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

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

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

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

Experts' recommendations in laser use for the treatment of upper tract urothelial carcinoma: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training Research in Urological Surgery and Technology (T.R.U.S.T.) group.

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

Holmium and Thulium Fiber Laser Safety in Endourological Practice: What Does the Clinician Need to Know?

PURPOSE OF REVIEW: To summarise the literature on laser safety during endourological practice. RECENT FINDINGS: Holmium and Thulium Fiber laser are the two main energy sources in the current clinical practice. The latter may have superior properties, but more clinical studies are needed to formally establish this. Laser injury to urothelium is more dependent on user experience rather than laser type. Smaller laser fibres allow for lower intra-renal temperature profiles. Operators should pay close attention to laser technique including maintaining the safety distance concept and only firing the laser when tip is clearly in view. When adjusting laser settings, pay close attention to resultant power given the associated heat changes. Prolonged periods of laser activation are to be avoided for the same reason. Outflow can be manipulated such as with access sheath to mitigate temperature and pressure changes. There is still limited evidence to support the mandate for compulsory use of eye protection wear during laser lithotripsy. Lasers are the gold standard energy source for stone lithotripsy. However, the safe clinical application of this technology requires an understanding of core principles as well as awareness of the safety and technical aspects that can help in protecting patient, surgeon and operating staff.

Management of Kidney Stone Disease in Pregnancy: A Practical and Evidence-Based Approach.

PURPOSE OF REVIEW: Suspected kidney stone disease during pregnancy is a difficult condition for health professionals to manage. This is partly due to the more limited range of diagnostic and therapeutic strategies, which can be safely applied. A comprehensive review of literature was performed to identify evidence to develop a practical guide to aid clinicians. RECENT FINDINGS: Ultrasound remains the recommended first line option for imaging. Complicated cases, such as suspected infected obstructed system, require urgent decompression such as in the form of percutaneous nephrostomy. This article highlights the pharmacotherapeutic agents, which are considered safe for use in pregnancy. Where surgical intervention is indicated, evidence supports ureteroscopy to be a safe option as long as infection has been treated. Ureteroscopy can offer definitive clearance of the stone(s) and can be less burdensome regarding bothersome symptoms compared to indwelling ureteral stent or nephrostomy, which also require regular exchange due to the high propensity for encrustation in pregnancy. A multidisciplinary approach is fundamental to safely manage suspected kidney stone disease in pregnancy. Adoption of a locally agreed pathway as suggested in this article supports improved patient care.

Current status of thulium fibre laser lithotripsy: an up-to-date review.

OBJECTIVE: To perform an up-to-date review to scope the current status of the thulium fibre laser (TFL) in the setting of stone lithotripsy and provide a guide for the clinical urologist. METHODS: A review of world literature was performed to identify original articles on TFL for stone lithotripsy. Our clinical experiences of using the technology have also been shared. RESULTS: To date there have been 11 clinical studies published on TFL for stone lithotripsy. Three of these have been in the setting of miniaturised percutaneous nephrolithotomy (mini-PCNL) and the remainder have been on ureteroscopy (URS). There has only been one randomised study on this technology, which has been for URS. For URS, the range of settings has been 0.1-4 J × 7-300 Hz for both URS and mini-PCNL. Stones ranging from 0.4-3.2 and 1.5-3 cm have been treated with URS and mini-PCNL, respectively. The final stone-free rate for TFL has ranged from 66.6% to 100% and 85-100% for URS and mini-PCNL, respectively. The average length of stay ranged from 0.5 to 2.4 days in the URS group, but no studies have been reported this for mini-PCNL. Operative times in all the studies (both URS and mini PCNL) were <60 min. CONCLUSION: Initial clinical studies reveal that TFL appears to be efficacious in the setting of stone lithotripsy. However, further randomised trials are warranted to delineate its formal position, as well as determine the optimal settings for use in clinical practice.

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

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

Temperature Measurements During Flexible Ureteroscopic Laser Lithotripsy: A Prospective Clinical Trial.

Objective: The primary aim of the study was to explore intrarenal temperatures (IRTs) during flexible ureteroscopic laser lithotripsy (FURSL). The secondary aim was to investigate the correlation between temperatures and renal pelvis anteroposterior diameter (APD). Materials and Methods: From February 2023 to June 2023, 10 patients with an indwelling nephrostomy tube (NT) undergoing FURSL were enrolled in the study. Sheathless FURSL was performed using gravitational irrigation (23°C) at 60 cm. A sterile K-type thermocouple was inserted through the NT. Temperatures were recorded for 120 seconds with continuous laser activation and for another 60 seconds after deactivation. Thulium fiber laser delivered energy using a 150 µm fiber and incremental power settings of 5, 10, 20, and 30 W. The laser was deactivated whenever the IRT reached 43°C. Results: IRT correlated directly to power settings. Each time the power settings were increased, the temperature rose significantly. The increase in average peak temperature was 2.6°C between 5 and 10 W (p < 0.001), 3.4°C between 10 and 20 W (p < 0.001), and 2.5°C between 20 and 30 W (p < 0.001). Temperatures reached 43°C in three patients applying 20 W and in eight patients applying 30 W. The shortest activation-time until threshold was 12 and 28 seconds with 30 and 20 W settings, respectively. When reaching 43°C, temperatures remained above this threshold for an additional 29 seconds on average. There was a significant correlation between IRT and renal APD. For example, when 10 W was applied in the setting of APD ≤20 mm, the recorded temperature was on average 2.3°C higher compared with APD >20 mm, with the same power settings applied, p < 0.001. Conclusion: During FURSL, IRT correlates directly with power settings and is inversely correlated with renal pelvic APD. Using a sheathless approach, power settings ≥20 W should arguably be avoided, especially in the context of a nondilated renal pelvis. ClinicalTrials: The study was registered on ClinicalTrials.gov (NCT05677425).

Robotic-assisted laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction - How should success be determined?

BACKGROUND: Ureteropelvic junction obstruction (UPJO) is characterised by stenosis of the ureteral lumen at the level of the renal pelvis and proximal ureter. At Haukeland University Hospital, robotic-assisted laparoscopic pyeloplasty (RLP) for UPJO has been performed since 2014. The aim of this study was to evaluate the results of the treatment and consider what determines treatment success. MATERIALS AND METHODS: Retrospective review was performed of consecutive patients undergoing RLP between 2014-2022. Outcomes of interest included symptom relief, complication rates and renographic findings at follow-up. Treatment success was defined in terms of symptom improvement and/or improvement as well as relief of obstruction on renography. RESULTS: In total, 95 RLPs were performed in 54 women and 41 men, with a mean age of 40 years (IQR: 21-58). Flank pain was the most frequent presenting complaint (n = 81, 85%) followed by infection (n = 33, 35%). More than one indication for surgery was present in 1/3 of the patients. Urodynamic relevant obstruction on renography was found in 62 patients (65%) preoperatively. Mean operative time was 123 minutes (range 60-270). Two patients experienced minor intraoperative complications. At three months follow-up, 91% of patients had symptom relief, and no obstruction on renography was recorded in 64%. There was no significant association between improvement in symptoms and renography findings at follow-up, p = 1. CONCLUSIONS: RLP can deliver a high success rate in terms of symptom relief and few complications. There was no association between renography findings and symptom relief at follow-up. Success after surgery should be determined by symptom relief rather than renography findings.

Adverse events related to accessory devices used during ureteroscopy: Findings from a 10-year analysis of the Manufacturer and User Facility Device Experience (MAUDE) database.

Objectives: The objective of this study was to evaluate adverse events and device events related to accessories used during ureteroscopy (URS). Materials and methods: Analysis was performed of the records available in the Manufacturer and User Facility Device Experience database in the United States. Information was collected on characteristics of problem, timing, manufacturer verdict, successful completion of planned surgery, prolonged anaesthesia and injury to patient or staff. Results: Five-hundred seventy-one events related to URS accessories were recorded. These were associated with the following devices: baskets (n = 347), access sheath (n = 86), guidewires (n = 78), balloon dilators (n = 27), ARDs (n = 17) and ureteral catheters (n = 16). Of the events, 12.7% resulted in patient injuries. Forty-eight per cent of the events resulted in prolonged anaesthesia, but the planned surgery was successfully completed in 78.4% of all cases. Collectively, the manufacturers accepted responsibility due to actual device failure in only 0.5% of cases. Common problems for baskets were failure to deploy (39.5%) and complete detachment of basket head (34.6%) and partial breakage of the basket head (12.4%). Of the basket group, 4.3% required open or percutaneous surgery to remove stuck basket. Full break of the body of the access sheath occurred in 41.9% and complete ureteral avulsion in 3.5%. For balloon dilators, there was a burst in 37% of cases. Broken guidewires were associated with 11.5% requiring repeat intervention for retrieval and 6.4% required JJ stent due to perforation to the collecting system. No injuries to operating staff were recorded with accessory usage. Conclusion: Accessories used during URS are fragile. Potential for serious injury does exist as a direct result of their use. Surgeons should familiarise themselves with these events and how they can be prevented.

Management of kidney stones in pregnancy: A worldwide survey of practice patterns.

Introduction Kidney stones is pregnant is not a common emergency, but it is one that is extremely challenging to manage. There exists no previous survey, which maps the different practice patterns adopted. Our aim was to deliver a survey to evaluate the current status of practice patterns across different parts of the world regarding the management of stone disease in pregnancy. Methods Through an iterative process, 19-item survey was devised. This contained the following five sections: 1. Demographics 2. General items 3. Diagnosis & Imaging 4. Initial management 5. Surgery. It was disseminated via social media and email chains. Results 355 responses were collected and the majority (66.2%) reported no established hospital protocol for stones in pregnancy. Ultrasound was the most popular first line imaging choice (89.9%) but 8% would choose non contrast CT. The latter was also chosen as second line choicer in 34.6% as opposed to MRI. A large proportion (42.5%) had requested CT in pregnancy previously. With equivocal US results, only 19.4% would proceed to ureteroscopy but 40.9% would opt for CT. 24-48 hours was the most popular (37.6%) time period to observe before surgical intervention. Ureteral stent and nephrostomy were regarded as equally effeftive.6 weeks was most popular frequency for an exchange. Most do not use fetal heart rate monitoring intra-operatively. 3.94% had previously performed PCNL during pregnancy. Conclusion Practice patterns vary widely for suspected kidney stones in pregnancy and use of CT appears increasingly popular. This includes when faced with equivocal ultrasound results and instead of proceeding to ureteroscopy. Most hospitals lack an established management protocol for this scenario.

Paediatric Ureteroscopy (P-URS) reporting checklist: a new tool to aid studies report the essential items on paediatric ureteroscopy for stone disease.

The burden of urolithiasis in children is increasing and this is mirrored by the number of surgical interventions in the form of ureteroscopy (URS). There exist many challenges in performing this surgery for this special patient group as well as a lack of consensus on technique. There is also large variation in how results are described and reported. There exists therefore, a need to improve and standardise the core outcomes, which are reported. To this end, we developed a new checklist to aid studies report the essential items on paediatric URS for stone disease. The Paediatric Ureteroscopy (P-URS) reporting checklist comprises four main sections (study details, pre-operative, operative and post-operative) and a total of 20 items. The tool covers a range of important elements, such as pre-stenting, complications, follow-up, stone-free rate, concomitant medical expulsive therapy and imaging, which are often lacking in studies. The checklist provides a summary of essential items that authors can use as a reference to improve general standards of reporting paediatric URS studies and increase the body of knowledge shared accordingly.

Ureteroscopy during pregnancy: Outcomes and lessons learned over 4 decades at a tertiary center in Norway.

Background: The management of suspected kidney stone disease in pregnancy is challenging. In cases of persistent flank pain and where investigations may have rendered equivocal results, ureteroscopy (URS) is a recognized diagnostic and therapeutic intervention. This study aimed to investigate the safety and outcomes associated with performing URS during pregnancy, as the technique has evolved over the past 4 decades at our center. Materials and Methods: We performed a retrospective analysis of pregnant patients who underwent URS at our tertiary center between 1984 and 2022. Outcomes of interest included anesthetic approach, operative time, hospital stay, and complications. Results: Eighty-seven pregnant patients underwent 96 URS procedures, and 60% (n = 57) of these procedures were performed during the third trimester. Overall, 58% (n = 56) of the procedures were achieved with local anesthesia and light sedation. During the most recent decade, the latter was successfully carried out in 97% of the procedures, with the remainder occurring under spinal anesthesia as per patient choice. Overall, 57% (n = 50) of the whole study group had ureteral calculi found at the time of surgery and in 88% (n = 44) of these cases, fragmentation/extraction was performed. The remainder had insertion of ureteral stent with definitive clearance deferred until postpartum. Mean operative time and postprocedure hospital stay was 33 minutes (range, 7-100 minutes) and 2.2 days (range, 0-16 days), respectively. The overall intraoperative and postoperative complication rates were 2% and 11%, respectively. During the final decade, the latter improved to 6% and all adverse events were minor (Clavien I/II), with the exception of a single case. Regarding exit strategy, ureteral stent was placed in 42% (n = 40) of the procedures, 23% (n = 22) had ureteral catheter inserted, and the remainder (35%, n = 34) had none. Conclusions: Ureteroscopy can be safely performed during pregnancy using anesthetic approach with local anesthesia and light sedation. Development of a local protocol and multidisciplinary management algorithm are instrumental in enabling the delivery of such a service.

Paediatric percutaneous nephrolithotomy (P-PCNL) reporting checklist.

OBJECTIVE: To develop a reporting checklist that serves to improve and standardise reporting in studies pertaining to paediatric percutaneous nephrolithotomy (PCNL). METHODS: Based on findings from systematic review of literature, a draft list of items was formulated. By process of review and revisions, a finalised version was established and consensus achieved. RESULTS: The finalised version of the checklist covers four main sections, which include the following areas: study details, pre-operative, operative and post-operative information. There are 18 further sub-items. Recommendations deemed to be of high importance to include are highlighted in bold. CONCLUSION: This practical tool can aid clinicians and researchers when undertaking and reviewing studies on paediatric PCNL. This is highly relevant given the current heterogeneity that exists as well as debate in best practice patterns.

Ureteroscopy during pregnancy under local anesthesia and light sedation: Technique and video.

Ureteroscopy during pregnancy has become increasingly recognized as a safe intervention. Performing it under local anesthesia and light sedation reduces the risks associated with general or regional anesthesia, such as difficult airway scenarios, hypothermia, and hypotension. In addition, this approach reduces the total amount of fetal exposure to medications and anesthetic agents. Performing ureteroscopy in this manner requires a number of adjustments and modifications to the standard technique. This article provides a summary in a step-by-step format, as well as an accompanying video demonstration.

Adult Ureteroscopy (A-URS) Checklist: A New Tool To Standardise Reporting in Endourology.

Ureteroscopy is increasingly being used for urolithiasis. Technological innovations have been accompanied by wide variations in practice patterns. At the same time, a common finding in many studies, especially systematic reviews, is that the heterogeneity of outcome measurements and lack of standardisation can limit both the reproducibility and generalisability of study findings. While many checklists are available to improve study reporting, there are no ureteroscopy-specific ones. The Adult-Ureteroscopy (A-URS) checklist is a practical aid for both researchers and reviewers for studies in this field. It contains five main sections (study details, preoperative, operative, postoperative, and long term data) and a total of 20 items. Patient summary: We developed a checklist to improve how studies on ureteroscopy (insertion of a telescope through the urethra to inspect the urinary tract) in adults are reported. This could help in advancing the field and improving patient outcomes, as all the key information is captured.

Mortality due to urolithiasis in England and Wales: updated findings from a national database over a 23-year period.

Introduction: Urolithiasis is a recognised disease of prevalence, and although not common, fatal sequelae can occur. There are few studies with population-based data that provide an overview of the mortality burden associated with this condition. Our aim was to perform an update based on national data from England and Wales. Material and methods: A search was performed of the database available through the Office of National Statistics (ONS), which collates relevant information from all death certificates in England and Wales. The cause of death is classified according to the conditions listed in the International Classification of Diseases, Tenth Revision (ICD-10). The codes N 20-23 were utilised. Data were collected on gender, location in the upper or lower urinary tract, and age. Results: Over the 23-year period, 3717 deaths caused by urolithiasis were recorded. The male-to-female ratio was 1:1.4. However, this gender gap steadily closed over time. The mean number of deaths per year was 161 (range: 98-308 year), and this gradually increased over the study period. By 2021, urolithiasis accounted for 0.1% of deaths in England and Wales. Over half of the deaths (64.9%) were in persons aged ≥75 years, while the mortality rate in persons under 50 years old was less than 4%. 0.1% of the deaths occurred in children under 15 years of age, and these were all females. Conclusions: The number of deaths caused by urolithiasis has increased in England and Wales. Although mortality is higher among females, this gender gap is narrowing.