Journal of endourology最新文献

Objective: To critically appraise the Radius, Exophytic/endophytic, Nearness of tumor to collecting system or sinus, Anterior/posterior, Location relative to polar lines (R.E.N.A.L.), Preoperative Aspects and Dimensions Used for an Anatomical classification (PADUA), and Radius, Position, iNvasion of sinus (RPN) nephrometry systems with respect to their classification of tumor complexity for surgical planning in robot-assisted partial nephrectomy (RAPN) and to compare their statistical validity, methodological rigor, and predictive performance.

Materials and methods: A structured synthesis of published evidence identified large multicenter series, prospective cohorts, and meta-analyses from 2009 to 2025 that evaluated the predictive accuracy, methodological design, and clinical relevance of these systems. Key evaluation domains included statistical validation, anatomical parameter selection, and correlation with surgeon-perceived difficulty in RAPN.

Results: Both the R.E.N.A.L. and PADUA scores were developed using empirically selected parameters and have historically been validated based on their correlation with perioperative outcomes. However, evidence in the literature now shows that such correlations are inconsistent and often clinically irrelevant in RAPN. In contrast, the RPN score was developed using a statistically modeled approach, reflecting the real-world surgical difficulty of RAPN as perceived by experienced robotic surgeons.

Conclusion: Current evidence does not support the continued use of R.E.N.A.L. and PADUA scores as validated tools in RAPN. The RPN score, with its statistically validated, anatomy-based methodology and alignment with surgical difficulty, represents a scientifically superior and clinically practical alternative for standardizing tumor complexity in RAPN.

Objective: To evaluate the predictability of postoperative complications in patients undergoing supine mini-percutaneous nephrolithotomy (mPNL) using the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system. The study investigated whether the E-PASS scoring system could serve as an objective criterion for identifying patients at high risk of complications. The ultimate goal was to enhance postoperative patient management and minimize complications.

Methods: The data of 224 patients who underwent supine mPNL in our clinic between April 2017 and July 2024 were retrospectively analyzed. Postoperative complications were assessed according to the modified Clavien-Dindo classification.

Results: Postoperative complications were observed in 31 (13.8%) of the 224 patients included in the study. While there were no significant differences between the groups in terms of age, sex, or body mass index, the complication group had a higher American Society of Anesthesiologists score (p = 0.007) and a higher Eastern Cooperative Oncology Group performance score (p = 0.001). Furthermore, the complication group exhibited greater blood loss (p = 0.001) and a longer hospital stay (p = 0.017). Comprehensive risk score (CRS) was identified as an independent predictor of postoperative complications (odds ratio: 7.481, 95% confidence interval: 3.054-18.322; p = 0.001). The area under the curve in the receiver operating characteristic curve analysis for CRS was calculated to be 0.862.

Conclusion: The E-PASS scoring system was found to be successful in predicting complications following supine mPNL. A CRS value exceeding 0.862 was associated with an increased risk of severe complications. Therefore, it is recommended that less invasive surgical options be considered for patients with high CRS values.

Purpose: To evaluate the effects of renal parenchymal thickness (RPT) and tract length (TL) on the stone-free rate (SFR) and complications in pediatric patients who underwent minimally invasive percutaneous nephrolithotomy (mini-PCNL).

Materials and methods: The data of pediatric age group (<18 years) patients who underwent mini-PCNL between 2017 and 2025 in our clinic, which is a tertiary referral center, were retrieved. Eighty patients were included in this study. SFR was determined using low-dose nonenhanced CT in all patients 1 month after procedure. Stone-free status was defined as the complete absence of stones, and the presence of any stone fragment, regardless of size, was defined as residual stone.

Results: The mean stone diameter was 22.8 mm, and the mean stone burden was 402 mm². Although 46.3% of the stones were located only in the renal pelvis, 32.5% were staghorn. Mean RPT was 13.6 ± 5.0 mm, TL was 33.0 ± 10.5 mm, and RPT/TL ratio was 0.42 ± 0.13. Complications occurred in 27.5% of the patients. No major (grade 4-5) complications were observed in any patient. After mini-PCNL, stone-free status was achieved in 65% of patients. The mean diameter of residual stone was 3.4 ± 5.9 mm. When comparing patients who were stone free and those with residual stones, RPT (p = 0.059), TL (p = 0.315), and RPT/TL ratio (p = 0.563) were similar between groups. When patients with and without complications were compared, no statistically significant difference was found between the two groups in RPT (p = 0.084), TL (p = 0.589), and RPT/TL ratio (p = 0.723).

Conclusions: Mini-PCNL appears to be an effective and safe surgical technique that can be applied in pediatric patients with kidney stones, regardless of RPT and TL; however, prospective multicenter studies are necessary to confirm our results in a larger number of patients.

Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment for benign prostatic hyperplasia (BPH) that has emerged as the gold standard. Pulse-modulated energy delivery, MOSES™ laser technology, optimizes the delivery of energy by reducing energy loss between the laser fiber and tissue. This study aims to compare the operative parameters of HoLEP using MOSES™ 1.0 vs 2.0.

Materials and methods: We prospectively enlisted patients undergoing HoLEP at two sites in a single institution. Patients were assigned to MOSES™ 1.0 or 2.0 by site and remained blinded to laser settings. Primary outcomes were differences in postoperative hemoglobin and enucleation, morcellation and hemostasis times. Secondary outcomes were improvement in International Prostate Symptom Score, maximum urinary flow rate, proportion of prostate enucleated and enucleation efficiency.

Results: Among 236 patients (median age 73 (46-90), 67 (28%) were assigned to the 1.0 group and 169 (72%) to the 2.0 group. Baseline demographics were similar, except higher rates of active anticoagulation in the 2.0 cohort (0 vs 8%, p < 0.03). The 2.0 group had significantly higher hemoglobin on postoperative day 1 (POD1) (1.0: 12.5 vs 2.0: 13.0, p < 0.05). Enucleation (51.0 vs 46.5 minutes) and morcellation (6.0 vs 7.0) were comparable. Hemostasis was 33% faster with the 2.0 (15.0 vs 10.0 minutes, p < 0.001), even when adjusted for prostate volume (p < 0.0001) and anticoagulation status (p = 0.001). Although not statistically different, the 1.0 cohort had higher rate of urinary tract infection (11.9% vs 6.0%), while the 2.0 cohort had more Clavien-Dindo IV complications (0% vs 1.2%) and clot retention (0% vs 1.2%).

Conclusions: Compared with the 1.0, the MOSES™ 2.0 laser demonstrated significantly improved intraoperative hemostasis while maintaining comparable enucleation efficiency. Although POD1 hemoglobin values were higher with the 2.0 system, the difference was small and unlikely clinically meaningful. Secondary postoperative outcomes were also similar between groups. Our findings suggest that the primary advantage of the updated technology lies in enhanced hemostatic performance rather than procedural efficiency.

Purpose: The ASPiration to Improve Renal Calculi Removal Effectiveness study showed steerable ureteroscopic renal evacuation (SURE) with CVAC that significantly reduced residual stone volume at 30 days vs standard ureteroscopy (URS). This report presents 2-year health care consumption and stone events (SE) and their link to residual stone volume and other variables (n = 101 at primary end point; n = 93 at 2 years).

Materials and methods: Logistic regression identified predictors of health care consumption events (HCEs), that is, emergency department visits, hospitalization, surgical retreatment, and SE across the study population. Incidence was compared between the treatment groups with Kaplan-Meier survival analysis.

Results: At 2 years, residual stone volume was significantly associated with both HCEs and SE. For every 100 mm³ increase in residual stone volume, the HCE risk increased by 50% to 54%, and the SE risk increased by 70%. Stone-free rate, the number of residual fragments (RFs), and RF total stone burden (based on diameter) were not predictors. Significantly fewer HCEs occurred in the SURE group (3 vs 20 events, p = 0.0004). Survival analysis confirmed this (4.3% vs 20%, log-rank p = 0.02), with a 73% risk reduction (hazard ratio 0.27, 95% Cl 0.09-0.80, p = 0.02). Fewer SE occurred in the SURE group, although not statistically significant. These subjects also had longer event-free survival.

Conclusion: High-quality volumetric analysis supports evaluation of stone removal therapies, as residual stone volume predicts HCEs and SE. SURE significantly reduces the downstream incidence and risk of HCEs compared with standard URS.

Purpose: Robotic-assisted urologic stone removal and any potential histopathological effects of this approach have not been well studied. Here we assess safety and user experience of the novel MONARCH™ Platform, Urology, in performing both robotic-assisted ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) within a preclinical setting, alongside conventional devices.

Materials and methods: Two endourologists conducted six simulated robotic-assisted URS and six robotic-assisted PCNL in a porcine model, comparing these with conventional approaches. The primary objectives were (1) perceived ease of completion as rated by the endourologists using a numerical 1-4 rating scale; (2) occurrence of adverse safety events as determined by the operating endourologists; (3) assessment of contrast extravasation seen on post-operative retrograde pyelogram; and (4) histopathological evaluation of the porcine models' urinary tracts. Mantel-Haenszel chi-square test was used, with p < 0.05 considered significant.

Results: Tasks within URS and PCNL exhibited comparable ease of completion score means (median of all scores 4 in conventional URS and 4 in robot-assisted URS, p = 0.131; 3.17 in conventional PCNL and 4 in robot-assisted PCNL, p = 0.258). No safety events were observed by the endourologist during URS or PCNL procedures for either the robotic-assisted or conventional devices. In post-procedure pyelograms, none of the robotic-assisted cohort had more than minimal contrast extravasation, statistically similar to conventional devices (URS: median [range]; conventional, 0 [0-2] vs. robotic-assisted, 0 [0-1], p = 0.337; and PCNL: conventional, 0 [0-2] vs. robotic-assisted, 0 [0-1], p = 0.379). Blinded pathology assessment demonstrated no biologically significant nor clinically relevant differences between robotic-assisted and conventional devices in any category.

Conclusions: This study demonstrates that the MONARCH™ Platform in Urology has a safety profile comparable with conventional devices and a trend of easier completion of some tasks. This foundational study establishes the feasibility of a single platform to complete both robotic-assisted URS and PCNL, as a new treatment paradigm for urologic stone management.

Introduction: Patients with ureteral stones and concurrent urinary tract infections (UTIs) are at risk of developing sepsis and warrant urgent urinary drainage. However, in the absence of overt signs of infection, antibiotics are unlikely to be beneficial. Patients without infection may be discharged from the emergency department (ED) with unnecessary empiric antibiotics, promoting antimicrobial resistance. This research evaluated trends in antibiotic use for kidney stone patients discharged from EDs in the United States from 2015 to 2022.

Methods: National Hospital Ambulatory Medical Care Survey data were scaled to national estimates. Concurrent infection was defined by International Classification of Diseases, Tenth Revision, codes for sepsis or UTI. Antibiotic use trends were estimated via logistic regressions on the date of the encounter; an interaction term accounted for an observed inflection point in antibiotic use in 2020.

Results: A total of 9,651,950 patients presented with kidney stones to the ED and were discharged the same day, including 12% with ICD-coded concurrent infection. Seventeen percent received a prescription at discharge. Among patients without infection, 18% received antibiotics. From 2015 to 2019, antibiotic use declined from 28% to 16% of encounters (annual odds ratio [OR] = 0.82, p = 0.006). However, this trend ended in 2020, and antibiotics were given in 32% of encounters by 2022. Antibiotic use was more common in females (OR = 2.24), those aged 65-74 (OR = 5.24), and patients with concurrent infection (OR = 11.15), all p < 0.01. Among those receiving antibiotics, the most common classes were cephalosporins (49%), fluoroquinolones (32%), and sulfonamides (12%).

Conclusions: Antibiotics are commonly given to kidney stone patients, even in the absence of infection, and many patients with concurrent infection are discharged from the ED, rather than urgently drained or admitted for observation. These data suggest that antibiotics are frequently overused in the care of kidney stone patients in the ED, and the COVID-19 pandemic may have set back national efforts in antibiotic stewardship.

Introduction: Pyeloplasty is a common reconstructive procedure in urology, traditionally involving internal stenting to enhance drainage and healing. However, conventional Double-J (DJ) stents are associated with complications such as discomfort, infection, and migration.

Materials and methods: This prospective pilot study evaluates the feasibility and clinical outcomes of using the JFil® stent, an alternative designed for improved patient tolerance and reduced complications, in robot-assisted Anderson-Hynes pyeloplasty. Four patients underwent the procedure with intraoperative JFil® stent placement. Outcomes were assessed through follow-up imaging, renal function tests, and a stent-specific symptom questionnaire.

Results: Results showed no peri- or postoperative complications of Clavien-Dindo ≥ grade III and improved postoperative kidney function. The questionnaire scores indicated minimal postoperative discomfort.

Conclusion: While the study's small sample size limits generalizability, findings support the JFil® stent as a promising alternative in pyeloplasty. Further research with larger cohorts is recommended to validate these results.

Purpose: Robot-assisted nephrectomy and inferior vena cava (IVC) thrombectomy are technically demanding and high-risk procedures. The role of multidisciplinary team (MDT) management in robotic surgeries has not been reported previously. This study aimed to evaluate the safety and feasibility of MDT management in robot-assisted nephrectomy and IVC thrombectomy.

Patients and methods: We retrospectively analyzed 209 patients who underwent robot-assisted nephrectomy and IVC thrombectomy for renal tumor with venous tumor thrombus (Mayo levels I-IV) in our center between June 2013 and December 2023. Since July 2018, a proactive, comprehensive, and full-process MDT management framework has been implemented perioperatively. Patients were divided into MDT management (n = 142) and non-MDT management (n = 67) groups, with propensity score matching (1:1) resulting in 67 patients in each group. Multivariable regression, survival analyses, and interrupted time series analysis were conducted to assess perioperative outcomes and survival.

Results: All procedures were completed without conversion. MDT management significantly improved perioperative outcomes compared with the non-MDT group. Specifically, MDT reduced estimated blood loss (p = 0.045), intraoperative blood transfusion (p = 0.009), blood transfusion volume (p = 0.005), postoperative intensive care unit stay (p = 0.002), and postoperative hospital stay (p < 0.001). Multivariable regression confirmed that these improvements were independent of other factors. MDT management was associated with a significant improvement in overall survival (hazard ratio [HR] = 0.27, p = 0.023) and a potential benefit in progression-free survival (HR = 0.40, p = 0.065), as indicated by survival analysis.

Conclusions: MDT management in robot-assisted nephrectomy and IVC thrombectomy improves perioperative safety and enhances survival outcomes. This study highlights the critical role of the standardized MDT framework we proposed in optimizing high-risk robotic procedures.