New Insights into Lynch Syndrome: A Narrative Review.

Lynch syndrome, characterized by DNA mismatch repair deficiency, represents a significant paradigm among cancer predisposition syndromes and is notably associated with heightened susceptibility to various cancers, particularly colorectal and endometrial malignancies. The primary aim of this research paper is to scrutinize specific associations and delve into the underlying molecular mechanisms of Lynch syndrome. Genetic alterations in MMR genes, including MLH1, MSH2, MSH6, PMS2, and EPCAM, compromise DNA repair mechanisms, predisposing affected individuals to a spectrum of malignancies. This paper comprehensively investigates current screening methodologies and preventive measures tailored for individuals identified or at risk of Lynch syndrome. The integration of advanced sequencing technologies and refined bioinformatics tools has significantly improved mutation detection accuracy, facilitating precise identification of mutation carriers and their at-risk relatives. Moreover, this review emphasizes the evolving diagnostic landscape, which have revolutionized the identification of potential mutation carriers. The structured diagnostic algorithm, incorporating clinical criteria, tumor testing, and genetic analysis, plays a pivotal role in systematically identifying and managing individuals with Lynch syndrome. While the well-established association of Lynch syndrome with colorectal and endometrial cancers is recognized, emerging evidence suggests an increased risk for other types of malignancies. A crucial aspect of this literature review is to extensively analyze the less commonly acknowledged correlation between Lynch syndrome and prostate or testicular malignancies. Understanding these correlations holds significant importance in guiding tailored screening protocols and preventive strategies for individuals carrying Lynch syndrome-associated genetic mutations. The comprehensive assessment of this diverse spectrum of cancers underscores the necessity for tailored surveillance strategies and multidisciplinary approaches to effectively manage and mitigate risks in individuals harboring Lynch syndrome-associated genetic alterations.

Morbidity of Retrograde Flexible Ureteral Approach for Pyelo-Caliceal Stones - A Retrospective Review of 4500 Procedures.

Introduction: The retrograde flexible ureteroscopic approach is an effective and relatively safe procedure. The aim of this study was to retrospectively evaluate the safety of retrograde flexible ureteroscopic approach in patients with pyelo-caliceal stones on a significant number of cases. Material and method: We retrospectively evaluated 4500 procedures of flexible retrograde ureteroscopic approach for pyelocaliceal lithiasis, operated in two centers. The complications associated with this approach were retrospectively evaluated and data was stratified according to Clavien- Dindo classification. Results: Intraoperative incidents occurred during 5.2% of the procedures. Overall complications occurred in 18.9% of the procedures. Around two thirds of them were septic complications, the use of ureteral access sheath proving to be a protective factor against them. Most of the complications were mild. In 4.8% of the cases in which ureteral access sheath was used, we encountered grade 2 and 3 ureteral wall lesions. Conclusions: Most of the complications associated with retrograde flexible ureteroscopic approach are mild, regardless the type of flexible ureteroscope used. Reduced pressure in the pyelo-caliceal system is important to maintain the complications rate low, both septic and non-septic.

Robotic Flexible Ureteroscopy Versus Classic Flexible Ureteroscopy in Renal Stones: the Initial Romanian Experience.

INTRODUCTION: Roboflex Avicenna represents a new device for flexible ureteroscopy, able to provide an efficient lithotripsy for renal calculi, Bucharest being the fourth place in the world where such a device is already in use. MATERIAL AND METHODS: The study was prospective and included a number of 132 patients equally randomized which underwent standard flexible ureteroscopy and robotic flexible ureteroscopy for renal calculi between July and February 2016. All the procedures were performed with aStorz XC flexible ureteroscope in association with Avicenna Roboflex. Stone fragmentation was performed using a Dornier Medilas 20H, Holmium Laser of 20 watt power and 2.1 µm wavelength. RESULTS: The mean age was 48 years (range 26-77 years) and the mean stone size was 2.1 cm (range 1.1-3.6 cm) for the first group (FURS), while for the second one (robotic FURS) the mean age was 51 years (range 25-74 years) and the mean stone size was 2.4 cm (range 1.0-3.7 cm). The fragmentation time of the stones was better for robotic FURS (37 min versus 39 min). After 3 months, the stone free rate was 89.4% versus 92.4%, that representing a performance of the robotic technique over the classical one. In some cases were noticed residual fragments smaller than 3 mm, in 13.6% of patients who underwent FURS, respectively in 12.1% of robotic FURS™ cases. CONCLUSIONS: The robotic treatment of kidney stones represents a comparative alternative to flexible ureteroscopy, with overall similar outcomes.

Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014?

Flexible uretero-renoscopy witnessed dramatic technological improvements, ultimately translating in more diverse indications, better instrument durability, procedural efficacy and safety. Diagnostic exploration of the upper urinary tract, treatment of selected cases of ureteral and especially pyelocaliceal stones, caliceal diverticulum and infundibular stenosis, treatment, and follow-up of upper urinary tract tumors are the main indications for this approach. We review the technique, results and complications of retrograde flexible ureteroscopy, with an emphasis on the latest developments of the method.

Retrograde Intrarenal Surgery for Lithiasis Using Suctioning Devices: A Shift in Paradigm?

New suction endoscopes, ureteral access sheaths (UAS) and catheters aim to improve the efficacy of flexible ureteroscopy and optimize its safety. Suction UAS with non-flexible tips have shown promising results, especially in maintaining low intrarenal pressure, but also in removing small debris and reducing the "snow globe" effect. In addition, suctioning UAS with a flexible tip offers the advantage of being able to be navigated through the pyelocaliceal system to where the laser lithotripsy is performed. It can also remove small stone fragments when the flexible ureteroscope is retracted, using the Venturi effect. Direct in-scope suction (DISS) involves aspirating dust and small stone debris through the working channel of a flexible ureteroscope, thus regulating intrarenal pressure and improving visibility. Steerable aspiration catheters are other devices designed to increase stone clearance of the pyelocaliceal system. They are inserted under fluoroscopic guidance into every calyx after retraction of the flexible ureteroscope, alternating irrigation and aspiration to remove dust and small gravels. Combining flexible-tip suction UAS and the DISS technique may offer some advantages worth evaluating. The advantage of using these instruments to achieve a low intrarenal pressure was demonstrated. The true practical impact on the long-term stone-free status is a matter requiring further studies.

Laser Lithotripsy in Renal Lithiasis - 2023 Update - a Narative Review.

INTRODUCTION: Urolithiasis is a serious health issue that is constantly getting worse around the world. In relation to laser lithotripsy, new techniques and technological advancements have emerged, giving urologists a wide range of choices for treating stone disease. The objective of the present review is to provide an overview of the most current developments and show how effective they are for reducing complications and boosting surgical effectiveness. MATERIAL AND METHOD: In October 2023, we performed a comprehensive search of the literature, including relevant articles using the PubMed international database to identify related publications concerning ureteroscopic laser stone lithotripsy in renal lithiasis. Both review and original articles were selected. Searches were limited to studies written in English which involved human and adult subjects. RESULTS: All eligible studies concerning ureteroscopic laser lithotripsy were published in 2022 and 2023. They were conducted in Asia (5/10), the North America (3/10) and Europe (2/10), and totalized 1570 patients with an age range between 18 and 85 years. Regarding the primary efficacy outcome, all studies focused on stone free rates (SFRs), complications and average operative time. CONCLUSION: The rising frequency and incidence of stone disease has led to ongoing breakthroughs in endourology through technological advancements and ongoing developments. Unlike the relatively well-known Holmium laser, which has several uses in the field of stone lithotripsy, Thulium fiber laser (TFL) is a brand-new technological arrangement.

Comparison of Flexible Ureteroscope Performance between Reusable and Single-Use Models.

BACKGROUND: Single-use flexible ureteroscopes for urinary retention have been developed in recent years as an alternative to reusable ureteroscopes in order to eliminate the risk of cross-infections and to solve the primary limitations of traditional reusable flexible ureteroscopes for urinary retention. METHODS: In this study, we evaluated and contrasted three of the most recent types of flexible ureteroscopes, including two digital reusable versions (Olympus URF-V and Olympus URF-V2) and one single-use model (Pusen Medi-calUscope UE3022), in both ex vivo and in vivo scenarios. The influence of a variety of instruments on the flow of irrigation and its deflection was investigated ex vivo. In the in vivo investigation, a total of 40 patients were treated with retrograde fURS utilizing URF-V, 20 patients were treated with URF-V2, and 20 patients were treated with single-use fURS. The visibility and maneuverability of each fURS were evaluated by the same urologist during the procedures, and the results were compared. RESULTS: Intraoperatively, we compared the image quality of reusable (URF-V and URF-V2) and single-use fURS USCOPE UE3022 cameras and found that there was no statistically significant difference between the two types of camera. The score for maneuverability was the same (4.2) regardless of whether we used the UscopeUE3022 or the URF-V2, but it was significantly lower (3.8, p = 0.03) when we utilized the URF-V. Irrigation was about the same when utilizing reused scopes, whereas employing a single-use scope was more than fifty percent more effective. CONCLUSIONS: The findings of our research indicate that reusable and single-use fURs have visibility and maneuverability characteristics that are at least comparable to one another. The possibilities of the single-use type in terms of irrigation flow and deflection are superior.

Combined semirigid and flexible ureterorenoscopy for the treatment of large renal stones.

Ureteroscopy is recognized as a minimally invasive and readily accessible method with low morbidity, favorable outcomes, and rapid post-interventional recovery. Recent advancements in rigid and flexible ureteroscopes have enhanced their efficiency, durability, and capability to accommodate accessory instruments. In this retrospective analysis, we evaluated 75 consecutive patients with large renal stones (stone burden between 2 and 4 cm) treated using a combination of semirigid and flexible ureteroscopy between January 1, 2020, and December 31, 2021. Stone properties and anatomical information were collected from the image archives derived from computed tomography (CT) and/or KUD radiography. Multiple ureteroscopy sessions were required for bigger stones. The length of the hospital stay, operation time, stone-free rate, preoperative and postoperative complications, and complication rates were examined. The average age of the patients was 52.7 years, with a mean stone burden of 31.45 mm. Most stones were in the renal pelvis, followed by the upper calyx. The average operative time was 56.2 minutes. After the initial ureteroscopy session, the stone clearance rate was 76%, which increased to 92% after two ureteroscopy sessions. Complication rates were evaluated using the Clavien-Dindo modified system, with an overall complication rate of 18.4%. Most of the complications were Clavien Grades I and II, with no grade V complication encountered. Large renal stones can be treated by combining semirigid and flexible ureteroscopy to reduce the operative time and protect the flexible ureteroscope.

The Impact of the Double J Stent on Health and Sexual Life.

Double J stents are commonplace tools used in modern urology, serving as a vital aid in the drainage of the upper urinary system. Along with the numerous advantages of these catheters, numerous negative consequences have also been addressed throughout time. Among the most common symptoms associated with ureteral catheters are those associated with LUTS (lower urinary tract symptoms), such as dysuria, urinary urgency, pollakiuria, the feeling of incomplete emptying of the bladder, urinary incontinence, or even urinary tract infections (UTIs). Complications associated with sexual dysfunction, including dyspareunia and pain during sex, which can lead to erectile dysfunction or loss of orgasm, are less discussed in the literature. This small review tries to focus on the most important aspects of low urinary symptoms that affect the general quality of life and those related to the quality of sexual life, which are less discussed but of particular importance in the lifestyle of any patient with such ureteral device.

Single-use versus conventional reusable flexible ureteroscopes - an evaluation of the functional parameters.

The purpose of single-use flexible ureteroscopes (su-fURS) was to overcome the limitations of conventional reusable ureteroscopes in terms of maneuverability and maintenance. We aimed to perform a systematic literature review on available su-fURS performance versus conventional reusable fURS focusing on clinical data. A systematic research using Pubmed was performed evaluating single-use fURS and reusable fURS in urinary tract stone disease, including prospective assessments and case series. This review aimed to provide an overview of single-use and disposable flexible ureteroscopes and to examine and compare their capabilities (deflection, irrigation, optical properties). We included 11 studies, where the single-use fURS were compared to the reusable fURS. The studies with single-use ureteroscopes included data on LithoVue (Boston Scientific), The Uscope UE3022 (Pusen, Zhuhai, China), NeoFlex-Flexible, (Neoscope Inc San Jose, CA), 23 YC-FR-A (Shaogang). For reusable ureteroscopes, data were included on three models, two digital (Karl Storz Flex-XC and Olympus URF-Vo) and one fiber optic (Wolf-Cobra). There were no significant differences in stone-free rate, procedure duration, or functional capabilities between single-use fURS and reusable fURS. The systematic literature review analyzed operative time, functional capabilities, stone-free rates, and postoperative complications of the ureteroscopes, and a special chapter about renal abnormalities to emphasize that they are a good choice having a high proportion of stone-free rates and few risks, particularly in treating difficult-to-access calculi. Single-use fURS demonstrate a comparable efficacy with reusable fURS in resolving renal lithiasis. Further studies on clinical efficacy are needed to determine whether single-use fURS will reliably replace its reusable counterpart.

Treatment changes and long-term recurrence rates after hexaminolevulinate (HAL) fluorescence cystoscopy: does it really make a difference in patients with non-muscle-invasive bladder cancer (NMIBC)?

OBJECTIVES: • To evaluate in a prospective, randomized study the impact of hexaminolevulinate blue-light cystoscopy (HAL-BLC) on the diagnostic accuracy and treatment changes in cases of non-muscle invasive bladder cancer (NMIBC) compared with standard white-light cystoscopy (WLC). • To compare the long-term recurrence rates in the two study arms. PATIENTS AND METHODS: • In all, 362 patients suspected of NMIBC were included in the trial based on positive urinary cytology and/or ultrasonographic suspicion of bladder tumours and underwent transurethral resection of bladder tumours. • A single postoperative mytomicin-C instillation was performed in all cases, intravesical chemotherapy for intermediate-risk patients and BCG instillations for high-risk cases. • The follow-up protocol consisted of urinary cytology and WLC every 3 months for 2 years. • Only first-time recurrences after the initial diagnosis were considered. RESULTS: • In the 142 patients with NMIBC in the HAL-BLC series, tumour detection rates significantly improved for carcinoma in situ, pTa andoverall cases. • In 35.2% of the cases, additional malignant lesions were found by HAL-BLC and consequently, the recurrence- and progression-risk categories of patients and subsequent treatment improved in 19% of the cases due to fluorescence cystoscopy. • In all, 125 patients in the HAL-BLC group and 114 of the WLC group completed the follow-up. • The recurrence rate at 3 months was lower in the HAL-BLC series (7.2% vs 15.8%) due to fewer 'other site' recurrences when compared with the WLC series (0.8% vs 6.1%). • The 1 and 2 years recurrence rates were significantly decreased in the HAL-BLC group compared with the WLC group (21.6% vs 32.5% and 31.2% vs 45.6%, respectively). CONCLUSIONS: • HAL-BLC was better than WLC for detecting NMIBC cases and improved tumour detection rates. • HAL-BLC significantly modified the postoperative treatment of cases. • The 3 months, 1 and 2 years recurrence rates were significantly improved in the HAL-BLC arm.

Bilateral same-session flexible ureteroscopy for renal stones: a feasible method.

A staged ureteroscopic procedure is generally preferred to treat bilateral renal stones. In this study, we evaluated the feasibility of bilateral same-session flexible ureteroscopy (BS-fURS) in renal stones. A total of 81 patients underwent bilateral BS-fURS between March 2014 and March 2021 for bilateral renal stones. The mean stone burden per patient was 17±4 (range 7-27 mm). The average stone density was 1240 HU (970 to 1510). We used 4 types of ureteroscopes: Olympus URF-V2 (34 cases), Storz Flex X2 (30 cases), single-use PUSEN PU 3022 (12 cases), and single-use PUSEN - PU 3033A (5 cases). We specifically set our Holmium laser for dusting, pop-corning, and fragmenting. We found 31 calcium oxalate monohydrate cases, 11 calcium oxalate dehydrate cases, 17 uric acid cases, and 22 magnesium ammonium phosphate cases. The mean operating time was 77 min. (range 52 to 85) for both renal units. The SFRs were evaluated between 1 and 3 months with computed tomography (fragments >3 mm were defined as residual). Double J stenting (6Fr.) was applied bilaterally in 8 cases (9.87%) and unilateral in 34 cases (41.97%). The overall SFRs after 1 and 2 procedures were 81.48% (66/81 cases) and 92.59% (75/81 cases), respectively. Postoperative complications after an overall 96 procedures were Clavien I-II (18.75%) and Clavien III (3.12%). Urinary tract infections were observed in 13 cases (16.04%) without any case of urosepsis. Our experience suggested some BS-fURS advantages as a single anesthetic session and potentially reduced cost associated with treatment. BS-fURS seem feasible, especially for medium-sized bilateral renal stones in high-volume centers.

Long-term efficacy of Serenoa repens treatment in patients with mild and moderate symptomatic benign prostatic hyperplasia.

INTRODUCTION: The study aimed to evaluate the long-term efficacy of treatment with extract of Serenoa repens (Prostamol Uno) in patients with lower urinary tract symptoms (LUTS) induced by benign prostatic hyperplasia (BPH). PATIENTS AND METHODS: We studied 120 patients with mild or moderate LUTS induced by BPH, maximal urinary flow (Q(max)) <15 ml with a voided volume ≥150 ml, prostate-specific antigen <4 ng/ml, and residual urinary volume <150 ml, treated daily for 24 months with one capsule of 320 mg ethanolic extract of Serenoa repens. RESULTS: Statistically significant improvements in the International Prostate Symptom Score (5.5 points), quality of life (QoL; 1.8 points), Q(max) (5.6 ml/s), International Index of Erectile Function (IIEF; 6.4 points) and reduction in residual urinary volume were observed during the study period. The mean prostate volume at 24 months was 36 ml, compared to 39.8 ml at baseline. CONCLUSIONS: Long-term treatment with 320 mg ethanolic extract of Serenoa repens proved to be efficient in reducing urinary obstruction, improving symptomatology and QoL of BPH patients. It also had a positive effect on sexual function, demonstrated by the statistically significant increase in the IIEF.

Romanian National premiere with the new Thulium SuperPulsed Laser in the endourological treatment of urolithiasis.

In this paper, we aimed to verify the efficiency and functionality of the new Soltive Thulium Fiber Laser (TFL) in the treatment of urinary stones. The Soltive Laser System was used in 17 urolithiasis cases: 10 renal, 5 ureteral, and 2 bladder stone patients. The average stone size was 13.1 mm (ranging between 11-29 mm) for the kidney, 8 mm (ranging between 6-12 mm) for the ureter, and 31 mm (ranging between 27-34 mm) for the bladder. Only single calculi patients were included in the study. We used 100 and 150 µm core-diameters fibers (CDF). Three settings were applied: 0.15 J/100 Hz for "fine dusting", 0.5 J/30 Hz for "dusting" and 1 J/15 Hz for the fragmentation mode. The mean operative time was 34 minutes for renal, 21 minutes for ureteral, and 39 minutes for bladder stones. The visibility was optimal in all cases. The stone-free rate at 1 month after treatment was 95% for renal calculi and 100% for ureteral and bladder stones. Very fine dust made of stone fragments smaller than 1 mm in size that passed spontaneously through the access sheath was observed, especially subsequent to the "fine dusting" mode. The complication rate was very low: 1 patient was classified as Clavien grade 1 and 1 patient as Clavien grade 2, and this was the case for renal stones only. No urinary tract infections were observed. The new Soltive TFL appears to be a remarkably promising tool in the therapeutic approach of urolithiasis. Lithotripsy was achieved up to the level of extremely small stone fragments with improved efficiency while also optimizing the operative time.

Transurethral resection (TUR) in saline plasma vaporization of the prostate vs standard TUR of the prostate: 'the better choice' in benign prostatic hyperplasia?

OBJECTIVE: To evaluate the efficiency, safety and short-term outcome of transurethral resection in saline plasma vaporization of the prostate (TURis-PVP), and to compare it to the standard TUR of the prostate (TURP). PATIENTS AND METHODS: In all, 155 patients with benign prostatic enlargement (BPE) secondary to benign prostatic hyperplasia (BPH), with a maximum urinary flow rate (Q(max) ) of <10 mL/s, an International Prostate Symptom Score (IPSS) of >19 and prostate volume of 30-80 mL were enrolled in this prospective, randomized trial. All patients were evaluated preoperatively and at 1, 3 and 6 months after surgery by IPSS, health-related quality of life (HRQL) score, Q(max) and postvoid residual urine volume (PVR). RESULTS: Patients from both series had similar preoperative characteristics. TURis-PVP and TURP were successfully performed in all cases (75 and 80, respectively). The operative duration, catheterization period and hospital stay were significantly shorter for TURis-PVP patients at 35.1 vs 50.4 min, 23.8 vs 71.2 and 47.6 vs 93.1 h, respectively (all P < 0.05). At the 1, 3 and 6 months follow-ups, improvements in the variables measured were better in the TURis-PVP group: the IPSS was 4.4 vs 8.3 and the Q(max) was 22.7 vs 20.5 mL/s at 1 month; the IPSS was 4.8 vs 8.6 and the Q(max) was 22.3 vs 20.0 mL/s at 3 months; and the IPSS was 5 vs 9.1 and the Q(max) was 21.8 vs 19.3 mL/s at 6 months (All P < 0.05). CONCLUSIONS: TURis-PVP represents a valuable endoscopic treatment alternative for patients with BPE, with superior efficacy, short-term results and complication rates compared with monopolar TURP.

Surgical management of urachal tumors: Can the umbilicus be sparred in localized disease?

Urachal adenocarcinoma represents the third most common histological type of non-urotelial bladder cancer. A very low incidence of this disease and the lack of prospective studies have led to a rich and heterogeneous treatment history. Currently, the standard of care for these patients is represented by partial cystectomy en bloc with resection of the urachal ligament and total omphalectomy. The aim of this article is to present our experience and results in the management of patients with urachal adenocarcinoma. Between 2005 and 2015, 16 patients have undergone surgical treatment for urachal adenocarcinoma in "Fundeni" Clinical Institute and Madrid University Hospital "Infanta Sofia." Partial cystectomy was performed in 11 (68.76%) patients, while radical cystectomy en bloc with omphalectomy was performed in 5 (31.25%) patients, which were not amendable to a limited resection. The Sheldon classification was used, as it provides appropriate disease staging and is the most commonly utilized. Postoperative pathological results showed that 7 (43.75%) patients had localized tumors, and more than one-third (37.5%) of the patients had locally advanced Sheldon III disease, while 3 patients had distant metastasis at the time of surgery. Lymph node involvement was present in 3 patients (18.75%). Mean follow-up time was 2.5 years, ranging from 4 months to 7.6 years. Three patients (18.75%) were lost to follow-up, without any documented signs of local or systemic recurrence and were cancer free at the time of the last evaluation. In cases with lymph node involvement, local recurrence or distant metastasis, patients underwent cisplatin- or 5-fluorouracil-based salvage chemotherapy. Surgical treatment represents the gold standard, while adjuvant chemotherapy has a limited impact on overall survival. The utility of navel resection is questionable due to the rarity of direct invasion or local recurrence.

Pushing the boundaries of ureteroscopy: current status and future perspectives.

Substantial advances in ureteroscopy have resulted in the incorporation of this procedure into routine urological practice in many centres worldwide. Subsequently, an abundance of clinical data and technological progression have enabled the development of novel solutions that have increased the efficacy of ureteroscopy, and reduced associated morbidity and costs. In addition the indications for this retrograde approach have been expanded, and pyelocalyceal diverticulum, infundibular stenosis, urolithiasis in pregnant women or in patients with urinary diversions, as well as upper urinary tract tumours can now be managed using this methodology. New endoscopes are continuously developed, with different manufacturers choosing various technical solutions to further increase the efficacy and safety-and sometimes decrease costs-of ureteroscopy, including miniaturization, inclusion of digital optical systems and dual working channels, and the introduction of disposable apparatus. The holmium laser, currently the most-versatile energy source available, enables tissue incision, tumour ablation, and intracorporeal lithotripsy. Modern ancillary instruments are diverse, flexible, and durable, and novel devices used in daily clinical practice can minimize ascendant migration of stone fragments and, therefore, decrease the failure rate of the retrograde ureteroscopic approach. However, the peak of ureteroscopy evolution seems to remain distant, with further improvement of endoscopes and ancillary instruments, and robot-assisted ureteroscopy representing only some of the areas in which future developments are possible.