Unveiling the challenges of UTUC biopsies and cytology: insights from a global real-world practice study.

PURPOSE: Diagnostic ureteroscopy (dURS) is optional in the assessment of patients with upper tract urothelial carcinoma (UTUC) and provides the possibility of obtaining histology. METHODS: To evaluate endoscopic biopsy techniques and outcomes, we assessed data from patients from the CROES-UTUC registry. The registry includes multicenter prospective collected data on diagnosis and management of patients suspected having UTUC. RESULTS: We assessed 2380 patients from 101 centers. dURS with biopsy was performed in 31.6% of patients. The quality of samples was sufficient for diagnosis in 83.5% of cases. There was no significant association between biopsy techniques and quality (p = 0.458). High-grade biopsy accurately predicted high-grade disease in 95.7% and high-risk stage disease in 86%. In ureteroscopic low-grade tumours, the prediction of subsequent low-grade disease was 66.9% and low-risk stage Ta-disease 35.8%. Ureteroscopic staging correctly predicted non-invasive Ta-disease and ≥ T1 disease in 48.9% and 47.9% of patients, respectively. Cytology outcomes did not provide additional value in predicting tumour grade. CONCLUSION: Biopsy results adequately predict high-grade and high-risk disease, but approximately one-third of patients are under-staged. Two-thirds of patients with low-grade URS-biopsy have high-risk stage disease, highlighting the need for improved diagnostics to better assess patient risk and guide treatment decisions. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).

Experts' recommendations in laser use for the treatment of bladder cancer: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training and Research in Urological Surgery and Technology (TRUST)-Group.

PURPOSE: To identify laser settings and limits applied by experts during laser vaporization (vapBT) and laser en-bloc resection of bladder tumors (ERBT) and to identify preventive measures to reduce complications. METHODS: After a focused literature search to identify relevant questions, we conducted a survey (57 questions) which was sent to laser experts. The expert selection was based on clinical experience and scientific contribution. Participants were asked for used laser types, typical laser settings during specific scenarios, and preventive measures applied during surgery. Settings for a maximum of 2 different lasers for each scenario were possible. Responses and settings were compared among the reported laser types. RESULTS: Twenty-three of 29 (79.3%) invited experts completed the survey. Thulium fiber laser (TFL) is the most common laser (57%), followed by Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) (48%), continuous wave (cw) Thulium:Yttrium-Aluminium-Garnet (Tm:YAG) (26%), and pulsed Tm:YAG (13%). Experts prefer ERBT (91.3%) to vapBT (8.7%); however, relevant limitations such as tumor size, number, and anatomical tumor location exist. Laser settings were generally comparable; however, we could find significant differences between the laser sources for lateral wall ERBT (p = 0.028) and standard ERBT (p = 0.033), with cwTm:YAG and pulsed Tm:YAG being operated in higher power modes when compared to TFL and Ho:YAG. Experts prefer long pulse modes for Ho:YAG and short pulse modes for TFL lasers. CONCLUSION: TFL seems to have replaced Ho:YAG and Tm:YAG. Most laser settings do not differ significantly among laser sources. For experts, continuous flow irrigation is the most commonly applied measure to reduce complications.

The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP-tool): a Delphi consensus project on standardised evaluation of flexible ureterorenoscopes.

OBJECTIVE: To develop a standardised tool to evaluate flexible ureterorenoscopes (fURS). MATERIALS AND METHODS: A three-stage consensus building approach based on the modified Delphi technique was performed under guidance of a steering group. First, scope- and user-related parameters used to evaluate fURS were identified through a systematic scoping review. Then, the main categories and subcategories were defined, and the expert panel was selected. Finally, a two-step modified Delphi consensus project was conducted to firstly obtain consensus on the relevance and exact definition of each (sub)category necessary to evaluate fURS, and secondly on the evaluation method (setting, used tools and unit of outcome) of those (sub)categories. Consensus was reached at a predefined threshold of 80% high agreement. RESULTS: The panel consisted of 30 experts in the field of endourology. The first step of the modified Delphi consensus project consisted of two questionnaires with a response rate of 97% (n = 29) for both. Consensus was reached for the relevance and definition of six main categories and 12 subcategories. The second step consisted of three questionnaires (response rate of 90%, 97% and 100%, respectively). Consensus was reached on the method of measurement for all (sub)categories. CONCLUSION: This modified Delphi consensus project reached consensus on a standardised grading tool for the evaluation of fURS - The Uniform grading tooL for flexIble ureterorenoscoPes (TULIP) tool. This is a first step in creating uniformity in this field of research to facilitate future comparison of outcomes of the functionality and handling of fURS.

Positioning the role of urine cytology within the diagnostic pathway for UTUC: supportive but inconclusive.

PURPOSE: With the introduction of kidney-sparing surgery (KSS) for low-risk Upper Tract Urothelial Carcinoma (UTUC), correct risk-stratification has become crucial. High-grade cytology is one of the decisive variables to stratify a tumor as high-risk. To position the role of urine cytology in the diagnostic pathway of UTUC patients, we evaluated the accuracy of urine cytology by comparing the outcomes with histopathology. METHOD: Patients with UTUC evaluated between 2010 and 2020, and diagnosed by imaging, cytology and histopathology were selected. Descriptive statistics were used to compare cytology with histopathological outcomes using crosstabs. Clinical performance characteristics of cytology were determined for the presence of a malignancy. RESULTS: This study included 176 patients with confirmed histopathological UTUC. Concordance between cytology and biopsy results was found in 14.8% of low-grade tumors and 16.8% of high-grade tumors. Comparing cytology with radical nephroureterectomy (RNU) specimens revealed concordance rates of 1.6% for low-grade tumors and 22.9% for high-grade tumors. Notably, 51.1% of urine cytology results were false negative. Sensitivity for detecting high-grade and low-grade tumors with a positive urine cytology was 56.6% and 52.6%, respectively, with specificities of 54.8% and 37.2%. CONCLUSION: In the current study, cytology appears to exhibit limited reliability when used as a sole diagnostic tool for assessing tumor grade and consequently risk stratification. It is imperative to recognize these limitations, optimize urine sampling techniques, and leverage a combination of diverse diagnostic methods for the most effective and individualized treatment decision-making.

Consultation on UTUC II Stockholm 2022: diagnostics, prognostication, and follow-up-where are we today?

PURPOSE: To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS: A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS: The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION: Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: 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 highlight and compare experts' laser settings during endoscopic laser treatment of upper tract urothelial carcinoma (UTUC), to identify measures to reduce complications, and to propose guidance for endourologists. METHODS: Following a focused literature search to identify relevant questions, a survey was sent to laser experts. We asked participants for typical settings during specific scenarios (ureteroscopy (URS), retrograde intrarenal surgery (RIRS), and percutaneous treatment). These settings were compared among the reported laser types to find common settings and limits. Additionally, we identified preventive measures commonly applied during surgery. RESULTS: Twenty experts completed the survey, needing a mean time of 12.7 min. Overall, most common laser type was Holmium-Yttrium-Aluminum-Garnet (Ho:YAG) (70%, 14/20) followed by Thulium fiber laser (TFL) (45%, 9/20), pulsed Thulium-Yttrium-Aluminum-Garnet (Tm:YAG) (3/20, 15%), and continuous wave (cw)Tm:YAG (1/20, 5%). Pulse energy for the treatment of distal ureteral tumors was significantly different with median settings of 0.9 J, 1 J and 0.45 J for Ho:YAG, TFL and pulsed Tm:YAG, respectively (p = 0.048). During URS and RIRS, pulse shapes were significantly different, with Ho:YAG being used in long pulse and TFL in short pulse mode (all p < 0.05). We did not find further disparities. CONCLUSION: Ho:YAG is used by most experts, while TFL is the most promising alternative. Laser settings largely do not vary significantly. However, further research with novel lasers is necessary to define the optimal approach. With the recent introduction of small caliber and more flexible scopes, minimal-invasive UTUC treatment is further undergoing an extension of applicability in appropriately selected patients.

Donor kidney lithiasis and back-table endoscopy: a successful combination.

INTRODUCTION: Urolithiasis in renal allografts is relatively rare with an incidence of 0.17-4.40%. It is nonetheless an important issue, as there is a risk of obstruction, sepsis and even loss of the renal allograft. The management of stones in renal allografts remains challenging because of the anatomy, the renal denervation and the use of immunosuppressive medication. CASE PRESENTATION: This report discusses the ex-vivo treatment of asymptomatic nephrolithiasis in a living donor kidney allograft. A CT abdomen revealed a lower pole stone (5.9 × 5.5 × 5.0 mm; 920 HU) in the right kidney of the potential donor. After multidisciplinary discussion, it was decided to procure the right kidney despite the presence of a documented nephrolithiasis. After discussion with both donor and recipient, an ex-vivo flexible ureterorenoscopy for stone removal on the back table just before implantation of the allograft was planned. The stone was found in the lower pole covered by a thin film of the urothelium. The thin film of urothelium was opened with a laser and the stone fragments were retrieved with a basket. CT after one month showed no residual stones in the transplanted kidney. CONCLUSION: Back-table endoscopy in a renal allograft is a feasible technique and should be discussed as an option in case of urolithiasis in a kidney that is considered for transplantation. Furthermore, the appropriate treatment of donor kidney lithiasis is another, although rare, method to expand the living donor renal allograft pool.

Could the region you live in prevent or precipitate kidney stone formation due to mineral intake through tap water? An analysis of nine distribution regions in Flanders.

OBJECTIVES: To analyse the mineral content of tap water in Flanders and assess if the region one lives in could prevent or precipitate stone formation due to a difference in mineral content. METHODS: Data from six water companies providing tap water to nine regions in Flanders regarding calcium, magnesium, potassium, sodium and sulphate content in tap water was retrieved. Minimum and maximum values were collected and compared between the different geographical regions. RESULTS: The highest calcium level was found in region 9 with a value of 157.0 mg/L, which is almost 10 times the value found in region 8 (16.1 mg/L). Region 6 had the highest magnesium (31.8 mg/L), potassium (30.5 mg/L), sodium (126.6 mg/L) and sulphate (218.5 mg/L) levels. The lowest level of magnesium (2.7 mg/L) was found in region 1, which was almost 12 times lower as in Region 6. Region 9 had the lowest level of potassium (1.5 mg/L), which is a factor 20 lower than Region 6. The lowest sodium and sulphate levels were found in region 8 (6.8 mg/L and 3.0 mg/L), respectively. The difference between the highest and lowest level of sulphate was a factor 70. CONCLUSION: There is a broad range in the minerals found in tap water between the different production sites in the nine distribution regions in Flanders. However, due to the high standards tap water has to meet in Flanders, the region one lives in will not lead to a higher or lower risk of kidney stone formation if the advised 2 to 3 L per day are consumed.

Adherence to guideline recommendations in the management of upper tract urothelial carcinoma: an analysis of the CROES-UTUC registry.

BACKGROUND: The European Association of Urology provides Clinical Practice Guideline on upper tract urothelial carcinoma (UTUC). Due to the rarity of UTUC, guidelines are necessary to help guide decision-making based on the highest quality of care evidence available. OBJECTIVES: To evaluate guideline adherence in the management of UTUC by assessing recommendations on diagnostics needed for risk classification and subsequent treatment selection; to assess predictors for the latter. PARTICIPANTS: Data from the Clinical Research Office of the Endo Urology Society UTUC-registry were included for analysis. STATISTICAL ANALYSIS: Overall compliance were evaluated by cross-tables, differences in risk groups characteristics and treatment selection were assessed by Chi-square tests, predictors for treatment selection by logistic regression analysis. RESULTS: Data from 2380 patients were included. Imaging by CT-scan had highest adherence (85%) but was low for other diagnostics (17.7-49.7%). Multivariable regression analysis showed higher odds of receiving radical nephroureterectomy in patients with large tumours (OR 5.45, 95% CI 3.77-7.87, p < 0.001), signs of invasion (OR 3.07,CI 2.11-4.46, p < 0.001), high tumour grade (OR 2.05, CI 1.38-3.05, p < 0.001) and multifocality (OR 1.76,CI 1.05-2.97, p =0.032). CONCLUSIONS: CT-imaging is the most used and most impactful decision tool for risk-stratification and treatment selection in UTUC. Due to the low compliance in most of the diagnostic recommendations, proper risk stratification is not possible in a significant group of patients raising the question whether current stratification is deemed applicable in daily practice. Established prognostic factors on survival guides decision-making regarding radical versus kidney-sparing surgery. Tumour size was the most influencing factor on treatment decision. CLINICAL TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (ClinicalTrials.gov NCT02281188; https://clinicaltrials.gov/ct2/show/NCT02281188 ).

How to evaluate a flexible ureterorenoscope? Systematic mapping of existing evaluation methods.

OBJECTIVES: The objective of this study was to identify, map and review scope-related and user-related parameters used to evaluate the quality of flexible ureterorenoscopes. Thereby identifying key items and variability in grading systems. METHODS: A literature search of four databases (MEDLINE [Ovid], EMBASE [Ovid], Web of Science, Google scholar and the Cochrane Library) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines encompassing articles published up to August 2020. A total of 2386 articles were screened. RESULTS: A total of 48 articles were included in this systematic scoping review. All studies had a prospective design. Five key items in the assessment of flexible ureterorenoscopy were distinguished: 'Manoeuvrability' (87.5%), 'Optics' (64.6%), 'Irrigation' (56.3%), 'Handling' (39.6%) and 'Durability' (35.4%). After regrouping, every key item could be divided into specific subcategories. However, the quality assessment showed a wide variation in denomination, method of measurement, circumstances of measurement, tools used during measurements, number of measurements performed, number of observers, and units of outcomes. CONCLUSION: The research field regarding quality assessment of ureterorenoscopes is heterogeneous. In this systematic scoping review we identified five key parameters: Manoeuvrability, Optics, Irrigation, Handling and Durability, used to grade flexible ureterorenoscopes. However, within these categories we found a wide variety in terms of method of measurements. A standardised, uniform grading tool is required to assess and compare the quality of flexible ureterorenoscopes in the future.

Consultation on kidney stones, Copenhagen 2019: aspects of intracorporeal lithotripsy in flexible ureterorenoscopy.

PURPOSE: To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. METHODS: A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. RESULTS AND CONCLUSIONS: Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Contemporary patterns of presentation, diagnostics and management of upper tract urothelial cancer in 101 centres: the Clinical Research Office of the Endourological Society Global upper tract urothelial carcinoma registry.

PURPOSE OF REVIEW: To assess patterns of presentation, diagnostics and treatment in patients with upper tract urothelial carcinoma (UTUC), a multicentre registry was launched. Clinical data of UTUC patients were prospectively collected over a 5-year period. RECENT FINDINGS: Data from 2380 patients were included from 2014 to 2019 (101 centres in 29 countries). Patients were predominantly male (70.5%) and 53.3% were past or present smokers. The majority of patients (58.1%) were evaluated because of symptoms, mainly macroscopic hematuria. Computed tomography (CT) was the most common performed imaging modality (90.5%). A ureteroscopy (URS) was part of the diagnostic process in 1184 (49.7%) patients and 488 (20.5%) patients were treated endoscopically. In total, 1430 patients (60.1%) were treated by a radical nephroureterectomy, 59% without a prior diagnostic URS. Eighty-two patients (3.4%) underwent a segmental resection, 19 patients (0.8%) were treated by a percutaneous tumour resection. SUMMARY: Our data is in line with the known epidemiologic characteristics of UTUC. CT imaging is the preferred imaging modality as also recommended by guidelines. Diagnostic URS gained a stronger position, however, in almost half of patients a definitive treatment decision was made without complete endoscopic information. Only one-third of patients with UTUC are currently treated with kidney sparing surgery.

Fluoroscopy-use during ureterorenoscopy: are urologists concerned about radiation exposure? A nationwide survey in Belgium and The Netherlands.

INTRODUCTION: To evaluate the use and awareness of radiation during URS among Belgian and Dutch urologists. MATERIAL AND METHODS: An online questionnaire was send to all members of the Belgian and Dutch Association of Urology. RESULTS: 170 urologists finished the complete questionnaire. 10% of the respondents are not familiar with the ALARA-principle. 29% starts with a KUB and 48% makes an XRPG at the beginning of the procedure. 85% uses fluoroscopy to place a wire or ureteral access sheet, 18% during stone treatment, 59% to screen for missed stones or calyces, 90% to place a JJ-stent or ureter-catheter and 23% to check for extravasation. 82% do not document radiation data. 51% does not wear a dosimeter during fluoroscopy. Almost all wear a lead apron during fluoroscopy, 47% uses additional thyroid shields and only 4% uses lead glasses. 88% intentionally reduces fluoroscopy time, 75% reduces the exposed area with a diaphragm, 72% brings the radiation source close to the patient and 44% uses pulsed fluoroscopy. CONCLUSION: There is a wide variety in the use and awareness of radiation during URS. To further reduce radiation and its negative effect for patients and medical staff, awareness about radiation safety should increase among urologists.

Pre-Use Ureteroscope Contamination after High Level Disinfection: Reprocessing Effectiveness and the Relation with Cumulative Ureteroscope Use.

PURPOSE: We assessed the frequency of preoperative and persistent microbial contamination of flexible ureteroscopes after reprocessing and the relation of contamination to cumulative ureteroscope use. MATERIALS AND METHODS: We evaluated the effectiveness of high level disinfection with peracetic acid as well as data on ureteroscope use for 20 new flexible ureteroscopes from December 2015 to December 2017 at a single center. In the operating room pre-use and postuse microbial samples of the ureteroscope shaft and working channel were collected to evaluate microbial contamination after reprocessing. Positive cultures were defined as 30 cfu/ml or greater of skin flora, or 10 cfu/ml or greater of uropathogenic microorganisms. A generalized estimating equation model was used to analyze whether cumulative ureteroscope use was associated with positive pre-use cultures. RESULTS: Microbial samples were collected during 389 procedures. Pre-use ureteroscope cultures were positive in 47 of 389 procedures (12.1%), of which uropathogens were found in 9 of 389 (2.3%) and skin flora in 38 of 389 (9.8%). Urinary tract infection symptoms did not develop in any of the patients who underwent surgery with a uropathogen contaminated ureteroscope. In 1 case the pre-use culture contained the same bacteria type as the prior postuse culture. Cumulative ureteroscope use was not associated with a higher probability of positive cultures. CONCLUSIONS: Microbial contamination of reprocessed ureteroscopes was found in an eighth of all procedures. Notably uropathogenic microorganisms were discovered in a small proportion of all procedures. Persistent ureteroscope contamination with uropathogens was only rarely encountered. Cumulative ureteroscope use was not associated with a higher probability of microbial contamination.

Consultation on UTUC, Stockholm 2018: aspects of treatment.

PURPOSE: To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC). METHODS: In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6-7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence. RESULTS: Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette-Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0-3M0 disease. CONCLUSIONS: Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease.

Consultation on UTUC, Stockholm 2018 aspects of diagnosis of upper tract urothelial carcinoma.

PURPOSE: To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers. METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018. RESULTS: Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice. CONCLUSIONS: Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Surgical teaching in urology: patient safety and educational value of 'LIVE' and 'SEMI-LIVE' surgical demonstrations.

PURPOSE: To evaluate the opinion of urologists and their audience regarding patient safety and educational value of live surgical demonstrations (LSD) and semi-live surgical demonstrations (semi-LSD). METHODS: Following the '2017 Challenges in Endourology' meeting, a survey addressing patient safety and the educational value of LSD and semi-LSD was disseminated online to all participants. Survey outcomes of LSD and semi-LSD were compared. RESULTS: All 279 respondents attended both LSD and semi-LSD. Overall, 53% of said respondents stated that patient safety was always the highest priority for LSD, while 74% noted the same for semi-LSD. The complication risk in LSD was perceived equal by 57% of the respondents when compared to cases of similar difficulty in routine practice, while 38% perceived it as a greater risk. For semi-LSD, the complication risk was perceived equal by 84%, while 5% perceived it to be a greater risk in comparison to general practice. On a scale from 0 (no value) to 10 (highly valuable), the average educational value of LSD and semi-LSD was rated 8.4 and 8.3, respectively. A substantial percentage of the surgeons who perform LSD express concerns that live surgery is not the optimal setting to ensure patient safety. CONCLUSIONS: LSD remains a popular tool for surgical education among urologists and their audience. However, patient safety remains a concern and is perceived less of a concern for semi-LSD. The educational value of LSD and semi-LSD was scored equally high. Therefore, we should consider to advocate the use of semi-LSD more often.

Outcome from 5-year live surgical demonstrations in urinary stone treatment: are outcomes compromised?

PURPOSE: To compare intra- and post-operative outcomes of endourological live surgical demonstrations (LSDs) and routine surgical practice (RSP) for urinary stones. METHODS: Consecutive ureterorenoscopic (URS) and percutaneous (PNL) urinary stone procedures over a 5-year period were reviewed. Procedures were divided into LSDs and RSP. Differences between the groups were separately analysed for URS and PNL. Primary outcomes included intra- and post-operative complication rates and grades. Secondary outcomes were operation time, length of hospital stay, stone-free rate, and retreatment rate. Pearson's Chi-square analysis, Mann-Whitney U test, and logistic and linear regression were used to compare outcomes between LSDs and RSP. RESULTS: During the study period, we performed 666 URSs and 182 PNLs, and 151 of these procedures were LSDs. Among URSs, the overall intra-operative complication rate was 3.2% for LSDs and 2.5% for RSP (p = 0.72) and the overall post-operative complication rate was 13.7% for LSDs and 8.8% for RSP (p = 0.13). Among PNLs, the overall intra-operative complication rate was 8.9% for LSDs and 5.6% for RSP (p = 0.52) and the overall post-operative complication rate was 28.6% for LSDs and 34.9% for RSP (p = 0.40). For both URSs and PNLs, no statistically significant differences in complication grade scores were observed between LSDs and RSP. Operation time was significantly longer for LSD-URS group, but there was no difference between the PNL groups. There were no significant differences in length of hospital stay and stone-free rate. The retreatment rate was higher in the LSD-URS group compared with RSP-URS group but similar between the PNL groups. Multiple logistic regression analyses, adjusting for confounders, revealed no association between LSD and more or less favourable outcomes as compared to RSP. CONCLUSION: Live surgical demonstrations do not seem to compromise patients' safety and outcomes when performed by specialised endourologists.

New technologies for upper tract urothelial carcinoma management.

PURPOSE OF REVIEW: Image enhancement techniques and optical diagnostic tools have emerged in the quest to improve diagnostics and treatment in patients with upper urinary tract carcinoma (UTUC). The aim of the present report is to describe their mechanisms of action and to assess the current evidence on applicability and utility in UTUC. RECENT FINDINGS: Image enhancement techniques including narrow band imaging, Image1 S, and photodynamic diagnosis aim at better visualization of malignant urothelium and especially flat tumours or carcinoma in situ which are often difficult to see with white light endoscopy. Conducted studies in the upper tract are scarce but first results show that tumour detection seems to be better for narrow band imaging and photodynamic diagnosis-guided inspection.Optical diagnostic tools as confocal laser endomicroscopy and optical coherence tomography aim at providing real time optical biopsies giving pathologic information. A pilot study of optical coherence tomography proved its feasibility to visualize, grade and stage low and high-grade UTUC. SUMMARY: Better visualization of suspect lesions and optical diagnostic techniques providing real time optical biopsies aim to facilitate in higher diagnostic precision and optimal individualized treatment of our patients with UTUC. As the disease is rare, studies are scarce but indispensable for future implication of these techniques.

Lessons learned from the CROES percutaneous nephrolithotomy global study.

PURPOSE: The purpose of the study was to give an overview of the data derived from the CROES PCNL Global Study published previously in 25 articles. METHODS: A comprehensive overview of the outcome of the CROES PCNL Global Study was made, analysed and compared with the current literature and guidelines. RESULTS: Percutaneous nephrolithotomy (PCNL) was predominately performed in prone position. Although the supine position claims to be favourable over the prone approach, the present study showed a longer operation time and lower stone-free rate (SFR). This might be explained by differences in definition in operation time and methods in the evaluation of residual stones. Ultrasound (US)-guided access proves beneficial in lowering puncture time and radiation exposure. Renal anomalies can safely be treated by PCNL and have similar outcomes to a normal situation. In patients with a solitary kidney, however, there is a lower SFR and more bleeding. Also, severe chronic kidney disease (CKD) patients have less favourable outcome. Morbidity and complications following PCNL are dominated by fever (10.5%) and bleeding (7.8%). A matched control analysis confirmed that antibiotic prophylaxis gives a threefold lower post-operative fever rate. In a multivariate analysis, it was elegantly demonstrated that bleeding was directly related to the size of the dilatation: the larger the bore, the higher the chance for bleeding. Elderly patients are at higher risk of complications and longer hospital stay. Overall, obese patients have similar outcome as the general population; however, super-obese (BMI > 40) patients have a higher chance of more severe complications. For the first time, this database illustrated a significant relationship between results and complications of PCNL, and caseload volume. The optimal case volume per centre appears to be 120 PCNL's/year. Finally, a nomogram has been developed that enables better patient counselling and decision-making. CONCLUSION: The CROES PCNL Global Study is the largest real-life study providing new insights into general and special conditions. Because of the vast number of patients included, rare conditions including renal anomalies, solitary kidneys and patient characteristics like severe CKD, super obesity and old age could be analysed. Besides this information, a nomogram was developed. And for the first time, the influence of caseload volume was established.