An Overview of the Effect of Aging on the Female Urethra.

Urethral function declines by roughly 15% per decade and profoundly contributes to the pathogenesis of urinary incontinence. Individuals with poor urethral function are more likely to fail surgical management for stress incontinence that focus on improving urethral support. The reduced number of intramuscular nerves and the morphologic changes in muscle and connective tissue collectively impact urethral function as women age. Imaging technologies like MRI and ultrasound have advanced our understanding of these changes. However, substantial knowledge gaps remain. Addressing these gaps can be crucial for developing better prevention and treatment strategies, ultimately enhancing the quality of life for aging women.

Comparison of Superpulse Thulium Fiber Laser vs Holmium Laser for Ablation of Renal Calculi in an In Vivo Porcine Model.

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.

Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

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 mm3/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.

Multidisciplinary Approach and Outcomes of Pretreatment Small (cT1a) Renal Mass Biopsy: Single-Center Experience.

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.

Emergency versus elective ureteroscopy for the management of ureteral stones.

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.

Ex Vivo Renal Stone Dusting: Impact of Laser Modality, Ureteral Access Sheath, and Suction on Total Stone Clearance.

Introduction and Objectives: Conventional renal stone dusting is challenging; the holmium (Ho:YAG) laser and holmium with MOSES effect (Ho:YAG-MOSES) fail to uniformly produce fragments ≤100 µm (i.e., dust). The superpulse thulium fiber laser (sTFL) may more effectively render uroliths into "dust," and may thus improve stone-free rates. Accordingly, we performed ex vivo evaluations with all three laser modalities, assessing stone fragments and stone clearance. Methods: Seventy-two ex vivo porcine kidney-ureter models were divided into 12 groups of 6: laser type (Ho:YAG, Ho:YAG-MOSES, sTFL), ureteroscope with and without applied suction, and the presence or absence of a 14F ureteral access sheath (UAS). Calcium oxalate stones were preweighed and implanted into each kidney via a pyelotomy. Stones were treated at 16W using dusting settings of 0.4J × 40Hz (Ho:YAG), 0.2J × 80Hz (Ho:YAG-MOSES), and 0.2J × 80Hz (sTFL) for up to 20 minutes. No stone basketing was performed. Kidneys were bivalved and residual fragments were collected, dried, weighed, and sieved to determine fragment size and stone clearance. Results: Initial stone mass (mg), procedure time (seconds), and laser energy expenditure (kJ) were similar in all 12 groups. The greatest stone clearance was seen with sTFL + suction + UAS (94%) compared with a conventional technique (Ho:YAG + no suction + no UAS) (65%, p < 0.01). The use of sTFL provided greater stone clearance than Ho:YAG or Ho:YAG-MOSES. Aspiration improved stone clearance for sTFL (p = 0.01), but not for Ho:YAG or Ho:YAG-MOSES, consistent with the creation of smaller fragments with sTFL. Presence of a 14F UAS improved stone clearance in all scenarios (p < 0.01). Conclusions: In this ex vivo study, stone clearance was optimized under the following conditions: sTFL, 14F UAS, and aspiration. This combination resulted in 94% of stone fragments being cleared; the 6% remaining fragments were all <2 mm. In all scenarios, deployment of a 14F UAS improved stone clearance.

Global Assessments of the Endockscope System: Long-Term Impact of Cyber Endoscopy.

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.

Caveat Emptor: The Heat Is "ON"-An In Vivo Evaluation of the Thulium Fiber Laser and Temperature Changes in the Porcine Kidney During Dusting and Fragmentation Modes.

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.

Nontransecting Anastomotic Urethroplasty Via Ventral Approach Without Full Mobilization of the Corpus Spongiosum Dorsal Semicircumference.

OBJECTIVE: To present a novel surgical approach to performing bulbar urethroplasty and to assess its initial outcomes and safety. MATERIALS AND METHODS: From January 2016 to March 2019, anastomotic urethroplasty without full mobilization and dissection of corpus spongiosum dorsal semicircumference was performed in 8 males with bulbar strictures by a single surgeon. Patients were given uroflowmetry, urethrography, and International Index of Erectile Function (IIEF) questionnaires at their 3- and 12- month follow-up visits postoperatively. RESULTS: Mean stricture length was 2.3 cm (±0.59 cm) and mean surgery time was 131 minutes. No early or late postoperative complications were observed. Median maximum flow rate (Qmax) assessed 3 months after surgery was 22.35 mL/sec (±6.4 mL/sec). There were no significant changes in median IIEF score postoperatively (preoperative IIEF = 18.4 vs postoperative IIEF = 19.6; P >.05). During patients' 1-year observation period, no signs of constriction in the anastomosis were revealed with urethrography. One of the limitations of this technique is a necessity of more precise corpus spongiosum preparation to ensure perioperative hemostasis and good visualization. This outcome may, however, require additional time and increased blood loss during a surgeon's learning curve of the procedure. CONCLUSION: The initial experience of this minimally invasive urethroplasty technique showed high efficiency and no early stricture recurrences. However, the clinical significance of additional preservation of innervation and blood supply, the potential to further optimize this technique's functional outcomes, and applicability of this technique in patients with spongiofibrosis requires further investigation. Our results make it possible to consider this technique as a possible alternative to classic anastomotic urethroplasty.