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.

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.

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.

Prostate enucleation, better with low or high-power holmium laser? A systematic review. / Enucleación prostática, de alta y baja potencia con laser holmium. Revisión sistemática.

OBJECTIVE: To assess current efficacyand safety of low power HoLEP (Holmium Laser Enucleationof the Prostate) for the treatment of obstructingand symptomatic prostatic adenomas and to identify themechanisms supporting the related clinical advantages. METHODS: A systematic review was conducted usingrelevant databases (Ovid Medline, PubMed, Scopusand Web of Sciences), employing ("low power" OR"high power") AND ("HoLEP" OR "holmium laser enucleationof the prostate") as search terms. Inherent publicationswere selected according to the Preferred ReportingItems for Systematic Reviews and Meta-analyses (PRISMA)guidelines. Additionally, the reference lists of theselected papers were checked manually. RESULTS: We included any kind of study (n=15) dealingwith low power HoLEP because of the scarcity of the resultsobtained with the bibliographic search. Low powerHoLEP seems to be fully comparable to the traditionalhigh power HoLEP in terms of feasibility, efficacy andsafety. An additional clinical advantage of the low powerapproach might be the reduced incidence of postoperativedysuria, with limited intensity and duration, possiblydue to the decreased amount of energy delivered tothe capsular plane with a less aggressive modality, conjugatedwith appropriate technical enucleative choices.The physical rationale of low power HoLEP is discussed. CONCLUSIONS: Low power HoLEP is feasible, safeand effective, and might play a not exclusive role in thereduction of incidence, intensity and duration of postoperative dysuria.

OBJETIVO: Determinar la eficacia y seguridadde el holmium de baja potencia en el tratamientode adenomas prostáticos obstructivos e identificar losmecanismos de soporte relacionados con las ventajasclínicas. MÉTODOS: Una revisión sistemática utilizando lasbases de datos más relevantes fue conducida (OvidMedline, PubMed, Scopus and Web of Sciences). Seutilizaron alta y baja potencia y HOLEP como palabrasde búsqueda. Las publicaciones fueron seleccionadassegún PRISMA. RESULTADOS: Se incluyó cualquier estudio (n=15) relacionadocon baja potencia HOLEP dados los pocos resultados obtenidos con la búsqueda. HOLEP de bajapotencia para ser totalmente comparable al HOLEPtradicional de alta potencia en términos de eficacia yseguridad. Una ventaja clínica adicional del de bajapotencia es que parece reducir la disuria postoperatoriacon intensidad limitada y de más corta duración, probablementedebido a la menor energía recibida por lacapsula prostática, así como por el uso conjugado delas técnicas enucleación correctas. El racional para elHOLEP de baja potencia se discutirá en el manuscrito. CONCLUSIONES: El HOLEP de baja potencia es seguroy efectivo y parece reducir la incidencia, intensidad yduración de la disuria postoperatoria.

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.

Endoscopic combined intrarenal surgery (ECIRS) - Tips and tricks to improve outcomes: A systematic review.

OBJECTIVE: This study aimed at assessing current efficacy and safety of endoscopic combined intrarenal surgery (ECIRS) for the treatment of large and/or complex urolithiasis and identifying relevant tips and tricks able to improve its outcomes, mainly deriving from the adjunct of retrograde flexible ureteroscopy to the traditional antegrade approach of percutaneous nephrolithotomy (PNL). MATERIAL AND METHODS: A systematic review was conducted using relevant databases (Ovid Medline, PubMed, Scopus, and Web of Sciences), employing "ECIRS" as the search term in all cases, and then adding "endoscopic combined intrarenal surgery" and "flexible ureteroscopy AND percutaneous nephrolithotomy" as search terms for PubMed and Scopus. Original articles and systematic reviews were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Additionally, the reference lists of the selected publications were checked manually. RESULTS: A total of 14 studies were selected for analysis: two systematic reviews, one randomized controlled trial, five nonrandomized comparative studies, three prospective case series, and three retrospective case series. ECIRS achieves high stone-free rates and rather low/low Clavien-Dindo grade complication rates, confirming the role of retrograde ureteroscopy in the maximization of its efficacy and safety. A narrative synthesis of the most recognized tips and tricks of ECIRS is provided. CONCLUSION: The contribution of retrograde flexible ureteroscopy during PNL is essential. It plays a dual role, both diagnostic and active, allowing tailoring of the procedure to the patient, urolithiasis, and anatomy of the collecting system and optimization of the PNL efficacy and safety. This is ECIRS: an updated, complete, and versatile version of PNL.

Holmium laser enucleation of the prostate: Problem-based evolution of the technique.

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive and size-independent treatment for benign prostatic hyperplasia with excellent long-term surgical outcome. Considered difficult to learn, different modifications of the technique have been proposed in the last 21 years to overcome the most common problems encountered during this procedure. We present a step-by-step technique including the reasons and advantages of each modification we have progressively adopted until we evolved into our totally en-bloc no-touch low-power HoLEP.

Invited review: the tale of ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position.

Modern-day percutaneous nephrolithotomy (PNL) has undergone considerable evolution, mainly driven by the improvement in access techniques, endoscopic instrumentation technology, lithotripsy devices and drainage management. The introduction of the supine and supine-modified positions is also part of this evolution, enabling comfortable and safe procedures from an anaesthesiological point of view, and an easy combined retrograde surgery [Endoscopic Combined IntraRenal Surgery (ECIRS)], allowing tailoring of the procedure on the patient, the dynamic anatomy of the collecting system and the urolithiasis. The conceptual value of ECIRS extends beyond the single diagnostic and active advantages due to the simultaneous contribution of the flexible retrograde ureteroscopy: the merit consists in the promotion of the versatile attitude of the urologist, and in the fulfillment of a personalized stone management. ECIRS has no pretensions of superiority, but for sure is a new safe and effective way of interpreting PNL, in the hands of an experienced surgical team.

Case Discussion: Kidney stone in a patient with an ileal conduit.

Kidney stones in patients with ileal conduit and multiple sclerosis are secondary to postoperative anatomical changes and ascending urinary tract infections by urea-splitting bacteria. PNL is the preferred treatment option in patients with urinary diversion and infectious renal stones.

Positioning for percutaneous nephrolithotomy.

PURPOSE OF THE REVIEW: To highlight the progressive evolution of the issue of patient positioning for percutaneous nephrolithotomy (PNL), explain the history of the prone and supine positions, report respective advantages and drawbacks, critically interpret the past and current literature supporting such arguments, identify the best candidates for each position, and reflect on the future evolution of the two approaches. RECENT FINDINGS: Positioning for PNL has become a matter of debate during the last decade. The traditional prone PNL position - most widely performed with good success and few complications, and exhibiting essentially no limits except for the treatment of pelvic kidneys - is nowadays flanked mainly by the supine and supine-modified positions, equally effective and probably safer from an anesthesiological point of view. Of course, both approaches have a number of advantages and drawbacks, accurately reported and critically sieved. SUMMARY: The current challenge for endourologists is to be able to perform PNL in both prone and supine positions to perfectly tailor the procedure on any patient with any stone burden, including increasingly challenging cases and medically high-risk patients, according to the patient's best interest. Intensive training and experience is especially needed for supine PNL, still less popular and underperformed worldwide. VIDEO ABSTRACT: http://links.lww.com/COU/A8.

Simulation of RIRS in soft cadavers: a novel training model by the Cadaveric Research On Endourology Training (CRET) Study Group.

PURPOSE: The aim of the current study was to evaluate the use of fresh-frozen concurrently with embalmed cadavers as initial training models for flexible ureteroscopy (fURS) in a group of urologists who were inexperienced in retrograde intrarenal surgery (RIRS). METHODS: Twelve urologists involved in a cadaveric fURS training course were enrolled into this prospective study. All the participants were inexperienced in fURS. Theoretical lectures and step-by-step tips and tricks video presentations on fURS were used to incorporate the technical background of the procedure to the hands-on-training course and to standardize the operating steps of the procedure. An 8-item survey was administered to the participants upon initiation and at the end of the course. RESULTS: Pre- and post-training scores were similar for each question. All the participants successfully completed the hands-on-training tasks. Mean pre-training duration [3.56 ± 2.0 min (range 1.21-7.46)] was significantly higher than mean post-training duration [1.76 ± 1.54 min (range 1.00-6.34)] (p = 0.008). At the end of the day, the trainers checked the integrity of the collecting system both by endoscopy and by fluoroscopy and could not detect any injury of the upper ureteral wall or pelvicalyceal structures. The functionality of the scopes was also checked, and no scope injury (including a reduction in the deflection capacity) was noted. CONCLUSIONS: The fURS simulation training model using soft human cadavers has the unique advantage of perfectly mimicking the living human tissues. This similarity makes this model one of the best if not the perfect simulator for an effective endourologic training.

The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is currently considered a safe and effective therapeutic option for the treatment of adenomas of any size. Being considered difficult to learn and to teach, HoLEP is not as diffused as it would deserve. In 2011, we started performing HoLEP reproducing the traditional Gilling's technique. Case after case, we introduced alterations in the surgical approach, trying to overcome our difficulties and minimize our learning curve. MATERIALS AND METHODS: We present a detailed step-by-step description of our modified HoLEP technique, developed in Torino, Italy, which we called en-bloc no-touch. RESULTS: The main steps of the en-bloc no-touch enucleation phase include: (1) the identification of the correct plane between adenoma and capsule only once, at the apex of the left lobe laterally to the veru montanum, extending the incision retrogradely towards the bladder at 5 o'clock; (2) the en-bloc enucleation of a horseshoe-like adenoma, sparing the 7 and 12 o'clock incisions; (3) the use of the beak of the endoscope, gently raising up the lobe from the capsular plane and creating a dihedral angle, crossed by connective bundles put in tension by this movement; and (4) the gradual no-touch lasing of such fibres, exploiting the effects of the plasma bubble at the tip of laser fibre, with no direct energy supply to the capsule. CONCLUSIONS: In our experience, the en-bloc no-touch technique has the potential to ease some difficult intraoperative steps and to improve the learning curve of HoLEP.