Trifecta in flexible ureteroscopy for treatment of renal and upper ureteral calculi: A multicenter study.

Purpose: To determine predictors for missing trifecta in patients who underwent flexible ureteroscopy (FURS) for treatment of renal and upper ureteric calculi. Patients and Methods: The data of adult patients with renal or upper ureteral stones who underwent FURS from June 2021 through December 2022 were retrospectively reviewed. Stone-free status (no residual stones > 3 mm) was evaluated after 3 months with non-contrast CT. Modified Clavien classification was used to grade complications. A stone-free status after a single intervention of FURS without complications was defined as trifecta. Patients were divided into two groups (trifecta and non-trifecta). Risk factors for missing trifecta were compared between both groups using univariate and multivariate analyses. Results: Three hundred twenty-three patients with mean age 48.9 ± 13 years and mean stone length 16 ± 5.9 mm were included. The trifecta criteria were applicable for 250 patients (71%). On multivariate analysis, risk factors for missing trifecta were stone multiplicity (OR: 3.326, 95%CI: 1.933-5.725) and non-experienced surgeons (OR: 1.819, 95%CI: 1.027-3.220). Conclusions: Multiple stones and performance of FURS by non-experienced surgeons are the independent risk factors for missing trifecta of FURS.

The Ideal Interval Between Repeated Shockwaves Lithotripsy Sessions for Renal Stones: A Randomized Controlled Trial.

Objectives: To assess the ideal interval between repeated extracorporeal shockwave lithotripsy (SWL) for renal stones. Patient and Methods: Eligible patients with a single renal stone ≤20 mm who required SWL were randomly assigned to one of three groups based on intervals between first and second sessions. Patients underwent the second session after 3, 7, and 14 days in Groups 1, 2, and 3, respectively. Tubular functions were assessed through comparisons of urinary execration of kidney injury molecule-1 (KIM-1), neutrophil gelatinase associated lipocalin (NGAL), and interleukin-18 (IL-18) with pre-SWL values, whereas glomerular function was assessed by comparisons of protein/creatinine ratio with pre-SWL and changes in ipsilateral renal function on isotope scans. Treatment success was assessed by noncontrast CT after 3 months. Results: All demographics of the 166 patients included in the study were comparable between the three groups. There were significant elevations of tubular biomarkers and protein/creatinine ratio after first and second SWL sessions compared with pre-SWL values (p < 0.0001). All tubular biomarkers returned to pre-SWL values at 7 and 14 days after second session, whereas they remained significantly elevated 3 days after second session (p = 0.027, < 0.001 and <0.001 for KIM-1, NGAL, and IL-18, respectively). SWL success was 73.6% in Group 1, 83.7% in Group 2, and 81% in Group 3. A significant decrease in ipsilateral renal split function was observed in Group 1 at the 3-month follow-up. Conclusions: An interval of 7 days is required between SWL sessions when treating renal stones to allow for complete recovery of kidney functions. Clinical Trial Registration: ID: NCT04575480.

Greenlight laser (XPSTM) 180W prostatectomy for treatment of benign prostate hyperplasia in patients with uncorrectable bleeding tendency.

Objectives: Safety of GreenLight™ laser prostatectomy (GL-LP) in patients with ongoing blood thinners has been proven. Yet, the possibility of drug manipulation makes it a less challenging situation compared to treating patients with uncorrectable bleeding tendency. Herein, we aim at evaluating the outcomes of XPS™-180 W GL-LP for treatment of BPH in patients who had uncorrectable bleeding tendency due to hepatic dysfunction. Methods: A prospectively maintained database for all patients who underwent GL-LP for symptomatic BPH was reviewed. Patients were divided into two groups based on the degree of hepatic dysfunction using Fib-4 index: Group 1 (indexed patients; low-risk Fib-4) and Group 2 (non-indexed patients; intermediate-high-risk Fib-4) included those who had chronic liver disease associated with either thrombocytopenia and/or hypoprothrombinemia. Primary outcome was the difference in perioperative bleeding complications between the two groups. Other outcome measures included all perioperative findings and complications as well-functional outcome measures. Results: The study included 140 patients (93 indexed patients and 47 non-indexed). There were no significant differences between both groups in operative time, laser time and energy, auxiliary procedures, catheter time, hospital stay, and hemoglobin deficit. The need for blood transfusion was significantly more in group 2 (two patients (4.3%) versus no patients in group 1, P = 0.045). Perioperative and late postoperative complications were comparable for both groups (P = 0.634 and 0.858, respectively). There were no significant differences in the postoperative uroflow, symptoms score, and PSA reduction between the two groups (P = 0.57, 0.87, and 0.05, respectively). Conclusions: XPS™-180 W GL-LP is a safe and effective technique for treatment of BPH in patients with uncorrectable bleeding tendency due to hepatic dysfunction.

One-stage versus staged ureteroscopy and percutaneous nephrolithotomy for simultaneous ureteral and renal stones.

Objectives: This study is aimed to investigate the outcome of one-stage ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for simultaneous ureteral and renal stones over 10years at a tertiary urology institute. Materials and methods: We retrospectively analyzed the data of patients who were operated on for simultaneous ureteral and renal stones from January 2011 to December 2020. Patients were divided into 2 groups: group A, who underwent one-stage URS and prone PCNL, and group B, who underwent staged procedures. The overall success, complications, operative time, and hospital stays were compared between the 2 groups. Results: Data for 190 patients were reviewed; mean age was 50 ± 13years old, and 146 (77%) were male. The one-stage (A) and staged (B) groups included 102 and 88 patients, respectively. Group A included older patients, with a high The American Society of Anesthesiologists score, while group B included more patients with multiple or staghorn stones. The one-stage group recorded shorter operative time (120 ± 12min vs. 140 ± 16min, p = 0.02) and shorter hospital stays (3days [2-6] vs. 4days [3-9], p = 0.06). Otherwise, both groups had equal outcomes in terms of success rates and complications. Conclusions: PCNL and URS can be performed in one-session for simultaneous ureteral and renal stones, except for multiple renal and staghorn stones. The results are comparable to those of the staged procedure in terms of success rate and complications, with the advantage of a shorter operative time and hospital stay.

The health-related quality of life in patients with prostate cancer managed with active surveillance using the Expanded Prostate Cancer Index Composite survey: Systematic review and meta-analysis.

Objective: To examine the health-related quality of life (HRQoL) of patients with prostate cancer managed with active surveillance (AS) compared with those who receive definitive treatment using the Expanded Prostate Cancer Index Composite (EPIC) Survey. Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched PubMed and ScienceDirect for articles published between April 2010 and April 2020. Eligible studies reported original data on the HRQoL of men undergoing AS for prostate cancer, including studies comparing AS to curative methods particularly radical prostatectomy, radiotherapy, and brachytherapy. Results: We identified nine eligible articles, all were non-experimental observational studies of which seven were longitudinal and two were cross-sectional studies. The EPIC questionnaire was the main instrument used in all studies to assess the HRQoL. AS was noted to show the highest calculated mean score among management groups in all comparative studies at study endpoints including cross-sectional studies (95% confidence interval 2.17-5.75, P < 0.001). The maximum score deterioration for patients who were managed with AS in all studies was only 7.5 points (12.2%) after 2 years follow-up. AS had the least mean score decline among all management groups. Patients with a normal testosterone level were found to have high HRQoL scores. The number of prostate biopsies did not correlate with the HRQoL score. Conclusion: Patients with prostate cancer managed with AS report less impacts on their HRQoL compared to patients who receive definitive treatments. However, further high-quality research with long-term data are required to help both the patient and the physician in making a well-informed management decision.

Comparison of standard- and mini-percutaneous nephrolithotomy for staghorn stones.

Objectives: To compare the outcomes of standard- and mini-percutaneous nephrolithotomy (PCNL) for the treatment of staghorn stones. Patients and Methods: The data of consecutive adult patients who underwent PCNL for the treatment of staghorn stones, between July 2015 and December 2019 from three hospitals, were retrospectively reviewed. All cases were performed in a prone position under fluoroscopic guidance. The nephrostomy tracts were dilatated to 30 F in standard-PCNL and to 18-20 F in mini-PCNL. Stones were fragmented with pneumatic lithotripsy in both groups. Fragments were removed with forceps in the standard-PCNL, while they were evacuated through the sheath using the vacuum clearance effect in mini-PCNL. A ureteric stent was inserted after mini-PCNL, while a nephrostomy tube was inserted after standard-PCNL. Results: The study included 153 patients; 70 underwent standard-PCNL and 83 underwent mini-PCNL. The stone-free rates of PCNL monotherapy were comparable for both groups (83% for mini-PCNL and 88.6% for standard-PCNL, P = 0.339). The incidence (12% vs 24.3%, P = 0.048) and severity of complications were significantly lesser with mini-PCNL (P = 0.031). Standard-PCNL was associated with increased rate of blood transfusion (12.9% vs 2.4%, P = 0.013) and a significant decrease in haemoglobin (P = 0.018). Hospital stay was significantly longer for standard-PCNL than mini-PCNL (median stay of 6 vs 3 days, P < 0.001). Conclusions: The efficacy of mini-PCNL was comparable to standard-PCNL in the treatment of staghorn stones. The advantages of mini-PCNL included a lesser incidence and severity of complications, and shorter hospital stay.

Tubeless mini-percutaneous nephrolithotomy for renal stones larger than 20 mm.

INTRODUCTION: The aim of this study is to evaluate the outcomes of tubeless mini- percutaneous nephrolithotomy (PCNL) for the treatment of large (>20 mm) renal stones. PATIENTS AND METHODS: This study included consecutive patients who underwent single-session tubeless mini-PCNL (tract size 16-20 F) for large (>20 mm) renal stones. Stone-free status meant complete clearance or residual fragments <4 mm. Complications were recorded and classified according to modified Clavien-Dindo classifications. Risk variables for significant residuals were determined with univariate (Chi-square and t-test) and multivariate logistic regression analyses. RESULTS: Between July 2015 and November 2018, 225 patients were included. The mean age was 42.9 years; the mean stone size was 30.2 ± 9.6 mm and 75% of patients were males. A single renal stone was present in 54 patients (24%), multiple stones in 108 (48%), and staghorn stones in 63 (28%). The stone-free rate was 87.6%. The complication rate was 8.4% (Grade I-II in 7.5%, III in 0.9%). Three patients (1.3%) required blood transfusion. Independent risk factor for significant residual fragments was the presence of stones in multiple sites inside the pelvicalyceal system (relative risk: 13.44, 95% confidence interval: 1.78-101.43, P = 0.012). CONCLUSIONS: Mini-PCNL is an effective and safe treatment option for patients with large renal stones (>20 mm). Stones located in multiple sites is the only predictor of significant residual stones.

Definition and Unfavorable Risk Factors of Trifecta in Mini-Percutaneous Nephrolithotomy.

Objectives: In performing mini-percutaneous nephrolithotomy (PCNL), we aimed at achieving the trifecta of stone-free status and no complications in a single treatment session. We analyzed our experience to determine negative predictors for achieving these three-fold goals. Patients and Methods: The data of all consecutive patients who underwent tubeless mini-PCNL between July 2015 and March 2020 in two hospitals were retrospectively reviewed. Stone-free was defined as no residual stones. Complications were recorded and graded according to modified Clavien classification. Patients were divided into two groups according to the outcome (trifecta and non-trifecta). Factors affecting the outcome were compared between both groups by using univariate and multivariate analyses to detect independent unfavorable risk factors. Results: The study included 944 patients with mean age 40.2 years (standard deviation: 13.6). The stone-free rate after one session of mini-PCNL was 90.7%. Auxiliary procedures were needed in 14 patients (1.5%). Complications were observed in 76 patients (8.1%). Trifecta was achieved in 792 patients (84%). Independent unfavorable risk factors in multivariate analysis were number of caliceal groups affected by the stones (relative risks were 1.95 to 2.27 and 5.7 for one, two, and three caliceal groups respectively) and number of percutaneous tracts (relative risk was 2.2). Stone size and complexity were not significant predictors of missing trifecta in multivariate analysis. Conclusions: Mini-PCNL can achieve a high rate of trifecta (84%) for different stone sizes and complexities. Stones distribution in multiple caliceal groups and multiple tracts are the independent unfavorable risk factor.

Parecoxib Vs Paracetamol for Treatment of Acute Renal Colic Due to Ureteric Calculi: A Randomized Controlled Trial.

OBJECTIVE: To compare efficacy and safety of parecoxib and paracetamol for treatment of acute renal colic due to ureteric stones. MATERIALS AND METHODS: A randomized, double blinded, controlled trial included adult patients presented to emergency department with acute renal colic due to ureteric calculi between June 2019 and August 2020. Patients with hypersensitivity to either drug, peptic ulcer, coronary ischemia, peripheral vascular or cerebrovascular disease, hepatic impairment (Child-Pugh score >10) or chronic kidney disease stage 4 or 5 were excluded. Eligible patients were randomized to group 1 who received 1g intravenous Paracetamol infusion or group 2 who received 40mg intravenous Parecoxib infusion. Pain analogue score was evaluated before treatment and 30 minutes afterwards. The primary endpoint was the need for rescue analgesia for persistent pain. Safety was evaluated by the incidence of adverse events. RESULTS: The study included 203 patients (102 in group 1 and 101 in group 2). Pretreatment patients' data were comparable for both groups. The mean pain analogue score decrease from 7.6 to 3.8 in paracetamol group (P <.001) and from 7.8 to 3.4 in parecoxib group (P <.001). Rescue analgesia were needed in 36 patients (35.3%) in paracetamol group and 27 patients (26.7%) in parecoxib group (P = .187). Minor adverse events developed in 2 patients (2%) in paracetamol group and 3 patients (3%) in parecoxib group (P=0.683). CONCLUSION: Paracetamol and Parecoxib were effective for treatment for patient with acute renal colic. Both treatments showed comparable results in reduction of pain and need for rescue analgesia with minimal adverse events.

Development and validation of a simple stone score to estimate the probability of residual stones prior to percutaneous nephrolithotomy.

BACKGROUND: The aim of the present study was to develop and internally validate a simple stone score (SSS) to estimate the probability of clinically significant residual fragments (CSRF) prior to percutaneous nephrolithotomy (PNL). METHODS: The files of 1170 PNL procedures between January and December 2015 were evaluated. CT-derived stone characteristics were examined. Caliceal stone distribution (CSD) was assigned three grades based on the number of calices involved regardless of the renal pelvis (I = no or single calix; II = more than one calix; and III = more than 2 calices or complete staghorn stones). CSRF was defined as any residuals >4 mm in postoperative CT. A logistic regression model to predict the CSRF was fitted, and coefficients were used to develop the SSS. The SSS was validated by discrimination, calibration, and decision curve analysis (DCA). RESULTS: Patients' data were split into training (936, 80%) and validating (234, 20%) datasets. In the training partition, independent predictors of CSRF were CSD-grade II (OR: 4.2; 95%CI: 2.5-7; P<0.001), grade III (OR: 7.8; 95%CI: 4.2-14.4; P<0.001) and largest stone diameter (LSD) (OR:1.3; 95%CI: 1.1-1.6; P<0.001). Score points 0, 1, 2, and 0, 3, 9 were given to LSD<30, 30-40, >40 mm, and CSD grades I, II, III, respectively. Discrimination of the SSS was 0.79 and after 10-fold cross-validation and internal validation was 0.86. The calibration plot and DCA highlighted the validity and clinical significance of the SSS. CONCLUSIONS: The novel SSS could be used to describe the risk of CSRF prior to PNL. Further studies are invited for external validation.

Preoperative risk factors for complications of percutaneous nephrolithotomy.

This study was conducted to evaluate preoperative risk factors for development of complications of percutaneous nephrolithotomy (PCNL). All consecutive patients aged ≥ 16 years who underwent PCNL during 2015 were retrospectively reviewed. Non-contrast CT (NCCT) was performed for all patients to evaluate stone complexity. The technique of PCNL was the same for all patients. Intra-operative and postoperative complications were recorded and classified based on modified Clavien system. The differences in preoperative data (patients, renal and stone characteristics including Guy's and STONE scores) between complicated and uncomplicated cases were compared using univariate and multivariate statistical analyses for detection of independent risk factors. The study included 1178 patients (61% were males). Mean age was 50 ± 12 years, and mean BMI was 30.7 ± 5.7 kg/m2. Complicated group included 166 patients (14.1%). Independent risk factors on multivariate analysis were infected preoperative urine culture (RR: 2.098, P 0.001, 95%CI: 1.380-3.189), largest stones diameter 30 mm or more (RR: 2.481, P > 0.001, 95%CI: 1.697-3.627) and number of calyces affected by the stones (RR: 2.431, P 0.002, 95%CI: 1.400-4.222 for affection of two calyces and RR: 2.778, P 0.005, 95%CI: 1.357-5.684 for affection of three calyces). While two scoring systems (Guy's and STONE) were not predictive of complications after PCNL, preoperative risk factors were infected preoperative urine culture, distribution of the stones or stone branches in two or three calyceal groups and stone size 30 mm or more.

Development and validation of a score for emergency intervention in patients with acute renal colic secondary to ureteric stones.

Objectives: To develop and validate a scoring system to assess the need for emergency intervention (EI) in patients with uncomplicated acute renal colic (ARC) due to ureteric stones. Patients and methods: From May 2017 to April 2019, 382 adult patients presented to emergency department with ARC due to ureteral stones diagnosed by non-contrast computed tomography. Patients with solitary kidney, complications secondary to obstruction (intractable vomiting, fever or sepsis), bilateral ureteric stones, Stage ≥3 chronic kidney disease or those who underwent treatment of urolithiasis within the past 6 months were excluded. EI was performed in cases with persistent or recurrent pain despite analgesics. Multivariate analysis was performed for the first 200 patients to detect risk factors for EI. The score was developed from significant factors. Sensitivity and specificity of the ARC score were calculated using receiver operator characteristic (ROC) curve analysis. The data of last 182 patients were used for validation of the score. Results: In the first 200 patients, EI was needed in 119 patients (59.5%) and included ureteric stents in 92, ureteroscopy in 25 and percutaneous nephrostomy in two. Significant factors for EI were stone location (relative risk [RR] 3.34, P = 0.026), creatinine level (RR 1.04, P < 0.001), leucocyte count (RR 1.69, P < 0.001), and stone length (RR 1.85, P < 0.001). A score using these four variables was developed. The ARC score sensitivity was 86%, specificity was 80% and the area under the ROC curve was 0.902. Validation of the score showed strong correlation between ARC score and need for EI (r = 0.788, P < 0.001). Conclusions: The ARC score is a validated, highly sensitive and specific novel score to determine the need for EI in patients with uncomplicated ARC secondary to ureteric stones. Abbreviations: ARC: acute renal colic; AUC: area under the ROC curve; CDR: clinical decision rules; CKD: chronic kidney disease; ED: emergency department; EI: emergency intervention; MET: medical expulsive therapy; NCCT: non-contrast CT; PCNL, percutaneous nephrolithotomy; ROC: receiver operator characteristic; S.T.O.N.E.: stone size (S), tract length (T), obstruction (O), number of involved calyces (N), and essence or stone density (E); SWL: extracorporeal shockwave lithotripsy; URS: ureteroscopy; WBC: white blood cell.

Emergency vs elective ureteroscopy for a single ureteric stone.

OBJECTIVE: To compare emergency with elective ureteroscopy (URS) for the treatment of a single ureteric stone. PATIENTS AND METHODS: The files of adult patients with a single ureteric stone were retrospectively reviewed. Patients with fever or turbid urine on passage of the guidewire beside the stone underwent ureteric stenting or nephrostomy drainage. Patients who underwent URS were included and divided into two groups: the emergency (EM) Group, those who presented with persistent renal colic and underwent emergency URS within 24 h; and the elective (EL) Group, who underwent elective URS after ≥14 days of diagnosis. Patients with ureteric stents were excluded. The technique for URS was the same in both groups. Safety was defined as absence of complications. Efficacy was defined as the stone-free rate after a single URS session. RESULTS: From March 2015 to September 2018, 179 patients (107 in the EM Group and 72 in the EL Group) were included. There were significantly more hydronephrosis and smaller stones in the EM Group (P = 0.002 and P = 0.001, respectively). Laser disintegration was needed in more patients in the EL Group (83% vs 68%, P = 0.023). Post-URS ureteric stents were inserted in more patients in the EM Group (91% vs 72%, P = 0.001). Complications were comparable for both groups (4.2% for EL and 5.6% for EM, P = 0.665). Stone-free rates were also comparable (93% in the EL Group and 96% in the EM Group, P = 0.336). CONCLUSIONS: Emergency URS can be as safe and effective as elective URS for the treatment of a single ureteric stone if it is performed in patients without fever or turbid urine.Abbreviations: EL Group: elective group; EM Group: emergency group; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; MET: medical expulsive therapy; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy.

Safety and efficacy of a single middle calyx access (MCA) in mini-PCNL.

To compare outcomes of a single middle calyx access (MCA) with a single upper or lower calyceal access in mini-PCNL. From May 2015 through August 2018, patients' files who underwent a single renal access mini-PCNL were retrospectively reviewed. All patients underwent fluoroscopic-guided access (16-20 F) in the prone position. They were categorized into group 1 (MCA) and group 2 (either upper or lower calyceal access). Compared preoperative items included stone location, size, number and complexity (according to Guy's score). The compared outcome parameters were complication and stone-free rates. The study comprised 512 consecutive patients, 374 patients in group 1 and 138 in group 2. A single MCA was utilized to access 95% of proximal ureteral calculi, 89% for ureteropelvic junction stones, and 84% for stones present in the pelvicalyceal system and ureter. MCA was used in 89% of complete staghorn stones and 73% of multiple stones. the Stone-free rates (93% vs 90.6%, P = 0.350) and the complications rates (8% vs 7.2%, P = 0.772) were comparable between group 1 and 2 despite that MCA was used for most cases with complex stones. Complications severity were also comparable (P = 0.579). Mini-PCNL performed through a single MCA is effective and safe. This access can be used for the treatment of renal and upper ureteral calculi of different complexities and locations.

Impact of case volume per year on flexible Ureteroscopy practice: an internet based survey.

BACKGROUND: To report current worldwide variation in techniques and clinical practice of flexible ureteroscopy (FURS) among endourologists of different case volumes per year. METHODS: Two invitations to complete an internet survey were emailed to Endourological Society members. Some of survey questions asked about indications of using FURS for renal and upper ureteral stones. Others were concerned with clinical practice of FURS (such as preoperative stenting, use of ureteral access sheath (UAS) and safety guidewire, technique of Laser lithotripsy and fragment retrieval, and post-FURS stenting. Responders were distributed into two groups; high-volume (> 100 cases/year) and low-volume surgeons (< 100 cases/year) and data were compared between both groups. RESULTS: Responses were received from 146 endourologists all over the world (62 high-volume and 84 low-volume). FURS for intrarenal stone > 20 mm was used by 61% of high-volume surgeons compared with 28.6% for low-volume (P < 0.001). Semirigid URS was used for upper ureteric stones in 68% among high-volume group and 82% in low-volume group (P = 0.044). UAS was used by 62% in low-volume group and 69% in high volume group (P = 0.516). Laser stone dusting was preferred by 63% in low-volume group versus 45% by high-volume (P = 0.031). More responders in low-volume group preferred to leave the stent for 6 weeks (P = 0.042). CONCLUSIONS: The use of FURS for treating upper tract calculi has expanded by high volume endourologists to include large renal stones > 20 mm. Low-volume surgeons prefer to use semi-rigid URS for treatment of upper ureteral stones, to apply Laser stone dusting and maintain ureteral stents for longer periods.

Single Versus Maintenance Intravesical Chemotherapy for the Prevention of Bladder Recurrence after Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Randomized Clinical Trial.

INTRODUCTION: The objective of this study was to determine the efficiency of 1-year maintenance intravesical chemotherapy (MIC) in reducing bladder recurrence (BR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma compared with single intravesical instillation (SIC). PATIENTS AND METHODS: Between January 2015 and May 2017, patients who underwent RNU were randomized to receive SIC (epirubicin 50 mg) or MIC (once weekly for 6 weeks plus once monthly for 1 year). The primary outcome was the rate of histologically proven BR. The secondary outcomes included chemotherapy-related toxicities and disease-specific survival (DSS). Thirty-five patients in each arm were required to achieve a power of 80%. RESULTS: A total of 38 (SIC) and 36 (MIC) patients were analyzed. In SIC, BR developed in 5 (13.2%) over a median follow-up of 3 months (range, 3-6 months) compared with 9 (25%) patients over 12 months (range, 3-28 months) in MIC (P = .08). The 6- and 12-month BR-free survivals were the same (86.8%) in SIC versus 88.9% and 83.3% in MIC, respectively (P = .2). Lymphovascular invasion was significantly associated with BR (P = .04). Post-RNU intravesical chemotherapy regimens did not alter DSS. Blood transfusion and advanced tumor stage were independent predictors for DSS. No significant medication toxicity was reported. CONCLUSIONS: Following RNU, MIC did not change the natural course of BR beyond a single instillation apart from potentially delaying its occurrence. Lymphovascular invasion and blood transfusion were associated with worse BR and DSS outcomes, respectively.

Dusting versus fragmentation for renal stones during flexible ureteroscopy.

Objectives: To compare stone dusting and spontaneous passage vs fragmentation and active fragment retrieval during flexible ureteroscopy (fURS) for renal calculi. Patients and methods: The study included patients who underwent fURS and holmium laser lithotripsy for renal calculi from January 2015 to March 2017. Dusting was done using low energy and high frequency (0.3-0.5 J and 15-20 Hz, respectively), and fragmentation was done with higher energy and lower frequency (1-1.2 J and 6-10 Hz, respectively) and then stone fragments were extracted using a basket. The stone-free rate (SFR) was evaluated after 2 months with non-contrast computed tomography. Operative time, complication rate, SFR, and the need for secondary procedures were compared. Results: The study included 107 consecutive patients, with a mean (SD) age of 49 (13) years. Dusting was performed in 51 patients and fragmentation in 56. The patients' demographics, laboratory tests, preoperative stents, stone and renal characteristics were comparable for both groups. Operative time was significantly shorter for dusting than fragmentation (76 vs 91 min, P = 0.009). Complication rates were comparable between the groups (7.8% for dusting and 8.9% for fragmentation, P = 0.840). The mean hospital stay was comparable for both groups (P = 0.686). The SFR was significantly better in fragmentation group (78.6%) compared with the dusting group (58.6%, P = 0.035). The need for a secondary procedure was 33.3% in the dusting group and 23.3% in fragmentation group (P = 0.244). Conclusions: During fURS for renal stones, the dusting technique had a significantly shorter operation time, whilst the fragmentation technique led to a significantly better SFR. Both techniques have comparable safety, hospital stay, and requirement for secondary procedures. Abbreviations: fURS: flexible ureteroscopy/ureteroscope; ICU: intensive care unit; KUB: plain abdominal radiograph of the kidney, ureter and bladder; NCCT: non-contrast CT; SFR: stone-free rate; SWL: shockwave lithotripsy; UAS: ureteric access sheath.