One advantage of urologists' increasing social media use is the opportunity for crowdsourcing or aggregating feedback from remote participants. This study assesses the purposes and extent of online crowdsourcing by urologists for surgical stone disease. Methods: Twitter was queried with 22 stone-related keywords during a 60-day study period. All public posts were reviewed to identify crowdsourcing requests by urologists seeking clinical advice or feedback about surgical stone management. Content analysis of the crowdsourcing posts was performed by two reviewers to assess the purposes of and responses to the requests. Results: A total of 399 posts linked to 29 crowdsourcing requests were analyzed. Crowdsourcing requests were answered rapidly; the median time from initial post to final reply by participants was 2 days. In the majority of requests, the author of the initial request posted a follow-up question or clarification, underscoring a bidirectional exchange of ideas. Most crowdsourcing engaged an international audience; requests originated from 27 urologists in 12 countries, and all but one of the 29 requests (97%) received replies from users outside the origin country. Four purposes for crowdsourcing were observed: patient-specific surgical planning (206 posts, 52%); colleagues' experiences with a device or technique (86 posts, 22%); general advice about stone-related concerns (57 posts, 14%); and solutions to complications or quality improvement challenges (50 posts, 12%). Finally, protection of patient privacy appeared to be a concern; among the 17 (59%) crowdsourcing requests that were about individual patients or cases, all included patient-specific images or radiography, but none noted whether patient permission had been obtained. Conclusions: Social media crowdsourcing facilitates a range of general, patient-specific, and quality improvement challenges in surgical stone management. Participants should consider privacy concerns when publicly sharing imaging or patient data.

Antepartum nephrolithiasis presents a complex clinical scenario which often requires an intervention such as ureteral stent or percutaneous nephrostomy tube (PCNT) placement, especially in the setting of urinary tract infection (UTI). We assess the risk of UTI and preterm labor in the setting of antepartum nephrolithiasis. A retrospective review of an administrative dataset for California and Florida was performed, which included pregnant women admitted for a delivery between 2008 and 2011. Antepartum nephrolithiasis admissions were identified, as were urological intervention (ureteral stent/ureteroscopy) or PCNT placement. Descriptive statistics were performed, as was multivariable logistic regression to identify predictors of UTI and preterm delivery. Of the 2,750,776 deliveries included in this dataset, 3904 (0.14%) were complicated by antepartum nephrolithiasis. 71.4% of these patients were managed conservatively, while 20.6% (n = 803) underwent urological intervention and 8.0% (n = 312) underwent PCNT placement. Preterm delivery rates increased from a baseline of 7.0% for patients without a stone to 9.1% for patients with stones managed conservatively, 11.2% for those undergoing a urologic intervention, and 19.6% for patients who had PCNT placement. On multivariable analysis, conservative management (adjusted odds ratio, aOR 1.3), urologic intervention (aOR 1.5), and PCNT (aOR 2.3) placement each independently increased the risk of preterm delivery (all p < 0.001). Antepartum nephrolithiasis is a condition that affects 1 in 714 women and has been correlated with increased risk of UTI and preterm labor. Intervention with ureteral stent or PCNT placement independently increase these risks, however, receipt of a nephrostomy tube confers the greatest risk of UTI and preterm delivery to the antepartum nephrolithiasis patient.

Objective: We aimed to evaluate the results of laparoscopic pyeloplasty with concomitant pyelolithotomy and compare results with a cohort of patients undergoing laparoscopic pyeloplasty without pyelolithotomy., Materials and Methods: We retrospectively reviewed records of 43 patients undergoing transperitoneal laparoscopic Anderson-Hynes dismembered pyeloplasty between December 2012 and July 2018 at our department. Eighteen patients (42%) underwent laparoscopic pyeloplasty with concomitant pyelolithotomy. The results of patients with renal stones were compared with 25 matched patients undergoing laparoscopic pyeloplasty without concomitant renal stones. Demographic data, operative and stone parameters were compared between the groups., Results: The groups were similar regarding to demographic characteristics. All operations were completed laparoscopically with no conversions to open surgery. In 3 cases without renal stones and 15 cases with renal stones, transposition of the ureter due to crossing vessels was performed. The mean stone size was 13±5.24 mm, and the median number of stones was 1 (1-18). The success of laparoscopic pyeloplasty with and without pyelolithotomy was 93.3% and 92.9%, respectively, as confirmed by negative diuretic renogram at postoperative 3rd months. Overall stone-free rate after laparoscopic pyelolithotomy was 93.3%. Mean operative time was 222.6765.71 minutes vs. 219.11±75.63 minutes for the pyeloplasty with concomitant pyelolithotomy vs. pyeloplasty, respectively (p=0.88)., Conclusions: Laparoscopic pyeloplasty with concomitant pyelolithotomy is a safe and effective intervention with associated good cosmetic results and high stone-free rates without significant increase in operative time or complications., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Introduction: Vascular access for hemodialysis is a key factor in every patient dependent on this treatment. Maintaining a central venous catheter can be a good choice when all the other options have been exhausted, but unwanted and rare complications may arise from longer catheter dwell time., Case Report: We describe a case of a 65-year-old woman undergoing hemodialysis treatment since 1986 after a bilateral nephrectomy due to complicated nephrolithiasis. Her last access, two Tesio® tunneled cuffed catheters implanted via the right internal jugular vein functioned correctly for 14 years without complications, and so, was not replaced in the meantime. She was referred to our hospital due to a rupture in a catheter lumen, which was corrected conservatively by creating a more proximal tunnel and excising the affected area. A few weeks later, a new rupture in the same lumen was identified, so the catheter was replaced with angiographic control. The catheter was frail, so upon its removal, the tip fractured and remained in the right ventricle, being swiftly removed by an endovascular snare without complications., Discussion: This case reports two rare complications associated with catheter handling and identifies a possible technique for conservative resolution of a lumen rupture.

Background: The use of ureteral access sheath (UAS) during ureteroscopy is controversial. We aimed to explore practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists worldwide., Methods: A 15-question survey was designed using the SurveyMonkey® platform. The questions covered the background and professional experience of the potential respondents, indications for UAS insertion, UAS caliber and possible complications associated with its use. The questions were anonymously tabulated in order to determine practice patterns of UAS during ureteroscopy for nephrolithiasis among endourologists. The survey was then distributed via e-mail to all the Endourological Society members., Results: 216 members responded. 99.53% of the respondents practice as endourologists, 63.4% are fellowship trained and 74.4% are at least 6 years post-fellow. 73.2% practice in an academic facility. 77.3% perform at least 100 ureteroscopies annually. 46 and 76% routinely use UAS for the treatment of ureteral and kidney stones, respectively. In both cases, the 12/14 access sheath is the most common. 42% use UAS in primary ureteroscopy. 90.3% believe that a double J stent insertion is not mandatory prior to UAS insertion. 79.1% think the use of UAS does not increase postoperative complications rate, and if the latter does encounter, then most likely it is either a ureteral stricture (93.2%) or pain (48%)., Conclusions: UAS is commonly used by highly skilled endourologists during ureteroscopy. 12/14 UAS is mostly used. Ureteral stricture and post-operative pain are proposed as possible complications following UAS introduction, however pre-stenting is not mandatory as overall low complication rate is expected.

Allograft lithiasis is a rare urologic complication of renal transplantation (RT). Our aim is to present our experience with minimally invasive surgical treatment of allograft lithiasis in our series of live-donor renal transplant recipients. In a retrospective analysis of 3758 consecutive live-donor RTs performed in our center between November 2009 and January 2017, the results of minimally invasive surgery for the treatment of renal graft lithiasis diagnosed at follow-up were evaluated. Twenty-two (0.58%) patients underwent minimally invasive surgery for renal graft lithiasis. The mean age was 41.6 years, and duration between RT and surgical intervention was 27.3 months (range 3-67). The mean stone size was 11.6 mm (range 4-29). Stones were located in the urethra in 1, bladder in 2, ureter in 9, renal pelvis in 7 and calices in 3 patients. Surgical treatment included percutaneous nephrolithotomy in 1, cystoscopic lithotripsy in 3, flexible ureteroscopic lithotripsy in 6 and rigid ureteroscopic lithotripsy in 12 patients. No major complications were observed. One patient (4.5%) who underwent flexible ureteroscopy developed postoperative urinary tract infection. All patients were stone-free except two (9%) patients who required a second-look procedure after flexible ureteroscopic lithotripsy for residual stones. Stone recurrence was not observed in any patient during a mean follow-up duration of 30.2 months (range 8-84). Renal transplant lithiasis is uncommon and minimally invasive surgical treatment is rarely performed for its treatment. Endourological surgery may be performed safely, effectively and with a high success rate in these patients.

This article reviews new advances in ultrasound technology for urinary stone disease. Recent research to facilitate the diagnosis of nephrolithiasis, including use of the twinkling signal and posterior acoustic shadow, have helped to improve the use of ultrasound examination for detecting and sizing renal stones. New therapeutic applications of ultrasound technology for stone disease have emerged, including ultrasonic propulsion to reposition stones and burst wave lithotripsy to fragment stones noninvasively. The safety, efficacy, and evolution of these technologies in phantom, animal, and human studies are reviewed herein. New developments in these rapidly growing areas of ultrasound research are also highlighted., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Diagnosis, treatment, and follow-up are all influential in determining the overall cost to the health care system for kidney stones. New innovations in the field of nephrolithiasis have been abundant, including disposable ureteroscopes, ultrasound-guided approaches to percutaneous nephrolithotomy, and advanced laser lithotripters. Identifying cost-effective treatment strategies encourages practitioners to be thoughtful about providing value-based high-quality care and remains on important principle in the treatment of urinary stone disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Patients with nephrolithiasis are exposed to significant quantities of ionizing radiation with the potential to cause secondary malignancy. This risk is magnified by the high recurrence rate of nephrolithiasis. In this article, we identify the risks of ionizing radiation as they pertain to patients with nephrolithiasis. We then identify evidence-based techniques for mitigating patient radiation exposure in the preoperative, intraoperative, and postoperative settings. Key factors include limiting the use of computed tomographic imaging, appropriate modulation of fluoroscopy settings, and minimizing rates of stone recurrence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Imaging following surgical intervention for nephrolithiasis is important to define operative success and ensure the absence of silent obstruction. We assessed nationwide postoperative imaging patterns in children undergoing ureteroscopy and shock wave lithotripsy., Materials and Methods: We reviewed the MarketScan® Commercial Claims and Encounters database from 2007 to 2013 for patients 1 to 18 years old undergoing ureteroscopy or shock wave lithotripsy. We assessed imaging exposure following index procedure within 90 days as a primary analysis and 180 days as a secondary analysis of the index procedure. Univariate and multivariate statistical analyses were performed to assess factors associated with undergoing postoperative imaging., Results: A total of 4,251 children met inclusion criteria, of whom 1,647 had undergone shock wave lithotripsy and 2,604 had undergone ureteroscopy. Postoperative imaging was performed in 57.5% of the cohort, with a higher proportion of children undergong imaging following shock wave lithotripsy compared to ureteroscopy (73% vs 47.8%, p <0.001). Noncomputerized tomographic imaging modalities were most common following ureteroscopy (70.8%) and shock wave lithotripsy (84.6%). Younger children and those with complex medical conditions or complicated postoperative courses were more likely to undergo followup imaging. Computerized tomography was more commonly used in older children and females. At 180-day followup 63% of the cohort had undergone any imaging, again more frequently following shock wave lithotripsy (77.0%) vs ureteroscopy (45.0%)., Conclusions: A large percentage of children with nephrolithiasis do not undergo followup imaging after shock wave lithotripsy, and even fewer undergo imaging after ureteroscopy. Most followup imaging is done within 90 days of surgery. Further work is needed to define appropriate postoperative imaging practices in this population.

Objective: To compare outcomes of patients undergoing single session bilateral ureteroscopy (SSBU) to those undergoing planned staged ureteroscopy (URS) for bilateral nephrolithiasis. While SSBU has the advantage of 1 anesthetic procedure, some may pursue a staged approach due to the potential higher risk of complications and patient discomfort with 2 ureteral stents., Methods: We retrospectively identified patients undergoing SSBU and planned staged URS for nephrolithiasis between December 2007 and December 2014. Preoperative characteristics, intraoperative techniques, and postoperative outcomes were compared. Stone burden was calculated as cumulative stone diameter. Residual stone fragments were defined as any stone visible on postoperative imaging., Results: Sixty-three patients underwent SSBU and 37 underwent planned staged URS. Both cohorts had a relatively large cumulative stone burden (30.9 mm vs 32.4 mm, P = .71). Total operative time was significantly longer for planned staged URS (139 vs 86 minutes, P <.0001). There were no significant differences in complications or emergency room visits between the 2 cohorts despite bilateral ureteral stents being placed in the majority of the SSBU cohort (73%). There were no differences in stone-free rates or the need for additional procedures., Conclusion: SSBU is safe and effective with overall shorter operative times and similar stone-free rates compared to planned staged URS. Bilateral ureteral stent placement did not increase the rate of unplanned emergency visits. For patients with bilateral nephrolithiasis, urologists should strongly consider SSBU to limit anesthetic exposure, overall operative time, and health care costs., (Copyright © 2018. Published by Elsevier Inc.)

We report the case of a 17-year-old male with Seckel syndrome and horseshoe kidneys which had a 7 mm kidney stone in the lower pole calyx of the right moiety. The patient had a history of rotoscoliosis with 60° dextroconvex curvature and hepatic steatosis. Attempted ureteroscopy was unsuccessful due to stone location and anatomy. Percutaneous nephrolithotomy was ultimately required. This case highlights the difficulties of endoscopic treatments of renal calculi in patients with abnormal renal anatomy and dysmorphia. To our knowledge, this is the first reported case of nephrolithiasis in a patient with Seckel syndrome and horseshoe kidneys., (Copyright © 2018. Published by Elsevier Inc.)

Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis., Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose., Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not., Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

Introduction: Successful surgical therapy for pediatric upper urinary tract calculi (UUTC) minimizes the need for repeat surgical interventions. However, staged procedures, whether planned or unplanned, are sometimes necessary. We assessed predictors of repeat intervention for children with UUTC using a nationwide administrative dataset., Methods: Using the Pediatric Health Information System (PHIS) dataset, we assessed children with UUTC undergoing shock wave lithotripsy (SWL) or ureteroscopy (URS) for an index stone from January 2010 to June 2015. Primary outcome was additional treatment for nephrolithiasis within 90 days. Patient and procedural variables were assessed as potential risks for retreatment. Multivariable logistic regression models were used to compare the risk of retreatment adjusting for potential confounding factors., Results: A total of 2788 patients undergoing URS (2,216, 79.5%) and SWL (572, 20.5%) were identified. SWL, stenting at the index operation without pre-index stenting, chronic comorbidities, renal calculi, and age <5 years were independent risk factors for retreatment. Use of ureteral stenting, most commonly employed in URS, was also a strong predictor of retreatment. Odds for reintervention, adjusted by multivariate modeling, are shown in the Figure., Conclusions: Adjusting for measured confounders, SWL is associated with a 2.6-fold higher risk of repeat stone-related interventions. Additional patient-related factors also increase likelihood of retreatment. Intra-operative stent placement is a strong predictor of retreatment, perhaps serving as a marker for complex cases or planned staged procedures. Prospective studies are needed to assess comparative effectiveness of SWL and URS and improve mono-therapeutic success for children with UUTC., (Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: To determine the clinical yield of stone culture in patients undergoing percutaneous nephrolithotomy (PCNL), and to identify patients who may benefit from this test., Materials and Methods: We queried our database for all patients who underwent PCNL from 2005 to 2017, from whom urine culture (UC) and stone culture (SC) were obtained. Study endpoint was systemic inflammatory response syndrome (SIRS) within 48 hours of PCNL. Risk factors for SIRS and for stone colonization with highly resistant pathogens were evaluated. Based on UC and SC results, we determined the proportion of patients in whom SC may alter the treatment, had SIRS occurred, with respect to the initial empiric treatment., Results: The study group comprised of 512 patients with a median age of 53, of whom 323 (63%) were male. Positive UC were found in 137 (26.7%) patients, and positive SC in 117 (22.8%) patients. UC did not identify pathogens isolated from SC in 66 (12.8%) patients. Postoperative SIRS occurred in 50 (9.8%) patients. On multivariate analysis only SC was associated with postoperative SIRS. SC pathogens resistance rates ranged from 67% for treatment with 2nd generation cephalosporins to 9% for treatment with meropenem, and may alter the choice of antibiotics in 73 to 12 patients (14.2%-2.3% of the whole cohort), respectively., Conclusions: In similar and earlier studies, we found substantial discordance between SC and UC results, and an association between stone colonization and SIRS. However, the practical yield of this test varies with the type of antibiotic given, and is limited when broad spectrum antibiotic is used.

Objective: To determine the efficacy of intercostal nerve block and nephrostomy tract infiltration (NTI) with ropivacaine in patients undergoing tubeless percutaneous nephrolithotomy (TPCNL)., Materials and Methods: From February 2015 to March 2017, a total of 226 patients undergoing TPCNL were enrolled. After excluding 130 patients who failed to meet the inclusion criteria, a total of 96 eligible patients were randomized into 3 groups: group I, control group (n = 32); group II, intercostal nerve block with 15 mL of 0.5% ropivacaine and epinephrine (n = 32); and group III, NTI with 20 mL of 0.25% ropivacaine and epinephrine (n = 32). Pain status was assessed at postoperative 2, 8, and 24 hours and at discharge by visual analog scale score at rest (RVAS) and on deep breathing and coughing., Results: Patient demographics and perioperative data between groups were comparable except for length of stay. Mean RVAS scores at postoperative 2 and 8 hours for group III were significantly less than those for group I (RVAS at 2 hours: 2.6 vs 4.9, P = .001; RVAS at 8 hours: 1.7 vs 3.3, P = .007). Mean RVAS scores at postoperative 24 hours had borderline significance (P = .050) among the 3 groups. Differences in mean deep breathing and coughing scores among groups were statistically significant (P = .002) only in the first 2 hours. All postoperative complications (5.4%, 5 per 92) were of grade 1 and not significantly different among groups., Conclusion: NTI is safe and effective in alleviating early postoperative pain for patients who underwent TPCNL., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The improvement of surgical care requires transparent, consistent and accurate reports concerning surgical outcomes which are assessed and documented in a standardized manner. No consensus has yet been reached as to how to define and assess postoperative complications with regard to the specificity of urological procedures. Therefore, the comparison of data from different centres is difficult. The modified Clavien-Dindo classification allows for a more uniform analysis of surgical complications. This study analyses the occurrence of perioperative complications after percutaneous nephrolithotomy assessed on the basis of the aforementioned classification., Aim: The aim of this study was to analyse perioperative complications with the use of modified Clavien-Dindo classification. Obtained results were compared with those from the multicentre Endourological Society Percutaneous Nephrolithotomy Global Study., Materials and Methods: This retrospective analysis involved 201 patients who underwent percutaneous nephrolithotomy during the period from 01.01.2013 to 31.12.2016. We assessed the frequency of complication and the characteristics of deposits. The modified Clavien- Dindo classification was used here. The surgery was performed by one operator in one centre., Results: In 83.08% of patients normal postoperative course was reported. In case of 12.44%, there were minor deviations from the standard intraoperative and postoperative course. 2,49% of patients required transfusions of red blood cell (Clavien II) after the procedure. Less than 1.5% of patients required surgical, endoscopic or radiological intervention under local anaesthesia (Clavien IIa) and one patient required such intervention under general anaesthesia (Clavien IIb). Serious complications were not reported. The most common complications were as follows: low-grade fever (15.42%), fever (5.97%) and bleeding (3.48%). Among the least frequent complications there were: injuries of renal pelvis or ureter 2.99%, residual stones (1.99%), urinary leakage (1.49%), urinary retention (0.995%), arteriovenous fistula (0.497%)., Conclusions: Percutaneous nephrolithotomy is a highly effective treatment of stones removal from the kidney. It is characterized by a small percentage of serious complications, especially when it is performed by an experienced operator. The modified Clavien-Dindo classification of complications is useful in monitoring and comparing the results obtained for this procedure.

Purpose: The study of diagnostic imaging after procedural intervention for nephrolithiasis is limited. We sought to characterize actual national imaging patterns and longitudinal trends after ureteroscopic or shock wave lithotripsy., Materials and Methods: We analyzed the MarketScan® database and identified a nationally representative sample of insured, employed patients, 17 to 64 years old who underwent ureteroscopic or shock wave lithotripsy for nephrolithiasis between 2007 and 2014. Patients were excluded from study if they lacked at least 1 year of postoperative database enrollment or underwent a repeat nephrolithiasis procedure of any type within 90 days after the initial procedure. We identified and tracked postoperative imaging modalities by medical billing codes., Results: We identified 101,554 patients treated with ureteroscopy, of whom 55% and 39% underwent no postoperative imaging within 3 and 12 months, respectively. Of the 101,590 patients treated with shock wave lithotripsy 23% and 16% underwent no postoperative imaging within 3 and 12 months, respectively. Abdominal x-ray was the most common imaging modality after either procedure type. Ultrasound use increased with time while computerized tomography decreased. In about 25% of ureteroscopy and shock wave lithotripsy cases at least 1 postoperative computerized tomography was done within a year. Female gender and older age were associated with higher imaging rates. Ultrasound was more commonly performed in the northeast region and in more densely populated areas., Conclusions: A notable portion of patients treated with ureteroscopy and a smaller percent treated with shock wave lithotripsy do not undergo any followup imaging within 1 year. In the majority who undergo imaging abdominal x-ray is done, precluding the ability to screen for hydronephrosis or silent obstruction in almost 75% of patients treated with ureteroscopy., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Percutaneous nephrolithotomy (PNL) is an endoscopic technique used for treating large stones, multiple stones, and staghorn calculi. Although minimally invasive, complication rate of PNL reaches 25%, and it is partially associated with needle puncture during nephrostomy tract preparation. Continuous improvement of armamentarium and imaging methods and the introduction of three-dimensional (3D) visualizations optimize the procedure; however, the rapid and precise establishment of the nephrostomy tract is still difficult. In the present short communication, we present the PNL procedure assisted by a personalized 3D-printed surgical guide (SG) to ensure fast and precise needle access to the renal collecting system. We also describe the workflow for SG preparation, which consists of CT image acquisition and data segmentation, planning a safe needle insertion path, SG designing, and guide manufacturing. With the growing market of low-cost 3D printers, the presented technique can shorten the PNL procedure time and decrease the complication rate associated with needle puncture in a cost-efficient manner., (© 2016 S. Karger AG, Basel.)

Objective: We report on the comparison of clinical results of the early phase of implementation of minimally invasive PNL (MIP) in a mentor-based approach with the later on clinical routine in a tertiary centre., Patients and Methods: From January 2010 until January 2015 MIP was performed in 190 patients. Stone and patient characteristics were recorded in prospective manner. Perioperative complications were recorded within the Clavien-Classification. The first 120 consecutive patients undergoing MIP were evaluated and divided into three groups of 40 patients each. Mentor-based introduction of MIP was done within the first 40 patients (group A). Further patients were treated on routine clinical practice basis (group B and C). Treatment outcome was compared within the three groups., Results: The groups did not significantly differ with regard to patient characteristics, operation time and decline in haemoglobin. In the mentor-based series mean stone size was 21.7 ± 12.6 vs. 15.6 ± 7.9 and 16.1 ± 8.4 mm in group B and C (p = 0.033). Primary stone-free rates were 65, 87.5 and 87.5% for the three groups (p = 0.015). Stone-free rate was higher in smaller and simple stones. Overall, complication rate was 41.7% including 36.7% Clavien grade I and II complications., Conclusions: MIP can be implemented safe and effectively with mentor-based approach. MIP has a high safety profile, which allows high safety and efficacy of MIP at the time of implementation.

Percutaneous nephrolithotomy (PCNL) using a nephrostomy tube as a drainage has been considered the standard procedure. However, recently many literatures have reported the use of tubeless and totally tubeless drainage following PCNL with excellent results. A literature search was conducted using MEDLINE databases to review each drainage technique following PCNL (tubeless, totally tubeless, or nephrostomy tube) and also to assess the most recent evidence that compare the safety of these drainage procedures with a clear-cut clinical parameter imposed. Tubeless or totally tubeless PCNL is significantly superior to standard PCNL in terms of length of hospital stay, postoperative pain (visual analog scale) score, demands or dosage of analgesics required, as well as faster return to activity for the patients. However, despite the many advantages of tubeless or totally tubeless PCNL over standard PCNL, there are a number of situations requiring the consideration of nephrostomy tube placement. Nonetheless, decision to use or not to use nephrostomy tube after PCNL depends on the surgeon's experience and clinical judgment., (Copyright © 2016. Published by Elsevier Taiwan.)

To review the clinical data of the patients who required repeated renal arteriography following initial super-selective renalartery embolization (SRAE) after Percutaneous Nephrolithotomy (PCNL) and to analyze the reasons for the failure. We retrospectively reviewed the data of the patients who underwent repeat renal arteriography after PCNL for persistent or recurrent severe hemorrhage from August 2001 through August 2015 at our hospital. Total of 427 SRAEs were performed in 369 patients who had undergone PCNL. 21 patients had repeated renal arteriography. Among them, 12 required 2 sessions, 5 required 3 sessions, 1 required 4 sessions, and 3 required 5 sessions. In those 37 repeated renal arteriography, 7 were due to missed pseudoaneurysm, 5 for recanalization of the embolized vessels, and finding of new renal vascular lesions in 22. These new findings included new pseudoaneurysm in sixteen, new arterio-venous fistula (AVF) in two, combination of new pseudoaneurysm and AVF in four, and no identifiable abnormity in three. Except for the missed pseudoaneurysm and the recanalization of the embolized vessels, new renal vascular lesion was the major reason for the repeated arteriography in our hospital. The cause of these new renal vascular lesions was unknown. The lesion might be missed during the initial arteriography due to arterial spasm. Progressive deterioration of the injured vessel integrity could be the other possibility.

Objective: To evaluate the feasibility and clinical performance of a novel surgeon technique and protocol targeting ultralow fluoroscopy usage in retrograde intrarenal surgery (RIRS)., Materials and Methods: All RIRS procedures between 2009 and 2015 for 10- to 20-mm renal calculi performed by the same 2 experienced urologists were eligible. All procedures were performed using a highly standardized step-by-step RIRS technique. This technique was modified by the ultralow radiation exposure RIRS protocol; herein, as much as possible of the standardized steps were performed without radiation control targeting ultralow fluoroscopy usage. Primary end points were fluoroscopy time and dose area product. Secondary end points were stone-free rate (SFR) and intraoperative complications according to Satava classification. End points were evaluated using scatter plots and linear regression model., Results: Overall, 174 procedures were assessed. Over the study period, fluoroscopy time and dose area product could be reduced from 167.7 s/318.4 cGy/cm 2 in 2009 to 7.4 s/6.4 cGy/cm 2 in 2015 (P <.001). SFR (66.7% in 2009; 100% in 2015) and complications (Satava 1 and 2: 28.5% and 4.8%, respectively) improved P <.1), and the surgical duration was reduced (91 minutes and 65 minutes, respectively, P <.001)., Conclusion: Our findings revealed a continuous reduction of the amount of radiation used by the implementation of a novel ultralow X-ray usage protocol. SFR, complications, and surgical duration all improved, demonstrating that the novel protocol is as effective as current methods. Exposure to ionizing radiation can be significantly reduced if the presented protocol is followed strictly., (Copyright © 2017 Elsevier Inc. All rights reserved.)