Journal of endourology最新文献

Purpose: Precise and efficient application of force on tissue is a core competency of surgical practice, ingrained into surgeons' hands through years of training. To date, safe force thresholds have only begun to be evaluated for urologic tissues. We introduce The Science of Surgical Force, an emerging discipline within Urology, by conducting the first comprehensive synthesis of force-related data across urologic procedures. We aim to define force thresholds that inform safe practice, enhance surgical technique, and guide future innovation.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant scoping review was registered with International Prospective Register of Systematic Reviews and conducted using PubMed, Cochrane Library, and Scopus. Two independent reviewers screened studies evaluating surgical mechanical force applied to human GU. Data were categorized by organ, instrument, and procedure. Study quality and bias were assessed using the Newcastle-Ottawa Scale and Cochrane Risk-of-Bias tool.

Results: Among 4988 studies identified (1974-2024), only 36 met our Urology-focused inclusion criterion; these studies involved 741 patients and 46 ex vivo tissue specimens. Force data were reported for the fascia (n = 2), kidney (n = 5), prostate (n = 10), ureter (n = 9), urethra (n = 5), and vagina (n = 5). Ureteral studies identified 6-8 Newtons (N) as a safety threshold. Prostate studies focused on brachytherapy and cancer localization, with needle insertion forces ranging from 2 to 9 N depending on tissue type and needle gauge. Other organs showed wide variability and limited data. Only seven studies were randomized controlled trials; the mean quality score was 6.3, indicating an overall low level of quality among the force studies.

Conclusions: This is the first comprehensive review defining surgical force thresholds across urologic tissues to support integration of force-aware technologies into practice and education. Future work should focus on standardizing force application to improve outcomes, especially as force-sensing tools are developed and artificial intelligence-guided platforms become more widely available.

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.

Background and aim: Percutaneous radiofrequency ablation (RFA) is an increasingly adopted treatment for small solid renal masses. However, its safety and oncological effectiveness in complex renal cysts, classified as Bosniak III and IV, remain poorly characterized. We aimed to evaluate oncological outcomes and safety of RFA in patients with Bosniak III-IV cysts.

Methods: We retrospectively identified patients who underwent ultrasound-guided percutaneous RFA for Bosniak III-IV renal cysts at our institute between June 2017 and February 2025. Clinical, radiological, histological, and functional data were collected. Technical success was defined as the absence of enhancement on intra- and postprocedural contrast-enhanced ultrasound.

Results: Overall, 34 patients underwent RFA for 38 cT1a complex renal cysts (mean diameter 2.11 ± 0.7 cm): 8 (21.1%) were Bosniak III and 30 (78.9%) Bosniak IV. Two patients with Bosniak III cyst were subsequently excluded from oncological analyses because of benign or nondiagnostic histology report. Technical success was achieved in 100% of cases. Postprocedural laboratory values showed Δ creatinine 0.02 mg/dL (interquartile range [IQR]: 0.01-0.05; p = 0.001), Δ estimated glomerular filtration rate -0.80 mL/min/1.73 m² (IQR: -2.0-0.0; p = 0.001), and Δ hemoglobin -0.2 g/dL (IQR: -1.0-0.0; p = 0.001). Postprocedural complications were observed in 2/34 patients (5.8%), both involving hemorrhages, one of which required transarterial embolization (Clavien-Dindo grade III). At a median follow-up of 62.5 months (IQR: 18-72.5), local recurrence occurred in 2/32 patients (6.2%). No cases of systemic progression or cancer-specific mortality rate were observed.

Conclusion: Ultrasound-guided RFA appears to be a safe and feasible nephron-sparing option for the management of Bosniak III-IV renal cystic lesions in selected patients.

Objectives: The objective of this study is to characterize the impact of stone disease on sexual quality of life (QoL). As a secondary end point, we identified predictors of reduced sexual QoL to identify characteristics of stone patients who may benefit from sexual counseling.

Subjects/patients and methods: A multicentric cross-sectional study in eight centers across North America was carried out from July 2022 to March 2024. Patients with a history of kidney stones were recruited. Patients taking medication affecting erectile or ejaculatory function were excluded. Participants filled out the Wisconsin Quality of Life questionnaire to assess stone disease burden. Indicators of sexual QoL included the Sexual Distress Scale, the Global Measure of Sexual Satisfaction, and either the Male Sexual Health Questionnaire or Sexual Function Questionnaire to evaluate sexual function in men and women, respectively. We examined the impact of kidney stone events on indicators of sexual QoL.

Results: A total of 202 patients, including 70% (142/202) men and 30% (60/202) women, were recruited. The mean age was 53 (standard deviation [SD] 13) with men averaging 7 (SD 13) stone events and women 10 (SD 32). Men had good erectile (12/15) and ejaculatory (28/35) function. Women had low levels of sexual arousal (16/40), enjoyment (14/30), and orgasm (7/15). Men with worse erectile function demonstrated a significant association with increased frequency of kidney stone disease: 2-5 stone events (β = 2.95, CI [0.92-4.98], p = 0.005), 6-10 events (2.64 [0.64-5.22], p = 0.045), and more than 10 events (3.75 [0.80-6.70], p = 0.014). Both men (28/35) and women (25/35) had good sexual satisfaction and low sexual distress (5/20 and 6/20), respectively.

Conclusion: This is the first study investigating sexual QoL among kidney stone formers. Both men and women had good satisfaction and low distress. Women had low sexual desire and arousal outcomes. Urologists may help in screening for these forms of dysfunction upon the diagnosis of kidney stones to better address their needs. Men reported worse erectile function with an increase in stone burden; however, this association may not be causal.

Purpose: Obstructing ureteral stones with urinary tract infection (UTI) represent a urological emergency requiring prompt decompression to prevent sepsis-related morbidity and mortality. Although percutaneous nephrostomy (PCN) is a widely used drainage method, the optimal timing for its insertion remains unclear. This study explored the association between the timing of PCN insertion and clinical outcomes.

Patients and methods: A retrospective review of 744 patients who underwent PCN insertion for ureteral stones and UTI between 2011 and 2023. Patients were grouped by time-to-drainage from emergency department arrival: Immediate (<6 hours, n = 241), early (6-24 hours, n = 232), and delayed (>24 hours, n = 271). Infectious status was assessed at presentation, before, and after PCN insertion. Primary outcomes were sepsis, septic shock, and intensive care unit (ICU) admission rates. Multivariable analysis identified predictors of non-immediate drainage.

Results: In the immediate drainage group, sepsis rate decreased following PCN insertion (61.4% pre-PCN vs 45.2% post-PCN, p = 0.03), whereas septic-shock rates remained unchanged (23.7% vs 23.2%, p = 0.6). In the early drainage group, sepsis remained unchanged (59.1% vs 59.5%, p = 0.11) after PCN insertion, whereas septic shock increased (12.9% vs 31%, p < 0.001). A similar pattern was observed in the delayed group, with unchanged sepsis (38.7% vs 36.9%, p = 0.14) but increased septic shock rates (7% vs.15.5%, p = 0.001) following PCN insertion. Immediate drainage was associated with shorter hospitalization, fewer ICU admissions, and earlier stone treatment (all p < 0.001). Predictors of non-immediate drainage included night-shift arrival (odds ratio [OR]: 4.846, p < 0.001), female gender (OR: 1.917, p = 0.002), elevated creatinine (OR: 1.262, p = 0.011), and older age (OR: 1.009, p = 0.018).

Conclusion: Decompression with PCN within 6 hours is associated with significantly improved infectious and clinical outcomes in patients with obstructed, infected kidneys caused by ureteral stones.

Objective: Pyeloplasty is the gold standard procedure for treating ureteropelvic junction obstruction (UPJO), but the occurrence of postoperative complications is a major challenge. This study aimed to identify the predictors of postpyeloplasty complications, which are not well characterized in contemporary literature.

Study design: We retrospectively analyzed data of children who underwent pyeloplasty in our hospital from January 2011 to August 2022, with a minimum follow-up of 1 year. Furthermore, a systematic review and meta-analysis of studies published from 2000 to 2023 was performed to identify predictors of complications.

Results: In cohort studies (n = 555), preoperative urinary tract infection (pre-UTI) (odds ratio [OR] = 5.65, 95% confidence interval [CI]: 2.96-10.78, p < 0.001), Double J-stent duration (OR = 1.005, 95% CI: 1.001-1.008, p = 0.005), renal cortical thickness (OR = 0.181, 95% CI: 0.071-0.461, p < 0.001), and collection system separation (OR = 1.170, 95% CI: 1.017-1.347, p = 0.028) were associated with total postoperative complications. Pre-UTI (OR = 4.87, 95% CI: 1.98-11.98, p = 0.001), Double J-stent duration (OR = 1.005, 95% CI: 1.001-1.009, p = 0.019), preoperative renal cortical thickness (OR = 0.197, 95% CI: 0.042-0.928, p = 0.040), and duration of operation (OR = 1.013, 95% CI: 1.003-1.022, p = 0.008) were associated with recurrence. Pre-UTI (OR = 5.33, 95% CI: 2.73-10.38, p < 0.001) and preoperative renal cortical thickness (OR = 0.351, 95% CI: 0.124-0.990, p = 0.048) were predictors of postoperative UTI. In the meta-analysis, sex (I² = 0%, relative risk [RR] = 1.19, 95% CI: 1.01-1.40, p = 0.04), operation methods, and split renal function (I² = 50%, RR = 0.76, 95% CI: 0.59-0.96, p = 0.02) were identified as predictors of postoperative complications.

Conclusions: We identified the predictors of postpyeloplasty complications. Early identification and treatment can help us reduce the incidence of complications.

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.

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.