Combined Charlson comorbidity/C-Reactive Protein Index Is a Novel Predictor in Renal Cell Carcinoma: Analysis of the International Marker Consortium for Renal Cancer (INMARC) Registry.

OBJECTIVE: To evaluate predictive ability of a novel combined index, Charlson comorbidity index and C-reactive protein (CCI-CRP), for outcomes in renal cell carcinoma (RCC), and compare predictive outcomes with of CCI-CRP to its separate components and to the UCLA integrated staging system (UISS). PATIENTS AND METHODS: We retrospectively analyzed INMARC registry of RCC patients. Receiver Operator Characteristics (ROC) analysis was fitted to identify threshold defining low-CRP (LCRP) and high-CRP (HCRP). Patients were stratified according to CCI [low-CCI ≤ 3 (LCCI); intermediate-CCI 4-6 (ICCI); high-CCI > 6 (HCCI)] and CRP level. Kaplan-Meier analysis (KMA) was conducted for overall (OS) and cancer-specific survival (CSS). Based on survival analysis distribution we proposed a new stratification: CCI-CRP. Model performance was assessed with ROC/area under the curve (AUC) analysis and compared to CCI and CRP alone, and UISS. RESULTS: We analyzed 2,890 patients (median follow-up 30 months). ROC identified maximum product sensitivity and specificity for CRP at 3.5 mg/L. KMA revealed 5-year OS of 95.6% for LCRP/LCCI, 83% LCRP/ICCI, 73.3% LCRP/HCCI, 62.6% HCRP/LCCI, 51.6% HCRP/ICCI and 40.5% HCRP/HCCI (P < .001). From this distribution, new CCI-CRP is proposed: low CCI-CRP (LCRP/LCCI and LCRP/ICCI), intermediate CCI-CRP (LCRP/HCCI and HCRP/LCCI), and high CCI-CRP (HCRP/ICCI and HCRP/HCCI). AUC for CCI-CRP showed improved performance for predicting OS/CSS vs. CCI alone (0.73 vs. 0.63/0.77 vs. 0.60), CRP alone (0.73 vs. 0.71/0.77 vs. 0.74) and UISS (0.73 vs 0.67/0.77 vs 0.73). CONCLUSIONS: CCI-CRP, exhibits increased prognostic performance for survival outcomes in RCC compared to CCI and CRP alone, and UISS. Further investigation is requisite.

Prostatic stents: a narrative review of current evidence.

Benign prostatic hyperplasia (BPH) is a common chronic urologic condition affecting approximately 50% of men above the age of 60. As per European Association of Urology Guidelines, BPH can be treated according to a stepwise approach starting from a conservative management, a pharmacologic approach, and finally surgery. Both medical and surgical therapies have side effects, impacting on ejaculation and sexual function and patients with multiple comorbidities might not be considered surgically suitable candidates. Prostatic stents offer a minimally invasive procedures in an out-patient setting, possibly under local anaesthesia. Utilized since the 1980s, the past stents encompassed permanent (epithelializing) or temporary (non-epithelializing) devices, like the Uro-Lume (American Medical Systems, Minnetonka, MN, USA) and the Memokath, or Memotherm (Engineers & Doctors A/S, Denmark), and the biodegradable stents made of self-reinforced poly-L-lactide or braided poly lactic-co-glycolic acid. Previous stents however showed a quite high rate of complications among which pain, incontinence, infections, stent migration or blockage, and incomplete degradation that might lead to premature removal of stent. The stents currently available on the market instead are the temporary device Allium Triangular Prostatic Urethral Stent (Allium Urological Solutions, Caesarea, Israel) and the temporary stent SPANNER (AbbeyMoor Medical, Inc., Parkers Prairie, MN, USA), which might be used in case of bladder outflow obstruction, post-operatively, or for acute urinary retention. Studies showed encouraging results, in terms of effectiveness and safety improving patients' quality of life and International Prostate Symptom Score, but longer-term studies are needed to identify the most suitable patients who might benefit from their use. Newer stents and nitinol devices are currently investigated, and we are waiting for the results of the ongoing clinical trials.

URS for de-novo urolithiasis after kidney transplantation: a systematic review of the literature.

INTRODUCTION: There is a gap in the available literature and guidelines concerning the optimal approach for treating allograft stones, which currently include external shockwave lithotripsy, ureteroscopy and laser lithotripsy, or percutaneous nephrolithotomy. The objective of this systematic review was to evaluate the safety and effectiveness of URS as a treatment option for patients in this scenario. EVIDENCE ACQUISITION: A comprehensive search of the literature was conducted until August 2023. Only original articles written in English were considered for inclusion. This review has been registered in PROSPERO (registration number CRD42023451154). EVIDENCE SYNTHESIS: Eleven articles were included (122 patients). The mean age was 46.9±9.5 years, with a male-to-female ratio of 62:49. The preferred ureteral reimplantation technique was the Lich-Gregoire. The mean onset time was 48.24 months. Acute kidney injury, urinary tract infections and fever were the most frequent clinical presentations (18.3% each), followed by hematuria (10%). The mean stone size measured 9.84 mm (±2.42 mm). Flexible URS was preferred over semirigid URS. The stone-free rate stood at 83.35%, while the overall complication rate was 13.93%, with six (4.9%) major complications reported. Stones were mainly composed of calcium oxalate (42.6%) or uric acid (14.8%). Over an average follow-up period of 30.2 months, the recurrence rate was 2.46%. No significant changes in renal function or allograft loss were reported. CONCLUSIONS: URS remains an efficient choice for addressing de-novo allograft urolithiasis, offering the advantage of treating urinary stones with a good SFR and a low incidence of complications. Procedures should be performed in an Endourology referral center.

Association of Elevated C-Reactive Protein with Worsened Outcomes in Different Histologies of Renal Cortical Tumors: Analysis of the INMARC Registry.

BACKGROUND: To evaluate relationship between histological subtypes of renal cell carcinoma (RCC) and preoperative c-reactive protein (CRP). PATIENTS AND METHODS: We queried the International Marker Consortium for Renal Cancer database for patients affected by RCC. Patients were classified according to their histology: benign tumors, clear cell (cc) RCC, chromophobe (ch) RCC, papillary (p) RCC, and variant histology (vh) RCC; and according to CRP (mg/L): low CRP ≤5 and high CRP >5. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cancer-specific mortality (CSM), recurrence and association between CRP and histology. Multivariable analysis (MVA) via Cox regression and multivariable logistic regression were fitted to elucidate predictors of outcomes. RESULTS: Total 3902 patients (high CRP n = 1266) were analyzed; median follow up 51 (IQR 20-91) months. On MVA elevated CRP was an independent risk factor associated with increased risk of ACM in benign tumors (HR 5.98, P < .001), ccRCC (HR 2.69, P < .001), chRCC (HR 3.99, P < .001), pRCC (HR 1.76, P = .009) and vhRCC (HR 2.97, P =.007). MVA for CSM showed CRP as risk factor in ccRCC (HR 2.77, P < .001), chRCC (HR 6.16, P = .003) and pRCC (HR 2.29, P = .011), while in vhRCC was not (P = .27). MVA for recurrence reported CRP as risk factor for ccRCC (HR 1.30, P = .013), while in chRCC (P = .33), pRCC (P = .34) and vhRCC (P = .52) was not. On multivariable logistic regression CRP was a predictor of pRCC (OR 1.003, P = .002), while decreasing CRP was associated with benign tumors (OR 0.994, P = .048). CONCLUSION: Elevated CRP was a robust predictor of worsened ACM in all renal cortical neoplasms. While most frequently observed in pRCC patients, elevated CRP was independently associated with worsened CSM in non-vhRCC. Conversely, elevated CRP was least likely to be noted in benign tumors, and elevation in this subgroup of patients should prompt further consideration for surveillance given increased risk of ACM. Further investigation is requisite.

Challenging the Urologist of the Future: Time for a Change?

Physicians need both medical expertise and diverse skills for effective patient care. Adaptability is also key in embracing advances in technology and new techniques. We outline six thought-provoking points to guide the new generation of urologists.

Retreatment for Lower Urinary Tract Symptoms After Water Vapor Thermal Therapy.

OBJECTIVE: To identify predictors of retreatment for symptomatic recurrence among men who undergo water vapor thermal therapy (WVTT; Rezum, Boston Scientific, Marlborough, MA), a minimally invasive surgical treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. METHODS: We retrospectively reviewed patients treated with WVTT at a single institution from August 2017 to February 2022. Patients who underwent a second benign prostatic hyperplasia procedure for persistent or recurrent lower urinary tract symptoms within 2years of original treatment were compared to the remaining cohort who did not undergo retreatment. Multivariate analysis was used to assess for predictors of retreatment. RESULTS: Data were obtained from 192 patients. 10 (5%) patients were retreated. The retreatment cohort had smaller prostate volumes (50.4±18.2 cc vs 48.5±35.7 cc; P = .003) and received a greater number of water vapor injections (4.4±1.8 vs 5.2±3.9; P < .001). At 6month follow-up, total International Prostate Symptom Score (IPSS; 10.13 ± 7.40 vs 18.5 ± 11.55, P = .044) and voiding subscores (4.59 ± 4.39 vs 9.5 ± 7.84, P = .006) were significantly worse in the retreatment group. On multivariate analysis, >1 treatment per lobe was independently associated with increased risk of retreatment (hazard ratio 8.509, 95% CI [1.109-65.293]; P = .039). CONCLUSION: WVTT has a low retreatment rate. Men who required retreatment received more injections and showed worsened voiding symptom scores 6months postoperatively. Decreasing the number of injections may help reduce treatment failure rates.

Effect of Sex on the Oncological Outcomes in Response to Immunotherapy and Antibody-drug Conjugates in Patients with Urothelial and Kidney Cancer: A Systematic Review and a Network Meta-analysis.

BACKGROUND AND OBJECTIVE: Immune checkpoint inhibitors (ICIs) and antibody-drug conjugates (ADCs) herald a transformative era in metastatic renal cell carcinoma (RCC) and transitional cell carcinoma (TCC) treatment, amid acknowledged sex-based disparities in these cancers. We conducted a systematic review and network meta-analysis (NMA) to identify sex-specific differences in the efficacy of ICI/ADC monotherapy or combination therapies for RCC and TCC survival, in metastatic and adjuvant settings. METHODS: A systematic search was conducted up to October 2023 for English articles on ICIs and ADCs as systemic therapies (ICIs in first-line and adjuvant treatment for RCC, ICIs and ADCs in first- and second-line treatment for TCC). Randomised clinical trials were considered. The primary objective was overall survival (OS) of ICIs and ADCs between males and females. The secondary outcomes included progression-free survival, overall response rate, disease-free survival, and recurrence-free survival. Treatment efficacy was evaluated by sex via odds ratios (ORs) and confidence intervals compared with controls. Log ORs were used for creating a frequentist NMA. This meta-analysis was registered on PROSPERO (CRD42023468632). KEY FINDINGS AND LIMITATIONS: Eighteen articles met the inclusion criteria. Females had an advantage for RCC-adjuvant treatment for atezolizumab (log OR [SE] = -0.57 ± 0.25, p = 0.024) in OS. Males showed a survival advantage in TCC second-line treatment for ADC-Nectin 4 (log OR [SE] = 0.65 ± 0.28, p = 0.02). No other significant results were shown. CONCLUSIONS AND CLINICAL IMPLICATIONS: The NMA revealed gender-specific variations in ICI and ADC responses for RCC and TCC, offering insights for personalised cancer care and addressing disparities in cancer care and outcomes. PATIENT SUMMARY: In this systematic review, we looked at the sex differences for metastatic renal cell carcinoma (RCC) and transitional cell carcinoma (TCC) for antibody-drug conjugates and immune checkpoint inhibitors. In our analysis, female and male sex has better overall survival for adjuvant and second-line therapies for RCC and TCC, respectively. Urgent research on gender-specific cancer therapies is imperative.

Does the Timing of Cytoreductive Nephrectomy Impact Outcomes? Analysis of REMARCC Registry Data for Patients Receiving Tyrosine Kinase Inhibitor Versus Immune Checkpoint Inhibitor Therapy.

Background and objective: The role of cytoreductive nephrectomy (CN) in the treatment of metastatic renal cell carcinoma (mRCC) has been called into question on the basis of clinical trial data from the tyrosine kinase inhibitor (TKI) era. Comparative analyses of CN for patients treated with immuno-oncology (IO) versus TKI agents are sparse. Our objective was to compare CN timing and outcomes among patients who received TKI versus IO therapy. Methods: This was a multicenter retrospective analysis of patients who underwent CN using data from the REMARCC (Registry of Metastatic RCC) database. The cohort was divided into TKI versus IO first-line therapy groups. The primary outcome was all-cause mortality (ACM). Secondary outcomes included cancer-specific mortality (CSM). Multivariable analysis was used to identify factors predictive for ACM and CSM. The Kaplan-Meier method was used to analyze 5-yr overall survival (OS) and cancer-specific survival (CSS) with stratification by primary systemic therapy and timing in relation to CN. Key findings and limitations: We analyzed data for 189 patients (148 TKI + CN, 41 IO +CN; median follow-up 23.2 mo). Multivariable analysis revealed that a greater number of metastases (hazard ratio [HR] 1.06; p = 0.015), greater primary tumor size (HR 1.10; p = 0.043), TKI receipt (HR 2.36; p = 0.015), and initiation of systemic therapy after CN (HR 1.49; p = 0.039) were associated with worse ACM. A greater number of metastases at diagnosis (HR 1.07; p = 0.011), greater primary tumor size (HR 1.12; p = 0.018), TKI receipt (HR 5.43; p = 0.004), and initiation of systemic therapy after CN (HR 2.04; p < 0.001) were associated with worse CSM. Kaplan-Meier analyses revealed greater 5-yr rates for OS (51% vs 27%; p < 0.001) and CSS (83% vs 30%; p < 0.001) for IO +CN versus TKI + CN. This difference persisted in a subgroup analysis for patients with intermediate or poor risk, with 5-yr OS rates of 50% for IO + CN versus 30% for TKI + CN (p < 0.001). A subanalysis stratified by CN timing revealed better 5-yr rates for OS (50% vs 30%; p = 0.042) and CSS (90% vs 30%, p = 0.019) for delayed CN after IO therapy, but not after TKI therapy. Conclusions and clinical implications: For patients who underwent CN, systemic therapy before CN was associated with better outcomes. In addition, IO therapy was associated with better survival outcomes in comparison to TKI therapy. Our findings question the applicability of clinical trial data from the TKI era to CN in the IO era for mRCC. Patient summary: For patients with metastatic kidney cancer treated with surgery, better survival outcomes were observed for those who also received immunotherapy in comparison to therapy targeting specific proteins in the body (tyrosine kinase inhibitors, TKIs). Immunotherapy or TKI treatment resulted in better outcomes if it was received before rather than after surgery.

Percutaneous Nephrolithotomy for De Novo Urolithiasis After Kidney Transplantation: A Systematic Review of the Literature.

Introduction and Objective: Renal transplantation is the treatment for end-stage renal disease that offers better quality of life and survival. Among the possible complications that might affect allografts, urolithiasis might have severe consequences, causing acute kidney injury (AKI) or septic events in immunocompromised patients. Allograft stones might be treated with percutaneous nephrolithotomy (PCNL). The aim of this Cochrane style review was to assess the safety and efficacy of PCNL in patients with renal transplant. Methods: A comprehensive search in the literature was performed including articles between July 1982 and June 2023, with only English original articles selected for this review. Results: The final review encompassed nine articles (108 patients). The mean age was 46.4 ± 8.7 years, with a male:female ratio of 54:44. The average time from transplantation to urolithiasis onset was 47.54 ± 23.9 months. Predominant symptoms upon presentation were AKI (32.3%), followed by urinary tract infection and fever (24.2%), and oliguria (12.9%). The mean stone size was 20.1 ± 7.3 mm, with stones located in the calices or pelvis (41%), ureteropelvic junction (23.1%), or proximal ureter (28.2%). PCNL (22F-30F) was more frequently performed than mini-PCNLs (16F-20F) (52.4% vs 47.6%). Puncture was guided by ultrasound (42.9%), fluoroscopy (14.3%), or both (42.9%). The stone-free rate (SFR) and complication rates were 92.95% (range: 77%-100%) and 5.5%, respectively, with only one major complication reported. Postoperatively, a ureteral stent and nephrostomy were commonly placed in 47%, with four patients needing a second look PCNL. During an average follow-up of 32.5 months, the recurrence rate was 3.7% (4/108), and the mean creatinine level was 1.37 ± 0.28 mg/dL. Conclusions: PCNL remains a safe and effective option in de novo allograft urolithiasis, allowing to treat large stones in one-step surgery. A good SFR is achieved with a low risk of minor complications. These patients should be treated in an endourology center in conjunction with the renal or transplant team.

Upper Tract Urothelial Cancer: Guideline of Guidelines.

BACKGROUND: Upper tract urothelial carcinoma (UTUC) is a rare disease with a potentially dismal prognosis. We systematically compared international guidelines on UTUC to analyze similitudes and differences among them. METHODS: We conducted a search on MEDLINE/PubMed for guidelines related to UTUC from 2010 to the present. In addition, we manually explored the websites of urological and oncological societies and journals to identify pertinent guidelines. We also assessed recommendations from the International Bladder Cancer Network, the Canadian Urological Association, the European Society for Medical Oncology, and the International Consultation on Bladder Cancer, considering their expertise and experience in the field. RESULTS: Among all the sources, only the American Urologist Association (AUA), European Association of Urology (EAU), and the National Comprehensive Cancer Network (NCCN) guidelines specifically report data on diagnosis, treatment, and follow-up of UTUC. Current analysis reveals several differences between all three sources on diagnostic work-up, patient management, and follow-up. Among all, AUA and EAU guidelines show more detailed indications. CONCLUSIONS: Despite the growing incidence of UTUC, only AUA, EAU, and NCCN guidelines deal with this cancer. Our research depicted high variability in reporting recommendations and opinions. In this regard, we encourage further higher-quality research to gain evidence creating higher grade consensus between guidelines.

Unraveling the BMI paradox in different renal cortical tumors: insights from the INMARC registry.

OBJECTIVE: To investigate impact of body mass index (BMI) on survival across different histologies and stages of renal cell carcinoma (RCC). METHODS: We conducted a retrospective multicenter analysis of clear cell (ccRCC) and non-ccRCC. Obesity was defined according to the WHO criteria (non-Asian BMI >30 Kg/m2, Asian BMI >27.5 Kg/m2). Multivariable analysis (MVA) via Cox regression model was conducted for all-cause (ACM), cancer-specific mortality (CSM) and recurrence. RESULTS: A total of 3,880 patients with a median follow-up of 31 (IQR 9-64) months were analyzed. Overall, 1,373 (35.3%) were obese; 2,895 (74.6%) were ccRCC and 985 (25.3%) were non-ccRCC (chRCC 246 [24.9%], pRCC 469 [47.6%] and vhRCC 270 [27.4%]). MVA in ccRCC revealed obesity associated with decreased risk of ACM, CSM and recurrence (hazard ratio [HR] 0.80, P = 0.044; HR 0.71, P = 0.039; HR 0.73, P = 0.012, respectively), while in non-ccRCC was not associated with decreased risk of ACM, CSM, and recurrence (P = 0.84, P = 0.53, P = 0.84, respectively). Subset analysis in stage IV ccRCC demonstrated obesity as associated with a decreased risk of ACM, CSM, and recurrence (HR 0.68, P = 0.04; HR 0.59, P = 0.01; HR 0.59, P = 0.01, respectively), while in stage I-III ccRCC was not (P = 0.21; P = 0.30; P = 0.19, respectively). CONCLUSION: Our findings refute a broad "obesity paradox" for RCC. Obesity was not associated with improved survival in non-ccRCC and in nonmetastatic ccRCC, while metastatic ccRCC patients with obesity had improved survival outcomes.

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review.

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN's surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

Current role of endoscopic combined intrarenal surgery in the management of renal stones: A scoping review.

Introduction: This study aims to review the current role of endoscopic combined intrarenal surgery (ECIRS) in the management of renal stones, with a focus on its efficacy and safety. The secondary outcome was to highlight the tips and tricks to improve the urologist's experience with ECIRS. Methods: A scoping review of the literature, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, was performed, using ECIRS and flexible ureteroscopy and percutaneous nephrolithotomy as the search terms. All original articles were screened and included. Results: Thirty-three studies were included in the analysis. ECIRS showed a good efficacy and safety profile, with an excellent stone-free rate and a low rate of complications, mostly Clavien-Dindo I/II. With ECIRS, a reduction in the need for multiple access tracts was noted and direct visualization of the targeted calyx during the puncture increased the ability to attain transpapillary punctures, thereby reducing the amount of bleeding. Conclusion: ECIRS, as the first-line minimal access intervention, is safe and efficacious, particularly for achieving a stone-free status in patients with large complex stones in a single stage. The ability to gain access under direct vision and the reduction in the number of tracts, in both the supine and the prone positions, makes this procedure an attractive surgical choice.

A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors.

Objective: Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors. Methods: A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes. Results: After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney. Conclusion: Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

Trends of 'Artificial Intelligence, Machine Learning, Virtual Reality and Radiomics in Urolithiasis' over the last 30 years (1994-2023) as published in the literature (PubMed): a Comprehensive review.

PURPOSE: To analyze the bibliometric publication trend on the application of "Artificial Intelligence (AI) and its subsets (Machine Learning-ML, Virtual reality-VR, Radiomics) in Urolithiasis" over the last 3 decades. We looked at the publication trends associated with AI and stone disease, including both clinical and surgical applications, and training in endourology. METHODS: Though a MeshTerms research on PubMed, we performed a comprehensive review from 1994-2023 for all published papers on "AI, ML, VR and Radiomics". Papers were then divided in three categories: A-Clinical (Non-surgical), B-Clinical (Surgical) and C-Training papers, and articles were then assigned to 3 periods: Period-1 (1994-2003), Period-2 (2004-2013), Period-3 (2014-2023). RESULTS: 343 papers were noted (Groups A-129, B-163 and C-51), and trends increased from Period-1 to Period-2 at 123% (p=0.009), and to period-3 at 453% (p=0.003). This increase from Period-2 to Period-3 for groups A, B and C was 476% (p=0.019), 616% (0.001) and 185% (p<0.001) respectively. Group A papers included rise in papers on "stone characteristics" (+2100%;p=0.011), "renal function" (p=0.002), "stone diagnosis" (+192%), "prediction of stone passage" (+400%) and "quality of life" (+1000%). Group B papers included rise in papers on "URS" (+2650%,p=0.008), "PCNL" (+600%, p=0.001) and "SWL" (+650%,p=0.018). Papers on "Targeting" (+453%,p<0.001), "Outcomes" (+850%,p=0.013) and "Technological Innovation" (p=0.0311) had rising trends. Group C papers included rise in papers on "PCNL" (+300%,p=0.039), and "URS" (+188%,p=0.003). CONCLUSION: Publications on AI and its subset areas for urolithiasis have seen an exponential increase over the last decade, with an increase in surgical and non-surgical clinical areas as well as in training. Future AI related growth in the field of endourology and urolithiasis is likely to improve training, patient centered decision making and clinical outcomes.

Development of a novel score (RENSAFE) to determine probability of acute kidney injury and renal functional decline post surgery: A multicenter analysis.

OBJECTIVE: To create and validate 2 models called RENSAFE (RENalSAFEty) to predict postoperative acute kidney injury (AKI) and development of chronic kidney disease (CKD) stage 3b in patients undergoing partial (PN) or radical nephrectomy (RN) for kidney cancer. METHODS: Primary objective was to develop a predictive model for AKI (reduction >25% of preoperative eGFR) and de novo CKD≥3b (<45 ml/min/1.73m2), through stepwise logistic regression. Secondary outcomes include elucidation of the relationship between AKI and de novo CKD≥3a (<60 ml/min/1.73m2). Accuracy was tested with receiver operator characteristic area under the curve (AUC). RESULTS: AKI occurred in 452/1,517 patients (29.8%) and CKD≥3b in 116/903 patients (12.8%). Logistic regression demonstrated male sex (OR = 1.3, P = 0.02), ASA score (OR = 1.3, P < 0.01), hypertension (OR = 1.6, P < 0.001), R.E.N.A.L. score (OR = 1.2, P < 0.001), preoperative eGFR<60 (OR = 1.8, P = 0.009), and RN (OR = 10.4, P < 0.0001) as predictors for AKI. Age (OR 1.0, P < 0.001), diabetes mellitus (OR 2.5, P < 0.001), preoperative eGFR <60 (OR 3.6, P < 0.001) and RN (OR 2.2, P < 0.01) were predictors for CKD≥3b. AUC for RENSAFE AKI was 0.80 and 0.76 for CKD≥3b. AKI was predictive for CKD≥3a (OR = 2.2, P < 0.001), but not CKD≥3b (P = 0.1). Using 21% threshold probability for AKI achieved sensitivity: 80.3%, specificity: 61.7% and negative predictive value (NPV): 88.1%. Using 8% cutoff for CKD≥3b achieved sensitivity: 75%, specificity: 65.7%, and NPV: 96%. CONCLUSION: RENSAFE models utilizing perioperative variables that can predict AKI and CKD may help guide shared decision making. Impact of postsurgical AKI was limited to less severe CKD (eGFR<60 ml/min 71.73m2). Confirmatory studies are requisite.

Advances in lasers for the minimally invasive treatment of upper and lower urinary tract conditions: a systematic review.

PURPOSE: Technological advancements in laser lithotripsy are expanding into numerous fields of urology, like ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), and benign and malignant soft-tissue treatments. Since the amount of research regarding lasers in urology has grown exponentially, we present a systematic review of the most recent and relevant advances encompassing all lasers used in urological endoscopic treatment. METHODS: We performed a literature search using PubMed (May 2023) to obtain information about lasers for urological purposes. We included only recent data from published articles between 2021 and 2023 or articles ahead of print. RESULTS: Lasers are widely used in lithotripsy for ureteric, renal, and bladder stones, benign prostate surgery, and bladder and upper tract tumor ablation. While the holmium (Ho:YAG) laser is still predominant, there seems to be more emphasis on pulse modulation and newer lasers such as thulium fiber laser (TFL) and pulsed Tm:YAG laser. CONCLUSION: The use of lasers and related technological innovations have shown increasing versatility, and over time have proven to be invaluable in the management of stone lithotripsy, treatment of benign and malignant prostate diseases, and urothelial tumors. Laser endoscopic treatment is heavily based on technological nuances, and it is essential to know at least the basics of these technologies. Ultimately the choice of laser used depends on its availability, cost, surgeon experience and expertise.

The role of 'artificial intelligence, machine learning, virtual reality, and radiomics' in PCNL: a review of publication trends over the last 30 years.

Introduction: We wanted to analyze the trend of publications in a period of 30 years from 1994 to 2023, on the application of 'artificial intelligence (AI), machine learning (ML), virtual reality (VR), and radiomics in percutaneous nephrolithotomy (PCNL)'. We conducted this study by looking at published papers associated with AI and PCNL procedures, including simulation training, with preoperative and intraoperative applications. Materials and Methods: Although MeSH terms research on the PubMed database, we performed a comprehensive review of the literature from 1994 to 2023 for all published papers on 'AI, ML, VR, and radiomics' in 'PCNL', with papers in all languages included. Papers were divided into three 10-year periods: Period 1 (1994-2003), Period 2 (2004-2013), and Period 3 (2014-2023). Results: Over a 30-year timeframe, 143 papers have been published on the subject with 116 (81%) published in the last decade, with a relative increase from Period 2 to Period 3 of +427% (p = 0.0027). There was a gradual increase in areas such as automated diagnosis of larger stones, automated intraoperative needle targeting, and VR simulators in surgical planning and training. This increase was most marked in Period 3 with automated targeting with 52 papers (45%), followed by the application of AI, ML, and radiomics in predicting operative outcomes (22%, n = 26) and VR for simulation (18%, n = 21). Papers on technological innovations in PCNL (n = 9), intelligent construction of personalized protocols (n = 6), and automated diagnosis (n = 2) accounted for 15% of publications. A rise in automated targeting for PCNL and PCNL training between Period 2 and Period 3 was +247% (p = 0.0055) and +200% (p = 0.0161), respectively. Conclusion: An interest in the application of AI in PCNL procedures has increased in the last 30 years, and a steep rise has been witnessed in the last 10 years. As new technologies are developed, their application in devices for training and automated systems for precise renal puncture and outcome prediction seems to play a leading role in modern-day AI-based publication trends on PCNL.

Role of simulation in kidney stone disease: A systematic review of literature trends in the 26 years.

BACKGROUND: Minimally invasive techniques for treatment of urinary stones requires expertise, experience and endoscopic skills. Simulators provide a low-stress and low-risk environment while providing a realistic set-up and training opportunities. AIM: To report the publication trend of 'simulation in urolithiasis' over the last 26 years. METHODS: Research of all published papers on "Simulation in Urolithiasis" was performed through PubMed database over the last 26 years, from January 1997 to December 2022. Papers were labelled and divided in three subgroups: (1) Training papers; (2) Clinical simulation application or surgical procedures; and (3) Diagnostic radiology simulation. Each subgroup was then divided into two 13-year time periods to compare and identify the contrast of different decades: period-1 (1997-2009) and period-2 (2010-2022). RESULTS: A total of 168 articles published on the application of simulation in urolithiasis over the last 26 years (training: n = 94, surgical procedures: n = 66, and radiology: n = 8). The overall number of papers published in simulation in urolithiasis was 35 in Period-1 and 129 in Period-2, an increase of +269% (P = 0.0002). Each subgroup shows a growing trend of publications from Period-1 to Period-2: training papers +279% (P = 0.001), surgical simulations +264% (P = 0.0180) and radiological simulations +200% (P = 0.2105). CONCLUSION: In the last decades there has been a step up of papers regarding training protocols with the aid of various simulation devices, with simulators now a part of training programs. With the development of 3D-printed and high-fidelity models, simulation for surgical procedure planning and patients counseling is also a growing field and this trend will continue to rise in the next few years.

Partial versus radical nephrectomy for complex renal mass: multicenter comparative analysis of functional outcomes (Rosula collaborative group).

BACKGROUND: Utility of partial nephrectomy (PN) for complex renal mass (CRM) is controversial. We determined the impact of surgical modality on postoperative renal functional outcomes for CRM. METHODS: We retrospectively analyzed a multicenter registry (ROSULA). CRM was defined as RENAL Score 10-12. The cohort was divided into PN and radical nephrectomy (RN) for analyses. Primary outcome was development of de-novo estimated glomerular filtration rate (eGFR)<45 mL/min/1.73 m2. Secondary outcomes were de-novo eGFR<60 and ΔeGFR between diagnosis and last follow-up. Cox proportional hazards was used to elucidate predictors for de-novo eGFR<60 and <45. Linear regression was utilized to analyze ΔeGFR. Kaplan-Meier Analysis (KMA) was performed to analyze 5-year freedom from de-novo eGFR<60 and <45. RESULTS: We analyzed 969 patients (RN=429/PN=540; median follow-up 24.0 months). RN patients had lower BMI (P<0.001) and larger tumor size (P<0.001). Overall postoperative complication rate was higher for PN (P<0.001), but there was no difference in major complications (Clavien III-IV; P=0.702). MVA demonstrated age (HR=1.05, P<0.001), tumor-size (HR=1.05, P=0.046), RN (HR=2.57, P<0.001), and BMI (HR=1.04, P=0.001) to be associated with risk for de-novo eGFR<60 mL/min/1.73 m2. Age (HR=1.03, P<0.001), BMI (HR=1.06, P<0.001), baseline eGFR (HR=0.99, P=0.002), tumor size (HR=1.07, P=0.007) and RN (HR=2.39, P<0.001) were risk factors for de-novo eGFR<45 mL/min/1.73 m2. RN (B=-10.89, P<0.001) was associated with greater ΔeGFR. KMA revealed worse 5-year freedom from de-novo eGFR<60 (71% vs. 33%, P<0.001) and de-novo eGFR<45 (79% vs. 65%, P<0.001) for RN. CONCLUSIONS: PN provides functional benefit in selected patients with CRM without significant increase in major complications compared to RN, and should be considered when technically feasible.