Endourological Interventions Research Articles

Can suction technology be a potential game changer that reshapes pediatric endourological interventions? Results from a scoping review.

To systematically review the use of suction/vacuum-assisted retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) in children/adolescents with kidney stones. The PICOS model (Patient Intervention Comparison Outcome Study type) was used to frame and answer the clinical question; P: children and adolescent men with kidney stones; I: use of suction during PCNL or RIRS; C: no suction devices or none; O: complications and stone-free rate (SFR); S: prospective and retrospective studies; case reports. The literature search was performed on 14th May 2024 using Embase, PubMed, and Scopus. Only English papers were accepted. Ten articles were included. There were 9 papers on mini-PCNL and the remaining one compared mini-PCNL with RIRS. PCNL studies found excellent SFR (73-100%) with zero transfusion rate and a low rate of infectious complications (fever up to 9.6% and sepsis rate of 1%). Among these studies, there was a case report on the use of shock pulse lithotripter with complete stone clearance. Our review shows that there is little data on the use of suction/vacuum-assisted mini-PCNL/RIRS in kidney stone children/adolescents. However, these preliminary data demonstrated that vacuum-assisted mini-PCNL had excellent SFR with a low rate of complications.

Robotic buccal mucosal graft ureteroplasty using combination of posterior-inlay and anterior-onlay technique.

Buccal mucosal graft (BMG) ureteroplasty, particularly with the anterior-onlay technique, shows promise for treating complex ureteral strictures. However, long and circumferential strictures remain challenging. This study aimed to present the surgical technique of the posterior-inlay and anterior-onlay technique in robotic ureteroplasty with a BMG (RU-BMG). A 37-year-old male patient with a medical background of failed laparoscopic ureteroplasty and multiple endourological interventions was admitted to our hospital. Preoperative anterograde and retrograde pyelography revealed a 5-cm ureteral stricture. During the surgical procedure, the ureteral posterior wall was insufficient to facilitate a complete posterior augmented anastomosis, resulting in a posterior defect subsequent to the partial posterior augmented anastomosis. Ultimately, a BMG was utilized to address the posterior defect initially, followed by anterior-onlay ureteroplasty with a BMG. The Foley catheter was removed 2 weeks after surgery, while the nephrostomy tube was clamped on postoperative day 14. The double-J stent was removed 3 months after surgery. The preoperative serum creatine was 102.9 μmol/L. The surgery was performed successfully within 240 min, with estimated blood loss of 100 mL. The postoperative hospitalization was 4 days. Throughout the 12-month follow-up period, no symptoms or complications were observed, with a serum creatine of 82.0 μmol/L. Computed tomography urography indicated relieved hydronephrosis. In conclusion, RU-BMG using a combination of posterior-inlay and anterior-onlay technique is safe and feasible in the management of ureteral stricture. More cases and longer follow-up for this procedure are needed for better perfection of this procedure.

Comparison of Tissue and Urine Microbiota in Male, Intervention Naive Patients with and without Non-Invasive Bladder Cancer

<bold></bold> Introduction: To investigate the presence of dysbiosis in patients with naive bladder cancer. Methods: Twelve male patients with non-invasive bladder cancer and twelve age-matched healthy males had midstream urine and tissue samples taken. A history of endourological interventions was determined as an exclusion criterion, ensuring that the study was designed solely with naïve participants. The bacterial 16s ribosomal RNA V3-V4 regions were used to examine urine and tissue samples. We compared the microbiota composition of the bladder cancer and control groups. Results: Escherichia Shigella (p < 0.001), Staphylococcus (p < 0.001), Delftia (p < 0.001), Acinetobacter (p < 0.001), Corynebacterium (p < 0.001), and Enhydrobacter (p < 0.001) were abundant in bladder cancer tissue samples. Escherichia Shigella (p < 0.001), Ureaplasma (p < 0.001), Lactobacillus (p = 0.005), Stenotrophomonas (p < 0.001), Streptococcus (p < 0.001), Corynebacterium (p < 0.001), and Prevotella (p = 0.039) were abundant in bladder cancer urine samples. Midstream urine has a sensitivity of 83% for detecting dysbiotic bacteria in cancer tissue. Conclusions: Our research is the first microbiota study of bladder cancer done with naive patients who have never had an endourological intervention. Escherichia Shigella, Staphylococcus, Acinetobacter, Enhydrobacter, Delftia, Corynebacterium, and Pseudomonas were detected as dysbiotic bacteria in bladder cancer. The sensitivity of the midstream urine sample in detecting dysbiosis in tissue is 83%.

The heat is on: the impact of excessive temperature increments on complications of laser treatment for ureteral and renal stones

ObjectiveTechnological advancements in the field of urology have led to a paradigm shift in the management of urolithiasis towards minimally invasive endourological interventions, namely ureteroscopy and percutaneous nephrolithotomy. However, concerns regarding the potential for thermal injury during laser lithotripsy have arisen, as studies have indicated that the threshold for cellular thermal injury (43 °C) can be exceeded, even with conventional low-power laser settings. This review aims to identify the factors that contribute to temperature increments during laser treatment using current laser systems and evaluate their impact on patient outcomes.Materials and methodsTo select studies for inclusion, a search was performed on online databases including PubMed and Google Scholar. Keywords such as 'temperature' or 'heat' were combined with 'lithotripsy', 'nephrolithotomy', 'ureteroscopy', or 'retrograde intrarenal surgery', both individually and in various combinations.ResultsVarious strategies have been proposed to mitigate temperature rise, such as reducing laser energy or frequency, shortening the duration of laser activation, increasing the irrigation fluid flow rate, and using room temperature or chilled water for irrigation. It is important to note that higher irrigation fluid flow rates should be approached cautiously due to potential increases in intrarenal pressure and associated infectious complications. The utilization of a ureteral access sheath (UAS) may offer benefits by facilitating irrigation fluid outflow, thereby reducing intrapelvic pressure and intrarenal fluid temperature.ConclusionAchieving a balance between laser power, duration of laser activation, and irrigation fluid rate and temperature appears to be crucial for urologists to minimize excessive temperature rise.

Use of artificial stones in training and laboratory studies, have we found the right material? Outcomes of a systematic review from the European School of Urology.

In this review, we investigated the current literature to find out which artificial stones (AS) are available in endourology, and in which experimental and training schemes they are used. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Twenty-one out of 346 studies met our inclusion criteria and are presented in the current review. The inclusion criteria were the existence of AS and their use for laboratory and training studies. There is a wide variety of materials used for the creation of AS. BegoStone powder (BEGO USA, Lincoln, Rhode Island) and plaster of Paris™ were used in most of the studies. In addition, Ultracal-30 (U. S. Gypsum, Chicago, IL) was also used. Other materials that were used as phantoms were AS created from plaster (Limbs and Things, UK), standardized artificial polygonal stone material (Chaton 1028, PP13, Jet 280; Swarovski), model stones consisting of spheres of activated aluminum (BASF SE, Ludwigshafen am Rhein, Deutschland), Orthoprint (Zhermack, Badia Polesine, Italy), and a combination of plaster of Paris, Portland cement, and Velmix (calcium sulfate powder). Many experimental settings have been conducted with the use of AS. Our research demonstrated nine studies regarding testing and comparison of holmium: yttrium-aluminum-garnet laser devices, techniques, and settings. Six studies were about extracorporeal shock wave lithotripsy testing and settings. Three experiments looked into treatment with percutaneous nephrolithotomy. Additionally, one study each investigated imaging perioperatively for endourological interventions, stone bacterial burden, and obstructive uropathy. AS have been used in a plethora of laboratory experimental studies. Independent of their similarity to real urinary tract stones, they present a tremendous potential for testing and training for endourological interventions.

Dynamics of inflammatory reaction markers in patients under endourological interventions

Introduction. Urolithiasis is one of the most widespread urological diseases and infectious complications remain one of the most common adverse events after surgical interventions for urolithiasis. Currently, in routine clinical practice in most clinics in the country, for the purpose of postoperative control and detection of infectious complications is used: a clinical blood test with assessment of the dynamics of the blood leukocyte count. Unfortunately, the current edition of the clinical guidelines does not contain recommendations on what indicators of postoperative follow-up examinations the clinician should focus on in order to identify infectious and inflammatory complications. For this reason, the study of the value of other markers of the inflammatory response appears to be an actual task.Objective. To assess the relationship between the dynamics of laboratory markers of infectious-inflammatory complications and the incidence of infectious-inflammatory response after endoscopic stone removal.Materials &amp; methods. The prospective cohort study included 217 patients diagnosed with urolithiasis and underwent surgical removal of stones by endoscopic method. Of total patient numbers, 43 patients underwent ureteroscopy (URS) with lithotripsy, 152 patients underwent percutaneous nephrolithotripsy (PNL), and 22 patients underwent flexible ureterolithotripsy with lithotripsy. An analysis of demographics, clinical parameters and postoperative complications was performed as a descriptive analysis. Patients underwent a standard list of laboratory and instrumental examination methods. The mandatory control of body temperature was carried out t.i.d. daily. Before surgical treatment, indicators of WBC, LYMP, CRP, and ESR content were recorded on the first and second days after surgical treatment.Results. Postoperative fever was recorded in 40 (18.5%) patients. During the postoperative period, an increase in CRP and ESR was observed in both the fever and the normal temperature group, exceeding the reference values on the first day. At the same time, in the fever group (in 40 patients — 18.5%), a significantly higher increase in CRP and ESR was observed (685% vs 323%) for CRP and (146% vs 80%) for ESR. According to the results obtained in our study, CRP and ESR indicators demonstrate the most clinically significant dynamics in patients with postoperative fever, increasing by more than 500% and 100%, respectively.Conclusions. Endoscopic removal of urinary stones is a safe treatment option in patients with sterile urine cultures. After endoscopic stone removal, all patients experience such reactive changes in peripheral blood parameters as: an increase in the level of leukocytes, lymphopenia, an increase in ESR and CRP levels. Indicators of CRP and ESR demonstrate the most clinically indicative dynamics.

Open Label, Pilot Evaluation of the Safety and Efficacy of Intravesical Sustained Release System of Lidocaine and Oxybutynin (TRG-100) for Patients With Interstitial Cystitis/Bladder Pain Syndrome, Overactive Bladder and Patients With Retained Ureteral Stents Following Endourological Interventions

Intravesical instillation of analgesic and anticholinergic drugs have shown efficacy in the treatment of pain and voiding symptoms. Unfortunately, drug loss with urination and dilution in the bladder limit their durability and clinical usefulness. We have recently developed and tested in vitro, a sustained delivery system (TRG-100) of fixed-dose combination of lidocaine and oxybutynin designed to allow for a longer exposure of the urinary bladder to the drugs. To asses the safety and efficacy of TRG-100 in Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS), overactive bladder (OAB), and endourological intervention stented (EUI) patients in an open-label, prospective study. Thirty-six patients were enrolled: 10 IC/BPS, 10 OAB, and 16 EUI. EUI patients received a once-weekly installation until stent removal, OAB and IC/BPS patient received weekly installations for 4 consecutive weeks. Treatment effect was assessed by visual analog scale (VAS) score for the EUI group, voiding diaries for OAB group and VAS score, voiding diaries and O'Leary Sant Questionnaires for the IC/BPS group. The EUI group showed a mean 4-point improvement in their VAS score. The OAB group showed 33.54% reduction in frequency of urination and IC/PBS group showed a mean of 3.2-point improvement in their VAS score, 25.43% reduction in frequency of urination, and a mean 8.1-point reduction in O'Leary Sant Questionnaires score. All changes were statistically significant. Intravesical instillation of TRG-100 was found to be safe and efficient in reducing pain and irritative bladder symptoms in our study population. TRG-100 efficacy and safety should be further assessed in a large, randomized control trial.

Urosymphyseal fistula after pelvic radiotherapy in a tertial referral centre – a rare entity with significant comorbidity requiring multidisciplinary management

To report population-based clinical presentation and outcomes in patients with urosymphyseal fistula (USF) after pelvic radiotherapy (RT). A retrospective chart review was performed in 33 consecutive patients diagnosed with suspicion of USF in a tertial referral center from 2014-2022 to ascertain information about diagnostic delay, clinical presentation, precipitating causes, treatments received and outcomes during the median 22 months follow-up. Out of 33 consecutive patients with suspicion of USF, one female with vesicovaginal fistula, one patient developing RT-associated bladder angiosarcoma, four patients with short follow-up (<3 months), and three patients that during chart review not were considered to have a USF were excluded. In all, 24 males with a median age of 77 years were diagnosed with USF. Local pain was the predominating symptom in 17/24 (71%) patients. Endourologic manipulations preceded the diagnosis of USF in 16 patients. Five patients had a diagnostic delay of more than 3 months. At diagnosis, 20/24 patients had radiological signs of osteomyelitis, and five had a concomitant rectourethral fistula. Due to comorbidity, five patients were not amenable to any other interventions than urinary catheter or suprapubic tube in conjunction with long-term antibiotics, of which three died from infections related to the USF. Out of the remaining 19 patients receiving some form of urinary diversion, five had recurrent osteomyelitis, of which four did not undergo cystectomy in conjunction with surgery for the USF. Urethral endourologic interventions in patients previously subjected to pelvic RT should be performed cautiously.

The American Association for the Surgery of Trauma Organ Injury Scale is Associated With Cystoscopic and Percutaneous Urologic Procedures in Renal Injuries.

The American Association for the Surgery of Trauma Organ Injury Scale for the kidney was created in 1989. It has been validated to various outcomes including operations. It was updated in 2018 to better predict endourologic interventions, but this change has not been validated. In addition, the AAST-OIS does not consider mechanism of trauma in its interpretation. We analyzed 3years of the Trauma Quality Improvement Program database including all patients with a kidney injury. We recorded rates of mortality, operation, renal operation, nephrectomy, renal embolization, cystoscopic intervention, and percutaneous urologic procedures. 26294 patients were included. In penetrating trauma, mortality, operation, renal-specific operation, and nephrectomy rates increased at every grade. Renal embolization and cystoscopy rates peaked in grade IV. Percutaneous interventions were rare across all grades. In blunt trauma, mortality and nephrectomy rates increased only in grades IV and V. Operation, renal operation, and renal embolization rates increased at every grade level. Cystoscopy rates peaked in grade IV. Percutaneous procedure rates only increased between grades III and IV. Penetrating injuries are more likely to require nephrectomy in grades III-V, cystoscopic procedures in grade III, and percutaneous procedures in grades I-III. Endourologic procedures are most utilized in grade IV injuries, which are in part defined by injuries with damage to the central collecting system. Despite penetrating injuries more frequently requiring nephrectomy, they also more frequently require nonsurgical procedures. Mechanism of trauma should be considered when interpreting the AAST-OIS for kidney injuries.

Evaluation of renal oxygenation by near-infrared spectroscopy during endoscopic injection of bulking agents in children with vesicoureteral reflux.

Near infrared spectroscopy (NIRS) is the measuring of regional tissue oxygenation (rSO2) by interpreting oxyhemoglobin and deoxyhemoglobin signals that come back by transmitting near infrared light to tissues. The effect of endourological interventions on renal perfusion in children is largely unknown. To evaluate the effects of endoscopic injection of bulking agents (EIBA) for vesicoureteral reflux (VUR) on renal oxygenation (RO) using renal NIRS monitoring, which shows renal perfusion and oxygenation changes. Case-control study. Group I had bilateral inguinal surgery, Group II cystoscopy, and Group III, EIBA for VUR with 30 patients in each group. During the operation, vital signs, peripheral oxygen saturation, end-tidal carbon dioxide, and renal regional oxygen saturation index (rSO2) values by bilateral renal NIRS monitoring were recorded. NIRS values before induction (T0) to postoperative (Tend) were determined. A 20% or more reduction in renal rSO2 (%20↓rSO2) was considered significant. Group III was also evaluated as subgroup III-A (not having "%20↓rSO2") and subgroup III-B ("%20↓rSO2"). The rSO2 decrease was observed in the first 5min for both sides in group III. The most significant drop was at T30 for the right kidney and a significant decrease in rSO2, 20% or more, was observed in 6 renal units of 4 patients having higher SFU grading and renal scar in group III. EIBA may transitionally impair renal oxygenation. Higher SFU grading and renal scar may increase the risk of renal hypoxia during EIBA.

Propensity score-matched analysis comparing retrograde intrarenal surgery with percutaneous nephrolithotomy in anomalous kidneys.

Endourologic interventions for urolithiasis in patients with anomalous kidneys can be challenging, and comparisons between these interventions are not well studied. We aim to compare the safety, outcomes and complications of retrograde intrarenal surgery (RIRS) versus percutaneous nephrolithotomy (PCNL) in patients with urolithiasis in anomalous kidneys. A propensity score-matched pair analysis (PSM) was performed on pooled patient data from 20 centers. 569 patients with anomalous kidneys (horseshoe kidney [HSK], ectopic kidney, malrotated kidney) and urolithiasis who received either PCNL or RIRS as the primary modality of intervention from 2010 to 2020 were analyzed. Patients were matched based on calculated propensity scores by a regression model using age, sex, comorbidities, stone size, and renal anomaly type as co-variates. Multivariate logistic regression of factors (mode of treatment [PCNL or RIRS], comorbidities, stone size) and their effects on outcomes of stone-free rate (SFR), need to abandon surgery due to intraoperative difficulty, postoperative hematuria and sepsis and were analyzed when applicable. After PSM, there were a total of 127 pairs in each group. Overall, PCNL conferred a higher SFR compared to RIRS (OR=3.69, 95% CI 1.91-7.46, P<0.001), particularly in HSK (OR=3.33, 95% CI 1.22-9.99, P=0.023), and ectopic kidneys (OR=18.10, 95% CI 3.62-147.63, P=0.002), with no significant difference in malrotated kidneys. There was no significant difference in postoperative sepsis observed. Surgery was abandoned more often in RIRS than PCNL (6.3% vs. 0%, P=0.014). Although PSM provides a robust analysis due to baseline differences in the unmatched cohorts, this study was limited by an inevitable degree of selection bias. While both modalities are safe and efficacious, PCNL yields better SFR than RIRS in patients with anomalous kidneys, with no difference in postoperative sepsis rates. Patients may benefit from personalized management best carried out in high volume endourology centers.

Monitoring renal oxygenation status by near-infrared spectroscopy during ureterorenoscopy in children.

: Near-infrared spectroscopy (NIRS) monitoring demonstrates renal blood flow, perfusion, and oxygenation changes. This study aimed to evaluate the effects of pediatric endourological interventions (PEI) on regional oxygen saturation value (rSO2) usingrenal NIRS monitoring. Patients having bilateral inguinal surgery (group I), cystoscopy (group II), and ureterorenoscopy (group III), 20 patients in each group, were included in the study. NIRS values before induction (T0) and at 5 min (T5), 10 min (T10), 15 min (T15), 20 min (T20), 25 min (T25), 30 min (T30) of the surgical procedure, and at the postextubation (Tend) were determined. The amount of irrigation fluid was recorded in groups II and III. The ureterorenoscopy group was also evaluated as two subgroups, as group III-R with patients having a "20%↓rSO2" and as group III-NoR, not having a "20%↓rSO2". The mean total volume of irrigation was higher in group III, but the difference was not significant between the subgroups III-R and III-NoR. Renal rSO2 decreased significantly in T25, T30, and T-end values in group III. "20%↓rSO2" was seen in 1 patient in group II and 7 patients in group III. In the subgroups III-R, all patients had an obstructive pathology and significant preoperative hydronephrosis with a mean renal pelvis AP diameter of 21.1 ± 16.4 mm. Although rSO2 significantly improves postoperatively, our data may suggest that congenital and acquired obstructive pathologies with hydronephrosis, prolonged operative time with continuous irrigation, and instrument movement in a narrow lumen may increase intrarenal pressure and the risk of renal hypoxia in endourological interventions. Preoperative evaluation of kidney functions and a meticulously well-planned intervention can prevent possible complications.

Endourological treatment of non-muscular-invasive bladder tumors

Background: Transurethral resection of the bladder is one of the essential methods in the diagnosis, treatment and management of non-muscularinvasive bladder cancer. The purpose of the procedure is to remove completely all visually detected tumors with a following establishment of a very precise histological diagnosis. The aim of the study is to compare the results of conventional transurethral endoscopic treatment and the En-bloc resection method using different types of energy sources in the treatment of bladder tumors. Material and methods: A total number of 88 patients underwent endourological interventions. Regarding the distribution, 23 patients had conventional transurethral resection, 22 – En-bloc monopolar resection, 21 – En-bloc bipolar resection and 22 – En-bloc with Thu:YAG laser. Clinical data, intraoperative and postoperative data and also the histopathological examination results were compared. Results: The compared groups were heterogeneous by age, sex, tumor characteristic (size, number, location). No significant differences were observed during the operations, comparing the intraoperative and postoperative complications of the studied groups. The detrusor musculature was detected in 74% of cases after conventional transurethral resection, in 91% of cases of En-bloc monopolar resection, in 95% of cases of En-bloc bipolar resection and in 96% of cases of En-bloc Thu:YAG laser. Conclusions: The En-bloc resection technique of non-muscular-invasive bladder tumors is a safe and effective method comparing with the conventional transurethral resection; it allows more favorable postoperative results and obtaining better quality tumor samples which allow establishing correct diagnosis of the disease.

Предикторы развития склероза шейки мочевого пузыря после трансуретральных вмешательств на предстательной железе

The development and widespread implementation of modern endourological procedures for the treatment of benign prostatic hyperplasia (BPH) has led to a significant reduction in postoperative complications, but these interventions are associated to an increase of bladder neck contracture (BNC) rate. Various data on the frequency, pathogenesis, and risk factors for the development of BNC after endourological interventions are presented in the literature review. The prevalence of BNC after transurethral procedures depending on the type of energy used reaches up to 10%. Risk factors of BNC included the presence of chronic prostatitis and urinary tract infections, as well as small volume BPH. The age, cardiovascular diseases, type 2 diabetes, obesity, and a long-term smoking are considered as additional risk factors. A detailed study of the risk factors for BNC will further minimize BNC rate after transurethral procedures, thus improving the quality of life of patients.

Сравнительная характеристика современных методов хирургического лечения доброкачественной гиперплазии предстательной железы (литературный обзор)

The article presents an overview of modern domestic and foreign literature, dedicated to the problem of surgical treatment of benign prostatic hyperplasia. There exists a wide range of approaches to surgical treatment of benign prostatic hyperplasia. A decision in favor of a certain method is individual and takes into account somatic status of the patient, peculiarities of growth of adenoma and the volume of prostate. In the article, a general tendency of using different endourologic interventions is emphasized. In case of moderate dimensions of the prostate the preferable methods are endoscopic enucleation, transurethral resection and photoselective vaporization of the prostate that are comparable in terms of functional, morphological parameters and duration of recovery period. However, application of non-invasive transurethral interventions in case of the gland volume more than 80 cm3 is limited and requires further improvement of surgical technique. Aquablation, transurethral microwave thermotherapy are promising methods requiring further independent randomized studies.

Robot-assisted Transplant Ureteral Repair to Treat Transplant Ureteral Strictures in Patients after Robot-assisted Kidney Transplant: A Case Series

To describe the use of robotic-assisted transplant ureteral repair (RATUR) for treating transplant ureteral stricture (TUS) in 3 patients who had undergone robot assisted kidney transplant (RAKT). We reviewed the medical records of 3 patients who experienced TUS after RAKT and who underwent RATUR between 2017 and 2020. The patients' RAKT, post-transplant clinical course, endourological interventions, reoperation, and recovery were assessed. All patients diagnosed with TUS presented with deterioration of kidney function after RAKT. Method of diagnosis included ultrasound, antegrade ureterogram, and CT scan. All 3 patients had a short (<1 cm) area of TUS and underwent RATUR. For 2 patients, distal strictures were bypassed with modified Lich-Gregoir ureteroneocystostomy reimplantation. One patient was treated with pyelo-ureterostomy to the contralateral native ureter. No intraoperative complications, conversions to open surgery, or significant operative blood loss requiring blood transfusion for any patient were observed. Also, no patients had urine leaks in the immediate or late postoperative period. After RATUR, 2 patients developed Clavien grade II complications with rectus hematoma or urinary tract infection. RATUR is a technically feasible operation for kidney transplant patients with TUS after RAKT. This procedure may provide the same benefits of open operation without promoting certain comorbidities that may occur from open surgical procedures.

Reduction of Radiation Dose Received by Surgeons and Patients During Percutaneous Nephrolithotomy: A New Shielding Method.

Due to high prevalence of urolithiasis, endourologic interventions have increased for the treatment of patients with urinary stones. During fluoroscopy-guided percutaneous nephrolithotomy (PCNL), the surgeon and the patient are exposed to X-ray and its harmful effects. This study aimed to assess the reduction of the radiation dose received by surgeons and patients after using a new shielding method. In this study, the dose of radiation exposure by the surgeon and patient during PCNL under fluoroscopic procedure with conventional shielding methods was compared to a new shielding method designed by the researcher. For this purpose, shields and lead cones with a thickness of 0.5 mm were used. Also, to evaluate the dose of radiation received by surgeons and patients in different parts of the body, thermoluminescent dosimeters (TLD) were used. By using the new shielding method, a 37 ± 2% reduction was found in the dose exposure as compared to the conventional shielding method. The maximum reduction in radiation dose was specified to the surgeon's hands, while the lowest reduction in radiation dose was related to the surgeon's thyroid gland. The maximum and minimum reductions in radiation exposure for patients were specified to patients' feet and chest respectively. There is a significant difference between the total dose received by the surgeons and the patients following the use of the new shielding method and the standard shielding method. The new shielding method can reduce 37 ± 2% of the x-ray received by the patient and the surgeon during fluoroscopy-guided PCNL.

Evidence and clinical trials in Endourology: where are we going.

There is an ongoing explosion in the amount and quality, of research in the field of Endourology. From a solid basis of systematic reviews and small, single centre trials it has been possible to design large randomised controlled trials in the UK and in the USA. This review will describe some of the more recent trials (small and large) that are helping to provide a solid evidence base for our practice in Endourology. Randomised controlled trial (RCTs) include: The Therapeutic Interventions for Stones in the Ureter (TISU), the Percutaneous nephrolithotomy, flexible Ureterorenoscopy and extracorporeal Shockwave lithotripsy for lower pole kidney stones (PURE RCTs) and the Prevention of Urinary Stones with Hydration (PUSH). Quality of life (QoL) measures and studies include: the Wisconsin Stone QoL Questionnaire, the Cambridge Renal Stone PROM, the Cambridge Ureteral Stone PROM, the Urinary stone and Intervention QoL questionnaire and the Study to Enhance Understanding of sTent-associated Symptoms (STENTS). The Core Outcome Set in Trials on treatments for Renal and UreteriC sTones (COSTRUCT) study aims to define a core outcome set to be used in future trials. On-going studies will provide higher quality evidence on the treatment of ureteric and renal stones to inform treatment decision making and guideline recommendations. They will also guide decisions relating to prevention and recurrence and give insight into the true impact of urinary stones and endourological interventions on patients' quality of life. Future studies will incorporate big data and artificial intelligence.

Clinical Significance of DJ Stent Culture in Patients with Indwelling Ureteral Stents Prior to Endourological Intervention- A Single Centre Prospective Cohort Study

Introduction: Ureteral Double J Stenting (DJS) is commonly done prior to endourological interventions for various indications. Aim: To compare Urine Culture (UC) with DJ Stent Culture (SC) in patients with indwelling ureteral stents prior to endourological intervention and to evaluate the clinical significance of SC with postendourological intervention sepsis. Materials and Methods: A prospective single centre observational study was conducted in the Department of Urology, Army Hospital Research and Referral, New Delhi, India, from August 2017 to March 2019. A total of 100 patients underwent DJS prior to definitive endourological intervention. Patient's demographic profile was recorded along with preoperative, intraoperative and postoperative parameters. UC was also recorded at these intervals along with SC. The data was analysed and compared using Statistical Package for the Social Sciences (SPSS) software. Results: Intraoperative UC of 14 patients were colonised, SC was colonised in 11 patients. Six patients developed Urosepsis, Postoperative UC was colonised in four patients. The Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of intraoperative UC for detecting stent colonisation with identical pathogens were 63.64%, 92.13%, 50.00% and 95.35%, respectively. Patients with colonised intraoperative UC, SC cranial tip and SC caudal tip had sepsis rates of 28.6%, 50%, and 44.4%, respectively. The sensitivity and PPV of SC in predicting postoperative sepsis were low at 83.33% and 45.45%, respectively, whereas the specificity and NPV were high at 93.6% and 98.8%. A 15.8% of diabetic patients and 50% immunocompromised patients developed urosepsis. E.Coliwas the commonest isolated pathogen from UC and SC. On univariate logistic regression analysis, operative time, positive intraoperative UC, positive SC were associated with postintervention sepsis. While on multivariate analysis, none of these factors were associated with postendourological intervention sepsis. Conclusion: Performing routine SC may not be cost effective but could be recommended in cases at higher risk of developing postoperative urosepsis such as those with Diabetes Mellitus (DM) or immunocompromised patients and those expected to take longer operative time.

Stenting of the upper urinary tract: from bottom, from top, from side...

Internal stenting of the upper urinary tract is a widespread urological surgery. Its frequency in modern practice is high and continues to grow due to the widespread use of endourological, percutaneous, and laparoscopic interventions. The presence of a stent in the patient's body often leads to a decrease in the quality of life due to the occurrence of stent-dependent symptoms, which often requires urgent hospitalization. According to various data, they are registered in at least 80% of patients. The most common stent-dependent symptoms are frequent and / or painful urination, urge to mix (up to imperative), nocturia, pain in the lumbar region, macrohematuria. According to existing data, a fair share of responsibility for the development of these symptoms lies with the distal (vesicular) curl of the internal stent, especially if the technology of its installation is not followed or the length of the drainage is incorrectly selected. The review describes methods for correct installation of internal ureteral stents by transurethral retrograde, antegrade, and laparoscopic approaches, as well as a method for installing and removing mono-pigtail drains. The internal drainage procedure is standard, so the focus is on the nuances and details of this widespread manipulation. The given cohort of patients and the range of surgical interventions indicate a significant experience of the authors in this issue. All illustrations are author's own and taken from the daily workflow. It should be noted that the modern understanding of the process and technological equipment ensure correct stenting when performing any interventions with any access. An adequate choice of installation method and correct positioning of the stent, knowledge of simple details and "secrets" allow not only to restore urodynamics, but also to effectively prevent the development of stent-dependent symptoms, thereby preserving patients quality of life.