Journal of endourology最新文献

Background: Ureteroscopy (URS) is a widely utilised procedure for the management of urinary stones, though failed access due to ureteric orifice tightness or spasms can be a potential outcome. Silodosin, an alpha-1A adrenergic receptor antagonist, has shown promise in recent randomized controlled trials (RCTs) in improving URS outcomes by relaxing ureteric smooth muscle.

Objective: This systematic review and meta-analysis aims to determine whether preoperative administration of silodosin enhances ureteroscopy outcomes, including ureteral access rates, operative time, complication rates, and stone-free rates.

Methods: After PROSPERO registration, a comprehensive search of PubMed, EMBASE, and the Cochrane Library was conducted for randomized controlled trials (RCTs) comparing silodosin with placebo or no medication before URS. Data extraction and bias assessment were performed independently by two reviewers. Statistical analysis was undertaken by Review Manager V5.4, employing random-effects models for heterogeneous variables.

Results: Eight RCTs with a total of 892 patients (416 in the silodosin group and 476 in the control group) met the inclusion criteria. Silodosin significantly reduced operative time by 15.74 minutes (p < 0.00001). The access rate was higher in the silodosin group (96.9%) compared to the control group (87.2%)(p = 0.0004). Total complication rates were lower in the silodosin group (14.39% vs. 27.47%, p < 0.00001), as were moderate to significant complications (5.0% vs. 11.7%, p = 0.003). Stone-free rates were also higher in the silodosin group (92.16% vs. 81.5%, p < 0.0001).

Conclusion: Preoperative administration of silodosin significantly improves URS outcomes by reducing operative time, increasing access rates, decreasing complication rates, and enhancing stone-free rates. These findings support the integration of silodosin into clinical practice guidelines for URS, potentially improving procedural efficiency and patient outcomes.

Introduction: Percutaneous nephrolithotomy (PCNL) remains the gold standard treatment for patients with complete staghorn stones, for which multiple access tracts may be required. In this study, we describe a series of patients undergoing PCNL with a minimum of five dilated access tracts. Materials and Methods: We performed a multi-institutional retrospective review of 10 patients with complete staghorn stones who underwent PCNL requiring five or more access tracts. We recorded patient demographics, stone characteristics postoperative complications, and stone-free rates (SFRs). The primary endpoint was any postoperative complication. Secondary endpoints included SFR, operative time, and length of stay. SFR was defined as absence of stones or residual fragments <4 mm. Results: A total of 10 patients from two institutions were included. Access tract number ranged from 5 to 11, and median stone volume was 233,042 mm³. Seven patients (70%) experienced postoperative complications, ranging from Clavien II to IVa. Three patients (30%) required blood transfusions. Median operative time was 312 minutes ranging from 180 to 560 minutes. Five patients (50%) were stone-free after the initial procedure. Of those with residual fragments, 4 (40%) required reoperation to be rendered stone-free. Median length of stay was 2.5 days, with a range of 1-6 days. Conclusion: To our knowledge, this is the largest series of patients undergoing PCNL with five or more access tracts reported to date. This study confirms that PCNL with five or more tracts is feasible and relatively safe, albeit with a high rate of complications in the immediate postoperative period.

Aim: To describe the operative technique and outcome of one trocar-assisted retroperitoneoscopic ureteroureterostomy (OTAU) in 40 cases of complete ureteral duplication in children. Patients and Methods: From September 2016 to December 2020, 40 patients (12 male and 28 female) less than 10 years of age underwent OTAU. A transverse skin incision of 12 mm in length was created approximately 1 cm above the iliac crest. Muscle was spared and retracted with stay sutures to expose the retroperitoneal space. Subsequently, a balloon trocar was then inserted, and pneumoperitoneum was achieved. A 10 mm operating laparoscope (Stema, Germany) with a Maryland was used to dissect and isolate the ureters from surrounding tissues. The ureters were then exteriorized and end-to-side ureteroureterostomy was performed using Polydioxanone (PDS) 6/0 running sutures. Patient's demographic, operative, and follow-up data were collected prospectively. Results: The mean age of patients was 25.2 months (range: 1-105 months). The mean operating time was 81.9 ± 11.3 minutes. There were no intraoperative conversions or complications. After a median follow-up time of 47.5 months, the differential renal function of the pathological upper pole moiety (UPM) was preserved in all patients. Ultrasound revealed a significant reduction in UPM's renal pelvis anterior-posterior diameter from 19.6 ± 9.1 mm preoperatively to 11.1 ± 6.7 mm postoperatively (p < 0.05), accompanied by a reduction in ureter's diameter from 10.8 ± 4.4 mm to 4.8 ± 1.2 mm (p < 0.05). Overall, all 32 patients with preoperative symptoms experienced complete symptom resolution. Conclusion: OTAU is a safe and feasible approach that yields excellent outcomes for complete ureteral duplication.

Introduction: We aimed to develop machine learning (ML) algorithms for the automated prediction of postoperative ureteroscopy outcomes for pediatric kidney stones based on preoperative characteristics. Materials and Methods: Data from pediatric patients who underwent ureteroscopy for stone treatment by a single experienced surgeon, between 2010 and 2023 in Southampton General Hospital, were retrospectively collected. Fifteen ML classification algorithms were used to investigate correlations between preoperative characteristics and postoperative outcomes: primary stone-free status (SFS, defined as stone fragments <2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments >2 mm at Xray kidney-ureters-bladder (XR KUB) or ultrasound kidney-ureters-bladder (US KUB) at 3 months follow-up) and complications. For the task of complication and stone status, an ensemble model was made out of Bagging classifier, Extra Trees classifier, and linear discriminant analysis. Also, a multitask neural network was constructed for the simultaneous prediction of all postoperative characteristics. Finally, explainable artificial intelligence techniques were used to explain the prediction made by the best models. Results: The ensemble model produced the highest accuracy (90%) in predicting SFS, finding correlation with overall stone size (-0.205), presence of multiple stones (-0.127), and preoperative stenting (-0.102). Complications were predicted by Synthetic Minority Oversampling Technique (SMOTE) oversampled dataset (93.3% accuracy) with relation to preoperative positive urine culture (-0.060) and SFS (0.003). Training ML for the multitask model, accuracies of 83.3% and 80% were respectively reached. Conclusion: ML has a great potential of assisting health care research, with possibilities to investigate dataset at a higher level. With the aid of this intelligent tool, urologists can implement their practice and develop new strategies for outcome prediction and patient counseling and informed shared decision-making. Our model reached an excellent accuracy in predicting SFS and complications in the pediatric population, leading the way to the validation of patient-specific predictive tools.

Background: Urethral stricture disease is a common and at times unsatisfying condition that can lead to complications severely impacting a patient's quality of life. Open urethroplasty remains the gold standard treatment; however, it is an invasive and highly specialized procedure. Strictures between 2 to 4 cm in length have been shown to recur at a rate of 50% within 12 months, a rate that typically decreases with each subsequent treatment. The Laborie Optilume drug-coated balloon (DCB) is the first of its kind developed for adjunct treatment of urethral strictures in men. The DCB initially treats the stricture through balloon dilatation and subsequently aims to prevent recurrence via the localized application of Paclitaxel. Our study assesses the safety and efficacy of the DCB in an Australian population with strictures exceeding 2 cm who have undergone at least two prior procedures for urethral stricture disease.

Methods: Patients were prospectively recruited from November 2019 to September 2021. International prostate symptom score (IPSS), IPSS quality of life (QOL) and voiding parameters were collected at baseline, and again at 1, 6, 12 and 18 months. The drug coated balloon was applied by a single consultant urologist under rigid cystoscope with shallow direct vision internal urethrotomy with a cold knife prior to application of the DCB.

Results: 17 patients were recruited with an average of 7.7 prior urethral procedures for recurrent stricture disease. 76% were stricture free at 30 months follow-up. There were improvements in almost all parameters including max flow, average flow, IPSS and IPSS QOL scores at 12 and 24 months. There were no complications.

Conclusion: The DCB is a safe and effective method at reducing the rates of recurrence for high-risk stricture disease and can delay or prevent the need for urethroplasty in what remains a very challenging cohort of patients.

Introduction: Kidney stones in pregnant is not a common emergency, but it is one that is extremely challenging to manage. There exists no previous survey, which maps the different practice patterns adopted. Our aim was to deliver a survey to evaluate the current status of practice patterns across different parts of the world regarding the management of stone disease in pregnancy. Methods: Through an iterative process, 19-item survey was devised. This contained the following five sections: (1) Demographics, (2) General items, (3) Diagnosis and Imaging, (4) Initial management, (5) Surgery. It was disseminated via social media and email chains. Results: A total of 355 responses were collected, and the majority (66.2%) reported no established hospital protocol for stones in pregnancy. Ultrasound was the most popular first line imaging choice (89.9%) but 8% would choose non-contrast CT. The latter was also chosen as second line choicer in 34.6% as opposed to magnetic resonance imaging. A large proportion (42.5%) had requested CT in pregnancy previously. With equivocal ultra sound results, only 19.4% would proceed to ureteroscopy (URS) but 40.9% would opt for CT. Twenty-four-48 hours were the most popular (37.6%) time period to observe before surgical intervention. Ureteral stent and nephrostomy were regarded as equally effective, and 6 weeks was most popular frequency for an exchange. Most do not use fetal heart rate monitoring intraoperatively. A total of 3.94% had previously performed percutaneous nephrolithotomy during pregnancy. Conclusion: Practice patterns vary widely for suspected kidney stones in pregnancy and use of CT appears increasingly popular. This includes when faced with equivocal ultrasound results and instead of proceeding to ureteroscopy. Most hospitals lack an established management protocol for this scenario.

Objectives: The super-pulsed thulium fiber laser (SP TFL) is a new alternative to high-power holmium laser for intracorporeal lithotripsy. The SP TFL has shown advantages in dusting regimes, but benefits in fragmentation regimes are less understood. The second-generation SP TFL introduces an advanced fragmentation pulse (AFP) sequence to maximize SP TFL's efficiency in fragmentation. This study evaluates safety and efficacy of the SP TFL fragmentation mode in ureteroscopy (URS) and mini percutaneous nephrolithotomy (mini-PCNL). Materials and Methods: The study was conducted in two phases. Safety of a new AFP was compared ex vivo to standard SP TFL fragmentation settings by measuring the dimensions of wounds created in porcine kidney after laser exposure for 0.5, 1.0, and 2.0 s. The resulting wounds were evaluated histologically using nitro blue tetrazolium chloride (NBTC) stain. In the clinical phase, the second-generation SP TFL was used to fragment and extract ureteral and renal stones in 40 patients using ureteroscopic and percutaneous approaches. The stone size, volume, density, laser-on-time, and total energy were recorded for each patient. In addition, the chemical composition, ablation rate, and ablation efficiency were assessed for each stone treatment. Results: The ex vivo mucosa damage profiles caused by AFP were similar to those caused by regular pulses. In clinical phase, the median volume and density for ureteral stones were 0.4 cm³ and 1029 Hounsfield units (HU), for renal stones 1.3 cm³ and 1113 HU, respectively. Different stone types were crushed into fragments suitable for extraction. The mean AFP energy was 3 J and the average power for ureteral stones was 10.5 W, whereas for renal stones it was 28.5 J and 31 W, respectively. The overall complication rate was low in both groups. Conclusion: ST PFL with AFP capability facilitates effective fragmentation of ureteral and renal stones of any composition during URS and mini-PCNL with minimal complication rates.