Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable.

PURPOSE: To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications. METHODS: The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI). RESULTS: A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time. CONCLUSION: URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.

Hydronephrosis severity as a predictor of postoperative renal function decline following laparoscopic radical nephroureterectomy.

BACKGROUND: This study aimed to investigate factors, including the degree of hydronephrosis, that may be associated with decreased renal function after radical nephroureterectomy (RNU). METHODS: This study included 252 patients who underwent laparoscopic RNU with an estimated glomerular filtration rate (eGFR) ≥ 30 ml/min/1.73 m2 in three institutions. We assessed the association between hydronephrosis grade and perioperative renal function and performed a stepwise multivariate linear regression analysis to identify factors associated with postoperative eGFR. Patients with preoperative eGFR ≥ 50 ml/min/1.73 m2 were divided into a training set and an independent external validation set to develop a predictive model for postoperative renal function. RESULTS: The median preoperative and postoperative eGFR were 61.1 and 46.4 ml/min/1.73 m2, respectively. The eGFR preservation rates were 66.9%, 66.6%, 88.1%, and 100.0% in groups without, with mild, moderate, and severe hydronephrosis, respectively, and this difference was statistically significant (p < 0.001). Multivariate analysis revealed that factors predictive of postoperative eGFR included sex, preoperative eGFR, clinical T stage (cT3-4), and the presence of moderate or severe hydronephrosis. Our predictive model, based on these factors, positively correlated with actual postoperative renal function, and the similarity in categories with or without renal function insufficiency between predicted and actual postoperative renal functions was 78% in both training and validation sets. CONCLUSION: Moderate or severe hydronephrosis is associated with a modest postoperative decline in renal function, while mild hydronephrosis is not. Our predictive model may be useful in predicting postoperative renal function insufficiency and guiding decision-making for perioperative medical treatment.

Minimally invasive total pelvic exenteration for symptomatic locally advanced prostate cancer with rectal invasion: Indications and technical considerations.

In cases of rectal invasion by locally invasive prostate cancer (LAPC) leading to severe pain or bleeding, total pelvic exenteration (TPE) is necessary. Here, we present two cases of successful minimally invasive TPE: one performed laparoscopically for local recurrence with rectal bleeding after laparoscopic radical prostatectomy, and another done robotically for LAPC (clinical T4N1M0) accompanied by rectal bleeding. Medical treatments were ineffective in the latter case, and the tumor occupied a significant portion of the pelvis. We adopted a simultaneous transperineal approach and performed intracorporeal ileal conduit formation. Our cases highlight the challenging nature of minimally invasive TPE for symptomatic LAPC. Despite its complexity, these techniques prove viable and valuable in managing LAPC-related symptoms, emphasizing their practical utility in clinical settings.

Preoperative risk classification for intravesical recurrence after laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma in a multi-institutional cohort.

INTRODUCTION: This study aimed to identify preoperative risk factors and create a risk classification for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy in a multi-institutional cohort. METHODS: We retrospectively analyzed 283 patients who had undergone laparoscopic radical nephroureterectomy for nonmetastatic upper tract urothelial cancer between March 2002 and March 2020. The cumulative incidence of intravesical recurrence for 224 patients without previous or concomitant bladder cancer was examined using multivariate Fine-Gray competing risks proportional hazards models. A risk stratification model was created to predict subsequent patient outcomes based on the results. RESULTS: The median follow-up duration was 33.3 months, and 71 (31.7%) patients experienced intravesical recurrence. The estimated cumulative incidence of intravesical recurrence at one and 5 years was 23.5% and 36.4%, respectively. In multivariate analysis, the presence of ureter tumors and multiple tumors were shown to be independently significant predictive factors for intravesical recurrence. Based on the results, we classified patients into three risk groups. The cumulative incidence rates of intravesical recurrence within 5 years after surgery were 24.4%, 42.5%, and 66.7% in the low-, intermediate-, and high-risk groups, respectively. CONCLUSIONS: We identified risk factors and created a risk classification model for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy. Based on this model, an individualized surveillance protocol or adjuvant therapy could be provided.

Atypical Oncologic Failure After Laparoscopic Radical Nephroureterectomy in a Japanese Multicenter Study.

Objectives: To investigate the recurrence patterns and the atypical oncologic failure (AOF) defined as the presence of atypical recurrences, such as retroperitoneal carcinomatosis or port-site recurrence, after laparoscopic radical nephroureterectomy (LRNU). Methods: LRNU performed at three institutions were included in this retrospective study. The primary endpoints were the first recurrence site and recurrence-free survival. The recurrence sites were classified as atypical recurrences, such as retroperitoneal carcinomatosis or port-site recurrence, as well as distant, local, and intravesical. The Kaplan-Meier curves were obtained to elucidate the time until recurrence and survival. Results: A total of 283 patients were included in the final analysis. Postoperative pathology was T3 or higher in 112 (40%) patients. The median follow-up period was 31 months, and the 3-year recurrence-free, cancer-specific, and overall survival rates were 69.6%, 78.1%, and 72.0%, respectively. The first recurrence sites involved distant, local, atypical, and intravesical recurrences in 51 (18%), 36 (13%), 14 (5%), and 94 (33%) patients, respectively. Of the 14 patients with AOF, 12 had pathologically locally advanced tumors, but seven patients had a preoperative diagnosis of clinical stage T2 or less. Conclusion: A small number of AOF cases were found after LRNU for patients with upper tract urothelial carcinoma. Careful patient selection is critical for AOF prevention.

The efficacy of ultrasonography for the detection of upper tract urothelial carcinoma.

PURPOSE: Ultrasonography and computed tomography urography are two commonly used modalities to image the upper tracts for the evaluation of hematuria. This study evaluated the efficacy of ultrasonography for the detection of upper tract urothelial carcinoma compared to computed tomography urography as a standard reference. METHODS: This retrospective study included patients with urothelial carcinoma of the renal pelvis and/or ureter who were diagnosed using computed tomography urography and underwent surgical treatment. We calculated the sensitivity of ultrasonography in upper tract urothelial carcinoma diagnosis, further classified the degree of hydronephrosis on ultrasonography, and analyzed the relationship between the sensitivity and the degree of hydronephrosis and tumor location. Additionally, the usefulness of the combination of the screening ultrasonography findings, the presence of gross hematuria, and/or urine cytology was analyzed. RESULTS: This study included 136 patients with upper urothelial carcinoma. Ultrasonography in the diagnosis had 45.6% sensitivity, and ultrasonography findings, including the detection of hydronephrosis, were present in 72.8%. The presence of hydronephrosis and tumor location were associated with detection by ultrasonography. The tumor was identified in a total of 134 (98.5%) patients by combining tumor detection and hydronephrosis using ultrasonography with gross hematuria and positive urine cytology as screening. CONCLUSION: Ultrasonography showed acceptable sensitivity for upper tract urothelial carcinoma diagnosis. Considering the hydronephrosis findings, ultrasonography is a useful screening tool for upper tract urothelial carcinoma. Additionally, excessive computed tomography examinations can be reduced by adding gross hematuria and positive urine cytology.

Clinical outcomes following laparoscopic radical nephroureterectomy in octogenarians.

BACKGROUND: This study aimed to compare the incidence of postoperative complications occurring within 30 days of surgery between octogenarians and younger patients and identify preoperative risk factors for the incidence of postoperative complications. Moreover, we also compared the oncological outcomes between octogenarians and younger patients. METHODS: This retrospective study included 283 patients who underwent laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma from 2002 to 2020. The patients were divided into octogenarians and younger patients (age: < 80 years), and their clinical characteristics, perioperative parameters, and postoperative complications were evaluated. The predictors of postoperative complications were evaluated using logistic regression models. Recurrence-free survival, cancer-specific survival, and overall survival were measured using the Kaplan-Meier method. RESULTS: Twelve (17.1%) octogenarians and 40 (18.7%) younger patients had postoperative complications. No significant difference in the incidence of postoperative complications was observed between octogenarians and younger patients (p = 0.14). A high body mass index was a significant risk factor for complications (p = 0.03). The 5-year recurrence-free survival, cancer-specific survival, and overall survival rates for octogenarians and younger patients were 72% and 64% (p = 0.31), 76% and 63% (p = 0.63), and 43% and 63% (p = 0.06), respectively. CONCLUSION: Laparoscopic radical nephroureterectomy can be performed in octogenarians with complication rates similar to those in younger patients. Similarly, the outcomes of laparoscopic radical nephroureterectomy for oncological control do not differ significantly between octogenarians and younger patients. This procedure is safe and effective for selected octogenarians.

Safety and efficacy of ureteroscopy for urolithiasis in octogenarians.

OBJECTIVE: To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications. METHODS: The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone-free rate. The predictors of postoperative complications were evaluated using logistic regression models. RESULTS: A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone-free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035). CONCLUSION: Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

Risk factors for Infectious Complications of Ureteroscopy after Obstructive Acute Pyelonephritis.

OBJECTIVES: To identify risk factors for infectious complication of ureteroscopy after obstructive acute pyelonephritis (OAPN). PATIENTS AND METHODS: This single-center, retrospective cohort study (#20200002, retrospectively registered in February 1st, 2020) included patients who underwent emergency drainage for OAPN and subsequently underwent ureteroscopic stone removal between January 2006 and December 2020. Multivariable analysis was conducted using demographic and stone-related factors to determine those that could predict postoperative febrile urinary tract infection (UTI). RESULTS: Overall, 432 patients underwent ureteroscopy after OAPN. The stone-free rate was 84.3%, whereas the overall and major complication rates were 17.6% and 3.2%, respectively. A total of 70 (16.2%) patient developed febrile UTI, among whom 34 (7.9%) and 11 (2.5%) developed sepsis and severe sepsis, respectively. Multivariable analysis identified diabetes mellitus [odds ratio (OR) 1.98, 95% confidence interval (CI) 1.05-3.74], duration from drainage to surgery >1 month (OR 2.28, 95% CI 1.20-4.74), and simultaneous retrograde intrarenal surgery (OR 2.96, 95% CI 1.35-6.48) as significant risk factors for UTI. After dividing patients into low- (0), intermediate- (1), and high- (2-3) risk groups according to the number of factors they had, the risk of postoperative UTI was 6.3%, 14.5%, and 27.7%, respectively (p for trend <0.001). CONCLUSIONS: Patients who underwent ureteroscopy after OAPN were at risk for postoperative UTI, despite its efficacy. Simultaneous retrograde intrarenal surgery should be carefully planned, especially for patients with diabetes mellitus or extended surgery wait times.

[Risk Factors for Febrile Urinary Tract Infection after Transurethral Ureterolithotripsy : ANALYSIS of Treatment Outcomes of 1,235 Patients at a Single Center].

Recently, ureteroscopic lithotripsy remains the standard treatment for urolithiasis, with postoperative febrile upper urinary tract infection (fUTI) being one of its most significant complications. The current study sought to investigate the treatment outcomes of ureterorenoscopy (URS), morbidity and risk factors of postoperative fUTI at our hospital. A total of 1,235 patients who underwent URS (including those who underwent only semi-rigid URS) for upper urinary tract stones at our hospital between October 2011 and December 2019 were retrospectively analyzed. Patients had a median age of 63 years and a median stone length of 11.4 mm. F-URS was performed in 1,188 cases (96.2%) among whom 92.1% were stone-free or had stones that fractured into dust. Postoperative fUTI and sepsis occurred in 127 (10.3%) and 18 (1.5%) patients, respectively. Multivariate analysis identified female sex, American Society of Anesthesiologists (ASA) score ≥ 3, calculus length ≥ 20 mm, history of diabetes mellitus, and history of obstructive pyelonephritis as risk factors for postoperative fUTI. The scoring system (range 0-4) were positively correlated with the postoperative fUTI rate (score 0 : 3.1%, 1 : 12.4%, 2 : 14.1%, 3 : 23.7%, 4 : 40%). A significant difference in the rates was noted between those with a score of 0 (low-risk group), 1-2 (intermediate-risk group), and 3-4 scores (high-risk group). In conclusion, the overall incidence of postoperative fUTI was 10.3%, which was associated with sex, poor ASA scores, stone size, presence of diabetes mellitus, and history of pyelonephritis. The scoring system created using these factors can be useful in predicting postoperative fUTI.

Oncological Outcomes of Retroperitoneal Lymph Node Dissection During Retroperitoneal Laparoscopic Radical Nephroureterectomy for Renal Pelvic or Upper Ureteral Tumors: Matched-Pair Analysis.

Objectives: The aim of this study was to investigate the oncological outcomes and recurrence patterns in clinically node-negative patients with renal pelvic and/or upper or middle ureteral tumors after template-based retroperitoneal lymph node dissection (RPLND) in conjunction with retroperitoneal laparoscopic radical nephroureterectomy (LRNU). Materials and Methods: A total of 283 patients who received LRNU with and without RPLND at three Japanese institutions were enrolled. The template for RPLND included the renal hilar and para-aortic lymph nodes (LNs) (left side) and renal hilar, paracaval, retrocaval, and intra-aortocaval LNs (right side). The LNs and kidneys were removed en bloc. The primary endpoint was set as recurrence-free survival. All RPLND cases were matched one-to-one with no-RPLND cases using a propensity score matching approach, and 47 matched pairs were included in analyses. Results: Compared with the control group, significant differences were not observed in the RPLND group in terms of operation time, blood loss, postoperative complication rate, and pathological findings. The estimated 5-year recurrence-free survival was significantly higher in the RPLND group (86.8%) compared with the group without RPLND (64.2%) (p = 0.014). The estimated 5-year cancer-specific survival showed a similar tendency; however, it did not reach a statistically significant difference (87.5% vs 71.3%, respectively; p = 0.168). As for the first recurrence site, the RPLND group showed a lower incidence of distant recurrence, while no significant difference was observed in the rate of regional LN recurrence. Conclusions: This study suggests that template-based RPLND in conjunction with retroperitoneal LRNU efficiently improves recurrence-free survival by reducing distant recurrences.

[Renal Subcapsular Hematoma after Transurethral Ureterolithotripsy].

Subcapsular renal hematoma is a complication of extracorporeal shock wave lithotripsy or percutaneous nephrolithotripsy. Although it can occur after transurethral ureterolithotripsy (TUL), there is no consensus on the risk factors, outcomes, and its management. This study aimed to elucidate the clinical courses of patients with subcapsular hematoma after TUL. We retrospectively investigated 1,235 patients who underwent TUL from October 2011 to December 2020 at our hospital and identified cases with subcapsular hematoma diagnosed after surgery. Subcapsular hematoma was diagnosed in 5 of the 1,235 (0.40%) patients, whose median age was 63 (49-69) years. The median operation time, hematoma diameter, and hemoglobin decrease were 66 (35-115) min, 8.2 (5.4-10.5) cm, and 1.6 (0.7-2.6) g/dl, respectively. All patients were conservatively managed without invasive interventions (eg, embolization), although one patient required blood transfusion. In conclusion, this study presented five cases with renal subcapsular hematoma after TUL that could be conservatively managed. It is important not to miss the timing of therapeutic intervention while observing the progress after diagnosis.

Complications and their management following retroperitoneal lymph node dissection in conjunction with retroperitoneal laparoscopic radical nephroureterectomy.

OBJECTIVES: To describe the detailed perioperative complications and their management after retroperitoneal lymph node dissection with retroperitoneal laparoscopic radical nephroureterectomy for patients with upper tract urothelial carcinoma at three institutions. METHODS: Retroperitoneal lymph node dissection was performed on patients with upper tract urothelial carcinoma located at the pelvis and/or upper or middle ureter, and its template included the renal hilar and para-aortic lymph nodes (left side) and the renal hilar, paracaval, retrocaval, and intra-aortocaval lymph nodes (right side). The lymph nodes and kidneys were removed en bloc. The primary endpoint was postoperative complication rates, and the secondary endpoints were intraoperative findings and chylous leakage management. The associations of retroperitoneal lymph node dissection with postoperative complications were examined using logistic regression with propensity score techniques. RESULTS: Eighty-eight (31%) and 195 (69%) patients underwent and did not undergo retroperitoneal lymph node dissection, respectively. There was no significant difference in postoperative complications and other perioperative findings in the entire cohort, except for prolonged operation time. Retroperitoneal lymph node dissection was not statistically significantly associated with total and serious complications in propensity score analyses. Postoperative chylous leakage could be conservatively managed even though it is common in patients with retroperitoneal lymph node dissection (14/88 (16%)). The incidence of chylous leakage was significantly lower in patients whose lymphatic vessels were meticulously clipped completely during retroperitoneal lymph node dissection (5.3% vs 24%; P = 0.017). CONCLUSION: There was no association between retroperitoneal lymph node dissection with laparoscopic radical nephroureterectomy and postoperative complications. However, chylous leakage is often observed after retroperitoneal lymph node dissection and careful management is highly required. The use of clips during retroperitoneal lymph node dissection is recommended to minimize chylous leakage risk.

Retrograde ureteroscopic lithotripsy in cross-fused renal ectopia.

INTRODUCTION: Cross-fused renal ectopia is a rare congenital malformation, and few cases of urolithiasis have been treated by retrograde ureteroscopic lithotripsy. We report a case of urolithiasis in right-to-left and superior-type cross-fused renal ectopia, successfully treated by the retrograde approach. CASE PRESENTATION: A 69-year-old woman with two 14-mm renal stones in cross-fused renal ectopia underwent retrograde ureteroscopic lithotripsy. Although we did not recognize the anomaly preoperatively, we could diagnose urolithiasis in the ectopic kidney intraoperatively. The patient had no complication, and follow-up computed tomography after 3 months showed only a 5-mm renal stone. CONCLUSION: Although urolithiasis in patients with cross-fused renal ectopia is a challenging condition for the urologist, the retrograde approach is a safe and effective treatment method. It is necessary to carefully examine the urinary tract especially in a patient with a history of unidentified solitary kidney.

[Efficacy and Safety of Retrograde Ureterorenoscopic Lithotripsy for Patients with Renal or Ureteral Anatomic Abnormalities or Urinary Diversion].

Retrograde ureterorenoscopic lithotripsy is one of the first-line therapies for urolithiasis. In some cases, however, thisapproach may be difficult to adopt because of factorss uch asrenal/ureteral anatomic abnormalities or urinary diversion. This study aims to investigate the safety and efficacy of retrograde ureterorenoscopic lithotripsy in patients with the above-mentioned conditions. We retrospectively investigated all such patients who underwent retrograde ureterorenoscopic lithotripsy from May 2009 to December 2019 at our hospital. "Stone free"was defined as the total absence of residual fragments, and "success"wasdefined asthe absence of hydronephrosisand residual fragmentsgreater than 4 mm at the end of 4 weeks. Complications were classified according to the modified Clavien-Dindo classification system. Twenty-one procedureswere performed in 19 patientswhos e conditionswere horseshoe kidney, ureteral duplex, cross-fused renal ectopia, cutaneous ureterostomy, ileal conduit, ureterocystoneostomy, and cystostomy. The median age was 67 (40-93) years, the median stone diameter was 9.6 (5.0-16.0) mm, the median operation time was 63 (12-158) minutes, and the complete stone-free rate and success rate were 42.9 and 71.4%, respectively. The complication rate was 19.0% ; however, no serious complications were observed. In conclusion, retrograde ureterorenoscopic lithotripsy is an effective and safe procedure for patientss uffering from urolithiasis with renal/ureteral anatomic abnormalitiesor previousurinary diversion.

[Two Cases of Renal Pelvic Rupture Due to Trauma in a Patient with Ureteropelvic Junction Stenosis].

A pathologic kidney with hydronephrosis is prone to rupture after minor trauma to the renal pelvis ; however, it is controversial whether drainage, such as nephrostomy and ureteral stenting, should be performed in this setting. Herein we report traumatic rupture of the renal pelvis in 2 patients with ureteropelvic junction stenosis at two centers. Case 1 : A 15-year-old boy sustained a blunt injury on his left back while playing football. His family physician referred the patient to our hospital for suspected left renal injury. Contrast-enhanced abdominal computed tomography showed left hydronephrosis and fluid accumulation in the left retroperitoneal space, which led to a diagnosis of rupture of the left renal pelvis. The patient was treated conservatively ; however, fluid accumulation around the kidney worsened. A ureteral stent was placed, and the patient's renal colic and imaging findings improved. Case 2 : A 13-yearold boy fell and bruised his abdomen while playing soccer. He was unable to walk because of pain, and was brought to our hospital by ambulance. Contrast-enhanced abdominal computed tomography showed left hydronephrosis and fluid accumulation in the left retroperitoneal space, which led to a diagnosis of rupture of the left renal pelvis. A ureteral stent was placed on the same day, and the patient's renal colic improved.

The Long-Term Follow-Up of Patients with Cystine Stones: A Single-Center Experience for 13 Years.

INTRODUCTION: Cystine stone development is relatively uncommon among patients with urolithiasis, and most studies have reported only on small sample sizes and short follow-up periods. We evaluated clinical courses and treatment outcomes of patients with cystine stones with long-term follow-up at our center. METHODS: We retrospectively analyzed 22 patients diagnosed with cystine stones between January 1989 and May 2019. RESULTS: The median follow-up was 160 (range 6-340) months, and the median patient age at diagnosis was 46 (range 12-82) years. All patients underwent surgical interventions at the first visit (4 extracorporeal shockwave lithotripsy, 5 ureteroscopy, and 13 percutaneous nephrolithotripsy). The median number of stone events and surgical interventions per year was 0.45 (range 0-2.6) and 0.19 (range 0-1.3) after initial surgical intervention. The median time to stone events and surgical intervention was 2 years and 3.25 years, respectively. There was a significant difference in time to stone events and second surgical intervention when patients were divided at 50 years of age at diagnosis (p = 0.02, 0.04, respectively). CONCLUSIONS: Only age at a diagnosis under 50 was significantly associated with recurrent stone events and intervention. Adequate follow-up and treatment are needed to manage patients with cystine stones safely.

Predictors of Repeat Surgery and Stone-related Events After Flexible Ureteroscopy for Renal Stones.

OBJECTIVES: To evaluate the risk of repeat surgery and stone-related events after flexible ureteroscopy (fURS) for renal stones, and to identify their predictive factors. PATIENTS AND METHODS: This was a single-center, retrospective cohort study of patients (n = 664) who underwent fURS for renal stones with or without concomitant ureteral stones between January 2012 and December 2019. The primary outcomes were time to ipsilateral stone-related surgical intervention and any stone-related event (including ipsilateral renal colic, symptomatic ureteral calculi, obstructive urinary tract infection, and surgical intervention). RESULTS: During median follow-up of 31.1 months, 103 (15.5%) and 135 (20.3%) patients experienced surgical intervention and any stone-related event, respectively. The estimated 2-year intervention-free survival and stone-event-free survival was 86.9% and 81.6%, respectively. On Cox multivariate analysis, younger age (hazard ratio [HR] 0.96), history of stone surgery (HR 2.17), larger preoperative stone burden (HR 1.03), and larger residual fragment (HR 1.09) showed an association with future intervention. Use of the four identified risk factors (age ≤60, history of stone surgery, stone burden ≥20 mm, and residual fragment ≥4 mm) allowed stratification of patients based on the risk of future intervention (low [score: 0-1], intermediate [2], and high [3-4] risk). The estimated 2-year intervention-free survival rates in low-, intermediate-, and high-risk groups were 96.2%, 86.4%, and 71.3%, respectively. CONCLUSION: Patients undergoing fURS are at risk of future ipsilateral surgical intervention and stone-related events. Our simple predictive tool can facilitate treatment decision-making by identifying patients who are at high risk of recurrence.

Extremely-slow, half-number shockwave lithotripsy for asymptomatic renal stones <20 mm.

PURPOSE: To compare the treatment success rate and safety of reduced (30 shocks/min, 1,200 shocks/session) versus standard (60 shocks/min, 2,400 shocks/session) extracorporeal shockwave lithotripsy for the management of renal stones. MATERIALS AND METHODS: We retrospectively analyzed 404 patients who underwent extracorporeal shockwave lithotripsy for 5-20-mm renal stones between April 2011 and March 2019. Patients selected the reduced or standard protocol (group R and S) after explaining the potential benefits and disadvantages. The primary outcome was treatment success within 12 weeks, which was defined as no residual fragment or fragments <4 mm on ultrasonography and plain radiograph. RESULTS: In total, 94 and 310 patients underwent shockwave lithotripsy with a reduced and standard protocol, respectively. The background characteristics of the participants did not significantly differ. The treatment success within 12 weeks was achieved in 78 (83.0%) patients in group R and 259 (83.5%) in group S (p=0.88). The median number of the session was 3 (interquartile range, 2-4) in both groups (p=0.53). The total complication rates were 5.4% in group R and 6.1% in group S. Three (1.0%) patients in group S experienced perirenal hematoma, which was conservatively treated. The reduced protocol was not associated with treatment success in the multivariate analysis adjusted for potential confounders (odds ratio, 0.91; 95% confidence interval, 0.46-1.80; p=0.78). CONCLUSIONS: The new treatment amendment with a slower delivery rate successfully reduced the total number of shocks need to fragment renal stones <20 mm without compromising the stone-free rate.

Decreased Recurrence of Urolithiasis After Simultaneous Ureteroscopic Surgery for Ureter and Ipsilateral Renal Calculi: Comparison to Shockwave Lithotripsy for Ureter Calculi Alone.

OBJECTIVE: To compare follow-up outcomes of ureteroscopy (URS) and shockwave lithotripsy (SWL) for ureter calculi in the setting of asymptomatic renal calculi <15 mm. METHODS: This study included 789 patients who underwent URS (n = 301) or SWL (n = 488) as primary treatment for ureter calculi and who had ipsilateral renal calculi <15 mm between January 2012 and December 2019. For the URS group, all renal calculi were simultaneously treated unless contraindicated. One-to-one matching was performed using the propensity score (PS). RESULTS: After PS matching, analysis included 262 matched pairs of URS and SWL patients. The stone-free rate for ureter calculi without auxiliary procedure was 97.3% in the URS group and 93.9% in the SWL group. Any complication rates were 11.0% and 9.2% in the URS and SWL group, respectively; 1.1% of the URS patients experienced complications classified as Clavien-Dindo ≥IIIb. The estimated 2-year intervention-free survival was 88.1% in the URS group and 84.2% in the SWL group (P = 0.045). The estimated 2-year stone-event-free survival was 80.1% in the URS group and 71.0% in the SWL group (P = 0.009). Cox multivariate analysis showed that the hazard ratios of URS were 0.62 (P = 0.025) for surgical interventions and 0.64 (P = 0.008) for stone-related events after adjusting for baseline variables. CONCLUSION: For patients with symptomatic ureter calculi and asymptomatic renal calculi <15 mm, URS with active treatment for renal calculi reduces future ipsilateral surgical intervention and stone-related events compared with SWL for ureter calculi.