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Background: Urologists frequently activate foot pedals in a low-light operating room (OR). Pedal activation in low-light conditions poses the potential for incorrect pedal activation, potentially leading to increased radiation exposure, patient burns, or OR fires. This study compares speed, accuracy, dark adaptation, and surgeon preference for pedal activation in 4 lighting conditions. Materials and Methods: During a simulated percutaneous nephrolithotomy (PCNL), pedals for C-arm, laser, and ultrasonic lithotripter (USL) were randomized to 3 different positions. Urology attendings, residents, and medical students activated pedals in a randomized order in 4 settings: a dark OR with no illumination, an OR with overhead illumination, a dark OR with glowstick illumination, and a dark OR with blacklight illumination. Endpoints included pedal activation time; number of attempted, incomplete, and incorrect activations; dark adaptation; and subjective pedal preference. ANOVA was used for analysis with p < 0.05 considered significant. Results: In our study with 20 participants, the mean pedal activation times were significantly faster when using glowstick illumination (6.77 seconds) and blacklight illumination (5.34 seconds) compared with the no illumination arm (8.47 seconds, p < 0.001). Additionally, individual pedal activations for the C-arm, laser, and USL were significantly faster with glowstick and blacklight illumination compared with a dark OR ( p < 0.001 for all). The blacklight illumination arm demonstrated decreased attempted (0.30 vs. 3.45, p < 0.001), incomplete (1.25 vs. 7.75, p < 0.001), and incorrect activations (0.35 vs. 1.25, p < 0.001) compared with the dark setting, while demonstrating no difference compared with having room lights on. Dark adaptation was significantly improved with blacklight illumination compared with having the room lights on (134.5 vs. 140.5 luminance, p < 0.001). All participants (100%) preferred illuminated pedals compared with the dark OR, with 90% favoring the blacklight illumination. Conclusions: During a simulated PCNL, blacklight illumination significantly improved accuracy and efficiency of pedal activation compared with the conventional dark OR, while maintaining the surgeon's dark adaptation.

Purpose: Current occupational recommendations limit fetal radiation dose to 1 mSv. With increased gender diversity in urology, understanding radiation exposure during pregnancy is crucial. The purpose of this study was to determine surgeon uterine radiation dose during percutaneous nephrolithotomy (PCNL) and compare effectiveness of several radiation reduction strategies in a cadaver model., Materials and Methods: Two cadavers were used to simulate the surgeon and the patient in a PCNL model. An ion chamber was placed behind the surgeon's anterior uterine wall to measure the radiation dose. Three radiation reduction methods were compared: pulsed fluoroscopy (1, 4, 8, 15, 30 pps), low-dose (LD) fluoroscopy, and surgeon shielding (none, 0.35-, 0.50-, 0.70-mm lead equivalents). The average radiation dose per second was recorded for 20 trials per combination. Assuming 5 minutes of fluoroscopy per PCNL, the number of cases required to exceed the fetal occupational limit was determined., Results: Decreasing pulse frequency from 30 to 1 pps reduced the dose by 96% ( P < .001). The LD setting decreased the dose by 56% ( P < .001). A 0.35-mm lead apron resulted in a 94% dose reduction ( P < .001), and the 0.50- and 0.70-mm lead aprons further reduced the dose by 12% and 47%, respectively. In conventional fluoroscopy settings of automatic exposure control and at 30 pps, a surgeon could perform 12 PCNLs using no lead or 189 PCNLs using a 0.35-mm lead apron before reaching the 1 mSv limit. In addition to shielding, using 1 pps with LD fluoroscopy further decreased radiation exposure, allowing over 6000 cases to be performed with < 1 mSv uterine radiation exposure., Conclusions: Within the limitations of this cadaver study, these data support that high-volume pregnant surgeons using active radiation reduction techniques such as pulsed fluoroscopy, LD fluoroscopy, and appropriate shielding can maintain surgical volume with relatively low risk. Fetal dosimeter use with monthly monitoring is still encouraged to confirm safety throughout pregnancy.

Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare.

Introduction: The thulium fiber laser (TFL) generates a focused beam, which can be transmitted to laser fibers with small core diameters and may facilitate in situ lower-pole lithotripsy. This study compares lithotripsy performance of the 150 and 200 µm TFL in a lower pole benchtop kidney model. Materials and Methods: Using a 3D model printed from an actual kidney, in situ laser lithotripsy was performed on 1 cm lower-pole BegoStones (calcium oxalate monohydrate consistency) using four different settings (all 20W) and two fiber sizes (150 and 200 µm). Procedure time, laser time, total pulse energy, and fiber stripping were compared between the two fibers using an ANOVA or independent t-test . Results: The 150 µm fiber at 0.2 J × 100 Hz had the shortest lasing and procedure time (17.3 and 18.5 minutes) and lowest total pulse energy (20.75 kJ) compared with other study arms ( p < 0.001). Overall procedure time, lasing time, and total pulse energy were significantly different between the 8 settings ( p < 0.001 for all). At higher frequency (100 and 200 Hz), lasing time was significantly faster compared with 20 and 50 Hz (19.9 vs 27.3 minutes; p < 0.001). Furthermore, the average total procedure time was shorter with 150 µm compared with 200 µm regardless of settings (23.2 vs 29.8 minutes; p < 0.001). Conclusion: The 150 µm fiber results in shorter procedure and lasing time at lower total energy levels during lower-pole in situ lithotripsy. Overall, the fastest setting was 0.2 J and 100 Hz with the 150 µm fiber. Smaller laser fibers can potentially allow more efficient in situ laser lithotripsy with better irrigation and visibility at higher deflection angles.

The purpose of this study was to measure and compare renal pelvic pressure (RPP) between prone and supine percutaneous nephrolithotomy (PCNL) in a benchtop model. Six identical silicone kidney models were placed into anatomically correct prone or supine torsos constructed from patient CT scans in the corresponding positions. A 30-Fr renal access sheath was placed in either the upper, middle, or lower pole calyx for both prone and supine positions. Two 9-mm BegoStones were placed in the respective calyx and RPPs were measured at baseline, irrigating with a rigid nephroscope, and irrigating with a flexible nephroscope. Five trials were conducted for each access in both prone and supine positions. The average baseline RPP in the prone position was significantly higher than the supine position (9.1 vs 2.7 mmHg; p < 0.001). Similarly, the average RPP in prone was significantly higher than supine when using both the rigid and flexible nephroscopes. When comparing RPPs for upper, middle, and lower pole access sites, there was no significant difference in pressures in either prone or supine positions (p > 0.05 for all). Overall, when combining all pressures at baseline and with irrigation, with all access sites and types of scopes, the mean RPP was significantly higher in the prone position compared to the supine position (14.0 vs 3.2 mmHg; p < 0.001). RPPs were significantly higher in the prone position compared to the supine position in all conditions tested. These differences in RPPs between prone and supine PCNL could in part explain the different clinical outcomes, including postoperative fever and stone-free rates., (© 2024. The Author(s).)

Introduction: Flat-panel detector C-arms (FCs) are reported to reduce radiation exposure and improve image quality compared with conventional image intensifier C-arms (CCs). The purpose of this study was to compare radiation exposure and image quality between three commonly used FCs. Materials and Methods: A cadaver model was placed in the prone position to simulate percutaneous nephrolithotomy. We compared the following three FCs: OEC Elite CFD from GE HealthCare, Zenition 70 from Philips, and Ziehm Vision RFD from Ziehm Imaging. To measure the radiation dose, optically stimulated luminescence dosimeters (OSLDs) were utilized during five 300-second trials, conducted under three settings: automatic exposure control (AEC), AEC with low dose (LD), and LD with the lowest pulse rate (LDLP). Ten blinded urologists evaluated the image quality. Data were statistically analyzed using the analysis of variance (ANOVA) and Tukey's B post hoc tests. Results: In the AEC setting, the Philips C-arm demonstrated lower ventral OSLD exposure (42,446 mrad) compared with both the GE (51,076 mrad) and Ziehm (83,178 mrad; p  < 0.001) C-arms. Similarly, in the LD setting, the Philips C-arm resulted in less ventral OSLD exposure (25,926 mrad) than both the Ziehm (30,956 mrad) and GE (38,209 mrad; p  < 0.001) C-arms. Meanwhile, in the LDLP setting, the Ziehm C-arm showed less ventral OSLD exposure (4019 mrad) than both the GE (7418 mrad) and Philips (8229 mrad; p  < 0.001) C-arms. All three manufacturers received adequate image quality ratings at the AEC and LD settings. However, at LDLP, the Ziehm C-arm received inadequate ratings in 8% of images, whereas both the GE and Philips C-arms received 100% adequate ratings ( p  = 0.016). Conclusions: Radiation produced by flat-panel C-arms varies dramatically, with the highest exposure (Ziehm) being almost double the lowest (Philips) in AEC. Improved picture quality at the lowest settings may come at the cost of increased radiation dose. Surgeons should carefully select the machine and settings to minimize radiation exposure while still preserving the image quality.

Objective: To compare the radiation dose and image quality between flat panel detector (FPD) and traditional image intensifier (II) C-arms at their lowest radiation settings., Methods: In a ureteroscopy simulation using a cadaver model, the radiation exposure was compared between FPD and II at 4 pulses-per-second (pps) using both low dose and automatic exposure control (AEC) settings. Additionally, the lowest dose settings for each machine were compared (4 pps with low dose in the FPD and 1 pps with low dose in the II). Five trials of 5 minutes were conducted for each setting. Four new optically stimulated luminescent dosimeters were used in each trial to record radiation exposure. Ten blinded urologists completed a survey rating image quality for each setting., Results: When comparing the FPD and II at their lowest possible settings, the FPD produced significantly more radiation (P <.05). Using both machines at 4 pps in low dose mode resulted in no significant difference between C-arms (P >.05). Conversely, operating the C-arms at 4 pps and AEC resulted in significantly higher radiation exposure from the FPD compared to the II (P <.05). There was no significant difference in image quality at each setting., Conclusion: FPDs produce significantly more radiation at the lowest settings compared to IIs. Surgeons should employ IIs when reducing radiation exposure as low as possible is imperative, such as when operating on pediatric and pregnant patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Percutaneous nephrolithotomy confers the highest radiation to the urologist's hands compared to other urologic procedures. This study compares radiation exposure to the surgeon's hand and patient's body when utilizing three different techniques for needle insertion during renal access. Simulated percutaneous renal access was performed using a cadaveric patient and separate cadaveric forearm representing the surgeon's hand. Three different needle-holding techniques were compared: conventional glove (control), a radiation-attenuating glove, and a novel needle holder. Five 300-s fluoroscopy trials were performed per treatment arm. The primary outcome was radiation dose (mSv) to the surgeon's hand. The secondary outcome was radiation dose to the patient. One-way ANOVA and Tukey's B post-hoc tests were performed with p < 0.05 considered significant. Compared to the control (3.92 mSv), both the radiation-attenuating glove (2.48 mSv) and the needle holder (1.37 mSv) reduced hand radiation exposure (p < 0.001). The needle holder reduced hand radiation compared to the radiation-attenuating glove (p < 0.001). The radiation-attenuating glove resulted in greater radiation produced by the C-arm compared to the needle holder (83.49 vs 69.22 mGy; p = 0.019). Patient radiation exposure was significantly higher with the radiation-attenuating glove compared to the needle holder (8.43 vs 7.03 mSv; p = 0.027). Though radiation-attenuating gloves decreased hand radiation dose by 37%, this came at the price of a 3% increase in patient exposure. In contrast, the needle holder reduced exposure to both the surgeon's hand by 65% and the patient by 14%. Thus, a well-designed low-density needle holder could optimize radiation safety for both surgeon and patient., (© 2024. The Author(s).)

Introduction: With the rise in the detection of incidental small renal masses (SRM), the management paradigm for these patients has become an issue of increasing concern. We aim to identify areas of consensus, controversy, and opportunities for improvement among recently published guidelines and assess the strength of evidence for the management of SRMs. Methods: We reviewed practice guidelines for SRMs promulgated by the American Urological Association, European Association of Urology, National Comprehensive Cancer Network, American Society of Clinical Oncology, European Society for Medical Oncology, and the Chinese Society of Clinical Oncology. Levels of evidence and strength of recommendations for evaluation, management and follow-up were analyzed with regard to consensus, conflict, and neglect. Results: There is consensus among guidelines for the initial evaluation and treatment of SRMs; however, discrepancies exist with regard to indications for active surveillance, thermal ablation, and timing/method of follow-up after treatment. Routine renal mass biopsy is not recommended by any guideline. Overwhelmingly, guideline statements are based on low to moderate levels of evidence; only 23% of the reviewed guidelines were based on high-level evidence, 38% based on moderate-level, and 39% on low-level evidence or expert opinion. Conclusions: Despite all six guidelines sharing a consensus on most management topics regarding SRMs, the ongoing lack of high-level evidence precludes gold standard recommendations in the areas of diagnosis, treatment, and follow-up. More high-quality studies are needed to develop a stronger, data-supported universal guideline for the management of SRMs.

Introduction and Objectives: We sought to compare the effectiveness and efficiency of the superpulse thulium fiber laser (sTFL to the holmium: yttrium-aluminum-garnet [Ho:YAG] laser for ureteroscopic "dusting" of implanted renal stones in an in vivo porcine model. Methods: Twenty-four porcine kidneys (12 juvenile female Yorkshire pigs) were randomized to Ho:YAG or sTFL treatment groups. Canine calcium oxalate stones were scanned with computed tomography to calculate stone volume and stone density; the stones were randomized and implanted into each renal pelvis via an open pyelotomy. In all trials, a 14F, 35 cm ureteral access sheath was placed. With a 9.9F dual lumen flexible ureteroscope, laser lithotripsy was performed using dusting settings: Ho:YAG 200 μm laser fiber at 16 W (0.4 J, 40 Hz) or sTFL 200 μm laser fiber at 16 W (0.2 J, 80 Hz). Lithotripsy continued until no fragments over 1 mm were observed. No stone basketing was performed. Throughout the procedures, intrarenal and renal pelvis temperatures were measured using two percutaneously positioned K-type thermocouples, one in the upper pole calyx and one in the renal pelvis. After the lithotripsy, the ureteropelvic junction was occluded, the kidneys were bivalved, and all residual fragments were collected, dried, weighed, and then measured with an optical laser particle sizer. Results: Implanted stones were similar in volume and density in both groups. Intraoperative collecting system temperatures were similar for both groups (all <44°C). Compared to Ho:YAG, sTFL ablated stones faster (9 vs 27 minutes, p  < 0.001) with less energy expenditure (8 vs 26 kJ, p  < 0.001), and a greater stone clearance rate (73% vs 45%, p  = 0.001). After sTFL lithotripsy, 77% of the remaining fragments were ≤1 mm vs 17% of fragments ≤1 mm after Ho:YAG treatment ( p  < 0.001). Conclusions: In an in vivo porcine kidney, using dusting settings, sTFL lithotripsy resulted in shorter ablation times, higher stone clearance rates, and markedly smaller stone fragments than Ho:YAG lithotripsy.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p  = 0.984) and basketing time (12 vs 19 minutes; p  = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p  = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm 3 /min, p  = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p  = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p  = 0.375) and postoperative complications (single: 7% vs dual: 11%, p  = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.

Objective: To develop a software for mixed reality (MR) anatomical model creation and study its intraoperative clinical utility to facilitate laparoscopic partial nephrectomy., Materials and Methods: After institutional review board approval, 47 patients were prospectively randomized for LPN into two groups: the control group (24 patients) underwent operation with an intraoperative ultrasound (US) control and the experimental group (23 patients) with smart glasses HoloLens 2 (Microsoft, Seattle, WA, USA). Our team has developed an open-source software package called "HLOIA," utilization of which allowed to create and use during surgery the MR anatomical model of the kidney with its vascular pedicle and tumor. The study period extended from June 2020 to February 2021 where demographic, perioperative, and pathological data were collected for all qualifying patients. The objective was to assess the utility of a MR model during LPN and through a 5-point Likert scale questionnaire, completed by the surgeon, immediately after LPN. Patient characteristics were tested using the chi-square test for categorical variables and Student's t -test or Mann-Whitney test for continuous variables., Results: Comparison of the variables between the groups revealed statistically significant differences only in the following parameters: the time for renal pedicle exposure and the time from the renal pedicle to the detection of tumor localization ( p < 0.001), which were in favor of the experimental group. The surgeon's impression of the utility of the MR model by the proposed questionnaire demonstrated high scores in all statements., Conclusions: Developed open-source software "HLOIA" allowed to create the mixed reality anatomical model by operating urologist which is when used with smart glasses has shown improvement in terms of time for renal pedicle exposure and time for renal tumor identification without compromising safety., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Nariman Gadzhiev et al.)

Purpose: We evaluated our experience of a multidisciplinary approach to renal mass biopsy (RMB) for small renal masses (SRMs) employing in-office ultrasound (US)-guided biopsy by urology (24%), CT, or US biopsy by interventional radiology (IR) (79%), and endoscopic ultrasound (EUS)-guided biopsy by gastroenterology (GI) (4%). Materials and Methods: A single-institution retrospective review of patients who underwent RMB for SRM from May 2013 to August 2019 was conducted. Data regarding patient demographics, tumor characteristics, biopsy technique, histopathology, and management were collected. Diagnostic rates, concordance with final pathology, complications, and outcomes were analyzed. Results: Of the 192 biopsies reviewed, 63% biopsies were malignant, 20% were benign, and 17% were nondiagnostic. Based on biopsy results, 71 patients (37%) elected active surveillance. Thirty-eight (20%) patients underwent cryoablation, 56 (29%) underwent partial nephrectomy, 14 (7%) underwent radical nephrectomy, and the remaining patients were treated elsewhere. The rate of surgery for benign pathology after pretreatment RMB was 3%. The concordance rate between biopsy and final pathology was 99% for malignancy, 96% for specific pathology subtype, and 85% for renal cell carcinoma grade. Median time from diagnosis to definitive treatment was 97 days (urology: 76, IR: 110 and GI: 54, p  = 0.002). Three (1.6%) Clavien I complications were reported. Conclusion: Our multidisciplinary approach to RMB for clinical stage T1a demonstrated favorable safety and diagnostic rates, which effectively directed management strategies and minimized surgery for benign disease. Urologist-performed office biopsies significantly shortened the time from diagnosis to definitive treatment. Our experience with GI EUS biopsy has demonstrated feasibility and safety for tumors that were otherwise not accessible percutaneously.

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

The goal of this study was to assess the ablation, coagulation, and carbonization characteristics of the holmium:YAG (Ho:YAG) laser and thulium fiber lasers (TFL). The Ho:YAG laser (100 W av.power), the quasi-continuous (QCW) TFL (120 W av.power), and the SuperPulsed (SP) TFL (50 W av.power) were compared on a non-frozen porcine kidney. To control the cutting speed (2 or 5 mm/s), an XY translation stage was used. The Ho:YAG was tested using E = 1.5 J and P av  = 40 W or P av  = 70 W settings. The TFL was tested using E = 1.5 J and P av  = 30 W or P av  = 60 W settings. After ex vivo incision, histological analysis was performed in order to estimate thermal damage. At 40 W, the Ho:YAG displayed a shallower cutting at 2 and 5 mm/s (1.1 ± 0.2 mm and 0.5 ± 0.2 mm, respectively) with virtually zero coagulation. While at 70 W, the minimal coagulation depth measured 0.1 ± 0.1 mm. The incisions demonstrated zero carbonization. Both the QCW and SP TFL did show effective cutting at all speeds (2.1 ± 0.2 mm and 1.3 ± 0.2 mm, respectively, at 30 W) with prominent coagulation (0.6 ± 0.1 mm and 0.4 ± 0.1 mm, respectively, at 70 W) and carbonization. Our study introduced the TFL as a novel efficient alternative for soft tissue surgery to the Ho:YAG laser. The SP TFL offers a Ho:YAG-like incision, while QCW TFL allows for fast, deep, and precise cutting with increased carbonization., (© 2020. Springer-Verlag London Ltd., part of Springer Nature.)

Background: The gold standard treatment for solitary medium-sized (1-2 cm) renal stones is not defined by recent guidelines, since management modalities including shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and percutaneous nephrolithotomy (PNL) are recommended. Improved ability to predict patient outcomes would aid in patients' counseling and decision-making., Objective: To develop a nomogram predicting treatment failure, based on preoperative clinical variables, to be used in the preplanning setting., Design, Setting, and Participants: We recruited 2605 patients from 14 centers and carried out a multicenter retrospective analysis of 699 SWL, 1290 RIRS, and 616 PN L procedures performed as first-line treatment for 1-2-cm kidney stones. The variables evaluated included age, gender, previous renal surgery, body mass index, stone size, location, stone density, skin-to-stone distance, presence of urinary tract infections (UTIs), and hydronephrosis., Outcome Measurements and Statistical Analysis: Multivariate logistic regression was fitted to predict treatment failure, defined as the presence of residual fragments >4 mm. A nomogram was developed based on the coefficients of the logit function., Results and Limitations: A total of 2431 (93.3%) patients were stone free; 174 (6.7%) treatment failures were recorded and considered the event to be predicted. On univariate analysis, type of procedure, preoperative hydronephrosis, stone density, stone location, and laterality turned out to be statistically significant. Skin-to-stone distance, UTIs, and previous renal surgery were predictors of failure on multivariate analysis. Each variable was given a score based on statistical relevance. The main limitation of the current study is its retrospective nature., Conclusions: This nomogram provides a prediction of treatment failure and need of reintervention for medium-sized kidney stones. External validation is needed to determine its reproducibility and validity., Patient Summary: We developed a preoperative model of treatment outcomes for 1-2-cm kidney stones. Its application may assist urologists to counsel patients with regard to stone management modality., (Copyright © 2020. Published by Elsevier B.V.)

The use of autologous tissue grafts for tunica albuginea repair in Peyronie's disease and congenital chordee is often restricted by limited tissue availability and donor site morbidity, therefore new biomaterial options are needed. In this study, bi-layer silk fibroin (BLSF) scaffolds were investigated to support functional tissue regeneration of tunica albuginea in a rabbit corporoplasty model. Eighteen adult male, New Zealand white rabbits were randomized to nonsurgical controls (NSC, N = 3), or subjected to corporoplasty with BLSF grafts ( N = 5); decellularized small intestinal submucosa (SIS) matrices ( N = 5); or autologous tunica vaginalis (TV) flaps ( N = 5). End-point evaluations were cavernosography, cavernosometry, histological, immunohistochemical, and histomorphometric assessments. Maximum intracorporal pressures (ICP) following papaverine-induced erection were similar between all groups. Eighty percent of rabbits repaired with BLSF scaffolds or TV flaps achieved full rigid erections, compared to 40% of SIS reconstructed animals. Five-minute peak erections were maintained in 60% of BLSF rabbits, compared to 20% of SIS and TV flap reconstructed rabbits. Graft perforation occurred in 60% of TV group at maximum ICP compared to 20% of BLSF cohort. Neotissues supported by SIS and BLSF scaffolds were composed of collagen type I and elastin fibers similar to NSC. SIS and TV flaps showed significantly elevated levels of corporal fibrosis relative to NSC with a corresponding decrease in corporal smooth muscle cells expressing contractile proteins. BLSF biomaterials represent emerging platforms for corporoplasty and produce superior functional and histological outcomes in comparison to TV flaps and SIS matrices for tunica albuginea repair., Competing Interests: JM is a co-inventor on the patented BLSF technology, paid consultant and co-founder of WeaveTech Corporation. GG is also a paid consultant for WeaveTech Corporation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gundogdu, Okhunov, Starek, Veneri, Orabi, Holzman, Sullivan, Khoury and Mauney.)

Introduction: We sought to examine the intrarenal fluid and tissue temperature alterations during dusting and fragmentation with the thulium fiber laser (TFL) in an in vivo porcine kidney. Materials and Methods: In two female Yorkshire pigs, temperature was continuously measured within the upper, interpolar, and lower calices along with the renal pelvis using multipoint thermal sensor probes; another temperature probe was situated at the tip of the ureteroscope. Four experimental protocols were performed for each animal: dual lumen ureteroscope with both warmed (37°C) irrigation and room temperature (20°C-22°C) irrigation and single lumen ureteroscope with warmed and room temperature irrigation. Of note, in each pig, one kidney underwent ureteroscopy (URS) with a 14F ureteral access sheath (UAS) in place, whereas the other kidney had no UAS placed. A 200-μm TFL fiber was fired at three laser settings: (1) dusting at 0.5 J, 80 Hz (40 W) with continuous activation until 5 minutes expired or a temperature of 44°C was reached, (2) low-power fragmentation 1 J, 10 Hz, (10 W), and (3) high-power fragmentation at 1.5 J, 20 Hz (30 W). In all cases, the pulse width was 1 ms. For fragmentation, the laser was activated for 10 seconds with a 2-second intermission for a 1-minute period (five cycles). Results: In the absence of a UAS, in all but one circumstance, temperatures reached or exceeded 44°C at all laser settings with the use of either warm or room temperature irrigation fluid, regardless of the type of ureteroscope used. Of concern, temperatures recorded at the tip of the URS were 4°C to 22°C less than the temperatures recorded in the renal calices. In contrast, with a 14F UAS in place, six distinct groups had temperatures that did not exceed 44°C, specifically at low- and high-power fragmentation settings with room temperature irrigation for both sets of ureteroscopes and at dusting and low-power fragmentation settings with warm temperature irrigation solely for the single lumen ureteroscope. Temperatures recorded at the tip of the ureteroscope with the deployment of a UAS yielded temperature differences ranging from 17°C less to 19°C more than the renal calices. Conclusions: TFL is a novel laser technology for lithotripsy. In the absence of a UAS, high-power TFL fragmentation settings in particular may create temperatures within the collecting system that could result in urothelial tissue injury. Of note, peak temperatures recorded at the tip of the ureteroscope may misrepresent the actual intrarenal temperature during TFL laser lithotripsy.

Introduction: The disproportionate costs of state-of-the-art endoscopic equipment prohibit urologists from performing endoscopy in underserved countries. Given the global prevalence of smartphones, we engineered a $45 alternative endoscope utilizing three-dimensional printed attachments, an 8 × lens, and a 1000-lumen light-emitting diode cordless flashlight (Endockscope System [ES]). Materials and Methods: At the 34th World Congress of Endourology in Cape Town, South Africa (WCE 2016; 4-year group), and at the 39th Congress of the Société Internationale d'Urologie (SIU) in Athens, Greece (SIU 2019; 8-month group), a total of 40 ES kits were distributed free of charge to an international group of urologists. Participants were given instructions and a hands-on demonstration of the device. Urologists given an ES were subsequently asked to complete a survey between June and September 2020 that included questions regarding user satisfaction, comfort, and comparability of the ES to standard endoscopic systems. Results: Urologists from 23 countries received ES kits. Overall, 10 of 22 urologists (10/22; 45%) from the 4-year group and 18 of 18 urologists (18/18; 100%) from the 8-month group completed the survey. The ES device was used by 80% (8/10) and 83% (15/18) of urologists from the 4-year and the 8-month groups, respectively. Of note, the greatest impact of ES usage was among urologists from the most impoverished countries. Of those who used the ES, 44% (4/9) of urologists from the 4-year cohort and 47% (8/17) from the 8-month cohort reported they were able to perform more endoscopic procedures directly because of the ES. Moreover, 57% (4/7) of the 4-year participants and 67% (10/15) of the 8-month participants found the ES equal or superior in quality to their standard endoscopic equipment. Conclusion: The ES provided an effective and inexpensive system that enabled urologists in resource-challenged countries to effectively perform and expand their use of urologic endoscopy.

Objective: To determine a) if surgical skills among urology resident applicants could be reliably assessed via crowdsourcing and b) to what extent surgical skills testing impacts resident selection., Design: Interviewees completed the following surgical skills tasks during their interview day: open knot tying (OKT), laparoscopic peg transfer (LPT), and robotic suturing (RS). Urology faculty and crowd-workers evaluated each applicant's video-recorded performance using validated scoring and were assessed for agreement using Cronbach's alpha. Applicants' USMLE scores, interview scores, and Jefferson Scale of Physician Empathy (JSPE-S) scores were assessed for correlation with skills testing scores and match rank. Additionally, a survey was distributed to interviewees assessing match outcomes., Setting: University of California Irvine Department of Urology, Surgical Skills Laboratory PARTICIPANTS: All 94 urology residency interviewees at the University of California Irvine Department of Urology from 2015-2018 were invited to complete the three surgical skills tasks on their interview day., Results: Survey responses were received from all 94 interviewees (100%). Crowd and expert agreement was good (α=0.88), fair (α=0.67), and poor (α=0.32) for LPT, RS, and OKT scores, respectively. The skills testing scores did not correlate with match rank, USMLE score, or JSPE-S score. On multivariate analysis, only interview score (r= -0.723; p<0.001) and faculty LPT score (r=-0.262; p=0.001) were significant predictors of match rank. Interviewees who reported matching into a top 3 residency choice had significantly higher faculty LPT scores than those who did not (11.9 vs. 9.7, p=0.03)., Conclusions: Surgical skills overall did not significantly impact match rank. Expert assessment of laparoscopic peg transfer skills and interview performance among urology resident applicants correlated with match rank., (Published by Elsevier Inc.)

Introduction and Objective: Artificial intelligence (AI) is in full development and its implementation in medicine has led to an improvement in clinical and surgical practice. One of its multiple applications is surgical training, with the creation of programs that allow avoiding complications and risks for the patient. The aim of this article is to analyze the advantages of AI applied to surgical training in urology., Material and Methods: A literary research is carried out to identify articles published in English regarding AI applied to medicine, especially in surgery and the acquisition of surgical skills., Results: Surgical training has evolved over time thanks to AI. A model for surgical learning where skills are acquired in a progressive way while avoiding complications to the patient, has been created. The use of simulators allows a progressive learning, providing trainees with procedures that increase in number and complexity. On the other hand, AI is used in imaging tests for surgical or treatment planning., Conclusion: Currently, the use of AI in daily clinical practice has led to progress in medicine, specifically in surgical training., (Copyright © 2021 AEU. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction: The role of renal biopsy prior to surgical intervention for a renal mass remains controversial despite the fact that for all other urological organs except the testicle, biopsy inevitably precedes treatment as is true for all other specialties dealing with solid masses (e.g. thyroid, breast, colon, liver, etc.). Accordingly, we sought to determine the impact of a routine biopsy regimen on the course of patients with cT1a lesions in comparison with a contemporary series of cT1a individuals who went directly to treatment without a preoperative biopsy., Methods: We analyzed a multi-institutional, prospectively maintained database of patients who underwent an office-based, ultrasound-guided, renal mass biopsy (RMB) for a cT1a renal mass (i.e. ≤4cm in largest dimension). Controls were selected from all patients in the database who had a cT1a renal lesion but did not undergo RMB. Both groups were analyzed for differences in treatment modality and surgical pathology results., Results: A total of 72 RMB and 73 control patients were analyzed. The groups were similar in regards to their baseline characteristics. Overall RMB diagnostic rate was 75%. Surgical pathology revealed that excision of benign tumors was eight-fold less in the RMB cohort compared to the control group (3% vs. 23%; P < 0.001). Additionally, the rate of active surveillance in the RMB cohort was nearly three times higher at 35% vs. 14% for the controls (P < 0.001). Biopsy was concordant with surgical pathology in 97% of cases for primary histology (i.e. benign vs. malignant), 97% for histologic subtype, and 46% for low (I or II) vs. high (III or IV) grade. On multivariate analysis patients who underwent surgical intervention without preoperative RMB were 6.7 times more likely to have benign histopathology compared to patients who underwent preoperative RMB (OR 6.7, 95% CI = 0.714 - 63.626, P = 0.096). There were no procedural or post-procedural RMB complications., Conclusions: For patients with cT1a lesions, the implementation of routine office-based RMB led to a significant decrease in the rate of surgical intervention for benign tumors. This practice also resulted in a higher rate of active surveillance for the management of renal cortical neoplasms with benign histopathology compared to a control group., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr., Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection., Evidence Acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses., Evidence Synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; -9.81 points, 95% confidence interval [CI] -11.37 to -8.25 at 1 mo; -13.13 points, 95% CI -14.98 to -11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (-10.10 ml, 95% CI -27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire., Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation., Patient Summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function., Take Home Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient's quality of life., (© 2021 The Author(s).)

Ureteral reconstruction with autologous tissue grafts is often limited by tissue availability and donor site morbidity. This study investigates the performance of acellular, bi-layer silk fibroin (BLSF) scaffolds in a porcine model of ureteroplasty. Tubular ureteroplasty with BLSF grafts in combination with transient stenting for 8 weeks was performed in adult female, Yucatan, mini-swine ( N = 5). Animals were maintained for 12 weeks post-op with imaging of neoconduits using ultrasonography and retrograde ureteropyelography carried out at 2 and 4 weeks intervals. End-point analyses of ureteral neotissues and unoperated controls included histological, immunohistochemical (IHC), histomorphometric evaluations as well as ex vivo functional assessments of contraction/relaxation. All animals survived until scheduled euthanasia and displayed mild hydronephrosis (Grades 1-2) in reconstructed collecting systems during the 8 weeks stenting period with one animal presenting with a persistent subcutaneous fistula at 2 weeks post-op. By 12 weeks of scaffold implantation, unstented neoconduits led to severe hydronephrosis (Grade 4) and stricture formation in the interior of graft sites in 80% of swine. Bulk scaffold extrusion into the distal ureter was also apparent in 60% of swine contributing to ureteral obstruction. However, histological and IHC analyses revealed the formation of innervated, vascularized neotissues with a -smooth muscle actin+ and SM22α+ smooth muscle bundles as well as uroplakin 3A+ and pan-cytokeratin + urothelium. Ex vivo contractility and relaxation responses of neotissues were similar to unoperated control segments. BLSF biomaterials represent emerging platforms for tubular ureteroplasty, however further optimization is needed to improve in vivo degradation kinetics and mitigate stricture formation., Competing Interests: JM is a co-inventor on the patented BLSF technology, paid consultant and co-founder of WeaveTech Corporation. All other authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Gundogdu, Okhunov, Cristofaro, Starek, Veneri, Orabi, Jiang, Sullivan and Mauney.)

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for kidney stones >2 cm in size. Obtaining a nephrostomy tract to access the kidney is a key step in this procedure that ultimately determines the patient's outcome. We describe each step of the endoscopic guided approach to PCNL as performed at the University of California, Irvine. Each step of the endoscopic guided PCNL is described and depicted in the video. Surgical steps depicted in the video are from various recorded PCNL procedures from our institution. This guide outlines the indications, preoperative preparation, patient positioning, surgical steps, and postoperative care for patients undergoing PCNL using the endoscopic guided approach. Direct observation of nephrostomy puncture, tract dilation using the balloon, and passing of the Amplatz sheath allow for proper access to the kidney and lower risk of injury. By following this systematic module of endoscopic guided PCNL, a nephrostomy tract can be created and accessed under direct observation, facilitating the routine steps of PCNL.

Purpose of Review: The goal of this paper is to evaluate the use of an office-based renal mass biopsy (RMB), whose feasibility could represent a paradigm shift in clinical practice., Recent Findings: Despite the earlier diagnosis of patients with renal masses, the lack of evidence showing a reduction in cancer-specific mortality warrants an examination in treatment practices. RMB is underutilized when compared to biopsy practice for all other neoplasms in every other solid organ (except testis), and the majority of RMB performed are outsourced to interventional radiologists. Performing an ultrasound-guided, office-based RMB is safe, reproducible, and has a meaningful impact on management decisions. The use of percutaneous RMB in clinical practice is growing, and the use of RMB has meaningful impact on management decisions for renal masses. Incorporating ultrasound-guided biopsy of a renal mass into clinical practice is feasible, and in contemporary practice, the urologist has the skill set to perform the procedure reliably, with low morbidity, and with minimal patient discomfort., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

To evaluate the impact of chronic stone recurrence on an individual's quality of life using the validated Wisconsin Stone Quality of Life (WISQOL) questionnaire. We collected cross-sectional data on patients with kidney stones from 14 institutions in North America. A stone event was defined as renal colic, stone-related procedure or emergency department visit. The regression analyses using general linear models and pairwise comparison determined the impact of the number of stone events on quality of life. The median number of stone events among the 2205 patients who completed the questionnaire was 3 (IQR 1-6). The mean total score was 107.4 ± 28.7 (max 140 points). The number of lifetime stone events was an independent predictor of lower quality of life (p < 0.001), specifically, score declined significantly beyond five events. Compared with patients who experienced a single stone event, there was a 0.4, 2.5, and 6.9 point decline in the adjusted mean WISQOL score after 2-5, 6-10, or > 10 events, respectively. The cumulative number of lifetime stone events was associated with a lower quality of life when more than five stone events were occurred. These findings underscore the importance of efforts to determine the underlying metabolic etiology of urolithiasis in the recurrent stone former, and the institution of a regimen to place their stone disease in remission., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Purpose: Ureteral injury is a frequent complication of ureteral access sheath deployment. We sought to define the safe threshold of force for the passage of a ureteral access sheath using a novel ureteral access sheath force sensor., Materials and Methods: Ureteral access sheath-force sensor measurements were recorded in 210 renal units. A 16Fr ureteral access sheath was deployed initially based on a prior porcine study. If 6 N was reached, the surgeon was advised to downsize the 16Fr ureteral access sheath. In each case, a post-ureteroscopic lesion scale was recorded. Regression models were used to estimate the impact of adjusted variables on post-ureteroscopic lesion scale grade, 16Fr ureteral access sheath deployment, and peak force., Results: A 16Fr ureteral access sheath was deployed in 127 (61%) renal units with a mean peak force of 5.7 N. Two high-grade ureteral injuries occurred; in both cases >6 N of force was recorded. Post-ureteroscopic lesion scale grade correlated directly with peak insertion force (p <0.01). Bacteriuria within 60 days of the procedure (OR 2.009, p=0.034), combination of preoperative stent plus oral tamsulosin (OR 2.998, p=0.045), and prior ipsilateral stone surgery (OR 2.13, p=0.01) were independent predictors of successful 16Fr ureteral access sheath deployment. Among patients with neither prior ipsilateral stone surgery nor preoperative stent, preoperative tamsulosin facilitated passage of a 16Fr ureteral access sheath (OR 2.750, p=0.034)., Conclusions: Ureteral access sheath associated ureteral injury can be averted by limiting the insertion force to ≤6 N. Prior stone surgery, preoperative indwelling ureteral stent plus oral tamsulosin, and recently treated bacteriuria favored passage of a 16Fr ureteral access sheath. In the naïve, unstented patient, preoperative tamsulosin favored deployment of a 16Fr ureteral access sheath.

Purpose: Computerized tomographic urography is the diagnostic tool of choice for evaluating hematuria. In keeping with the ALARA (As Low As Reasonably Achievable) principle, we evaluated a triple bolus computerized tomography protocol designed to reduce radiation exposure., Materials and Methods: Patients with macroscopic or microscopic hematuria were prospectively randomized to conventional computerized tomography (100) or triple bolus computerized tomography (100). The triple bolus computerized tomography protocol entails 2 scans: pre-contrast scan followed by 3 contrast injections at 40 seconds, 60 seconds and 20 minutes prior to the second scan to capture all 3 phases. The conventional computerized tomography protocol requires 4 scans: pre-contrast scan, and 3 post-contrast scans at the corticomedullary, nephrographic and excretory phases. Radiation exposure and the detection of urological pathology were recorded based on radiology reports., Results: There were no differences in patient demographics or body mass index between the 2 groups. Triple bolus computerized tomography exposed patients to 33% less radiation (1,715 vs 1,145 mGy*cm for conventional vs triple bolus computerized tomography; p <0.001). For macroscopic hematuria, the pathology detection rates were 70% for triple bolus and 73% for conventional computerized tomography (p=0.72). For microscopic hematuria, the detection rates were 59% for triple bolus and 50% for conventional computerized tomography (p=0.68). In both groups, the rates of detection of urolithiasis, renal cysts, urological masses, bladder pathology and prostate pathology were no different between triple bolus and conventional computerized tomography., Conclusions: In both the settings of macroscopic and microscopic hematuria evaluation, triple bolus computerized tomography significantly reduces radiation exposure while providing equivalent detection of genitourinary pathology compared to conventional computerized tomography. The ability to detect upper tract filling defects was not specifically tested.