Off-clamp vs on-clamp robot-assisted partial nephrectomy: a systematic review and meta-analysis.

OBJECTIVE: To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate-matched studies (propensity score-matched or matched-pair analysis). METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off-clamp to on-clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random-effects meta-analyses were performed to generate mean differences (MDs) or odds ratios (ORs). RESULTS: A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off-clamp and on-clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] -0.9 to 44.7 mL; P = 0.06, I2 = 58%). Off-clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05-5.16%; P = 0.008, I2 = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40-0.94; P = 0.03, I2 = 0%). No significant differences were found for all secondary outcomes. CONCLUSIONS: Off-clamp and on-clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off-clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin-positive rates.

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.

Endoscopic intervention versus radical nephroureterectomy for the management of localized upper urinary tract urothelial carcinoma: a systematic review and meta-analysis of comparative studies.

OBJECTIVE: Localized Upper Urinary Tract Urothelial Carcinoma (UTUC) is an uncommon cancer typically detected at an advanced stage. Currently, radical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for high-risk UTUC. This meta-analysis aims to evaluate the 5-year overall and cancer-specific survival and bladder recurrence rates in studies comparing endoscopic kidney-sparing surgeries (E-KSS) with RNU in localized UTUC. EVIDENCE ACQUISITION: We performed a literature search on 20th April 2023 through PubMed, Web of Science, and Scopus. The PICOS model was used for study inclusion: P: adult patients with localized UTUC; I: E-KSS. C: RNU; O: primary: overall survival (OS); secondary: cancer-specific survival (CSS), bladder recurrence rate, and metastasis-free survival (MFS). S: retrospective, prospective, and randomized studies. EVIDENCE SYNTHESIS: Overall, 11 studies involving 2284 patients were eligible for this meta-analysis, 737 in the E-KSS group and 1547 in the RNU group. E-KSS showed a similar overall 5-year OS between E-KSS and RNU, and for low-grade tumors, while 5-year OS favored RNU for high-grade tumors (RR 1.84, 95% CI 1.26-2.69, p = 0.002). No difference emerged for 5-year CSS between the two groups, even when the results were stratified for low- and high grade tumors. Bladder recurrence rate and 5-year MFS were also similar between the two groups. CONCLUSIONS: Our review showed that E-KSS is a viable option for patients with localized UTUC with non-inferior oncological outcomes as compared with RNU, except for 5-year OS in high-grade tumors which favoured RNU.

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.

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.

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.

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.

Functional and safety outcomes after benign prostatic enlargement surgeries in men with detrusor underactivity compared with normal detrusor contractility: Systematic review and meta-analysis.

INTRODUCTION: Men with detrusor underactivity (DUA) and concomitant bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC). MATERIALS AND METHODS: This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software. RESULTS: There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eight TURP (transurethral resection of the prostate) studies, four GreenLight PVP (photoselective vaporization of the prostate) studies, two HoLEP (Holmium laser enucleation of the prostate) studies, one GreenLight PVP/HoLEP study, one Holmium laser incision of the prostate study, and one study did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS), lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR) of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up. CONCLUSION: In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery.

Evaluating the Safety of Retrograde Intrarenal Surgery (RIRS): Intra- and Early Postoperative Complications in Patients Enrolled in the Global Multicentre Flexible Ureteroscopy Outcome Registry (FLEXOR).

PURPOSE: To assess the incidence of the most common intra- and early postoperative complications following RIRS in a large series of patients with kidney stones. METHODS: We conducted a retrospective analysis of patients with kidney stones who underwent RIRS across 21 centers from January 2018 to August 2021, as part of the Global Multicenter Flexible Ureteroscopy Outcome (FLEXOR) Registry. RESULTS: Among 6669 patients undergoing RIRS, 4.5% experienced intraoperative pelvicalyceal system bleeding without necessitating blood transfusion. Only 0.1% of patients, required a blood transfusion. The second most frequent intraoperative complication was ureteric injury due to the ureteral access sheath requiring stenting (1.8% of patients). Postoperatively, the most prevalent early complications were fever/infections requiring antibiotics (6.3%), blood transfusions (5.5%), and sepsis necessitating intensive care unit admission (1.3%). In cases of ureteric injury, a notably higher percentage of patients exhibited multiple stones and stone(s) in the lower pole, and these cases were correlated with prolonged lasing and overall surgical time. Hematuria requiring a blood transfusion was associated with an increased prevalence of larger median maximum stone diameters, particularly among patients with stones exceeding 20 mm. Furthermore, these cases exhibited a significant prolongation in surgical time. Sepsis necessitating admission to the intensive care unit was more prevalent among the elderly, concomitant with a significantly larger median maximum stone diameter. CONCLUSIONS: Our analysis showed that RIRS has a good safety profile but bleeding requiring transfusions, ureteric injury, fever, and sepsis are still the most common complications despite advancements in technology.

Comparison Between Holmium:YAG Laser with MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-matched Analysis From the FLEXible Ureteroscopy Outcomes Registry.

PURPOSE: We evaluated stone-free rate and complications after flexible ureteroscopy for renal stones, comparing thulium fiber laser and holmium:YAG laser with MOSES technology. MATERIALS AND METHODS: Data from adults who underwent flexible ureteroscopy in 20 centers worldwide were retrospectively reviewed (January 2018-August 2021). Patients with ureteral stones, concomitant bilateral procedures, and combined procedures were excluded. One-to-one propensity score matching for age, gender, and stone characteristics was performed. Stone-free rate was defined as absence of fragments >2 mm on imaging within 3 months after surgery. Multivariable logistic regression analysis was performed to evaluate independent predictors of being stone-free. RESULTS: Of 2,075 included patients, holmium:YAG laser with MOSES technology was used in 508 patients and thulium fiber laser in 1,567 patients. After matching, 284 patients from each group with comparable baseline characteristics were included. Pure dusting was applied in 6.0% of cases in holmium:YAG laser with MOSES technology compared with 26% in thulium fiber laser. There was a higher rate of basket extraction in holmium:YAG laser with MOSES technology (89% vs 43%, P < .001). Total operation time and lasing time were similar. Nine patients had sepsis in thulium fiber laser vs none in holmium:YAG laser with MOSES technology (P = .007). Higher stone-free rate was achieved in thulium fiber laser (85% vs 56%, P < .001). At multivariable analysis, the use of thulium fiber laser and ureteral access sheath ≥8F had significantly higher odds of being stone-free. Lasing time, multiple stones, stone diameter, and use of disposable scopes showed significantly lower odds of being stone-free. CONCLUSIONS: This real-world study favors the use of thulium fiber laser over holmium:YAG laser with MOSES technology in flexible ureteroscopy for renal stones by way of its higher single-stage stone-free rate.

The current evidence on surgical management for synchronous bilateral renal tumors: results from a scoping review.

PURPOSE: Synchronous bilateral renal masses (SBRM) account for a low percentage of kidney tumors, and there is no current recommendation for their management. The objective was to review evidence regarding the best surgical approach for SBRM in terms of type and timing of surgery. METHODS: A broad literature search was performed on 28th January 2023 using Scopus, PubMed, and EMBASE. Only English papers dealing with adults were included. Meeting abstracts were excluded. RESULTS: Twenty-four papers were accepted and included. SBRM behave less aggressively than metachronous tumors, and partial nephrectomy (PN) is the preferred therapeutic option to preserve renal function. Open, laparoscopic, and robot-assisted approaches were found to be similar in oncological outcomes, though robot-assisted surgery resulted in lower comorbidities. Same-sitting PN was demonstrated to be a safe approach, particularly in the robotic-assisted one. Finally, the same-siting and staged NSS were similar in preserving renal function. CONCLUSIONS: PN should be the desirable treatment for SBRM whenever feasible and if patients are fit, but surgeon expertise should also be taken into the account.

Dietary management of hypocitraturia in children with urolithiasis: results from a systematic review.

PURPOSE: Hypocitraturia is a low urinary excretion of citrate and a well-known risk factor for kidney stone development in children. This systematic review aimed to evaluate the dietary management of hypocitraturia in children with urolithiasis. METHODS: Literature search was performed on 30th September 2022 using Embase, PubMed, and Cochrane Central Controlled Register of Trials. Studies were included if children with stones and hypocitraturia were managed with diet supplements. RESULTS: Six papers were included. Four studies evaluated the role of oral potassium citrate associated with high fluid intake on stone resolution and recurrence. Two studies assessed the impact of oral potassium citrate on long-term stone recurrence after percutaneous nephrolithotomy and shock wave lithotripsy. All studies demonstrated that the association of potassium citrate and high fluid intake was well tolerated with no side effects and restored normal urine citrate excretion, allowed a reduction in stone size, and, following definitive treatments, was associated with a lower rate of stone regrowth and recurrence compared with controls. These effects were demonstrated across all pediatric ages. CONCLUSIONS: Our review infers that oral potassium citrate and high fluid assumption are safe and effective in restoring urine citrate excretion, treating and preventing stone recurrence with no serious adverse events, and should probably be the first-line treatment of pediatric patients with asymptomatic stones and hypocitraturia.

Holmium laser with MOSES technology (MoLEP) vs Thulium fiber laser enucleation of the prostate (ThuFLEP) in a real-world setting. Mid-term outcomes from a multicenter propensity score analysis.

PURPOSE: To compare Holmium laser with MOSES technology (MoLEP) and Thulium fiber laser enucleation of the prostate (ThuFLEP) in terms of surgical and functional outcomes. METHODS: We performed a retrospective analysis of all patients who underwent either procedure in five centers (January 2020-January 2022). EXCLUSION CRITERIA: previous urethral/prostatic surgery, radiotherapy, concomitant surgery. Propensity score matching (PSM) analysis was performed to adjust for the bias inherent to the different characteristics at baseline. Differences between procedures were estimated using Firth Penalized Likelihood regression for International prostate symptom score (IPSS), quality of life (QL), maximum flow rate (Qmax). RESULTS: PSM retrieved 118 patients in each group. Baseline characteristics were similar except for PSA and number of men on indwelling catheter (higher in MoLEP group). Median surgical time was significantly longer in the MoLEP group despite the enucleation and morcellation times being similar. Median catheter dwelling time and postoperative length of stay were similar. Most of the early complications were Clavien ≤ 2 grade. There were only two Clavien grade 3 complications (one for each group), one grade 4 in MoLEP group. Rate and type of early and persistent incontinence (> 3 months) were similar. At 12-month, proportion of patients reaching a decrease (Δ) of IPSS ≥ 18 from baseline was significantly larger in MoLEP group, with no significant difference in ΔQmax > 12 ml/sec and ΔQL ≥ -3. CONCLUSION: MoLEP and ThuFLEP were safe and efficacious procedures with similar short-term operative and functional outcomes. At 1-year, MoLEP patients had a sustained reduction of IPPS score.

Radiomics vs radiologist in prostate cancer. Results from a systematic review.

PURPOSE: Radiomics in uro-oncology is a rapidly evolving science proving to be a novel approach for optimizing the analysis of massive data from medical images to provide auxiliary guidance in clinical issues. This scoping review aimed to identify key aspects wherein radiomics can potentially improve the accuracy of diagnosis, staging, and extraprostatic extension in prostate cancer (PCa). METHODS: The literature search was performed on June 2022 using PubMed, Embase, and Cochrane Central Controlled Register of Trials. Studies were included if radiomics were compared with radiological reports only. RESULTS: Seventeen papers were included. The combination of PIRADS and radiomics score models improves the PIRADS score reporting of 2 and 3 lesions even in the peripheral zone. Multiparametric MRI-based radiomics models suggest that by simply omitting diffusion contrast enhancement imaging in radiomics models can simplify the process of analysis of clinically significant PCa by PIRADS. Radiomics features correlated with the Gleason grade with excellent discriminative ability. Radiomics has higher accuracy in predicting not only the presence but also the side of extraprostatic extension. CONCLUSIONS: Radiomics research on PCa mainly uses MRI as an imaging modality and is focused on diagnosis and risk stratification and has the best future possibility of improving PIRADS reporting. Radiomics has established its superiority over radiologist-reported outcomes but the variability has to be taken into consideration before translating it to clinical practice.

The efficacy of retrograde intra-renal surgery (RIRS) for lower pole stones: results from 2946 patients.

PURPOSE: To evaluate the perioperative outcomes of retrograde intra-renal surgery (RIRS) for lower pole stones (LPS) and factors affecting stone-free rate (SFR). METHODS: Data from 20 centers were retrospectively reviewed. Inclusion criteria were adult patients, normal renal anatomy, and LPS. Exclusion criteria were bilateral surgery, concomitant surgery for ureteral stones. SFR was defined as a single residual fragment (RF) ≤ 2 mm and evaluated 3-months after surgery. A multivariable logistic regression analysis was performed to assess factors associated with RF. Statistical significance was set at p value < 0.05. RESULTS: 2946 patients were included. Mean age and stone size were 49.9 years 10.19 mm, with multiple LPS in 61.1% of cases. Total operation and laser time were 63.89 ± 37.65 and 17.34 ± 18.39 min, respectively. Mean hospital stay was 3.55 days. Hematuria requiring blood transfusion and fever/urinary infections requiring prolonged antibiotics occurred in 6.1% and 169 5.7% of cases, while sepsis with intensive-care admission in 1.1% of patients. On multivariate analysis, Multiple stones (OR 1.380), stone size (OR 1.865), and reusable ureteroscopes (OR 1.414) were significantly associated with RF, while Thulium fiber laser (TFL) (OR 0.341) and pre-stenting (OR 0.750) were less likely associated with RF. CONCLUSIONS: RIRS showed safety and efficacy for LPS with a mean diameter of 10 mm. This procedure can achieve a satisfactory SFR in pre-stented patients with a single and smaller stone, particularly with TFL use.

Do Hounsfield Units have any significance in predicting intra- and postoperative outcomes in retrograde intrarenal surgery using Holmium and Thulium fiber laser? Results from the FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To evaluate outcomes of flexible ureteroscopy for renal stones by comparing hard versus soft stones based on their attenuation on computed tomography (Hounsfield Units-HU). METHODS: Patients were divided into two groups according to the type of laser employed [Holmium:YAG (HL) or Thulium fiber laser (TFL)]. Residual fragments (RF) were defined as > 2 mm. Multivariable logistic regression analysis was performed to evaluate factors associated with RF and RF needing further intervention. RESULTS: 4208 patients from 20 centers were included. In whole series, age, recurrent stones, stone size, lower pole stones (LPS), and multiple stones were predictors of RF at multivariable analysis and LPS and stone size with RF requiring further treatment. HU and TFL were associated with lesser RF and RF requiring an additional treatment. In HU < 1000 stones, recurrent stones, stone size, and LPS were predictors of RF at multivariable analysis, whereas TFL was less likely associated with RF. Recurrent stones, stone size, and multiple stones were predictors of RF requiring further treatment, while LPS and TFL were associated with lesser RF requiring further treatment. In HU ≥ 1000 stones, age, stone size, multiple stones, and LPS were predictors of RF at multivariable analysis, while TFL was less likely associated with RF. Stone size and LPS were predictors of RF requiring further treatment, whereas TFL was associated with RF requiring further treatment. CONCLUSION: Stone size, LPS, and use of HL are predictors of RF after RIRS for intrarenal stones regardless of stone density. HU should be considered an important parameter in predicting SFR.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting.

PURPOSE: To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP). METHODS: Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022. INCLUSION CRITERIA: lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery. EXCLUSION CRITERIA: prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy. RESULTS: Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort. CONCLUSION: Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Indications, preferences, global practice patterns and outcomes in retrograde intrarenal surgery (RIRS) for renal stones in adults: results from a multicenter database of 6669 patients of the global FLEXible ureteroscopy Outcomes Registry (FLEXOR).

PURPOSE: To collect a multicentric database on behalf of TOWER research group to assess practice patterns and outcomes of retrograde intrarenal surgery (RIRS) for kidney stones. METHODS: Inclusion criteria: age ≥ 18 years, normal renal/calyceal system anatomy, calculi of any size, number, and position. STUDY PERIOD: January 2018 and August 2021. Stone-free status: absence of fragments > 2 mm, assessed post procedure according to the local protocol (KUB X-Ray and/or ultrasound or non-contrast CT scan). RESULTS: Twenty centers from fifteen countries enrolled 6669 patients. There were 4407 (66.2%) men. Mean age was 49.3 ± 15.59 years. Pain was the most frequent symptom indication for intervention (62.6%). 679 (10.2%) patients underwent RIRS for an incidental finding of stones. 2732 (41.0%) patients had multiple stones. Mean stone size was 10.04 ± 6.84 mm. A reusable flexible ureteroscope was used in 4803 (72.0%) procedures. A sheath-less RIRS was performed in 454 (6.8%) cases. Holmium:YAG laser was used in 4878 (73.1%) cases. A combination of dusting and fragmentation was the most common lithotripsy mode performed (64.3%). Mean operation time was 62.40 ± 17.76 min. 119 (1.8%) patients had an intraoperative injury of the ureter due to UAS insertion. Mean postoperative stay was 3.62 ± 3.47 days. At least one postoperative complication occurred in 535 (8.0%) patients. Sepsis requiring intensive care admission occurred in 84 (1.3%) patients. Residual fragments were detected in 1445 (21.7%) patients. Among the latter, 744 (51.5%) patients required a further intervention. CONCLUSION: Our database contributes real-world data to support to a better understanding of modern RIRS practice and outcomes.

Perioperative outcomes and risk factors for major complications associated with nephrectomy for Xanthogranulomatous pyelonephritis: a multicenter study.

PURPOSE: To determine the risk factors associated with major complications in patients with histologically confirmed Xanthogranulomatous pyelonephritis (XGP) who underwent nephrectomy. METHODS: A multicenter retrospective study was performed including patients who underwent nephrectomy between 2018 and 2022 with histopathological diagnosis of XGP. Clinical and laboratory parameters at the initial presentation were evaluated. Data on extension of XGP was recorded as per the Malek clinical-radiological classification. Characteristics of nephrectomy and perioperative outcomes were obtained. The primary outcome was major complications, defined as a CD ≥ grade 3 and the need for intensive care unit (ICU) admission. Secondary outcomes included the comparison of complications evaluating the nephrectomy approach (transperitoneal, retroperitoneal, and laparoscopic). A sub-analysis stratifying patients who needed ICU admission and Malek classification was performed. RESULTS: A total of 403 patients from 10 centers were included. Major complications were reported in 98 cases (24.3%), and organ injuries were reported in 58 patients (14.4%), being vascular injuries the most frequent (6.2%). Mortality was reported in 5 cases (1.2%). A quick Sepsis-related Organ Failure Assessment (qSOFA) score ≥ 2, increased creatinine, paranephric extension of disease (Malek stage 3), a positive urine culture, and retroperitoneal approach were independent factors associated with major complications. CONCLUSION: Counseling patients on factors associated with higher surgical complications is quintessential when managing this disease. Clinical-radiological staging, such as the Malek classification may predict the risk of major complications in patients with XGP who will undergo nephrectomy. A transperitoneal open approach may be the next best option when laparoscopic approach is not feasible.

PCNL vs RIRS in management of stones in calyceal diverticulum: outcomes from a global multicentre match paired study that reflects real world practice.

INTRODUCTION: Calyceal diverticulum (CD) is the outpouching of a calyx into the renal parenchyma, connected by an infundibulum. Often associated with recurrent stones, common surgical options include percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS). We aim to present the real-world practises and outcomes comparing both approaches and the technical choices made. MATERIALS AND METHODS: Retrospective data including 313 patients from 11 countries were evaluated. One hundred and twenty-seven underwent mini-PCNL and one hundred and eighty-six underwent RIRS. Patient demographics, perioperative parameters, and outcomes were analysed using either T test or Mann-Whitney U test. Categorical data between groups were analysed using the Chi-squared test. Propensity score matching (PSM) was performed matching for baseline characteristics. Subgroup analyses for anomalous/malrotated kidneys and difficult diverticulum access were performed. RESULTS: After PSM, 123 patients in each arm were included, with similar outcomes for stone-free rate (SFR) and complications (p < 0.001). Hospitalisation was significantly longer in PCNL. Re-intervention rate for residual fragments (any fragment > 4 mm) was similar. RIRS was the preferred re-intervention for both groups. Intraoperative bleeding was significantly higher in PCNL (p < 0.032) but none required transfusion. Two patients with malrotated anatomy in RIRS group required transfusion. Lower pole presented most difficult access for both groups, and SFR was significantly higher in difficult CD accessed by RIRS (p < 0.031). Laser infundibulotomy was preferred for improving diverticular access in both. Fulguration post-intervention was not practised. CONCLUSION: The crux lies in identification of the opening and safe access. Urologists may consider a step-up personalised approach with a view of endoscopic combined approach where required.