Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis.

BACKGROUND: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. RESULTS: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. CONCLUSION: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomised, double-blinded, placebo-controlled trial.

OBJECTIVES: To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones undergoing percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: In a randomised, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomised (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anaesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236. RESULTS: The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%; relative risk, 0.21, 95% confidence interval [CI] 0.03-0.76, P = 0.033; number-needed-to-treat: 12). Patients randomised to the tranexamic acid group had a higher immediate and 3-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [OR] 2.37, 95% CI 1.15-4.87, P = 0.019, and 46.2% vs 28.1%, OR 2.20, 95% CI 1.20-4.02, P = 0.011, respectively). Faster haemoglobin recovery occurred in patients in the tranexamic acid group (mean, 21.3 days; P = 0.001). No statistical differences were found in operative time and complications between groups. CONCLUSIONS: Tranexamic acid administration is safe and reduces the need for blood transfusion by five-times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contribute to better stone clearance rate and faster haemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anaesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.

Supine versus Prone Percutaneous Nephrolithotomy for Complex Stones: A Multicenter Randomized Controlled Trial.

PURPOSE: High-quality evidence comparing supine to prone percutaneous nephrolithotomy (PCNL) for the treatment of complex stones is lacking. This study aimed to compare the outcomes of supine position (SUP) and prone position (PRO) PCNL. MATERIALS AND METHODS: A noninferior randomized controlled trial was performed according to the CONSORT (Consolidated Standards for Reporting Trials) criteria. The inclusion criteria were patients over 18 years of age with complex stones. SUP was performed in the Barts flank-free modified position. Except for positioning, all the surgical parameters were identical. The primary outcome was the difference in the success rate on the first postoperative day (POD1) between groups. The secondary outcome was the difference in the stone-free rate (SFR) on the 90th postoperative day (final SFR). A noninferiority margin of 15% was used. Demographic, operative, and safety variables were compared between the groups. Statistical significance was set at p <0.05. RESULTS: Overall, 112 patients were randomized and their demographic characteristics were comparable. The success rates on POD1 were similar (SUP: 62.5% vs PRO: 57.1%, p=0.563). The difference observed (-5.4%) was lower than the predefined limit. The final SFRs were also similar (SUP: 55.4% vs PRO: 50.0%, p=0.571). SUP had a shorter operative time (mean±SD 117.9±39.1 minutes vs 147.6±38.8 minutes, p <0.001) and PRO had a higher rate of Clavien ≥3 complications (14.3% vs 3.6%, p=0.045). CONCLUSIONS: Positioning during PCNL for complex kidney stones did not impact the success rates; consequently, both positions may be suitable. However, SUP might be associated with a lower high-grade complication rate.

Comparing public interest on stone disease between developed and underdeveloped nations: are search patterns on google trends similar?

ABSTRACT Objective: The big data provided by Google Trends may reveal patterns in health information-seeking behavior on population from Brazil and United States (US). Our objective was to explore and compare patterns of stone disease online information-seeking behaviors in both nations. Materials and Methods: To compare Relative Search Volume (RSV) among different urologic key words we chose "US" and "Brazil" as country and "01/01/2009 - 31/12/2018" as time-range. The final selection included 12 key words in each language. We defined "ureteroscopy" as a reference and compared RSV against it for each term. RSV was adjusted by the reference and normalized in a scale from 0-100. Trend presence was evaluated by Mann Kendall Test and magnitude by Sen's Slope (SS) Estimator. Results: We found an upward trend (p <0.01) in most of the researched terms in both countries. Higher temporal trends were seen for "Kidney Stone" (SS=0.36), "Kidney Pain" (SS=0.39) and "Tamsulosin" (SS=0.21) in the US. Technical treatment terms had little search volumes and no increasing trend. "Kidney Stent" and "Double J" had a significant increase in search trend over time and had a relevant search volume overall in 2018. In Brazil, "Calculo Renal", "Colica Renal", "Dor no Rim" and "Pedra no Rim" had a significant increase in RSV (p <0.001). More common and popular terms as "Kidney Stent" and "Tamsulosin" were highly correlated with "Kidney Pain" and "Kidney Stone" in both countries. Conclusions: In the last decade, there was a significant increase in online search for medical information related to stone-disease. Population from both countries tend to look more for generic terms related to symptoms, the disease, medical management and kidney stent, than for technical treatment vocabulary.

Comparing public interest on stone disease between developed and underdeveloped nations: are search patterns on google trends similar?

OBJECTIVE: The big data provided by Google Trends may reveal patterns in health information-seeking behavior on population from Brazil and United States (US). Our objective was to explore and compare patterns of stone disease online information-seeking behaviors in both nations. MATERIALS AND METHODS: To compare Relative Search Volume (RSV) among different urologic key words we chose "US" and "Brazil" as country and "01/01/2009 - 31/12/2018" as time-range. The final selection included 12 key words in each language. We defined "ureteroscopy" as a reference and compared RSV against it for each term. RSV was adjusted by the reference and normalized in a scale from 0-100. Trend presence was evaluated by Mann Kendall Test and magnitude by Sen's Slope (SS) Estimator. RESULTS: We found an upward trend (p<0.01) in most of the researched terms in both countries. Higher temporal trends were seen for "Kidney Stone" (SS=0.36), "Kidney Pain" (SS=0.39) and "Tamsulosin" (SS=0.21) in the US. Technical treatment terms had little search volumes and no increasing trend. "Kidney Stent" and "Double J" had a significant increase in search trend over time and had a relevant search volume overall in 2018. In Brazil, "Calculo Renal", "Colica Renal", "Dor no Rim" and "Pedra no Rim" had a significant increase in RSV (p<0.001). More common and popular terms as "Kidney Stent" and "Tamsulosin" were highly correlated with "Kidney Pain" and "Kidney Stone" in both countries. CONCLUSIONS: In the last decade, there was a significant increase in online search for medical information related to stone-disease. Population from both countries tend to look more for generic terms related to symptoms, the disease, medical management and kidney stent, than for technical treatment vocabulary.

The impact of COVID-19 in medical practice. A review focused on Urology

ABSTRACT COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties nondirectly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

The impact of COVID-19 in medical practice. A review focused on Urology.

COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

Percutaneous nephrolithotomy in patients with spinal cord injury: should all these patients be automatically assigned a Guy's stone score of 4?

PURPOSE: To assess the complication and stone-free rates of PCNL in patients with spinal cord injury (SCI) and to evaluate whether this population should be assigned a Guy's stone score (GSS) of 4. METHODS: A case-control study was conducted, and electronic charts were reviewed to search for patients with SCI, bladder dysfunction, and kidney stones who had undergone PCNL. Control cases were randomly selected from among patients with complete staghorn calculus (GSS = 4). RESULTS: One hundred and seventeen patients were included. Patients with SCI had a significant shorter operative time (119 vs. 141 min; p = 0.018). There were no significant differences between the groups in terms of the patients' position, number of renal tracts, bleeding or transfusion rate; however, there was a significantly higher complication rate (23.1% vs. 7.8%; p = 0.009) and a longer hospital stay (5.8 vs. 3.1 days; p = 0.002) among patients with SCI. With regards to the stone-free rate in patients with different grades of GSS patients with SCI who had a GSS of 1 had a stone-free rate of 85.7%, while those with a GSS of 2, 3, or 4 had 50%, 50%, and 31.5%, respectively (p = 0.024). Only patients with a GSS of 4 in the SCI group had outcomes that were similar to those of control patients (31.5% vs. 31.6%). CONCLUSION: Patients with SCI should not be automatically assigned GSS 4. Stone-free rate is related to stone burden in these patients, although they do show a higher complication rate and a longer hospital stay than non-neurological patients.

Understanding urologic scientific publication patterns and general public interests on stone disease: lessons learned from big data platforms.

PURPOSE: To analyse patterns of stone disease online information-seeking behaviours in the United States and to correlate with urological literature publication aspects. METHODS: To compare Relative Search Volume (RSV) among different twelve preselected urologic keywords we chose "United States" as country and "01/01/2009-31/12/2018" as time range on Google Trends (GT). We defined "ureteroscopy" as a reference and compared RSV against it for each term. RSV was adjusted and normalized in a scale 0-100. Trend presence was evaluated by Mann-Kendall Test and magnitude by Sen's Slope Estimator (SS). Weather influence on RSV was also investigated by comparison of the ten hottest versus ten coldest states. Pearson correlation analysis was performed between number of Pubmed publications and RSV for each term over time. RESULTS: We found an upward tendency (p < 0.01) for most terms. Higher temporal trends were seen for "kidney stone" (SS = 0.36), "kidney pain" (SS = 0.39) and "tamsulosin" (SS = 0.21). Technical treatment terms had little search volumes and no increasing trend. States with hotter weather showed higher mean RSV for "kidney stone" than colder ones. There was little correlation between GT and Pubmed for most terms, with the exception of "kidney stone" (R = 0.89; p < 0.01), "URS" (R = 0.81; p < 0.01), and "laser lithotripsy" (R = 0.74; p = 0.01). CONCLUSION: There was a significant increase in online search for medical information related to stone disease. Citizens tend to look for generic terms related to symptoms or the disease itself. States with hotter weather show higher RSV than colder states. There is a discrepancy between public and medical community medical terms.

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function.

INTRODUCTION: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. METHODS: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. RESULTS: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). CONCLUSION: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function

SUMMARY INTRODUCTION: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. METHODS: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. RESULTS: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). CONCLUSION: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.

RESUMO INTRODUÇÃO: Paciente com cálculos renais bilaterais e de grande volume são casos desafiadores para os endourologistas. A nefrolitotripsia percutânea bilateral simultânea (NLPbs) é um opção, entretanto esse procedimento pode ser acompanhado de morbidade importante. Uma alternativa é a NLP estagiada, operando um lado de cada vez. Aqui, nós comparamos o impacto da NLPbs e da NLP estagiada nas taxas de complicações e função renal. MÉTODOS: Pacientes que foram submetidos a NLPsb ou NLP stagiada com intervalo de até 6 meses foram pesquisados em nossa base de dados de cálculos renais prospectivamente coletada. Os grupos foram comparados em idade, gênero, índice de massa corpórea (IMC), comorbidades (classificação da Sociedade Americana de Anestesiologia - ASA), tamanho do cálculo, Classificação de Guys, taxa de pacientes livres de cálculos, função renal, perda sanguínea, taxa de transfusão, taxa de complicações e tempo de internação hospitalar. RESULTADOS: Vinte e seis paciente e 52 unidades renais foram incluídas. O tempo operatório médio foi de 134,7 min. Apenas 11.3% dos casos tiveram complicações, sendo todas menores (Clavien ≤ 2). No geral, a taxa de pacientes livres de cálculos foi de 61,5%. Comparando os grupos houve um tempo operatório significativamente maior no grupo NLPbs(172,5 vs. 126,3 min; p=0,016), assim como uma maior taxa de transfusão (12,5% vs. 5,6%; p=0.036). Não houve diferença significante nos níveis de creatinina entre os grupos. Em relação a taxa de doentes livre de cálculos houve uma proporção significativamente maior de pacientes livres de cálculos na NLP estagiada (64,9% vs. 43,8%; p=0,012). CONCLUSÃO: A NLPsb é um procedimento seguro, entretando quando comparada ao procedimento estagiado apresenta uma maior taxa de transfusão e uma menor taxa de pacientes livres de cálculos.

Renal Stone Features Are More Important Than Renal Anatomy to Predict Shock Wave Lithotripsy Outcomes: Results from a Prospective Study with CT Follow-Up.

Introduction: Lower pole kidney stones have been associated with poor shock wave lithotripsy (SWL) outcomes because of its location. However, the real impact of collecting system anatomy on stone clearance after SWL is uncertain. There is a lack of prospective well-controlled studies to determine whether lower pole kidney stones have inferior outcomes than nonlower pole kidney stones when treated with SWL. Methods: We prospectively evaluated patients with a single kidney stone of 5-15 mm undergoing SWL from June 12 through January 19. All patients were subjected to computed tomography before and 3 months after the procedure. Demographic data (age, gender, and body mass index), stone features (stone size, stone area, stone density, and stone-skin distance-SSD), and collecting system anatomy (infundibular length and width, and infundibulopelvic angle) were recorded. Outcomes (fragmentation and stone clearance rates) were compared between lower pole and nonlower pole cases. Then, a multivariate analysis including all variables was performed to determinate which parameters significantly impact on SWL outcomes. Results: One hundred and twenty patients were included in the study. Mean stone size was 8.3 mm and mean stone density was 805 Hounsfield units. Overall stone fragmentation, success, and stone-free rates were 84.1%, 64.1%, and 34.1%, respectively. There were no significant differences in stone fragmentation (76.0% vs 71.4%; p = 0.624), success rate (57.6% vs 53.3%; p = 0.435), and stone-free rate (40.2% vs 35.7%; p = 0.422) in the lower vs nonlower pole groups, respectively. On multivariate analysis, only stone density (p < 0.001) and SSD (p = 0.006) significantly influenced fragmentation. Stone size (p = 0.029), stone density (p = 0.002), and SSD (p = 0.049) significantly influenced kidney stone clearance. Conclusions: Stone size, stone density, and SSD impact on SWL outcomes. Lower pole kidney stones have similar fragmentation and stone clearance compared with nonlower pole kidney stones.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

PURPOSE: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. MATERIALS AND METHODS: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. RESULTS: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition. CONCLUSIONS: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices

ABSTRACT Purpose to critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. Materials and Methods A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. Results 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive financial cost-effective decision model to flexible ureteroscope acquisition. Conclusions The cost-effectiveness of a flexible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

Endoscopic guided PCNL in the prone split-leg position versus supine PCNL: a comparative analysis stratified by Guy's stone score.

INTRODUCTION: The optimal patient positioning for percutaneous nephrolithotomy (PCNL) based on the complexity of stone burden is not yet defined. Thus, we aimed to evaluate the intraoperative parameters, effectiveness and complications of patients undergoing PCNL between the endoscopic-guided prone split-leg PCNL (ePSL) and the supine PCNL by stratifying patients according to Guy's stone score (GSS). MATERIALS AND METHODS: A retrospective chart review was conducted of patients undergoing PCNL at two high-volume tertiary referral centers. At one center, patients underwent PCNL using the ePSL technique, while at the second center, patients underwent PCNL in supine. Patient demographics and stone characteristics, operative details, complications and effectiveness were compared between groups. The impact of obesity was also investigated. RESULTS: Of 830 subjects, a total of 449 (54%) underwent PCNL in ePSL and 381 (46%) in supine. The ePSL group had a greater mean age and body mass index. No statistical differences were found in gender, serum chemistry and Charlson comorbidity index. After stratifying patients by GSS, the differences in baseline stone burden between PSL and supine lost significance and both groups could be compared. Complications were not statistically different between both groups. Univariate analysis demonstrated that multiple tracts and lower pole access were more prevalent in supine. In addition, for GSS1-3, ePSL was correlated with reduced operative time, radiation exposure, length of hospital stay and need for secondary procedure. Multivariate analysis correlated ePSL with lower radiation exposure and need for secondary procedures (p = 0.01). In comparison to the whole trial population, the same tendencies were appreciated for obese cohort. CONCLUSIONS: This is the first report focusing on the performance differences between ePSL and supine PCNL stratified by GSS. Both techniques are safe, with a low rate of complications. For GSS1-3, ePSL reduces radiation exposure and requires less need for both multiple access and secondary procedure.

Recurrent Penile Fracture-Case Report and Alternative Surgical Approach.

INTRODUCTION: Penile refracture is an exceedingly rare event, with very few published studies. To the best of our knowledge, this is the first documented case in the literature of penile fracture with 3 same-site recurrences. AIMS: To describe the case of a 25-year-old Caucasian man with recurrent penile fracture ultimately treated with resuture and patch reinforcement. METHODS: Patient history (clinical and surgical) and literature review. RESULTS: After the 3rd same-site recurrence, patch reinforcement over the sutured area was performed. The patient had an uneventful recovery and no recurrences to date. CONCLUSION: There is no evidence indicating the superiority of non-absorbable sutures. Bovine pericardium reinforcement over the sutured area was used to minimize the chance of another recurrence. More studies are necessary to investigate its safety and efficacy in this scenario. Nascimento B, Guglielmetti GB, Miranda EP, et al. Recurrent Penile Fracture-Case Report and Alternative Surgical Approach. Sex Med 2018;6:263-266.

Calcium Oxalate Urolithiasis: A Case of Missing Microbes?

INTRODUCTION: Urinary stone disease (USD) has known associations with the gut microbiota. Approximately 80% of kidney stones contain oxalate as a primary constituent and diverse oxalate-degrading bacteria exist within the human gut, which may protect against USD. Although bacteriotherapy represents a promising strategy to eliminate oxalate and reduce the risk of USD, oxalate-degrading probiotics have had limited success. To identify limitations of oxalate-degrading probiotics and refine development of bacteriotherapies to prevent USD, we review the literature associated with the gut microbiota and USD. MATERIALS AND METHODS: A literature search was performed to identify publications that examine the role of oxalate-degrading bacteria or the whole gut microbiota in oxalate metabolism and the pathophysiology of USD. We conducted a meta-analysis of studies that examined the association of the whole gut microbiota with USD. In addition, we evaluated the gut microbiota of healthy individuals and those with comorbidities related to USD using publically available data from the American Gut Project (AGP). RESULTS: Studies on Oxalobacter formigenes reveal that colonization by this species is not a good predictor of USD risk or urinary oxalate excretion. The species of oxalate-degrading bacteria used in probiotics and duration of administration do not impact efficacy or persistence. Studies focused on the whole gut microbiota reveal broad shifts in the gut microbiota associated with USD and a diverse microbial network is associated with oxalate metabolism. AGP data analysis demonstrated a strong overlap in microbial genera depleted in diseased individuals among USD and comorbidities. CONCLUSIONS: The associations between the gut microbiota and USD extend beyond individual functional microbial species. Common shifts in the gut microbiota may facilitate the onset of USD and/or comorbidities. The successful development of bacteriotherapies to inhibit USD will need to incorporate strategies that target a broad diversity of bacteria rather than focus on a few specialist species.