Litigation claims in Urology in the UK National Health Service: an analysis of the trends, costs and causes over a 16-year period.

OBJECTIVE: To analyse the litigation trends and the reasons for claims within the specialty of Urology, within the UK National Health Service (NHS), over a 16-year period. MATERIALS AND METHODS: Data were requested from NHS Resolution under the Freedom of Information Act 2000. This included the total number of claims in Urology, the number of these that were successful (settled or closed), and the costs in damages paid out per financial year between 2006 and 2022. A breakdown of the successful claims by their primary cause was also collected. These were coded into the categories: 'non-operative', 'intraoperative', 'postoperative', and 'other'. RESULTS: A total of 4124 litigation claims were made between 2006 and 2022 and 60.9% (2511/4124) of these claims were successful. In all, £145 million (British pounds) was paid out in damages. The number of successful claims increased 2.9-fold from the start to end of this 16-year period, and the costs in damages paid out increased 10-fold. Regarding primary causes for the successful claims, failure or delay in treatment (20.9%, 525/2511), failure or delay in diagnosis (14.5%, 364/2511), and intraoperative problems (9.1%, 229/2511) accounted for the highest proportion. Overall, non-operative causes for successful claims accounted for 73.3% (1840/2511), intraoperative for 20.1% (504/2511), and postoperative for 3.9% (98/2511). CONCLUSIONS: The number of successful urological litigation claims, and their associated costs is rising. The majority are due to non-operative causes, which may be partially explained by NHS waiting lists alongside the effects of the coronavirus disease 2019 (COVID-19) pandemic.

Salvage holmium laser enucleation of the prostate after previous interventions: a systematic review.

OBJECTIVE: To investigate the feasibility, safety and efficacy of holmium laser enucleation of the prostate (HoLEP) in the re-treatment setting (salvage HoLEP) and compare it to the primary HoLEP procedure that is commonly used for the treatment of benign prostate hyperplasia (BPH). MATERIALS AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, PubMed, Scopus, and Cochrane databases were systematically screened, from inception to 8 August 2022. Other potentially eligible studies were retrieved using the reference lists of the included studies. Retrospective and prospective studies, both comparative and non-comparative, were included. RESULTS: A total of 12 studies met the inclusion criteria and were included in the final qualitative synthesis. One study was prospective comparative (non-randomised), seven studies were retrospective comparative, and four studies were retrospective non-comparative or case series. In total, 831 patients were treated with salvage HoLEP in the above studies. Previous intervention before salvage HoLEP ranged among studies. The most commonly performed was transurethral resection of the prostate. Intraoperative parameters of salvage HoLEP were comparable with those reported during primary HoLEP, while all postoperative outcomes were significantly improved after salvage HoLEP and were similar with those observed after primary HoLEP. No major complications were noted after salvage HoLEP according to Clavien-Dindo classification. CONCLUSIONS: Salvage HoLEP after previous interventions for treating recurrent or residual BPH is a feasible, safe, and efficient procedure. Data presented in selected studies, along with the holmium laser's physical properties to resect more tissue and to dissect along the true anatomical plane of BPH, render HoLEP an ideal salvage treatment modality for recurrent or residual BPH symptoms.

Perspectives on technology: to use or to reuse, that is the endoscopic question-a systematic review of single-use endoscopes.

OBJECTIVE: To compare clinical outcomes of single-use endoscopes with those of reusable endoscopes to better define their role within urology. METHODS: A systematic search of electronic databases was performed. All studies comparing the clinical outcomes of participants undergoing urological procedures with single-use endoscopes to those of participants treated with reusable endoscopes were included. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. RESULTS: Twenty-one studies in 3943 participants were identified. Six different single-use flexible ureteroscopes and two different single-use flexible cystoscopes were assessed. There were no differences in mean postoperative infection rates (4.0% vs 4.4%; P = 0.87) or overall complication rates (11.5% vs 11.9%; P = 0.88) between single-use and reusable endoscopes. For patients undergoing flexible ureteroscopy there were no differences in operating time (mean difference -0.05 min; P = 0.96), length of hospital stay (LOS; mean difference 0.06 days; P = 0.18) or stone-free rate (SFR; 74% vs 74.3%; P = 0.54) between the single-use and reusable flexible ureteroscope groups. CONCLUSION: This study is the largest to compare the clinical outcomes of single-use endoscopes to those of reusable endoscopes within urology, and demonstrated no difference in LOS, complication rate or SFR, with a shorter operating time associated with single-use flexible cystoscope use. It also highlights that the cost efficiency and environmental impact of single-use endoscopes is largely dependent on the caseload and reprocessing facilities available within a given institution. Urologists can therefore feel confident that whether they choose to 'use' or to 'reuse' based on the financial and environmental implications, they can do so without negatively impacting patient outcomes.

Retrograde intrarenal surgery for asymptomatic incidental renal stones: a retrospective, real-world data analysis.

OBJECTIVE: To determine surgical outcomes and stone-free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists. PATIENTS AND METHODS: This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR. RESULTS: Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06-0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19-0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re-interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%). CONCLUSION: Our multicentre real-world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre-emptively discussing potential re-intervention helps patients make informed decisions, particularly in cases involving large and multiple stones.

Effect of infundibulopelvic angle on outcomes of ureteroscopy: a systematic review and meta-analysis.

PURPOSE: The infundibulo-pelvic angle (IPA) is reportedly a predictor of successful ureteroscopy for lower pole renal stones, however there is uncertainty at which IPA success is likely. We therefore aimed to perform a meta-analysis and determine at which the angle of likely success and failure. METHODS: We performed a systematic review and meta-analysis as per Cochrane guidelines in accordance to the PRISMA statement. The review was registered with PROSPERO prior to commencement (ID: CRD42022296732). We included studies reporting on outcomes of ureteroscopy for lower pole stones, with IPA. We excluded patients undergoing alternative treatments for lower pole stones, anatomical abnormalities and studies with < 10 patients. We assessed bias with the Newcastle-Ottawa scale. We performed meta-analysis in R, and summarised the findings as per GRADE. RESULTS: Overall, there were 13 studies included, with 10 included for meta-analysis. These studies covered n = 1964 patients (71% stone free). Overall, the stone free patients had a significantly less acute mean IPA (52o ± 9o), compared to the non-stone free patients (39o ± 7o), on meta-analysis (REM MD = -13.0, 95% CI: -18.7 to -7.2, p < 0.001). On examination of forest plots, at IPA < 30o no patients were stone free, whilst > 50o all were stone free. Risk of bias was moderate, and certainty of evidence was 'very low'. CONCLUSION: With a very low certainty of evidence, we demonstrate that at an IPA of < 30o no patient is stone free, whilst > 50o all patients (in this review) are stone free. More evidence is therefore needed.

A machine learning approach using stone volume to predict stone-free status at ureteroscopy.

INTRODUCTION: To develop a predictive model incorporating stone volume along with other clinical and radiological factors to predict stone-free (SF) status at ureteroscopy (URS). MATERIAL AND METHODS: Retrospective analysis of patients undergoing URS for kidney stone disease at our institution from 2012 to 2021. SF status was defined as stone fragments < 2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments > 2 mm at XR KUB or US KUB at 3 months follow up. We specifically included all non-SF patients to optimise our algorithm for identifying instances with residual stone burden. SF patients were also randomly sampled over the same time period to ensure a more balanced dataset for ML prediction. Stone volumes were measured using preprocedural CT and combined with 19 other clinical and radiological factors. A bagged trees machine learning model with cross-validation was used for this analysis. RESULTS: 330 patients were included (SF: n = 276, not SF: n = 54, mean age 59.5 ± 16.1 years). A fivefold cross validated RUSboosted trees model has an accuracy of 74.5% and AUC of 0.82. The model sensitivity and specificity were 75% and 72.2% respectively. Variable importance analysis identified total stone volume (17.7% of total importance), operation time (14.3%), age (12.9%) and stone composition (10.9%) as important factors in predicting non-SF patients. Single and cumulative stone size which are commonly used in current practice to guide management, only represented 9.4% and 4.7% of total importance, respectively. CONCLUSION: Machine learning can be used to predict patients that will be SF at the time of URS. Total stone volume appears to be more important than stone size in predicting SF status. Our findings could be used to optimise patient counselling and highlight an increasing role of stone volume to guide endourological practice and future guidelines.

Follow-up of urolithiasis patients after treatment: an algorithm from the EAU Urolithiasis Panel.

OBJECTIVE: To develop a follow-up algorithm for urinary stone patients after definitive treatment. MATERIALS AND METHODS: The panel performed a systematic review on follow-up of urinary stone patients after treatment (PROSPERO: CRD42020205739). Given the lack of comparative studies we critically evaluated the literature and reached a consensus on the follow-up scheme. RESULTS: A total of 76 studies were included in the analysis, including 17 RCTs. In the stone-free general population group, 71-100% of patients are stone-free at 12 months while 29-94% remain stone-free at 36 months. We propose counselling these patients on imaging versus discharge after the first year. The stone-free rate in high-risk patients not receiving targeted medical therapy is < 40% at 36 months, a fact that supports imaging, metabolic, and treatment monitoring follow-up once a year. Patients with residual fragments ≤ 4 mm have a spontaneous expulsion rate of 18-47% and a growth rate of 10-41% at 12 months, supporting annual imaging follow-up. Patients with residual fragments > 4 mm should be considered for surgical re-intervention based on the low spontaneous expulsion rate (13% at 1 year) and high risk of recurrence. Plain film KUB and/or kidney ultrasonography based on clinicians' preference and stone characteristics is the preferred imaging follow-up. Computed tomography should be considered if patient is symptomatic or intervention is planned. CONCLUSIONS: Based on evidence from the systematic review we propose, for the first time, a follow-up algorithm for patients after surgical stone treatment balancing the risks of stone recurrence against the burden of radiation from imaging studies.

Super-mini PCNL (SMP) with suction versus standard PCNL for the management of renal calculi of 1.5 cm-3 cm: a randomized controlled study from a university teaching hospital.

PURPOSE: To assess the safety and efficacy of super-mini PCNL (SMP, 14 Fr) when compared to standard PCNL (sPCNL, 24-30 Fr) in the management of renal calculi of size ranging from 1.5 to 3 cm. METHODS: From February 2021 to January 2022, a total of 100 patients were randomized to either SMP group or sPCNL group in a 1:1 ratio (50 in each group) using computer-generated simple randomization. Demographic data, stone characteristics, operative times, perioperative complications, blood transfusions, postoperative drop in haemoglobin, postoperative pain, duration of hospital stay and stone-free rates were compared between the two groups. RESULTS: Mean stone volume (2.41 cm2 vs 2.61 cm2) and stone-free rates (98% vs 94%, p = 0.14) were similar in both the SMP and sPCNL groups, respectively. The SMP group had significantly longer mean operative times (51.62 ± 10.17 min vs 35.6 ± 6.8 min, p = 0.03). Intraoperative calyceal injury (1/50 vs 7/50, p = 0.42) and mean postoperative drop in haemoglobin (0.8 ± 0.7 g/dl vs 1.2 ± 0.81, p = 0.21) were lower in the SMP group, but not statistically significant. SMP group showed significantly lower mean postoperative pain VAS scores (5.4 ± 0.7 vs 5.9 ± 0.9, p = 0.03) and mean duration of hospital stay (28.38 ± 3.6 h vs 39.84 ± 3.7 h, p = 0.0001). Complications up to Clavien grade 2 were comparable, with grade ≥ 3 complications higher in the standard group, but not statistically significant. CONCLUSION: Super-mini PCNL is equally effective as standard PCNL in treating renal calculi up to 3 cm, with significantly reduced postoperative pain and duration of hospital stay and lower risk of Clavien grade ≥ 3 complications, although with higher operative times.

Radiation exposure of urologists during endourological procedures: a systematic review.

INTRODUCTION: Ionizing radiation is used daily during endourological procedures. Despite the dangers of both deterministic and stochastic effects of radiation, there is a lack of knowledge and awareness among urologists. This study reviewed the literature to identify the radiation exposure (RE) of urologists during endourological procedures. METHODS: A literature search of the Medline, Web of Science, and Google Scholar databases was conducted to collect articles related to the radiation dose to urologists during endourological procedures. A total of 1966 articles were screened. 21 publications met the inclusion criteria using the PRIMA standards. RESULTS: Twenty-one studies were included, of which 14 were prospective. There was a large variation in the mean RE to the urologist between studies. PCNL had the highest RE to the urologist, especially in the prone position. RE to the eyes and hands was highest in prone PCNL, compared to supine PCNL. Wearing a thyroid shield and lead apron resulted in a reduction of RE ranging between 94.1 and 100%. Educational courses about the possible dangers of radiation decreased RE and increased awareness among endourologists. CONCLUSIONS: This is the first systematic review in the literature analyzing RE to urologists over a time period of more than four decades. Wearing protective garments such as lead glasses, a thyroid shield, and a lead apron are essential to protect the urologist from radiation. Educational courses on radiation should be encouraged to further reduce RE and increase awareness on the harmful effects of radiation, as the awareness of endourologists is currently very low.

Real world propensity score matched analysis evaluating the influence of en-bloc vs. non en-bloc techniques, energy and instrumentation on enucleation outcomes for large and very large prostates.

PURPOSE: The primary aim of the study was to evaluate if en-bloc vs. non en-bloc made a difference to intra-, peri- and post-operative surgical outcomes of anatomical endoscopic enucleation (AEEP) in large (> 80 cc) and very large prostates (> 200 cc). The secondary aim was to determine the influence of energy and instruments used. METHODS: Data of patients with > 80 cc prostate who underwent surgery between 2019 and 2022 were obtained from 16 surgeons across 13 centres in 9 countries. Propensity score matching (PSM) was used to reduce confounding. Logistic regression was performed to evaluate factors associated with postoperative urinary incontinence (UI). RESULTS: 2512 patients were included with 991 patients undergoing en-bloc and 1521 patients undergoing non-en-bloc. PSM resulted in 481 patients in both groups. Total operation time was longer in the en-bloc group (p < 0.001), enucleation time was longer in the non en-bloc group (p < 0.001) but morcellation times were similar (p = 0.054). Overall, 30 day complication rate was higher in the non en-bloc group (16.4% vs. 11.4%; p = 0.032). Rate of late complications (> 30 days) was similar (2.3% vs. 2.5%; p > 0.99). There were no differences in rates of UI between the two groups. Multivariate analysis revealed that age, Qmax, pre-operative, post-void residual urine (PVRU) and total operative time were predictors of UI. CONCLUSIONS: In experienced hands, AEEP in large prostates by the en-bloc technique yields a lower rate of complication and a slightly shorter operative time compared to the non en-bloc approach. However, it does not have an effect on rates of post-operative UI.

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.

Incidence of complications and urinary incontinence following endoscopic enucleation of the prostate in men with a prostate volume of 80 ml and above: results from a multicenter, real-world experience of 2512 patients.

PURPOSE: To evaluate complications and urinary incontinence (UI) after endoscopic enucleation of the prostate (EEP) stratified by prostate volume (PV). METHODS: We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with different energy sources in 14 centers (January 2019-January 2023). INCLUSION CRITERIA: prostate volume ≥ 80 ml. EXCLUSION CRITERIA: prostate cancer, previous prostate/urethral surgery, pelvic radiotherapy. PRIMARY OUTCOME: complication rate. SECONDARY OUTCOMES: incidence of and factors affecting postoperative UI. Patients were divided into 3 groups. Group 1: PV = 80-100 ml; Group 2 PV = 101-200 ml; Group 3 PV > 200 ml. Multivariable logistic regression analysis was performed to evaluate independent predictors of overall incontinence. RESULTS: There were 486 patients in Group 1, 1830 in Group 2, and 196 in Group 3. The most commonly used energy was high-power Holmium laser followed by Thulium fiber laser in all groups. Enucleation, morcellation, and total surgical time were significantly longer in Group 2. There was no significant difference in overall 30-day complications and readmission rates. Incontinence incidence was similar (12.1% in Group 1 vs. 13.2% in Group 2 vs. 11.7% in Group 3, p = 0.72). The rate of stress and mixed incontinence was higher in Group 1. Multivariable regression analysis showed that age (OR 1.019 95% CI 1.003-1.035) was the only factor significantly associated with higher odds of incontinence. CONCLUSIONS: PV has no influence on complication and UI rates following EEP. Age is risk factor of postoperative UI.

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.

Ureterorenoscopy for stone disease in pregnancy: a literature review and update.

PURPOSE OF REVIEW: Management of stone disease in pregnancy poses a challenge for all healthcare professionals involved in their care. During pregnancy, there is an increase in the incidence of urolithiasis. Major technological and procedural advances have been seen in the last decade for endoscopic management of urolithiasis. The purpose of this review is to provide a comprehensive workup of available literature on use of ureteroscopy for stone treatment during pregnancy. RECENT FINDINGS: We identified 268 articles on screening, of which 28 were included in the final review. Overall adverse event rates were low, with no severe complications reported in the included studies. On multivariate analysis, the only significant correlation was an inverse relationship between calculated caseload and adverse obstetric events. No further correlation could be found between caseload, operation technique and adverse event rates. Data quality was low among the included studies. SUMMARY: While ureteroscopy is a relatively safe and effective option for active stone treatment during pregnancy, they should be performed in experienced endourology centres in conjunction with obstetric teams.

ChatGPT in urology practice: revolutionizing efficiency and patient care with generative artificial intelligence.

PURPOSE OF REVIEW: ChatGPT has emerged as a potentially useful tool for healthcare. Its role in urology is in its infancy and has much potential for research, clinical practice and for patient assistance. With this narrative review, we want to draw a picture of what is known about ChatGPT's integration in urology, alongside future promises and challenges. RECENT FINDINGS: The use of ChatGPT can ease the administrative work, helping urologists with note-taking and clinical documentation such as discharge summaries and clinical notes. It can improve patient engagement through increasing awareness and facilitating communication, as it has especially been investigated for uro-oncological diseases. Its ability to understand human emotions makes ChatGPT an empathic and thoughtful interactive tool or source for urological patients and their relatives. Currently, its role in clinical diagnosis and treatment decisions is uncertain, as concerns have been raised about misinterpretation, hallucination and out-of-date information. Moreover, a mandatory regulatory process for ChatGPT in urology is yet to be established. SUMMARY: ChatGPT has the potential to contribute to precision medicine and tailored practice by its quick, structured responses. However, this will depend on how well information can be obtained by seeking appropriate responses and asking the pertinent questions. The key lies in being able to validate the responses, regulating the information shared and avoiding misuse of the same to protect the data and patient privacy. Its successful integration into mainstream urology needs educational bodies to provide guidelines or best practice recommendations for the same.

Digital health innovations in urology: telemedicine, wearables, and mobile applications - a systematic review of literature.

PURPOSE OF REVIEW: There are enough publications on the use of telemedicine, wearable devices, and mobile applications in urology; however, their collective impact on urological care has not been adequately studied. This review seeks to address this deficiency by providing a descriptive analysis of the recent use of telemedicine, wearable technology, and mobile applications in urology as well as elucidating their associated challenges. RECENT FINDINGS: There are studies that were dedicated to the use of telemedicine, wearables, and mobile apps in urology according to inclusion criteria, respectively. They were successfully implemented in different urological subfields, such as urogynecology, endourology, pediatric urology, and uro-oncology, and led to time safety, remote monitoring, and better patient awareness. However, several concerns also exist, such as issues with data safety, measurement deviations, technical limitations, and lack ofquality. SUMMARY: Telemedicine, wearables, and mobile apps have already shown their potential in urological practice. However, further studies are needed to expand both our understanding of their current state and their potential for further development and clinical use.

Single use flexible ureteroscopes: a review of current technologies and cost effectiveness analysis.

PURPOSE OF REVIEW: Flexible ureteroscopy (fURS) has evolved into both diagnostic and therapeutic modalities. Our review discusses the cost-effectiveness of single use flexible ureteroscopes (su-fURS) and the use of these instruments in routine urological practice. RECENT FINDINGS: There are studies which support the use of su-fURS with an argument of both cost and clinical utility over reusable flexible ureteroscopes (ru-fURS). However, the cost may vary across countries, hence is difficult to compare the results based on the current literature. Perhaps therefore there is a role for hybrid strategy incorporating ru- and su-fURS, where su-fURS are employed in complex endourological cases with a high risk of scope damage or fracture to preserve ru-fURS, with the ability to maintain clinical activity in such an event. SUMMARY: While there seems to be some cost advantages with su-fURS with reduced sterilization and maintenance costs, the data supporting it is sparse and limited. This choice of scope would depend on the durability of ru-fURS, procedural volumes, limited availability of sterilization units in some centers and potential risk of infectious complications. It is time that cost-benefit analysis is conducted with defined outcomes for a given healthcare set-up to help with the decision making on the type of scope that best serves their needs.

Measuring quality of life in patients with kidney stone disease: is it the future in endourology?

PURPOSE OF REVIEW: Kidney stone disease is recognized to negatively impact quality of life. This pertains to acute episodes, surgical interventions and even during asymptomatic periods. Over time there has been increased attention towards assessing this subjective parameter, including as a determinant of treatment success. Our aim was to evaluate the current status and emerging trends in this field. RECENT FINDINGS: Patient groups most affected appear to be recurrent stone formers, cystine stone formers, women, younger populations, non-Caucasians and low-income populations. Several stone specific patient reported outcome measures are now available of which, WISQol has been implemented the most in clinical research studies. More invasive interventions such as percutaneous nephrolithotomy impede quality of life to greater extent than alternatives such as shockwave lithotripsy. SUMMARY: There are certain patient groups who are more vulnerable to the negative impact of kidney stone disease on their quality of life. Urologists can improve patient care by recognizing these particular populations as well as by implemented patient reported outcome measures in their routine clinical practice and when performing research.

Navigation systems and 3D imaging in percutaneous nephrolithotripsy: improving outcomes and safety.

PURPOSE OF REVIEW: Percutaneous nephrolithotripsy (PCNL) is the first-line management option for large kidney stones (>2 cm). It remains, however, a demanding procedure with considerable morbidity. The present narrative review summarizes recent knowledge from original research studies investigating navigation systems/three-dimensional (3D) imaging in PCNL, particularly on publications during the past 12-18 months. RECENT FINDINGS: Navigation systems and 3D imaging are primarily used for preoperative planning, with few intra-operative applications. Patient management and residents' training could benefit from their use. SUMMARY: Navigation systems and 3D imaging technology have emerged as a potential game-changer in PCNL. Even though available evidence is currently scarce/inconclusive, the safety/efficacy of navigation systems and 3D dimensional imaging use in PCNL appears promising. This advanced technology offers precise anatomical mapping, improved visualization, and surgical accuracy. Enabling a comprehensive preoperative evaluation and improving guidance, navigation systems, and 3D imaging technology may improve the safety and efficacy of PCNL. With continuous technological evolution, it is expected that improvements/innovations will offer further aid in such demanding procedures. Familiarization and cost reduction are necessary for widespread application, while larger-scale prospective studies and well designed randomized controlled trials are still needed.

Should endoscopic laser excision be offered as the first-line management for patients with eroded mesh? Outcomes of a systematic review of literature.

PURPOSE OF REVIEW: Mesh erosions following previous synthetic sling/mesh surgery for stress urinary incontinence (SUI) have become increasingly common. This systematic review provides evidence for the role of laser excision as a first-line management in patients with eroded mesh. RECENT FINDINGS: Fourteen articles (173 patients) were included for the final review. Among these, 138 patients (79.8%) were submitted to trans-urethral laser excision of eroded urethral/bladder mesh over a median time to presentation of 36.6 months. Over a median follow-up of 23.6 months, 88 (63.7%) reported a complete resolution, 32 (23.2%) reported persistence or recurrence of SUI and 17 (12.3%) presented with recurrent mesh erosion. The success rate after a single endoscopic procedure was 66.5, vs. 93.5% after additional endoscopic procedures, with only 9 (6.6%) requiring open surgical excision. Overall, there were seven (5.1%) postoperative complications including two urethrovaginal fistulas, two UTIs and haematuria each, and one case of urethral diverticulum. SUMMARY: Laser excision of eroded mid-urethral slings into either the bladder or urethra is a challenging complication of minimally invasive incontinence surgery. Laser excision was able to achieve a good success rate with single or staged endoscopic procedure with a low risk of complication. It represents a valid first treatment option, although patients should be managed in mesh referral centres in collaboration with uro-gynaecology teams.