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Although percutaneous nephrolithotomy (PCNL) is less morbid than open surgery, it still carries risks of significant complications as well as injury to the renal parenchyma. Flexible ureteroscopic stone removal, although causes no appreciable damage to the renal parenchyma, has limitations, most notably, a lower stone-free rate than PCNL. Advances in our knowledge regarding ureteral physiology combined with technical developments applied to ureteral access sheath deployment and size may well propel retrograde intrarenal surgery to the forefront of kidney stone removal, regardless of stone size or location.

To study patients who presented to the Emergency Department with acute renal colic to determine if resolution of hydronephrosis and pain accurately predicts stone passage on follow-up CT.This is a secondary analysis of a multicenter prospective randomized clinical trial of patients diagnosed by computed tomography (CT) scan with a symptomatic ureteral stone9 mm in diameter. Participants were followed after randomization to evaluate for analgesic use and to assess stone passage and hydronephrosis on a repeat CT scan obtained at 29-36 days.Four-hundred-three patients were randomized in the original study and patients were included in this analysis if they did not have surgery for stone removal and had a CT scan and information on pain medication at follow-up (N = 220). Hydronephrosis was detected in 181 (82%) on initial CT. At follow-up CT, 43 (20%) participants had a persistent ureteral stone. Of these patients, 36 (84%) had no pain, 26 (60%) did not have hydronephrosis, and 23 (53%) had neither pain nor hydronephrosis. Resolution of hydronephrosis was associated with stone passage (RR 4.6, 95% CI 1.9, 11.0), while resolution of pain was not (RR 1.1, 95% CI 0.9, 1.4).In patients with urinary stone disease, stone passage is associated with resolution of hydronephrosis but not resolution of pain. In patients with persistent ureteral stones, neither pain nor hydronephrosis are consistently present. These findings have important implications on follow-up imaging of patients with urinary stone disease.

Summary. Purpose. To optimize the tactics of endoscopic interventions for cholelithiasis complicated by obstruction of the terminal portion of the common bile duct to reduce the incidence of postoperative complications and mortality in elderly and senile people. Materials and methods. The results of examination and treatment of 221 elderly and senile patients with cholelithiasis complicated by obstruction of the terminal section of the common bile duct were analyzed. Results. Using of existing methods and proposed new methods of endoscopic management of cholelithiasis complicated by obstruction of the terminal section of the common bile duct allow to reliably reduce the incidence of postoperative complications in elderly and senile patients from 19.8 to 9.5%, postoperative mortality from 10.3 to 2.9% Conclusions. In elderly and senile patients with obstruction of the terminal section of the common bile duct and common bile duct stones who bear high operational risk, endoscopic papillosphincterotomy with stone removal is a sufficient method of treatment. In case of unremovable common bile duct stones, endoscopic papillosphincterotomy and stenting allow to avoid revision of the common bile duct, and in high-risk patients those methods allow to refrain from open surgery.

Renal stones are the third most common problem affecting about 10% of global population. The management of nephrolithiasis has undergone a complete transformation since the 1980s. Percutaneous nephrolithotomy (PCNL) has established itself an effective and safe technique that delivers high stone-free rate as well as overall shorter treatment time. We aim to compare the outcome of mini-PCNL with standard-PCNL in patients presenting with renal stones. In all, 90 patients fulfilled the selection criteria and randomized into two groups. Group A underwent mini-PCNL whereas Group B underwent standard-PCNL. Pre-operative hemoglobin level was recorded. Duration of procedure as well as drop in hemoglobin level was also recorded. A kidney, ureter, and bladder (KUB) X-ray was performed to confirm the presence of of stone and stone-free status. The mean age of patients in mini-PCNL group was 43.11 years and in standard-PCNL group, it was 36.91 years. The mean stone size in patients of mini-PCNL group was 29.53 mm and 31.58 mm in standard-PCNL group. The mean duration of renal stone in mini-PCNL group was 1.91 years and that in standard-PCNL group 1.80 years. The mean operative time in mini-PCNL group was 59.56 min and 61.22 min in standard-PCNL group. The mean fall in hemoglobin in mini-PCNL group was 0.38 g/dL and that in standard-PCNL group 0.51 g/dL. In mini-PCNL group, stone clearance was observed in 42 (93.3%) patients, while in standard-PCNL group, it was observed in 45 (100%) patients. This difference was insignificant (P > 0.05). Mini-PCNL and standard-PCNL have no significant differences in terms of outcome, operative time, and stone clearance, although fall in hemoglobin level was less in mini-PCNL group, which showed less blood loss in this group, thereby making it a more appropriate method for renal stone removal.

Objectives/hypothesis For patients with submandibular sialolithiasis, there are many gland-preserving treatment options including sialendoscopy. Sialendoscopy, however, requires expensive instrumentation with limited availability, which may not be required for routine cases. The objective of this study is to compare the outcomes of patients with submandibular sialolithiasis undergoing sialendoscopy versus those undergoing transoral incisional sialithotomy. Study design Longitudinal, prospective study of patient undergoing gland-preserving therapy for submandibular sialolithiasis. Methods The study was a prospective, nonrandomized trial of 30 patients with submandibular sialolithiasis who received gland-preserving treatment by either sialendoscopy-assisted techniques (Scope group; 14 patients) or transoral sialithotomy with or without dochoplasty (No Scope group; 16 patients). Factors analyzed between the two groups included age, race, gender, size of stone, location of stone, gland(s) involved, surgical method, and modified salivary Oral Health Impact Profile (sOHIP) scores before and after therapy. Results There were no significant differences between the Scope and No Scope groups regarding age, race, or gender. There was a significant difference in stone size between the groups, with the No Scope group having larger stones on average. Both treatments led to statistically significant symptomatic improvement in sOHIP scores. There was no statistically significant difference in salivary quality of life improvement between the Scope and No Scope groups (P = .33). Conclusions Sialendoscopy is an important diagnostic and therapeutic tool in the management of salivary disorders, but is not associated with improved outcomes in gland-preserving treatments for routine submandibular sialolithiasis. Transoral stone removal alone may have equivalent symptomatic outcomes in the management of select sialoliths. Level of evidence III Laryngoscope, 2021.

Introduction and Objectives We aimed to point out the ureteral access facility and obstruction removal efficiency of mini-URS in the use of proximal ureteral stone management in children under five-year-old. Patients We retrospectively reviewed the data of 26 children who underwent mini-URS-LL for obstructive stones in proximal ureter between January 2016 and August 2018. The effectiveness of the mini-URS-LL was assessed based on the feasibility, reliability, and success of the technique. Results Mean age was 3 ± 1.3 years, and 11 (42.3%) patients were ≤2 years old, remaining 15 (57.7%) were aged 3−5 years. Mean stone size was 9.11 ± 3.02 mm. A stone-free status was obtained at the end of 31 ureteroscopic procedure in 24 (92.3%) patients. The mean age was found significantly higher in patients who had the procedure without pre-stenting than the others who did (P = .027). No perioperative complication was experienced. Conclusion In preschool-age children, laser lithotripsy with mini-URS may be a safe technique in the hands with advanced endo-urological skills but it has low efficacy with higher rates of prestenting causing additional anesthesia sessions.

Objective The safety and prognosis of complete stone removal for the treatment of choledocholithiasis in older patients are unknown. This multicenter retrospective study assessed the outcomes of complete stone removal in elderly patients (≥90 years) with respect to the prognosis. Methods We divided patients who underwent endoscopic cholangiopancreatography for choledocholithiasis into two groups: complete stone removal or incomplete stone removal with plastic stent insertion. The patient characteristics, adverse events, number of endoscopic cholangiopancreatographies, overall survival rates, and disease-specific cumulative death were compared between the groups. Patients Two hundred and twenty-three participants ≥90 years old were included in the study, including 48 (22%) men and 175 (78%) women. The median age was 92 (range, 90-104) years old. There were 160 (72%) and 63 (28%) patients in the complete and incomplete groups, respectively. Results: The age, performance status, comorbidities, severe complication rates, and stone diameter were comparable between the groups. The proportion of patients with at least 5 stones was significantly higher in the incomplete group than in the complete group (complete group: 8.1% [13/160] and incomplete group: 21% [13/63], p

The detection of residual or fragmented common bile duct (CBD) stones after lithotripsy can be improved by the high-resolution imaging quality of digital, single-operator cholangioscopy (SOC). However, therapeutic interventions for the removal of residual CBD stones are limited by the lack of appropriate tools. We retrospectively evaluated the role of SOC and the newly developed Dormia basket for the evaluation and removal of stones remaining after lithotripsy. Thirty-four patients who had undergone lithotripsy for retained CBD stones with no evidence of filling defects in occluded balloon cholangiography from March 2017 to October 2018 were included in the study. After balloon cholangiography, the bile duct was evaluated by SOC for complete evacuation of the stones. The detected residual CBD stones were directly retrieved by inserting the newly developed Dormia basket into the working channel of the SOC. The incidence of residual stones detected by SOC and the success rate of residual stone retrieval by SOC were investigated. Digital SOC was successfully performed in all patients. Of these, 11 patients (32.4%) had residual CBD stones. The residual stones were successfully removed in 10 patients (90.9%) by SOC using the Dormia basket, except in one case of residual stones left in the hepatic duct. There were no adverse events associated with the SOC procedures or direct stone removal. Digital SOC combined with the newly developed Dormia basket was useful for the detection and extraction of residual CBD stones under direct visualization after lithotripsy.

To evaluate factors affecting the outcomes of short-term Mono-J insertion for 6 h following ureteroscopic stone removal. Patients treated with a Mono-J for 6 h after ureterorenoscopy and stone removal were analysed. FaST 1 and 2 (Fast Track Stent Studies), two consecutive single academic centre studies, were conducted between August 2014 and April 2018. In each study, we randomized patients with renal or ureteral calculi to two groups before ureterorenoscopy. FaST 1 compared a Mono-J insertion for 6 h versus Double-J insertion for 3–5 days after ureterorenoscopy. FaST 2 compared a Mono-J insertion to a tubeless procedure in the same clinical setting. All patients were pre-stented for 3–5 days before URS. The study endpoint was stent-related symptoms as assessed by a validated questionnaire (USSQ). Results were stratified by clinical parameters, stone characteristics and operation details. 108 of 156 initially randomized patients undergoing ureterorenoscopy were included. USSQ scores covering the time 3–5 weeks after stone removal showed a significantly reduced urinary symptoms and pain index compared to the scores before ureterorenoscopy. USSQ results before and after stone removal did not correlate with stone size or operation time and did not differ significantly depending on stone localization, the treating endourologist, or ureterorenoscopic device used (p > 0.05). Six patients (5%) required reintervention. Following secondary ureterorenoscopy and ureteral drainage with a Mono-J for 6 h, quality of life is independent of stone size and localization, operation time, the treating endourologist, and the URS device used. Supplementary Information The online version contains supplementary material available at 10.1007/s00240-021-01264-4.

Objective Endoscopic papillary large-balloon dilation (EPLBD) with limited endoscopic sphincterotomy (EST) is widely used for removing multiple large common bile duct (CBD) stones. However, the safety and effectiveness of immediate EPLBD after limited EST and EPLBD at an interval after limited EST is unclear. Thus, this multicenter retrospective study was conducted to examine this matter. Methods Propensity score-matching was performed to adjust the baseline characteristics between the immediate and interval EPLBD groups. We compared the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications and the early outcomes of ERCP between the 2 matched groups, which comprised 66 patients each. Results The complete stone clearance rate in each study group was 100%. The overall incidence of post-ERCP complications in the propensity score-matched interval and immediate EPLBD groups was 3/33 (9.1%) and 1/33 (3.0%), respectively (p=0.61). The immediate EPLBD group had significantly fewer mean ERCP sessions for complete stone removal and a significantly lower rate of endoscopic mechanical lithotripsy (EML) usage than the interval EPLBD group (1.6 vs. 2.4 sessions, p

To evaluate the safety and efficacy of percutaneous stone removal using a compliant balloon after papillary balloon dilatation.Between March 2014 and May 2020, 123 patients with choledocholithiasis, in whom endoscopy was unsuccessful, were enrolled in this study. The ampulla of Vater was dilated using a noncompliant balloon, and stone removal was attemptedBiliary stones were completely removed in 118 of 123 patients. Major complications occurred in five patients. One patient experienced duodenal bleeding, which was successfully treated by endoscopy. Hemobilia occurred in three patients, which required transfusion, and one patient experienced four days of abdominal pain. Minor complications, including self-limiting pain, effusion, minimal hemobilia, elevated amylase and fever, occurred in 21 patients. Stone size was the only significant risk factor associated with the rate of complications (Odds ratio: 1.14, 95% confidence interval = 1.04, 1.26). Bilirubin and white blood cell levels significantly decreased after the procedure.Percutaneous stone removal using a compliant balloon after papillary balloon dilatation is a safe and effective method in patients in whom endoscopic or surgical treatment is not feasible.

Background and study aim Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound-guided antegrade (EUS-AG) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques. Methods This was a single-center retrospective study. Patients with SAA who underwent the EUS-AG procedure or DB-ERC to remove intra- or extra-BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate. Results Of the 54 patients enrolled, 23 underwent the EUS-AG procedure and 31 DB-ERC. The technical success rates of EUS-AG and DB-ERC were 87.0% and 64.5%, respectively (P = 0.11). The procedure time was significantly shorter in the EUS-AG group than in the DB-ERC group (51.9 ± 15.4 vs 72.6 ± 32.2 min; P = 0.01), and the early AE rates were 26.1% and 12.9%, respectively (P = 0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS-AG group and 85.7% in the DB-ERC group (P = 0.61). Conclusion The EUS-AG afforded technical success and complete stone removal rates comparable with those of DB-ERC, but the former procedure was shorter. The AE rate was acceptable.

There is plethora of treatment options for surgeons dealing with salivary stones. During recent decades, emphasis has been laid on gland-preserving minimally invasive techniques for stone removal. In this context, visualization of salivary ducts with semirigid endoscopes for diagnostic and therapeutic purposes, the so-called sialendoscopy, has become increasingly important. This article gives an overview of indications for sialendoscopy and how the procedure is performed. Furthermore, sialendoscopy is discussed in the context of other modalities for salivary stone treatment.

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

Background: Urolithiasis is the most common and painful urological disease. Intracorporeal lithotripsy has high success rate in management of ureteric stone. Objective: To do comparison of the intracorporeal ultrasonic lithotripsy and intracorporeal pneumatic lithotripsy in terms of rate of stone removal and post-operative complications. Study Design: Randomized Control Trial. Settings: Department of Urology, Lahore General Hospital, Lahore Pakistan. Duration: Six months from September 01, 2015 to February 29, 2016. Methodology: Total sixty patients were selected fulfilling the inclusion criteria into 2 groups. In group A, 30 patients were selected for intracorporeal ultrasonic lithotripsy and in group B, 30 patients were selected for intracorporeal pneumatic lithotripsy. In both groups all patients were compared in terms of rate of stone removal and postoperative complications then results were analyzed by SPSS 21. Results: Mean stone size in group A (Ultrasonic lithotripsy) was 1.13 ± 0.17 cm and in group B (Pneumatic lithotripsy) was 1.14 ± 0.18 cm. At first week after procedure, in group A 25(83.33%) and in group B 21(70%) of the cases had stone clearance, at 2nd week after procedure a total of 26(86.66%) in group A and 24(80%) cases in group B had stone clearance. At 3rd week after procedure there were 28(93.33%) cases in group A and 27(90%) cases in group B had stone clearance. The stone clearance in both groups at each follow up was statistically insignificant, p-value > 0.05. At 1st week, in group A 3(10%) cases and in group B 6(20%) cases had pain, at 2nd week after procedure there were 1(3.33%) cases in group A and 3(10%) in group B who reported pain and at 3rd week after procedure there were 1(3.3%) case in each group had pain. The pain at each follow up was statistically same in both groups, p-value > 0.05. According to complications, in group A and group B, 2(6.66%) and 3(10%) cases had fever, 3(10%) and 4(13.33%) had infection respectively. Only one case (3.3%) had retention of urine. All complications were statistically same in both groups, p-value > 0.05. Conclusion: Through the findings of this study we conclude that both intracorporeal pneumatic lithotripsy and intracorporeal ultrasonic lithotripsy are equally effective and had fewer complications. However, the ultrasonic procedure had higher rate of stone removal at each follow up (but difference was insignificant with similar morbidity compared to pneumatic devices.

Recurrent pyogenic cholangitis is a chronic infection characterized by intrahepatic biliary stones and strictures. Escherichia coli is the commonest infecting organism. This disease is very common in East Asia but infrequent in Western countries, and few reports have been published in European series. The therapeutic approach for hepatolithiasis is highly individual and includes antibiotic therapy, endoscopic and percutaneous biliary drainage with stone removal and dilation of strictures, surgical resection of affected liver segments and liver transplantation. We report two cases of RCP in Chinese patients treated with liver transplantation at our center out of the 34 published in the literature.

Secondary intra- and extrahepatic bile duct dilatation is a very common condition that can be caused by several diseases. However, it has been rarely discussed in the specialized literature. Moreover, no distinct etiology can be determined in some cases, which hampers the diagnosis and treatment. Here, we discuss the etiological classification and treatment strategies of secondary intra- and extrahepatic bile duct dilatation based on an extensive literature review, as well as our experimental research and clinical experience. The etiology of secondary intra- and extrahepatic bile duct dilatation can be classified in different ways. From a clinicopathological perspective, it can be classified into obstruction-, lesion-, and compression-induced dilatation. Treatment varies depending on the cause. For example, endoscopic dilation or stenting is used for biliary strictures, laparoscopic choledochectomy for stone removal, and resection for cholangiocarcinoma.

Purpose:Ureteral access sheaths are commonly used during ureteroscopy to facilitate stone removal, improve visibility and maintain low intrarenal pressures. However, the use of a ureteral access sh...

To assess the effect of our new classification on surgical outcomes after flexible ureteroscopy (fURS) for kidney stones.We retrospectively examined 128 patients after single renal fURS procedures performed using ureteral access sheaths (UASs) with the fragmentation technique. Based on the gap (calculated by subtracting the ureteroscope diameter from the UAS diameter), enrolled patients were divided into three groups: small ( 0.6 mm), medium (0.6 to 1.2 mm), and large space groups (≥ 1.2 mm). Stone-free (SF) status was defined as either complete absence of stones (SF) or the presence of stones 4 mm in diameter on non-contrast computed tomography (NCCT).The SF rate was significantly lower in the small space group (50% in small, 97.9% in medium, 89.2% in large; p = 0.001). Perioperative complications over Clavien-Dindo Grade I were observed in 16.7%, 4.2%, and 8.1% of patients, respectively (p = 0.452). The ratio of stone volume and operative time (efficiency of stone removal) was significantly higher in the large space group compared to the small and medium space groups (0.009 ± 0.003 ml/min, 0.013 ± 0.005 ml/min, 0.027 ± 0.012 ml/min, respectively; p 0.001).Our findings that gaps 0.6 mm (1.8 Fr), including the combination of a 9.5-Fr UAS and a small caliber ureteroscope, improve SF rates, and larger gaps facilitate stone removal efficiency providing the basis for future development of clinical protocols aimed at improving outcomes.

Background The study aimed to construct an intelligent difficulty scoring and assistance system (DSAS) for endoscopic retrograde cholangiopancreatography (ERCP) treatment of common bile duct (CBD) stones. Methods 1954 cholangiograms were collected from three hospitals for training and testing the DSAS. The D-LinkNet34 and U-Net were adopted to segment the CBD, stones, and duodenoscope. Based on the segmentation results, the stone size, distal CBD diameter, distal CBD arm, and distal CBD angulation were estimated. The performance of segmentation and estimation was assessed by mean intersection over union (mIoU) and average relative error. A technical difficulty scoring scale, which was used for assessing the technical difficulty of CBD stone removal, was developed and validated. We also analyzed the relationship between scores evaluated by the DSAS and clinical indicators including stone clearance rate and need for endoscopic papillary large-balloon dilation (EPLBD) and lithotripsy. Results The mIoU values of the stone, CBD, and duodenoscope segmentation were 68.35 %, 86.42 %, and 95.85 %, respectively. The estimation performance of the DSAS was superior to nonexpert endoscopists. In addition, the technical difficulty scoring performance of the DSAS was more consistent with expert endoscopists than two nonexpert endoscopists. A DSAS assessment score ≥ 2 was correlated with lower stone clearance rates and more frequent EPLBD. Conclusions An intelligent DSAS based on deep learning was developed. The DSAS could assist endoscopists by automatically scoring the technical difficulty of CBD stone extraction, and guiding the choice of therapeutic approach and appropriate accessories during ERCP.

Endoscopic ultrasonography (EUS)-guided interventions are often performed using a single guidewire (SGW), but there are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement during EUS-guided drainage of pancreatic fluid collections. This DGW technique may have advantages other than multiple drainage placement during EUS-guided interventions such as scope stabilization, support for stone extraction and device insertion. Consecutive patients who underwent EUS-guided interventions between Feb 2012 and Apr 2019 were retrospectively reviewed. The rate and reasons of DGW technique, and clinical outcomes were evaluated. DGW technique was performed, using an uneven double lumen cannula (UDLC), which facilitates insertion of 0.025-in. and 0.035-in. guidewires. A total of 249 EUS-guided interventions were analyzed, and DGW technique was utilized primarily in 65 cases (25.7%) and as a salvage after failed SGW technique in 18 cases (7.1%). The reasons for DGW technique were 60 multiple drainage placement, 10 scope stabilization, 7 device insertion, 5 safety guidewire, and 4 antegrade stone removal. Insertion of UDLC and DGW was successful in 100%. Technical success rate of preplanned interventions was 92.7% (96.9% in primary DGW and 77.8% in salvage DGW technique). Adverse events were observed in 19.5% after DGW but were not related to DGW technique. DGW technique using UDLC during EUS-guided interventions was technically feasible and safe. In addition to multiple drainage insertion, it can potentially support complex EUS-guided interventions.

BACKGROUND Common bile duct stones (choledocholithiasis) generally lead to several health problems such as pain, jaundice, infection, acute pancreatitis etc. For which it needs surgical intervention. We conducted this study to compare success and complication rate between ERCP stone removal and open CBD exploration. METHODS A total of 50 patients were selected from those attending Department of Surgery of KPC Medical College and were divided in two groups randomly, with 25 patients in each group. Group I patients underwent ERCP stone removal while those in Group II were subjected to open CBD exploration. Both the groups were compared on the basis of their success and complication rate, time taken for the procedure, time taken to return to work, and duration of hospital stay. RESULTS A total of 50 patients were selected, with mean age being 37.5 ± 11.71 yrs., 62% were female and 38% male. In Group I success rate was 92% and in Group II it was 96%. Complication rate was significantly more (p=.032504) in Group II (45.83%) compared to that in Group I (13.04%). Time taken for the procedure in Group I (36.09 ± 6.39 mins) was much less than that in Group II (120.63 ± 11.92 mins). Mean duration of hospital stay in group I was 2.91 ± 1.08 days while in Group II it was 11.79 ± 1.58 days. 8.35 ± 1.61 days were taken to return to work in Group I compared to 20.53 ± 1.95 days in Group II. CONCLUSIONS This comparative study of CBD stone removal is a small endeavour on our part to assess the advantages of ERCP stone removal. With appropriate infrastructure ERCP stone removal carries a greater advantage compared to that by open surgery.

Objective To compare the safety and effectiveness of using a conventional nephrostomy sheath (NS) vs using a new NS with suction and evacuation functions in minimally invasive percutaneous nephrolithotomy (MPCNL) for the treatment of staghorn stones. Patients and methods A prospective and randomised study of 60 patients with staghorn stones randomly assigned into two groups of 30 patients. One group underwent MPCNL using conventional NS, whereas the other group underwent MPCNL with suction-evacuation NS (SENS). Patient demographics, stone characteristics, intraoperative data, perioperative data, and surgical results were collected and analysed. Results The patient demographics and stone characteristics were similar amongst the two groups. The SENS group had a significantly lower peak and a significantly lower average renal pelvic pressure (RPP) throughout the procedure. The SENS group was more efficient for stone removal and had a much shorter stone treatment time, a lesser use of the stone extractor, and ultimately a higher stone-free rate (SFR). The effects of a lower RPP and shorter stone treatment time translated into less severe postoperative complications as measured per modified Clavien grade. Conclusion Using SENS in MPCNL for the treatment of staghorn stones has the advantages of lower RPP, increased effectiveness in stone retrieval, decreased surgery related complications, and an improved SFR.

Background and Aim Endoscopic stone removal has some complications. Although the life expectancy of elderly patients has increased dramatically worldwide, little information is available on the necessity of complete endoscopic stone removal in extremely elderly patients. This study aimed to evaluate the safety and efficacy of complete endoscopic stone removal in extremely elderly patients. Methods All extremely elderly patients (>90 years) who underwent endoscopic stone removal for choledocholithiasis at our hospital between January 2012 and January 2017 were retrospectively evaluated. The included patients were divided into complete stone removal and incomplete stone removal groups. Complication rate, overall survival (OS), and disease‐specific survival (DSS) rates were compared between the two groups. Results Overall, 73 patients were included in this study. The median number of stones was one (range, 0–10) and two (range, 1–12) (P = 0.043), while the median diameter of the largest stones was 9 (range, 0–27) and 14 (range, 5–46) mm (P = 0.001) in the complete and incomplete stone removal groups, respectively. During the follow‐up period, OS was 60% and 39% and DSS was 95% and 97% in the complete and incomplete stone removal groups, respectively. Kaplan–Meier analysis found no significant difference in OS and DSS between the two groups (P = 0.052 and P = 0.646, respectively). Conclusion Complete stone removal might not always be necessary in extremely elderly patients aged ≥90 years., A total of 73 extremely elderly patients (>90 years) who underwent endoscopic stone removal for choledocholithiasis were retrospectively evaluated. The patients were divided into complete stone removal and incomplete stone removal (plastic stent insertion) groups. Kaplan–Meier analysis found no significant difference in overall survival (OS), and disease‐specific survival (DSS) between the two groups.

Introduction: Previous studies have shown that prestenting in ureterorenoscopic stone removal (URS) is carried out more frequently in Germany than in other countries. Objective: This investigation evaluated the impact of high prestenting rates on outcomes as well as the influence of stone characteristics and treatment habits on prestenting. Methods: The dataset from the BUSTER observational study was used. Patient and stone characteristics, as well as treatment outcomes, were analyzed for 307 cases from 14 urological clinics in Germany. Results: The overall prestenting rate was 70.0%. Prestenting rates were significantly higher for renal stones than ureteric stones (84.6 vs. 60.6%, p < 0.0001). Compared to the unstented cases, prestenting for renal stones improved stone-free rates (73.2 vs. 11.1%, p < 0.0001) and increased the rate of completely lesion-free URS (45.4 vs. 16.7%, p = 0.034) while reducing the rate of poststenting (from 100 to 80.8%, p = 0.041). None of these effects could be demonstrated when prestenting for ureteric stones. Prestenting rates were less variable for renal stones (57–100%) than for ureteric stones (0–100%, p < 0.01). Conclusions: This study confirms the benefits of prestenting in URS for renal stones but not for ureteric stones. There were considerable differences in prestenting rates between the participating clinics.

Common bile duct (CBD) stone is a relatively common but potentially life-threatening disease. Endoscopic sphincterotomy (EST) has been performed as standard therapy for CBD stones, but the rate of recurrence of CBD stones is high. Risk factors have been poorly defined, and no effective means for the prevention of the recurrence of CBD stones have been established so far. We aimed to identify significant risk factors for the recurrence of bile duct stones. This study included 477 patients (231 women; mean age, 80.5 years) who underwent EST and cleared CBD stones on cholangiography. A retrospective analysis was performed for the consecutively collected data. During the follow-up period of 6-75 months, the recurrence of CBD stones was observed in 99 patients (20.8%). The median time to the recurrence was 19.0 months (range 4-72 months). Multivariate analysis identified the need for mechanical lithotripsy, which was used for stone fragmentation, as a risk factor. Mechanical lithotripsy caused cholangiography-negative small residua. Notably, saline solution irrigation of the bile duct reduced the recurrence of CBD stones. These results demonstrate that subsequent biliary irrigation after stone removal may prevent the recurrence of CBD stones by clearing small residual fragments.

Background/Aim: A sufficiently open papilla is needed to remove common bile duct stones (CBDS) but endoscopic sphincterotomy (EST) requires a high level of skill and is difficult with endoscopic papillary balloon dilation (EPBD). The main adverse event of EST is bleeding and perforation and that of EPBD is post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. To reduce these adverse events we employed minimal EST followed by papillary dilation (ESBD), and retrospectively evaluated its efficacy and safety compared with EST. Patients and Methods: CBDS patients who underwent EST (n = 114) or ESBD (n = 321) at Juntendo University Hospital from January 2009 to December 2018 were consecutively enrolled, retrospectively. The exclusion criteria were large-balloon dilation (≥ 12 mm), large CBDS (>12 mm), and previous EST/EPBD. We compared the overall stone removal rate, incidence of adverse event, procedure time, number of ERCP procedures, and rate of mechanical lithotripsy (ML) between the two groups. Results: Complete stone removal was successful in both ESBD and EST group. However, the rate of multiple ERCP sessions was significantly lower (35.1% vs. 12.8%, P < 0.001), procedure time was shorter (31.6 vs. 25.8 min, P = 0.01), and rate of ML was lower (16.7% vs. 7.8%, P = 0.01) in ESBD group. Bleeding was significantly more frequent in the EST group (9.6% vs. 1.2%, P < 0.001), particularly acute bleeding (7.9% vs. 0.9%, P < 0.001). Conclusions: ESBD is more efficient and safer in the management of CBD stones than EST. A prospective randomized study comparing ESBD with EST is needed to establish this combination technique.

Background: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST. Methods: A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years. Results: A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%). Conclusions: Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Purpose: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm 2/min) and using the 3D calculated stone volume (526.7 mm 3/min). Methods: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1–10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1–10 scale (10 = extremely effective). Results: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13–84 years). Mean stone clearance rate was 65.55 mm 2/min or 945 mm 3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien–Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. Conclusions: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

We present a case of life-threatening septic shock undergoing ureteroscopic stone removal in the operation theatre just after the surgery. Patient was symptomatically diagnosed on the operation table and intensively managed to stabilize quickly without wasting time and later it was confirmed by investigations that it was a septic shock resulted due to Gram negative bacilli E. coli. There have been very few cases reported in the literature.

INTRODUCTION AND OBJECTIVE:The purpose of the study is to test whether removing small, asymptomatic stones from the kidneys of patients being treated for kidney or ureteral stones will reduce recur...

Introduction: While the Tokyo Guidelines 2018 suggest primary stone removal for mild to moderate cholangitis, a guideline for severe acute cholangitis is not mentioned. We, therefore, investigated the clinical outcomes of patients with severe acute cholangitis to confirm the usefulness and safety of primary stone removal. Method: This study included 104 severe acute cholangitis patients without gallstone pancreatitis diagnosed at our institution between January 2014 and December 2020. Patients with percutaneous transhepatic biliary drainage as the primary drainage, bile duct stenosis, and endoscopically unidentified bile duct stones were excluded from this study. The clinical results of 14 patients with primary stone removal (primary group) and 23 patients with elective stone removal (elective group) were then retrospectively examined (excluding abnormal values due to underlying diseases). Results: Upon comparing the patient characteristics between groups, the elective group had significantly higher cardiovascular dysfunction (57% vs 7%; p = 0.004), septic shock (39% vs 0%; p = 0.006), disseminated intravascular coagulation treatment (57% vs 14%; p = 0.016), and positive blood cultures (91% vs 43%; p = 0.006) than those in the primary group. Endoscopic sphincterotomy for naïve papilla (90% vs 21%; p = 0.01) and endoscopic nasobiliary drainage (50% vs 9%; p = 0.014) were higher in the primary group, while endoscopic biliary stenting (7% vs 87%; p Discussion: There were no significant differences in adverse events or complete stone removal rates between the two groups. In the primary group, the period from the first endoscopic retrograde cholangiopancreatography to stone removal (0 days vs 12 days; p Conclusion: If patients are appropriately selected, bile duct stones may be safely removed for the treatment of severe acute cholangitis.

Author(s): Malone, John; Gebner, Riley; Weyand, Jonathan | Abstract: Case Presentation: A 25-year-old woman presented to the emergency department with two weeks of crampy right-flank pain, and urinary urgency and frequency. She was found to have a staghorn calculus filling her entire right renal pelvis on computed tomography imaging.Discussion: In contrast to ureteral calculi, staghorn calculi are more commonly observed in female patients and typically present with an indolent clinical course. A low threshold for imaging should be maintained, as prompt referral to urology for stone removal or treatment is necessary. Staghorn calculi have a high likelihood of leading to renal failure or urosepsis without treatment.

This study aimed to characterize the computed tomography (CT) findings of pseudolithiasis and investigate the outcomes and natural history in adult patients receiving CTRX therapy. A total of 17 patients were diagnosed with CTRX-associated biliary pseudolithiasis on CT between April 2013 and March 2017. The medical records, characteristics, complications, treatment options, and outcomes of these patients were examined. Serial CT images and the form, density, and location of pseudolithiasis were reviewed by two radiologists. Of the 17 patients with CTRX-associated pseudolithiasis, seven were men and ten were women. The median patient age was 78 years (range 31–88 years). The median interval from CTRX administration to the diagnosis of pseudolithiasis was 10 days (range 4–32 days). The CT findings of pseudolithiasis included a sludge pattern (11 patients [64.7%]), stone pattern (two patients [11.8%]), and stone plus sludge pattern (four patients [23.5%]). Seven patients (41.2%) showed gall bladder enlargement along with a common bile duct (CBD) stone. Two patients with CBD stones underwent endoscopic CBD stone removal. The median time to pseudolithiasis resolution after CTRX cessation was 69 days. The high-density sludge pattern is the most common typical CT finding of CTRX-associated pseudolithiasis in adults.

Background Endoscopic sphincterotomy plus balloon dilation (ESBD) is considered to be a promising method for the removal of large common bile duct (CBD) stones. However, when compared with endoscopic sphincterotomy (EST) alone, the efficacy and safety of ESBD remain controversial. This meta-analysis aimed to compare the efficacy and safety of ESBD vs. EST for the removal of large CBD stones. Methods Electronic databases were searched up to 15 July 2018 for literature that compared ESBD with EST for the removal of CBD stones. Pooled odds ratios (ORs) of the stone clearance rate and the complication rate were used to compare the efficacy and safety of ESBD vs. EST. Results A total of 18 studies with 2789 patients were included. The results showed that the stone removal rate was much higher in the ESBD group than in the EST group, both across all endoscopic retrograde cholangiopancreatography (ERCP) sessions (OR 2.68, 95 % confidence interval [CI] 1.79 to 4.01) and during the first ERCP session (OR 2.07, 95 %CI 1.37 to 3.12). The ESBD group had fewer complications than EST alone (OR 0.63, 95 %CI 0.47 to 0.85). Moreover, the ESBD group needed less mechanical lithotripsy (OR 0.38, 95 %CI 0.24 to 0.61) and had a shorter procedure time (mean difference – 4.05, 95 %CI – 7.02 to – 1.09) than EST alone. Conclusion The efficacy and safety of ESBD were superior to those of EST for the removal of large CBD stones. Moreover, less mechanical lithotripsy and shorter procedure times were needed with ESBD to manage large stones.

Purpose To evaluate the safety and effectiveness of percutaneous transcholecystic removal of common bile duct (CBD) stones in 114 patients. Materials and Methods This retrospective study was approved by the institutional review board. From September 2011 through February 2017, 114 consecutive patients (68 men, 46 women; mean age, 73 years) underwent percutaneous transcholecystic removal of CBD stones. All patients had acute cholangitis or cholecystitis. Stones were extracted through a 12-F sheath by using a Wittich nitinol stone basket uder fluoroscopic guidance. Technical success rates, complications, and long-term follow-up were evaluated. Results Technical success was achieved in 96 of 114 (84.2%) patients. In 18 patients, stone removal was unsuccessful due to failure of cystic duct cannulation (n = 11), proximal migration of the CBD stone (n = 3), multiple CBD stones (n = 3), and low insertion of the cystic duct (n = 1). No major procedure-related complications were seen. During the mean follow-up of 644 days (range, 11-2206 days), CBD stones recurred in 12 patients after a mean of 884 days (range, 439-1799 days) after the procedure. Conclusion Percutaneous transcholecystic removal of common bile duct stones seems to be a safe and effective method. © RSNA, 2018 Online supplemental material is available for this article . See also the editorial by vanSonnenberg and Panchanathan in this issue.

Purpose A prospective study evaluating impact of percutaneous nephrolithotomy (PCNL) on renal function following PCNL using ethylenedicysteine (EC) renal scan. Does multiplicity of access tracts play a role? Materials and methods A prospective observational study was done and patients undergoing PCNL for renal calculi at our urology department were selected. Renal Tc99m EC scan was done pre-surgery and at 3 months follow-up. An assessment was done on decline in glomerular filtration rate (GFR) in postoperative period based on number of access tracts required. Results A total of 110 patients were enrolled in the study. The total number of punctures was 170 with 141 being supra-costal puncture and 29 infra-costal. The total number of single punctures were 60 and classified as Group I whereas patients with double puncture and triple puncture (40 and 10 patients, respectively) were classified as Group II. Mean postoperative split renal function (in Tc99m EC scans) of patients of Group I (40.93±19.62%) was found to be higher than that of Group II (32.82±16.98%). Mean change (decline) in GFR for single, double and triple tracts were 2.68 mL/min, 3.80 mL/min, and 4.2 mL/min, respectively. Conclusions PCNL used for stone removal can improve renal function by eradicating obstruction; however, this procedure may itself negatively impact the functions of the targeted kidney. Our study showed post PCNL decrease in GFR which worsens with an increasing number of accesses.

A retro-renal colon (RRC) is a rare but important anatomical variant to consider when planning percutaneous stone surgery. CT scanning of the abdomen is critical to detect this and to plan the surgical approach to avoid injury to the colon. In this case report, a 38-year-old woman with large obstructing bilateral symptomatic renal stones was found to have a left retro-renal colon on image review prior to left percutaneous nephrolithotomy. An open pyelolithotomy was performed to surgically remove the stone and to prevent any injury to the colon. An RRC can occur in up to 16% of patients undergoing percutaneous renal access. A CT scan is important to rule out this anatomical variant and to allow for surgical planning to avoid injury to the colon. The modern era of endourology has brought a significant reduction in open stone surgery. An open pyelolithotomy is still a safe option for stone removal if an RRC is detected preoperatively. Injury to the colon during percutaneous access can most commonly be managed conservatively. Occasionally open intervention may be required. An RRC detected on a preoperative CT scan may influence surgical planning and an open pyelolithotomy can be performed to safely remove renal stones and prevent colonic injury, especially in resource-limited settings.

Although Spy DS (SpyGlass DS Direct Visualization System) is considered to be useful for the diagnosis of bile duct strictures and the treatment of bile duct stones, there is limited data to date validating its efficacy. We hence retrospectively evaluated the clinical outcomes of the use of Spy DS in a large number of patients. A total of 183 patients who underwent Spy DS-guided procedures for indeterminate bile duct strictures (n = 93) and bile duct stones (n = 90) were analyzed retrospectively. All patients (93/93) with bile duct strictures successfully underwent visual observation, and 95.7% (89/93) of these patients successfully underwent direct biopsy. The sensitivity, specificity, and overall accuracy were 94.7%, 83.3%, and 90.3%, respectively, for visual impression, 80.9%, 100%, and 89.2%, respectively, for histopathological analysis of a direct biopsy, and 96.5%, 91.7%, and 94.6%, respectively, for visual impression combined with biopsy. Successful visualization of the stones was achieved in 98.9% (89/90) of the patients, and complete stone removal was achieved in 92.2% (83/90) of the patients, with an average of 3.3 procedures. The adverse events rate was 17.5% (32/183, cholangitis in 15 patients, fever the following day in 25, pancreatitis in 1, hemorrhage in 1, and gastrointestinal perforation in 1). No administration of antibiotics before the procedure was found to be a statistically significant risk factor for the development of fever after the procedure (p &lt, 0.01). Spy DS-guided procedures are effective for the diagnosis and treatment of bile duct lesions and can be performed with a low risk of serious adverse events.

Gallstone ileus is an uncommon cause of intestinal obstruction in the elderly. It is typically recognized on computed tomography by the presence of pneumobilia and a gallstone in the right iliac fossa. Nonetheless, it is important to consider that gallstone ileus may represent the presentation of another pathology rather than an entity on its own. Here, we report successful retrieval of a gallstone that was causing ileus. Intraoperatively, the gallstone was noted lodged in the terminal ileum distal to an incidentally noted Meckel’s diverticulum. The gallstone was milked proximally into the Meckel’s diverticulum and the base was transected. This case illustrates a rare, but unique, surgical technique utilizing a small bowel diverticulum as a vector for stone removal.

Endoscopic stone removal becomes challenging owing to a distal common bile duct stricture. A new dumbbell-shaped covered self-expanding metallic stent is efficient in removing the common bile duct stones with common bile duct strictures that occur due to chronic pancreatitis.

Different methods of surgical stone removal have been discussed in previous chapters. As a Urologist, suitable stone management should be tailor-made for each patient after discussing the potential benefit and risks of different approaches with them. With consideration of their background, premorbid and medical history, stone characteristics and stone management history, an evidence-based management will definitely benefit our patients. In short, we would like to highlight different indications and special considerations for each treatment in this chapter.

Objective: To investigate the effect of ureterorenoscopic stone removal timing on kidney function in unilateral ureteral stones. Materials and Methods: Hundred and eighty-seven patients included in the study were divided into two groups: 98 patients who underwent surgery ≤14 days after the stone diagnosis constituted the Early Surgery Group and 39 patients who were operated >14 days after the stone diagnosis comprised the Late Surgery Group. Preoperative serum levels of creatinine, blood urea nitrogen (BUN), and glomerular filtration rates (GFR) were recorded for the patients in both groups. In the postoperative first month, serum creatinine, BUN, and GFR were again recorded and compared with the preoperative values. Results: The mean preoperative serum creatinine, GFR, and BUN levels in the Early Surgery Group were 1.25 ± 0.65μmol/L, 80.04 ± 33.6ml/min/1.73m2, and 50 ± 16.6mmol/L, respectively. A decrease was observed in serum creatinine (0.82 ± 0.22μmol/L, p< 0.001) and BUN (14.08 ± 7.25mmol/L, p< 0.001) levels one month after surgery, whereas GFR increased (105.33 ± 21.6ml/min/1.73m2, p< 0.001). In the Late Surgery Group, postoperative levels of serum creatinine (0.94 ± 0.33 vs. 0.95 ± 0.30μmol/L, p= 0.102), and BUN (17.38 ± 9 vs. 17.92 ± 8.8mmol/L, p= 0.283), increased minimally, also a minimal decrease was observed in GFR (95.15 ± 27.3 vs. 93.77 ± 24.3ml/min/1.73m2, p= 0.338) without any statistically significant difference. Conclusion: We believe that surgical treatment should be planned within two weeks at the latest, as prolonged obstruction may result in kidney damage.

Objectives Endoscopic sphincterotomy (EST) damaged the sphincter of Oddi (SO) function. This study aimed to explore the feasibility and efficacy of endoclip papillaplasty in restoring SO function. Methods This prospective pilot study included consecutive patients with choledocholithiasis (stone size ≥10 mm) who underwent large-EST for stone removal, followed by endoclip papillaplasty, between May 2018 and March 2019. Results Thirty patients were enrolled in this trail. Overall, 80% of the patients had a SO basal pressure of >10 mmHg after endoclip papillaplasty. Manometric parameters, including SO basal pressure, phasic wave contraction amplitude, phasic waves per minute, recovered after endoclip papillaplasty (P > 0.05). There were no significant differences in the manometric parameters of SO between healing grades A and B. Six patients developed mild post-endoscopic retrograde cholangiopancreatography pancreatitis, including three that had pancreatic stenting. Bile duct stone recurrence developed in 3.3% of the patients (1/30) during an 18-month follow-up. Conclusions Endoclip papillaplasty might restore SO function and possibly prevented biliary stone and cholangitis recurrence.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is the primary method for the treatment of renal calculi. The preservation of the nephrostomy tube after operation brings severe pain to the patients. We use a 1,470 nm semiconductor laser to stop bleeding after the operation, which cannot reserve the nephrostomy tube, fully reflect its safety and effectiveness, and provide a new method for clinical practice. METHODS: Forty-two patients with renal stones who came to our hospital from March 2016 to September 2019 were randomly divided into two groups: laser operation group (20 patients) and traditional operation group (22 patients). The stone removal rate, surgical effect, and postoperative complications were compared between the two groups. RESULTS: There was no significant difference in the stone clearance rate between the two groups at the 4th week after operation (P>0.05). However, the incidence of postoperative infection, incision pain, and massive bleeding in the laser surgery group were lower than those in the traditional surgery group (P0.05). The average postoperative hospital stay in the laser surgery group was shorter than that in the traditional surgery group, and the difference was statistically significant (P0.05). CONCLUSIONS: The 1,470 nm laser is safe, effective, and feasible in PCNL operation, especially in hemostasis of the renal puncture channel, and it is worth popularizing.

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Equipment used in endourology is constantly evolving due to increasing incidence of urolithiasis. Suctioning has been used mainly in PCNL in conjunction with ultrasonic and ballistic devices for stone removal. Recently technological advances permitted the use of suctioning in more endourological techniques. This review aims to summarize the literature regarding these advancements and analyze the upcoming results. Several centers have conducted experimental and clinical studies on suctioning use during PCNL, mPCNL, and ureteroscopy and concluded that it is an effective and safe adjustment that improves stone-free rates and limits complication rates after these procedures. Suctioning use during common endourological procedures led to improved safety and efficacy among several indications. Due to the observational nature and small sample size of many studies, larger RCTs are needed to make safe conclusions.

Background and aim Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self-expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent-induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. Methods Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5-6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow-up period were measured. Results Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138-196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow-up period (median 635 days) after stent removal, only one recurrence developed. Conclusions Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution.