Illumination matters part IV: blackout and whiteout in flexible ureteroscopy - first report on a phenomenon observed by PEARLS.

PURPOSE: To date, no study has evaluated effects of varying brightness settings on image quality from flexible ureteroscopes submerged in saline. The aim was to evaluate blackout and whiteout occurrences in an in-vitro kidney calyx model. MATERIAL AND METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed enclosed pink in-vitro kidney calyx model submerged in saline. Endoscopic images were captured with ureteroscope tip placed at 5 mm,10 mm and 20 mm distances. The complete range of brightness settings and video capture modes were evaluated for each scope. Distribution of brightness on a grayscale histogram of images was analyzed (scale range 0 to 255). Blackout and whiteout were defined as median histogram ranges from 0 to 35 and 220 to 255, respectively (monitor image too dark or too bright for the human eye, respectively). RESULTS: Blackout occurred with the P7, Pusen 7.5F, 9.2F and WiScope at all distances, and V3 at 20 mm - with lowest brightness settings. Whiteout occurred with Flex-X2s, V3 and P7 at 5 mm and 10 mm, as well as with V3 and P7 at 20 mm - mostly with highest brightness settings. The Flex-Xc had neither blackout nor whiteout at all settings and distances. CONCLUSION: Blackout or whiteout of images is an undesirable property that was found for several scopes, possibly impacting diagnostic and therapeutic purposes during ureteroscopy. These observations form a guide to impact a urologist's choice of instruments and settings.

Illumination matters Part II: advanced comparative analysis of flexible ureteroscopes in a kidney model by PEARLS.

PURPOSE: The aim of the study was to evaluate illumination properties in an in-vitro kidney calyx model in saline. DESIGN AND METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU WiScope using a 3D-printed closed pink kidney calyx model, submerged in saline. A spectrometer was used for illuminance and color temperature measurements at different openings located at center (direct light), 45° (direct and indirect light) and 90°(indirect light) to the axis of the scope. RESULTS: Maximum illuminance was at the center opening for all scopes (range: 284 to 12,058 lx at 50% brightness and 454 to 11,871 lx at 100% brightness settings). The scope with the highest center illuminance (Flex-Xc) was 26 times superior to the scope with the lowest illuminance (Pusen 7.5Fr) at 100% brightness setting. For each scope, there was a peripheral illuminance drop ranging from - 43 to - 92% at 50% brightness and - 43% to - 88% at 100% brightness settings, respectively (all p < 0.01). Highest drop was for the P7 and the Pusen 9.2F. All scopes had illuminance skew, except the V3. All scopes had a warm color temperature. CONCLUSION: Illumination properties vary between ureteroscopes in an enclosed cavity in saline, and differs at center vs 45° and 90° positions within scopes. Peripheral illuminance drop can be as high as - 92%, which is undesirable. This may affect the choice of ureteroscope and light brightness settings used in surgery by urologists.

Evaluation of Guidelines for Surgical Management of Urolithiasis.

PURPOSE: Many urological societies have provided evidence-based guidelines to help the urologist make therapeutic choices. However, the recommendations in these guidelines may be heterogeneous because they were developed using various methods. The objective of this study was to review key guidelines on the surgical management of urinary stones to provide practical guidance for clinical application. MATERIALS AND METHODS: Guidelines on urolithiasis from all international urological societies were searched through the society websites. A search on PubMed® and Medline® restricted to publications in English was also performed for guidelines published between January 1, 2010 and July 1, 2017. Only the latest versions of guidelines containing an evaluation of the level of evidence and the grade of recommendation were included in the final analysis. All recommendations on surgical stone management and recommended techniques for each surgical modality were included. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument was used to assess the quality of the included guidelines. RESULTS: Three international guidelines were included in analysis, including those of AUA (American Urological Association)/ES (Endourological Society), EAU (European Association of Urology) and SIU (Société Internationale d'Urologie)/ICUD (International Consultation on Urological Diseases). We highlighted the heterogeneity in the level of evidence and the grade of recommendation which arose due to the different methods of evaluations that had been adopted. Despite this our review highlighted the considerable similarities among the guidelines. In certain specific situations for which no good evidence was available the recommendations could only be based on expert opinion. CONCLUSIONS: An option to provide clear guidance to the urologist might be to combine these international guidelines into one to reduce confusion about the surgical management of urolithiasis.

Short and Intermediate-Term Outcome of Robot-Assisted Inverted YV-Plasty for Recurrent Bladder Neck Stenosis - a Single Centre Study.

OBJECTIVE: To report the technique and preliminary results for extraperitoneal robot-assisted laparoscopic YV-plasty (RAYV) for refractory bladder neck stenosis (BNS) and vesicoureteral anastomosis stenosis (VUAS). MATERIALS AND METHODS: Included were patients with recurrent BNS and VUAS who underwent RAYV at our institution. Primary outcome was short and intermediate-term functional results measured with urinary peak flow (Qmax), post-void residual urine (PVR) as well as quality of life assessment with the international prostate symptom score (IPSS) and short form health survey (SF-8). Short- and intermediate-term follow-up periods were defined as 1-6 months and 6-24 months, respectively. Secondary, all patients were reviewed for etiology as well as perioperative data. Treatment success was defined by absence of further treatment and/or need for intermittent or permanent catheterization. RESULTS: Between March 2016 and October 2020 a total of 30 patients with a median age of 70.8 (64-77) years underwent RAYV with a median follow-up of 27 months. Median operative time (skin-skin) was 131 (112-145) minutes. The transurethral indwelling catheter was removed after 10 (5 - 16) days. There were no intraoperative complications but 2 postoperative major complications Clavien-Dindo IIIa and IV, respectively. Short- and intermediate-term results revealed significant improvement of IPS score from 17 (11-24) points to 11 (6-13) points and 6 (3-9) points, respectively. Further PVR decreased from 90 (5-302) mL to 0 (0-30) mL and 0 (0-90) mL, respectively, and Qmax increased from 7.4 mL/s to 13 (8-16) mL/s and 17 (12-4) mL/s, respectively. Improvement of SF-8 did not reach significance. A total of 5/30 (16.7%) patients had a treatment failure after 24 months whereof 2 had a re-stricture. CONCLUSION: RAVY-Plasty for recurrent bladder neck stenosis is a safe and effective procedure with good functional short- and intermediate-term outcome.

[Urinary incontinence - what can be done by the family doctor and when is the urologist needed?]. / Harninkontinenz - was kann der Grundversorger machen und wann braucht es den Urologen?

About 15% of the women and 10% of the men past the age of 65 years suffer from urinary incontinence. In most cases, accurate history taking can help differentiate between urge incontinence, stress incontinence and overflow incontinence, and is essential in choosing the appropriate treatment. Initial diagnostic testing can be conducted by the general practitioner, especially tests to exclude urinary tract infections or to rule out an overactive bladder. Patient education on changes to fluid intake and voiding habits as well as advice on suitable incontinence products are important first steps in the management of urinary continence. Also, drug treatment can be initiated in general practice. Patients with refractory urinary incontinence, particularly those who did not respond to anticholinergic medication, should be referred to a urologist for further evaluation since there may be an underlying tumour or other disorder of the bladder that is causing the incontinence.

Environ 15% des femmes et 10% des hommes âgée de plus de de 65 ans souffrent d'incontinence urinaire. Dans le plupart des cas, une anamnèse soigneuse peut aider à différencier entre l'incontinence par impériosité, l'incontinence de stress et l'incontinence par regorgement, ce qui est essentiel pour choisir le traitement approprié. L'évaluation diagnostique initiale peut être effectuée par le médecin généraliste, en particulier les tests pour exclure une infection urinaire ou une incontinence par regorgement. L'éducation des malades visant à changer les habitudes de prise liquidienne et d'uriner, ainsi qu'à conseiller des produits appropriés à l'incontinence représente une importante première étape dans la prise en charge de ce problème. Le traitement médicamenteux peut également être instauré en pratique générale. Les malades ayant une incontinence urinaire réfractaire, en particulier ceux qui ne répondent pas à un anticholinergique, devraient être référés à un urologue pour étendre les investigations puisqu'une tumeur sous-jacente ou une autre anomalie de la vessie peut être responsable de l'incontinence.