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.

A Delphi consensus to standardize the technique of anatomical endoscopic enucleation of prostate: a study by ESUT endoscopic enucleation of prostate study group.

PURPOSE: Our objective was to establish a standardized technique for Anatomical Endoscopic Enucleation of Prostate (AEEP) utilizing a consensus statement to provide robust recommendations for urologists who are new to this procedure. METHODS: The participants were electronically sent a questionnaire in three consecutive rounds. In the second and third rounds, the anonymous aggregate results of the previous round were presented. Experts' feedback and comments were then incorporated to refine existing questions or to explore more controversial topics in greater depth. RESULTS: Forty-one urologists participated in the first round. In the second round, all Round 1 participants received a 22-question survey, resulting in a consensus on 21 items. In the third round, 76% (19/25) of the second-round respondents also participated, reaching a consensus on 22 additional items. The panelists consensually agreed on detaching the urethral sphincter at the beginning of the enucleation and not at the end of the enucleation. To prevent incontinence, it was recommended that the apical mucosa be preserved through various approaches between 11 and 1 o'clock while gently disrupting the lateral lobes in their apical part, avoiding an excess energy delivery approximation to the apical mucosa. CONCLUSION: To optimize laser AEEP procedures, urologists must follow expert guidelines on equipment and surgical technique, including early apical release, using the 3-lobe technique for enucleation, preserving apical mucosa with appropriate approaches, gently disrupting lateral lobes at their apical regions, and avoiding excessive energy delivery near the apical mucosa. Following these recommendations can lead to improved outcomes and patient satisfaction.

Thulium fiber laser vs Ho:YAG in RIRS: a prospective randomized clinical trial assessing the efficacy of lasers and different fiber diameters (150 µm and 200 µm).

INTRODUCTION: The aims of the study: (1) to compare the Super Pulse Thulium Fiber Laser (SP TFL) and the holmium: yttrium-aluminium-garnet (Ho:YAG) lasers in retrograde intrarenal surgery (RIRS); (2) to compare the efficacy of SP TFL laser fibers of different diameters (150 µm and 200 µm). METHODS: A prospective randomized single-blinded trial was conducted. Patients with stones from 10 to 20 mm were randomly assigned RIRS in three groups: (1) SP TFL (NTO IRE-Polus, Russia) with fiber diameter of 150 µm; (2) SP TFL with 200-µm fiber; and (3) Ho:YAG (Lumenis, USA) with 200-µm fiber. RESULTS: Ninety-six patients with kidney stones were randomized to undergo RIRS with SP TFL using a 150-µm fiber (34 patients) and a 200-µm fiber (32 patients) and RIRS with Ho:YAG (30 patients). The median laser on time (LOT) in the 200-µm SP TFL group was 9.2 (6.2-14.6) min, in 150-µm SP TFL-11.4 (7.7-14.9) min (p = 0.390), in Ho:YAG-14.1 (10.8-18.1) min (p = 0.021). The total energy consumed in 200-µm SP TFL was 8.4 (5.8-15.2) kJ; 150-µm SP TFL - 10.8 (7.3-13.5) kJ (p = 0.626) and in Ho:YAG-15.2 (11.1-25.3) kJ (p = 0.005). CONCLUSIONS: Irrespective of the density, RIRS with SP TFL laser has proven to be both a safe and effective procedure. Whilst the introduction of smaller fibers may have the potential to reduce the duration of surgery, SP TFL results in a reduction in the LOT and total energy for stone ablation in RIRS compared with Ho:YAG.

Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: 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 expert laser settings for BPH treatment and evaluate the application of preventive measures to reduce complications. METHODS: A survey was conducted after narrative literature research to identify relevant questions regarding laser use for BPH treatment (59 questions). Experts were asked for laser settings during specific clinical scenarios. Settings were compared for the reported laser types, and common settings and preventive measures were identified. RESULTS: Twenty-two experts completed the survey with a mean filling time of 12.9 min. Ho:YAG, Thulium fiber laser (TFL), continuous wave (cw) Tm:YAG, pulsed Tm:YAG and Greenlight™ lasers are used by 73% (16/22), 50% (11/22), 23% (5/22), 13.6% (3/22) and 9.1% (2/22) of experts, respectively. All experts use anatomical enucleation of the prostate (EEP), preferentially in one- or two-lobe technique. Laser settings differ significantly between laser types, with median laser power for apical/main gland EEP of 75/94 W, 60/60 W, 100/100 W, 100/100 W, and 80/80 W for Ho:YAG, TFL, cwTm:YAG, pulsed Tm:YAG and Greenlight™ lasers, respectively (p = 0.02 and p = 0.005). However, power settings within the same laser source are similar. Pulse shapes for main gland EEP significantly differ between lasers with long and pulse shape modified (e.g., Moses, Virtual Basket) modes preferred for Ho:YAG and short pulse modes for TFL (p = 0.031). CONCLUSION: Ho:YAG lasers no longer seem to be the mainstay of EEP. TFL lasers are generally used in pulsed mode though clinical applicability for quasi-continuous settings has recently been demonstrated. One and two-lobe techniques are beneficial regarding operative time and are used by most experts.

Holmium laser enucleation of the prostate: Problem-based evolution of the technique.

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive and size-independent treatment for benign prostatic hyperplasia with excellent long-term surgical outcome. Considered difficult to learn, different modifications of the technique have been proposed in the last 21 years to overcome the most common problems encountered during this procedure. We present a step-by-step technique including the reasons and advantages of each modification we have progressively adopted until we evolved into our totally en-bloc no-touch low-power HoLEP.

The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is currently considered a safe and effective therapeutic option for the treatment of adenomas of any size. Being considered difficult to learn and to teach, HoLEP is not as diffused as it would deserve. In 2011, we started performing HoLEP reproducing the traditional Gilling's technique. Case after case, we introduced alterations in the surgical approach, trying to overcome our difficulties and minimize our learning curve. MATERIALS AND METHODS: We present a detailed step-by-step description of our modified HoLEP technique, developed in Torino, Italy, which we called en-bloc no-touch. RESULTS: The main steps of the en-bloc no-touch enucleation phase include: (1) the identification of the correct plane between adenoma and capsule only once, at the apex of the left lobe laterally to the veru montanum, extending the incision retrogradely towards the bladder at 5 o'clock; (2) the en-bloc enucleation of a horseshoe-like adenoma, sparing the 7 and 12 o'clock incisions; (3) the use of the beak of the endoscope, gently raising up the lobe from the capsular plane and creating a dihedral angle, crossed by connective bundles put in tension by this movement; and (4) the gradual no-touch lasing of such fibres, exploiting the effects of the plasma bubble at the tip of laser fibre, with no direct energy supply to the capsule. CONCLUSIONS: In our experience, the en-bloc no-touch technique has the potential to ease some difficult intraoperative steps and to improve the learning curve of HoLEP.

The new concept of ureteral access sheath with guidewire disengagement: One wire does it all.

PURPOSE: To prospectively evaluate the new Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) access sheath (UAS) which allows the use of a single wire to serve as both safety and working guide. MATERIALS AND METHODS: Between June and September 2014, adult patients from five European centers who underwent flexible ureteroscopy (fURS) for therapeutic and diagnostic purposes were included. The 12/14Fr Flexor©Parallel™ UAS was evaluated. Data were collected and examined by both univariate and multivariate analyses. The UAS material and usage characteristics were rated per case by the surgeons on a scale from very bad to very good. RESULTS: In total, 134 UASs were used in 67 male and 67 female patients. Fifty percent of ureters (67 patients) were pre-stented. Ninety percent of the procedures were therapeutic. The overall successful insertion rate was 94 %. Pre-stenting status was the only independent factor for a successful access sheath insertion: 98.5 % of the pre-stented patients had a successful UAS placement vs. 82 % of non-pre-stented (p = 0.001, C.I. 95 %: 1.2). Evaluation of the material and radiopacity was considered very good in over 90 % of cases. Release of the guidewire, hydrophilic coating, gliding of the endoscope and repeatability were considered very good in over 80 %. There were two (1.4 %) UAS malfunctions and one submucosal lesion reported. CONCLUSIONS: The use of the Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) with usage of a single guidewire in a prospective multicentric scenario was clinically applicable in the majority of cases. Pre-stenting increased the chance of a successful insertion from 82 to 98.5 %.

Mortality and flexible ureteroscopy: analysis of six cases.

PURPOSE: Advancements in the endourological equipment have made retrograde intrarenal surgery (RIRS) an attractive, widespread technique, capable of competing with traditional shock wave lithotripsy and percutaneous nephrolithotomy. Since the complication rate is generally low, even less is known about dramatic and fatal complications after RIRS. METHODS: We performed a survey asking 11 experienced endourologists to review their RIRS series and report the cases of mortality to their best knowledge. RESULTS: Six urologists reported on six fatal cases. In three cases, a history of urinary tract infections was present. Four patients died from urosepsis, one due to an anesthetic and one due to hemorrhagic complication. The use of ureteral access sheath was not common. CONCLUSION: Even respecting the standards of care, it may happen that physicians are occasionally tempted to overdo for their patients, sometimes skipping safety rules with an inevitable increase in risks. Despite the fact that RIRS has become a viable option for the treatment of the majority of kidney stones, its complication rates remain low. Nevertheless, rare fatal events may occur, especially in complex cases with a history of urinary tract infections, and advanced neurological diseases.

Simulation of RIRS in soft cadavers: a novel training model by the Cadaveric Research On Endourology Training (CRET) Study Group.

PURPOSE: The aim of the current study was to evaluate the use of fresh-frozen concurrently with embalmed cadavers as initial training models for flexible ureteroscopy (fURS) in a group of urologists who were inexperienced in retrograde intrarenal surgery (RIRS). METHODS: Twelve urologists involved in a cadaveric fURS training course were enrolled into this prospective study. All the participants were inexperienced in fURS. Theoretical lectures and step-by-step tips and tricks video presentations on fURS were used to incorporate the technical background of the procedure to the hands-on-training course and to standardize the operating steps of the procedure. An 8-item survey was administered to the participants upon initiation and at the end of the course. RESULTS: Pre- and post-training scores were similar for each question. All the participants successfully completed the hands-on-training tasks. Mean pre-training duration [3.56 ± 2.0 min (range 1.21-7.46)] was significantly higher than mean post-training duration [1.76 ± 1.54 min (range 1.00-6.34)] (p = 0.008). At the end of the day, the trainers checked the integrity of the collecting system both by endoscopy and by fluoroscopy and could not detect any injury of the upper ureteral wall or pelvicalyceal structures. The functionality of the scopes was also checked, and no scope injury (including a reduction in the deflection capacity) was noted. CONCLUSIONS: The fURS simulation training model using soft human cadavers has the unique advantage of perfectly mimicking the living human tissues. This similarity makes this model one of the best if not the perfect simulator for an effective endourologic training.

Positioning for percutaneous nephrolithotomy.

PURPOSE OF THE REVIEW: To highlight the progressive evolution of the issue of patient positioning for percutaneous nephrolithotomy (PNL), explain the history of the prone and supine positions, report respective advantages and drawbacks, critically interpret the past and current literature supporting such arguments, identify the best candidates for each position, and reflect on the future evolution of the two approaches. RECENT FINDINGS: Positioning for PNL has become a matter of debate during the last decade. The traditional prone PNL position - most widely performed with good success and few complications, and exhibiting essentially no limits except for the treatment of pelvic kidneys - is nowadays flanked mainly by the supine and supine-modified positions, equally effective and probably safer from an anesthesiological point of view. Of course, both approaches have a number of advantages and drawbacks, accurately reported and critically sieved. SUMMARY: The current challenge for endourologists is to be able to perform PNL in both prone and supine positions to perfectly tailor the procedure on any patient with any stone burden, including increasingly challenging cases and medically high-risk patients, according to the patient's best interest. Intensive training and experience is especially needed for supine PNL, still less popular and underperformed worldwide. VIDEO ABSTRACT: http://links.lww.com/COU/A8.

The Impact of Lasers in Percutaneous Nephrolithotomy Outcomes: Results from a Systematic Review and Meta-Analysis of Randomized Comparative Trials.

Background: Percutaneous nephrolithotomy (PCNL) is the first-choice treatment of renal stones larger than 2 cm. We aimed to evaluate if lasers perform as equal as non-laser devices in patients with kidney stones candidate to PCNL. Materials and Methods: A comprehensive literature search was performed in MEDLINE through PubMed, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) to assess differences in the perioperative course, incidence of postoperative complications, and stone-free rate (SFR) in patients with kidney stones undergoing laser vs non-laser PCNL in randomized studies. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and expressed as risk ratios (RRs), 95% confidence intervals (CIs), and p-values. Surgical time and length of stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% CI, and p-values. Analyses were two tailed, with a significance set at p ≤ 0.05. Results: Six articles, including 732 patients (311 patients undergoing holmium laser and 421 non-laser PCNL), were included in meta-analysis. Surgical time and postoperative stay were shorter in the non-laser group (MD: 11.14, 95% CI: 2.32 to 19.96, p = 0.002; MD: -0.81, 95% CI: -2.18 to 0.57, p = 0.25, respectively). SFR was significantly higher in the non-laser group (RR: 1.08, 95% CI: 1.01 to 1.15, p = 0.03). Patients undergoing laser PCNL had a nonsignificant higher risk of postoperative fever >38°C (RR: 0.64, 95% CI: 0.31 to 1.30, p = 0.22). Transfusion rate did not differ between the two groups (RR: 1.02, 95% CI: 0.50 to 2.11, p = 0.95). The need for stent positioning because of urine extravasation was higher risk in the laser group, but the difference did not reach significance (RR: 0.49, 95% CI: 0.17 to 1.41, p = 0.19). Conclusions: Non-laser PCNL showed better perioperative outcomes and SFR compared to holmium laser PCNL.

Is endoscopic combined intrarenal surgery ready for primetime in endourology? Outcomes from a systematic review and meta-analysis.

Introduction: We aimed to review the outcomes of endoscopic combined intrarenal surgery (ECIRS) as compared to conventional percutaneous nephrolithotomy (PCNL) for kidney stones. Material and methods: We performed a systematic literature review using MEDLINE, EMBASE, and Cochrane Central Controlled Register of Trials. We included all studies comparing ECIRS and conventional PCNL. Surgical time, hemoglobin drop, and postoperative stay were pooled using the inverse variance of the mean difference (MD) with a random effect, 95% confidence intervals (CI), and p-values. Complications, stone-free rate, and retreatment were assessed using Cochran-Mantel-Haenszel method with random effect model and expressed as odds ratio (OR), 95% CI, and p-values. Results: A total of 17 studies were included. Surgical time and mean postoperative length did not significantly differ between the groups (MD -8.39 minutes 95%CI -21.30, 4.53, p = 0.20; 5.09 days 95%CI -19.51, 29.69, p = 0.69). Mean hemoglobin drop was significantly lower in the ECIRS group (MD -0.56 g/dl 95%CI -1.08, -0.05, p = 0.03), while blood transfusion rate did not differ between the two groups (OR 0.88 95%CI 0.64, 1.23, p = 0.15). While the incidence of postoperative sepsis did not differ between the two groups (OR 0.52 95% CI 0.17, 1.59, p = 0.25), the incidence of postoperative fever was lower in the ECIRS group but the difference was not significant (OR 0.61 95%CI 0.35, 1.06, p = 0.08). The stone-free rate was significantly higher in the PCNL group (OR 2.52 95%CI 1.64, 3.90, p <0.0001) and the retreatment rate was lower in the ECIRS group (OR 0.34 95%CI 0.14, 0.87, p = 0.002). Conclusions: ECIRS showed shorter operative time, lower complication rate, and retreatment compared to PCNL. Conventional PCNL showed a higher stone-free rate.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy.

CONTEXT: Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. OBJECTIVE: To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. EVIDENCE ACQUISITION: An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. EVIDENCE SYNTHESIS: The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. CONCLUSIONS: Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. PATIENT SUMMARY: Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

ECIRS (Endoscopic Combined Intrarenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?

BACKGROUND: Percutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL. METHODS: The recent literature regarding supine PNL and ECIRS has been reviewed, namely about patient positioning, synergy between operators, procedures, instrumentation, accessories and diagnostic tools, step-by-step standardization along with versatility of the surgical sequence, minimization of radiation exposure, broadening to particular and/or complex patients, limitation of post-operative renal damage. RESULTS: Supine PNL and ECIRS are not superior to prone PNL in terms of urological results, but guarantee undeniable anesthesiological and management advantages for both patient and operators. In particular, ECIRS requires from the surgeon a permanent mental attitude to synergy, standardized surgical steps, versatility and adherence to the ongoing clinical requirements. ECIRS can be performed also in particular cases, irrespective to age or body habitus. The use of flexible endoscopes during ECIRS contributes to minimizing radiation exposure, hemorrhagic risk and post-PNL renal damage. CONCLUSIONS: ECIRS may be considered an evolution of the PNL procedure. Its proposal has the merit of having triggered the critical analysis of the various PNL steps and of patient positioning, and of having transformed the old static PNL into an updated approach.

Determination of Face and Content Validity of Cadaveric Model for Holmium Anatomic Endoscopic Enucleation of the Prostate Training: An ESUT AEEP Group Study.

BACKGROUND: Bench and virtual reality nonbiological simulator models for anatomic endoscopic enucleation of the prostate (AEEP) surgery have been reported in the literature. These models are acceptable but have limited practical applications. OBJECTIVE: To validate a fresh-frozen human cadaver model for holmium AEEP training and assess its content validity. DESIGN SETTING AND PARTICIPANTS: Holmium AEEP operations on fresh-frozen cadavers performed by an experienced surgeon were recorded, and a video, including the main steps of the operation, was produced. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The video and an accompanying questionnaire were subsequently distributed electronically to ESUT AEEP study group experts and associates (N = 32) for assessment of the AEEP training model. A ten-point Likert global rating scale was used to measure the content validity. RESULTS AND LIMITATIONS: A total of 26 answers were returned (81%). The experts agreed on the model's suitability for AEEP training (mean Likert score: 8). According to the responses, "identifying anatomic structures and landmarks" was the most valuable aspect of the model in terms of AEEP training (median Likert score: 9). Conversely, the experts found the model's ability, in terms of demonstrating laser and tissue reactions, to be weak (median Likert score: 6). CONCLUSIONS: Based on the content validity assessment, the fresh-frozen cadaver-training model for laser AEEP seems to be a promising model for demonstrating and learning the correct prostate enucleation technique. PATIENT SUMMARY: An increasing number of researchers have proposed that anatomic endoscopic enucleation of the prostate (AEEP) should replace transurethral resection of the prostate surgery and become the gold standard for treatment of bladder outlet obstruction due to benign prostatic hyperplasia. AEEP requires anatomic familiarity for enucleation, technical knowledge, and a solid training program before starting with the first cases. This is the first cadaver study to assess the content validity of a fresh-frozen human cadaver model for AEEP training.