Patients undergoing double J substitution with a pigtail suture stent report a significant decrease of stent-related symptoms. Results from a prospective multicenter longitudinal trial.

PURPOSE: To compare stent-related symptoms (SRS) in patients with double J (DJ) undergoing substitution with a pigtail suture stent (PSS) after ureteroscopy (URS), through the Ureteral Stent Symptom Questionnaire (USSQ). MATERIALS AND METHODS: Patients with DJ undergoing URS for stone treatment were enrolled in this prospective multicenter longitudinal study. The USSQ was submitted thrice: 2 weeks after DJ, 2 weeks after PSS and 4 weeks after PSS removal (baseline). PRIMARY ENDPOINT: to compare Urinary Symptom Index Score and the rate of patients with pain 2 weeks after DJ and PSS. Secondary endpoints: to compare other USSQ scores and single answers 2 weeks after DJ and PSS, and DJ and PSS USSQ scores with baseline. RESULTS: 93 patients were enrolled. 2 weeks Urinary Symptom Index Score (p < 0.001) and the percentage of patients complaining of pain (60.2% vs 88.2%, p < 0.001) were significantly in favour of PSS compared to DJ. 2 weeks scores were significantly improved with PSS compared to DJ: Pain Index (p < 0.001), VAS (p < 0.001), General Health Index (p < 0.001) and Work Performance Index (p < 0.001). All urinary symptoms were significantly decreased with PSS, including renal pain during micturition and pain interfering with life. Pain Index Score (p = 0.622) and VAS (p = 0.169) were comparable to baseline with PSS, while differed with DJ. CONCLUSIONS: Patients undergoing DJ substitution with PSS after URS report a significant decrease of SRS. Urologists may consider positioning PSS after URS in pre-stented patients to reduce the impact of SRS.

Physician preferences for nonmetastatic castration-resistant prostate cancer treatment in China.

Introduction: The treatment preferences of Chinese physicians who treat nonmetastatic castration-resistant prostate cancer (nmCRPC) and how they weigh the benefits and risks of nmCRPC treatment are still unknown. This study aimed to evaluate Chinese physicians' benefit-risk treatment preferences for nmCRPC and assist in setting nmCRPC treatment goals. Methods: A paper-based discrete choice experiment (DCE) survey was administered to 80 nmCRPC-treating physicians. DCE responses were analyzed to produce the preference weight and the relative importance score for each attribute level. The marginal rate of substitution (MRS) was used to quantify the amount of overall survival (OS) physicians were willing to trade for a reduction in treatment-related adverse events (AEs). We further conducted the exploratory analysis, stratifying physicians from 5 perspectives into different subgroups and examining the treatment preferences and OS trade-off in each subgroup. Results: In terms of efficacy attributes, physicians placed greater emphasis on OS than time to pain progression. With regard to safety attributes, serious fracture was perceived as the most important AE by physicians, followed by serious fall, cognitive problems, skin rash, and fatigue. In the exploratory analysis, we found generally that physicians with less clinical practice experience and those from more economically developed regions placed more emphasis on AEs and were willing to give up more of their patients' OS to reduce the risk of AEs. Conclusion: Physicians from mainland China value the importance of minimizing treatment-related AEs when considering different treatment options for patients with nmCRPC, and they are willing to trade a substantial amount of OS to avoid AEs.

Real-world retrospective study of prostate-specific antigen and safety assessment with darolutamide plus androgen deprivation therapy for metastasis hormone-sensitive prostate cancer.

Background: ARASENS has demonstrated the efficacy and safety for darolutamide (DARO) with androgen deprivation therapy (ADT) plus docetaxel in metastasis hormone-sensitive prostate cancer (mHSPC). There is a lack of reports for DARO with ADT in mHSPC though the regimen is used in clinical from time to time. Moreover, recent studies have supported the importance of early and rapid prostate-specific antigen (PSA) reduction, which correlates with reduced disease progression and improved survival in patients with mHSPC. This study aims to evaluate PSA reduction as a primary endpoint for DARO with ADT in the treatment of mHSPC and to evaluate the real-world short-term PSA control of DARO with ADT from two leading medical centers in China. Methods: We retrospectively reviewed the clinical records of patients with mHSPC receiving ADT and DARO (600 mg, b.i.d.). The collection of data spanned from March 1, 2022, to July 31, 2023. The main observation indicators were PSA level and drug-related adverse events (AE) after medication. PSA levels were closely monitored prior to treatment initiation and at 2-week intervals, as well as at 1, 3, and 6 months after the initiation of treatment. We also conducted an analysis to determine the proportion of patients achieving a PSA reduction of 50% or more (PSA50) and 90% or more (PSA90) as well as the percentage of patients with a notable decrease in PSA level to 0.2 ng/mL and PSA nadir of ≤0.02 ng/mL. Results: Fifty-one patients were included in the study, with a median age of 73 years. At diagnosis of HSPC, the majority of patients had a Gleason score ≥8 (n=40, 78.40%) and a median baseline PSA level of 88 ng/mL. Approximately 45.1% (n=23) of patients had a Charlson Comorbidity Index over 1 and were receiving one or more nontumor-related treatments. The median follow-up time was 9.3 months (range, 1.16-15.8 months). The median reductions in PSA levels compared to baseline were 84.37%, 91.48%, 94.67% and 99.81% at 2 weeks, 1 month, 3 months and 6 months after administration of DARO with ADT, respectively. The median time to PSA50, PSA90, significant PSA reduction (PSA <0.2 ng/mL), and PSA nadir (PSA <0.02 ng/mL) was 0.97, 1.27, 1.98, and 2.08 months, respectively. AE mainly included fatigue (two patients) and arm pain (one patient), all of which were grade I or II AE. No grade III or AE were observed. Conclusions: For treating prostate cancer, DARO with ADT has good early efficacy, demonstrating prompt and substantial control of PSA levels, with a favorable safety profile.

FIRST WORLDWIDE MULTICENTRIC SERIES OF MINI-ECIRS IN CHILDREN: OUTCOMES FROM 2 TERTIARY ENDOUROLOGY CENTERS.

INTRODUCTION Endoscopic combined intrarenal surgery (ECIRS) is a combination of both retrograde and antegrade approaches for treatment of large or complex renal stones in one procedure, that are currently being treated with multiple tracts or sessions of PCNL, increasing the complications. The aim of our study is describe the clinical outcomes of Mini-ECIRS in a pediatric population. MATERIAL AND METHODS A retrospective study was performed in pediatric patients with lithiasis disease treated with mini-ECIRS between 2006 and 2023 in 2 referral centers in Europe. Demographic data, clinical data, stone size and location, laser settings, intraoperative variables, stone- free rate (SFR) and complications were collected. Pearson's chi-squared test, Fisher´s test and logistic regression, were performed. RESULTS 32 mini-ECIRS were included. The mean age was 9,8 years, 56,3% girls. The mean size and volume of the stone were 21,5mm and 3298,2mm3, 53,1% were multiple. Ureteral access sheath (UAS) was used in 93,8% of the surgeries and only 37,5% had preoperative JJ stent. 53,1% of percutaneous access were with 14Fr sheath. High power laser (HPL) was the most frequent energy source for lithotripsy, including TFL. The mean operative time was 166,6 minutes. There was one perforation of the collecting system that was managed with JJ stent and in the postoperative period 81,2% of the patients had no complications. 3 presented fever, 1 developed urinary sepsis and 1 required reintervention. The SFR was 75% and the size, volume, hardness and complexity of the lithiasis, as well as the non-use of lithotripsy in the retrograde approach were statistically significant in decreasing the success of the surgery. CONCLUSIONS ECIRS is a feasible, safe and efficient procedure in children with complex renal lithiasis, decreasing the number of procedures needed for stone free. Multicenter studies are required to validate these results on a population scale.

Current applications of ex-vivo fluorescent confocal microscope in urological practice: a systematic review of literature.

BACKGROUND: Histopathological examination, a cornerstone in diagnosing cancer, faces challenges due to its time-consuming nature. This review explores the potential of ex-vivo fluorescent confocal microscopy (FCM) in urology, addressing the need for real-time pathological assessment, particularly in prostate cancer. This systematic review aims to assess the applications of FCM in urology, including its role in prostate cancer diagnosis, surgical margin assessment, and other urological fields. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search of PubMed and SCOPUS was conducted, focusing on English written original articles published after January 1, 2018, discussing the use of FCM in urological practice. The search included keywords related to FCM and urological terms. The risk of bias assessment was performed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: A total of 17 relevant studies were included in the review that focuses on three main urological issues: prostate cancer (15 articles), bladder cancer (1 article), and renal biopsy (1 article). FCM exhibited significant promise in diagnosing prostate cancer. These studies reported an accuracy range of 85.33% to 95.1% in distinguishing between cancerous and non-cancerous prostate tissues. Moreover, FCM proved valuable for assessing surgical margins in real-time during radical prostatectomy, reducing the need for frozen section analysis. In some investigations, researchers explored the integration of artificial intelligence (AI) with FCM to automate diagnostic processes. Concerning bladder cancer, FCM played a beneficial role in evaluating urethral and ureteral margins during radical cystectomy. Notably, it showed substantial agreement with conventional histopathology and frozen section examination. In the context of renal biopsy, FCM demonstrated the potential to differentiate normal renal parenchyma from cancerous tissue, although the available evidence is limited in this area. The main limitation of the current study is the scarcity of data regarding the topic of interest. CONCLUSIONS: Ex-vivo FCM holds promise in urology, particularly in prostate cancer diagnosis and surgical margin assessment. Its real-time capabilities may reduce diagnostic delays and patient stress. However, most studies remain experimental, requiring further research to validate clinical utility.

Application of AI in urolithiasis risk of infection: a scoping review.

INTRODUCTION: Artificial intelligence and machine learning are the new frontier in urology; they can assist the diagnostic work-up and in prognostication bring superior to the existing nomograms. Infectious events and in particular the septic risk, are one of the most common and in some cases life threatening complication in patients with urolithiasis. We performed a scoping review to provide an overview of the current application of AI in prediction the infectious complications in patients affected by urolithiasis. EVIDENCE ACQUISITION: A systematic scoping review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) guidelines by screening Medline, PubMed, and Embase to detect pertinent studies. EVIDENCE SYNTHESIS: A total of 467 articles were found, of which nine met the inclusion criteria and were considered. All studies are retrospective and published between 2021 and 2023. Only two studies performed an external validation of the described models. The main event considered is urosepsis in four articles, urinary tract infection in two articles and diagnosis of infection stones in three articles. Different AI models were trained, each of which exploited several types and numbers of variables. All studies reveal good performance. Random forest and artificial neural networks seem to have higher AUC, specificity and sensibility and perform better than the traditional statistical analysis. CONCLUSIONS: Further prospective and multi-institutional studies with external validation are needed to better clarify which variables and AI models should be integrated in our clinical practice to predict infectious events.

Computer Vision and Machine-Learning Techniques for Automatic 3D Virtual Images Overlapping During Augmented Reality Guided Robotic Partial Nephrectomy.

OBJECTIVES: The research's purpose is to develop a software that automatically integrates and overlay 3D virtual models of kidneys harboring renal masses into the Da Vinci robotic console, assisting surgeon during the intervention. INTRODUCTION: Precision medicine, especially in the field of minimally-invasive partial nephrectomy, aims to use 3D virtual models as a guidance for augmented reality robotic procedures. However, the co-registration process of the virtual images over the real operative field is performed manually. METHODS: In this prospective study, two strategies for the automatic overlapping of the model over the real kidney were explored: the computer vision technology, leveraging the super-enhancement of the kidney allowed by the intraoperative injection of Indocyanine green for superimposition and the convolutional neural network technology, based on the processing of live images from the endoscope, after a training of the software on frames from prerecorded videos of the same surgery. The work-team, comprising a bioengineer, a software-developer and a surgeon, collaborated to create hyper-accuracy 3D models for automatic 3D-AR-guided RAPN. For each patient, demographic and clinical data were collected. RESULTS: Two groups (group A for the first technology with 12 patients and group B for the second technology with 8 patients) were defined. They showed comparable preoperative and post-operative characteristics. Concerning the first technology the average co-registration time was 7 (3-11) seconds while in the case of the second technology 11 (6-13) seconds. No major intraoperative or postoperative complications were recorded. There were no differences in terms of functional outcomes between the groups at every time-point considered. CONCLUSION: The first technology allowed a successful anchoring of the 3D model to the kidney, despite minimal manual refinements. The second technology improved kidney automatic detection without relying on indocyanine injection, resulting in better organ boundaries identification during tests. Further studies are needed to confirm this preliminary evidence.

The Utility and Safety of Ureteral Access Sheath During Retrograde Intrarenal Surgery in Children.

OBJECTIVE: To compare retrograde intrarenal surgery (RIRS) with and without ureteral access sheath (UAS) in different pediatric age groups. METHODS: The data of RIRS for kidney stone in children were obtained from 9 institutions. Demographic characteristics of patients and stones, intraoperative and postoperative results were recorded. While analyzing the data, patients who underwent RIRS without UAS (group 1) (n = 195) and RIRS with UAS (group 2) (n = 194) were compared. RESULTS: Group 1 was found to be young, thin, and short (P <.001, P = .021, P <.001), but there was no gender difference and similar symptoms were present except hematuria, which was predominant in group 2 (10.6% vs 17.3%, P <.001). Group 1 had smaller stone diameter (9.91 ± 4.46 vs 11.59 ± 4.85 mm, P = .001), shorter operation time (P = .040), less stenting (35.7% vs 72.7%, P = .003). Re-intervention rates and stone-free rates (SFR) were similar between groups (P = .5 and P = .374). However, group 1 had significantly high re-RIRS (P = .009). SFR had a positive correlation with smaller stone size and thulium fiber laser usage compared to holmium fiber laser (HFL) (P <.001 and P = .020), but multivariate analysis revealed only large stone size as a risk factor for residual fragments (P = .001). CONCLUSION: RIRS can be performed safely in children with and without UAS. In children of smaller size or younger age (<5 years), limited use of UAS was observed. UAS may be of greater utility in stones larger than 1 cm, regardless of the age, and using smaller diameter UAS and ureteroscopes can decrease the complications.

Percutaneous and endoscopic combined treatment of bladder and renal lithiasis in mitrofanoff conduit

ABSTRACT Introduction and Objectives: Treatment of bulky lithiasis in continent and non-continent urine storage reservoirs has been widely described and debated (1). Less is known about the optimal treatment in patients with a Mitrofanoff conduit. If voiding in these patients is incomplete, leading to recurrent symptomatic bacteriuria, formation of large lithiasis can be a common long-term complication (2, 3). Materials and Methods: This video describes a 19-year-old woman who underwent major open surgery at the age of six, with the configuration of a continent intestinal reservoir with a Mitrofanoff conduit. In 2020, she was referred to our center with a large stone in the reservoir and a minor stone in the inferior left renal calyx. We decided to proceed using a percutaneous approach with an "endovision technique" puncture for the bladder stone, combined with a retrograde intrarenal surgery for the renal stone. The MIP System "M size" was used to perform the percutaneous procedure, thus allowing a single-step dilation. The puncture and the dilation were followed endoscopically with a flexible ureterorenoscope avoiding the use of x-rays. The procedure was carried out as follows. The first step consisted in the insertion of a hydrophilic guidewire through the Mitrofanoff conduit. A flexible ureterorenoscope was then inserted coaxial to the guidewire. The percutaneous puncture, using an 80G needle, was followed endoscopically. Two guidewires were inserted, the first as a safety guidewire and the second for the tract dilation. The "single-step" dilation technique using the MIP system was performed and followed endoscopically. For the bladder lithotripsy, a dual-action lithotripter that combines ultrasonic and mechanical energy was used. Finally, a flexible ureterorenoscope and a basket for the retrieval of a single inferior caliceal stone were used. The procedure ended after positioning a single J stent in the left kidney and a nephrostomy tube in the reservoir. Results: The operative time was 80 minutes and the fluoroscopy time was 6 seconds. Hemoglobin and creatinine serum levels remained stable after the procedure and the patient was discharged on the third post-operative day, after removing both the single J and the nephrostomy tube. Follow-up lasted 12 months, with no bladder or renal stone recurrence, maintaining good continence of the Mitrofanoff conduit. Conclusion: In patients who have undergone several major surgeries a mini-invasive approach is advisable, not only for the morbidity of an open approach, but also for the increased risk of complications while handling an intestinal reservoir. Regarding a pure endoscopic approach, the passage of a nephroscope or a cystoscope through the Mitrofanoff conduit, combined with the continuous traction during the lithotripsy, could damage and compromise its continence. For this reason, the percutaneous approach is the most suitable method in these specific and rare cases.