Impact of Either Trendelenburg or Reverse Trendelenburg Positioning for Ureteroscopy Lithotripsy Procedures: A Systematic Review and Meta-Analysis.

PURPOSE: Urologists encounter multiple challenges in managing ureteral stones with ureteroscopic laser lithotripsy. This meta-analysis assesses the effectiveness of alternative surgical positioning, Reverse Trendelenburg (RevTren) and Trendelenburg (Tren), in reducing stone migration and enhancing outcomes compared with standard dorsal lithotomy positioning. MATERIALS AND METHODS: A systematic review was conducted following PRISMA guidelines, searching Medline, Embase, Scopus, Cochrane, and WoS up to March 2024. This review focused on studies evaluating RevTren or Tren positioning during ureteroscopic lithotripsy compared with standard dorsal lithotomy, analyzing end points such as stone migration, conversion rates, success rates, complications, and operative time. RESULTS: Of 137 studies identified, 8 met the inclusion criteria, encompassing 1374 patients. RevTren significantly reduced ureteral stone migration (odds ratio [OR], 0.20; 95% CI, 0.08-0.47), lowered the need for conversion to a flexible ureteroscope (OR, 0.28; 95% CI, 0.12-0.67), and improved success rates (OR, 2.90; 95% CI, 1.88-4.48). Tren increased migration of ureteral and calyceal stones toward upper renal calyces (OR, 2.12; 95% CI, 1.48-3.04) and achieved a higher success rate (OR, 3.56; 95% CI, 2.15-5.92). Complications were comparable across all positions. CONCLUSION: Adjusting patient positioning during ureteroscopic laser lithotripsy can enhance procedure outcomes. RevTren effectively reduces ureteral stone migration and the necessity for flexible ureteroscopes, whereas Tren facilitates ureteral and calyceal stone migration toward upper calyces, increasing success rates. Both positioning techniques offer significant advantages over standard positioning and can be safely adopted in clinical practice without compromising patient safety.

Holmium:yttrium-aluminium-garnet laser with MOSES technology is more efficient than thulium fibre laser in supine mini-percutaneous nephrolithotomy.

OBJECTIVES: To address the paucity of literature comparing outcomes achieved with utilisation of the high-power holmium:yttrium-aluminium-garnet (Ho:YAG) laser with MOSES technology vs those achieved with the thulium fibre laser (TFL) in mini-percutaneous nephrolithotomy (PCNL). METHODS: A retrospective review was performed of patients undergoing supine mini-PCNL between August 2021 and May 2023. Exclusion criteria were urinary diversion, simultaneous utilisation of >1 laser platform, use of any other form of fragmentation, and ureteric stones. The Ho:YAG platform (Lumenis Pulse P120H™ with MOSES technology, 120W; Boston Scientific®) and the TFL (Soltive SuperPulsed Thulium Fibre [SPTF], 60W; Olympus®) were compared. Data on stone-free rate (SFR) were determined by computed tomography performed on the first postoperative day and presented as absence of stone fragments, no fragments larger than 2 mm, or no fragments larger than 4 mm. RESULTS: A total of 100 patients met the inclusion criteria, 51 mini-PCNLs with the Ho:YAG laser and 49 with the SPTF laser. No significant differences in demographics or stone characteristics were detected between the two groups. The Ho:YAG laser utilised less energy and time, resulting in higher ablation efficiency (P < 0.05) and less total operating time (P < 0.05). Overall, there was no difference in SFR in any category between the Ho:YAG group and the SPTF group (no fragments: relative risk [RR] 0.81, 95% confidence interval [CI] 0.59-1.12, P = 0.21; fragments <2 mm: RR 0.86, 95% CI 0.67-1.10, P = 0.23; fragments <4 mm: RR 0.96, 95% CI 0.80-1.15, P = 0.67). CONCLUSIONS: Although we observed an equivalent postoperative SFR, this study supports a shorter operating time and greater intra-operative laser efficiency with the Ho:YAG laser over the SPTF laser in mini-PCNL.

Preoperative urine culture with contaminants is not associated with increased risk for urinary tract infection after ureteroscopic stone treatment.

PURPOSE: We aimed to assess whether the presence of contaminants in the pre-operative urine culture (preop-UC) predicts postoperative urinary tract infection (postop-UTI) in patients undergoing elective ureteroscopy with laser lithotripsy. METHODS: A retrospective chart review was performed from 01/2019 to 12/2021 examining patients with unilateral stone burden ≤ 2 cm who underwent ureteroscopy with laser lithotripsy and had a preop-UC within 3 months. Positive, negative, contaminated, and polymicrobial definitions for UCs were established in accordance with current guidelines. Patients with positive and polymicrobial cultures were excluded. Postop-UTI was defined as the presence of urinary symptoms and a positive UC within 30 days of the procedure. Multivariable logistic regression models were utilized to evaluate risk factors for contamination in the preop-UC and the risk of postop-UTI. RESULTS: A total of 201 patients met the inclusion-exclusion criteria. Preop-UC was negative in 153 patients and contaminated in 48 patients. Significant contaminant-related factors included female gender and increased BMI. Postop-UTI was diagnosed in 3.2% of patients with negative preop-UCs and 4.2% of patients with contaminants, with no difference between groups (p = 0.67). The regression model determined that the presence of contaminants in preop-UC failed to predict postop-UTI (OR 0.69, p = 0.64). CONCLUSION: The presence of contaminants in preop-UCs is not associated with an increased risk of postop-UTIs after ureteroscopy. Our study supports that contaminants in the preop-UC can be interpreted as a negative UC in terms of postop-UTI risk stratification. Preoperative antibiotics should not be prescribed for patients undergoing uncomplicated ureteroscopy for stone surgery in the setting of a contaminated preop-UC.

Intrarenal pressure and flow rate profile using LithoVue™ elite: impact of different irrigation systems and working channel instruments.

PURPOSE: To report real-time IRP and FR while performing flexible ureteroscopy in porcine kidney model utilizing LithoVue™ Elite (Boston Scientific®) with different irrigation systems, including automated pumps. METHODS: Using an ex-vivo model of porcine kidney, IRPs were measured with LithoVue Elite. Ureteroscopic settings (US) were tested with all permutations of irrigation methods (IM), working channel occupant (WCO), and ureteral access sheaths (UAS). IMs included: Single Action Pumping System (SAPS™, Boston Scientific), Thermedx FluidSmart™ (Stryker®), and ENDOMAT™ (Karl Storz®). Pumps were tested at 50, 100, and 150 mmHg. WCOs included a 1.9Fr zero-tip basket, 200 µm, and 365 µm laser fibers. UASs utilized 11/13Fr and 12/14Fr 36 cm. RESULTS: 84 different US were tested (252 experiments). ENDOMAT had higher IRP but the same FR as Thermedx at the same US for 50 and 100 mmHg (p < 0.01). SAPS had higher IRP and FR than pumps in all US studies (p < 0.01). There was positive correlation between pressure set by the pump and both IRP and FR (rho > 0.9). As the diameter of the WCO increased, lower IRP and FR were observed with the pumps (p < 0.01). With SAPS, IRP was similar regardless of WCO, but FR was decreased with the increased diameter of WCO (p = 0.81 and p < 0.01, respectively). There was significantly higher IRP when using 11/13Fr UAS than 12/14Fr (p < 0.01). CONCLUSION: IRP was higher with SAPS than automated pumps. ENDOMAT showed higher IRP than Thermedx when under 150 mmHg. IRP and FR increase with higher pump pressure and decrease with larger diameter WCO. Likewise, a larger UAS significantly reduced IRP.

Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis.

BACKGROUND: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. RESULTS: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. CONCLUSION: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.

On the rocks: can urologists identify stone composition based on endoscopic images alone? A worldwide survey of urologists.

PURPOSE: As part of the management of nephrolithiasis, determination of chemical composition of stones is important. Our objective in this study is to assess urologists' accuracy in making visual, intraoperative determinations of stone composition. MATERIALS AND METHODS: We conducted a REDCap survey asking urologists to predict stone composition based on intraoperative images of 10 different pure-composition kidney stones of 7 different types: calcium oxalate monohydrate (COM), calcium oxalate dihydrate (COD), calcium phosphate (CP) apatite, CP brushite, uric acid (UA), struvite (ST) and cystine (CY). To evaluate experience, we examined specific endourologic training, years of experience, and number of ureteroscopy (URS) cases/week. A self-assessment of ability to identify stone composition was also required. RESULTS: With a response rate of 26% (366 completed surveys out of 1,370 deliveries), the overall accuracy of our cohort was 44%. COM, ST, and COD obtained the most successful identification rates (65.9%, 55.7%, and 52.0%, respectively). The most frequent misidentified stones were CP apatite (10.7%) and CY (14.2%). Predictors of increased overall accuracy included self-perceived ability to determine composition and number of ureteroscopies per week, while years of experience did not show a positive correlation. CONCLUSIONS: Although endoscopic stone recognition can be an important tool for surgeons, it is not reliable enough to be utilized as a single method for stone identification, suggesting that urologists need to refine their ability to successfully recognize specific stone compositions intraoperatively.

Temperature rise during ureteral laser lithotripsy: comparison of super pulse thulium fiber laser (SPTF) vs high power 120 W holmium-YAG laser (Ho:YAG).

PURPOSE: The holmium-YAG (Ho:YAG) Laser system is the current gold standard for laser lithotripsy (LL). Super Pulse Thulium Fiber Laser (SPTF) has emerged as an effective alternative. We compared the temperature profile of both the 120 W Ho:YAG and the 60 W SPTF systems during ureteral lithotripsy. METHODS: Antegrade ureteroscopy with LL was performed in ex-vivo porcine kidneys with 3 mm Begostones. Intra-ureteral temperature was measured using one probe proximal and one distal to the site of lithotripsy. LL was performed using a 200 µm core fiber at dusting (SPTF-0.1 J, 200 Hz, SP; Ho:YAG-0.3 J, 70 Hz, LP) and fragmenting (0.8 J, 8 Hz, SP for both) settings for 5 s. Fifteen repetitions were recorded for each laser at each setting. Tissue samples of the ureter were collected for histological analysis. RESULTS: There was a rise in temperature at the site of lithotripsy using both systems at every setting evaluated. The median temperatures were greater for the SPTF on the fragmenting setting (33.3 °C vs 30.0 °C, p = 0.004). On the dusting setting, the median temperature was not statistically greater for Ho:YAG (40.6 °C vs 35.8 °C, p = 0.064), (Graphic 1). Histological analysis did not show any signs of injury or necrosis in any of the tested settings. CONCLUSION: Higher power settings used for dusting have a higher temperature rise in the ureter during lasering. Median ureteral intra-luminal temperature rise during LL was equivalent during dusting and higher in the SPTF during fragmentation, but neither reached the threshold for thermal injury based on the duration of exposure.

Stone size on endoscopic view as a predictor of successful stone retrieval during flexible ureteroscopy: an in vitro analysis.

PURPOSE: Basketing plays an important role during flexible ureteroscopy, but it can be time-consuming, especially when fragments are too large to pass through the ureteral access sheath. We aim to present the optimal on-screen, endoscopic stone size that predicts successful basketing through various access sheaths. METHODS: A tipless basket, individually extended to 5 mm from multiple ureteroscopes: (Flex-Xc, Karl Storz; Flex-X2s, Karl Storz; LithoVue, Boston Scientific; or URF-P6R, Olympus) and via differently sized access sheaths (10-12 Fr through 13-15 Fr), was used in retrieval attempts of various artificial stone sizes (2 mm through 5 mm). A relative endoscopic stone size was recorded as the stone's maximum diameter on endoscopic view compared to the total image diameter. RESULTS: Basketing of stones up to 2.5 mm, yielding relative endoscopic stone sizes of 0.38 (Flex-Xc), 0.30 (Flex-X2s), 0.32 (LithoVue), and 0.34 (URF-P6R), was successful using all access sheaths. Only the 12-14 Fr and greater sheaths allowed for successful basketing of 3 mm stones. Larger stones did not successfully pass through any of the access sheaths. CONCLUSION: Successful stone retrieval can be predicted by estimating the stone's size on screen, which is influenced by the type of flexible ureteroscope and access sheath. In our testing, stones of approximately one-third of the screen size passed successfully in all cases.

Subcapsular hematoma after ureteroscopy and laser lithotripsy.

Subcapsular hematoma is an uncommon complication after ureteroscopy and laser lithotripsy. We report on a 38-year-old male with an 8 mm lower pole stone who underwent a left ureteroscopy and laser lithotripsy. The stone was successfully fragmented. Several hours after being discharged home, the patient returned complaining of back pain and hematuria. He was hemodynamically stable. Laboratory exams were normal. A CT study showed a crescent renal subcapsular hematoma surrounding the left kidney. The patient was admitted to the ward for conservative treatment. No additional intervention was necessary. Most subcapsular hematomas tend to resolve spontaneously.

Evaluation of emissivity and temperature profile of laparoscopic ultrasonic devices (blades and passive jaws).

OBJECTIVES: We examined the emissivity and temperature profile of passive and active jaws of various laparoscopic ultrasonic devices during cutting, coagulation, and cooling time. METHODS: The Harmonic ACE™ (ACE), Covidien Sonicision™ (SNC), and Olympus SonoSurg™ (SS) were applied using pre-set factory cutting and coagulation settings to Bovine mesentery and Lamb renal veins, respectively. The maximum temperature and cooling time to reach 60 °C were recorded using an infrared Fluke Ti55 thermal imager. Histological examination was evaluated after application of energy. RESULTS: The ACE, Sonicision, and SonoSurg had emissivity measurements of 0.49 ± 0.01, 0.40 ± 0.00, and 0.39 ± 0.01, respectively. Maximum cutting temperatures were: ACE = 191.1°, SNC = 227.1°, and SNS 184.8° * (*p < 0.001). Maximum coagulation temperatures did not differ significantly among devices (p = 0.490). The cooling time to reach 60 °C after activation were 35.7 s (ACE), 38.7 s (SNC), and 27.4 s* (SS) (*p < 0.001). The cooling time of passive jaws to reach 60 °C after activation were 25.4 s* (ACE), 5.7 s (SNC), and 15.4 s (SS) (*p < 0.001). CONCLUSION: Laparoscopic ultrasonic instruments obtain the same cutting and coagulation objectives but in different manners. The Sonicision improves cutting by getting the blade hotter while the SonoSurg has more precise coagulation effects by heating slower. Emissivity values varied among instruments, providing equally varied results. Depending on the purpose of the devices, a certain device may be more appropriate. Based on emissivity, more studies are needed to identify the ideal material that can predictably and effectively perform in clinical settings. Although different blade geometry is apparent between instruments, the jaws are also designed differently between the generations of instruments.

Bipolar energy in the treatment of benign prostatic hyperplasia: a current systematic review of the literature.

INTRODUCTION: For decades, the monopolar transurethral resection of the prostate has been established as the minimally invasive surgical treatment for patients with benign prostatic hyperplasia (BPH). In recent years, new technologies and devices emerged to reduce the morbidity and improve outcomes for this treatment approach. Bipolar energy introduced the use of saline irrigation and laser technology increased the urological armamentarium to treat BPH. We performed a systematic review of the literature regarding bipolar technology for the treatment of BPH. MATERIALS AND METHODS: A MEDLINE database search using the PRISMA methodology. Selected literature was restricted to articles published in English and published between 2005 and 2015. Articles regarding techniques using bipolar energy were included, while manuscripts that used a different technique, hybrid techniques, or techniques other than bipolar resection, bipolar vaporization, and bipolar enucleation were excluded. RESULTS: The use of bipolar energy in the endoscopic treatment of BPH presented a significant reduction in operative time, perioperative complications, shorter catheterization time, reduced number of blood products transfused, and shorter hospital stay compared to standard techniques. Postoperative outcomes showed that bipolar energy was safe and offered significant outcome improvement when compared to traditional monopolar transurethral resection of the prostate (TURP). CONCLUSION: The use of bipolar energy in the surgical treatment of patients with BPH is safe and is associated with improvements in perioperative outcomes. Short and mid-term functional outcomes are comparable to standard techniques, but long term functional outcomes need better clinical evaluation.

Laminar and turbulent surgical plume characteristics generated from curved- and straight-blade laparoscopic ultrasonic dissectors.

OBJECTIVE: To characterize laparoscopic ultrasonic dissector surgical plume emission (laminar or turbulent) and investigate plume settlement time between curved and straight blades. MATERIALS AND METHODS: A straight and a curved blade laparoscopic ultrasonic dissector were activated on tissue and in a liquid environment to evaluate plume emission. Plume emission was characterized as either laminar or turbulent and the plume settlement times were compared. Devices were then placed in liquid to observed consistency in the fluid disruption. RESULTS: Two types of plume emission were identified generating different directions of plume: laminar flow causes minimal visual obstruction by directing the aerosol downwards, while turbulent flow directs plume erratically across the cavity. Laminar plume dissipates immediately while turbulent plume reaches a second maximum obstruction approximately 0.3 s after activation and clears after 2 s. Turbulent plume was observed with the straight blade in 10 % of activations, and from the curved blade in 47 % of activations. The straight blade emitted less obstructive plume. CONCLUSION: Turbulent flow is disruptive to laparoscopic visibility with greater field obstruction and requires longer settling than laminar plume. Ultrasonic dissectors with straight blades have more consistent oscillations and generate more laminar flow compared with curved blades. Surgeons may avoid laparoscope smearing from maximum plume generation depending on blade geometry.

Ethnic minorities (African American and Hispanic) males prefer prostate cryoablation as aggressive treatment of localized prostate cancer.

INTRODUCTION: Our safety net hospital offers minimally invasive, traditional open and perineal radical prostatectomies, as well as radiation therapy and medical oncological services when appropriate. Historically, only few African American and Hispanic patients elected surgical procedures due to unknown reasons. Interestingly, after initiation of the prostate cryoablation program (Whole Gland) in 2003 at Denver Health Medical Center (DHMC) we noticed a trend towards cryotherapy in these specific patient populations for the treatment of localized prostate cancer. We analyzed the profile of ethnic minority men evaluated for localized prostate cancer and evaluated the associated factors in the decision making for the treatment of localized prostate cancer. MATERIALS AND METHODS: A retrospective review of 524 patients seen for prostate cancer from January 2003 to January 2012 in our safety net hospital was conducted. The treatment selected by the patient after oncologic consultation was then recorded. The health insurance status, demographic data, and personal statements of reasons for elected procedure were obtained. A multivariate logistic regression for associated factors influencing treatment decisions was then formed. Patients were categorized by using the D'Amico risk stratification criteria. RESULTS: The insurance status revealed that only 1% of African American patients had private health insurance versus 5% Hispanic and 26% of Caucasians. African American men were at higher D'Amico risk with more positive metastasis evaluation yet were less likely to undergo surgery and instead often elected for radiation therapy. Conversely, Hispanic and Caucasian men often elected cryoablation and radical prostatectomy for their treatment. Referrals for surgery were primarily Caucasian males with private health insurance. Most minority patients had indigent health coverage. Statistical analysis further revealed that age, marital status, indigent enrollment, D'Amico risk, and the option of cryoablation may influence patient's selection for surgical management of localized prostate cancer. CONCLUSION: Many factors influence treatment selection including race, age, marital status, enrollment in an indigent program, and a high D'Amico risk. The less invasive nature of cryoablation appeared to influence patients' opinion regarding surgery for the treatment of localized prostate cancer, especially in African American men.

The S.T.O.N.E. Score: a new assessment tool to predict stone free rates in ureteroscopy from pre-operative radiological features.

OBJECTIVE: To develop a user friendly system (S.T.O.N.E. Score) to quantify and describe stone characteristics provided by computed axial tomography scan to predict ureteroscopy outcomes and to evaluate the characteristics that are thought to affect stone free rates. MATERIALS AND METHODS: The S.T.O.N.E. score consists of 5 stone characteristics: (S) ize, (T)opography (location of stone), (O)bstruction, (N)umber of stones present, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale. The S.T.O.N.E. Score was applied to 200 rigid and flexible ureteroscopies performed at our institution. A logistic model was applied to evaluate our data for stone free rates (SFR). RESULTS: SFR were found to be correlated to S.T.O.N.E. Score. As S.T.O.N.E. Score increased, the SFR decreased with a logical regression trend (p < 0.001). The logistic model found was SFR=1/(1+e^(-z)), where z=7.02-0.57•Score with an area under the curve of 0.764. A S.T.O.N.E. Score ≤ 9 points obtains stone free rates > 90% and typically falls off by 10% per point thereafter. CONCLUSIONS: The S.T.O.N.E. Score is a novel assessment tool to predict SFR in patients who require URS for the surgical therapy of ureteral and renal stone disease. The features of S.T.O.N.E. are relevant in predicting SFR with URS. Size, location, and degree of hydronephrosis were statistically significant factors in multivariate analysis. The S.T.O.N.E. Score establishes the framework for future analysis of the treatment of urolithiasis.

Impact of Renal Access Angle and Speed of Nephroscope Retrieval Movements on the Vortex Effect.

OBJECTIVE: To analyze the influence of different renal access angles (AAs) and nephroscope retrieval speeds on the efficacy of the vortex effect (VE) in mini-percutaneous nephrolithotomy (mini-PCNL). This study aimed to understand the poorly understood physical components of the VE. MATERIALS AND METHODS: A Pexiglas™ (KUS®) model was built based on the dimensions of a 15/16 F mini-PCNL set (Karl Storz). The flow rate was continuous via an automatic pump and calibrated to achieve hydrodynamic equivalence to the real equipment. One experiment consisted of manually retrieving all 30 stone phantoms (3 mm diameter) utilizing only the VE. Cumulative time to retrieve all stones was measured. An accelerometer recorded instant speeds of the nephroscope every 0.08 seconds (s), and 3 experiments were performed at each angle (0°, 45°, and 90°). A logistic regression model was built utilizing maximum speeds and access angles to predict the effectiveness of the VE. RESULTS: Mean cumulative time for complete stone retrieval was 28.1 seconds at 0° vs 116.5 seconds at 45° vs 101.4 seconds at 90° (P < .01). We noted significantly higher speeds at 0° compared to 45° and 90° (P < .01); however, differences in average and maximum speed between 45° and 90° were not statistically significant (P = .21 and P = .25, respectively). The regression model demonstrated a negative association between increasing maximum speed and VE's effectiveness (OR 0.547, CI 95% 0.350-0.855, P < .01). When controlling for maximum speed, the 0° angle had significantly higher chances of achieving at least a partially effective VE. CONCLUSION: Increasing the renal access angle or nephroscope extraction speed negatively impacts the effectiveness of the VE. This significantly increased procedure time in the laboratory model, suggesting that the VE is less effective at higher sheath angles.

Laparoscopic ureteroneocystostomy for ureteral injuries after hysterectomy.

OBJECTIVES: To examine the feasibility of early laparoscopic ureteroneocystostomy for ureteral obstruction due to hysterectomy injury. METHODS: We retrospectively reviewed a 10-y experience from 2 institutions in patients who underwent early (<30 d) or late (>30 d) laparoscopic ureteroneocystostomy for ureteral injury after hysterectomy. Evaluation of the surgery included the cause of the stricture and intraoperative and postoperative outcomes. RESULTS: A total of 9 patients with distal ureteral injury after hysterectomy were identified. All injuries were identified and treated as early as 21 d after hysterectomy. Seven of 9 patients underwent open hysterectomy, and the remaining patients had vaginal and laparoscopic radical hysterectomy. All ureteroneocystostomy cases were managed laparoscopically without conversion to open surgery and without any intraoperative complications. The Lich-Gregoir reimplantation technique was applied in all patients, and 2 patients required a psoas hitch. The mean operative time was 206.6 min (range, 120-280 min), the mean estimated blood loss was 122.2 cc (range, 25-350 cc), and the mean admission time was 3.3 d (range, 1-7 d). Cystography showed no urine leak when the ureteral stent was removed at 4 to 6 wk after the procedure. Ureteroneocystostomy patency was followed up with cystography at 6 mo and at least 10 y after ureteroneocystostomy. CONCLUSION: Early laparoscopic ureteral reimplantation may offer an alternative surgical approach to open surgery for the management of distal ureteral injuries, with favorable cosmetic results and recovery time from ureteral obstruction due to hysterectomy injury.

Outcomes of intracorporeal lithotripsy of upper tract stones is not affected by BMI and skin-to-stone distance (SSD) in obese and morbid patients.

PURPOSE: The purpose of this study is to determine if body mass index (BMI) and stone skin distance (SSD) affect stone free rate (SFR) in obese and morbid obese patients who underwent flexible URS for proximal ureteral or renal stones < 20 mm. MATERIALS AND METHODS: A retrospective chart review was performed of consecutive patients that underwent flexible URS. Inclusion criteria were: proximal ureteral stones and renal stones less than 20 mm in the preoperative computed tomography (CT). SFR were then compared according to SSD and BMI. RESULTS: A total of 153 patients were eligible for this analysis, 49 (32.02%) with SSD < 10 cm and 104 (67.97%) with SSD ≥ 10 cm. The mean stone size was 10.5 ± 6.4 mm. The overall SFR in our study was 82.4%. The SFR for the SSD < 10 and ≥ 10 were 79.6% and 83.7% respectively (p = 0.698) and for BMI < 30, ≥ 30 and < 40 and ≥ 40 were 82.9%, 81.7% and 90.9% respectively. Regression analysis showed no affect between BMI or SSD regarding SFR. CONCLUSION: Ureteroscopy should be considered as a first-line of treatment for renal/proximal stones in obese and morbid obese patients. URS may be preferable to SWL in obese patients independently of the SSD, BMI or the location of proximal stones.