Treatment of Urolithiasis with Thulium Fiber Laser in Fragmentation Mode Using Optimized Pulse Sequences.

Objectives: The super-pulsed thulium fiber laser (SP TFL) is a new alternative to high-power holmium laser for intracorporeal lithotripsy. The SP TFL has shown advantages in dusting regimes, but benefits in fragmentation regimes are less understood. The second-generation SP TFL introduces an advanced fragmentation pulse (AFP) sequence to maximize SP TFL's efficiency in fragmentation. This study evaluates safety and efficacy of the SP TFL fragmentation mode in ureteroscopy (URS) and mini percutaneous nephrolithotomy (mini-PCNL). Materials and Methods: The study was conducted in two phases. Safety of a new AFP was compared ex vivo to standard SP TFL fragmentation settings by measuring the dimensions of wounds created in porcine kidney after laser exposure for 0.5, 1.0, and 2.0 s. The resulting wounds were evaluated histologically using nitro blue tetrazolium chloride (NBTC) stain. In the clinical phase, the second-generation SP TFL was used to fragment and extract ureteral and renal stones in 40 patients using ureteroscopic and percutaneous approaches. The stone size, volume, density, laser-on-time, and total energy were recorded for each patient. In addition, the chemical composition, ablation rate, and ablation efficiency were assessed for each stone treatment. Results: The ex vivo mucosa damage profiles caused by AFP were similar to those caused by regular pulses. In clinical phase, the median volume and density for ureteral stones were 0.4 cm3 and 1029 Hounsfield units (HU), for renal stones 1.3 cm3 and 1113 HU, respectively. Different stone types were crushed into fragments suitable for extraction. The mean AFP energy was 3 J and the average power for ureteral stones was 10.5 W, whereas for renal stones it was 28.5 J and 31 W, respectively. The overall complication rate was low in both groups. Conclusion: ST PFL with AFP capability facilitates effective fragmentation of ureteral and renal stones of any composition during URS and mini-PCNL with minimal complication rates.

Conventional white light imaging-assisted transurethral resection of bladder tumour (TURBT) versus IMAGE1S-assisted TURBT in non-muscle-invasive bladder cancer patients: trial protocol and 18 months results.

PURPOSE: White light (WL) is the traditional imaging modality for transurethral resection of bladder tumour (TURBT). IMAGE1S is a likely addition. We compare 18-mo recurrence rates following TURBT using IMAGE1S versus WL guidance. METHODS: Twelve international centers conducted a single-blinded randomized controlled trial. Patients with primary and recurrent non-muscle-invasive bladder cancer (NMIBC) were randomly assigned 1:1 to TURBT guided by IMAGE1S or WL. Eighteen-month recurrence rates and subanalysis for primary/recurrent and risk groups were planned and compared by chi-square tests and survival analyses. RESULTS: 689 patients were randomized for WL-assisted (n = 354) or IMAGE1S-assisted (n = 335) TURBT. Of these, 64.7% had a primary tumor, 35.3% a recurrent tumor, and 4.8%, 69.2% and 26.0% a low-, intermediate-, and high-risk tumor, respectively. Overall, 60 and 65 patients, respectively, completed 18-mo follow-up, with recurrence rates of 31.0% and 25.4%, respectively (p = 0.199). In patients with primary, low-/intermediate-risk tumors, recurrence rates at 18-mo were significantly higher in the WL group compared with the IMAGE1S group (31.9% and 22.3%, respectively: p 0.035). Frequency and severity of adverse events were comparable in both treatment groups. Immediate and adjuvant intravesical instillation therapy did not differ between the groups. Potential limitations included lack of uniformity of surgical resection, central pathology review, and missing data. CONCLUSION: There was not difference in the overall recurrence rates between IMAGE1S and WL assistance 18-mo after TURBT in patients with NMIBC. However, IMAGE1S-assisted TURBT considerably reduced the likelihood of disease recurrence in primary, low/intermediate risk patients. REGISTRATION: ClinicalTrials.gov Identifier NCT02252549 (30-09-2014).

Clinical Comparison of Super Pulse Thulium Fiber Laser and High-Power Holmium Laser for Ureteral Stone Management.

Purpose: To evaluate the efficacy of new super pulse thulium fiber laser (SP TFL) and compare it with holmium laser for ureterolithotripsy. Patients and Methods: A total of 174 patients with solitary ureteral calculi were enrolled in 2016 to 2018. Stone sizes ranged between 0.6 and 2.4 cm. The SP TFL FiberLase U2 and 120H Ho:YAG laser with fibers diameters of 400 and 365 µm, respectively, were used. The laser settings were 1 J × 10 Hz = 10 W for both devices. All patients were randomized into two groups. The age, stone size, location, and density were comparable in both groups. The evaluated parameters were operation time, endoscopic view quality, retropulsion grade, stone-free rate, and complication rate. Results: The total operation time and lasering time were longer in the Ho:YAG group (24.7 ± 0.7 minutes vs 32.4 ± 0.7 minutes, p = 0.05), and postoperative stenting was necessary in one vs four cases, respectively. At 30 days of follow-up, no residual stones were observed in the SP TFL group (vs five cases of Ho:YAG). Conclusion: SP TFL technology was associated with excellent efficacy/safety ratio. The SP TFL may be considered as a viable alternative to Ho:YAG laser stone management.

Thermoexpandable Urethral Nickel-Titanium Stent Memokath for Managing Urethral Bulbar Stricture After Failed Urethroplasty.

Introduction: Urethral stenting became popular two decades ago, but nowadays its frequency is slightly decreased because of the rising application of urethroplasty. Today urethral stenting is reserved only for failure after urethral reconstruction or in cases when the plastic surgery is unfavorable. The Memokath stent (Pnn Medical A/S, Kvistgaard, Denmark) is manufactured from a biocompatible alloy of nickel and titanium and known to be the most popular in this field. Case Description: A 38-year-old man with a history of 9 years Memokath urethral stenting was admitted to our clinic with obstructive lower urinary tract symptoms. The indication for Memokath stenting was repeated recurrences after endoscopic and reconstructive operations. The plain radiography showed a normal position of the stent and only the endoscopic examination revealed its total calcification. New superpulse thulium fiber laser has been used to free the stent from the stones and safely remove it without additional urethral injury. Results: The postoperative time was within normal limits, the catheter was removed on the fourth day after operation. Three months follow-up was without stricture recurrence. We continue active surveillance of the patient. Conclusion: The calcification of the stent could be properly diagnosed endoscopically; the Memokath stent could be safely removed in 9 years after implantation; thulium fiber laser is effective and safe in the management of encrusted urethral stent.

Transurethral resection of a large bladder hemangioma of mixed histological composition: a case report.

Hemangioma is a rare benign vascular tumor of the bladder, which occurs mainly in children. It has no specific clinical symptoms but can result in severe and fatal complications as well as relapse. In the current clinical observation, a 35-year-old patient had a large solid tumor of the bladder spreading into the muscular layer. In histological and immunohistochemical analyses, verified hemangioma consisted of capillary, cavernous and arterio-venous components. The patient underwent transurethral resection of the bladder using computer chromoendoscopy. It is the first to the best of our knowledge complete transurethral removal of 3 cm in diameter bladder hemangioma.

Risks and Benefits of Postoperative Double-J Stent Placement After Ureteroscopy: Results from the Clinical Research Office of Endourological Society Ureteroscopy Global Study.

PURPOSE: Double-J stent placement after stone removal by ureteroscopy (URS) is common and recommended in many cases but debatable in others. In this study, the risks and benefits of postoperative Double-J stent placement in URS stone treatment procedures undertaken in current clinical practice are examined. MATERIALS AND METHODS: The Clinical Research Office of Endourological Society (CROES) URS is a prospective, observational, international multicenter study, in which patients are candidates for URS as primary treatment or after failure of prior treatment for ureteral and renal stones. Baseline, intraoperative, and postoperative data were collected. Predictors and outcomes of postoperative stent placement were analyzed by inverse probability-weighted regression adjustment of the relationship between a Double-J stent placement and outcomes (complications, readmission [including retreatment], and length of hospital stay). RESULTS: Significant predictors of postoperative Double-J stent placement in URS treatment of ureteral stones were intraoperative complications, impacted stones, operation time, stone burden, age, presence of a solitary kidney, and stone-free rate. In renal stone treatment, the predictors identified included operation time, age, preoperative stent placement, anticoagulant use, presence of a solitary kidney, and intraoperative complications. In both ureteral and renal stone treatment groups, postoperative placement of a Double-J stent resulted in significantly fewer postoperative complications (p < 0.001) compared with patients who did not receive a stent. CONCLUSIONS: Patient- and procedure-related variables were identified, which may enable an individualized approach to postoperative stenting, resulting in improved clinical outcomes in urologic stone treatment by URS.

En bloc resection of urothelium carcinoma of the bladder (EBRUC): a European multicenter study to compare safety, efficacy, and outcome of laser and electrical en bloc transurethral resection of bladder tumor.

PURPOSE: En bloc resection of bladder tumors (ERBT) may improve staging quality and perioperative morbidity and influence tumor recurrence. This study was designed to evaluate the safety, efficacy, and recurrence rates of electrical versus laser en bloc resection of bladder tumors. METHODS: This European multicenter study included 221 patients at six academic hospitals. Transurethral ERBT was performed with monopolar/bipolar current or holmium/thulium laser energy. Staging quality measured by detrusor muscle involvement, various perioperative parameters, and 12-month follow-up data was analyzed. RESULTS: Electrical and laser ERBT were used to treat 156 and 65 patients, respectively. Median tumor size was 2.1 cm; largest tumor was 5 cm. Detrusor muscle was present in 97.3 %. A switch to conventional TURBT was significantly more frequent in the electrical ERBT group (26.3 vs. 1.5 %, p < 0.001). Median operation duration (25 min), postoperative irrigation (1 day), catheterization time (2 days), and hospitalization (3 days) were similar. Overall complication rate was low (Clavien ≥ 3, n = 6 [2.7 %]). Hemoglobin was significantly lower after electrical ERBT (p = 0.0013); however, overall hemoglobin loss was not clinically relevant (0.38 g/dl). Patients (n = 148) were followed for 12 months; 33 (22.3 %) had recurrences. In total, 63.6 % recurrences occurred outside the ERBT resection field. No difference was noted between ERBT groups. CONCLUSIONS: ERBT is safe and reliable regardless of the energy source and provides high-quality resections of tumors >1 cm. Recurrence rates did not differ between groups, and the majority of recurrences occurred outside the ERBT resection field.

Technical solutions to improve the management of non-muscle-invasive transitional cell carcinoma: summary of a European Association of Urology Section for Uro-Technology (ESUT) and Section for Uro-Oncology (ESOU) expert meeting and current and future perspectives.

The aim of the present review was to compare state-of-the-art care and future perspectives for the detection and treatment of non-muscle-invasive transitional cell carcinoma (TCC) of the bladder. We provide a summary of the third expert meeting on 'Optimising the management of non-muscle-invasive bladder cancer, organized by the European Association of Urology Section for Uro-Technology (ESUT) in collaboration with the Section for Uro-Oncology (ESOU), including a systematic literature review. The article includes a detailed discussion on the current and future perspectives for TCC, including photodynamic diagnosis, optical coherence tomography, narrow band imaging, the Storz Professional Image Enhancement system, magnification and high definition techniques. We also provide a detailed discussion of future surgical treatment options, including en bloc resection and tumour enucleation. Intensive research has been conducted to improve tumour detection and there are promising future perspectives, that require proven clinical efficacy. En bloc resection of bladder tumours may be advantageous, but is currently considered to be experimental.

Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: a matched case-control analysis on antibiotic prophylaxis from the CROES URS global study.

PURPOSE: To examine the effects of antibiotic prophylaxis on postoperative infection rate in patients with negative urine cultures undergoing ureteroscopy (URS). PATIENTS AND METHODS: Using the Clinical Research Office of the Endourological Society (CROES) URS Global Study database, patients with a negative baseline urine culture undergoing URS for ureteral stones (n=1141) or kidney stones (n=184) not receiving antibiotic prophylaxis were matched with those who were predefined by risk factors, including gender, American Society of Anesthesiologists (ASA) score, and ureteral stent placement. Patient characteristics, operative data, and postoperative outcomes, including the development of urinary tract infection (UTI) and fever, in the two groups were compared. RESULTS: Antibiotic prophylaxis use differed widely across participating countries (13%-100%). Differences were found between patients who did or did not receive antibiotic prophylaxis regarding the frequency of anticoagulation medication, previous treatment with URS, stone burden, previous presence of kidney stones, duration of current URS, and complications post-URS. The prevalence of fever and UTI was low (≤2.2%) and similar in both groups. Factors predictive of postoperative UTI or fever were female gender, Crohn's and cardiovascular disease, a high stone burden, and an ASA score of II or higher. CONCLUSIONS: In patients with a negative baseline urine culture undergoing URS for ureteral or renal stones, rates of postoperative UTI and fever were not reduced by preoperative antibiotic prophylaxis. Female gender and a high ASA score were specific risk factors for postoperative infection in this patient group.

Investigation of differences between nanosecond electropulse and electrohydraulic methods of lithotripsy: a comparative in vitro study of efficacy.

PURPOSE: To compare the effectiveness of novel nanosecond electropulse lithotripsy with standard electrohydraulic lithotripsy to demonstrate and authenticate their differences because both modalities appear to be similar. MATERIALS AND METHODS: An in vitro fragmentation study was conducted using cuboid BegoStone phantoms, which mimic hard and soft stones, based on an established model. Three different stone sizes were used in the testing having volumes of 100, 256, and 320 mm(3). A nanosecond electropulse lithotripter (NEPL) and an electrohydraulic lithotripter (EHL) were operated using a range of probe sizes at comparable energy settings and pulse rates with the objective of obtaining a stone fragment <2 mm. To compare the efficacy of these two lithotripters, the number of pulses needed for stone phantom fragmentation was recorded according to probe size and energy setting, which were then converted into units of cumulative energy. RESULTS: The results clearly demonstrated that, for all operating modes and stone phantom types, the NEPL device needs much less cumulative energy and thus fewer pulses and consequently less time to achieve stone fragmentation than the EHL device. The disparity in the results is explained by the dissimilar mechanisms at work in the compared lithotripters during destruction of the stone. The electropulse stone disintegration mechanism transfers energy directly into the stone because of discharge penetration into a solid body. This contrasts with the electrohydraulic mechanism in EHL in which energy is transferred through the liquid medium, which also creates a damaging shockwave. CONCLUSIONS: The findings demonstrate that, for all operating modes and stone types, the NEPL device needs much less cumulative energy and thus fewer pulses for stone fragmentation than the EHL device. The disparity in the results is explained by the dissimilar mechanisms at work in the compared lithotripters during destruction of the stone.

Comparative in vitro study of the effectiveness of nanosecond electrical pulse and laser lithotripters.

A comparative in vitro research of the efficiency of nanosecond electropulse (Urolit-105M) and Holmium laser (Auriga) lithotripters is presented in this work. Four sizes of BegoStone cement stones of various densities were fabricated for these tests. A comparison of the efficiency of the lithotripters was performed in the experiments on pairs of probes corresponding to a predetermined stone size. The probes and stones sizes that were used simulate an actual clinical situation to some extent. During the execution of the tests, stones of the specified size were placed on a stainless steel grid with the 2×2 mm cells, immersed in a liquid. The distal part of each probe type was placed in contact perpendicularly with regard to the horizontal surface of a stone. The experiment was discontinued when the destroyed particles did not remain on the grid's surface (i.e., when the sample had been shattered into fragments of less than 2 mm). It was ascertained that, for all of the stone samples used in the given experiments the nanosecond electropulse lithotripter demands significantly less cumulative energy and less time for destruction of the stones than the laser lithotripter, that is, according to physical parameters, it is more effective. With that, various dependences from pulse energy and from stones properties at their disintegration for two examined methods of contact lithotripsy are confirmed experimentally. Operation of the compared lithotripters differs according to the mechanism by which the stones are destroyed, accounting for the variable influence of sample density on the received results.