Residual Fragments Research Articles

Study on the Mechanical Characteristics and Degradation Response of Unloading Rocks Surrounding Tunnels in Cold Regions

The excavation of the rock mass at the tunnel entrance in regions characterized by high altitudes and elevated stress levels results in the direct exposure of the surrounding rock to atmospheric conditions. This surrounding rock is subjected to the compounded effects of excavation-induced unloading damage and freeze–thaw erosion, which contribute to the degradation of its mechanical properties. Such deterioration has a negative impact on production and construction operations. Following tunnel excavation, the lateral stress exerted by the surrounding rock at the tunnel face is reduced, leading to a predominance of uniaxial compressive stress. As a result, the failure mode and mechanical behavior of the rock exhibit characteristics similar to those observed in uniaxial loading tests conducted in controlled laboratory environments. This study conducts laboratory-based uniaxial loading and unloading tests, as well as freeze–thaw tests, to examine the strength, deformation characteristics, and fracture attributes of unloading sandstone subjected to freeze–thaw erosion. A damage deterioration model for unloading sandstone under uniaxial conditions is developed, and the patterns of damage response are further analyzed through the identification of compaction points and the definition of damage response points. The results indicate that (1) as the degree of freeze–thaw erosion increases, the failure threshold of the sandstone significantly decreases, with the residual rock fragments on the fracture surface transitioning from hard and sharp to soft and sandy; (2) freeze–thaw erosion has a pronounced negative impact on the cohesion of the sandstone, while the reduction in the internal friction angle is relatively moderate; and (3) the strain induced by damage following three, six, and nine freeze–thaw cycles exhibits a gradual decline and appears to reach a state of stabilization when compared to conditions without freeze–thaw exposure. Investigating the mechanical properties and deterioration mechanisms of the rock in this specific context is crucial for establishing a theoretical foundation to assess the stability of the tunnel’s surrounding rock and determine the necessary support measures.

Torsion and ruptured ovarian cystadenocarcinoma with internal bleeding complicated with retroperitoneal hematoma after tumor transection: A case report.

Ovarian tumor torsion is a critical gynecological emergency, predominantly affecting women of reproductive age, with benign teratomas being the most common culprits. In contrast, malignant ovarian tumors, such as mucinous cystadenocarcinoma, infrequently present with torsion due to their invasive and angiogenic characteristics. The occurrence of torsion in malignant tumors complicates diagnosis and management, particularly when associated with complications like congestion, infarction, and internal bleeding. This report details a rare case of primary ovarian mucinous cystadenocarcinoma presenting with acute torsion and significant internal bleeding. Our study highlights the diagnostic challenges and the urgent need for clear treatment guidelines, addressing an important gap in the existing literature regarding the management of torsion malignant ovarian tumors. By documenting this case, we aim to contribute to the understanding of this rare condition and provide insights that may help clinicians in similar scenarios. A 51-year-old postmenopausal woman presented with acute abnormal pain. Transvaginal ultrasound examination showed an 8-cm heterogeneous right ovary mass without ovarian blood flow on color Doppler. Laparoscopy revealed torsion and rupture of the right ovarian tumor with 900 mL hemoperitoneum. The patient underwent right salpingo-oophorectomy complicated by continuous oozing and hematoma formation in the infundibular ligament. Unexpectedly, histopathology revealed a mucinous cystadenocarcinoma of the right ovary, pT1c2. The patient underwent staging surgery and prophylactic hyperthermic intraperitoneal chemotherapy. After 4 years of follow-up, no tumor recurrence or metastasis was found. Currently, there are no effective preoperative diagnostic and treatment guidelines for ruptured malignant ovarian tumors with torsion. The possibility of malignancy should be considered, and frozen section biopsy should be considered during surgery. Full detorsion before tumor resection to avoid incomplete pedicle coagulation and bleeding. Specimen removal by in-bag morcellation in minimally invasive surgery to prevent complications related to residual fragments of the specimen or dissemination of an occult malignancy.

Semi-closed-circuit vacuum-assisted mini percutaneous cystolithotomy (vamPCL) in the pediatric population: Initial experience of a novel technique in native and augmented bladders.

Bladder stones (BS) in children are a rare condition and represent 1-5% of all urinary tract stones. With advances in miniaturized endoscopes and intracorporeal lithotripters, percutaneous cystolithotomy has been demonstrated to be an effective, safe and quick technique, despite the longer operative time. This limitation may be overcome by a semi-closed-circuit vacuum-assisted technology (vamPCL), characterized by a continuous inflow and a suction-controlled outflow (ClearPetra®). To assess the safety and efficacy of a vamPCL characterized by continuous inflow and suction-controlled outflow to treat bladder stones in pediatric patients with native or augmented bladder. From January 2021 up to December 2023, we prospectively collected variables on consecutive vamPCL procedures (Fig.) The stone-free rate (SFR) was defined as absence of stones or residual fragment <5mm diagnosed with ultrasound. Six patients with a median age of 139 months (55-212) were recruited for the study. Three patients (50%) with the initial diagnosis of extrophy-epispadia complex had an augmented bladder, whereas of the remaining three (50%) with an initial diagnosis of anorectal malformation two had an augmented bladder. All patients had a Mitrofanoff conduit opening on the right flank, except for one (16%) with umbilical access. The mean cumulative stone size was 24mm±14,2. The mean operating time was 78,3min±14,7. One procedure was interrupted after 90min due to the overall size (>50mm). Stone removal was achieved only via suction in all cases. All vamPCL procedures were completed without intraoperative complications. Fever for 24h (1/6; 16%) was the only post-operative complication. The mean stay of the suprapubic catheter was 3.4 days±1,5 and of the trans-Mitrofanoff catheter was 9.3 days±4,5. The SFR was confirmed in all the cases with US performed after 2 months. Only one male patient (16%) had recurrent stones after 8 months and he is waiting for second surgery. Mean follow-up was 7.2 months±9,4. In the present study we demonstrated that vamPCL is safe and feasible in selected cases especially in those with augmented bladder. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. The vamPCL seems to be sustainable, safe and feasible for bladder stones treatment in selected children.

Assessment of Outcomes andAnatomical Changes in the Upper Urinary Tract Following Flexible Ureteroscopy With a Flexible and Navigable Suction Ureteral Access Sheath: 3-Month Results From a Multicenter Study.

To study the long-term outcomes of the flexible and navigable suction ureteral access sheath (FANS) in flexible ureteroscopy (FURS). FANS has well-established efficiency and 30-day perioperative safety; however, its influence on pelvicalyceal and ureteric anatomy remains to be investigated. This was a prospective study of patients with normal renal anatomy who underwent FURS with FANS for renal stones from April 2023 to August 2024 in 16 centers worldwide. Thirty-day postoperative stone-free rate and delayed complications after 3 months were analyzed with a non-contrast CT scan and contrasted CT urogram respectively. The primary aim was to report if FANS could potentially cause pelviureteric junction, pelvicalyceal or ureteric complications. Three hundred-tenpatients were analyzed. Median age was 51; median stone volume was 1584mm3. Disposable scopes were used in 58.1%. Predominant laser energies were Thulium fiber laser (56.1%) followed by Thulium-YAG laser (20.6%). Median laser time was 14minutes, median ureteroscopy time was 30minutes, and median total operation time was 45minutes. Ureteric injury occurred in 11 patients (3.5%), of which 10 were Traxer-Thomas Grade 1. On 30-day NCCT, 63.5% of patients had zero residual fragments; overall stone-free status was seen in 95.1%. Thirty-day reintervention rate was 4.2% (13 cases). Three-month CT urogram showed ureteric stenosis in only 1 patient (0.3%) who was managed by dilatation and stenting. No other anatomical anomalies were recorded. The extremely low rates of 3-month adverse outcomes, high immediate SFR, and low 30-day reintervention rates further strengthen the evidence for safety and effectiveness of FANS.

Stone-event-free survival after retrograde intrarenal surgery: is the stone-free-status so relevant for the future outcomes?

The primary aim of stone treatment is to achieve stone-free status. Residual fragments can cause stone growth, recurrence, urinary tract infections, and ureteric obstruction. Our goal was to describe the natural history of stone burden after retrograde intrarenal surgery (RIRS) based on stone-free status (SFS), evaluating stone growth and stone-events. We retrospectively reviewed data from patients who underwent RIRS at a tertiary care center between October 2014 and September 2019. The stone burden was assessed by measuring the maximum diameter (mm) and volume (mm3). Patients were divided into four groups according to SFS-(A) absolute stone-free, no stones on non-contrast-enhanced computed tomography (NCCT); (B) relative stone-free with ≤ 2mm fragments, (C) relative stone-free with 2.1-4mm fragments, and (D) residual fragments > 4mm. Our main outcomes were stone growth over time (defined as an increase in diameter compared to first postoperative measurement) and incidence of stone-related events (pain or additional intervention to treat symptoms, obstruction, or removing fragments). A total of 98 patients were included in the study-42 were classified as absolute stone-free (Group A), 20 were categorized as relatively stone-free (Groups B and C), and 36 had a residual stone burden with fragments larger than 4mm (Group D) on postoperative NCCT. There was a significant difference in the number of stones among the groups (p < 0.001). The pre-operative stone volume differed significantly among the groups (p = 0.003). Group A had the lowest median total stone volume (551.3mm3). Twenty patients (20.4%) developed stone-events during a mean follow-up period of 62.3months (± 26.0). Stone-event-free survival differed significantly between the groups (p = 0.028), with Group D demonstrating a higher incidence of stone-related events post-RIRS compared to the other groups. Sixteen patients (16.3%) had renal colic requiring a hospital visit across all groups. Thirteen patients (13.3%) required re-intervention (3 patients belonged to Group A, 1 to Group B, 2 to Group C, and 7 to Group D). Group D shows a higher rate of stone-related events post-RIRS. Ensuring complete stone-free status after RIRS is crucial for treatment success. Other factors should be considered in the management, including ensuring compliance with general preventive measures and stone-specific pharmacological treatments to prevent recurrence.

Comparison of three different scoring systems in predicting success of retrograde intrarenal surgery in kidney stones larger than 20 millimeters.

To evaluate stone free rate (SFR) predictivity of three different scoring systems in patients with kidney stones larger than 20 millimeters undergoing retrograde intrarenal surgery(RİRS). Digital records of a total of 166 patients were reviewed retrospectively. Epidemiological characteristics (age, gender, medical history) of the patients, stone and affected kidney characteristics (size, volume, location, density, opaque, presence of urinary system anomaly, presence of stones in different calyx, number of stones, lower pole stone, renal infundibulopelvic angle (IPA), renal infundibulopelvic length (RIL), hydronephrosis), and operative characteristics (preoperative ureteral stent, operation duration, postoperative residual fragments, hospitalization time and complications were recorded. Each patient was scored separately according to the Resorlu-Unsal Scoring System (RUSS), the modified Seoul National University Renal Stone Complexity (S-ReSC) and R.I.R.S scoring systems based on the stone characteristics seen on CT. All three methods had statistically acceptable sensitivity and specificity values. Sensitivity for R.I.R.S nomogram is 62.3%, specificity is 77.1% (cut-off: 7.5 points, area under the curve (AUC):0.735, p < 0.001), sensitivity for RUSS nomogram is 60.7%, specificity is 77.9% (cut off: 2.5, AUC = 0.749, p < 0.001), sensitivity for the Modified S-ReSC nomogram was determined as 65.6% and specificity as 71.2% (cut off: 2.5, AUC = 0.743, p < 0.001). The residual stone ratio was found to be higher in the presence of lower pole stone. While the cut-off value for IPA was 44.5°, this value was calculated as 24.5mm for RIL. Three scoring systems demonstrate accceptable sensitivity and specificity in predicting stone free rate(SFR) with stones ≥ 20mm. Multivariate analysis highlighted the superiority of the R.I.R.S. scoring system for SFR predictivity. In the presence of lower pole stones, IPA and RIL are important factors in predicting surgical success.

Assessing flexible ureteroscopy outcomes for lower Pole versus non lower Pole stones using the flexible and navigable suction ureteric access sheath: a prospective multicenter study by EAU Endourology and PEARLS group.

Use of suction in flexible ureteroscopy is increasing lately. The introduction of flexible and navigable suction access sheath (FANS) has shown improved stone free rate (SFR). However, its efficacy in lower pole stone (LPS) in terms of SFR and complications is yet to be studied. We collected data from 25 centers that included 394 adult patients undergoing ureteroscopy using FANS. Non contrast CT (NCCT) scan was done within first 30 days post operatively to access the SFR. Residual fragments were graded as A: 100% SFR; B: single fragment ≤ 2mm; C: single fragment 2.1-4mm; D: Single or multiple fragments > 4mm. Post operative complications were recorded. Out of 394 patients, non LPS (group1) comprised of 268 patients, rest 126 patients had LPS (group 2). Single stage zero fragment SFR was seen in 58.6% (group 1) vs. 54.8% (group 2) (P = 0.619). Single stage grade A + B SFR was achieved in 96.6% vs. 98.4% in groups 1 and 2 respectively. On multivariate analysis Thulium fiber laser use was significantly associated with higher odds of being grade A stone-free, while stone volume with lower odds. In LPS group only two patients needed reintervention. The highest grade of complication was Clavien 2, which was seen in 3.2% LPS group. Use of flexible and navigable suction ureteric access sheath for lower pole stones is effective and safe. The stone free rate of lower pole stones is comparable to non-lower pole locations with very low reintervention rate in both groups.

A Prospective, Randomized, Noninferiority Study to Evaluate the Safety and Effectiveness of Steerable Ureteroscopic Renal Evacuation Compared with Standard Ureteroscopy: 30-Day Results of the ASPIRE Study.

Purpose: We report the first multicenter, prospective, randomized noninferiority controlled trial of steerable ureteroscopic renal evacuation (SURE) for nephrolithiasis treatment. Materials and Methods: Candidates for laser lithotripsy ≥18 years with ≥1 renal stone ≥7 mm and 7-20 mm stone burden were randomized 1:1 SURE vs ureteroscopy (URS). SURE was performed using the CVAC Aspiration System, a novel steerable irrigation-aspiration catheter. The primary efficacy end point was noninferiority in stone-free rate (SFR) based on zero residual fragments (RFs) 30 days postprocedure on noncontrast computed tomography. Secondary end points were superiority tests, stone clearance (percent stone volume reduction), residual stone volume (RSV), SFR (no RF >2 mm), and SFR (no RF >4 mm) 30 days postprocedure. Results: Of the subjects, 123 were randomized and 101 qualified for efficacy analysis (SURE 46 vs URS 55). Despite randomization, baseline URS stone volume was higher (SURE 485.0 ± 432.5 mm3 vs URS 713.3 ± 558.5 mm3). The primary noninferiority end point was achieved (SURE SFR 48% vs URS SFR 49%, p = 0.027, -1.3% [90% confidence interval; -18%, 15%]). Stone clearance was significantly higher for SURE vs URS subjects (SURE 96.9 ± 5.6% vs URS 92.9 ± 11.6%, p = 0.036); RSV was significantly lower (SURE 14.3 ± 3 0.9 mm3 vs URS 70.2 ± 144.9 mm3, p = 0.012). SURE stone clearance and RSV were independent of baseline stone volume, but for URS degraded with increasing baseline stone volume. Safety was comparable between groups. Conclusions: SFR for SURE subjects was noninferior compared with URS subjects; stone clearance and RSV were significantly better with SURE, independent of baseline stone volume.

The initial clinical application of standard PCNL combined with visual needle nephroscope in the treatment of complex renal calculi by holmium YAG laser: a retrospective case series study

This study aims to evaluate the feasibility, safety, and effectiveness of an optimized treatment approach for complex renal calculi, utilizing visual needle nephroscopy in conjunction with standard PCNL and holmium YAG laser. We collected data from 62 patients diagnosed with complex kidney stones who underwent this combined procedure using the visual needle nephroscope (Needle-perc®, Youcare Tech, Wuhan, China). The percutaneous nephroscopic working channel was established by visual needle nephroscope, and the primary channel was expanded to 20 F to treat most of the main body of the calculi with a 550 μm holmium laser fiber. Visual needle nephroscope was used to locate the renal calyx where the residual calculi were located for precise puncture as a secondary channel, and the residual stones were treated by a 200 μm holmium laser fiber. Clinical data were collected, and intraoperative variables, postoperative complications and outcomes were assessed. All 62 patients successfully completed the operation without severe complications. The S.T.O.N.E. score of 62 patients before operation was 10.5 ± 0.9 points and above, of which the N score was more than 2 points. The average operation time was (65.5 ± 12.7) minutes, and the average hospital stay was (7.3 ± 2.1) days. After operation, 2 patients developed a fever, which improved after symptomatic treatment by intravenous antibiotics. 4 patients had clinically significant residual fragments, and the stone-free rate of primary operation was 93.5% (58/62). The optimized operation for the treatment of complex renal calculi based on standard PCNL combined with visual needle nephroscope by holmium YAG laser has good feasibility, safety and effectiveness.

The impact of Mayo Adhesion probability score on the success of extracorporeal shock wave lithotripsy for kidney stones.

Urolithiasis is a prevalent condition in urology, with extracorporeal shock wave lithotripsy (ESWL) serving as a common treatment for kidney stones under 2cm. The Mayo Adhesion Probability (MAP) score, calculated from perinephric fat characteristics, is traditionally used to assess surgical outcomes but has not been explored in the context of ESWL. This study aims to evaluate the effect of MAP score on the success rate of ESWL. This retrospective study included patients who underwent ESWL for kidney stones between January 2018 and June 2024 at a tertiary care center. Demographic data, stone characteristics, and MAP scores were obtained through CT imaging. ESWL success was defined as either complete stone clearance or a residual fragment less than 4mm at three months post-procedure. Logistic regression and ROC analysis were employed to identify predictors of treatment success and to determine the optimal MAP score cutoff. A total of 260 patients were analyzed, divided into two groups: MAP score < 3 (n = 154) and MAP score ≥ 3 (n = 106). Patients with a MAP score ≥ 3 had a significantly lower ESWL success rate (49.1%) compared to those with a MAP score < 3 (71.4%; p = 0.001). Multivariate analysis identified MAP score, BMI, and stone size as significant predictors of ESWL success. ROC analysis established a MAP score cutoff of 2, with 76.5% sensitivity and 64.3% specificity. The MAP score is an independent predictor of ESWL success in kidney stone treatment. Preoperative MAP evaluation may improve patient selection and optimize ESWL outcomes.

An Analysis of Percutaneous Nephrolithotomy (PCNL) Performed at the Institute of Kidney Disease, Pakistan: Stone Clearance and Complications.

Percutaneous nephrolithotomy (PCNL) is the preferred treatment for large renal stones, yet variability in outcomes arises from patient-specific factors and institutional practices. Understanding complications and predictors of success is essential to improving procedural efficacy. This study aimed to evaluate stone clearance rates, complications classified using the Clavien-Dindo system, and predictors of PCNL outcomes, with a focus on improving lower calyx stone clearance. A retrospective analysis was conducted on 422 PCNL procedures performed from July 2021 to December 2023 at the Institute of Kidney Disease, Hayatabad Medical Complex, Peshawar, Pakistan. Patient demographics, stone characteristics, and postoperative outcomes were analyzed. Stone clearance rates were calculated, and complications were categorized by severity. Associations between patient and stone characteristics and outcomes were tested using Chi-square analysis, with significance set at p < 0.05. A total of 422 PCNL cases were analyzed, with an overall stone-free rate of 75.82% (320/422). The average patient age was 45.39 ± 12.43 years, with male patients comprising 56.87% of the cohort and a mean BMI of 27.82 ± 4.21 kg/m². Hypertension (21.43%), diabetes mellitus (18.95%), and chronic kidney disease (7.11%) were notable comorbidities. Stones averaged 3.21 ± 1.13 cm in size, predominantly composed of calcium oxalate (35.55%), and were most frequently located in the upper calyx (28.44%). Postoperative outcomes revealed a 21.33% complication rate, with 16.59% classified as minor (Clavien-Dindo Grades I-II) and 4.74% as major (Grades III-IV). Follow-up data showed that 11.83% of patients had residual stone fragments, and 9.48% experienced delayed complications, primarily minor. Stone size and location significantly influenced outcomes, with clearance rates of 80.00% for 2-3 cm stones versus 65.57% for stones >3 cm (p = 0.155). Lower calyx stones had markedly reduced clearance rates (50.00%, p < 0.001) compared to upper (75.00%) and mid-calyx (70.00%) stones, while stones in multiple locations also showed poor clearance (57.69%, p = 0.001). Key predictors of complications included higher BMI and prolonged operative times, emphasizing the need for tailored approaches, technical refinements, and institutional audits to optimize outcomes for anatomically or clinically complex cases. This study highlights the high efficacy of PCNL in managing large renal stones, achieving a stone-free rate of 75.82%. However, the findings underscore the significant challenges associated with lower calyx stones and larger stone sizes, both linked to reduced clearance rates. The Clavien-Dindo classification of complications shows that while minor complications are more frequent, major complications remain a concern, especially in patients with elevated BMI or prolonged operative times. To optimize outcomes, this study recommends refining surgical techniques and adopting technological advancements to improve lower calyx clearance, implementing institutional audits to standardize practices, and personalizing treatment strategies through preoperative risk stratification. Future multicenter prospective studies are needed to validate these findings, further explore predictors of outcomes, and develop comprehensive care protocols addressing anatomical and patient-specific challenges in PCNL procedures.

Evaluation of the Efficacy of the Vaccine Production Process in Removing Residual Host Cell DNA from the Vero Cell Rabies Vaccine.

The Vero cell rabies vaccine is currently the most widely used human rabies vaccine. However, owing to the presence of residual host cell DNA (HCD) in the final product and the potential tumorigenicity of the DNA of high-passage Vero cells, the WHO not only sets a limit on the number of times cells used in production can be passaged, but also imposes strict requirements on the amount of residual HCD in the final vaccine product. To systematically reduce the HCD level in the final vaccine product, multiple purification steps are included in the vaccine production process. This study investigated the effectiveness of key production steps in antigen recovery and DNA removal. The residual HCD fragment content and size distribution were detected using fluorescence quantitative PCR (qPCR) and capillary gel electrophoresis (CGE), and the rabies virus glycoprotein antigen content was detected using enzyme-linked immunosorbent assay (ELISA). The antigen recovery rate and HCD removal rate in each key process were calculated to evaluate the scientific basis and effectiveness of each production step. Additionally, the stability of the process was studied using multiple commercial batches of the product. The results revealed that the total antigen recovery rate in the production process described in this report was no less than 8.5%, and the effective removal rate of residual HCD was not lower than 99.99%. Moreover, the amount of residual HCD in the final product was far below the quality standard of 2 ng/dose, and most of the residual HCD fragments were smaller than 200 bp. The results of the process stability studies on multiple commercial batches showed that the bulk human rabies vaccine produced by this process had excellent safety and efficacy and that the production process was stable and thus suitable for large-scale batch production. The production process described in this study achieved effective recovery of viral antigens and efficient removal of residual HCD, and the process was stable and controllable, enabling the continuous and stable production of vaccine products that meet WHO recommendations and the relevant requirements of the current edition of the Chinese Pharmacopeia. In addition, this study provides theoretical guidance for optimizing the vaccine production process.

Predictors of Persistent Residual Stones After Second Look Percutaneous Nephrolithotomy.

Introduction: Second look flexible nephroscopy (SLFN) is often offered after percutaneous nephrolithotomy (PCNL). However, even after SLFN, residual fragments (RFs) occasionally persist. We sought to determine the incidence of persistent RFs in patients who undergo SLFN for RFs after PCNL and to identify parameters predictive of persistent RFs. Methods: We identified all patients at our institution with RFs on post-PCNL computed tomography (CT) that underwent SLFN between 1/2016 and 5/2020. Patient demographics, stone characteristics, and perioperative parameters were analyzed for each study patient. Post-SLFN fragments were identified on either follow-up kidney, ureter, and bladder radiograph or CT imaging obtained within 3 months of PCNL. Multivariable logistic regression analyses (MVA) was performed to identify predictors of persistent fragments. Results: A total of 201 renal units met the inclusion criteria. The median size of the largest RF at the time of SLFN was 5 mm (IQR 2-8) and the median cumulative RF stone size was 8 mm (IQR 5-14). The final stone-free rate of patients with RFs on initial PCNL who then underwent SLFN was 60.7% (n = 122). The median cumulative RF stone size and the median size of the largest RF post SLFN was 6.5 mm (IQR 4-12) and 5 mm (IQR 3-8), respectively. On MVA, bilateral preoperative stones and greater RF stone burden at time of SLFN were independent predictors of radiographically detected post-SLFN fragments. Conclusions: Among patients who underwent SLFN for RFs after PCNL, 60% were rendered stone-free. Patients with bilateral stones prior to PCNL and greater RF stone burden at time of SLFN are more likely to have persistent fragments, despite attempts at aggressive stone removal during both the initial PCNL and subsequent SLFN. The risk of adverse stone events from such fragments is unknown and may be lower because of their inaccessibility.

Small Diameter (7.5 Fr) Single-Use Flexible Ureteroscopy with Direct In-Scope Suction (DISSTM) in Conjunction with Aspiration-Assisted Flexible Access Sheath: A New Hype for Real Stone-Free?

Background: Renal lithiasis continues to represent a great challenge for modern urology in terms of minimally invasive management of lithotripsy procedures. The recent revolution of endoscopes with the miniaturization of instruments and the development of improved disposable ureteroscopes combined with recent suction methods such as suction access sheaths or direct in-scope suction (DISSTM) systems promise to further improve the outcome of renal stone treatment. Methods: Considering this technological advance, this study aims to evaluate the results obtained by combining these methods in three groups: Group 1-Single-use 7.5 Fr flexible ureteroscope with standard access sheath, Group 2-Single-use 7.5 Fr flexible ureteroscope with direct in-scope suction (DISSTM) with standard access sheath, Group 3-Single-use 7.5 Fr flexible ureteroscope with DISSTM with suction access sheath. A total number of 105 consecutive patients were enrolled in the study, divided equally in each group. Several parameters were followed, such as size and location of the stones, operative time, duration of hospitalization, the need for ureteral stent insertion, residual fragments, and subjective evaluation of the lithotripsy environment visualization. Results: The best results were highlighted in Group 3 for almost all evaluated parameters. Significant improvements were indicated in terms of stone-free rates. Conclusions: Additional large studies are needed to support these initial results, but preliminary data indicate a valuable advantage for every urologist who treats urolithiasis.

Influence of in vitro pectin fermentation on the human fecal microbiome and O-glycosylation of HT29-MTX cells

Pectin is a structurally complex heteropolysaccharide that affects intestinal microorganisms and mucin O-glycans. The present study employed an in vitro model to investigate dynamic changes in microbiota during pectin fermentation. Residual pectin fragments arising from its fermentation were applied to HT29-MTX cells to study the effect of pectin structure on mucin O-glycosylation. Prevotella, Bacteroides, and Parabacteroides were found to preferentially degrade galactose, arabinose, and on the rhamnogalacturonan RG-I side chain region and methyl esterification groups of pectin. Bifidobacterium, Enterococcus, Megamonas, and Dorea metabolized the galacturonic HG region on pectin to produce butyrate. All pectin fragments were found to up-regulate total O-glycans (1.55–2.73 fold) and neutral O-glycans (1.11–1.49 fold) on HT29-MTX mucins. The large HG fragment (81.04 kDa) increased significantly the amount of non-fucosylated glycans (by 2.46-fold); whereas the small HG fragment (16.02 kDa) promoted fucosylated (by 9.25 fold), and especially di-fucosylated O-glycans. Collectively, these results demonstrate that gut microorganisms degrade pectin fragments in the following order of utilization: RG-I, RG-II, and HG. The small fragment of HG improves the expression of fucosylated O-glycans in HT29-MTX cells, mainly owing to an increase in di-fucosylated O-glycans.

Multicenter outcome analysis of different sheath sizes for Flexible and Navigable Suction ureteral access sheath (FANS) ureteroscopy: an EAU Endourology collaboration with the global FANS study group.

Flexible and navigable suction ureteral access sheath (FANS) is a potential game changer in flexible ureteroscopy (FURS). The influence of sheath size on outcomes needs research. The primary aim was to analyze 30-day single stage stone free status (SFS), zero fragment rate (ZFR) and complications when using 10/12Fr sheaths vis a vis other sheath sizes. The global FANS research group published the 30-day outcomes in patients who underwent FANS and reasoned this can be a potential game changer. We included 295 patients from this anonymized dataset with division into two groups: Group 1 (Smaller sheath) - 10/12Fr FANS, and Group 2 (Larger sheath) - 11/13Fr or 12/14Fr sheaths. Stone volume was similar between both groups (median 1320 mm3, p = 0.88). Ureteroscopy and total operative time was longer in the smaller sheath group (35 vs. 32min, p = 0.02 and 50 vs. 45min, p = 0.001, respectively). While 30-day computed tomography SFS (100% stone free or single residual fragment ≤ 2mm) were not significantly different (96% vs. 95%, p > 0.99), ZFR (100% stone-free) was better with smaller sheaths (68% vs. 53%, p = 0.02). There was no difference in postoperative complication rates, and no sepsis in both groups. Urologists should consider individualizing appropriate sheath size in normal adult kidneys. Sheath size did not affect complication rates, risk of perioperative injury to the pelvicalyceal system or ureteric injury, but smaller FANS sheaths had similar high SFS. The ZFR with smaller sheaths was better, but this needs to be validated. These smaller sheath outcomes need to be balanced with longer ureteroscopy time, operative time, reach to the lower pole, ease of suction and visibility during lithotripsy. Large volume studies in different types of pelvicalyceal anatomy can determine if indeed smaller FANS is the best choice in FURS.

Factors influencing operative time for mini-endoscopic combined intrarenal surgery for renal stones

Mini-endoscopic combined intrarenal surgery (ECIRS) offers improved advantages in the treatment of renal stones. However, the factors influencing the operative time remain poorly understood. This study aimed to identify the factors that enhance treatment planning and minimize complications. Clinical data from consecutive patients who underwent mini-ECIRS for renal stones and achieved a stone-free status between 2015 and 2021 at three high-volume centers in Japan were analyzed. The final treatment outcome was evaluated by computed tomography imaging at postoperative 1 month, and a successful outcome was defined as complete stone-free or residual stone fragments < 4 mm. Logistic and linear regression models were used to predict the operative duration of mini-ECIRS. An operative time of ≥ 120 min was significantly associated with punctured pole and body mass index (BMI), and septic shock was only observed in patients with operative times of ≥ 120 min. The multivariate model for the operative time for mini-ECIRS identified five clinical factors: punctured pole, number of stones, number of involved calyces, BMI, and preoperative nephrostomy. We believe these findings will help surgeons and patients plan suitable treatment strategies, predict the additional need for a second mini-ECIRS or retrograde intrarenal surgery alone, and avoid severe complications.

Intraorbital Trauma with Wooden Foreign Body: Report of An Atypical Surgical Case

Among the various types of injuries that affect the maxillofacial region, perforating objects can result in doubtful prognosis due to the possibility of reaching vessels, nerves, and other key structures, causing hemorrhages, airway obstruction, brain damage and even death. Foreign bodies in the orbital cavity are usually divided into two categories: inorganic and organic. This report intends to present an atypical case of wooden foreign body remotion from the intraorbital area which was performed surgically in a Public Hospital Center in Sergipe, Brazil. Facial injuries should be evaluated with a rigid protocol to provide quality healthcare, thus minimizing problems during the management of the cases. Imaging examinations should not be neglected, so that careful evaluation of the extent of the lesions and presence of foreign objects can be performed. Although CT is regarded as the gold standard, MRI scans are superior to CT in the diagnosis of small pieces of wood. Surgery is the preferred treatment, in which the surgeons should carefully remove all foreign bodies and residual fragments will result in orbital infection. Postoperative sinus drainage and systemic antibiotic treatments are necessary.

Prospective Evaluation of Outcomes and Complications in Ultra-Mini-Percutaneous Nephrolithotomy for Pediatric Nephrolithiasis: A Three-Year Study

Objective: This prospective study aimed to evaluate the outcomes and complications of Ultra-Mini Percutaneous Nephrolithotomy (UM-PCNL) in pediatric patients with renal calculi over a three-year period (2021-2023). We assessed Stone-Free Rates (SFR), operative success and perioperative complications to determine the efficacy and safety of UM-PCNL in children. Methods: Seventy-eight pediatric patients (aged 1-17 years) underwent UM-PCNL for renal calculi larger than 10 mm. Preoperative imaging, including ultrasonography and computed tomography, was utilized to assess stone size and location. Surgical outcomes, including SFR, operative time and the need for second-look procedures, were evaluated. Complications were graded using the Clavien-Dindo classification. Statistical analysis was conducted using SPSS, with a significance threshold of p &lt; 0.05. Results: The mean stone size was 18.2 ± 5.4 mm and the overall SFR after a single UM-PCNL procedure was 78.2%. Clinical success (defined as either stone-free status or clinically insignificant residual fragments) was achieved in 89.7% of patients. The mean operative time was 67 ± 22 minutes. Second-look procedures were required in 11.5% of cases. The overall complication rate was 19.2%, with no major complications (Clavien grade III-V). Minor complications included transient fever (6.4%), hematuria (12.8%) and urinary leakage (5.1%). Conclusion: UM-PCNL is a safe and effective procedure for managing pediatric nephrolithiasis, offering high stone-free rates and low complication risks. The use of smaller instruments reduces renal trauma, bleeding and the need for blood transfusions. These findings support UM-PCNL as a first-line treatment option for larger renal stones in pediatric patients. Further studies with long-term follow-up are recommended to assess recurrence and long-term renal function outcomes.

RIRS with FV-UAS vs. ESWL for the management of 1-2 cm lower pole renal calculi in obese patients: a prospective study.

To evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) combined with flexible vacuum-assisted ureteral access sheath (FV-UAS) versus extracorporeal shock wave lithotripsy (ESWL) for the management of 1-2 cm lower pole renal calculi (LPC) in obese patients. This prospective, randomized study included 149 obese patients with 1-2 cm LPC. Patients were allocated into two groups: 76 patients underwent RIRS with FV-UAS, and 73 patients received ESWL. The parameters assessed included stone-free rate (SFR), retreatment rate, complications, operative time, and pain intensity measured by the visual analog scale (VAS). Stone-free status was defined as the absence of stones on computed tomography or residual fragments smaller than 4 mm at 4 weeks post-procedure. The baseline characteristics of the two groups were comparable. The SFR was significantly higher in the RIRS group, reaching 86.8%, compared to 63.0% in the ESWL group (p = 0.034). Furthermore, the retreatment rate was significantly lower in the RIRS group, at 5.2%, versus 24.7% in the ESWL group (p < 0.001). The average operative time for RIRS was notably longer, at 65.3 ± 6.4 min, compared to 25.3 ± 7.8 min for ESWL (p < 0.001). The complication rates were 9.2% for the RIRS group and 6.8% for the ESWL group, with no statistically significant difference (p = 0.326). All complications were classified as Grade I or II according to the modified Clavien classification system. No significant differences were observed between the two groups regarding pain VAS scores and the composition of the stones. RIRS with FV-UAS demonstrated superior efficacy, evidenced by a higher SFR and reduced retreatment rates compared to ESWL, despite a longer operative duration. Both treatment modalities showed comparable safety profiles. RIRS with FV-UAS emerges as a viable, effective, and reproducible intervention for managing 1-2 cm LPC in obese patients, providing significant clinical advantages.