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Objective: To determine surgical outcomes and stone‐free rates (SFRs) when offering upfront retrograde intrarenal surgery (RIRS) to patients with asymptomatic incidental renal stones (AIRS), as active surveillance, shockwave lithotripsy or upfront intervention in patients with AIRS is still a debate among urologists. Patients and Methods: This retrospective FLEXible Ureteroscopy Outcomes Registry (FLEXOR), supported by the Team of Worldwide Endourological Researchers (TOWER), examines adult patients who underwent RIRS. We analysed a subset of asymptomatic patients with renal stones on imaging who were treated with RIRS. Data includes patient characteristics, stone specifications, anaesthesia type, perioperative details, complications, and SFR. A multivariable logistic regression analysis was performed to assess factors associated with the SFR. Results: Among 679 patients with AIRS, 640 met the inclusion criteria. The median age was 55 years, with 33.4% being female. In all, 22.1% had positive urine cultures. The median stone diameter was 12 mm, commonly in lower and interpolar locations. RIRS was preferentially performed under general anaesthesia using a reusable scope in 443 cases. Prophylactic antibiotics were administered to 314 patients. The median operation time was 58 min and the median laser time was 24 min. The SFR was 68.8%. The use of holmium laser (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.06–0.63; P < 0.01) and multiple stones (OR 0.38, 95% CI 0.19–0.76; P < 0.01) were factors associated with lower odds of being stone free. Overall complications were minimal, with sepsis in 1.6% of patients. Re‐interventions were performed in 76 cases (11.8%), with RIRS being the most common in 67 cases (10.6%). Conclusion: Our multicentre real‐world study is the first of its kind that highlights the pros and cons of offering RIRS to patients with AIRS and demonstrates a favourable SFR with acceptable complications. Pre‐emptively discussing potential re‐intervention helps patients make informed decisions, particularly in cases involving large and multiple stones. [ABSTRACT FROM AUTHOR]

The ureteral access sheath (UAS) has been a boon and a bane in flexible ureteroscopy (FURS), with its merits and demerits well established. Its design and dimensions were instrumental in reshaping the way flexible scopes were used and were key adjuncts to establishing retrograde intrarenal surgery (RIRS) as a standard of care in the endourological management of renal stones. With the ever-changing landscape of RIRS over the decades shaped by technological advancements in lasers and flexible scopes, the UAS has also continuously evolved. The utility of suction in endourology has recently changed the way RIRS is performed and is a game changer for FURS outcomes. With strong clinical and experimental evidence to support its use, the UAS has undergone a transformative change in the recent past, with its ability to monitor intrarenal pressure and provide a superior vacuum-cleaner effect that improves the trifecta of RIRS, namely an improved single-stage stone-free rate (SFR), minimise complications, and reduce reinterventions. Our comprehensive review outlines the key clinical and experimental evidence and traces the developments that were key to modifying the traditional UAS into a flexible and navigable suction ureteric access sheath (FANS) and highlights how the design and modifications, in turn, influence the ability to push the boundaries of RIRS. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to compare the efficacy and safety of extracorporeal shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), mini-percutaneous nephrolithotomy (mPNL), and standard-percutaneous nephrolithotomy (stPNL) for the treatment of 20–30 mm kidney stones. Methods: The records of 1197 patients (SWL = 149, RIRS = 205, mPNL = 525, and stPNL = 318) from 8 centers were reviewed retrospectively. Four procedures were compared for stone-free rates (SFRs), auxiliary treatment, and associated complications. Results: Initial SFRs were 43.6%, 54.6%, 86.7%, and 87.7% in SWL, RIRS, mPNL, and stPNL, respectively (P < .001), whereas the final SFRs were 71.8%, 80%, 90.5%, and 89.6% (P < .001). The rate of auxiliary treatment in the groups was 38.3%, 26.8%, 5%, and 4.4%, respectively (P < .001). The initial and final SFRs in the mPNL and stPNL groups were higher than those in SWL and RIRS groups (P < .001). The rate for auxiliary treatment was lower in the mPNL and stPNL groups (P < .001). The operation time was longer in the RIRS group (P = .005). According to the Clavien–Dindo classification, the complication rate in the SWL group was lower than that in the surgical approaches (P < .001); however, no statistical difference was detected between RIRS, mPNL, and stPNL groups. mPNL and stPNL had a higher success rate than RIRS or SWL for treating 20–30 mm kidney stones. Conclusion: In the treatment of 2–3 cm renal stones, RIRS and PNL were more effective than SWL to obtain a better SFR and less auxiliary treatment rate. Compared with RIRS, mPNL and stPNL provided a higher SFR with similar complication rates. [ABSTRACT FROM AUTHOR]

Retrograde intrarenal surgery (RIRS) is accepted as a primary modality for the management of renal stones up to 2 cm. The limitations of RIRS in larger volume stones include limited visualization due to the snow-globe effect and persistence of fragments that cannot be removed. We describe a new, simple, cost-effective modification that can be attached to any flexible ureteroscope which allows simultaneous/alternating suction and aspiration during/after laser lithotripsy using the scope as a conduit to remove the fragments or dust from the pelvicalyceal system called direct in-scope suction (DISS) technique. Between September 2020 and September 2021, 30 patients with kidney stones underwent RIRS with the DISS technique. They were compared with 28 patients who underwent RIRS with a 11Fr/13Fr suction ureteral access sheaths (SUASs) in the same period. RIRS and laser lithotripsy were carried out traditionally with a Holmium laser for the SUAS group or a thulium fiber laser for the DISS group. There was no difference in age, gender, and history of renal lithiasis between the two groups. Ten (40%) patients had multiple stones in the DISS groups, whilst there were no patients with multiple stones in the SUAS group. Median stone size was significantly higher in the DISS group [22.0 (18.0–28.8) vs. 13.0 (11.8–15.0) millimeters, p < 0.001]. Median surgical time was significantly longer in the DISS group [80.0 (60.0–100) minutes] as compared to the SUAS group [47.5 (41.5–60.3) minutes, p < 0.001]. Hospital stay was significantly shorter in the DISS group [1.00 (0.667–1.00) vs. 1.00 (1.00–2.00) days, p = 0.02]. Postoperative complications were minor, and there was no significant difference between the two groups. The incidence of residual fragments did not significantly differ between the two groups [10 (33.3%) in the DISS group vs. 10 (35.7%) in the SUAS group, p = 0.99] but 10 (33.3%) patients required a further RIRS for residual fragments in the DISS group, whilst only one (3.6%) patient in the SUAS group required a subsequent shock wave lithotripsy treatment. Our audit study highlighted that RIRS with DISS technique was feasible with an acceptable rate of retreatment as compared to RIRS with SUAS. [ABSTRACT FROM AUTHOR]

The introduction of robotics has revolutionized surgery. Robotic platforms have also recently been introduced in clinical practice specifically for flexible ureteroscopy. In this paper, we look at the robotic platforms currently available for flexible ureteroscopy, describing their advantages and limitations. The following robotic platforms are discussed: Roboflex Avicenna®, EasyUretero®, and ILY® robot. Finally, potential future advancements in this field are presented. [ABSTRACT FROM AUTHOR]

Objective: In this multicenter prospective study, we aimed to evaluate the use of holmium:yttrium--aluminum-garnet laser during retrograde intrarenal surgery for kidney stones and the relationship between laser-related parameters and procedure-related perioperative parameters. Material and methods: The 769 patients whose laser setting parameters (fiber thickness, number of shots, frequency (max.), laser power (max.), and total energy) were completely registered were included in this study program. The intraoperative ureteral lesions were evaluated using postureteroscopic lesion scale (PULS) scores and the postoperative complications with the modified Clavien-Dindo classification system. Results: The maximum levels of laser power and the frequency were used in the middle calyceal stones; the value of total energy consumed was found to be higher gain in cases with multiple stones (all parameters P < .05). There was a significant positive correlation among (mean number of shots [P < .001, r = 0.46], frequency [P = .009, r = 0.1], maximum power [P < .001, r = 0.11], total energy [P < .001, r = 0.25]), anesthesia time (P < .001, r = 0.42), surgery time (P < .001, r = 0.47), and stone size. The mean number of shots increased (P < .001, r = 0.25), and the frequency level decreased (P < .001, r = -0.17) significantly with increasing Hounsfield unit (HU) values. Again, the mean number of shots and maximum laser power increased in correlation with the increasing hospitalization time (P = .004, r = 0.09 and P = .02, r = 0.07, respectively). In addition, it was observed that higher laser subparameter values and thicker fibers were used in PULS grade 2. Conclusion: As the stone size and HU values increased, laser-setting parameters were found to show significant variability. The increase in different parameters of the laser setting was found to be associated with longer anesthesia time, surgery time, and hospitalization period and increased risk of local trauma with PULS grade. [ABSTRACT FROM AUTHOR]

Objectives: To compare the safety and effectiveness of super‐mini‐percutaneous nephrolithotomy (SMP) and retrograde intrarenal surgery (RIRS) for the treatment of 1–2 cm lower‐pole renal calculi (LPC). Patients and Methods: An international multicentre, prospective, randomised, unblinded controlled study was conducted at 10 academic medical centres in China, India, and Turkey, between August 2015 and June 2017. In all, 160 consecutive patients with 1–2 cm LPC were randomised to receive SMP or RIRS. The primary endpoint was stone‐free rate (SFR). Stone‐free status was defined as no residual fragments of ≥0.3 cm on plain abdominal radiograph of the kidneys, ureters and bladder, and ultrasonography at 1‐day and on computed tomography at 3‐months after operation. Secondary endpoints included blood loss, operating time, postoperative pain scores, auxiliary procedures, complications, and hospital stay. Postoperative follow‐up was scheduled at 3 months. Analysis was by intention‐to‐treat. The trial was registered at http://clinicaltrials.gov/ (NCT02519634). Results: The two groups had similar baseline characteristics. The mean (sd) stone diameters were comparable between the groups, at 1.50 (0.29) cm for the SMP group vs 1.43 (0.34) cm for the RIRS group (P = 0.214). SMP achieved a significantly better 1‐day and 3‐month SFR than RIRS (1‐day SFR 91.2% vs 71.2%, P = 0.001; 3‐months SFR 93.8% vs 82.5%, P = 0.028). The auxiliary procedure rate was lower in the SMP group. RIRS was found to be superior with lower haemoglobin drop and less postoperative pain. Blood transfusion was not required in either group. There was no significant difference in operating time, hospital stay, and complication rates, between the groups. Conclusions: SMP was more effective than RIRS for treating 1–2 cm LPC in terms of a better SFR and lesser auxiliary procedure rate. The complications and hospital stay were comparable. RIRS has the advantage of less postoperative pain. [ABSTRACT FROM AUTHOR]

Aim: To assess the efficacy and safety of two different techniques (Percutaneous nephrolithotomy (PNL) vs Retrograde intrarenal surgery (RIRS)) in the management of stones in patients with horseshoe kidneys (HSK). Patients and methods: Departmental files of 88 cases with radiopaque kidney stones in horseshoe kidneys undergoing two different approaches (PNL vs RIRS) were evaluated with respect to the success and complication rates of in a retrospective manner. In addition to the factors related with the procedures (success and complication rates, additional procedures), patient and stone characteristics were all well evaluated. Findings obtained in both groups were evaluated in a comparative manner with respect to the statistical significance. Results: Stone free rates were comparable in both groups after 1-week period (81.6% PNL vs 80% RIRS). As well as 3 months evaluation (84.2% PNL and 82.0% RIRS). The percentage of the cases with residual fragments (> 4 mm) were similar in both groups and while all PNL procedures were completed in one session, mean number of RIRS sessions was higher (1.22 ± 0.05). Mean duration of the procedure was slightly higher in RIRS group and based on Clavien scoring system, despite a higher risk of Hb drop noted in patients treated with PNL, all complication rates were found to be similar in both groups. Conclusion: Our results demonstrate that of the available minimally invasive treatment alternatives, both PNL and RIRS could be safe and effective alternatives for renal stone removal in patients with HSK. [ABSTRACT FROM AUTHOR]

Objective: A wide selection of both anterograde and retrograde mini-invasive procedures exist for stones' treatment. The 2016 European Association of Urology (EAU) guidelines still don't univocally define a best option. Our purpose is to give an overview on some European Stone Centers' customs and to compare real life clinical practice with statements of opinion leaders and Guidelines. Materials and Methods: In 2015 we performed a survey in 3 step about the spread of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) techniques among EAU Section of Urolithiasis (EULIS) members. The 1st and 2nd steps dealt with the definition of EULIS urologist and department by collecting personal opinions about the endoscopic techniques. The third step was about clinical results. This paper presents data from the first two steps. Results: Ninety-one people answered. Out of them, 80% are European and 42% work in Centres fully dedicated to stone treatment. In particular, 50% of responders perform more than 80 RIRS/year, 25% more than 80 PCNL/year, 48% more than 100 extracorporeal shock wave lithotripsy (SWL)/year. RIRS is mainly used to treat stones < 2 cm both as primary treatment and after SWL failure. 73% don't perform routine pre-stenting and 66% ordinarily use a ureteral sheath. Hospital stay for RIRS is 24h for 70% of responders. Regular PCNL is performed by 87% of the responders, MiniPCNL by 58%, Ultra-MiniPCNL by 23% and MicroPCNL by 28%. Pneumatic balloon dilation is the favourite dilation technique (49%). 37% of responders perform PCNL always in the supine position, 21% always in the prone one. Almost all the responders agree about using Mini, Ultra-Mini and MicroPCNL for 1-2 cm stones. Approximately 50% also use MiniPCNL for stones > 2 cm. Conclusion: our survey confirms the great heterogeneity existing in stones' treatment techniques in daily practice. [ABSTRACT FROM AUTHOR]

Background An improved armamentarium has had a significant impact on the emerging role of flexible ureteroscopy (FURS) for the management of nephrolithiasis; however, FURS still represents a challenging technique. Objective To examine a robotic device designed for FURS for its impact on ergonomics and outcome of the procedure based on the IDEAL (idea, development, evaluation, assessment, long-term study) framework. Design, setting, and participants Roboflex Avicenna consists of a surgeon's console and a manipulator for the flexible ureterorenoscope. Following experimental evaluation of the prototype (IDEAL stage 1) and receipt of ethical approval, seven surgeons treated 81 patients (mean age: 42 yr [range: 6–68]) with renal calculi (mean volume: 1296 ± 544 mm 3 [range: 432–3100 mm 3 ]) in an observational study (IDEAL stage 2). Surgical procedure Robotic FURS was performed with the Roboflex Avicenna robotic device. Outcome measurements and statistical analysis Numerical data were analysed with the Mann-Whitney test, and categorical variables were analysed using the chi-square test or Fisher exact test. P values <0.05 were considered statistically significant. Results and limitations Mean robot docking time was 59.6 ± 45 s. Mean operative time was 74 min (range: 40–182). Mean fragmentation speed was 29.1 ± 6.1 mm 3 /min. Ergonomics based on a validated questionnaire showed significant advantage for robotic FURS (total score: 5.6 vs 31.3; p < 0.01). A 10/12F-access sheath was used in 72 patients. Two cases required secondary FURS, one because of malfunction of the flexible digital ureteroscope and another because of larger residual fragments. In the remaining 79 cases, complete stone disintegration was accomplished. Conclusions Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics. Future studies should evaluate its impact on the clinical outcome of FURS. Patient summary Robotic flexible ureteroscopy (FURS) was performed with the Roboflex Avicenna robotic device. Results showed that Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics. [ABSTRACT FROM AUTHOR]