Journal of Endourology

To compare stone clearance, stone-free status, and complications between patients undergoing ureteroscopy for renal stones using either Flexible and Navigable Ureteral Access Sheath (FANS) or the CVAC 2.0 system.

A prospective study was completed on patients undergoing flexible ureteroscopy for renal stones at a single institution from March 2024 to December 2024. Subject demographics, intra-op data, volumetric and single-dimension stone clearance on non-contrast CT, and complications were compared. Stone-free rates (SFRs) using standardized cutoffs were compared. Pearson correlation analysis was performed to assess the relationship between preoperative stone volume and postoperative stone burden. Subanalysis was performed for patients with preoperative stone burden >1.5 cm.

A total of 123 cases (CVAC 2.0-36, FANS-87) were included, with 64 eligible for volumetric analysis. Preoperative stone volume was larger in the CVAC group vs FANS (1075 mm³ vs 397 mm³; p < 0.001). Absolute stone clearance was greater in the CVAC group (1016 mm³ vs 392 mm³; p < 0.001), whereas residual stone volume (4.1 mm³ vs 15.0 mm³; p = 0.55) and SFRs (90% vs 81%; p = 0.48) were similar. In individuals with >1.5 cm preoperative stone burden, relative stone clearance was greater with CVAC 2.0 (98.9% vs 95.1%; p = 0.026). Pearson correlation analysis revealed positive linear relationship between preoperative stone volume and residual stone volume for FANS, but not for CVAC 2.0.

In this comparative study of FANS and CVAC 2.0, over 95% stone clearance was observed in both groups despite large initial stone burdens. In contrast to FANS, residual stone volumes with CVAC 2.0 did not increase significantly with increasing preoperative stone volumes.

This study compared the stone-free rate (SFR) and complications of two holmium laser lithotripsy techniques—active fragment extraction (FRAG) and dusting (DUST)—during flexible ureteroscopy (FURS) for renal stones using noncontrast computed tomography (NCCT).

A total of 100 patients with renal stones (5–20 mm) undergoing FURS were randomized into FRAG and DUST groups. All surgical parameters, except lithotripsy strategy, were standardized, and ureteral access sheaths were used. The primary outcome was SFR at 90 days, defined as residual fragments ≤2 mm (Grade A + B) on NCCT. Secondary outcomes included the influence of stone volume, density, and complication rates.

Ninety-three patients completed follow-up (FRAG: 45; DUST: 48). Baseline demographics and stone parameters (diameter, density, volume, location) were similar. Mean stone size (FRAG: 13.9 ± 5.2 mm vs DUST: 13.0 ± 4.7 mm, p = 0.378) and density (FRAG: 999.7 ± 267.6 Hounsfield unit [HU] vs DUST: 1,111.8 ± 249.1 HU, p = 0.044) were comparable. SFRs were 66.7% (FRAG) and 68.8% (DUST) (p = 0.751). Multivariate analysis identified higher body mass index as a predictor of improved SFR (odds ratio 1.17, p = 0.022), whereas stone volume (p = 0.179) and density (p = 0.884) had no significant impact. Operative time, complications, and ancillary procedure rates were comparable.

Both techniques achieved similar SFRs, with no significant influence from stone volume or density. Postoperative complications and ancillary procedures were comparable. These findings suggest either method is effective, with technique selection based on surgeon preference.

This study aims, for the first time, to assess and quantify the environmental impact of ureteroscopy. We conducted a life cycle assessment of flexible ureteroscopy for lithiasis in four different centers, with objective of comparing their respective impacts, determining the most environmentally unsustainable steps of the procedure, and comparing the toll of different medical devices, such as single-use and reusable flexible ureteroscopes (SUFU and RFU). In order to identify eco-designed approaches and to suggest recommendations for sustainable and eco-responsible strategies.

For each step of the procedure, we collected the reference of every medical device, their quantities, composition, transport, and disposal methods. Reusable devices’ impacts were divided by their lifespans, with sterilization processes included. Data analysis was carried out by Agence Primum non nocere—an independent company specialized in sustainable development—using SimaPro 9.5 with the Ecoinvent 3.9 database and assessing 18 environmental impacts.

The steps with the highest environmental cost were equipment installation, surgical staff attire, calculi exploration, and patient setup. There was no clear overall difference between SUFU and RFU regarding global warming, though differences were more significant in certain specific impact categories. Reusable laser fibers exhibit significantly lower environmental impacts compared with single-use fibers. The absence of transparency regarding production data from manufacturers constitutes a significant limitation to our study. We recommend designing optimized ureteroscopy packs, promoting the use of reusable fabric attire, using RFU sterilized with the low-temperature hydrogen peroxide method, prioritizing SUFU with a recycling program, revising disinfection protocols, and increasing waste valorization in operative rooms. We further recommend a hybrid approach to increase the lifespan of reusable ureteroscopes.

To investigate the safety and feasibility of non-papillary puncture in total ultrasound (US)-guided standard size access percutaneous nephrolithotomy (PCNL) for patients with complex renal stones.

We retrospectively reviewed the charts of complex renal stones (Guy’s scoring system 3–4) patients who had undergone standard size access PCNL in our department from January 2019 to October 2023 (n = 422). Renal abnormalities, history of PCNL and pyelolithotomy/nephrolithotomy, and multiple tracts PCNL were excluded. Two hundred A total of 218 eligible patients were finally enrolled. These patients were allocated to two groups according to puncture site: papillary (Group 1, n = 182) and non-papillary (Group 2, n = 36). All procedures were guided by total US. Single standard access (22–24 F) was achieved in all patients. Relevant patient characteristics, operative variables, and postoperative data were collected and analyzed, with a focus on the stone-free rate (SFR) and bleeding complications.

Successful percutaneous renal puncture was achieved in all patients. Patients’ basic characteristics (gender, age, body mass index, stone size, surgical side) were similar between the two groups. The SFRs in the papillary puncture group were significantly higher than the non-papillary puncture group (81.3% vs 69.4%, p = 0.03). Hemoglobin loss in Group 2 is much more significant than in Group 1 (18.4 ± 5.4 g/L vs 10.4 ± 4.7 g/L, p = 0.02). Overall non-severe complication (Clavien-Dindo Grade 1–2) rates were significantly lower in Group 1 (p = 0.02, 0.03). The operative duration, transfusion rate, severe complication rate, and renal function changes show no significant difference between the two groups.

US-guided PCNL through a standard-access tract is necessary for renal papilla puncture. Non-papillary puncture increases bleeding volume and reduces SFR, and should be avoided in complex stones whenever possible.

Surface lubricity is a desirable characteristic of ureteral access sheaths (UAS), allowing for atraumatic navigation of the urinary tract. This study aimed to characterize the surface lubricity of commonly available 14F UAS, as well as 14F ureteral and urethral dilators, using a tribometer and a novel ex vivo ureteral tissue holder.

The surface lubricity of 12, 14F urological catheters (8 UAS, 1 urethral dilator, and 3 ureteral dilators) was tested in six ex vivo Yorkshire porcine ureteral segments. A tribometer, capable of measuring force in thousandths of a Newton (N), measured frictional force during insertion and retraction cycles under a 4.0 N normal force. The coefficient of friction (COF) was calculated. Individual and cumulative lubricity scores (ILS and CLS) were calculated based on COF percentiles, enabling a comparative evaluation of device performance. Surface roughness was assessed via white light interferometry.

The Cook Flexor® UAS consistently demonstrated the highest lubricity, as reflected in its CLS for both insertion and retraction phases, followed closely by the Wellead ClearPetra® UAS. Dilators, including the Cook AQ hydrophilic-coated ureteral and urethral dilators, exhibited higher COF values, correlating with greater surface roughness. COF values were significantly higher during retraction cycles than insertion cycles (p < 0.05). Variability in COF across devices underscored the influence of surface properties on lubricity.

Among all the UAS/dilators tested, the Cook Flexor® AQ-coated UAS and Wellead ClearPetra UAS had the best lubricity. Catheter retraction resulted in higher COF than catheter advancement.

To describe our 10-year experience with EBD for primary obstructive megaureter.

Children needing intervention for primary obstructing megaureters (POM) (based on increasing distal dilatation >1.4 cm, differential renal function [DRF] <40%, or symptoms) were counseled to undergo a trial of EBD. A 9.5Fr cystoscope and stent “pusher” were used to insert a 14’’ guidewire to allow insertion of a 4/25 mm coronary dilatation balloon that was insufflated to 15 ATM for 5 minutes. Afterwards a 4.7Fr Double-J stent was positioned for 6 weeks. Ureteral diameter, DRF, length of obstruction, and complications were registered. Success was defined as improvement of the indication without further need for a more invasive procedure.

A total of 31 dilated ureters in 28 patients (23/5 M/F) were included, with a median age of 9 months (M) (range: 1–111) and a follow-up of 41 M (range: 12–84). EBD showed a narrow ring in 29 (93.5%) and longer narrow distal ureters in 2 (6%). EBD was successful in 29/31 ureters (93.5%), with different success rates for a narrow ring (96.6%) and a longer narrow distal ureter (50%).

As most POM resolve spontaneously, hard indications are needed before treatment is offered. Symptomatic patients (e.g., infections) and declining DRF with dilated ureters are strong indications. In such cases, EBD with a coronary dilatation balloon has a high success rate and provides diagnostic information regarding the length of the narrow ureteral segment. Longer narrow ureteral segments are rare but result in a higher failure rate.

Poor adherence to potassium citrate (KCit) therapy due to palatability issues and gastrointestinal side effects presents a significant barrier to effective kidney stone prevention. While liquid and powder alternatives have emerged as potential solutions, comprehensive comparative palatability data remain limited, hampering evidence-based recommendations for clinical practice. This study aimed to evaluate and compare the palatability of four commercially available liquid KCit formulations (Litholyte, Moonstone StoneStopper, KSPTabs, and Bulk Supplements) in healthy non-stone-forming adults.

We conducted a blinded swish-and-spit taste-testing study enrolling 63 healthy participants who sampled each liquid KCit formulation in a randomized order. Participants rated each formulation using a validated five-point Likert scale survey assessing overall palatability, mouthfeel, taste intensity, and aftertaste. Swish-and-spit protocol was followed to minimize systemic absorption while allowing thorough taste evaluation.

Moonstone StoneStopper (cranberry-raspberry flavored) demonstrated superior overall palatability (mean score: 4.3 ± 0.6), followed by KSPTabs (3.2 ± 0.8), Litholyte (2.8 ± 1.1), and Bulk Supplements (1.7 ± 0.7). Mouthfeel and aftertaste scores correlated strongly with overall preference (r = 0.87 and r = 0.82, respectively).

Flavor-masked formulations consistently outperformed unflavored options across all taste parameters. These findings suggest that flavored liquid alternatives to KCit therapy are preferred in non-stone formers. Further studies in stone-forming populations are warranted to confirm these results, assess gastrointestinal side effects and evaluate long-term adherence.

With recent technological advances, high-power laser systems with maximum power output of 150 W have shown advantages over standard-power laser systems in urological procedures. Our study aims to utilize the Manufacturer and User Facility Device Experience (MAUDE) database to examine the real-world safety profile of high-power laser systems.

We searched the MAUDE database for reports on high-power laser systems, including Holmium Yttrium-Aluminum-Garnet (YAG), Thulium fiber laser, and Thulium YAG, from 1993 to 2024. Complications were identified and categorized.

A total of 1294 reports were found on initial search, of which 273 reports pertaining to high-power laser systems met inclusion criteria. We found 205 reports involving Holmium YAG, with 138 reports for laser lithotripsy and 67 for laser enucleation of the prostate. Most Holmium YAG complications were Clavien Dindo grade I and II events (n = 170, 92.9%), with renal colic (n = 38) and fever (n = 34) being the most frequently reported. There were 68 reports involving Thulium fiber laser systems, 66 of which were for laser lithotripsy. These reports consisted of a high number of grade III and IV postoperative events (n = 24, 85.7%), with ureteral stricture being the most common complication (n = 17). Ten ureteral strictures took place between first clinical use in June 2020 and June 2021, while 6 occurred between July 2021 and October 2024. No Thulium YAG reports met inclusion criteria.

Our analysis showed minor adverse events associated with high-power Holmium YAG laser systems, indicating an overall strong safety profile. We also found that Thulium fiber laser systems showed a high number of CD grade III and IV complications, particularly ureteral strictures, most of which occurred prior to June 2021. We suggest that urologists should appreciate the risks associated with the use of novel technologies and be thoughtful about technology uptake.

One of the major limitations of the current diagnostic techniques for upper urinary tract carcinoma (UTUC) is the risk of both understaging and overstaging, highlighting the need for real-time, high-resolution intraoperative imaging. We evaluated the diagnostic accuracy and safety of ureteral optical coherence tomography (OCT) under ureterorenoscopy for T staging of UTUC.

In this study, patients with suspected UTUC were prospectively enrolled. The safety analysis set included 16 patients who underwent ureteral OCT for ureteral tumors. Because two (13%) patients underwent ureterorenoscopic ablation therapy, the diagnostic accuracy analysis set included 14 of 16 patients who had both ureteral OCT data and a final pathological T (pT) stage from surgical specimens. The concordance, underdiagnosis, and overdiagnosis rates were compared between radiographical imaging-based T (cT) and OCT-based T (octT) diagnoses. The primary outcome was the diagnostic accuracy of ureteral OCT in discriminating between pTis/Ta/T1 (non–muscle-invasive UTUC) and T2/T3 (muscle-invasive UTUC) cancers.

Concordance between cT-based and pT-based diagnoses was observed in 11 (79%) of the 14 patients, whereas a higher concordance rate (13/14, 93%) was noted for octT diagnosis. Additionally, the underdiagnosis and overdiagnosis rates of octT were 0% and 7.1%, respectively, which were lower than those of cT (7.1% and 14%, respectively). Although no intraprocedural urinary injury was observed, postprocedural complications included hematuria in five patients (31%), urinary tract pain in two (13%), and urinary tract infection in one patient (6.3%).

Ureteral OCT exhibited a high diagnostic performance in discriminating between non–muscle-invasive UTUC and muscle-invasive UTUC with a safety profile. Further prospective trials with large sample sizes are necessary to determine the true diagnostic value and the wide use of ureteral OCT.

The RADPAD is a novel lead-free shield that can be positioned directly in the surgical field to block scatter radiation. The primary objective of this study was to assess the effectiveness and added protection of the RADPAD compared with conventional lead during simulated percutaneous nephrolithotomy (PCNL).

To simulate a PCNL, a radiographical phantom patient and a mannequin surgeon were utilized. Using a real-time dosimeter, radiation doses were measured in µSv at seven surgeon locations: head, neck, chest, abdomen, pelvis, forearm, and leg. Two shielding strategies were evaluated: conventional lead apron and thyroid shield (LATS) and triple-thickness RADPAD. The effectiveness of combining LATS with RADPAD was compared with baseline (no lead). Five trials of 5 seconds of fluoroscopy were conducted for each location and shielding combination. The Mann–Whitney U test was used to compare exposures with p < 0.05 considered significant.

LATS alone significantly reduced radiation exposure at all locations compared with baseline (>95%; p < 0.05) except the surgeon head, forearm, and leg. RADPAD alone significantly reduced radiation at all tested locations (p < 0.05), except the legs. Compared with LATS alone, RADPAD significantly reduced radiation exposure to the head (as much as 48%) and forearm (as much as 84%; p < 0.05). LATS with RADPAD yielded the greatest radiation reduction, performing significantly better than LATS alone at the head, pelvis, and forearm (p < 0.05). No device or combination significantly reduced radiation exposure to the leg.

The LATS alone reduced radiation >95% at shielded sites, but provided no protection to the head, forearm, and leg. Addition of the RADPAD to conventional LATS functions as an effective and novel strategy that reduces radiation exposure at all measured sites except the legs and provides important protection to the head and arms of the surgeon without increasing the weight burden.

Data on complications following holmium laser enucleation of the prostrate (HoLEP) are primarily single-center experiences. Although postoperative urethral stricture rates are well described in the literature, secondary urinary incontinence surgeries (UIS) are poorly characterized. We aimed to quantify the incidence of long-term complications, notably UIS, following HoLEP using a large national dataset.

We retrospectively reviewed a limited dataset from the TriNetX Research Network Database, which carries clinical data of 104 US academic medical centers and health care organizations. A search query between 1 year prior to and 2 years after HoLEP identified patients of interest from 45 providers. The following diagnoses and procedures were queried: HoLEP, urinary incontinence, anti-spasmodic prescription, artificial urethral sphincter (AUS), male sling, cystourethroscopy with injection for chemodenervation, injection of urethral bulking material, meatotomy/meatoplasty, urethrotomy, transurethral resection of bladder neck contracture, urethroplasty, and urinary retention.

Of the 11,559 patients that underwent HoLEP, 2391 (20.7%) were diagnosed with urinary incontinence, and 1921 (16.6%) were prescribed urinary antispasmodics in the year preceding the surgical procedure. The risk of short-term incontinence in the first 3 months following the surgical procedure was 1185 (10.3%). This decreased to 551 (4.8%) between 1 and 2 years after the surgical procedure. Thirteen (0.1%) underwent insertion of an AUS or sling placement, 90 (0.8%) had cystoscopy with chemodenervation, and 10 (0.10%) underwent urethral bulking in the 2 years following HoLEP. The same dataset shows 209 (1.8%) patients required surgical treatment of postoperative urethral stricture disease, excluding bladder neck contracture, in the 24 months following HoLEP.

Data from a large national database show a low rate (4.8%) of persistent urinary incontinence beyond 1 year following HoLEP and an expected low rate of urinary incontinence procedures.

Throughout the last several years various robotic platforms have emerged with increasing relevance in clinical practice. However, direct comparisons of their perioperative outcomes in robot-assisted radical prostatectomy (RARP) are limited. To address this gap, we conducted a systematic review and network meta-analysis of RARP outcomes across different robotic platforms.

A systematic search was carried out using PubMed, CINAHL, Scopus, and Cochrane for cohort studies, randomized controlled trials (RCTs), and non-RCTs, focusing on patients undergoing RARP for localized prostate cancer. Key outcomes included operative time (OT), estimated blood loss (EBL), and length of stay (LOS).

Eighteen studies with 3511 patients were included, representing 9 robotic platforms. LOS was reported in 11 studies, with a mean range of 1.34 to 9.5 days. Compared with the da Vinci Multiport (MP) platforms (XI and SI), the MP1000 platform showed the lowest mean difference (MD) of 1.08 days (95% confidence interval [95% CI]: 0.04–2.13), although this was not statistically significant. OT, reported in 16 studies, showed significant differences. Da Vinci MP platforms had longer OT than Shurui Single-Port (SP), KangDuo, Revo-i, and da Vinci SP, with MDs ranging from 17.16 to 111.83 minutes. In contrast, Senhance showed a shorter OT, with an MD of –34.5 minutes (95% CI: 9.02–59.98). EBL data from 15 studies revealed no significant differences across platforms.

This is the first network meta-analysis comparing perioperative outcomes of RARP across emerging robotic platforms. Our findings suggest no clinically significant differences in LOS and EBL, but significant variation in OT, potentially reflecting the impact of novel robotic technologies.

This study aims to develop a predictive model for identifying patients at increased risk of prolonged hospital stay after robotic-assisted radical prostatectomy, either via multi-port or single-port techniques, to improve postoperative care and assist in selecting ideal candidates for same-day discharge.

The study included patients who underwent robotic-assisted radical prostatectomy at the University of Illinois at Chicago between January 2013 and December 2022. The dataset comprises preoperative variables such as age, race, body mass index, comorbidities, prostate-specific antigen levels, Gleason score, surgical approach, and length of hospital stay. A logistic regression model was employed to predict the likelihood of a hospital stay exceeding 24 hours. The model’s performance was assessed using the area under the Receiver Operating Characteristic curve and fivefold cross-validation.

The predictive model identified significant factors associated with prolonged hospital stays, including body mass index, prostate-specific antigen levels, Gleason score, surgical approach, and specific comorbidities. The transperitoneal approach was strongly associated with lower chances of same-day discharge, demonstrating an odds ratio of 4.23 (p < 0.00001). The model achieved an accuracy of 73.7% as evaluated by cross-validation.

The nomogram effectively predicts the likelihood of prolonged hospital stay following robotic-assisted radical prostatectomy, enabling surgeons to make informed decisions about patient counseling, surgical planning, and postoperative management. This model may assist in identifying ideal candidates for same-day discharge while improving hospital resource utilization. Future studies should validate this model externally and explore the impact of additional perioperative and social factors.

Robotic surgery belongs to the standard therapies for patients with benign prostate hyperplasia (BPH) with large prostates (over 80 g). To evaluate postoperative outcomes and complications of transvesical vs transcapsular multiport robot-assisted simple prostatectomy (RASP) for BPH.

Between September 2019 and November 2024, 100 consecutive patients were included and divided into group 1, n = 40 transvesical, and group 2, n = 60 transcapsular. Outcomes included operative time, catheter duration, hospital stay, and complications (Clavien–Dindo).

Patients in the transvesical group had higher baseline symptom bother (International Prostate Symptom Score: 27 vs 18; quality of life: 5.5 vs 3.5). Transcapsular RASP demonstrated shorter console time (71 vs 91 minutes), reduced catheter duration (4.3 vs 6.7 days, p = 0.001), and shorter hospitalization (5 vs 6 days, p = 0.02). Major complications were recorded more frequently in the transvesical group (12.5% vs 3.3%, p = 0.04). Minor complications and readmissions were similar among the study groups (p = 0.3 and 0.8).

Transcapsular RASP may lead to quicker recovery, whereas transvesical techniques are more appropriate for complex cases involving bladder issues. The choice of method depends on the surgeon’s preference, but further prospective studies are necessary to gather more information.