Journal of endourology最新文献

Introduction and objectives: Traditionally, robot-assisted kidney transplant (RAKT) is performed using a transperitoneal approach, with patient in steep Trendelenburg position, leading to potential concerns for cardio-respiratory, bowel, and ocular complications. To circumvent these, we evaluated the feasibility, technical aspects, and outcomes of an extraperitoneal approach (EP-RAKT) and compared it with the transperitoneal approach (TP-RAKT).

Materials and methods: We reviewed our prospective database of patients who underwent RAKT with extraperitoneal approach between June 2023 and May 2024. This cohort was propensity matched in a 12 ratio with patients who underwent RAKT with transperitoneal approach for confounding variables (age, sex, BMI, graft kidney GFR, and graft number of vessels). Clinical parameters were recorded for all patients, including their demographic profile, radiological parameters, operative details and postoperative outcomes, and the cohorts were compared for intraoperative and postoperative outcomes.

Results: During our study period, 10 patients underwent EP-RAKT and were propensity matched with 20 patients with similar characteristics who underwent TP-RAKT. The mean duration of postoperative ileus (1.3 vs. 2.9 days), mean drain output (131 vs. 786 mL), and mean postoperative pain score (Visual Analog Scale score 10.2 vs. 14.8) were shorter for the extraperitoneal when compared with transperitoneal approach. No statistical differences were observed between the two groups for blood loss, rewarm ischemia time, vascular anastomosis time, or graft function. Patients in EP-RAKT group had more consistent tacrolimus levels in the therapeutic range in early postoperative period. However, the mean total operative time (288 ± 35.2 vs. 240 ± 28.2 minutes) and the mean time spent in port placement and bed preparation (50.8 ± 8.4 vs. 28.3 ± 6.1 minutes) were longer in EP-RAKT vs TP-RAKT.

Conclusions: EP-RAKT is a safe and feasible procedure, with similar graft function and reduced early postoperative complications compared with TP-RAKT, albeit with higher operative times.

Purpose: Ureteral complications are among the most common types of complications following kidney transplantation (KT). In the past, these complications were often managed using endoscopic and open surgical approaches. However, the robot-assisted approach has been recently implemented. Nevertheless, the available data regarding the potential impact of robotic surgery in this field are sparse. This systematic review (SR) aims to summarize the available evidence of robot-assisted ureteral reconstruction following KT, focusing on postoperative outcomes and complications.

Methods: Studies eligible for inclusion focused on evaluating the success and/or complications associated with robot-assisted ureteral reconstruction after KT. An SR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search was performed using the Web of Science, PubMed, and Scopus databases, with no restrictions on the time period. Only articles published in English were considered.

Results: After screening 5337 publications, this SR included 9 studies with a total of 127 patients. The most common indication for reconstruction was ureteral stricture (n = 108, 85%), and the most frequently performed procedure was ureteroneocystostomy (n = 59, 46.8%). Following robot-assisted ureteral reconstruction procedures, the average success rate was 91.3%. Regarding intraoperative complications, six patients (4.7%) required conversion to open surgery. As for postoperative complications, the number of patients experiencing Clavien-Dindo Grade 1, 2, 3, and 4 complications were 15/121 (12.4%), 20/121 (16.5%), 4/121 (3.3%), and 2/121 (1.6%), respectively.

Conclusion: With the advancements in robotic platforms as well as KT surgeons' expertise in minimally invasive surgery, robot-assisted ureteral reconstruction after KT is increasingly recognized as a safe and effective option for recipients with ureteral complications.

Introduction: To evaluate the feasibility, safety, and patient satisfaction of Double-J (DJ) ureteral stenting using a flexible cystoscope under local anesthesia (LA).

Materials and methods: We analyzed prospectively collected data from all patients who underwent DJ stent insertion or replacement using flexible single-use cystoscope under LA between February 2022 and September 2024 at two tertiary referral centers. Failure was defined as the inability to effectively complete the scheduled stent insertion or replacement. Pain was assessed using the Visual Analog Scale, whereas overall patient satisfaction and willingness to undergo future ureteral stenting under LA were also recorded.

Results: A total of 189 consecutive procedures were performed, including 131 (69.3%) unilateral and 31 (16.5%) bilateral DJ replacements and 22 (11.6%) unilateral and 5 (2.6%) bilateral DJ insertions. The median patient age was 76 years (interquartile range [IQR] 66-80), the median Charlson Comorbidity Index was 8 (IQR 6-12), and the median hospital stay was 0 days (0-0.25). Technical failure occurred in 13 cases (7.3%). Causes of failure were DJ encrustation, urethral stricture, or inability to identify the ureteral orifice (9 cases, 69.2%). These cases were effectively managed by percutaneous nephrostomy (PNS) or stent placement under sedation. Four (30.8%) procedures were interrupted because of pain felt by patients. Complications included one case of stent migration necessitating ureteroscopy, three cases necessitating PNS placement, and 10 grade 2 complications (5.6%). Overall, 170 patients (89.9%) expressed willingness to undergo the same procedure under LA in the future.

Conclusion: These results demonstrate that DJ stenting using a flexible cystoscope under LA in an outpatient setting is a feasible, safe, and well-tolerated procedure. It offers a high success rate with a low incidence of minor complications.

Objective: Real-time assessment of calyceal and tissue temperatures during laser lithotripsy.

Methods: Patients eligible for endoscopic combined intrarenal surgery were assigned to Soltive 60 W SuperPulsed thulium fiber laser (TFL; Olympus, Inc.) or holmium:YAG (Ho:YAG; Lumenis Pulse™ 120H) based on availability. After translocation of stones, a 1.5-mm multipoint thermal sensor needle measuring temperatures 5, 15, 25, and 35 mm from the tip was placed percutaneously with ultrasound guidance. The 5-mm mark recorded calyceal fluid temperature and the others parenchymal temperatures for 2 minutes during fragmentation (1 J/2 Hz TFL and 0.5 J/5 Hz Ho:YAG, 2-2.5 W), dusting (0.3 J/50 Hz, 15 W), and pop-dusting (0.5 J/80 Hz, 40 W). If tissue temperature exceeded 43°C, lasering was paused. After measurements, tract dilation and percutaneous nephrolithotomy were performed. Categorical data were compared using chi-square or Fisher's exact tests and continuous variables via t-tests.

Results: The 20 patients (10 TFL and 10 Ho:YAG) had similar baseline characteristics. During fragmentation, calyceal (T_calyx) and parenchymal (T_tissue) temperatures never exceeded 41°C. During dusting, T_calyx exceeded 43°C in four patients for each laser and T_tissue exceeded 43°C in one Ho:YAG patient (49°C after 60 seconds). Maximum calyceal temperature (T_max) in TFL and Ho:YAG patients was 51°C and 56°C (p = 0.18), respectively. During pop-dusting, T_calyx exceeded 43°C in 10 TFL and 8 Ho:YAG patients, and average maximum temperature (avgT_max) was significantly higher for TFL (52.9°C vs 45.1°C, p = 0.027). The tissue T_max was 47°C and 49°C (p = 0.96), respectively, with 43°C exceeded in three TFL and three Ho:YAG patients.

Conclusion: During high-powered lasering, temperatures can exceed 43°C in as little as 15 seconds. This is concerning since temperatures >43°C may be associated with permanent tissue injury.

Introduction: To evaluate the impact of the treatment for renal artery pseudoaneurysm (RAP) on long-term renal function after robot-assisted partial nephrectomy (RAPN).

Materials: We retrospectively reviewed 581 consecutive RAPNs performed by a single surgeon from February 2008 to February 2022. We evaluated patient variables, postoperative complications, and renal function at postoperative day one, 1 month, and 6 months after RAPN. Renal function was defined as estimated glomerular filtration rate (eGFR) based on the chronic kidney disease epidemiology collaboration Cr 2009 equation. We utilized the Fisher's exact test and Kruskal-Wallis rank sum test to analyze our data through categorical and continuous variables.

Results: Twenty-one patients (3.61%) developed a symptomatic RAP after RAPN that was treated with Interventional Radiology embolization. Patients with a RAP had a median age of 61.8 years (IQR: 53.5-69.7), median preoperative eGFR of 83.9 (IQR: 69.5-85.2), median BMI of 29.4 (IQR: 25.4-33.1), and median mass size of 3 cm (IQR: 2.5-4.2). There was no statistical difference in baseline characteristics between patients with RAP and patients without RAP. Patients with RAP had a longer length of stay (LOS) (3.0 IQR: 2.0-4.0 vs 2.0 IQR: 2.0-3.0). Patients with a RAP had a larger change in absolute eGFR value based on the difference from baseline to 1 month and 6 months (1 month: 20.5 vs 11.2, p < 0.001; 6 months: 18.1 vs 10.4, p = 0.001). RAP patients were also less likely to be within 10% of pre-RAPN levels (1 month: 24% vs 49%, p = 0.021; 6 months: 18% vs 47%, p = 0.016).

Conclusions: Patients treated for RAP post-RAPN had a decrease in renal function recovery at 1 month and 6-month intervals compared to patients not requiring post-RAPN RAP treatment.

Background: A 24-hour urine collection is central to the metabolic evaluation and prevention of nephrolithiasis. Despite its widespread use, methodological inconsistencies in data reporting and analysis limit the reliability, reproducibility, and clinical utility of findings. We aim to review and evaluate how 24-hour urine parameters are reported, analyzed, and interpreted in nephrolithiasis research. Materials and Methods: We conducted a methodological review of 264 studies involving 450,624 patients with nephrolithiasis. Data extraction covered urine collection protocols, parameter reporting, units used, statistical methods, and missing data handling. Results: Retrospective cohort studies comprised 42.8% of included articles; cross-sectional and prospective cohort studies made up 25.0% and 19.3%, respectively. Only 6.8% (18/264) of studies reported power calculations, and 40.9% (108/264) provided reference ranges. Calcium was the most frequently reported parameter (93.9%), followed by citrate (87.5%), oxalate (86.7%), and uric acid (84.1%). Supersaturation indices were reported in 44.3% of studies. Reporting formats varied: continuous units were used in 94.7% for supersaturation, 91.7% for calcium/creatinine ratio, and 77.9% for calcium. Most common units were mg/day (e.g., calcium: 78.9%) and mmol/day (e.g., sodium: 56.9%). Regarding statistical analysis, 72.3% of studies used t-tests or Mann-Whitney U tests, 39.4% used chi-square tests, and only 21.6% used multivariate regression. Missing data were handled by complete case analysis in 71.2% of studies, while 27.7% did not report their approach. Conclusions: There is significant variability in how 24-hour urine data are reported and analyzed across nephrolithiasis studies. This inconsistency undermines evidence synthesis, limits external validation, and obstructs the integration of advanced tools like artificial intelligence. We recommend creating a standardized reporting checklist to improve the rigor, reproducibility, and clinical relevance of future research.

Objective: 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. Methods: 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. Results: 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.

Purpose: 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. Patients and Methods: 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. Results: 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. Conclusion: 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.

Introduction: 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. Materials and Methods: 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. Results: 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. Conclusions: 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.

Purpose: 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. Methods: 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. Results: 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. Conclusion: 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.