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Özet Amaç: Bu çalışmada, kullanılan double- J (DJ) stent çapının, flexible üreteroskopik (fURS) böbrek taşı tedavisinin taşsızlık oranları ve postoperatif ağrı durumuna olası etkisini araştırdık. Gereç ve Yöntemler: Böbrek taşı nedeniyle fURS uygulanan toplam 104 hasta çalışmaya dahil edildi. Taş tedavisi sonrası 51 hastaya 4.7 Fr DJ stent takılırken, 53 hastaya 6 Fr stent takıldı. Postoperatif 3. ayda kontrastsız bilgisayarlı tomografi ile incelenen taşsızlık durumuna ek olarak, iki grubun genel ağrı semptomları, postoperatif ilk haftayı takiben uygulanan görsel ağrı skalası ile değerlendirildi. Başarı, taşların tamamen temizlenmesi veya küçük taş parçalarının (, Objective: This study’s main goal was to evaluate the possible impact of different-sized double-J (DJ) stents on the pain and stone-free status following flexible ureteroscopic laser disintegration (fURS) of renal stones. Material and Methods: A total of 104 patients who underwent fURS for kidney stones were included in our study. In 51 patients, a 4.7 Fr DJ stent was used after stone fragmentation, while in the remaining 53 cases, a 6 Fr stent was chosen. Between the two groups, general pain symptoms were evaluated using a visual pain scale at the end of the first postoperative week. The stone-free status was evaluated using non-contrast computed tomography (NCCT) after three months following surgery. Success was determined by either the complete clearance of the stones or the presence of small stone fragments (

Introduction and objectives Currently, there are no established criteria regarding treatment for lumbar ureteral stones. The objective of this work is to present our results in the endourological treatment of this pathology, analyzing the variables associated with the use of the flexible ureterorenoscope. Material and methods Retrospective review of 103 patients who underwent retrograde URS with semi-rigid or flexible ureterorenoscope. Proximal location: L2–L3. Medial location: L4–L5. Semirigid URS was the initial treatment, with conversion to flexible URS when it was required to complete the procedure. Success was defined as absence of residual fragments (6 weeks). Demographic, surgical, immediate postoperative variables, and those related to the stone, were analyzed. Their correlation with the use of the flexible ureterorenoscope was evaluated. Results Mean age: 57.2 years (SD 15.6); there were 73 men (70.9%). Stone size: 8 mm (range 4–30; IQR 4.5). Proximal location: 58 (56.3%). Previous JJ: 44.7%. Previous nephrostomy: 10.7%. Semirigid URS with conversion to flexible URS: 51 (49.5%). Impacted stones: 28.2%. Intraoperative complications: 2 (1.9%). Postoperative JJ: 84.5%. Immediate postoperative complications: 23 (22.3%) (Clavien-Dindo I–II: 91.3%). Postoperative ureteral stricture: 5.8%. Success: 88.4%. Residual fragments: 12 (11.7%). Spontaneous passage: 6 (50%). Greater performance of flexible URS in proximal ureteral stones (p = 0.001) of more than 11 mm (p = 0.02) in univariate analysis, and in proximal stones [OR 3.5; 1.5–8.1; p = 0.004] in multivariate analysis. Conclusions Endourological treatment obtained a high success rate in our sample. Size greater than 11 mm and proximal ureteral location in univariate and multivariate analysis, respectively, behaved as predictors of flexible URS.

Objectives: To determine which flexible ureterorenoscopy program would be most cost-efficient in our center, a cost efficiency analysis and a formula to assess cost efficiency feasibility of a hybr...

Purpose: This study aimed to investigate the effect of preoperative stenting (POS) on the perioperative outcomes of flexible ureterorenoscopy (fURS). Materials and Methods: A systematic review and meta-analysis was conducted based on the PRISMA statement. From the initially retrieved 609 reports, we excluded the ineligible studies at 2 stages. We only included studies that contained fURS patients with and without POS in the same report. Data of patients who underwent semirigid ureteroscope only were excluded from the analysis. The Newcastle-Ottawa Scale (NOS) system was applied for risk of bias assessment. Results: A total of 20 studies including 5,852 patients were involved. 48.5% of the patients had preoperative stent. Stone-free rate was significantly higher with prestenting; odds ratio (OR) was 1.98 (95% CI: 1.51–2.58) (Z = 5.02; p = 0.00001). It also displayed tendency toward lower complications; OR was 0.74 (95% CI: 0.52–1.05) (Z = 1.67; p = 0.09). POS significantly increased the use of ureteral access sheath; OR was 1.49 (95% CI: 1.05–2.13) (Z = 2.22; p = 0.03). Risk of bias assessment showed 13 and 7 studies with low and moderate risk, respectively. Conclusions: POS clearly improves the stone-free rates after fURS. It might reduce the complications, especially ureteral injury. These findings might help solve the current debate and can be useful for urologists during patient counselling for a proper decision-making.

Objective: Flexible ureterorenoscopy (fURS) is one of the standard treatments for renal calculi up to 20 mm. This study aims to identify factors associated with stone-free status. Materials and Methods: We included patients undergoing fURS for treatment of small to medium-size renal stone (no single stone larger than 20 mm) from April 2017 to September 2019 at King Chulalongkorn Memorial Hospital. All patients had a preoperative CT scan and postoperative imaging for comparison. We collected patient characteristics (sex, age, previous ipsilateral urinary tract surgery, preoperative ureteral stent placement), stone factors (total stone burden, stone number, stone density) and renal factors (anatomical abnormalities, stone location in a lower pole, number of caliceal involvement) and correlated the data against postoperative stone-free status (defined as residual fragment ≤ 2 mm). Results: The overall stone-free rate was 53.3%. From the univariate analysis, previous surgery, total stone burden, stone number, stone location in the lower pole, and the number of caliceal involvement were associated with stone-free status. However, only the total stone burden remained statistically significant in the multivariate analysis (p-value < 0.05). The stone-free rates were 75.9%, 57.1%, and 11.1% in the total stone burden ≤ 10 mm, 11-20 mm, > 20 mm, respectively. Conclusion: Following treatment of renal stones ≤ 20 mm with fURS, the stone-free rate was 53.3% and was significantly associated with the preoperative total stone burden.

OBJECTIVE To comparatively investigate the efficacy, safety and complications of flexible ureterorenoscopy (f-URS) in the treatment of patients of different age groups (

Introduction: Elevated intrarenal pressure (IRP) during flexible ureterorenoscopy (FURS) is a predictor of postoperative complications. The aim of this study is to evaluate IRP during FURS in a por...

Objective:The elderly population has been increasing due to extension in lifespan. Chronic comorbid disorders and medications render a recheck of the treatment modalities of urinary stones for this population. This study aimed to analyse the results of mini-percutaneous nephrolithotomy (PNL) and flexible ureterorenoscopy (F-URS), which are minimally invasive techniques for the treatment of kidney stones in elderly patients.Materials and Methods:Data of patients who are older than 65 years with 10-25-mm kidney stones and who underwent F-URS (n=51) and mini-PNL (n=33) between 2015 and 2019 were retrospectively studied. Demographic data, operative data and postoperative data were evaluated.Results:The mean age of group 1 (F-URS) was 71.5±6.4 and of group 2 (mini-PNL) 70.2±5.6 and the mean stone size was 16.1±3.8 mm for group 1 and 19.7±3.5 mm for group 2. The complete stone-free rate was similar in groups 1 and 2 at 1 month postoperatively (78.4% and 72.7%, respectively; p=0.549). Haemoglobin decrease and operation and hospitalisation time were found to be higher in group 2 (p=0.000, 0.0001, 0.002). Complication rates (transfusion-required haemorrhage, fever and colon perforation) were not statistically different between the two groups (p=0.8).Conclusion:In this study, although the stone-free rate in the F-URS and mini-PNL groups was similar, we believe that F-URS is a safer treatment method in elderly patients with 10-25-mm kidney stones than mini-PNL because of its shorter operation time and lower haemoglobin decrease.

Background To analyze the impact of metabolic syndrome on the safety and efficacy of flexible ureterorenoscopy (fURS) in managing kidney calculi. Methods We retrospectively analyzed the records of 151 patients who received fURS for the renal stones in our center between January 2014 and December 2016. The patients were divided into two groups based on whether they were diagnosed with metabolic syndrome. Information related to the patients, stones and surgeries were analyzed, and the stone-free rates (SFRs) and complications after fURS were reviewed. Results Group 1 consisted of patients with metabolic syndrome, and group 2 contained patients without metabolic syndrome. The mean stone size was 71.9±58.3 mm2 in group 1 and 64.9±43.7 mm2 in group 2 (P=0.399). The mean hospitalization and surgical durations were similar between both groups (P>0.05). The overall complication rates were 8.3% vs. 12.1% (P=0.514). The SFR at 3 months postoperative in group 1 was significantly lower than that in group 2 (80% vs. 92.3%, P Conclusions Our study results revealed that patients with metabolic syndrome can be treated safely with fURS. however, metabolic syndrome has a negative impact on the efficacy of fURS in the treatment of patients with kidney stone.

The effect of preoperative Double-J (DJ) ureteral stenting before flexible ureterorenoscopy (FURS) in the treatment for urinary stones was evaluated. We retrospectively enrolled 306 consecutive patients who underwent FURS from Jan. 2014 to Dec. 2017. All the patients were classified into two groups according to whether they had DJ ureteral stenting before FURS. Baseline characteristics (age, sex, stone location, stone size, surgical success rate, operation time, stone-free rate of the first day after surgery, stone-free rate of the first month after surgery, total complication rate) were compared using Chi-square test for categorical variables and Kruskal-Wallis test for continuous variables. In total, 306 patients were included in this study. The group of DJ stenting before FURS included 203 (66.3%) patients, and non-DJ stenting before FURS was observed in 103 (33.7%) patients. The group of DJ stenting before FURS was significantly associated with a shorter operation time (53.8 vs. 59.3 min, P

Background In ureterorenoscopy, anaesthesiologists are preferring regional anaesthesia to avoid postoperative complications, while surgeons are preferring general anaesthesia to avoid ureteral trauma. China has not published its guidelines and not referring to the European Association of Urology guidelines. The objectives of study were to evaluate the effects of general, spinal, and epidural anaesthesia on ureter access and surgical outcomes of ureterorenoscopy. Methods Charts of a total of 392 patients with the American Society of Anaesthesiologists grade I or II, and underwent flexible ureterorenoscopy for removal of the proximal, middle, or distal ureteral single stone under general anaesthesia (GA group; n = 145) or spinal anaesthesia (SA group; n = 131) or epidural anaesthesia (EA group; n = 116) were reviewed retrospectively. Results The dilatation time for patients of GA group was fewer than those of SA (104.01 ± 12.77 sec/patient vs. 130.55 ± 22.53 sec/patient, p

Purpose To compare the effect of general anesthesia (GA) and regional anesthesia (RA) on f-URS outcomes and surgeon comfort. Material and Methods The study was conducted between June 2017 to January 2018 and data collection was applied in a prospective, randomized fashion. 120 patients participated in the study and were divided into RA group (n=56) and GA group (n=64). Demographic, operative and post-operative parameters of patients were analysed. The end point of this study was the effect of two anesthesia regimens on the comfort of the surgeon, and the comparability of feasibility and safety against perioperative complications. Results The study including 120 randomized patients, 14 patients were excluded from the study and completed with 106 patients (45 in RA group and 61 in GA group). No difference was detected between the two groups in terms of preoperative data. During the monitorization of operative vital signs, 3 patients in RA group experienced bradycardia, and this finding was significant when compared with GA group (p=0.041). Additionally, 2 patients in RA group experienced mucosal tears and 1 patient experienced hemorrhage during the operation, but no complications were observed in the GA group (p=0.041). Postoperative surgeon comfort evaluation revealed statistically significant results in favor of GA group (p=0.001). Conclusions Both GA and RA are equally effective and safe anesthesia methods for f-URS procedures. However, RA group showed significantly increased likelihood of bradycardia and mucosal injury during surgery, and significantly decreased surgeon comfort during surgery.

Extracorporeal shockwave lithotripsy and especially flexible ureterorenoscopy (URS) are first-choice treatments of upper ureteral and renal pelvis stones. In our study, we aimed to demonstrate that the treatment of upper ureteral and renal pelvis stones smaller than 2 cm could be performed by semirigid URS under spinal anesthesia. The data of 292 patients were retrospectively analyzed. Stones were localized in upper ureter and renal pelvis in 191 (65.4%) and 101 (34.6%) patients, respectively. The stone-free rate was found to be 72.6%. The final stone-free rate was 95.2% after additional treatments administered to 80 patients with residues. While no peri-operative complication was observed, hematuria was observed in three patients during the post-operative period, high fever was observed in 27 patients and sepsis was observed in four patients. It is a well-known fact that flexible URS is the first-choice surgical method in the treatment of upper ureteral and renal pelvis stones. In the current study, we aimed to investigate whether laser lithotripsy with semirigid URS could also be a good and cheap alternative in clinical practice, and if upper urinary tract surgeries could be performed with spinal anesthesia especially in patients with a high risk of general anesthesia. Level of evidence

Purpose: The aim of the current systematic review and meta-analysis is to provide an answer on which is the most appropriate approach for the management of the lower pole stones with a maximal dimension of 2 cm or less. Materials and Methods: A systematic review was conducted on PubMed (R), SCOPUS (R), Cochrane and EMBASE (R). The PRISMA guidelines and the recommendations of the EAU Guidelines office were followed. Retrograde intrarenal surgery, shock wave lithotripsy and percutaneous nephrolithotomy were considered for comparison. The primary end point was the stone-free rate. Results: A total of 15 randomized controlled trials were eligible. Percutaneous nephrolithotripsy and retrograde intrarenal surgery have higher stone-free rates in comparison to shock wave lithotripsy and require fewer re-treatment sessions. Operative time and complications seem to favor shock wave lithotripsy in comparison to percutaneous nephrolithotripsy, but this takes place at the expense of multiple shock wave lithotripsy sessions. Retrograde intrarenal surgery seems to be the most efficient approach for the management of stones up to 1 cm in the lower pole. Conclusions: The pooled analysis of the eligible studies showed that the management of lower pole stones should probably be percutaneous nephrolithotripsy or retrograde intrarenal surgery to achieve stone-free status over a short period and minimal number of sessions. For stones smaller than 10 mm, retrograde intrarenal surgery is more efficient in comparison to shock wave lithotripsy. The decision between the 2 approaches (percutaneous nephrolithotripsy or retrograde intrarenal surgery) should be individual, based on the anatomical parameters, the comorbidity and the preferences of each patient.

To evaluate the efficacy and safety of mini percutaneous nephro-lithotripsy (mini PCNL) and retrograde intrarenal surgery (RIRS) in treatment of renal stones larger than 20mm in its longest diameter. Patients & Methods: In a prospective randomized study including 40 patients divided into two groups each 20 patient. Gathering An included 12 guys and 8 females with age went from 15 to 62 years had smaller than expected PCNL for renal pelvic and calyceal stones. Gathering B included 8 guys and 12 females with age extended from 18 to 65 years of age had RIRS. Adaptable ureteroscopy was utilized for pelvic and calyceal stones utilizing holmium:YAG laser (tidying approach). In the two gatherings the strategy result regarding Operative time, Blood misfortune, clinic remain, entanglements utilizing changed Clavien reviewing framework , the need of assistant systems , stone free rates following 3 weeks by utilizing CTUT, were assessed measurably. Measurable investigation of the information indicated that there was immaterial contrast between the {mean ± SD} of the BMI in patients of gathering A which was {27.850±3.183} kg/m2; while in patients of gathering B was {29.700±7.927} kg/m2 . With respect to measure, there was immaterial contrast between the {mean ± SD} of gathering A which was 2.57±0.22mm, while in bunch B was 2.6±0.24mm. With respect to usable time the {mean ± SD} of gathering A was 104.43±14.79 minutes which was altogether (P

Objective: To objectively assess the performance of graduating urology residents performing flexible ureterorenoscopy (fURS) using a simulation-based model and to set an entrustability standard or benchmark for use across the educational spectrum. Methods: Chief urology residents and attending endourologists performed a standardized fURS task (ureterorenoscopy and repositioning of stones) using a Boston Scientific© Lithovue ureteroscope on a Cook Medical© URS model. All performances were video-recorded and blindly scored by both endourology experts and crowd-workers (C-SATS) using the Ureteroscopic Global Rating Scale, plus an overall entrustability score. Validity evidence supporting the scores was collected and categorized. The Borderline Group (BG) method was used to set absolute performance standards for the expert and crowdsourced ratings. Results: A total of 44 participants (40 chief residents, 4 faculties) completed testing. Eighty-three percent of participants had performed >50 fURS cases at the time of the study. Only 47.7% (mean score 12.6/20) and 61.4% (mean score 12.4/20) of participants were deemed "entrustable" by experts and crowd-workers, respectively. The BG method produced entrustability benchmarks of 11.8/20 for experts and 11.4/20 for crowd-worker ratings, resulting in pass rates of 56.9% and 61.4%. Conclusion: Using absolute standard setting methods, benchmark scores were set to identify trainees who could safely carry out fURS in the simulated setting. Only 60% of residents in our cohort were rated as entrustable. These findings support the use of benchmarks to earlier identify trainees requiring remediation.

OBJECTIVE To describe a novel syphoning ureteric access sheath (UAS) intended for use during flexible ureterorenoscopy (URS). We aimed to assess if in vitro it could reduce intrarenal pressure (IRP) and increase irrigant flow compared to traditional UASs. MATERIALS AND METHODS A validated phantom kidney with fibre optic pressure sensing capabilities was used to assess the IRP. Standardised 80 cmH2 O irrigation via a ureterorenoscope was instilled through traditional UASs (11/13 and 12/14 F) and compared to the novel 11/13-F syphoning UAS. The measured minute volume, calculated hourly flow volume, and steady state IRP were compared. RESULTS The traditional 11/13 and 12/14-F UASs had statistically poorer irrigant flow than the novel syphoning UAS, at 19.3 vs 29.3 mL/min (P

espanolOBJETIVOS: El objetivo es determinar si la ureterolitectomia laparoscopica (UL) es una buena alternativa a la ureterorenoscopia flexible con litotricia (URSF) a traves de la comparacion de ambas tecnicas en lo que a coste y efectividad radica. METODOS: Analizamos 79 pacientes con litiasis ureterales proximales de mas de 1,5 cm que recibieron URSF o UL en relacion a coste-efectividad. Los datos recogidos incluyeron edad, IMC, tamano de la litiasis, tiempo de la cirugia, tiempo de hospitalizacion, complicaciones y tasa libres de litiasis a los 15 dias y 3 meses de la cirugia. Auditamos los costes de las URSF y UL y se compararon en relacion a coste-efectividad. RESULTADOS: No hubo diferencias estadisticamente significativas entre los grupos en relacion a la edad, IMC, tamano de la litiasis, tasa libre de litiasis a los 3 meses y complicaciones (p>0,05). Los tiempos quirurgicos fueron estadisticamente menores en URSF en comparacion a UL (61,5±24,3 min y 140,9±49,1 min, respectivamente, (pz0,05). La tasa libre de litiasis a los 15 dias fue mas baja en el grupo de URSF que UL (31 (81,6%) y 41 (100%), respectivamente, p Aunque la diferencia estadistica desaparece a los 3 meses (p>0,05). El coste medio de URSF y UL fue de $194,2 ± 12,4 y $ 179,2 ± 58,5, respectivamente (p CONCLUSION: URSF es igualmente efectiva que UL en terminos de tasa libre de litiasis. Los costes de URSF es mas alto que UL. URSF es la primera opcion en el tratamiento de litiasis de mas de 1 cm en ureter proximal. En caso de experiencia laparoscopica de alto nivel, UL puede sustituir a URSF, especialmente en casos dificiles. EnglishOBJECTIVES: We aimed to understand whether laparoscopic ureterolithotomy (LU) is a good alternative to flexible ureterorenoscopic lithotripsy (FURS) by comparing these techniques concerning cost-effectiveness. METHODS: We analysed 79 patients with upper ureteral stones larger than 1.5 cm underwent FURS or LU concerning cost-effectiveness analysis. The data including age, body mass index (BMI), stone size, operation time, hospitalisation time, complications and stone-free rates of 15th day and 3rd months. We audited the costs of FURS and LU and compared them concerning cost-effectiveness. Arch. Esp. Urol. 2021; 74 (6): 592-598 https://doi.org/10.37554/en-20201213-3423-7 ORIGINAL ARTICLE Keywords: Flexible ureterorenoscopy. Laparoscopic ureterolitotomy. Cost-effectiveness. Lithotripsy. RESULTS: There was not any statistically significant difference between the two groups with regard to age, BMI, stone size, stone-free rates at the 3rd month, and complication rates, (p>0.05). The operation times were statistically lower in the FURS than in the LU (61.5±24.3 min and 140.9±49.1 min, respectively, p However, this statistical difference disappears at 3 months (p>0.05). The mean costs of FURS and LU were $194.2±12.4 and $179.2±58.5, respectively (p CONCLUSION: FURS is equally effective to LU in terms of stone-free rates. The cost of FURS is higher statistically than LU. FURS is shown as the first choice for the upper ureteral stones larger than 10 mm in size, if the laparoscopic experience is in high-level situations in that clinic, LU may be a suitable alternative to FURS, especially for challenging cases

Background: Preoperative bladder urine culture (PBUC) analysis has become a standard application before any stone surgery. When growth is detected in PBUC, it is contraindicated to perform flexible ureterorenoscopy (f-URS). The results of the PBUC susceptibility test do not correlate well with those of the renal pelvic urine culture (RPUC) analysis. Previous studies have demonstrated the positivity of RPUC as an important marker for the development of infections after endoscopic operations. In the current study, we aimed to evaluate the consistency between PBUC and RPUC and to identify preoperative markers associated with a positive RPUC. Methods: Data from 129 patients who underwent f-URS on renal and proximal ureteral stones in two centers between 2015 and 2020 were prospectively recorded in a database and retrospectively analyzed. PBUC was obtained from all the patients preoperatively, and RPUC was taken at the beginning of the f-URS operation. The results of the two cultures were compared. Results: There was growth in PBUC in 25 (19.4%) patients and RPUC in 35 (27.1%) patients. Possible predictive markers in predicting a positive RPUC were evaluated using multivariate logistic regression analysis. Preoperative urine density at the renal pelvis [odds ratio (OR): 0.848, p

Aim: Percutaneous nephrolithotomy (PNL) and retrograde intrarenal surgery (RIRS) are common surgical methods in the treatment of kidney stones. Possible effects on kidneys are an important factor in determining the surgical procedure and the surgical method. In our study, kidney injury molecule-1 (KIM-1) and myo-inositol oxygenase (MIOX) were used to compare acute kidney injury in patients that underwent PNL and RIRS. Material and Method:Eighty patients aged 20 to 75, who underwent PNL or RIRS in our urology clinic between November 2018 and February 2020 were included in the study. In this prospective study, the demographic characteristics, stone size, operation time, preoperative and postoperative hemoglobin and biochemistry values of the patients were recorded. 5 cc blood samples taken from the patients before the operation and at the fourth hour after the operation were centrifuged and kept at -80 °C, and the KIM-1 and MIOX levels were measured in the biochemistry department. Results: There was no difference between the groups in terms of demographic data; however,the operation time and length of hospital stay were significantly longer in the PNL group. The mean increase in MIOX was 10.583±9.73 ng/ml and 7.501±16.46 ng/ml in the PNL and RIRS groups, respectively. Although there was a statistically significant increase in both groups, this increase was greater in the PNL group. A significant increase was observed only in the PNL group in the postoperative period (p=0.003). Discussion and Conclusion:The findings of the study suggest that the PNL procedure causes more damage to the kidneys than RIRS.

Amac: Bu calismada ust kaliks tasi tedavisinde fleksible ureterorenoskopi uyguladigimiz obez hastalarin sonuclari analiz edilmistir. Gerec ve Yontem: Ocak 2015-Aralik 2018 tarihleri arasinda ust kaliks taslarina yonelik fleksible ureterorenoskopi uygulanan obez hastalarin verileri geri donuk olarak analiz edildi. Hastalarin demografik verileri, tas boyutlari, ameliyat sonrasi stent kullanimi, ameliyat sureleri, hastanede kalis zamani, komplikasyon ve tassizlik orani degerlendirildi. Bulgular: Calismaya 18'si erkek, 12'u kadin olmak uzere 30 obez hasta alindi. Hastalarin yas ortalamasi 52.6±12.06 yil idi. Ortalama tas boyutu 19.46±6.6 idi. Ortalama operasyon suresi 72.1±16.8 dakika ve ortalama hastanede kalis suresi 1.5±1.1 gun olarak hesaplandi. Basari orani %73.3 olarak belirlendi. Islem sonrasi hastalarin %76.6'sinda d-j stent uygulandi. Postoperatif takiplerinde 3 hastada siddetli kolik agri, 5 hastada kan transfuzyonu gerektirmeyen 24 saatten kisa suren hematuri ve 2 hastada uriner sistem enfeksiyonu goruldu. Hicbir hastada morbite veya mortaliteye neden olacak major komplikasyon izlenmedi. Sonuc: Obez hastalarda ust kaliks taslarinin tedavisinde yuksek tassizlik ve dusuk komplikasyon oranlariyla fleksible ureterorenoskopi etkin bir tedavi yontemidir.

Objectives: To evaluate the safety and effectiveness of flexible ureterorenoscopy (fURS) with holmium laser lithotripsy for treating kidney stones without fluoroscopy as method of best practice for patients and endourologists. Patients and Methods: All patients treated for kidney stones by fURS with holmium laser lithotripsy from February 2016 to February 2017 were retrospectively evaluated. The patients’ demographic characteristics, stone features (size, number, and location), surgical variables (use of fluoroscopy, operative and fluoroscopy time), complications, and success rate (employing stone-free rate [SFR]), were included in the analysis. Results: In all, 100 patients met the inclusion criteria: 33 fURS were performed under fluoroscopy (Group 1) and 67 without it (Group 2). The mean operating time was 94.33 vs 98.29 min (P = 0.888), respectively. The mean stone volume was 78.5 vs 82.4 mL (P = 0.885), respectively. The SFR was 63.6% and 64.2% (P = 0.771), the perioperative complications rate was 18.2% vs 11.9% (P = 0.285), and the postoperative complications rate was 24.2% and 10.4%, in groups 1 and 2 respectively (P = 0.174). Conclusions: fURS with holmium laser lithotripsy without fluoroscopy was a feasible and safe treatment for kidney stones. There was no difference between the use of fluoroscopy or not regarding complications or SFR. Thus, we can reduce the risks of radiation exposure to patients and medical staff whilst maintaining surgical success. However, multicentre randomised controlled studies are necessary to evaluate fluoroless URS further and to confirm our present results. Abbreviations: PTFE: polytetrafluoroethylene; SFR: stone-free rate; (f)URS: (flexible) ureterorenoscopy/ureterorenoscopies; US: ultrasonography

Context and objectives The first-line treatment for >2 cm lithiasis is percutaneous nephrolithotomy (PNL), leaving flexible ureteroscopy (FURS) as a second option. In the present review, the stone-free rate and the complications of both techniques were evaluated in the treatment of 2–3 cm stones. Material and methods Systematic review of studies that compared both techniques. Studies that were not comparative, as well as those carried out in the paediatric population or with 3 cm stones, were excluded. Two researchers independently performed the investigation, obtaining 5 studies that made up a total of 815 patients: 252 belonged to the FURS group and 563 to the PNL group. Four studies were retrospective, and one was non-randomised prospective. Results Stone-free rate ranged between 47.0% and 95.0% for the FURS and between 87.0% and 100% for the PNL. The complication rate was 8.8–29.0% in the FURS and 11.9–27.0% in the PNL. FURS required a greater number of procedures, and had a lower decrease in haemoglobin and creatinine rise compared to PNL. Conclusions The stone-free rate was higher for PNL, although the FURS could reach comparable results at the expense of performing several procedures. Both techniques have a similar frequency of complications, but the PNL has more postsurgical analytical alterations.

In the present study, we aimed to clarify predictive factors that may cause postoperative infectious complications after flexible ureterorenoscopy (f-URS). In a 4-year prospective study, charts of patients who underwent f-URS between January 2014 and January 2018 for renal stone(s) in a tertiary academic center were reviewed. A standardized f-URS procedure was performed for all patients. Post-operative infectious complications including fever, sepsis and septic shock were categorized into same group. Patients with and without infectious complications were compared in the terms of preoperative, operative and post operative characteristics. In total, 463 patients who did not face infectious complications and 31 patients who faced infectious complications were enrolled into the study. The mean age was significantly lower in patients who did face infectious complications (34.8 vs 44.7 years old, p

Development of surgical expertise and technology has affected the way renal tract stones are treated. Our hypothesis was that flexible ureteroscopy (FURS) for upper tract stones in children produces good results. Our outcomes were reviewed. A retrospective case note review was performed for children with upper tract calculi who were treated by FURS. There were 56 stone episodes in 36 patients. Median age was 10.6 years. Stones were 3-23 mm (median 8 mm); 64.3% had multiple calculi. Median follow-up was for 17.1 months. After the first FURS there was stone clearance in 42/56 (75%). Although there were no immediate complications, two required re-admission; one with stent symptoms, the other with urinary infection. A second FURS was performed in 11, bringing the cumulative clearance to 89%, although this was often done as "another look" before stent removal. There was no statistically significant difference in stone clearance after first FURS for those with single stones (81.0%) compared to those with multiple stones (72.2%). Clearance rates of more than 70% after first FURS were achieved with stones of up to 17 mm. Unexpected disease was found and treated during FURS in 9 (16.1%) children. FURS is safe in children and good clearance rates are achieved. Multiple stones at different sites may be treated during the same treatment. In addition, FURS allows diagnosis and treatment of unexpected problems.

OBJECTIVES To externally validate and compare Resorlu-Unsal stone score (RUSS), modified Seoul National University Renal Stone Complexity Score(S-ReSC), Ito's nomogram, and Retrograde Intra-Renal Surgery (R.I.R.S.) scoring systems for predicting capabilities of both the stone-free status and complications in a multi-institutional study. MATERIALS AND METHODS We performed a retrospective analysis of 949 patients who underwent flexible ureterorenoscopy (f-URS) and laser lithotripsy for renal stones in two institutions between March-2015 and June-2020. The RUSS, modified S-ReSC, Ito's nomogram, and R.I.R.S. scores were calculated for each patient by the same surgeon on imaging methods. Results were compared for their predictive capability of stone-free status and complications. RESULTS Of 949 patients 603 were male and 346 were female with a mean age of 47.2 ± 14.3 (range 2-84 years). Mean stone burden was 102.6 ± 42.2 (48-270 mm2 ). All nomograms predicted stone-free status (Area Under Curve (AUC) were 0.689, 0.657, 0.303, and 0.690, respectively). All four scoring systems predicted complications with AUC values of 0.689, 0.646, 0.286, and 0.664 for RUSS, modified S-ReSC, Ito's nomogram, and R.I.R.S., respectively. Although all scoring systems were able to predict complications only Ito's nomogram was able to predict Clavien ≥2 complications. CONCLUSION All four scoring systems (RUSS, modified S-ReSC, Ito's nomogram, and R.I.R.S.) could predict stone-free status after f-URS, however, the AUC values are not satisfactory in our large patient cohort. Although these scoring systems were not developed for predicting post-operative complications, they were associated with complications in our study. However, these four scoring systems have some significant limitations. The ideal scoring system is yet to be developed.

Introduction: The primary aim of this study is to compare the efficacy and safety of retrograde intrarenal surgery (RIRS) among the children and adults with similar stone burdens and locations. Also, the secondary aim of this study is to identify the factors affecting the stone-free rates (SFRs) of RIRS. Methods: We retrospectively compared perioperative results, SFRs, and complication rates (CRs) between pediatric (group 1, n: 55) and adult (group 2, n: 220) age groups diagnosed with kidney stones and treated by flexible ureterorenoscopy using the same instruments. Furthermore, multivariate analysis was performed to determine the factors affecting the SFR. Results: A total of 275 patients (pediatric group: 55; adult group: 220) were included in this study. The mean age of pediatric and adult groups was 7.2 ± 5.3 and 43.9 ± 15.1, respectively. The mean stone size was 13.9 ± 6.6 mm in the pediatric group compared to 14.8 ± 6.7 mm in the adult group (p = 0.35). Stone localizations and number were similar. JJ stenting for passive dilatation and use of UAS were higher in the pediatric group (p = 0.002; p = 0.017). However, postoperative double pigtail stenting rate was higher in the adult group (p < 0.001). Total CR was 13.8% and mostly Clavien I–II, and no difference was observed between the 2 groups (p = 0.541). The SFRs between the groups were similar (pediatric group: 81.8%; adult group: 78.2%; p = 0.554). On multivariate analysis, stone size (p < 0.001) and lower calyx stone (p < 0.001) were the negative predictive factors for SFR. Conclusion: There are small technical differences between pediatric patients and adult patients in our study, but RIRS in children is as safe and efficient as it is in adults.

Introduction Residual stone fragments remain a challenging topic for urologists following retrograde intrarenal surgery (RIRS). This study investigates the effectiveness of second-look flexible ureterorenoscopy (URS) to achieve a true stone-free status and decrease stone-related events. Material and Method A total of 176 consecutive patients treated with RIRS for kidney stones were included in the study. Patients were divided into two groups, group 1 receiving the standard of care (n=51) and group 2 receiving second-look flexible URS (n=125). In all cases, one or more calyceal stones of 1 to 4 mm were extracted with a basket at the time of stent removal. Unless earlier intervention was necessary, patients were followed up every six months to determine if they had experienced SREs. Results The mean follow-up time for the whole group was 21±11.1 months. The mean number of stones in group 1 and group 2 was 1.25±0.11 and 1.56±0.19, respectively. Postoperative stone-free rate after RIRS for group 1 and group 2 were 37.25% (n=19/51) and 40.8% (n=51/125), respectively. The SFR improved to 93.6% (n=117/125) in group 2. Multivariable analysis showed that type of intervention, stone size, and body mass index were independent prognostic factors for SREs. When group 2 was taken as a reference, the odds ratio for SREs was 8.48 (95% CI: 2.95–24.42) in group 1. Conclusion This study found that second-look flexible URS increased the SFRs and diminished the number of SREs. We propose performing second-look flexible URS following RIRS in the presence or suspicion of RSFs to provide better treatment results, less radiation exposure, and greater patient satisfaction. Key Words Retrograde Intrarenal Surgery, Flexible Ureteroscopy, Stone-free Rate, Residual stone Fragments, Stone-Related Event, Second-look Flexible Ureteroscopy.

Introduction: Although spinal anesthesia (SA) may reduce postoperative morbidity, most urologists perform flexible ureterorenoscopy (fURS) under general anesthesia (GA). The objective of our study is to provide technical details, results, complications, and patients’ satisfaction with fURS performed under exclusive SA. Methods: We analyzed all consecutive fURS performed under SA to treat renal stones from March 2011 to February 2017. Details of technique, operative time, outcomes, need for further treatments, complications, and patients’ satisfaction were evaluated. Results: Two hundred thirty-four fURS under SA were considered. SA was performed through L2-L3 vertebral interspace in 64.1%. Patients were discharged the same day of surgery. Mean stone burden was 13.5 ± 6.6 mm and mean operative time 76.9 ± 34.6 min. Single-procedure SFR was 69.7%. Further treatments were performed in 22.8%. 96.6% had no anesthesia-related complications. No Clavien-Dindo grade ≥ IIIb complications were noticed. 99.6% of patients were satisfied with SA. No cases of conversion from SA to GA occurred. Conclusion: fURS can be performed safely and efficiently under SA, taking into account a few details of the technique. Patients’ satisfaction with SA is very high, and complications are rare. Although SA is usually adopted in unfit patients for GA, it may be considered as a viable alternative in fit patients.

Purpose: Recently developed robotic devices may significantly compensate for ergonomic deficiencies of flexible ureterorenoscopy (FURS) respectively retrograde intra-renal surgery (RIRS). We want to update on current developments.

Resumen Objetivo: Establecer validez aparente, de contenido y constructo, de un programa de simulación de ureterorrenoscopía flexible. Materiales y Método: Se desarrolló un modelo de simulación de silicona para ureterorrenoscopía flexible, en el cual se establecieron 8 marcas de colores en los distintos cálices. Para la validación, se reclutaron urólogos expertos y residentes de urología con experiencia variable en este procedimiento. Se separaron en 3 grupos: G1 para residentes sin experiencia en ureteroscopía, G2 para residentes con experiencia variable y G3 para urólogos expertos. Se les solicitó realizar una navegación completa del modelo, en un tiempo máximo de 600 segundos. Al finalizar, cada participante contestó una encuesta respecto a la utilidad y realismo del modelo. Además, se midió tiempo total, número de puntos encontrados y cantidad de veces de reingreso a los cálices para validación de constructo. Resultados: 15 personas participaron en la evaluación. Se obtuvo una mediana de 8,6 puntos para la utilidad del modelo y 6,75 puntos para el realismo de este. Los tiempos totales de navegación fueron 504, 293 y 133 segundos para G1, G2 y G3 respectivamente (p = 0,02). De las 8 marcas, se encontraron en promedio 5,1, 6,6 y 7,3 (p = 0,18), presentando un promedio de 9,5, 3,8 y 1,3 reintentos de exploración de los cálices en los respectivos grupos (p = 0,11). Conclusiones: Se establece validez aparente y contenido para un modelo de ureterorrenoscopía flexible. El programa de simulación de ureterorrenoscopía flexible establecido, permite diferenciar novatos de expertos en cuanto a reducción en los tiempos de navegación.

Background The number of patients diagnosed and subsequently treated for kidney stones is increasing, and as such the number of post-operative complications is likely to increase. At present, little is known about the role of specific biomarkers, following flexible ureterorenoscopy (FURS) for the surgical treatment of kidney stones. The main aim of the study was to evaluate the role of kidney and infection biomarkers, in patients undergoing FURS. Methods Included were 37 patients (24 males, 13 females), who underwent elective FURS, for the treatment of kidney stones. Venous blood samples were collected from each patient: pre-operatively, and at 30 min, 2 and 4 h post-operatively. Changes to kidney (NGAL, Cystatin-C) and infection (MPO, PCT) biomarkers was quantified by means of ELISA, Biomerieux mini-vidas and Konelab 20 analysers. Results Four patients developed post-operative complications (3 - UTIs with urinary retention, 1 - urosepsis. NGAL concentration increased significantly following FURS (p = 0.034). Although no significant changes were seen in Cystatin C, MPO and PCT (p ≥ 0.05) some key clinical observation were noted. Limiting factors for this study were the small number of patients recruited and restriction in blood sampling beyond 4 h. Conclusions Although not confirmative, changes seen to biomarkers such as Cystatin C, NGAL and MPO in our observational clinical pilot-study may warrant further investigation, involving larger cohorts, to fully understand the role of these biomarkers and their potential association with post-operative complications which can develop following FURS.

Introduction Renal stones are common, with a lifetime prevalence of 10% in adults. Global incidence is increasing due to increases in obesity and diabetes, with these patient populations being more likely to suffer renal stone disease. Flank pain from stones (renal colic) is the most common cause of emergency admission to UK urology departments. Stones most commonly develop in the lower pole of the kidney (in ~35% of cases) and here are least likely to pass without intervention. Currently there are three technologies available within the UK National Health Service to remove lower pole kidney stones: extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and flexible ureterorenoscopy (FURS) with laser lithotripsy. Current evidence indicates there is uncertainty regarding the management of lower pole stones, and each treatment has advantages and disadvantages. The aim of this trial is to determine the clinical and cost effectiveness of FURS compared with ESWL or PCNL in the treatment of lower pole kidney stones. Methods The PUrE (PCNL, FURS and ESWL for lower pole kidney stones) trial is a multi-centre, randomised controlled trial (RCT) evaluating FURS versus ESWL or PCNL for lower pole kidney stones. Patients aged ≥16 years with a stone(s) in the lower pole of either kidney confirmed by non-contrast computed tomography of the kidney, ureter and bladder (CTKUB) and requiring treatment for a stone ≤10 mm will be randomised to receive FURS or ESWL (RCT1), and those requiring treatment for a stone >10 mm to ≤25 mm will be randomised to receive FURS or PCNL (RCT2). Participants will undergo follow-up by questionnaires every week up to 12 weeks post-intervention and at 12 months post-randomisation. The primary clinical outcome is health status measured by the area under the curve calculated from multiple measurements of the EuroQol five dimensions five-level version (EQ-5D-5L) questionnaire up to 12 weeks post-intervention. The primary economic outcome is the incremental cost per quality-adjusted life year gained at 12 months post-randomisation. Discussion The PUrE trial aims to provide robust evidence on health status, quality of life, clinical outcomes and resource use to directly inform choice and National Health Service provision of the three treatment options. Trial registration ISRCTN: ISRCTN98970319. Registered on 11 November 2015.

INTRODUCTION AND OBJECTIVE:Pressured irrigation is routinely utilised in treatment of urinary calculi by uretero-renoscopic surgery. Although this can be in multiple forms, standardised pneumatic p...

Purpose of review The aim of the article is to evaluate the actual role of extracorporeal shock-wave lithotripsy (ESWL) in the management of urolithiasis based on the new developments of flexible ureterorenoscopy (FURS) and percutaneous nephrolithotomy (PCNL). Recent findings In Western Europe, there is a significant change of techniques used for treatment of renal stones with an increase of FURS and a decrease of ESWL. The reasons for this include the change of indications, technical improvement of the endourologic armamentarium, including robotic assistance. Mostly relevant is the introduction of digital reusable and single-use flexible ureterorenoscopes, whereas micro-PCNL has been abandoned. Some companies have stopped production of lithotripters and novel ideas to improve the efficacy of shock waves have not been implemented in the actual systems. Promising shock-wave technologies include the use of burst-shock-wave lithotripsy (SWL) or high-frequent ESWL. The main advantage would be the very fast pulverization of the stone as shown in in-vitro models. Summary The role of ESWL in the management of urolithiasis is decreasing, whereas FURS is constantly progressing. Quality and safety of intracorporeal shock-wave lithotripsy using holmium:YAG-laser under endoscopic control clearly outweighs the advantages of noninvasive ESWL. To regain ground, new technologies like burst-SWL or high-frequent ESWL have to be implemented in new systems.

Background: Urolithiasis affects 5-15% of the world population, with high recurrence, (2) which at 5 years can be up to 50%, with high frequency in the labor force population, which produces a high individual and hospital cost, so it constitutes a health problem of high socio-sanitary interes. Objective: To compare the treatment outcomes of Flexible ureterorenoscopy and extracorporeal shock wave lithotripsy for patients with lower pole stones. Patients and method: Data base review for the patients in the period from first of Jan 2018 to the end of June 2019, in which 131 patients underwent interventions for the management of small lower pole stone. Sixty-seven patients were treated by ESWL and the rest (64) treated by F-URS. The most common complication was UTI 9/19 Results: 86/131 were male and 45/131 were female with mean age for F-URS group (52±9.7 years) and (49.6±12.3 years) for ESWL group, with highly significant differences regarding the stone size between the studied groups. The treatment rate, operative time and procedure per patient were highly significantly decrease in F-URS group than in ESWL (p

Introduction Saline solution is the standard irrigant used during ureteroscopy. However, there is an opinion that water has better visual clarity. We aimed to compare the visual clarities of saline, water, and 5% mannitol as an irrigant during ureteroscopy. Material and methods An in vitro model consisting of an irrigant-filled container and a fiberoptic flexible ureteroscope was designed. A 1951 USAF Resolution Test Target and color checker within irrigants were used to evaluate the clarity of vision. The visual clarity was compared for 0.9% saline, distilled water and 5% mannitol solution with screen resolution and color contrast. The tests were repeated after adding human blood (2/400 ml) and contrast (20/400 ml) to the irrigants. Results There was no significant difference in resolution values of three plain irrigants at a distance of 10 mm. However, when blood was added to the irrigants, a better resolution of 29.3% for water and 20.6% for mannitol was achieved compared to saline. At 20 mm of distance, it was observed that the difference was more pronounced in irrigants with blood. Water and mannitol had 55.6% and 37.1% better resolution than saline, respectively. In the color reproduction test, there was no significant difference in the three plain irrigants, however, water had better color contrast compared to the others. Conclusions Water and 5% mannitol did not provide a significant image clarity advantage compared to saline. However, when blood was added to the irrigants, water provided significantly better visual clarity compared to saline. The use of water during various clinical scenarios in flexible ureteroscopy should be further investigated.

Urolithiasis is a multifactorial disease; in recent years, its incidence has gradually increased in pediatric age. Among the factors involved in urolithiasis pathophysiology, urinary tract anomalies and metabolic diseases are the most relevant, although ethnicity and environmental factors may have an important role. The advances in technology and miniaturization of endoscopic devices have permitted the use of Retrograde Intrarenal Surgery (RIRS) to treat kidney and ureteral stones. Nowadays, flexible ureterorenoscopy and laser lithotripsy, which are techniques that have been applied in the management of adult upper urinary tract disorders, are also used in children as a minimally invasive treatment of urolithiasis with encouraging, effective and safe results. The Authors report a retrospective review of their record of cases considering 21 pediatric urolithiasis treatment procedures performed between October 2017 and April 2019 in a total of 17 patients (10 males and 7 females). Six procedures involved the use of the flexible ureterorenoscope (FURS) while in 15 procedures the application of the laser fiber was used (FURSL). A case of laser lithotripsy for bladder stone was included. The average age of patients was 10.5 years (2-18 years). The renal pelvis dilatation pretreatment was evaluated in post-operative follow-up. From the evaluation of the sample in analysis, the use of RIRS has good results in the treatment of paediatric urolithiasis, emerging as a valid option in the management of the paediatric population in terms of efficacy and safety, with an improvement in patient outcomes.

Aim: Although the advantage of ureteral double j(D/J) stenting has been shown in reducing post- operative pain afterureteroscopic surgery, its contribution to stone clearance for additionaltreatment has not been fully assessed. In this study we aimed to evaluate theeffect of stenting on stone free rates at the end of the additional treatment. Methods: We reviewed the medical records of allpatients who underwent flexible ureterorenoscopy (FURS) for kidney stonesbetween October 2009 and January 2015. Patients with malignant ureteralstricture, severe skeletal malformation, renal unit malformation, non-opaquerenal stone or lost to follow-up were excluded. 47 of 289 patients (stenting 24patients, non-stenting 23 patients) assessed. The perioperative andpostoperative parameters and stone-free rates were compared in patients whetherthey had intraoperative D/J stent (group 1) or not (group 2). Results: No differences were found between groups according to age, gender, body mass index, operation history, preoperative stenting history, shockwave lithotripsy history, ureteral stricture, stone size, access sheath rate, retreatment, or additional treatment number and stone location. Operation time was significantly higher in group 1. Those who refused additional treatment were insignificantly lower in group 1. Although the stone-free rates were similar for the two groups at the end of the first month, the stone-free rates after the additional treatments were significantly higher in group 1.Conclusion: Stenting during FURS, improved the stone-freerate on final follow-up, if residual stones remain., Amaç: Her ne kadar üreteroskopikcerrahi sonrası üreteral çift J uçlu (Double J-D/J) stent yerleştirilmesininpostoperatif ağrıyı azaltmaktaki avantajı gösterilmiş olsa da taşlarıntemizlenmesi ve ek işlem için hasta uyumuna etkisi tamolarak değerlendirilmemiştir. Biz bu çalışmada stent takılmasının ek tedavilersonunda taşsızlık oranlarına olan etkisini araştırdık.Yöntem: Kasım 2009 veOcak 2015 tarihleri arasında fleksibl üreterorenoskopi (FURS) uygulananhastaların tıbbi kayıtları gözden geçirildi. Maling üreteral darlık, ileriderecede iskelet malformasyonu, böbrek malformasyonu olan hastalar ve takiptençıkan hastalar çalışmadan çıkarıldı. 289 hastanın 47’si (24 stent takılan, 23stent takılmayan) değerlendirilmeye alındı. Operasyon sırasında D/J stenttakılan (grup 1) ve takılmayan (grup 2) hastaların perioperatif ve postoperatifparametreleri ve taşsızlık oranları karşılaştırıldı.Bulgular: Gruplararasında yaş, cinsiyet, vücut kitle indeksi, operasyon öyküsü, operasyon öncesistent yerleştirilmesi, şok dalga litotripsi hikayesi, üreteral darlık, taşboyutu, akses kılıfı kullanım oranı, tekrar tedavi, ek tedavi taş sayısı velokalizasyonu açısından fark yoktu. Stent uygulanan grupta anlamlı olarakoperasyon süresi uzun izlendi. Ek tedavileri red etme oranı grup 1’de dahadüşük izlendi. İlk ay sonunda taşsızlık oranları iki grup için benzer olmasınarağmen, ek tedavilerden sonra taşsızlık oranları grup 1’de anlamlı olarakyüksek izlendi. Sonuç: FURS sırasında stent yerleştirilmesi,rezidüel taşların kalması durumunda son takipte taşsızlık oranınıarttırmaktadır.

Objective: To evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) using flexible ureterorenoscopy (F-URS) and laser lithotripsy as a treatment option for multiple renal stones greater than 1 cm. Patients and methods: Between June 2015 and February 2017, 42 patients who were treated with RIRS via F-URS and laser lithotripsy were evaluated. Stones were divided into two categories according to stone burden, 11–20 mm and 21–30 mm. Patient’s demographics, stones characteristics, operative outcomes and complications were evaluated prospectively. Stone free rate (SFR) was determined 4 weeks postoperatively using findings on non-contrast computed tomography (NCCT). Results: Mean stones burden was 25.7 mm (range from 1.3 to 30 mm), 8 patients had 11–20 mm stones burden with SFR 100% and 34 had 21–30 mm stone burden with SFR 91.2%. The overall SFR was 92.8%. Multiple stones were two in 31 patients (73.8%), three in 9 (21.4%) and four in 2 (4.8%). Regarding stone number per kidney and SFR, SFR was 100%, 77.7% and 50% for kidneys with two, three and four stones respectively. In terms of stone location in the pelvi-calyceal system and corresponding SFR, there were renal pelvic stones in 6 (14.3%) patients with 100% SFR, upper calyx and or mid calyx and or renal pelvis in 12 (28.6%) with SFR 91.6% and lower calyx with or without other locations in 24 with SFR 91.6% also. Complications were minor and included, UTI in 3 patients (7.1%), hematuria of 4 days duration in 2 (4.8%), severe DJ stent irritative symptoms in one (2.4%) and minor ureteral perforations in one (2.4%). Conclusion: RIRS via F-URS and laser lithotripsy is a safe and effective treatment option with high success rate for patients with multiple renal stones of 11–30 mm stone burden. It is indicated when other stone treatment modalities contraindicated or have failed. However, for complex or challenging stones, staged procedures may be required. Keywords: Renal stones; Retrograde; Flexible ureterorenoscopy; Laser lithotripsy

Conventional PCNL leads to a high stone-free rate but is associated with a significant treatment morbidity. To decrease the morbidity of PCNL but to achieve an equal stone-free rate, in 2001 a miniaturised version of a conventional PCNL (Mini-PCNL) was introduced. Meanwhile numerous modifications of the Mini-PCNL were reported. The ongoing experience with the Mini-PCNL technique showed that Mini-PCNL is not only a miniaturisation but also a different method to remove the stones, as the stones come out of the calyceal system only by means of the irrigation flow without any further need of forceps or baskets. Due to a limited number of papers in the literature, the guidelines so far do not distinguish between conventional and Mini-PCNL, although the Mini-PCNL already became a frequent treatment modality in daily routine worldwide. From the current point of view, Mini-PCNL can be recommended to treat all kinds of upper urinary tract stones exceeding a diameter of 10 mm. In this context, Mini-PCNL is a treatment alternative to flexible ureterorenoscopy, SWL and conventional PCNL. The available literature shows that the morbidity of Mini-PCNL is less and the stone-free rate is equal to that of conventional PCNL. It seems that there is no limitation to Mini-PCNL in the treatment of upper urinary tract stones. The future will show what kind of further miniaturisation of the Mini-PCNL procedure will be appropriate.

Duplication of renal system is one of the commonest renal anomalies. It is infrequently associated with renal calculus, ureterocele and vesico ureteric reflux. We report a 29-year male with right complete duplex system having upper moiety multiple ureteric calculi and lower moiety inferior renal calculus. Single sitting fURS was done and calculi in both systems were tackled one at a time. Calculi were dusted with holmium laser and double J stent placed in upper moiety ureter. Calculus management in anomalous kidney is challenging. Single sitting flexible ureterorenoscopy is feasible option in duplex renal system with low burden calculi.

To assess the clinical features, outcomes, complications, and cost-effectiveness of shockwave lithotripsy (SWL), flexible ureterorenoscopy (FURS), and percutaneous nephrolithotomy (PCNL) in the treatment of lower pole (LP) stones (10-20 mm) in a large tertiary referral center.Consecutive patients treated for solitary LP stones (10-20 mm) between 2008 and 2013 were identified from a prospective database. SWL was used as primary treatment in all cases (following a stone multidisciplinary team assessment), with FURS and PCNL reserved for SWL contraindications, failure, or patient choice. "Success" was defined as stone free and/or clinically insignificant stone fragments (≤3 mm) at 1 and 3 months follow-up. Effect of anatomy on SWL success was determined from using CT images and regression analysis. Average cost per treatment modality (including additional second-line treatments) was calculated for each group using the National Health Service England 2014/15 National Tariff Healthcare Resource Group codes.Two hundred twenty-five patients were included (mean age 54.9; median stone size 12 mm). One hundred ninety-eight (88%), 21 (9.3%), and 6 (2.7%) patients underwent SWL, FURS, and PCNL as primary treatments, respectively, for median stone sizes of 12, 12, and 20 mm. Overall success rates were 82.8%, 76.1%, and 66.7%, respectively (p 0.05). Sixty-three percent of patients undergoing primary SWL were effectively treated after one session. Anatomical analysis determined infundibulopelvic angle and infundibular length to be significantly different in patients effectively treated with SWL (p = 0.04). The average cost per treatment modality was also significantly lower for SWL (£750) than for FURS (£1261) or PCNL (£2658) (p 0.01).SWL is both an efficacious and cost-effective primary treatment for patients with solitary LP stones (10-20 mm). The majority of patients can be effectively treated with primary SWL in a dedicated stone center, with the benefits of a short length of stay, low complication, and auxiliary treatment rates. The referral of such patients to high-volume lithotripsy centers with demonstrable outcomes should be given due consideration.

Objective Describe our initial experience in the treatment of renal lithiasis with extracorporeal lithotripsy controlled by simultaneous flexible ureterorenoscopy and combined with holmium laser lithotripsy. Material and methods We performed this novel technique in a previously selected patient with left renal lithiasis, two in the superior calix, two in the medium calix and two in the inferior calix, the biggest of which was placed in medium calix and was 6 mm long. We proceeded to an extracorporeal shock wave lithotripsy and a simultaneous flexible ureterorenoscopy for better controlling the fragmentation of the lithiasis with the use of a holmium laser. In the immediate post-operative, an ultrasound was performed and, one month later, a computerized tomography (CT) was done. Results The complete fragmentation of all the lithiasis was obtained and a double-J catheter was placed. After the assessment of the absence of stone fragments by CT the catheter was removed. No intra-operative or post-operative complications were described. Conclusions The technique described is novel, safe and reproducible. The good result obtained through this combined technique increases our interest in continuing with its application and consider it as an option for the treatment of renal lithiasis in our patients.