Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group.

PURPOSE: To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications. METHODS: After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely. CONCLUSIONS: Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Strengths and Difficulties Questionnaire (SDQ): An update of the literature and instrumental study with schoolchildren

Introduction: Considering the current controversy regarding the factorial structure of the SDQ, this paper aimed to analyse the dimensionality and reliability of the parents' version for children from 4 to 16 years of age, and to present descriptive data according to sociodemographic variables. Method: The factor structure of the original five- and three-factor models, and the reliability of the SDQ were examined among a sample of 621 parents of Uruguayan children between 7 and 12 years of age (52% girls) from different socioeconomic levels. Results: Confirmatory factor analyses did not provide support for the five- and three-factor models. Data adjusted to three factors (prosociality, externalising symptoms, internalising symptoms) in an exploratory analysis with adequate reliability indices. Conclusions: The results of this study show the relevance of continued investigation of the SDQ internal structure, and further analysis of the behaviour of several of its items.

Introducción: Considerando la controversia vigente respecto a la estructura factorial del SDQ, este trabajo tuvo como objetivo analizar la validez de constructo y fiabilidad de la versión para padres de niños de 4 a 16 años y presentar datos descriptivos según variables sociodemográficas. Método: Se examinó la estructura factorial de los modelos originales de cinco y tres factores y la fiabilidad del SDQ en una muestra de 621 padres de niños uruguayos entre 7 y 12 años (52 % niñas) de distintos niveles socioeconómicos. Resultados: Los análisis factoriales confirmatorios no pudieron dar apoyo a los modelos de cinco y tres factores. Los datos se ajustaron a tres factores (prosocialidad, síntomas externalizantes y síntomas internalizantes) en un análisis exploratorio con adecuados índices de fiabilidad. Conclusiones: Los resultados de este estudio muestran la pertinencia de continuar investigando la estructura interna del SDQ y analizar con mayor profundidad el comportamiento de algunos de sus ítems.

Advances in percutaneous renal puncture: a comprehensive review of the literature.

PURPOSE OF REVIEW: Percutaneous nephrolithotomy (PCNL) constitutes the gold standard procedure for patients suffering from more than 2 cm renal stones. The puncture is a very critical step of PCNL, affecting manoeuvrability of the nephroscope, possibility to remove stone fragments, risk of bleeding and radiation exposure. The aim of the current review was to discuss the advances in percutaneous renal puncture. RECENT FINDINGS: Following technological evolution in medicine, there was a consistent development in the puncture techniques, aiming at the improvement of its efficacy and safety. The use of specific agents can improve ultrasonic guidance, making the challenging step of gaining access to the kidney easier for the experienced surgeon and more accessible for the resident urologist. Future developments in the electromagnetic and three-dimensional (3D) technology may establish a high level of accuracy with decreased rates of related complications, even in the hands of beginners. SUMMARY: The advances in percutaneous puncture can lead to improved safety and accuracy of this procedure decreasing the radiation exposure and the complication rate.

Is endoscopic combined intrarenal surgery ready for primetime in endourology? Outcomes from a systematic review and meta-analysis.

Introduction: We aimed to review the outcomes of endoscopic combined intrarenal surgery (ECIRS) as compared to conventional percutaneous nephrolithotomy (PCNL) for kidney stones. Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We included all studies comparing ECIRS and conventional PCNL. Surgical time, hemoglobin drop, and postoperative stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% confidence intervals (CI), and p-values. Complications, stone-free rate, and retreatment were assessed using Cochran-Mantel-Haenszel method with random effect model and expressed as odds ratio (OR), 95% CI, and p-values. Results: A total of 17 studies were included. Surgical time and mean postoperative length did not significantly differ between the groups (MD -8.39 minutes 95%CI -21.30, 4.53, p = 0.20; 5.09 days 95%CI -19.51, 29.69, p = 0.69). Mean hemoglobin drop was significantly lower in the ECIRS group (MD -0.56 g/dl 95%CI -1.08, -0.05, p = 0.03), while blood transfusion rate did not differ between the two groups (OR 0.88 95%CI 0.64, 1.23, p = 0.15). While the incidence of postoperative sepsis did not differ between the two groups (OR 0.52 95% CI 0.17, 1.59, p = 0.25), the incidence of postoperative fever was lower in the ECIRS group but the difference was not significant (OR 0.61 95%CI 0.35, 1.06, p = 0.08). The stone-free rate was significantly higher in the PCNL group (OR 2.52 95%CI 1.64, 3.90, p <0.0001) and the retreatment rate was lower in the ECIRS group (OR 0.34 95%CI 0.14, 0.87, p = 0.002). Conclusions: ECIRS showed shorter operative time, lower complication rate, and retreatment compared to PCNL. Conventional PCNL showed a higher stone-free rate.

Experiences of miscarriage: the voice of parents and health professionals.

The death of a child in the intrauterine stage has legal, psychological, spiritual, and health-related connotations that condition the woman's experience. To understand better the processes set in motion around early pregnancy loss, this ethnographic study explores the experiences of miscarriage in a group of 15 women. The following themes are analyzed: Experience of losing the child, spirituality, health care, and the need to physically recognize the child. The study shows that the need women have to honor the child who did not live may be conditioned by the perception of an uncertain loss and by the absence of a place to honor him/her. Attitudes among professionals are revealed that could be perceived as gender-related abuse. The care of women places emphasis on physical aspects, underlining the lack of comprehensive care during the grieving process.

The Impact of Lasers in Percutaneous Nephrolithotomy Outcomes: Results from a Systematic Review and Meta-Analysis of Randomized Comparative Trials.

Background: Percutaneous nephrolithotomy (PCNL) is the first-choice treatment of renal stones larger than 2 cm. We aimed to evaluate if lasers perform as equal as non-laser devices in patients with kidney stones candidate to PCNL. Materials and Methods: A comprehensive literature search was performed in MEDLINE through PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to assess differences in the perioperative course, incidence of postoperative complications, and stone-free rate (SFR) in patients with kidney stones undergoing laser vs non-laser PCNL in randomized studies. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as risk ratios (RRs), 95% confidence intervals (CIs), and p-values. Surgical time and length of stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% CI, and p-values. Analyses were two tailed, with a significance set at p ≤ 0.05. Results: Six articles, including 732 patients (311 patients undergoing holmium laser and 421 non-laser PCNL), were included in meta-analysis. Surgical time and postoperative stay were shorter in the non-laser group (MD: 11.14, 95% CI: 2.32 to 19.96, p = 0.002; MD: -0.81, 95% CI: -2.18 to 0.57, p = 0.25, respectively). SFR was significantly higher in the non-laser group (RR: 1.08, 95% CI: 1.01 to 1.15, p = 0.03). Patients undergoing laser PCNL had a nonsignificant higher risk of postoperative fever >38°C (RR: 0.64, 95% CI: 0.31 to 1.30, p = 0.22). Transfusion rate did not differ between the two groups (RR: 1.02, 95% CI: 0.50 to 2.11, p = 0.95). The need for stent positioning because of urine extravasation was higher risk in the laser group, but the difference did not reach significance (RR: 0.49, 95% CI: 0.17 to 1.41, p = 0.19). Conclusions: Non-laser PCNL showed better perioperative outcomes and SFR compared to holmium laser PCNL.

Tips and Tricks to Improve Ergonomics, Efficacy, Versatility, and Overcome Limitations of Micro Percutaneous Nephrolithotomy.

Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over. Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones. Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same. Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference. Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.

Percutaneous Nephrolithotomy in Horseshoe Kidneys: Results of a Multicentric Study.

Objective: To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. Methods: We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of p < 0.05 were considered significant. Results: We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 vs 27.7, p = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% vs 2.6% (p = 0.99), 16.9% vs 18.4% (p = 0.99), and 52.5% vs 69.2% (p = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 vs 100 minutes, p = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group (p < 0.001). The prone group had significantly more Clavien 2 complications than the supine (p = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. Conclusion: PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.

Consultation on kidney stones, Copenhagen 2019: lithotripsy in percutaneous nephrolithotomy.

PURPOSE: To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). METHODS: A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled "Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy" held in Copenhagen, Denmark, in September 2019. RESULTS: New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). CONCLUSION: Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

Efficacy of the Endoscopic Combined Intrarenal Surgery for the Treatment of a Staghorn Calculus in Crossed Fused Renal Ectopia.

Background: Crossed fused renal ectopia (CFRE) is an unusual anomaly in which both kidneys lie fused on one side, with double pelvis and ureters draining into both sides of the bladder. Complex renal stones are a considerable challenge to endourologists, and when a staghorn stone is associated with abnormal anatomy, its treatment is even more difficult. Today there is no consensus about the right treatment for complex renal stones in CFRE. So, the objective of this case is to present the efficacy of the endoscopic combined intrarenal surgery (ECIRS) for the treatment of a staghorn renal stone in one patient with CFRE. Case Presentation: We described a case of a 23-year-old man with prolonged lasting and pain on the left flank associated with intermittent gross hematuria. Enhanced CT revealed a crossed fused kidney on the left side, drained by an intercommunicating pelvis and a single ureter, with a staghorn stone wholly occupying both renal units. The patient was effectively treated by one single session of ECIRS. Conclusion: The ECIRS is a good alternative to consider in patients with CFRE that have a staghorn calculus with a reasonable success rate.