Sodium-glucose cotranspor ter 2 (SGLT2) inhibitors in nephrolithiasis: should we "gliflozin" patients with kidney stone disease? / Inibidores de cotransportadores sódio-glicose-2 (SGLT2) na nefrolitíase - devemos "gliflozinar" os litiásicos?

ABSTRACT The prevalence of nephrolithiasis is increasing worldwide. Despite advances in understanding the pathogenesis of lithiasis, few studies have demonstrated that specific clinical interventions reduce the recurrence of nephrolithiasis. The aim of this review is to analyze the current data and potential effects of iSGLT2 in lithogenesis and try to answer the question: Should we also "gliflozin" our patients with kidney stone disease?

RESUMO A prevalência da nefrolitíase está aumentando em todo o mundo. Apesar dos avanços na compreensão da patogênese da doença litiásica, poucos estudos demonstraram que intervenções clínicas específicas diminuem a recorrência da nefrolitíase. O objetivo desta revisão é analisar os dados atuais e efeitos potenciais dos iSGLT2 na doença litiásica e tentar responder à pergunta: devemos também "gliflozinar" os litiásicos?

Validation of stone-kidney size score to predict outcome and complications of pediatric percutaneous nephrolithotomy.

INTRODUCTION: The prevelance of urinary system stone disease in children is emphasizing the need for minimally invasive treatments to decrease morbidity and recurrence risk. Percutaneous nephrolithotomy (PCNL) has emerged as a preferred approach for pediatric patients with complex stones due to its minimally invasive nature, including miniaturized and vacuum-assisted access sheaths, advanced laser technology and tubeless and outpatient procedures. However, adult scoring systems have proven ineffective in predicting success and complications in pediatric PCNL. This highlights the need for specialized scoring systems, such as the Stone-Kidney Size (SKS) scoring system, tailored to pediatric patients and will be evaluated in our study for its association with the stone-free rate (SFR) and complications. MATERIALS AND METHODS: The data of 144 patients aged <17 years who had undergone PCNL between January 2008 and December 2019 were evaluated retrospectively. Demographics, stone characteristics, perioperative/postoperative outcomes were recorded for each patient. The SKS scoring system comprises the stone kidney index (SKI) and the number of stones, assigns one or two points based on single or multiple stones and an SKI value of <0.3 or ≥0.3, respectively. The SKI is computed by dividing the stone's longest axis by the kidney's longest axis. Residual stones less than 4 mm on non-contrast computed tomography are considered clinically insignificant residual fragments (CIRFs). Stone-free and CIRF patients were considered successful results. The relationship between the SKS scoring system and SFR, success, and complication rates after surgery was investigated. Statistical analyses were conducted using SPSS 22.0 software. RESULTS: The SFR was 67.36% and 74.31% when CIRF patients were included, respectively, with a complication rate of 27%. In multivariate analysis, stone treatment history, stone burden, and SKS score were statistically significantly associated with SFR (p < 0.001, p = 0.032, p < 0.001, respectively). Furthermore, the SKS score was the only variable that showed a statistically significant relationship with success. No significant association was found between SKS score and complications (p = 0.342). DISCUSSION: Our study demonstrates a relationship between the SKS scoring system and SFR in pediatric PCNL patients. However, shortcomings have been observed in its capacity to accurately predict post-PCNL complications. Despite being a retrospective analysis and having a single-center design, our study externally validates the relationship between the SKS scoring system and SFR after pediatric PCNL. CONCLUSIONS: The SKS scoring system is associated with SFR in pediatric patients undergoing PCNL; however, this relationship has not been established for complications.

Safety and efficacy of vacuum-assisted mini-percutaneous nephrolithotomy for the treatment of renal stone disease: an analysis of stone free status and postoperative infectious complications.

PURPOSE: Vacuum-assisted mini-percutaneous nephrolithotomy (vmPCNL) is being increasingly adopted due to its faster operating times and lower incidence of postoperative infectious complications (IC), however, studies have been limited by small sample sizes. We hypothesize that vmPCNL is an efficacious treatment for renal stone disease with acceptable stone-free rates (SFR) and low incidence of IC. The objectives of this study were to measure SFR three months after surgery, determine the factors influencing SFR, and determine the rates of postoperative IC after vmPCNL. MATERIALS AND METHODS: Seven hundred and sixty seven patients underwent vmPCNL for the treatment of renal stones > 20 mm at a single institution. Patients underwent postoperative computed tomography at three months to assess SFR. Postoperative fever and SIRS/Sepsis were recorded for individual patients. Multivariate logistics regression was performed to assess predictors of SFR. RESULTS: The SFR was found to be 73.7% at three months. Stone burden (OR 0.39, 95% CI [0.33-0.46]) and age (OR 1.03, 95% CI [1.01-1.04]) emerged as statistically significant predictors of SFR on multivariate analysis. 5.5% of patients experienced postoperative fever, while 2.9% experienced SIRS/Sepsis. CONCLUSIONS: This is the largest continuous cohort of patients to undergo vmPCNL for stone disease and demonstrates that vmPCNL is safe and efficacious, with an SFR of 74% at three months. The incidence of postoperative fever and SIRS/Sepsis is 5.5% and 2.9% respectively. Further randomized studies with large sample sizes are required to ascertain the rates of these complications in comparison to conventional approaches.

High-risk patients for septic shock after percutaneous nephrolithotomy.

PURPOSE: to identify risk factors for urinary septic shock in patients who underwent percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Data from PCNL procedures performed between January 2009 and February 2020 were retrospectively analyzed. The study included all patients over 18 years old with kidney stones larger than 15 mm who underwent PCNL. Patients who underwent mini-PCNL or combined surgeries, such as ureteroscopy or bilateral procedures, were not included in the study. Logistic regression was conducted to determine the risk factors for urinary septic shock within 30 days post-operation in patients who underwent PCNL. RESULTS: Urinary septic shock was observed in 8 out of the 1,424 patients analyzed (0.56%). The presence of comorbidities, evaluated using the Charlson Comorbidity Index (CCI) (OR 1.46 [CI 95% 1.15-1.86], p=0.01), larger stones (41.0 mm [IQR 30.0-47.5 mm] vs. 24.0 mm [IQR 17.0-35.0 mm], OR 1.03 [CI 95% 1.01-1.06], p=0.04), and a positive preoperative urine culture (OR 8.53 [CI 95% 1.71-42.45], p < 0.01) were shown to significantly increase the risk of postoperative urinary septic shock. Patients with a CCI > 2, larger stones (≥ 35 mm), and a positive preoperative urine culture were at even higher risk of urinary septic shock (OR 15.40 [CI 95% 1.77-134.21], p=0.01). CONCLUSION: Patients with larger stones, positive preoperative urine culture, and a higher CCI are at risk for urinary septic shock after PCNL. These findings are of utmost importance for optimizing the perioperative care of these patients to prevent life-threatening complications.

Work absence and productivity loss of patients undergoing a trial of spontaneous passage for ureteral stones.

Patients with ureteral stones are often managed with a spontaneous trial of passage. While cost effective, the current literature has not examined the effects of a trial of passage on patients' work productivity. In this study, we aim to characterize work absence and productivity losses in a cohort of patients undergoing a trial of passage for ureteral stones. Actively employed patients aged 18 to 64 and discharged from Duke emergency departments without surgical intervention for ureteral stones ≤ 10 mm were contacted by phone four weeks after their presentation. Participants completed the Institute for Medical Technology Assessment Productivity Cost Questionnaire which assesses three domains: absenteeism - missed work; presenteeism -productivity when returning to work; and unpaid work - assistance with household work. Linear regression associated demographic and stone factors with productivity losses.109 patients completed the survey. In total, 67% of patients missed work, 46% had decreased productivity when returning to work, and 55% required assistance with unpaid work. 59% of patients with stones ≤ 5 mm missed work versus 84% with stones > 5 mm (p = 0.009). African American race (coefficient 23.68, 95% confidence interval 2.24-45.11, p = 0.031), first-time stone formers (coefficient 20.28, 95% confidence interval 2.50-38.07, p = 0.026), and patients with stones > 5 mm (coefficient 25.34, 95% CI 5.25-45.44, p = 0.014) were associated with increased productivity losses. The majority of patients miss work while undergoing a trial of passage and many have decreased productivity when returning to work. This information may help counsel patients in emergency departments, especially first-time stone formers, and prevent return visits.

Fabrication of acoustically and physically validated artificial stones to natural kidney stones under shock waves and laser lithotripsy.

To present an efficient method for fabricating artificial kidney stones with acoustic and physical properties to assess their fragmentation efficiency under shock waves and laser lithotripsy for very hard stones. The mixture ratio of super-hard plaster and water was adjusted to produce artificial kidney stones for comparison with > 95% human genuine calcium oxalate monohydrate (COM) and uric acid (UA) stones. Acoustic and physical properties, such as wave speed, stone hardness, density, compressive strength, and stone-free rates under shock-wave and laser lithotripsy, were assessed. The longitudinal wave speed of artificial stones prepared at a plaster-to-water ratio of 15:3 closely matched that of COM stones. Similarly, the transverse wave speed of artificial stones prepared at a plaster-to-water ratio of 15:3 to 15:5 aligned with that of COM stones. Stone fragmentation using shock-wave of artificial stones with mixed ratios ranging from 15:3 to 15:5 resembled that of COM stones. The Vickers hardness was similar to that of artificial stones produced with a mixing ratio of 15:3, similar to that of COM stones, while that of artificial stones produced with a mixing ratio of 15:5 was similar to that of UA stones. Density-wise, artificial stones with mixing ratios of 15:4 and 15:5 resembled COM stones. Compressive strength test results did not confirm the similarity between natural and artificial stones. The stone fragmentation using laser showed that stones produced with higher moisture content at a mixing ratio of 15:6 were similar to COM stones. This novel method for fabricating artificial kidney stones could be used to provide reliable materials for lithotripsy research.

Outcomes of ureteroscopy and laser fragmentation using a 60 W MOSES laser: a 3-year prospective study from a University Teaching Hospital.

Introduction: Modulated optics enhancement system (MOSES) holmium lasers use "pulse modulation" to increase the efficacy of laser lithotripsy. As the clinical evidence on the efficacy of 60 W holmium laser with MOSES technology is scarce, we analyzed the outcomes of patients treated with this laser at our institution. Methods: A total of 96 consecutive patients with urinary stones (72 renal stones and 24 ureteral stones) were treated with the 60 W MOSES laser from 2019 until 2022 and were included in our analysis. Patient data and outcomes were prospectively collected, and analysis was performed regarding patient demographics, stone parameters, as well as stone-free rate, operating time, length of stay, and perioperative and postoperative complications. Results: With a median age of 55 (IQR: 35-69.25) years, the male:female ratio was 53:43. The median stone size was 12 mm (IQR: 7-19), with a mean number of urinary stones of 1.82 (SD ± 1.4). While 36 (35%) patients were pre-stented, a ureteral access sheath was inserted in 36 (37.5%) patients. The median operative time was 44 min (IQR: 22.5-59.5), and 63 (65.5%) patients received postoperative stenting. Perioperative complications (all Clavien ⩽ II complications) were observed in 5 (5.2%) patients (four urinary tract infections and one acute urinary retention), and after the first procedure, 90 (93.8%) patients were stone-free. The median length of hospital stay was 1 day (IQR: 1-1). Conclusion: This study demonstrated that the 60 W MOSES laser was safe and efficient for the treatment of urinary stones with high stone-free rates and a small risk of minor complications. More studies with larger cohorts are necessary in the future to confirm our results.

Comparison of ureteoroscopy and laser stone fragmentation between Holmium: YAG laser with MOSES versus non-MOSES technology: a prospective single-center propensity score-matched analysis using similar laser settings.

Background: In vitro studies have shown that the holmium Modulated Optics Enhancement Systems (MOSES) technology can lead to an increase in the efficacy of lithotripsy and a reduction of retropulsion, but clinical evidence comparing it to non-MOSES technology is still scarce. We did a comparison of ureteoroscopy and laser stone fragmentation (URSL) between Holmium:YAG laser with MOSES versus non-MOSES technologies. Methods: Patient data and outcomes were prospectively collected and analyzed regarding patient demographics, stone parameters, and clinical outcomes. Patients undergoing URSL with standard holmium laser without MOSES technology (Group 1) were compared to holmium laser with MOSES (Group 2) using the same clinical laser settings (0.4-1 J, 20-40 Hz) with dusting and pop-dusting technique. The independent t-test, Mann-Whitney U test, and Chi-squared test were used, with a p-value of < 0.05 as significant. Given the different sizes of the cohorts, we performed a propensity score 1:1 matched analysis. Results: A total of 206 patients (1:1 matched) with a male:female ratio of 94:112 and a median age of 56 (range: 39-68) years were analyzed. Groups 1 and 2 were matched for ureteric stones (27.7% and 22.3%, p = 0.42), pre-stenting (37% and 35%, p = 0.66), the mean number of stones (1.76 ± 1.3) and (1.82 ± 1.4, p = 0.73), and ureteral access sheath use (37% and 35%, p = 0.77) respectively.While there was no significant statistical difference in clinical outcomes, the stone size was slightly larger in Group 2, 14.8 ± 10.8 mm vs 11.7 ± 8.0 mm, for a lower operative time 42.7 ± 30.6 min versus 48.5 ± 25 min, lower perioperative complication rates 3.9% versus 4.9% and a higher stone-free rate 90.3% versus 87.4%. Conclusion: While the use of MOSES technology was slightly beneficial for the treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high-quality randomized studies to show if there is a true difference in these outcomes.

We compare the outcomes of ureteroscopy and laser stone fragmentation (URSL), using Holmium:YAG laser with MOSES vs Non-MOSES technology: It is a prospective single-centre propensity score-matched analysis using similar laser settings It is a single-centre propensity score-matched analysis using similar laser settings. While the use of MOSES technology was slightly beneficial for treatment of stones in terms of clinical outcomes, this was not statistically significant. As this debate continues, there is a need for high quality randomized studies to show if there is a true difference in these outcomes.

Evaluation of Genetic Associations with Clinical Phenotypes of Kidney Stone Disease.

Background and objective: Previous studies have reported a strong genetic contribution to kidney stone risk. This study aims to identify genetic associations of kidney stone disease within a large-scale electronic health record system. Methods: We performed genome-wide association studies (GWASs) for nephrolithiasis from genotyped samples of 5571 cases and 83 692 controls. This analysis included a primary GWAS focused on nephrolithiasis and subsequent subgroup GWASs stratified by stone composition types. For significant risk variants, we performed association analyses with stone composition and first-time 24-h urine parameters. To assess disease severity, we investigated the associations with age at first stone diagnosis, age at first stone-related procedure, and time between first and second stone-related procedures. Key findings and limitations: The primary GWAS analysis identified ten significant loci, all located on chromosome 16 within coding regions of the UMOD gene. The strongest signal was rs28544423 (odds ratio 1.17, 95% confidence interval 1.11-1.23, p = 2.7 × 10-9). In subgroup GWASs stratified by six kidney stone composition subtypes, 19 significant loci were identified including two loci in coding regions (brushite; NXPH1, rs79970906 and rs4725104). The UMOD single nucleotide polymorphism rs28544423 was associated with differences in 24-h excretion of urinary analytes, and the minor allele was positively associated with calcium oxalate dihydrate stone composition (p < 0.05). No associations were found between UMOD variants and disease severity. Limitations include an omitted variable bias and a misclassification bias. Conclusions and clinical implications: We replicated germline variants associated with kidney stone disease risk at UMOD and reported novel variants associated with stone composition. Genetic variants of UMOD are associated with differences in 24-h urine parameters and stone composition, but not disease severity. Patient summary: We identify genetic variants linked to kidney stone disease within an electronic health record (EHR) system. These findings suggest a role for the EHR to enable a precision-medicine approach for stone disease.

A Machine Learning Predictive Model for Ureteroscopy Lasertripsy Outcomes in a Pediatric Population-Results from a Large Endourology Tertiary Center.

Introduction: We aimed to develop machine learning (ML) algorithms for the automated prediction of postoperative ureteroscopy outcomes for pediatric kidney stones based on preoperative characteristics. Materials and Methods: Data from pediatric patients who underwent ureteroscopy for stone treatment by a single experienced surgeon, between 2010 and 2023 in Southampton General Hospital, were retrospectively collected. Fifteen ML classification algorithms were used to investigate correlations between preoperative characteristics and postoperative outcomes: primary stone-free status (SFS, defined as stone fragments <2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments >2 mm at Xray kidney-ureters-bladder (XR KUB) or ultrasound kidney-ureters-bladder (US KUB) at 3 months follow-up) and complications. For the task of complication and stone status, an ensemble model was made out of Bagging classifier, Extra Trees classifier, and linear discriminant analysis. Also, a multitask neural network was constructed for the simultaneous prediction of all postoperative characteristics. Finally, explainable artificial intelligence techniques were used to explain the prediction made by the best models. Results: The ensemble model produced the highest accuracy (90%) in predicting SFS, finding correlation with overall stone size (-0.205), presence of multiple stones (-0.127), and preoperative stenting (-0.102). Complications were predicted by Synthetic Minority Oversampling Technique (SMOTE) oversampled dataset (93.3% accuracy) with relation to preoperative positive urine culture (-0.060) and SFS (0.003). Training ML for the multitask model, accuracies of 83.3% and 80% were respectively reached. Conclusion: ML has a great potential of assisting health care research, with possibilities to investigate dataset at a higher level. With the aid of this intelligent tool, urologists can implement their practice and develop new strategies for outcome prediction and patient counseling and informed shared decision-making. Our model reached an excellent accuracy in predicting SFS and complications in the pediatric population, leading the way to the validation of patient-specific predictive tools.

Efficacy of mini-endoscopic combined intrarenal surgery for pediatric kidney calculi: a single center retrospective study.

Management of large pediatric kidney calculi (PKC) is challenging. This study aimed to evaluate the efficacy and safety of miniature endoscopic combined intrarenal surgery (mini-ECIRS) for PKC. We retrospectively analyzed mini-ECIRS in 16 pediatric patients undergoing kidney stone treatment between November 2014 and October 2023 to determine its safety, efficacy, and associated outcomes. The median age was 50.50 (interquartile range: 36.75, 84.75) months, and the mean stone size was 21.63 ± 11.65 mm. The stone-free rate was 81.25%. The median decrease in hemoglobin level on the day after surgery was 1.10 (0.80, 1.55), and no patient required a blood transfusion. The median number of general anesthesia procedures was 2.00 (2.00, 2.00). Postoperative complications included fever in two patients and difficulty in removing the ureteral stent in one patient. In this cohort, five patients underwent pre-stenting under general anesthesia before mini-ECIRS. Age was significantly lower in the pre-stenting group than in the non-pre-stenting (P < 0.01); however, there were no significant differences in operative time, stone-free rate, total number of general anesthesia procedures, hemoglobin loss, or postoperative hospital stay between the groups. Mini-ECIRS was found to be a safe and efficient treatment method with a high stone removal rate in pediatric patients.

[Efficacy and safety of mini-track, mini-nephroscopy and mini-ultrasonic probe percutaneous nephrolithotomy for the treatment of 1.5-2.5 cm kidney stones].

OBJECTIVE: To investigate the efficacy and safety of mini-track, mini-nephroscopy and mini-ultrasonic probe percutaneous nephrolithotomy (3mPCNL) for the treatment of 1.5-2.5 cm kidney stones. METHODS: The perioperative data and postoperative follow-up data of a total of 25 patients with about 1.5-2.5 cm kidney stones who underwent 3mPCNL under ultrasound guidance in Peking University People's Hospital from November 2023 to January 2024 were retrospectively analyzed. During the matching period, the 25 patients with 1.5-2.5 cm kidney stones receiving standard percutaneous nephrolithotomy (sPCNL) were matched one-to-one according to the criterion that the absolute difference of the maximum diameter of stones between the two groups was less than 1 mm. The operative time, renal function changes, postoperative stone-free rate, hemoglobin changes, and complication rate of the two treatments were compared, and then the effectiveness and safety of 3mPCNL were preliminarily analyzed. RESULTS: There were no significant differences in mean age, preoperative median creatinine, preoperative mean hemoglobin, preoperative mean hematocrit, median stone maximum diameter, and median stone CT density between the 3mPCNL group and the sPCNL group. The median operation time in the 3mPCNL group was 60.0 (45.0-110.0) min, with no statistical significance compared with the sPCNL group, and all the patients underwent single-channel operations. The mean hemoglobin after operation in the 3mPCNL group was (115.3±15.5) mmol/L, and there was no significant difference between the preoperative group and the sPCNL group, and the mean hemoglobin decreased significantly between the sPCNL group and the sPCNL group [(9.5±2.2) mmol/L vs. (10.1±1.9) mmol/L]. The mean hematocrit after operation was (28.0±5.2)%, and the difference was statistically significant compared with that before operation (t=2.414, P=0.020). The mean hematocrit drop was not statistically signi-ficant compared with the sPCNL group (2.3% vs. 2.7%). The median serum creatinine in the 3mPCNL group was 74.0 (51.0-118.0) µmol/L after operation, and the difference was statistically significant compared with that before operation (Z=-2.980, P=0.005). The stone-free rate in the 3mPCNL group and the sPCNL group was 96.0% and 97.3%, respectively, and the mean hospital stay was (4.3± 1.4) d and (5.5±2.0) d, respectively, with the statistical significance (t=0.192, P=0.025). After the operation, one patient in sPCNL group had massive hemorrhage after the nephrostomy tube was removed, which was improved after selective renal artery embolization. One patient in the 3mPCNL group developed mild perirenal hematoma, which was improved after conservative treatment, and no complications were observed in the other patients. CONCLUSION: 3mPCNL in the treatment of 1.5-2.5 cm kidney stones can achieve an effective rate comparable to sPCNL, and can achieve the ideal stone-free rate in a shorter operative time with a lower rate of surgery-related complications.

Endovascular Treatment for Renal Vein Embolism by a Renal Calculus After Percutaneous Nephrolithotomy.

PURPOSE: This report presents the endovascular strategies adopted to treat a kidney calculus venous embolism after percutaneous nephrolithotomy and the versatility of endovascular techniques to manage even the most unexpected renovascular complications after urological intervention. According to the literature available in PubMed, Cochrane, SciELO, and Science.gov repositories, this is the first case to our knowledge of renal vein calculus embolism as a complication of percutaneous treatment of kidney stones. CASE REPORT: A 62-year-old woman underwent percutaneous nephrolithotomy to treat a left kidney 2.8-cm staghorn calculi. The stone cracked, leaving a residual fragment in the ureteropelvic junction. Abdominal computed tomography revealed a 0.9-mm extrarenal calculus located inside the left retroaortic renal vein. Calculus was captured using a basket catheter system through a 6F 45-cm sheath positioned in the left common femoral vein (CFV) and accessed by dissection to safely conclude the calculus extraction by venous cut down. The patient was asymptomatically discharged 48 hours after the endovascular procedure, under a rivaroxaban anticoagulation regimen, with no symptoms or renal function impairment until the 6 months of follow-up. CONCLUSION: The endovascular strategy proposed in this case was effective for calculus rescue and venous flow restoration. CLINICAL IMPACT: This case reinforces the adaptability of endovascular therapy in an unexpected scenario. A potentially life-threatening extremely rare adverse event following a common urological procedure could be treated with minimally invasive hybrid treatment, preserving renal function and maintaining venous vascular patency. This report may add a discussion of procedures to manage similar events and bring to the literature a possible strategy to solve the problem.

Artificial Intelligence in Urology: Application of a Machine Learning Model to Predict the Risk of Urolithiasis in a General Population.

This research presents our application of artificial intelligence (AI) in predicting urolithiasis risk. Previous applications, including AI for stone disease, have focused on stone composition and aiding diagnostic imaging. AI applications centered around patient-specific characteristics, lifestyle considerations, and diet have been limited. Our study comprised a robust sample size of 976 Chilean participants, with meticulously analyzed demographic, lifestyle, and health data through a comprehensive questionnaire. We developed a predictive model using various classifiers, including logistic regression, decision trees, random forests, and extra trees, reaching high accuracy (88%) in identifying individuals at risk of kidney stone formation. Key protective factors highlighted by the algorithm include the pivotal role of hydration, physical activity, and dietary patterns that played a crucial role, emphasizing the protective nature of higher fruit and vegetable intake, balanced dairy consumption, and the nuanced impact of specific protein sources on kidney stone risk. In contrast, identified risk factors encompassed gender disparities with males found to be 2.31 times more likely to develop kidney stones than females. Thirst and self-perceived dark urine color emerged as strong predictors, with a significant increase in the likelihood of stone formation. The development of predictive tools with AI, in urolithiasis management signifies a paradigm shift toward more precise and personalized health care. The algorithm's ability to process extensive datasets, including dietary habits, heralds a new era of data-driven medical practice. This research underscores the transformative impact of AI in medical diagnostics and prevention, paving the way for a future where health care interventions are not only more effective but also tailored to individual patient needs. In this case, AI is an important tool that can help patients stay healthy, prevent diseases, and make informed decisions about their overall well-being.

Can Machine Learning Correctly Predict Outcomes of Flexible Ureteroscopy with Laser Lithotripsy for Kidney Stone Disease? Results from a Large Endourology University Centre.

Background and objective: The integration of machine learning (ML) in health care has garnered significant attention because of its unprecedented opportunities to enhance patient care and outcomes. In this study, we trained ML algorithms for automated prediction of outcomes of ureteroscopic laser lithotripsy (URSL) on the basis of preoperative characteristics. Methods: Data were retrieved for patients treated with ureteroscopy for urolithiasis by a single experienced surgeon over a 7-yr period. Sixteen ML classification algorithms were trained to investigate correlation between preoperative characteristics and postoperative outcomes. The outcomes assessed were primary stone-free status (SFS, defined as the presence of only stone fragments <2 mm on endoscopic visualisation and at 3-mo imaging) and postoperative complications. An ensemble model was constructed from the best-performing algorithms for prediction of complications and for prediction of SFS. Simultaneous prediction of postoperative characteristics was then investigated using a multitask neural network, and explainable artificial intelligence (AI) was used to demonstrate the predictive power of the best models. Key findings and limitations: An ensemble ML model achieved accuracy of 93% and precision of 87% for prediction of SFS. Complications were mainly associated with a preoperative positive urine culture (1.44). Logistic regression revealed that SFS was impacted by the total stone burden (0.34), the presence of a preoperative stent (0.106), a positive preoperative urine culture (0.14), and stone location (0.09). Explainable AI results emphasised the key features and their contributions to the output. Conclusions and clinical implications: Technological advances are helping urologists to overcome the classic limits of ureteroscopy, namely stone size and the risk of complications. ML represents an excellent aid for correct prediction of outcomes after training on pre-existing data sets. Our ML model achieved accuracy of >90% for prediction of SFS and complications, and represents a basis for the development of an accessible predictive model for endourologists and patients in the URSL setting. Patient summary: We tested the ability of artificial intelligence to predict treatment outcomes for patients with kidney stones. We trained 16 different machine learning tools with data before surgery, such as patient age and the stone characteristics. Our final model was >90% accurate in predicting stone-free status after surgery and the occurrence of complications.

Association between pulp stones and systemic diseases: a case-control study

Introduction: Pulp stones (PS) are calcifications commonly found in the pulp tissue that may be associated with systemic diseases. Objective: To evaluate the association between PS and systemic diseases. Methods: A case-control study with the inclusion of individuals from 18 to 65 years of age, of both sexes. Analysis was made of 1047 digital panoramic radiographs. The controls could not have any teeth with PS; the cases were the contrary. A questionnaire comprising demographic, habit, and general health (diabetes, problems with blood vessels, altered cholesterol level, heart attack, kidney or gallbladder stone, arthritis, or autoimmune disease, and for women, endometriosis, and ovarian cyst). Data were submitted to the Student's t-test to identify differences between groups about sex and age. The Chi-square test was applied to the cross-tabulation. The analyses were performed using SPSS®, version 25.0, with a 5% significance level. Results: 490 patients participated (242 cases and 248 controls). There was no difference between groups for the sex (p=0.966) and age (p=0.186). Only "kidney stone" was associated with the case group (p=0.001), being almost three times higher when compared to the control group. No significant differences were found in females about the presence or absence of PS (p>0.05). Conclusion: In this research, it is suggested the existence of an association between kidney stones and the presence of pulp stones.

A machine learning approach using stone volume to predict stone-free status at ureteroscopy.

INTRODUCTION: To develop a predictive model incorporating stone volume along with other clinical and radiological factors to predict stone-free (SF) status at ureteroscopy (URS). MATERIAL AND METHODS: Retrospective analysis of patients undergoing URS for kidney stone disease at our institution from 2012 to 2021. SF status was defined as stone fragments < 2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments > 2 mm at XR KUB or US KUB at 3 months follow up. We specifically included all non-SF patients to optimise our algorithm for identifying instances with residual stone burden. SF patients were also randomly sampled over the same time period to ensure a more balanced dataset for ML prediction. Stone volumes were measured using preprocedural CT and combined with 19 other clinical and radiological factors. A bagged trees machine learning model with cross-validation was used for this analysis. RESULTS: 330 patients were included (SF: n = 276, not SF: n = 54, mean age 59.5 ± 16.1 years). A fivefold cross validated RUSboosted trees model has an accuracy of 74.5% and AUC of 0.82. The model sensitivity and specificity were 75% and 72.2% respectively. Variable importance analysis identified total stone volume (17.7% of total importance), operation time (14.3%), age (12.9%) and stone composition (10.9%) as important factors in predicting non-SF patients. Single and cumulative stone size which are commonly used in current practice to guide management, only represented 9.4% and 4.7% of total importance, respectively. CONCLUSION: Machine learning can be used to predict patients that will be SF at the time of URS. Total stone volume appears to be more important than stone size in predicting SF status. Our findings could be used to optimise patient counselling and highlight an increasing role of stone volume to guide endourological practice and future guidelines.

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.

Is ureteroscopy and active stone treatment safe and effective in octogenarians? A review of current literature.

Background: With the aging of our patient population, and the increasing incidence of kidney stone disease in the elderly, active stone treatment is becoming more common. In this review of current literature, we aim to assess safety and efficacy of ureteroscopy (URS) as primary treatment for urolithiasis in the octogenarians. Materials and methods: A scoping review of literature according to the PRISMA guidelines was performed, using the relevant search terms. Original articles were screened and included. A narrative review of the studies is provided, with emphasis on outcomes of URS in the elderly. Results: 10 studies were included in the analysis. URS performed in the elderly population showed a good safety and efficacy, with stone-free rates (SFR) comparable to the general population. URS specific complication rates seems to be comparable to the other age groups, with postoperative events mostly related to anaesthesia and pre-existing medical conditions. The overall complication rate was still low, with a slightly prolonged hospital stay. Predictors for SFR were age, severe comorbidities and stone burden. Conclusion: URS for stone treatment in the elderly population is safe and effective, with comparable surgical outcomes to that of the general population. As comorbidities play an important role in the fitness for surgery and overall survival, risks and benefit of active stone treatment should be carefully balanced in this group.