Is There a Correlation Between Platelet Count, Mesenteric Lymph Node Involvement, and Hematogenous Metastases in Advanced Stage Ovarian Cancer?

BACKGROUND/AIM: Ovarian cancer remains a major cause of death in women worldwide, mainly due to late diagnosis and the lack of a reliable screening test for early detection of the disease. In this context, attention has been focused on the identification of other prognostic factors that might allow a better identification of cases with worse long-term outcome. PATIENTS AND METHODS: Data of patients who underwent cytoreductive surgery between 2014-2019 were retrospectively reviewed and 57 patients were considered eligible for this study. These cases were further classified according to preoperative platelet count, with a cut-off value of 335,000/µl as a positive predictive value for long-term survival. RESULTS: According to this value, there were 27 cases with a preoperative platelet count lower than 335,000/µl and 30 cases with a preoperative platelet count higher than 335,000/µl. Cases in the second group had a significantly higher peritoneal carcinomatosis index (p=0.002), a higher proportion of digestive serosa involvement (p<0.001), and a higher proportion of mesenteric lymph node involvement and hematogenous metastases (p=0.005 and p=0.001, respectively). When analyzing long-term outcomes, all these factors had a significant impact on overall survival. CONCLUSION: Preoperative thrombocytosis appears to be positively associated with gastrointestinal serosa involvement, mesenteric lymph node invasion, and the presence of hematogenous metastases, thus significantly influencing the long-term outcome of patients with advanced ovarian cancer.

Prognostic Factors in Intrahepatic Cholangiocarcinoma - A Systematic Review.

Introduction: intrahepatic cholangiocarcinoma (ICCA) are rare, aggressive cancers that develop in second order or smaller bile ducts. The aim of this review is to systematically review the most important prognostic factors affecting the long-term outcomes of these patients. Material and Methods: articles conducted on this issue, written in English, published between from January 2000 to December 2023 in Cochrane Library, PubMed, Embase, MedLine, Web of Science, Elsevier, Google Scholar were systematically researched and reviewed. Results: ICCA are usually late diagnosed cancers because of the asymptomatic character, and curative procedures are often not feasible, only 20 to 30% of patients being fit for surgery. With the prognostic of this aggressive malignancy being baleful, the most important risk factors but also prognosis factors seem to be represented by socioeconomic factors, morphological presentation, dimensions, number and extension of the tumor as well as resection margins. Conclusions: once these factors are widely recognized and identified in each case, the clinician will be able to find the best treatment for these patients in order to improve the long-term outcomes.

Management of Severe Bilateral Symptomatic Internal Carotid Artery Stenosis: Case Report and Literature Review.

Multiple strategies for tandem severe carotid artery stenosis are reported: bilateral carotid artery endarterectomy (CEA), bilateral carotid artery stenting (CAS), and hybrid procedures (CEA and CAS). The management is controversial, considering the reported high risk of periprocedural stroke, hemodynamic distress, and cerebral hyperperfusion syndrome. We present the case of a 64-year-old patient with severe symptomatic bilateral internal carotid artery stenosis (95% stenosis on the left internal carotid artery with recent ipsilateral watershed anterior cerebral artery-medial cerebral artery (ACA-MCA) and medial cerebral artery-posterior cerebral artery (MCA-PCA) ischemic strokes and 90% stenosis on the right internal carotid artery with chronic ipsilateral frontal ischemic stroke) managed successfully with staged CEA within a 3-day interval. The patient had a history of coronary angioplasty and stenting. Strategies for brain protection included shunt placement after the evaluation of carotid stump pressure, internal carotid backflow, and near-infrared spectroscopy. A collagen and silver-coated polyester patch was used to complete the endarterectomy using a 6.0 polypropylene continuous suture in both instances. Management also included neurological consults after extubation, dual antiplatelet therapy, head CT between the two surgeries, myocardial ischemia monitoring, and general anesthesia. Staged CEA with a small time interval between surgeries can be an option to treat tandem symptomatic carotid artery stenosis in highly selected patients. The decision should be tailored according to the patient's characteristics and should also be made by a cardiology specialist, a neurology specialist, and an anesthesia and intensive care physician.

Septic shock in the immunocompromised cancer patient: a narrative review.

Immunosuppressed patients, particularly those with cancer, represent a momentous and increasing portion of the population, especially as cancer incidence rises with population growth and aging. These patients are at a heightened risk of developing severe infections, including sepsis and septic shock, due to multiple immunologic defects such as neutropenia, lymphopenia, and T and B-cell impairment. The diverse and complex nature of these immunologic profiles, compounded by the concomitant use of immunosuppressive therapies (e.g., corticosteroids, cytotoxic drugs, and immunotherapy), superimposed by the breakage of natural protective barriers (e.g., mucosal damage, chronic indwelling catheters, and alterations of anatomical structures), increases the risk of various infections. These and other conditions that mimic sepsis pose substantial diagnostic and therapeutic challenges. Factors that elevate the risk of progression to septic shock in these patients include advanced age, pre-existing comorbidities, frailty, type of cancer, the severity of immunosuppression, hypoalbuminemia, hypophosphatemia, Gram-negative bacteremia, and type and timing of responses to initial treatment. The management of vulnerable cancer patients with sepsis or septic shock varies due to biased clinical practices that may result in delayed access to intensive care and worse outcomes. While septic shock is typically associated with poor outcomes in patients with malignancies, survival has significantly improved over time. Therefore, understanding and addressing the unique needs of cancer patients through a new paradigm, which includes the integration of innovative technologies into our healthcare system (e.g., wireless technologies, medical informatics, precision medicine), targeted management strategies, and robust clinical practices, including early identification and diagnosis, coupled with prompt admission to high-level care facilities that promote a multidisciplinary approach, is crucial for improving their prognosis and overall survival rates.

Reinitiating Chemotherapy beyond Progression after Maintenance Immunotherapy in Extensive-Stage Small-Cell Lung Cancer.

Introduction: Small-cell lung cancer (SCLC) is an aggressive form of cancer with a poor prognosis. The two-year survival rate is 8% of all cases. Case presentation: We present the case of a male patient who was 50 years old at the time of diagnosis in May 2022. He was diagnosed with extensive-stage small-cell lung cancer, treated with immunotherapy in combination with chemotherapy (Durvalumab in combination with Etoposide plus Carboplatin) as a first-line treatment, followed by maintenance immunotherapy. In December 2023, a PET-CT scan revealed progressive disease with multiple metastases. Chemotherapy was reinitiated with Etoposide plus Cisplatin in January 2024. After two cycles of chemotherapy, the patient developed post-chemotherapy anemia, for which treatment with Epoetinum alpha was initiated. Chemotherapy was continued for another five cycles, until May 2024, with the maintenance of hemoglobin at a level within 9.9 mg/dL-11 mg/dL. Upon assessment at the end of May 2024, the patient presented an ECOG = 2 performance status, with a moderate general state, moderate-intensity fatigue, no pain, no anxiety or depression and no dyspnea. Discussions, Literature Review and Conclusions: Reinitiating chemotherapy after the failure of maintenance immunotherapy may be an option in patients with SCLC. Epoetinum allows oncological treatment by preventing chemotherapy-induced anemia.

Diagnostic Challenge in Heterotopic Pancreas in the Ampulla of Vater with Obstructive Jaundice - A Case Report and Literature Review.

Heterotopic pancreas is a rare congenital abnormality. The most common location is the stomach, duodenum and proximal jejunum. Rare locations are represented by the ampulla of Vater, esophagus, ileum, Meckel diverticulum, biliary tract, mesentery and spleen. We present the case of a 49 year old patient investigated for obstructive jaundice and diagnosed with an ampullar heterotopy of pancreas parenchyma, initially considered to be a malignant tumor. A Whipple pancreatoduodenectomy was performed with good postoperative evolution, the serum levels of bilirubin being normal after the first postoperative week.

The financial burden of SARS-CoV-2 pregnancies in a tertiary exclusive COVID-19 maternity.

The COVID-19 pandemic had a major impact on health systems worldwide, and Romania was no exception. The impact on healthcare expenses for pregnant women was considerable, especially in COVID-19-only tertiary centers. This study aimed to analyze the impact of the COVID-19 pandemic on healthcare costs in a designated COVID-19 maternity ward. We conducted an observational study comparing pregnant women with SARS-CoV-2 (study group) to those without the infection (control group). Patients were recruited at Bucur Maternity Hospital from March 2020 to March 2022. We evaluated expenses for the entire period of hospitalization, treatment, medical supplies, and medical investigations. The study included 600 pregnant women, divided equally into two groups of 300 each. Significant cost differences were observed between the COVID-19 and non-COVID-19 groups: medication costs (664.56 EUR vs. 39.49 EUR), administrative costs (191.79 EUR vs. 30.28 EUR), and medical investigation costs (191.15 EUR vs. 29.42 EUR). The costs for a severe case of COVID-19 were about two times higher than a mild case and 70 times higher than a non-COVID-19 case (P <0.001). We identified a significant cost increase due to SARS-CoV-2 infection in our unit. The expenses were augmented by the time of hospitalization, medication, and medical investigations. COVID-19 had a significant impact on healthcare costs, mostly among pregnant women with severe disease. The strategy of operating exclusively as a COVID-19 unit proved to be inefficient and highly costly to our hospital.

Implications of using artificial intelligence in the diagnosis of sepsis/sepsis shock.

Introduction: Sepsis and septic shock represent severe pathological states, characterized by the systemic response to infection, which can lead to organ dysfunction and high mortality. Early diagnosis and rapid intervention are crucial for improving survival chances. However, the diagnosis of sepsis is complex due to its nonspecific symptoms and the variability of patient responses to infections. Methods: The objective of this research was to analyze the implications of using artificial intelligence (AI) in the diagnosis of sepsis and septic shock. The research method applied in the analysis of the implications of using artificial intelligence (AI) in the diagnosis of sepsis and septic shock is the literature review. Results: Among the benefits of using AI in the diagnosis of sepsis, it is noted that artificial intelligence can rapidly analyze large volumes of clinical data to identify early signs of sepsis, sometimes even before symptoms become evident to medical staff. AI models can use predictive algorithms to assess the risk of sepsis in patients, allowing for early interventions that can save lives. AI can contribute to the development of personalized treatment plans, adapting to the specific needs of each patient based on their medical history and response to treatment. The use of patient data to train AI models raises concerns regarding data privacy and security. Conclusions: Artificial intelligence has the potential to revolutionize the diagnosis and treatment of sepsis, offering powerful tools for early identification and management of this critical condition. However, to realize this potential, close collaboration between researchers, clinicians, and technology developers is necessary, as well as addressing ethical and implementation challenges.

Prognostic Factors in Liver Transplant with Marginal Grafts - Review of the Literature.

Liver transplantation is the last life-saving solution for patients with end stage liver disease. The low number of available liver grafts and the increasing waiting time on transplant lists have led to the appearance of extended donation criteria and the marginal grafs, initially considered suboptimal. Allocation of grafts and identification of the most suitable "donor-recipient" pair is still under development. The fact is that the appearance of marginal grafts has expanded the donation lists and seems to have a prognosis at least comparable to the use of ideal grafts.

Docosahexaenoic Acid (DHA) and Eicosapentaenoic Acid (EPA)-Should They Be Mandatory Supplements in Pregnancy?

Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are essential fatty acids for the human body. Seafood and microalgae are the most important sources of omega-3 fatty acids. Supplementation with 200 mg/day of DHA during pregnancy and breastfeeding has been suggested for women and infants in countries with low seafood consumption. Maternal concentration of DHA and EPA was associated with concentration in cord blood and breast milk. High concentrations of DHA and EPA were identified at the level of retinal photoreceptors and neuronal cell membranes. It was observed that supplementation with DHA and EPA during pregnancy had beneficial effects on the neurological development of the fetus and infant by improving language, memory, attention, and hand coordination, affecting sleep patterns, and improving visual acuity. Beneficial effects on the development of the infant were also associated with the maternal intake of omega-3 fatty acids during breastfeeding. Supplementation with DHA and EPA may reduce the risk of preterm birth but also of preeclampsia in low-risk pregnancies. Women of childbearing age should have an intake of 250 mg/day of DHA + EPA from their diet or supplements. To reduce the risk of premature birth, pregnant women must additionally receive at least 100-200 mg of DHA every day. It is recommended that supplementation with omega-3 fatty acids starts before 20 weeks of pregnancy. Beneficial effects on the mother have been identified, such as the reduction of postpartum depression symptoms, the decrease of cardiovascular risk, and the anti-inflammatory role.

The Influence of Inflammatory and Nutritional Status on the Long-Term Outcomes in Advanced Stage Ovarian Cancer.

BACKGROUND: Despite improving surgical techniques and achieving more often complete debulking procedures, certain patients with advanced-stage ovarian cancer still have a very poor prognosis. The aim of the current paper is to investigate whether inflammatory and nutritional status can predict the long-term outcomes of ovarian cancer patients. METHODS: A retrospective analysis of 57 cases diagnosed with advanced-stage ovarian cancer submitted to surgery as first intent therapy was carried out. In all cases, the preoperative status was determined by calculating the CRP/albumin ratio, as well as the Glasgow score, the modified Glasgow score and the prognostic nutritional index. RESULTS: Patients presenting higher values of the CRP/albumin ratio, with a higher Glasgow score, modified Glasgow score and prognostic nutritional index (PNI), were more frequently associated with incomplete debulking surgery, a higher peritoneal carcinomatosis index and poorer overall survival (20 months versus 9 months for the CRP/albumin ratio p = 0.011, 42 versus 27 versus 12 months for the Glasgow score p = 0.042, 50 versus 19 versus 12 months for the modified Glasgow score, p = 0.001, and 54 months versus 21 months, p = 0.011 for the prognostic nutritional index). CONCLUSIONS: A strong relationship between the nutritional and inflammatory status in advanced-stage ovarian cancer seems to exist.

Risk Factors and Prognostic Factors in GBC.

Background: Gallbladder cancer (GBC) is a rare entity with a poor prognosis, usually discovered late due to nonspecific symptoms; therefore, over the last years, attention has been focused on identifying the risk factors for developing this malignancy in order to provide an early diagnosis, as well as new prognostic factors in order to modulate the long-term evolution of such cases. The aim of this review is to discuss both major risk factors and prognostic factors in GBC for a better understanding and integration of relevant and currently available information. Methods: A literature search was performed using Cochrane Library, PubMed, Google Scholar, Elsevier, and Web of Science; studies published after the year of 2000, in English, were reviewed. Results: Over time, risk factors associated with the development of GBC have been identified, which outline the profile of patients with this disease. The most important prognostic factors in GBC remain TNM staging, safety margin, and R0 status, along with perineural invasion and lymphovascular invasion. Both the technique and experience of the surgeons and a pathological examination that ensures final staging are particularly important and increase the chances of survival of the patients. Conclusions: improvements in surgical techniques and pathological analyses might provide better and more consistent guidance for medical staff in the management of patients with GBC.

Emergency and Elective Colorectal Cancer-Relationship between Clinical Factors, Tumor Topography and Surgical Strategies: A Cohort Study.

Background and Objectives: The purpose of the study was to analyze the relationships among several clinical factors and also the tumor topography and surgical strategies used in patients with colorectal cancer. Materials and Methods: We designed an analytical, observational, retrospective study that included patients admitted to our emergency surgical department and diagnosed with colorectal cancer. The study group inclusion criteria were: patients admitted during 2020-2022; patients diagnosed with colorectal cancer (including the ileocecal valve); patients who benefited from a surgical procedure, either emergency or elective. Results: In our study group, consisting of 153 patients, we accounted for 56.9% male patients and 43.1% female patients. The most common clinical manifestations were pain (73.2% of the study group), followed by abdominal distension (69.3% of the study group) and absence of intestinal transit (38.6% of the study group). A total of 69 patients had emergency surgery (45.1%), while 84 patients (54.9%) benefited from elective surgery. The most frequent topography of the tumor was the sigmoid colon, with 19.60% of the patients, followed by the colorectal junction, with 15.68% of the patients, and superior rectum and inferior rectum, with 11.11% of the patients in each subcategory. The most frequent type of procedure was right hemicolectomy (21.6% of the study group), followed by rectosigmoid resection (20.9% of the study group). The surgical procedure was finished by performing an anastomosis in 49% of the patients, and an ostomy in 43.1% of the patients, while for 7.8% of the patients, a tumoral biopsy was performed. Conclusions: Colorectal cancer remains one of the most frequent cancers in the world, with a heavy burden that involves high mortality, alterations in the quality of life of patients and their families, and also the financial costs of the medical systems.

Neurasites®-A Standardized Plant Extract in the Treatment and Prevention of Migraine Attacks.

Background/Objectives: Migraine is one of the most common diseases in highly developed countries, being even more common than diabetes and asthma. Migraines can affect emotional, social, and physical wellbeing as well as professional life. The most common symptoms are severe headaches associated with nausea, vomiting, photophobia and sonophobia, difficulty concentrating, sensitivity and emotional disorders. Many studies have been published to establish the best migraine-management drugs, but not many of them refer to plant extracts, which have been given more attention by patients lately. Among these generically called herbal medicines, the effect of tussilago hybrida standardized extract has been studied since the early twenties. This stands as the fundamental component of Neurasites® and the reason for research on materials and methods, results on treatment schemes for diminishing migraine attack features, as well as migraine prevention. Methods: There are two directions of research (herbal and placebo medicine) considered to be of interest due to the actual trend toward natural medicine and against chemicals and associated drugs. For quantitative research, the research tool used was that of the Neurasites® Questionnaire Survey (NQS). Results: The obtained results prove the efficacy of treatment by reducing the duration of headache attacks, diminishing pain intensity and decreasing the frequency of migraine episodes. Conclusions: Further research development should focus on other dosages and treatment schemes and on other similar natural products to be used in migraine attack treatment.

Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review.

Endometriosis is a chronic inflammatory disease, characterized by the presence of ectopic endometrial tissue, that leads to dysmenorrhea, painful intercourse and infertility. The shift in paradigm from the previous belief that endometriosis exclusively impacts women of reproductive age has brought attention to the condition in both premenarchal and postmenopausal women. Currently, 2-4% of postmenopausal women have endometriosis. Many women experience menopausal symptoms during the peri- and postmenopausal periods and require extensive investigations and monitoring in order to avoid the recurrence of endometriosis symptoms or the risk of malignant transformation when treatment with menopausal hormones is elected. Our goal was to compile and present a clear and concise overview of the existing literature on postmenopausal endometriosis, offering an up-to-date and precise summary of the available information.

Is Marginal Donor an Efficient Solution for Expanding the Donor Pool for Liver Transplant?

Once the techniques of hepatobiliopancreatic surgery improved, liver transplantation widely extended in different hospitals; therefore, the need of grafts and automatically of liver donors reported a significant increase in the last decade. In this respect, attention was focused on increasing the liver donor pool. The aim of this review is to study the benefits of using marginal grafts in liver transplantation. With the advent of multiple methods of liver preservation, the use of grafts previously considered unsuitable has become possible. Thus, extended allocation criteria have emerged. However, the allocation of these grafts must be carefully considered and analyzed in the context of both recipient and donor factors.

Prognostic Factors in Intrahepatic Cholangiocarcinoma - A Systematic Review.

Introduction: intrahepatic cholangiocarcinoma (ICCA) are rare, aggressive cancers that develop in second order or smaller bile ducts. The aim of this review is to systematically review the most important prognostic factors affecting the long-term outcomes of these patients. Material and Methods: articles conducted on this issue, written in English, published between from January 2000 to December 2023 in Cochrane Library, PubMed, Embase, MedLine, Web of Science, Elsevier, Google Scholar were systematically researched and reviewed. Results: ICCA are usually late diagnosed cancers because of the asymptomatic character, and curative procedures are often not feasible, only 20 to 30% of patients being fit for surgery. With the prognostic of this aggressive malignancy being baleful, the most important risk factors but also prognosis factors seem to be represented by socioeconomic factors, morphological presentation, dimensions, number and extension of the tumor as well as resection margins. Conclusions: once these factors are widely recognized and identified in each case, the clinician will be able to find the best treatment for these patients in order to improve the long-term outcomes.

Prenatal Features of MIRAGE Syndrome-Case Report and Review of the Literature.

MIRAGE syndrome is a recently described congenital condition characterized genetically by heterozygous gain-of-function missense mutations in the growth repressor sterile alpha domain containing 9 (SAMD9) located on the arm of chromosome 7 (7q21.2). The syndrome is rare and is usually diagnosed in newborns and children with myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes, and enteropathy, hence the acronym MIRAGE. The aims of this paper are (1) to present fetal ultrasound features in a case where MIRAGE syndrome was diagnosed prenatally and (2) to review the existing literature records on prenatal manifestations of MIRAGE syndrome. In our case, the fetus had severe early fetal growth restriction (FGR) with normal Doppler studies, atypical genitalia, oligohydramnios, and hyperechogenic bowel at the routine mid-gestation anomaly scan. Amniocentesis excluded infections and numeric or structural chromosomal abnormalities while whole exome sequencing (WES) of the fetal genetic material identified the specific mutation. Targeted testing in parents was negative, suggesting the "de novo" mutation in the fetus. We could not identify other specific case reports in the literature on the prenatal diagnosis of MIRAGE syndrome. In cases reported in the literature where the diagnosis of MIRAGE syndrome was achieved postnatally, there are mentions related to the marked FGR on prenatal ultrasound. Severe early-onset FGR with no other apparent cause seems to be a central prenatal feature in these babies, and WES should be offered, especially if there are other structural abnormalities. Prenatal diagnosis of MIRAGE syndrome is possible, allowing for reproductive choices, improved counseling of parents, and better preparation of neonatal care.

The Beginner Laparoscopists Trends in the Learning Process of Laparoscopy for Adnexal Gynecological Pathologies-The Experience of Our Center.

BACKGROUND: Laparoscopy for benign ovarian pathology is the appropriate surgical approach and it has many well-known advantages. Minimal invasive gynecological surgery increases the quality of life of the patient. The learning process of laparoscopy is difficult and requires many interventions to acquire manual skills. The objectives of the study were to assess the learning process of laparoscopy for adnexal pathology surgery performed by beginner laparoscopists. MATERIALS AND METHODS: This study included three gynecological surgeons who were beginners in laparoscopy and who were named A, B, and C. We collected information about patients, diagnosis, surgical technique, and complications. RESULTS: We have analyzed the data from 159 patients. The most frequent primary diagnosis was functional ovarian cyst, and the laparoscopic cystectomy was performed in 49.1% of interventions. The need to convert a laparoscopy into laparotomy was necessary in 1.3% of patients. There were no cases of reintervention, blood transfusion, or ureteral lesions. The duration of the surgical intervention varied statistically significantly according to patient's BMI and to the surgeon. After 20 laparoscopic interventions, a significant improvement was found in the time needed to perform ovarian cystectomy (operators A and B) and salpingectomy (operator C). CONCLUSIONS: The process of learning laparoscopy is laborious and difficult. We found a significant decrease in operating time after a twenty laparoscopic interventions.

Single-Center Experience with Swiss LithoClast® Trilogy for Kidney Stones.

INTRODUCTION: PCNL remains the gold standard for larger kidney stones. Reducing the operating time of PCNL and its complication rate seems to be the next logical step in optimizing this classical technique. To achieve these objectives, some new methods of lithotripsy emerge. We present the data of a single, high-volume, academic center with combined ultrasonic and ballistic lithotripsy in PCNL using the Swiss LithoClast® Trilogy device. MATERIALS AND METHODS: We designed a prospective, randomized study including patients who underwent PCNL or miniPerc with lithotripsy using the new EMS Lithoclast Trilogy or EMS Lithoclast Master. The procedure was carried out with all patients in prone position, by the same surgeon. The working channel size was 24 Fr-15.9 Fr. We evaluated the stones' features, operative time, fragmentation time, complications, stone clearance rate and stone-free rate. RESULTS: Our study included 59 patients, 38 females and 31 males, of an average age of 54.5 years old. The Trilogy group included 28 patients and the comparator included 31 patients. Urine culture was positive in seven cases which required seven days of antibiotics. The mean stone diameter was 35.6 mm with a mean Hounsfield unit (HU) of 710.1. The average number of stones was 2.08 (6 complete staghorn stones and 12 partial staghorn stones). A total of 13 patients presented a JJ stent (46.4%). We found a very significant difference in all the parameters favoring the Trilogy device. The most important result in our opinion is the probe active time, which was almost six times shorter in the Trilogy group. The stone clearance rate was about double in the Trilogy group, leading to shorter overall and intra-renal operating times. The overall complication rate was 17.9% in the Trilogy group and 23% in the Lithoclast Master group. The mean hemoglobin drop was 2.1 g/dL with a mean creatinine rise of 0.26 mg/dL. CONCLUSIONS: Swiss LithoClast® Trilogy, a device combining ultrasonic and ballistic energy, is a safe and efficient method of lithotripsy for PCNL, proving statistically significant benefits over its predecesor. It can achieve the goal of reducing complication rates and operative times for PCNL.