Journal of endourology最新文献

Purpose: To evaluate outcomes after water vapor thermal therapy (WVTT) for benign prostatic hyperplasia (BPH), stratified by varying degrees of median lobe (ML) protrusion.

Patients and methods: We enrolled men aged ≥45 years with BPH who underwent WVTT from July 2020 to September 2023. Inclusion criteria were an estimated prostate volume of 30-80 cc, International Prostate Symptom Score (IPSS) ≥12, and maximum urinary flow rate <16 mL/sec. ML protrusion was assessed using ultrasound (with bladder volume ≥250 cc) and flexible cystoscopy; the average of both measurements was used to classify ML protrusion into <5 mm, 5-10 mm, and >10 mm. Primary outcomes included postoperative complications such as surgical retreatment, acute urinary retention (AUR), and urinary tract infections (UTIs).

Results: With a median follow-up of 29.1 months (range: 24-36), improvements in lower urinary tract symptoms (LUTS) were similar across all groups, with consistent symptom reduction (Δ = -13) in both obstructive and irritative IPSS components. Rates of AUR and UTIs showed no significant variation across groups: AUR (no ML 9.5%; <5 mm 8.7%; 5-10 mm 12%; >10 mm 17%; p = 0.7) and UTI (no ML 8.4%; <5 mm 4.3%; 5-10 mm 9.3%; >10 mm 8.3%; p = 0.8). Despite comparable preoperative characteristics, surgical retreatment rates varied significantly with ML protrusion: no ML (3.2%), <5 mm (4.3%), 5-10 mm (14%), and >10 mm (21%) (p = 0.007), highlighting increased retreatment risk associated with greater ML protrusion.

Conclusions: WVTT effectively relieves LUTS across all ML configurations. However, patients with greater ML protrusion may face a higher risk of retreatment, likely because of increased bladder neck and urethral involvement. These findings suggest that detailed ML assessment can aid in patient counseling and stratification.

Background: The flexible and navigable suction sheath (FANS) is designed for the effective treatment of renal stones of various sizes. This study aimed to assess and compare the safety and postoperative outcomes at 30 days following FANS treatment for stones smaller and larger than 20 mm.

Materials and methods: From January to December 2024, patients undergoing retrograde intrarenal surgery performed with FANS were prospectively recruited and divided into two groups based on stone diameter (Group 1: DMAX <20 mm, Group 2: DMAX ≥20 mm). Baseline, perioperative, and follow-up characteristics were analyzed. Stone-free rate (SFR) was evaluated with a non-contrast CT scan at 1-month. Statistical analysis was performed using the unpaired Student's t-test and chi-squared test with Yates' correction.

Results: A total of 140 patients were enrolled, with 77 having stones <20 mm and 63 having stones ≥20 mm. While a significant difference in stone diameters was observed, no discrepancies were noted regarding the mean stone density between the two groups, thus minimizing the potential for bias. No major Clavien-Dindo complications occurred in either group without differences in hospital length of stay, but Group 1 reported lower visual analogue scale pain. No significant differences in Grade A, B, and C SFR (all p > 0.05) and re-intervention (p = 0.58) were observed, suggesting similar efficacy for both stone sizes.

Conclusions: This study demonstrates that the FANS as a valuable tool for enhancing patient safety and outcomes in managing larger stones, achieving adequate SFR, and reducing the need for re-intervention without major complications. In the future, FANS may effectively change the indications for stone's treatment according to diameter.

Introduction and objective: Percutaneous nephrolithotomy percutaneous nephrostomy (PCNL) is a minimally invasive procedure for kidney stone removal traditionally guided by fluoroscopy. This study aimed to evaluate the feasibility and outcomes of radiation-free PCNL using ultrasonography alone compared with standard fluoroscopy-guided PCNL.

Methods: A total of 63 PCNL cases were eligible for radiation-free PCNL, but 27 were excluded (intraoperatively aborted, ureteroscopy performed instead, preoperative complex anatomy). Of the remaining 36 cases eligible for radiation-free PCNL, 11 were converted intraoperatively to fluoroscopic-based PCNL. Postoperative computed tomography (CT) imaging was available for only 16 of the 25 radiation-free PCNL cases and 4 of the 11 converted cases. We designated these 16 prospective radiation-free PCNL cases (2024-2025) as Group A. For comparison purposes, we identified a historical case-matched cohort of 150 PCNLs. Of these, 67 were excluded (similar reasons), leaving 83 retrospective fluoroscopy-guided PCNL cases (2022-2024) called Group B. A subset of Group A cases was converted from radiation-free intraoperatively to fluoroscopy and were designated as Group C. The primary outcome was stone-free rate (SFR), assessed postoperatively by noncontrast CT (2-3 mm slices). Secondary outcomes included estimated blood loss, complication rates (Clavien-Dindo), and postoperative stone events.

Results: The median preoperative stone burden was 35 mm in Group A and 27 mm in Groups B and C [p = 0.3]. SFR (Grade A) was comparable across Groups A, B, and C [38%, 30%, and 25%, respectively (p = 0.8)]. No differences were observed in complications or secondary outcomes.

Conclusions: Radiation-free PCNL is feasible and yields comparable outcomes to standard fluoroscopy-guided PCNL, offering a promising method to reduce radiation exposure without compromising surgical success. However, we identified a consistent theme of poor visualization that prompted conversion to fluoroscopy for some of the cases. Innovation directed toward improving tool echogenicity is key to diffusing this technique.

Background: Renal stones in anomalous kidneys pose surgical challenges due to altered anatomy. Miniaturized percutaneous nephrolithotomy (mini-PCNL) reduces morbidity, but concerns remain about stone-free rates (SFRs) and infection. Suction-assisted mini-PCNL (SM-PCNL) enhances fragment removal and controls intrarenal pressure, but its role in anomalous kidneys is unclear.

Objective: To evaluate perioperative outcomes of SM-PCNL in anomalous kidneys in a multicenter, real-world study and assess variations based on positioning, lithotripsy modality, and renal anomalies.

Methodology: This prospective study across 15 centers (January-December 2024) included 287 adults undergoing SM-PCNL for renal stones in anomalous kidneys. Patients with normal anatomy, non-suction PCNL, or incomplete data were excluded. SFR was assessed via a 30-day non-contrast CT: 100% stone-free (Grade A), residual fragments ≤4 mm (Grade B), or >4 mm/multiple (Grade C, requiring reintervention).

Results: Malrotation (65.5%) was the most common anomaly, followed by duplex systems (25.1%), horseshoe kidneys (8.4%), and ectopic kidneys (1.0%). Median stone size was 1.7 cm. Supine positioning was used in 54.4%. Lithotripsy was performed with holmium laser (50.9%), thulium fiber laser (11.1%), or pneumatic lithotripsy (26.1%). Intraoperative clearance was 95.4%. At 30 days, 93.4% achieved Grade A, 5.6% Grade B, and 1.0% required reintervention. Complications were low; 0.7% had sepsis requiring intensive care unit admission. No transfusions or pleural injuries occurred.

Conclusion: SM-PCNL using 18F suction sheaths with laser in a single stage achieved 93.4% complete SFR with negligible complications and minimal reintervention.

Purpose: To report the first multicentric comparison between Hugo™ robot-assisted surgery/system (RAS) and Da Vinci® Xi for robot-assisted partial nephrectomy (RAPN).

Methods: Between October 2022 and March 2024, a total of 258 patients underwent off-clamp RAPN (Hugo RAS = 52 patients, and Da Vinci = 206 patients). Da Vinci and Hugo cases were matched in a 1:1 ratio using propensity score matching (PSM), adjusting for the Radius Exophytic Nearness Anterior Location score and renorrhaphy technique. Trifecta was defined as the coexistence of negative surgical margin status, no Clavien-Dindo grade ≥ 3 complications, and ≤ 30% estimated glomerular filtration rate (eGFR) reduction at discharge.

Results: After 1:1 PSM, two comparable populations of 52 patients each were selected. No intraoperative blood transfusion occurred in any group. The Hugo cohort displayed a higher rate of postoperative transfusions (7.7% vs 0%, p = 0.04). Nevertheless, perioperative complications were comparable (p = 0.32). The median length of stay (LOS) was shorter in the Da Vinci group (2 days vs 3 days, p < 0.001), as for median eGFR at discharge (74.5 mL/min/1.73m² vs 87.3 mL/min/1.73m², p = 0.03). No significant difference in positive surgical margins was shown between the two groups (p = 0.08). Finally, a comparable Trifecta rate was achieved for both platforms (88.5% in the Hugo RAS group and 90.4% in the Da Vinci group, p = 0.75).

Conclusions: Despite the hierarchical role of Da Vinci in the robotic surgical landscape, RAPN can be safely carried out with the new Hugo RAS System, with satisfactory perioperative surgical outcomes comparable to the Da Vinci Xi System.

Introduction: This study aimed to evaluate the feasibility and safety of patients undergoing holmium laser enucleation of prostate (HoLEP), under transurethral intraprostatic anesthesia (TUIA) using Schelin Catheter (SC) and sedoanalgesia.

Materials and methods: We retrospectively analyzed data of patients affected by benign prostatic obstruction candidate to HoLEP under TUIA using SC, from November 2023 to May 2024.

Results: A total of 50 patients were enrolled, median age 67 years; 14% were ASA ≥ 3, 2% and 22% had anticoagulation and antiplatelet drug therapy; 60% received alpha blockers, and 22% had both alpha blockers and 5α-reductase inhibitors; and 18% with an indwelling catheter. Preoperative median International Prostate Symptom Score (IPSS) and IPSS-quality of life (IPSS-QoL) were 16 (IQR: 11-21) and 4 (IQR: 4-6), median Qmax 10 mL/sec (IQR 3-19), median postvoid residual (PVR) 79 mL (IQR: 0-500). The median prostate volume was 50 mL (IQR 41-70 cc). Median preoperative Prostate Specific Antigen (PSA) was 1,70 (IQR 1,1-2,95). A prostate volume ≥ 80 mL was present in 10% of patients. The median enucleation time was 13,6 minutes (IQR 11,15-21,45) and the median morcellation time was 8,3 minutes (IQR 4,2-10,8). The median enucleated weight was 33 g (IQR 19,50-50). Median pain numeric rating scale before surgical procedure, at SC insertion, during enucleation, during morcellation, 2-hours postoperatively, on day 1 and 2 were 1 (0-3), 5 (2-6), 5 (3-7), 7 (5-10), 2 (1-4), 2 (1-4), and 3 (2-6). During enucleation, 10% required to start the target-controlled infusion with propofol. During morcellation, a half needs to get started propofol administration. The catheter was removed within 2 days in 100% of patients, and all were discharged within 48 hours. IPSS, IPSS-QoL, Qmax, and PVR showed significant improvement at 3 months.

Conclusions: TUIA with sedoanalgesia in HoLEP of small/medium prostate volume offers good pain control, preserving the significant improvement of postoperative outcomes.

Introduction: Prophylactic ureteral catheterization (PUC) is routinely performed during non-urologic procedures to avoid iatrogenic ureteral injury. However, evidence of its benefit is conflicting, as data suggest that the rate of ureteral injury is unchanged and there is lack of data reporting associated complications. The purpose of this study was to evaluate the outcomes of routine PUC in non-urologic surgeries.

Methods: All consecutive patients who underwent PUC during non-urologic procedures between January 2019 and March 2024 were reviewed. Demographic, clinical, and perioperative characteristics, including ureteral injury rates, were reviewed. Complications within 90 days were divided into low-grade (urinary tract infection [UTI], gross hematuria, and flank pain) and high-grade (new or worsening hydronephrosis and need for nephrostomy or indwelling stent). Logistic regression was performed to identify predictors of PUC-related complications.

Results: Among 233 patients, 63.5% were female. Median age and body mass index were 57 years and 28, respectively. Patient history included neoadjuvant chemotherapy in 54 (23%), pelvic radiation in 43 (18%), and pelvic surgery in 119 (51%). Surgery types included colorectal (75.1%), gynecological (14.2%), or both (10.7%). A total of 101 urologic complications affected 43% of patients, including UTI (22.3%), gross hematuria (24.4%), flank pain (10.7%), new/worsening hydronephrosis (9.9%), and need for nephrostomy tube/stent (1.3%). Intraoperative ureteral injury rate was 3.9%. On multivariate analysis, prior pelvic radiation was significantly associated with the occurrence of high-grade complications (odds ratio 3.29, 95% CI 1.04, 10.43).

Conclusion: PUC during non-urologic procedures is associated with a small but significant risk of urologic complications and does not eliminate the risk of ureteral injury. Prior pelvic radiation is a significant risk factor for PUC-related complications.

Objective: To develop an interpretable machine learning (ML) model for predicting surgical outcomes in renal hilar tumors and propose a hilar-specific anatomical nephrometry scoring system.

Methods: A total of 414 patients with renal hilar tumors who underwent robot-assisted partial nephrectomy (RAPN) were included in this study, comprising 304 patients from the First Affiliated Hospital of Nanchang University and 110 patients from the Second Affiliated Hospital of Nanchang University, which served as the external validation cohort. To identify predictors of trifecta achievement, we used least absolute shrinkage and selection operator regression and the Boruta algorithm, followed by multivariate logistic regression to identify independent factors. Five ML models were developed and evaluated using receiver operating characteristic curves, calibration plots, decision curve analysis, and precision-recall curves. The generalizability of the model was further validated in external cohort. Finally, we used SHapley Additive exPlanations (SHAP) to interpret the contribution of each predictor and enhance the model's explainability. Furthermore, based on anatomical features identified through logistic regression, we developed a modified nephrometry scoring system and compared its risk stratification performance with the traditional R.E.N.A.L. (i.e., Radius, Exophytic or endophytic, Nearness, Anterior or posterior, and Location) scoring system.

Results: Among the 304 patients in the primary cohort, 168 achieved trifecta outcomes. Eight variables were incorporated into the predictive model, with logistic regression model ultimately being selected as the optimal predictive model. It showed robust predictive performance in internal and external validation. SHAP methods identified surgeon, classification of hilar tumor, and radius as the three most significant predictive variables. Compared with the traditional R.E.N.A.L. score, the modified R.E.N.A.L. score demonstrated superior stratification ability for operation time, change in serum creatinine, change in estimated glomerular filtration rate, and trifecta achievement.

Conclusion: The interpretable ML model accurately predicts trifecta in RAPN for hilar tumors. The modified R.E.N.A.L. score provides refined anatomical stratification and facilitates individualized surgical planning.

Urologists face a significant challenge when presented with cases in which complete, yet reversible, urinary diversion is desirable. With multidisciplinary collaboration, we have used a novel technique involving the antegrade deployment of distally-ligated covered metal (Allium®) ureteral stents, achieving ureteral occlusion and complete urinary diversion via nephrostomy tubes. We have used this technique, with good early results, in complex cases, including that of a young male patient with complex pelvic injuries after polytrauma and a female patient with a malignant vesicovaginal fistula, neither of whom were candidates for definitive surgical reconstruction or diversion at the time of treatment. We describe our experience, which we believe may be of interest to urologists and interventional radiologists managing similarly challenging cases.

Purpose: Percutaneous nephrolithotomy (PCNL) is the gold standard for treating kidney stones >20 mm because of its superior stone-free rates (SFR). However, high-power holmium lasers may challenge this standard. This study evaluates the feasibility, safety, and efficacy of high-power holmium laser retrograde intrarenal surgery (RIRS) for the treatment of kidney stones >20 mm.

Methods: We conducted a retrospective analysis of patients with kidney stones >20 mm treated with either 80W- or 120 W holmium laser RIRS between January 2020 and August 2024. Clinical, intraoperative, and postoperative data were collected. Outcomes included SFR, operative time, complications, and hospital stay. Comparisons between the older-generation (80 W) and newer-generation (120 W) systems were performed using the Mann-Whitney U test and chi-square test, and multivariable analyses identified predictors of non-stone-free status.

Results: A total of 118 patients were included: 31 in the older-generation (80 W) group and 87 in the newer-generation (120 W) group. RIRS using the newer-generation 120 W laser was associated with a shorter operative time (66 vs 79 minutes, p < 0.001) and higher SFR at 5 weeks (82.7% vs 58.1%, p = 0.006), 6 months (92% vs 64.5%, p < 0.001), and 1 year (96.5% vs 83.8%, p = 0.016) postoperative evaluations. Complication rates did not differ significantly between groups (5.7% vs 3.2%, p = 0.208). In multivariable analysis, the use of older-generation 80 W laser was an independent predictor of non-stone-free status at both the first (OR 4.4, p = 0.004) and second (OR 8.8, p = 0.001) follow-up visits.

Conclusions: Treatment of renal stones larger than 2 cm with the newer-generation 120 W Ho:YAG laser is effective, with higher SFR rate and shorter operative time, compared to the older-generation 80 W Ho:YAG laser.