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Background Urolithiasis is a pathology that changes with time and with the evolution of human societies. The prevalence of this pathology has gradually increased during the last decades, especially because of dietary changes. Methods This work is a retrospective descriptive epidemiological study of the temporal type carried out at the level of the urology service of the University Hospital Center of Oran between the first January 1965 and December 31, 2014. The objectives of this work are to study the epidemiological profile of urolithiasis and to determine the evolutionary trend of the disease over time. Results This study confirms some current data in the direction of an increase in surgical activity concerning the treatment of urinary stones. The analysis over time shows us a significant decrease (p Conclusion The analysis of epidemiological data is essential to better evaluate the evolution of the urolithiasis disease, which was affirmed in our study, where a constant evolution of the characteristics of the disease was revealed, testifying the change of the socio-economic level in Algeria.

Background Medical dissolution of struvite uroliths in dogs is commonly recommended, but data on success rates and complications are limited. Objectives To evaluate the efficacy of medical dissolution for suspected struvite cystoliths in dogs. Animals Fifty client-owned dogs fed a therapeutic dissolution diet, with or without administration of antimicrobials, for treatment of suspected struvite cystoliths. Methods Single institution, retrospective case series. Medical records were reviewed for dogs with at least 1 follow-up visit. Dissolution success, complications, and possible predictors of success were evaluated. Results Full dissolution of cystoliths was achieved in 58% (29/50) of dogs within a median of 35 days (range, 13-167). Of 21 dogs without success, 7 each had partial dissolution, no dissolution, or undetermined outcome. Uroliths containing >10% nonstruvite mineral were common in the nonsuccess group (11/16 analyzed). Maximum urolith diameter, number of uroliths, and baseline urine pH did not differ significantly between dogs with and without success. Dissolution was more likely in dogs receiving antimicrobial therapy (OR = 16.3, 95% confidence interval 1.9-787.4, P = .002). Adverse events occurred in 9 dogs (18%); urethral obstructions were the most common, but 3 of 4 dogs with this complication were obstructed on presentation, before trial initiation. Conclusions and clinical importance Results support a medical dissolution trial for dogs with suspected struvite cystoliths. If no reduction in urolith size or number occurs by 1 month, a nonstruvite composition is likely, and alternative interventions should be considered. Dogs presenting with urethral obstructions should not be considered candidates for medical dissolution.

Objectives: To study a modification to the conventional retrograde ureteroscopic approach for treating proximal ureteric stones of 1–2 cm; we intentionally push the stone from the proximal ureter into a favourable calyx then the flexible ureteroscope is used to fragment the trapped stone using laser lithotripsy (‘boxing in the corner’). Patients and methods: The study was conducted in a randomised prospective manner and included 100 patients who presented with a single proximal ureteric stone of 1–2 cm. We randomised the patients into two equal groups: Group A (50 patients) underwent the conventional retrograde technique (CRT) and Group B (50 patients) underwent the modified retrograde technique (MRT) with the primary intention of relocating the stone into a favourable calyx. Intended relocation of the proximal ureteric stone in the MRT group was achieved in a stepwise manner. All intraoperative parameters and postoperative outcomes were recorded and compared between the two groups. Results: There was no statistical significant difference in terms of the patients’ demographics and stone criteria between the two groups. The stone-free rate (SFR) was significantly higher in Group B (92%) compared to Group A (78%) (P = 0.049). Fluoroscopy time was significantly longer in Group B (P

Objectives To assess the effectiveness of incorporating hygienic-dietary recommendations in laboratory reports in reducing the incidence of renal colic (RC). A study was performed to compare the incidence of RC in two groups of patients who had suffered at least a crystalluria event associated with the risk of urolithiasis. Recommendations were only incorporated in the laboratory reports of one group. Methods A retrospective observational study. The study sample was composed of patients who had at least an episode of crystalluria associated with a higher risk of urolithiasis. The laboratory reports of patients in Group A (n=1,115), treated in 2017, did not include any hygienic-dietary recommendations, whereas patients in Group B (n=1,692), treated in 2018, received hygienic-dietary recommendations through their laboratory reports. χ2 and Mann-Whitney U test were used to assess differences based on sex, age, and type of urinary crystals. Results The incidence of RC was 2.02 times higher in group A (2.24%) than in group B (1.12%). No significant differences were observed in the incidence of RC based on the type of urinary crystal. The incidence of RC was substantially higher in patients who suffered at least an event of crystalluria associated with a higher risk for urolithiasis as compared to the general population during the same period (0.46%, consistently with the incidence rates reported in the literature). Conclusions The incorporation of messages alerting on the risk of urolithiasis and the inclusion of hygienic-dietary recommendations in laboratory reports may be useful for reducing the incidence of RC.

Objectives: To see the effect of intra operative antegrade flexible nephroscopy during Percutaneous nephrolithotomy on stone free rate. Methods: We retrospectively reviewed electronic medical records of patients who underwent percutaneous nephrolithotomy from 2010 to 2017 for renal stones >2cm. Patients found eligible were divided in, Group-I who did not have intraoperative Flexible nephroscopy and Group-II who had flexible nephroscopy during percutaneous nephrolithotomy. All procedures were done by senior consultants. Variables like Mean age, side, stone size, skin to stone distance and Hounsfield unit were compared. Outcomes like Stone free rate, hospital stay and operative time were compared between the groups. Results: The study included 248 patients, consisting 85 (34.3%) females and 163 (65.7%) males. Mean age ± SD was 45.8±13.8 years. Both group were similar in characteristics like mean age, stone size, skin to stone distance and Hounsfield units. The overall stone free rate was 71%. It was not significantly different between the groups, 76% in Group-II vs. 67% in Group-I. However stone free rate markedly improved with flexible nephroscopy in patients with staghorn calculi. Mean operative time and hospital stay were similar between the groups. Conclusions: Intraoperative flexible nephroscopy during percutaneous nephrolithotomy significantly increases stone free rate in patients with staghorn stones. doi: https://doi.org/10.12669/pjms.37.3.3565 How to cite this:Masood Y, Iqbal N, Farooq RM, Iqbal S, Khan F. Intraoperative flexible nephroscopy during percutaneous nephrolithotomy: An 8 years’ experience. Pak J Med Sci. 2021;37(3):716-720. doi: https://doi.org/10.12669/pjms.37.3.3565 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Urinary stones affect 8%–15% of the world population. In Nigeria, contemporary reports have shown that the incidence of urinary stones is rising. The distal ureter has been described as the most common location of ureteric stones. This study seeks to review our experience in the ureteroscopic management of distal ureteric stones with a view to appraising the stone clearance rate and the complications seen in our patients. Patients and Methods: This descriptive study reviewed the record of 21 patients, who had semirigid ureteroscopy and pneumatic lithotripsy for distal ureteric stone between October 2015 and September 2018. All patients had computed tomography urography preoperatively to locate the stone. Data on patients' demographics, indication for the surgery, location and size of stone, preoperative double-J (DJ) placement, postoperative DJ stent placement, intraoperative and postoperative complications, and status of stone clearance were retrieved and subjected to statistical analysis. Results: The mean age of the patients was 37.95 ± 11.09 (range, 21–67) years. The mean stone size was 8.06 ± 2.87 mm with a range of 4.8 mm–15.0 mm. Out of the 21 patients, 20 (95.2%) had the procedure for recurrent ureteric colic and 1 (48%) was for hematuria. Four (19.0%) patients had DJ stent preoperatively, whereas 17 (81.0%) patients did not have. Fourteen (66.7%) patients had intraoperative ureteric dilatation. Postoperative DJ stent was placed in 17 (81.0%) patients, whereas 4 (19.0%) patients did not have. Three (14.3%) patients had mucosal flap, 6 (14.3%) had mucosal abrasion, 2 (9.5%) had bleeding, 1 (4.8%) patient had transient hematuria postoperatively, and 2 (9.5%) patients had urinary tract infection. Nineteen (90.5%) patients had complete clearance in a single surgery. Two (9.5%) patients had symptomatic residual fragments that required repeat ureteroscopy. Conclusion: Our study has shown that ureteroscopy is a useful and safe technique in the removal of stones in distal ureter.

Objective To presents a novel clinically oriented system to report stone attenuation on non-contrast computed tomography (NCCT) using colour-coded density-gradients stone mapping and its clinical applications. Patients and methods This study was performed on 50 patients with 63 stones. All patients had a recent history of failed shockwave lithotripsy (SWL) or failed dissolution therapy by alkalinisation of urine for radiolucent stones. A multi-detector NCCT examination of the abdomen and pelvis was performed in all patients. The stones were isolated and displayed in ‘Volume Rendering Technique’ using four-colour encoding. Results Eight patients with failed dissolution therapy for radiolucent stones showed an outer layer of >500 Hounsfield units (HU) or a heterogeneous composition. A total of 42 patients with failed SWL had mean attenuations of 1000 HU) that failed to be clearly demonstrated by the mean HU alone. Conclusion The initial use of a colour-coded density-gradients stone mapping reporting system for stone density on NCCT is useful for explaining failure of SWL or failure of dissolution therapy for radiolucent stones in selected cases. Abbreviations: HU: Hounsfield units; MSD: mean stone density; NCCT: non-contrast computed tomography; PCNL: percutaneous nephrolithotomy; SWL: shockwave lithotripsy; VRT: Volume Rendering Technique

The Temple of Apollo Pythios, built in the Hellenistic era (3rd&ndash, 1st century BC), is located in the ancient Acropolis of Rhodes. It was excavated during the Italian occupation and reconstructed by the Italians in the period 1937&ndash, 8. The method of the &ldquo, scenographic&rdquo, restoration was the &ldquo, mixed structure&rdquo, technique using a core of reinforced concrete in combination with new biocalcarenite stones and the integration of very few ancient architectural members. Its proximity to the sea and the corresponding salt decay phenomena, aggravated by the erroneous reconstruction methodology and materials, have further deteriorated its state of preservation. Today, the four columns, epistyle and entablature of the Italian interventions demand immediate restoration actions to ensure the monument&rsquo, s sustainability. This can only be achieved through a combined study of the performance of potential restoration materials and assessment of their compatibility with the historical materials. In the present study, the characteristics of the Temple&rsquo, s historical porous stones are presented along with the characteristics of five quarry stones, aiming to evaluate which quarry stone is the most appropriate for use in the upcoming restoration. Restoration mortars are designed and evaluated in respect to both the historical materials and the quarry stones, aiming to select the optimum restoration mortar, which can achieve the required level of performance and compatibility and ensure sustainability of the structure as a whole.

Objective: The aim of this study is to evaluate the efficacy of a food supplement containing Phyllanthus niruri and Chrysanthellum americanum in association with potassium and magnesium citrates in the treatment and prophylaxis of urinary stones. Materials and methods: Eighty-two patients (mean age 49.7 ± 11.2) with history of urinary stones received this food supplement, one capsule a day for 6 months. Each administration contained a combination of the following ingredients: 244 mg Potassium citrate, 735 mg Magnesium citrate, Phyllanthus (Phyllantus niruri) herb d.e. 15% mg Tannins 220 mg, Chrysanthellum (Chrysanthellum americanum Vatke) plant d.e. ¼ 55 mg. After 6 months, all patients underwent urologic visit, urinalysis, imaging and quality of life (QoL) questionnaires evaluation. Each patient was also evaluated by computed tomography (CT) scan at baseline and at 6 months. Result: From January 2018 to March 2019, 82 patients (mean age 49.7 ± 11.2) completed the follow-up period and were analyzed. Fifty patients showed lower stone dimensions (60.9%). The average stone size was 0.9 mm, with a significant reduction in comparison with the baseline (-6.7 mm ± 3 mm) (p < 0.001). Forty-nine patients (59.7%) did not show any symptomatic episode with an improving in QoL (+0.4 ± 0.1) (p < 0.001) in comparison with the baseline. At the end of the follow-up period, 27 patients out of 82 were stone-free (32.9%). Moreover, we report a significant reduction of patients with asymptomatic bacteriuria (ABU) between the baseline and the end of the follow-up evaluation (p < 0.001). Conclusions: In conclusion, this food supplement is able to improve quality of life in patients with urinary stones, reducing symptomatic episodes and the prevalence of ABU.

This study aimed to report a multi-institutional experience with robot-assisted laparoscopic surgery (RALS) for treatment of urinary tract stones in children. The medical records of 15 patients (12 boys), who underwent RALS for urolithiasis in 4 international centers of pediatric urology over a 5-year period, were retrospectively collected. The median patient age was 8.5 years (range 4–15). Eleven/fifteen patients (73.3%) had concurrent uretero–pelvic junction obstruction (UPJO) and 2/15 patients (13.3%) had neurogenic bladder. Stones were in the renal pelvis in 8/15 (53.3%), in the lower pole in 3/15 (20%), in the bladder in 2/15 (13.3%), and in multiple locations in 2/15 (13.3%). One patient (6.6%) had bilateral multiple kidney stones. The median stone size was 10.8 mm (range 2–30) in upper tract location and 27 mm (range 21–33) into the bladder. Eleven patients with concomitant UPJO underwent simultaneous robot-assisted pyelolithotomy and pyeloplasty in 12 kidney units. Two patients with isolated staghorn stones received robot-assisted pyelolithotomy. Robot-assisted cystolithotomy was performed in two patients with bladder stones. The median operative time was 131.8 min (range 60–240). The stone-free rate was 80% following initial surgery and 100% after secondary treatment. Clavien 2 complications (hematuria, infections) were recorded in 5/15 patients (33.3%). Three/fifteen patients (20%) with residual renal stones were successfully treated using ureterorenoscopy (Clavien 3b). RALS was a feasible, safe and effective treatment option for pediatric urolithiasis in selected cases such as large bladder stones, bilateral kidney stones, staghorn stones or concomitant anomalies such as UPJO requiring simultaneous pyeloplasty. Supplementary Information The online version contains supplementary material available at 10.1007/s00240-021-01271-5.

Ureteroscopy is a minimally invasive treatment option for upper tract stones. The distorted kidney anatomy in patients with autosomal dominant polycystic kidney disease (ADPKD) may place them at higher risk for ureteroscopic complications.To compare the 30-day risk of ureteroscopic complications between patients with and without ADPKD.Retrospective cohort study.Ontario, Canada.Seventy three patients with ADPKD and 81 445 patients without ADPKD who underwent ureteroscopy for upper urinary tract stones between April 1, 2002, and March 1, 2018.A 30-day risk of (1) hospital presentation with ureteroscopic complications (which was a composite outcome of either emergency department visit or hospital admission with acute kidney injury, urinary tract infection, or sepsis); (2) all-cause hospital presentation; (3) all-cause hospital admission; and (4) all-cause emergency department visit.We regressed outcomes on demographic variables, health care use in the prior 1-year, various procedures and comorbidities related to the outcome in the prior 5 years, and prescribed medications filled in the past 120 days using modified Poisson regression to compare the risk ratio (RR) of each outcome between patients with and without ADPKD.The median (interquartile, IQR) age was 44 (38-60 years) in the ADPKD group and 53 (42-64) in the control group. About 40% were women in both groups. The risk of ureteroscopic complications was not significantly different in patients with versus without ADPKD (8.2% vs 4.3%; adjusted RR = 1.5, 95% confidence interval [CI] = 0.7-3.2). Patients with versus without ADPKD were more likely to present to hospital after their procedure (35.6% vs. 20.0%; adjusted RR = 1.6, 95% CI = 1.2-2.2), which included a statistically significant increase in the risk of presenting to the emergency department (32.9% vs. 19.0%; adjusted RR = 1.6, 95% CI = 1.1-2.2) but not hospital admissions (10.9% vs. 5.0%; adjusted RR = 1.8, 95% CI = 0.9-3.4).The low numbers of events led to imprecision around the estimates.Patients with ADPKD have a higher risk of return to the hospital within 30 days of ureteroscopy for stone disease.We did not register this study.L’urétéroscopie est une option minimalement invasive pour traiter les calculs des voies urinaires hautes. Cependant, les distorsions anatomiques des reins présentes chez les patients atteints de polykystose rénale autosomique dominante (ADPKD) exposent ces derniers à un risque accru de complications liées à la procédure.Comparer le risque de complications liées à l’urétéroscopie chez des patients atteints ou non d’ADPKD dans les 30 jours suivant la procédure.Étude de cohorte rétrospective.Ontario, Canada.L’étude porte sur 73 patients atteints d’ADPKD et 81 445 patients témoins ayant subi une urétéroscopie entre le 1Le risque dans les 30 jours de: 1) visite à l’hôpital pour des complications liées à l’urétéroscopie (résultat composite d’une visite aux urgences ou d’une admission en raison d’une insuffisance rénale aiguë, d’une infection urinaire ou d’un sepsis); 2) toute autre cause de visite à l’hôpital; 3) toute autre cause d’admission; et 4) toute autre cause de visite aux urgences.Une régression de Poisson modifiée a été employée pour l’analyze des résultats sur les variables démographiques, l’utilization des soins de santé au cours de l’année précédente, les différentes procédures et maladies concomitantes liées au résultat au cours des cinq années précédentes et les médicaments prescrits au cours des 120 derniers jours afin de comparer le rapport de risque (RR) de chaque résultat entre les patients atteints ou non d’ADPKD.L’âge médian des sujets (écart interquartile) s’établissait à 44 ans (38-60 ans) dans le groupe de patients ADPKD et à 53 ans (42-64 ans) dans le groupe témoin; les femmes représentaient environ 40 % des sujets dans les deux groupes. Le risque de complications liées à l’urétéroscopie n’était pas significativement différent entre le groupe ADPKD et le groupe témoin (8,2 % vs 4,2 %; RR corrigé: 1,5; IC 95 %: 0,7 à 3,2). Tous les patients, avec ou sans ADPKD, étaient plus susceptibles de se présenter à l’hôpital après l’intervention (36,6 % vs 20,0 %; RR corrigé: 1,6; IC 95 %: 1,2 à 2,2). Ce résultat incluait un risque significativement plus élevé de se présenter aux urgences (32,9 % vs 19,0 %; RR corrigé: 1,6; IC 95 %: 1,1 à 2,2), mais pas d’être hospitalisé (11 % vs 5 %; RR corrigé: 1,8; IC 95 %: 0,9 à 3,4).Le faible nombre d’événements a mené à l’imprécision des estimations.Les patients atteints d’ADPKD présentent un risque accru de retourner à l’hôpital dans les 30 jours suivant une urétéroscopie pour traiter des calculs urinaires.L’étude n’a pas été enregistrée.

This study aimed to evaluate the urinary tract for dynamic function and stones and calcifications in patients with alkaptonuria. Thirty-eight patients were prospectively divided into two groups. Study group (A) involved 17 patients; the average age was 42 years. The control group (B) involved 21 patients; the average age was 37 years. All patients from the two groups underwent uroflowmetry assessment and ultrasonography for the kidneys and urinary bladder, and prostate in two phases (full bladder and empty bladder). Group A—Bladder volume ranged between 400 and 520 cc. The peak flow rate was between 7 and 23 mL/s, with an average of 18.6 mL/s. Flow rate curves shape were acceptable to the normal bell-shape curve in 11 patients. Seven patients (41%) had prostate calcification accounting for 5%–35% of prostate size. Group B—Bladder volume ranged between 290 and 510 cc. The peak flow rate was 8–27 ml/s, with an average of 20 mL/sec. Normal bell shape voiding curves were observed in 17 patients (80%). Four patients (19%) had prostate calcification accounting for 2%–12% of prostate size. Renal measurements on ultrasonography were the same in both groups. Patients with alkaptonuria developed prostate calcification at younger age; they have a slight but not statistically significant reduced peak urinary flow rate and post void residual urine.

Subtidal hard substrate habitats are unique habitats in the marine environment. They provide crucial ecosystem services that are socially relevant, such as water clearance or as nursery space for fishes. With increasing marine usage and changing environmental conditions, pressure on reefs is increasing. All relevant directives and conventions around Europe include sublittoral hard substrate habitats in any manner. However, detailed specifications and specific advices about acquisition or delineation of these habitats are internationally rare although the demand for single object detection for e.g., ensuring safe navigation or to understand ecosystem functioning is increasing. To figure out the needs for area wide hard substrate mapping supported by automatic detection routines this paper reviews existing delineation rules and definitions relevant for hard substrate mapping. We focus on progress reached in German approval process resulting in first hydroacoustic mapping advices. In detail, we summarize present knowledge of hard substrate occurrence in the German North Sea and Baltic Sea, describes the development of hard substrate investigations and state of the art mapping techniques as well as automated analysis routines.

Background Single-operator peroral cholangioscopy (sPOCS) is considered a valuable diagnostic modality for indeterminate biliary strictures. Nevertheless, studies show large variation in its characteristics and measures of diagnostic accuracy. Our aim was to estimate the diagnostic accuracy of sPOCS visual assessment and targeted biopsies for indeterminate biliary strictures. Additional aims were: estimation of the clinical impact of sPOCS and comparison of diagnostic accuracy with brush cytology. Methods A retrospective single-center study of adult patients who underwent sPOCS for indeterminate biliary strictures was performed. Diagnostic accuracy was defined as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The clinical impact of sPOCS was assessed by review of medical records, and classified according to its influence on patient management. Results 80 patients were included, with 40 % having primary sclerosing cholangitis (PSC). Prior ERCP was performed in 88 %, with removal of a biliary stent prior to sPOCS in 55 %. The sensitivity, specificity, PPV, and NPV for sPOCS visual impression and targeted biopsies were 64 %, 62 %, 41 %, and 84 %, and 15 %, 65 %, 75 %, and 69 %, respectively. The clinical impact of sPOCS was limited; outcome changed management in 17 % of patients. Sequential brush cytology sensitivity, specificity, PPV, and NPV were 47 %, 95 %, 80 %, and 83 %. Conclusions The diagnostic accuracy of sPOCS for indeterminate biliary strictures was found to be inferior to brush cytology, with a low impact on patient management. These findings are obtained from a select patient population with a high prevalence of PSC and plastic stents in situ prior to sPOCS.

Background: Because of the fear of being infected with coronavirus disease 2019 (COVID-19), patients with nephrolithiasis, who choose to stay home, may suffer serious complications such as obstructive uropathy, deterioration of renal function, sepsis, and death. We present such a case that led to renal failure and necessitated emergent urologic intervention. Case Presentation: A 60-year-old Caucasian man presented with right flank pain, dizziness, and dyspnea at the emergency room. History was significant for a previous diagnosis of right renal pelvic stone that was scheduled for retrograde intrarenal surgery before the pandemic lockdown. Upon evaluation, he was found to have an elevated creatinine of 40.2 mg/dL, bilateral hydronephrosis, pericardial and pleural effusion. The patient underwent emergency hemodialysis, followed by preliminary bilateral percutaneous nephrostomy, and subsequently by ureteral stenting. He was discharged stable with the future plan for endoscopic stone management. Conclusions: In the midst of the COVID-19 pandemic, urologists should follow up all known kidney stone patients, regularly assess their condition, and prioritize those who need urgent care. Patient education and telemedicine are useful tools for this purpose and may help minimize the risk of complications during a community lockdown.

Background Aim of our study is to analyze the incidence of postoperative infectious complications and to assess its predictors in patients with indwelling ureteral stent treated with ureteroscopy (URS). Methods We retrospectively evaluated data of patients treated with URS from January 2017 to July 2018 at our center. We included 88 consecutive patients with available stent culture (SC) and urine culture (UC). Cefoxitin 2 g IV was given as prophylaxis in all patients with negative preoperative UC; otherwise, the choice of antibiotic was based on antibiogram. Ureteral stent was removed before URS procedure and analyzed. No postoperative antibiotic was given. Multivariable logistic regression analysis was built to assess preoperative predictors of postoperative infectious complications. Results Nineteen patients (22%) developed postoperative infectious complications and fever was the most common one. E. faecalis, which is not responsive to common prophylaxis schemes in force in our institution, was the most frequent pathogen isolated. Overall, 26% of patients were found to have a discordance between SC and UC. At multivariable logistic regression analysis preoperative SC positivity (Odds Ratio [OR]: 11.00, 95% Confidence Interval [CI]:1.08-111.41, P=0.04) was the only significant predictor of postoperative infectious complications. Conclusions About one to five patients treated with URS developed an infectious complication and E. faecalis and E. coli were the most frequent pathogen isolated. A positive SC is the only independent risk factor for postoperative infection: consequently, an early SC analysis could allow a prompt antibiotic therapy in all patients with positive SC even if mildly symptomatic.

Background To report current worldwide variation in techniques and clinical practice of flexible ureteroscopy (FURS) among endourologists of different case volumes per year. Methods Two invitations to complete an internet survey were emailed to Endourological Society members. Some of survey questions asked about indications of using FURS for renal and upper ureteral stones. Others were concerned with clinical practice of FURS (such as preoperative stenting, use of ureteral access sheath (UAS) and safety guidewire, technique of Laser lithotripsy and fragment retrieval, and post-FURS stenting. Responders were distributed into two groups; high-volume (> 100 cases/year) and low-volume surgeons ( Results Responses were received from 146 endourologists all over the world (62 high-volume and 84 low-volume). FURS for intrarenal stone > 20 mm was used by 61% of high-volume surgeons compared with 28.6% for low-volume (P P = 0.044). UAS was used by 62% in low-volume group and 69% in high volume group (P = 0.516). Laser stone dusting was preferred by 63% in low-volume group versus 45% by high-volume (P = 0.031). More responders in low-volume group preferred to leave the stent for 6 weeks (P = 0.042). Conclusions The use of FURS for treating upper tract calculi has expanded by high volume endourologists to include large renal stones > 20 mm. Low-volume surgeons prefer to use semi-rigid URS for treatment of upper ureteral stones, to apply Laser stone dusting and maintain ureteral stents for longer periods.

Background Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention. Methods Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration. Results A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5–73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively. Conclusion SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.

Purpose: The aim is to assess the outcomes of different approaches for the management of renal stones associated with horseshoe kidneys (HSKs) in our institution over a 12-year period. Methods: A retrospective review of 144 patients with HSKs who presented from 2000 to 2012 was performed. Twenty-eight patients (19.4%) were found to have renal stones. Demographic data were collected; the method of treatment and the outcomes of stone management were reviewed. We excluded patients with non-functioning moieties and associated genitourinary anomalies, and those with incomplete data. Results: We included 25 patients, of which 16 males (64%) and 9 females (36%), with a mean age of 37 years. Mean serum creatinine level was 66 mmol/L. Eleven patients with a stone size 2 cm were treated with percutaneous nephrolithotomy. One patient with a 10 mm stone was treated using flexible ureteroscopy. No significant perioperative complications were encountered. Conclusions: Indications, methods of treatment, and outcomes of management of stones associated with HSKs were comparable to those for stones associated with normal kidneys. Tailored approach based on stone size is highly recommended. ESWL accompanied with ureteric stenting is a promising strategy for the management of stones associated with HSKs in selected patients requiring intervention.

Although rare, sulfamethoxazole-induced urolithiasis has been reported in patients taking trimethoprim-sulfamethoxazole (TMP/SMX). We present the case of a 79-year-old female who formed sulfamethoxazole stones in the setting of chronic indwelling catheterization with recurrent urinary tract infections (UTIs). The patient was a recurrent stone former with five prior stone composition analyses over a 10-year period varying from calcium phosphate to calcium oxalate, to struvite. We highlight the need for further investigation of this phenomenon given the frequent use of TMP/SMX in stone formers with recurrent infections.

BACKGROUND: Extracorporeal shockwave lithotripsy (ESWL) is the management of choice for renal stones 20 mm or smaller, with a stone clearance rate of up to 89%. The purpose of the present is to investigate the efficacy of a commercialised ESWL service, being performed as an outsourced treatment using a mobile lithotripsy system on an outpatient basis. Furthermore, the study aims to evaluate the risk of needing treatment with an internal ureteral double-J stent (JJ) after ESWL treatment.METHODS: During an eight-year period, 461 patients with a total of 589 renal stones were treated using a mobile lithotripsy system at a single Danish institution. A commercial company performed all treatments using a Storz Modulith SLK® system. Each stone was prospectively registered according to size, intra renal location and the presence of a JJ at the time of treatment. The number of required ESWL treatments and auxiliary procedures were retrospectively evaluated.RESULTS: The success rate after the initial ESWL procedure was 69%, which increased to an overall success rate of 93% after repeated treatment. A negative correlation was found between stone size and the overall success rate (r = -0.2, p < 0.01). The upper calyx was associated with a significantly better success rate, but otherwise intra renal stone location was not predictive for treatment success. A total of 17 patients (2.9%) required treatment with a JJ after the ESWL procedure. No significant difference was observed between the stone size or intra renal location and the risk of needing treatment with JJ after ESWL.CONCLUSIONS: Commercialised ESWL treatment can achieve an overall success rate of more than 90% using a mobile lithotripsy system. As expected, an inverse relation between stone size and success rate was found. Patients who do not require treatment with a JJ prior to ESWL will only rarely need treatment with a JJ after ESWL, irrespective of stone size and intra renal stone location.

Aims and Objectives: This study aims to evaluate the efficacy of tamsulosin and alfuzosin for the distal ureteral stone. This study assessed the spontaneous passage and expulsion of the stone. Materials and Methods: The study was conducted in the Department of Surgery at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, from May 2013 to May 2014. A total number of 136 patients diagnosed as distal ureteric stone (US) of size

PURPOSE: To investigate the prospective outcomes of day-case ureterorenoscopy (DC-URS) for stone disease. With the rising prevalence of stone disease in the face of finite resources, there is increasing pressure to undertake procedures as a day case avoiding in-patient stay. There are a limited number of studies reporting on the feasibility of ureteroscopy as a day-case procedure. This study aimed to investigate the prospective outcomes and predictors precluding to DC-URS for stone disease in patients treated in our university teaching hospital.MATERIALS AND METHODS: Between March 2012 and July 2016, consecutive cases of adult stone ureteroscopy performed or supervised by a single surgeon were recorded in a prospective database. Patients underwent pre-operative counselling in a specialist stone clinic and were admitted to a dedicated 'Surgical day unit' on the day of surgery. A standardised anaesthetic protocol was adhered to in all cases. Data on patient demographics, stone parameters, pre-operative assessment, operative details, length of stay, stone-free rate and complication rates were collected and analysed.RESULTS: A total of 544 consecutive adult ureteroscopy for stone disease were conducted over the study period with a day-case rate of 77.7%. Thirty-nine percent of failed day-case ureteroscopy were due to late completion of ureteroscopy and due to associated social circumstances of patients. The mean stone size, operating time duration and post-operative stent insertion rates for DC-URS patients were 14 mm, 46 min and 96.5%, respectively. Post-operatively, the mean stone-free rate (SFR), unplanned re-admissions and complications for DC-URS patients were 95, 4 and 4%, respectively. A higher failure of DC-URS was related to patient's age (p = 0.003), positive pre-operative urine culture (p < 0.001), elevated pre-operative serum creatinine (p < 0.001) and higher mean operating time (p < 0.02).CONCLUSION: Based on our results, a day-case ureteroscopy rate of nearly 78% can be achieved. With its acceptable complication rate, and low re-admission rates, DC-URS is a safe and feasible option in a majority of patients with stone disease.

Tuberculosis is rapidly reemerging as a major health problem due to rising incidence of HIV cases across the globe. Central nervous system involvement is rare, but rarely multiple intracerebral granulomas can occur or occasional solitary tuberculoma also develops. The authors report a unique case of 24-year-old woman suffering from pulmonary tuberculosis developed headache and vomiting. Cranial CT scan revealed multiple widespread deposit of intracranial granuloma of sizeable lesion mimicking starry sky at night appearance. Excision of one tuberculoma was done for confirmation of definitive diagnosis, and histopathology was suggestive of tuberculoma. The patient also underwent VP shunt surgery. At last follow-up at 15 years following surgery, she was doing well.

Images of Sculptures in the Poetry of Giorgis Manousakis The imagery of fragmentary sculptures, statues and stones appears often in Modern Greek Poetry in connection with the question of Modern Greeks’ relation to ancient Greek past and legacy. Many famous poets such as the first Nobel Prize winner in literature, George Seferis (1900-1971), as well as Yannis Ritsos (1909-1990) frequently use sculptural imagery in order to allude to, among other things, though in different approaches, the classical past and its existence in modern conscience as a part of cultural identity. In the present paper we focus on some selected poems by a well-known Cretan poet Giorgis Manousakis (1933-2008) from his collection “Broken Sculptures and Bitter Plants” (Σπασμένα αγάλματα και πικροβότανα, 2005), trying to shed some light on his very peculiar usage of sculpture imagery in comparison with the earlier Greek poets. We attempt to categorize Manousakis’ metaphors and allusions regarding the symbolism of sculptures in correlation with existential motives of his poetry and the poet’s attitude to the classical legacy.

Presence of multiple calculi in a single system ureterocele is a rare condition. A 3-year-old boy presented with recurrent urinary tract infections in whom multiple calculi were noted in the urinary bladder on x-ray and ultrasound scan. In addition, ultrasound showed the presence of ureterocele in the size of 18x15x12 mm. Open surgery revealed an ureterocele with multiple stones. Here, we present a boy with multiple stones in the left ureterocele diagnosed intra-operatively due to its rarity, etiology and treatment options.

Introduction The general prevalence of bilateral urolithiasis has risen to 15% and bilateral non-simultaneous treatment has been reported to have good outcomes. The objective of this study was to evaluate the effectiveness and safety of simultaneous bilateral endoscopic surgery (SBES). Material and methods An international multicenter analysis was performed between May 2015 and December 2017. All patients with bilateral stone disease that underwent SBES were included. Patients were treated under general anesthesia in either the supine or lithotomy position. Demographic, clinical, intraoperative and postoperative data were analyzed. Results A total of 47 patients were included. Mean age was 53.8 years and 70% of the patients were males. The mean American Society of Anesthesiology (ASA) score was 2. The mean diameter of right- and left-sided stones was 29.43 mm (2-83 mm) and 31.15 (4-102 mm), respectively. Staghorn stones were treated in 18 cases (8 right-sided and 10 left-sided), four of them were defined as complete staghorn. The procedures performed were 42 cases of bilateral URS and PCNL and ureteroscopy. Additionally, 5 bilateral flexible ureteroscopy (fURS) cases were described. Intraoperative complications occurred in five patients: four of them were classified as Clavien-Dindo (CD) I and one as CD II. Postoperatively, there were two cases with CD I, 6 with CD II and one CD IIIa.The stone-free status was 70%. Residual stones (30%) were detected only on the side treated for high-volume (complete) staghorn calculi. Conclusions SBES is a feasible, effective and safe procedure. It may potentially avoid repeated anesthetic sessions as needed for staged procedures and reduce the length of patients' hospital stay.

Background It is generally thought that gallbladder motility plays a more or less important role in the pathogenesis of gallstones. Some studies have shown that some abnormalities of its intrinsic innervations, but these studies were usually limited to one cell component. Aims We investigated the main cell components of gallbladder intrinsic innervation in patients with and without gallstones. Methods Archival gallbladder specimens from 39 patients, 27 with gallstones (age range 45–69 yrs) and 12 patients without gallstones (age range 39–71 yrs) were obtained. Full thickness sections were obtained from the gallbladder neck and immunohistochemistry was carried out for enteric neurons (neuron-specific enolase and calretinin), enteric glia (S100) and interstitial cells of Cajal (CD117 and CD34); tryptase staining was also done to distinguish the latter from mast cells. Results Apart from calretinin-positive neurons, patients with gallstones featured a significant decrease of neurons, enteric glial cells (EGC) and mast cells compared to those without gallstones; interstitial cells of Cajal were extremely few and only found in two patients, one for each group. Conclusions The intrinsic innervations of the gallbladder is abnormal in gallstone patients, and this may contribute to gallstone formation in these subjects.

Objective To review the literature reporting the technique of percutaneous nephrolithotomy (PCNL) and outcomes for prone and supine PCNL, as PCNL is an established treatment for renal calculi and both prone and supine PCNL have been described, but there has been much debate as to the optimal position for renal access in PCNL. Methods A review of the medical literature was conducted using the PubMed database to identify relevant studies reporting on prone and supine PCNL published up until July 2015. Only publications in English were considered. Search terms included ‘supine’, ‘prone’, ‘percutaneous nephrolithotomy’, ‘PCNL’ and ‘randomised controlled trial’. Articles relevant to the particular aspect of PCNL discussed were selected. Results In all, 30 articles were included in the literature review. Nine of these articles were of Level 1 Evidence as graded by the Oxford System of Evidence-based Medicine. Conclusion The present systematic review highlights the benefits and disadvantages of supine and prone PCNL. The published data on supine and prone PCNL have shown no significant superiority of either approach. Whether prone or supine PCNL is optimal, remains a debatable topic.

Introduction The management of nephrolithiasis in patients with a solitary kidney poses a treatment challenge. The study aimed to evaluate the outcomes of ureteroscopy and laser stone fragmentation (URSL) for renal stones in these patients treated in our university teaching hospital. Material and methods Between July 2012 and December 2014, seventeen cases of URSL for stones in a solitary kidney were reviewed. Patient demographics, stone dimensions, perioperative and post-operative outcomes were recorded in a prospectively maintained database. Serum creatinine levels pre-procedure and at follow-up were also compared. Results Seventeen cases of URSL were conducted with a mean age of 52.9 ±19.9 years. 8 of the 17 (47%) patients had stones in multiple locations and 13 (76%) were in the lower pole. The mean ± SD stone size and BMI were 13.0 ±8.9 mm and 31.6 ±5.8 kg/m(2), respectively. The stone free rate (SFR) was 82.5%. Fourteen (82.5%) patients were discharged the same day and 16 cases (94%) were discharged within 24 hours. For patients with deranged pre-operative serum creatinine, the mean serum creatinine level improved from 131.2 ±68.3 µmol/L pre-URSL to 106.5 ±36.7 µmol/L at follow-up. There was one Clavien grade II complication with a patient requiring additional antibiotics for post-operative urinary tract infection. There were no other major or minor complications. Conclusions Day case ureteroscopy for stone disease in a solitary kidney is safe and feasible with a low complication rate and an overall improvement in renal function.

Conselho Nacional de Pesquisa e Desenvolvimento (CNPq) Uric acid nephrolithiasis and unduly acidic urinary pH are both considered a renal manifestation of insulin resistance but the underlying mechanisms for the development of low urinary pH and the propensity for uric acid stone formation are not completely elucidated. Nevertheless, excessive dietary acid intake, increased endogenous acid production and/or defective NH4+ excretion play an important role, among other factors. The main principles of therapy for uric acid nephrolithiasis are aimed at urinary alkalinization through diet modification or pharmacologic agents, increase of urinary volume, and less importantly at the reduction of uric acid excretion. Fed Univ Sao Paulo UNIFESP, Div Nephrol, Rua Botucatu 740, BR-04023900 Sao Paulo, SP, Brazil Fed Univ Sao Paulo UNIFESP, Div Nephrol, Rua Botucatu 740, BR-04023900 Sao Paulo, SP, Brazil CNPq: 305638/2012-2 Web of Science

Introduction: Flexible ureteroscopy (fURS) is an endoscopic procedure for the minimally invasive treatment of ureteral and renal calculi. Due to improvements in technique and ureteroscopic instrumentation over the past two decades, complications associated with URS are infrequent. However, in the event of an unexpected device malfunction or failure, the operating surgeon must employ prompt, resolute decision-making to resolve any intraoperative complications and avoid significant injury to the kidney or ureter. Case Presentation: The patient was a 53-year-old male with a 7 mm left upper pole renal stone managed by fURS and laser lithotripsy. A ureteral access sheath (UAS) was not deployed during the procedure. During fragmentation of the stone, we were unexpectedly unable to retract the ureteroscope from the ureter. Herein, we describe the procedural details leading up to the complication and the careful maneuvering required to remove the ureteroscope without damaging the ureter or the instrument. Conclusions: We recommend use of a UAS during fURS for the treatment of ureteral and renal calculi, if not using ureter access sheath, not advancing the ureteroscope above the stone, leaving it behind the tip of the instrument, while in the ureter. Utilization of a ureter access sheath could have possibly avoided this kind of complication.

Objectives: The objective is to evaluate the relative risks of ureteric stents application while managing uric acid stones with potassium citrate in terms of stone encrustations and urinary tract infection (UTI). Patients and Methods: We prospectively enrolled patients with renal uric acid stones who received K citrate from 2013 to 2018. Patient's demographics were collected. All patients were evaluated using noncontrast computed tomography (CT) scan to measure the stone size and density. JJ ureteric stent was inserted prior to the initiation of treatment. At follow-up, all patients underwent urine analysis for pH and to detect UTI. CT was repeated at 1 month and those patients who showed incomplete stone resolution underwent another course of treatment for another month. CT was repeated prior to stent removal. The presence of encrustations was inspected and collected. Results: We collected 59 patients with a median age of 36 years (18–73) and median stone burden of 26 mm3 (15–50). The median stone density was 310 HU (175–498). Twenty-one patients (35.6%) received K citrate treatment for 1-month, while the remaining patients had 2 months treatment. Sixteen patients (27.1%) had a complete stone dissolution, 41 patients (69.5%) had more than 50% decrease of stone burden while only 2 patients (3.4%) had stones with poor dissolution. Four patients (6.8%) experienced UTI while 2 patients (3.4%) had visible JJ encrustations. Most of these complications occurred when the treatment was offered for the 2nd month. Conclusion: Short-term use of ureteral stents is safe during the management of uric acid stones with K citrate.

Background There are abnormalities in vitamin D metabolism in people with calcium nephrolithiasis, but limited data are available on vitamin D status in dogs with calcium oxalate (CaOx) urolithiasis. Objective To compare serum concentrations of vitamin D metabolites in dogs with and without hypercalciuric CaOx urolithiasis. Animals Thirty-eight dogs with (n = 19) and without (n = 19) a history of CaOx urolithiasis and hypercalciuria. Methods Retrospective cross-sectional study. Serum 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)2 D], and 24,25-dihydroxyvitamin D [24,25(OH)2 D] were measured. The ratios of 25(OH)D/24,25(OH)2 D and 1,25(OH)2 D/25(OH)D were compared between cases and controls. Results There were no significant differences between cases and controls when comparing 25(OH)D, 24,25(OH)2 D, 1,25(OH)2 D, or 1,25(OH)2 D/25(OH)D. Cases had higher 25(OH)D/24,25(OH)2 D (median = 1.40, range = 0.98-1.58) compared to controls (median = 1.16, range = 0.92-2.75; P = .01). There was overlap in the ranges for 25(OH)D/24,25(OH)2 D between cases and controls, but 6 cases (32%) had ratios above the control dog range. There was a moderate positive correlation between the ratio of 25(OH)D/24,25(OH)2 D and urinary calcium-to-creatinine ratios (r = 0.40, 95% confidence interval = 0.10-0.64; P = .01). Conclusions and clinical importance These data suggest that decreased conversion of 25(OH)D to 24,25(OH)2 D occurs in a subset of dogs with CaOx urolithiasis. Abnormalities in vitamin D metabolism might contribute to stone risk in dogs.

In this paper, preliminary results of variations as a function of applied pressure in the reflection coefficient of a planar patch resonator, placed in contact with cultural heritage stone materials, will be presented. The general aim of the experimental project is to correlate the resonant frequency of the planar sensor, for the different pressures applied to the resonator, with the different levels of water content $\theta_{v}$ of the tested stone material. In fact, in previous works, it has been demonstrated that by placing a planar resonator in contact with the considered stone sample, it is possible to associate the resonant frequency of the resonator with the moisture content of the stone sample, through reflection scattering parameter measurements. In previous studies, however, the level of applied pressure is not standardized and controlled. An application of an external force could improve the repeatability and increase the detectability of the first resonance peak. The current study shows a negligible resonant frequency shift among measurements with different applied pressures at the same water content $\theta_{v}$ level, but a significant change regarding Q factor. Moreover, applying an external force on the patch, the first resonance peak can be identified more easily, thanks to an increase in the Q factor.

Background and objective: This study aimed to evaluate the effect of adding postoperative antibiotics in reducing the incidence of symptomatic urinary tract infections following ureteroscopic stone treatment beyond the recommended preoperative dose. Methods: This prospective comparative study was conducted between March and November 2017. A total of 80 patients with preoperative negative urine cultures who underwent ureteroscopy were randomly allocated. All the patients received a single dose antibiotic before the induction of anesthesia, and a group of them also received postoperative antibiotics. The rate of symptomatic urinary tract infection was compared between the patients who received only preoperative antibiotics (group 1) and those who received pre- and postoperative antibiotics (group 2). Results: Eighty patients underwent ureteroscopy for stone treatment. The time to follow up was 4±2 weeks from ureteroscopy. Eleven (13.8%) patients in total developed urinary tract infections postoperatively, including five (12.5%) from group 1 and six (15%) from group 2, P = 0.74. In group 1, four patients presented with cystitis and one with sepsis; those patients with infections in group 2 presented with pyelonephritis (n=2) and cystitis (n=4). Risk factors such as preoperative stenting, nephrostomy tubes, and Foleys catheters did not differ between groups. Conclusion: The postoperative symptomatic urinary tract infection rate in this study (13.8%) is in agreement with previous reports. This study suggests that a single preoperative dose of antibiotics is sufficient, and additional postoperative antibiotics do not decrease infection rates after ureteroscopic stone treatment.

Introduction. We analyzed efficacy and complications of extracorporeal shock wave lithotripsy (SWL) and analgesia requirement during the treatment in two groups of patients treated with different lithotripters. Materials and methods. The patients treated were 189, 102 between September 2016 and April 2017 with HMT Lithotron® LITS 172, electrohydraulic, and 87 between May and September 2017 with Storz Medical Modulith® SLK, electromagnetic. The main differences between the lithotripters are: type of energy source, patient position, frequency and number of shock waves. All the patients underwent sonography before and four to eight weeks after the treatment. The targeting was sonographic for renal stones and X-ray for ureteral stones. All the patients received Ketorolac before the treatment with a supplement of Pethidine if needed. People lost to follow-up and with incomplete data were excluded. Results. We enrolled 173 patients, 94 treated with the electrohydraulic lithotripter and 79 with the electromagnetic one. 43 patients (54%) in the electromagnetic group and 31 (33%) in the electrohydraulic group were stone free or presented clinically insignificant residual fragments (CIRFs), defined as asymptomatic, noninfectious, ≤ 3 mm. The association between CIRFs and the kind of lithotripter was statistically significant (p = 0.004). An increased need for analgesia was found in 14.9% of patients in the electromagnetic group and in 81% of patients in the electrohydraulic group (p < 0.001). The access to emergency room (intractable pain, kidney failure, fever, Steintrasse) after the treatment was similar in the two groups (p = 0.37). Conclusions. The best results in stones fragmentation and less analgesia requirement were demonstrated in the electromagnetic lithotripter group. No differences were demonstrated considering the need for emergency room after the treatment

Background Gallbladder disease (GBD) is a highly prevalent condition; however, little is known about potential differences in risk factors by sex and ethnicity/race. Our aim was to evaluate dietary, reproductive and obesity-related factors and GBD in multiethnic populations. Methods We performed a prospective analysis from the Multiethnic Cohort study who self-identified as non-Hispanic White (n = 32,103), African American (n = 30,209), Japanese (n = 35,987), Native Hawaiian (n = 6942) and Latino (n = 39,168). GBD cases were identified using Medicare and California hospital discharge files (1993–2012) and self-completed questionnaires. We used exposure information on the baseline questionnaire to identify exposures of interest. Associations were estimated by hazard ratios and 95% confidence intervals using Cox models adjusted for confounders. Result After a median 10.7 years of follow-up, there were 13,437 GBD cases. BMI over 25 kg/m2, diabetes, past and current smoking, red meat consumption, saturated fat and cholesterol were significant risk factors across ethnic/racial populations (p-trends

Urinary tract stone disease is common, important and increasing: the lifetime prevalence of stones is ~10 % in developed countries, and it disproportionately affects people of working age. After passage of a first stone, the risk of recurrence is 40 % at 5 years and 75 % at 20 years [1]. The incidence of stone disease has always been higher in certain areas such as the Arabian Gulf countries but is increasing internationally [2, 3]. Some of this is due to improvements in stone detection using CT scanning, but changes in dietary and fluid intake habits [4–7] and increased rates of obesity and metabolic syndrome [7, 8] are more important contributors. The incidence of stones in children has increased by 19 % in the last 10 years, the age at first presentation is reducing, and the traditional male to female ratio of 3:1 is changing to a greater proportion of women.

OBJECTIVE: To compare the results of balloon dilatation (BD) vs. telescopic metal dilators (TMDs) in establishing the tract for percutaneous nephrolithotomy (PCNL) in patients with calyceal stones or staghorn stones, but with no hydronephrosis. PATIENTS AND METHODS: Data from selected patients over 4 years were recorded retrospectively. Patients with complex staghorn stones, an undilated targeted calyx, or the stone filling the targeted calyx, were included in the study. In all, 97 patients were included, of 235 undergoing PCNL between March 2010 and March 2014, and were divided into two groups according to the technique of primary tract dilatation. Group A included patients who had BD and group B those treated using TMDs. RESULTS: In group A (BD, 55 patients) dilatation was successful in 34 (62%). The dilatation failed or there was a need for re-dilatation using TMD in 21 patients (38%). In one of these 21 patients the dilatation failed due to extravasation. In group B (TMD, 42 patients) dilatation was successful in 38 (90%) patients, with incomplete dilatation and a need for re-dilatation in four (10%) patients, and no failed procedures. Group A had a significantly higher failure rate than group B (P

The fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism (PHPT) has recently suggested that skeletal and renal imaging be routinely conducted. So far, no study has systematically assessed this issue.The objective was to evaluate the prevalence of kidney stones (KS) and vertebral fractures (VFs) in a cohort of patients with PHPT utilizing noninvasive imaging technology.This was a prospective study evaluating patients consecutively diagnosed with PHPT in a single center over a 5-year period (2009-2013).The setting was a referral center.There were a total of 140 patients with PHPT (127 women [18 premenopausal and 109 postmenopausal] and 13 men; mean age, 63.2 ± 11 y).Main outcome measures were the prevalence of KS by abdominal ultrasound, osteoporosis by dual-energy x-ray absorptiometry (DXA) (lumbar spine, femoral neck, total hip, and distal 1/3 radius), and VFs by vertebral spine x-ray, with attention to those categorized as symptomatic or asymptomatic.Fifty-five percent of all subjects had KS by ultrasound, 62.9% had osteoporosis by T-score at any site, and 35.1% had VFs by x-ray. There was no difference in the incidence of VFs and densitometric osteoporosis between symptomatic and asymptomatic patients (VFs, 34.4 vs 34.7%; osteoporosis by DXA, 59.4 vs 65.8%), whereas more KS were detected in symptomatic (78%) than asymptomatic (35.5%). Twenty-two percent of patients classified as asymptomatic at baseline without osteoporosis by DXA were found to have KS and/or VFs.Nephrolithiasis and VFs are common in asymptomatic subjects with PHPT. The results provide evidence in support of recent recommendations that a more proactive approach be taken to detect silent bone and stone disease in asymptomatic PHPT.

Purpose: Double-J stent placement after stone removal by ureteroscopy (URS) is common and recommended in many cases but debatable in others. In this study, the risks and benefits of postoperative Double-J stent placement in URS stone treatment procedures undertaken in current clinical practice are examined.Materials and Methods: The Clinical Research Office of Endourological Society (CROES) URS is a prospective, observational, international multicenter study, in which patients are candidates for URS as primary treatment or after failure of prior treatment for ureteral and renal stones. Baseline, intraoperative, and postoperative data were collected. Predictors and outcomes of postoperative stent placement were analyzed by inverse probability-weighted regression adjustment of the relationship between a Double-J stent placement and outcomes (complications, readmission [including retreatment], and length of hospital stay).Results: Significant predictors of postoperative Double-J stent placement in URS treatment of ureteral stones were intraoperative complications, impacted stones, operation time, stone burden, age, presence of a solitary kidney, and stone-free rate. In renal stone treatment, the predictors identified included operation time, age, preoperative stent placement, anticoagulant use, presence of a solitary kidney, and intraoperative complications. In both ureteral and renal stone treatment groups, postoperative placement of a Double-J stent resulted in significantly fewer postoperative complications (p Conclusions: Patient-and procedure-related variables were identified, which may enable an individualized approach to postoperative stenting, resulting in improved clinical outcomes in urologic stone treatment by URS.

Purpose To compare intra- and post-operative outcomes of endourological live surgical demonstrations (LSDs) and routine surgical practice (RSP) for urinary stones. Methods Consecutive ureterorenoscopic (URS) and percutaneous (PNL) urinary stone procedures over a 5-year period were reviewed. Procedures were divided into LSDs and RSP. Differences between the groups were separately analysed for URS and PNL. Primary outcomes included intra- and post-operative complication rates and grades. Secondary outcomes were operation time, length of hospital stay, stone-free rate, and retreatment rate. Pearson’s Chi-square analysis, Mann–Whitney U test, and logistic and linear regression were used to compare outcomes between LSDs and RSP. Results During the study period, we performed 666 URSs and 182 PNLs, and 151 of these procedures were LSDs. Among URSs, the overall intra-operative complication rate was 3.2% for LSDs and 2.5% for RSP (p = 0.72) and the overall post-operative complication rate was 13.7% for LSDs and 8.8% for RSP (p = 0.13). Among PNLs, the overall intra-operative complication rate was 8.9% for LSDs and 5.6% for RSP (p = 0.52) and the overall post-operative complication rate was 28.6% for LSDs and 34.9% for RSP (p = 0.40). For both URSs and PNLs, no statistically significant differences in complication grade scores were observed between LSDs and RSP. Operation time was significantly longer for LSD-URS group, but there was no difference between the PNL groups. There were no significant differences in length of hospital stay and stone-free rate. The retreatment rate was higher in the LSD-URS group compared with RSP-URS group but similar between the PNL groups. Multiple logistic regression analyses, adjusting for confounders, revealed no association between LSD and more or less favourable outcomes as compared to RSP. Conclusion Live surgical demonstrations do not seem to compromise patients’ safety and outcomes when performed by specialised endourologists. Electronic supplementary material The online version of this article (doi:10.1007/s00345-017-2050-4) contains supplementary material, which is available to authorized users.

A best evidence topic in surgery was written according to a structured protocol. The question addressed was: in patients with symptomatic gallstones and concomitant common bile duct (CBD) stones, is a single-stage surgical strategy (laparoscopic cholecystectomy (LC) with common bile duct exploration) preferable, or a two-stage procedure involving LC with pre or post-operative endoscopic retrograde cholangiography (ERCP)? Two hundred and six papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. A recent large meta-analysis concluded no significant difference in the clinical effectiveness or complication rate of either strategy. Three recent smaller studies concurred with this conclusion; however each noted improved cost-effectiveness of the single-stage approach advocating its use as the superior strategy when local resources and expertise are available. We conclude that for patients with symptomatic gallstones and concomitant choledocholithiasis, a single-stage surgical procedure is equivalent to two-stage LC and ERCP in terms of clinical outcomes, is associated with a shorter overall hospital stay and may be more cost-effective. On this basis a single-stage procedure is recommended for management of symptomatic gallstones and choledocholithiasis where local resources and expertise permit.

The objective of this review article is to present the current literature on medical expulsive therapy (MET) and help guide practitioners in the appropriate use of MET for treatment of stone disease. Kidney stones can be treated with multiple modalities including medical therapy, ureteroscopy, shock wave lithotripsy (SWL), percutaneous nephrostolithotomy, open/laparoscopic stone removal, and/or combinations of these modalities. The choice of intervention depends on patient factors, anatomical considerations, surgeon preference, and stone location and characteristics. MET is an excellent treatment modality in the appropriately selected patient. The AUA/EAU guidelines suggest MET as a reasonable treatment choice in select patients. A review of the data suggests the use of alpha antagonist and calcium channel blockers can improve stone expulsion rates. Most data suggests alpha antagonists as superior to calcium channel blockers. There are numerous available alpha antagonists, all of which have supporting data for their use in MET. Evidence suggests that MET can decrease colic events, narcotic use, and hospital visits. MET may also reduce medical costs and prevent unnecessary surgeries and the associated risks. Further, there is a role for alpha antagonists and calcium channel blockers in improving stone passage and decreasing pain in those subjects treated with other modalities (i.e. SWL and ureteroscopy). Despite this evidence, MET remains underutilized as a treatment modality.

Objective: This study aims to determine the yield of EUS in patients with common bile duct (CBD) dilation and normal liver function tests (LFTs). Materials and Methods: Between October 2000 and December 2016, all patients referred for EUS for unexplained CBD dilatation (CBD ≥7 mm), with normal aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and bilirubin and no history of sphincterotomy, were eligible. Linear-array EUS was performed by one of the two experienced endosonographers. Data were extracted from a prospectively maintained database. Results: Of 29,920 upper gastrointestinal EUS procedures performed, 840/29,920 (3%) were for unexplained CBD dilation. Of 840 patients, 199 (24%) had normal LFTs, 99% were Caucasian, 46% had biliary-type abdominal pain, and 41% were postcholecystectomy. EUS diagnosed choledocholithiasis (CDL) or sludge in 18/199 (9%) patients (7/18 had CBD sludge only). No other pathology was diagnosed. Of 18 CDL patients, 15 (83%) had an intact gallbladder, and all 15 patients had cholelithiasis. The frequency of CDL or sludge in postcholecystectomy patients was only 3.7% (3/82); none of these patients were younger than 69 years of age. Regression analyses showed no associations between EUS diagnosis of CDL or sludge and biliary-type abdominal pain, other symptoms, sex, or race. Each additional year of age was associated with an increase in the risk of CDL or sludge by a factor of 1.05 (odds ratio: 1.05; P = 0.034). Summary: In patients with CBD dilation and normal LFTs, the only significant pathology identified is CBD stones or sludge (almost exclusively in elderly patients with cholelithiasis). Conclusion: EUS should be avoided in patients with dilated bile ducts and normal LFTs, especially if under 65 years of age and postcholecystectomy.

Objectives: The main objective of this study is to determine the prevalence and risk factors of urolithiasis among the Saudi population in Makkah region. Methods: A cross-sectional survey was conducted on February 2017 in Makkah region (Makkah, Jeddah, and Taif). Data were obtained through direct interviews with participants, using an 18-questions-self-questionnaire, inquiring about demographic data (age, gender, weight, height, location, and occupation), educational level, history of renal stone disease (symptoms, modality of diagnosis, hospital admission, and previous treatment), and risk factors of stone formation such as family history and daily fluid intake. Results: A total of 1506 individuals were interviewed, including 82% from Makkah, 15.7% from Jeddah, and only 2.3% from Taif. The overall percentage of those diagnosed urolithiasis was 6.2%; including 6.6% males and 5.8% females (P = 0.06). Of those with stones, 5% were medically treated, 1.7% were hospitalized, and 1.2% were surgically managed for stones. There was a positive linear correlation between the prevalence of stones and participants' age group (r = 0.87, P = 0.01). More than 80% of participants were highly educated, which did not impact the prevalence of stones formation (P = 0.14). Urolithiasis was reported by 8.9% obese participants, 5.9% overweight, and 5.4% with normal body mass index (r = 0.68, P = 0.03). When stratified by jobs, stone prevalence significantly increased in retired participants (17.2%) than in workers (8.8%), followed by those without work (7.7%) and finally by students (3.3%) (P < 0.001). There was no significant difference between urolithiasis and type of drinking water (P = 0.62). Conclusion: The prevalence of urolithiasis in the Western region of Saudi Arabia has not changed much since the previous report, which was 30 years ago. It seems that the middle-aged population in their third decade of life, those who are overweight and obese people are at a high risk of developing urolithiasis.

OBJECTIVE To discuss the current concepts in lower ureteric stone management. MATERIAL AND METHODS Between October 2008 and November 2010, 190 patients of both sexes and of different age groups with lower ureteric stones, underwent in situ extracorporeal shock wave lithotripsy (ESWL) (48 cases), ureterorenoscopy (URS) (120 cases) and open stone surgery (OSS) (22 cases). The patients' clinical and radiological findings, as well as stone characteristics, were reviewed and correlated with the stone-free status. RESULTS In the ESWL group, the operative time was 43.13 +22.5 min; the average number of sessions/patients was 1.5 sessions; the average number of SW/patients was 4500 SW/patients; the average energy was 16.5 kV; the average stone burden was 7.8/mm; the overall stone-free rate was 75% (36/48); and the average radiation exposure time was 3.5 min. In the URS group, the operative time was 49.21 +16.09 min; the average stone burden was 10.81mm; the overall stone-free rate was 97.5% (117/120); the average hospital stay was 3.99 days; and the average radiation exposure time was 0.75 min. In the OSS group, the operative time was 112.38 +37.1 min; the overall stone-free rate was 100% (22/22); and the average hospital stay was 9.74 days. CONCLUSION In the management of patients with lower ureteral stones, URS, SWL and OSS were considered acceptable treatment options. This recommendation was based on the stone-free results, morbidity and retreatment rates for each therapy.