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Purpose: Use of suction in flexible ureteroscopy is increasing lately. The introduction of flexible and navigable suction access sheath (FANS) has shown improved stone free rate (SFR). However, its efficacy in lower pole stone (LPS) in terms of SFR and complications is yet to be studied. Methods: We collected data from 25 centers that included 394 adult patients undergoing ureteroscopy using FANS. Non contrast CT (NCCT) scan was done within first 30 days post operatively to access the SFR. Residual fragments were graded as A: 100% SFR; B: single fragment ≤ 2 mm; C: single fragment 2.1–4 mm; D: Single or multiple fragments > 4 mm. Post operative complications were recorded. Results: Out of 394 patients, non LPS (group1) comprised of 268 patients, rest 126 patients had LPS (group 2). Single stage zero fragment SFR was seen in 58.6% (group 1) vs. 54.8% (group 2) (P = 0.619). Single stage grade A + B SFR was achieved in 96.6% vs. 98.4% in groups 1 and 2 respectively. On multivariate analysis Thulium fiber laser use was significantly associated with higher odds of being grade A stone-free, while stone volume with lower odds. In LPS group only two patients needed reintervention. The highest grade of complication was Clavien 2, which was seen in 3.2% LPS group. Conclusion: Use of flexible and navigable suction ureteric access sheath for lower pole stones is effective and safe. The stone free rate of lower pole stones is comparable to non-lower pole locations with very low reintervention rate in both groups. [ABSTRACT FROM AUTHOR]

BCG is the standard of care for non-muscle invasive high-risk bladder cancer. Notwithstanding the high rate of cure, cancer may recur. A non-muscle invasive high-risk recurrence may be defined as BCG refractory or naïve. BCG refractory patients have been further divided into BCG unresponsive and BCG exposed. A recurrent high-risk bladder cancer within 1 year after BCG induction plus maintenance or two courses of BCG induction defines an unresponsive disease. Any recurrence after 24 months since induction and maintenance should be considered as BCG naïve. The remaining cases are BCG exposed. The standard of care for BCG exposed and naïve patients is another cycle of BCG in the first place, while radical cystectomy should be discussed as alternative with the patient. The preferred therapy for BCG unresponsive patients is radical cystectomy according to AUA or EAU guidelines. However, systemic immunotherapy with pembrolizumab or gene therapy with intravesical nadofaragene firadenovec may be administered for patients unfit or unwilling to undergo radical cystectomy with outcomes superior to intravesical docetaxel, gemcitabine or valrubicin. Our narrative review tries to elucidate BCG refractory definition and treatment specifically regarding alternative therapies to radical cystectomy yet approved or under investigation. The last years have been exciting regarding new developments in this field after a long period of stagnation. Unfortunately, data available on some alternative therapies are mainly limited mainly to Phase I or II studies with a lack of robust evidence, but a clear trend in future treatments has just been drawn. [ABSTRACT FROM AUTHOR]

Byline: Carlotta. Nedbal, Victoria. Jahrreiss, Clara. Cerrato, Daniele. Castellani, Wissam. Kamal, Zeeshan. Hameed, Vineet. Gauhar, Patrick. Juliebo-Jones, Lazaros. Tzelves, Panagiotis. Kallidonis, Theodoros. Tokas, Bhaskar. Somani Introduction: This study aims to [...]

Objective: Sepsis is the most serious complication of flexible ureteroscopy (F-URS) and laser lithotripsy. We assessed the influence of positive stone culture (SC) on major infectious complications (sepsis, septic shock). Methods: This prospective study enrolled adult patients deemed suitable for F-URS and laser lithotripsy from nine centers (January 2022–August 2023). Inclusion criteria were as follows: kidney stone(s), preoperative midstream urine culture (MSUC), stone(s) assessed at computed tomography scan, and SC. Exclusion criteria were as follows: bilateral procedures, ureteral stones, and children. Group 1 included patients with sterile SC. Group 2 included patients with positive SC. Data are presented as median (interquartile range). A multivariable logistic regression analysis was performed to evaluate factors associated with having a positive SC. Results: In total, 293 patients were included. Median age was 51.0 (24) years. There were 167 (57.0%) males. Group 2 included 32 (2.5%) patients. Group 2 patients were significantly older [75.0 (14) vs 51.0 (23) years, p = 0.02]. Stone features were similar. Major infectious complications were higher in Group 2 (15.6% vs 0.4%). One patient died because of sepsis in Group 2. Two out of 6 (33.3%) patients with major infectious complications had the same pathogen in MSUC and SC. In the multivariable regression analysis, diabetes (OR 3.23), symptomatic urinary infections within 3 months before operation (OR 4.82) and preoperative stent/nephrostomy (OR 2.92) were factors significantly associated with higher odds of positive SC. Conclusions: Patients with positive SC have a higher incidence of major infectious complications after F-URS lithotripsy. SC should be performed whenever feasible because there is a poor correlation between MSUC and SC. [ABSTRACT FROM AUTHOR]

Purpose: Traditionally, bilateral urolithiasis treatment involved staged interventions due to safety concerns. Recent studies have shown that same-sitting bilateral retrograde intrarenal surgery (SSB-RIRS) is effective, with acceptable complication rates. However, there's no clear data on the optimum laser for the procedure. This study aimed to assess outcomes of SSB-RIRS comparing thulium fiber laser (TFL) and high-power holmium:yttrium-aluminum-garnet (Ho:YAG) laser in a multicenter real-world practice. Materials and Methods: Retrospective analysis was conducted on patients undergoing SSB-RIRS from January 2015 to June 2022 across 21 centers worldwide. Three months perioperative and postoperative outcomes were recorded, focusing on complications and stone-free rates (SFR). Results: A total of 733 patients were included, with 415 in group 1 (Ho:YAG) and 318 in group 2 (TFL). Both groups have similar demographic and stone characteristics. Group 1 had more incidence of symptomatic pain or hematuria (26.5% vs. 10.4%). Operation and lasing times were comparable. The use of baskets was higher in group 1 (47.2% vs. 18.9%, p<0.001). Postoperative complications and length of hospital stay were similar. Group 2 had a higher overall SFR. Multivariate regression analysis indicated that age, presence of stone at the lower pole, and stone diameter were associated with lower odds of being stone-free bilaterally, while TFL was associated with higher odds. Conclusions: Our study shows that urologists use both lasers equally for SSB-RIRS. Reintervention rates are low, safety profiles are comparable, and single-stage bilateral SFR may be better in certain cases. Bilateral lower pole and large-volume stones have higher chances of residual fragments. [ABSTRACT FROM AUTHOR]

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]

Purpose: To analyze the bibliometric publication trend on the application of "Artificial Intelligence (AI) and its subsets (Machine Learning–ML, Virtual reality–VR, Radiomics) in Urolithiasis" over 3 decades. We looked at the publication trends associated with AI and stone disease, including both clinical and surgical applications, and training in endourology. Methods: Through a MeshTerms research on PubMed, we performed a comprehensive review from 1994–2023 for all published articles on "AI, ML, VR, and Radiomics." Articles were then divided into three categories as follows: A-Clinical (Nonsurgical), B-Clinical (Surgical), and C-Training articles, and articles were then assigned to following three periods: Period-1 (1994–2003), Period-2 (2004–2013), and Period-3 (2014–2023). Results: A total of 343 articles were noted (Groups A-129, B-163, and C-51), and trends increased from Period-1 to Period-2 at 123% (p = 0.009) and to period-3 at 453% (p = 0.003). This increase from Period-2 to Period-3 for groups A, B, and C was 476% (p = 0.019), 616% (0.001), and 185% (p < 0.001), respectively. Group A articles included rise in articles on "stone characteristics" (+2100%; p = 0.011), "renal function" (p = 0.002), "stone diagnosis" (+192%), "prediction of stone passage" (+400%), and "quality of life" (+1000%). Group B articles included rise in articles on "URS" (+2650%, p = 0.008), "PCNL"(+600%, p = 0.001), and "SWL" (+650%, p = 0.018). Articles on "Targeting" (+453%, p < 0.001), "Outcomes" (+850%, p = 0.013), and "Technological Innovation" (p = 0.0311) had rising trends. Group C articles included rise in articles on "PCNL" (+300%, p = 0.039) and "URS" (+188%, p = 0.003). Conclusion: Publications on AI and its subset areas for urolithiasis have seen an exponential increase over the last decade, with an increase in surgical and nonsurgical clinical areas, as well as in training. Future AI related growth in the field of endourology and urolithiasis is likely to improve training, patient centered decision-making, and clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction To provide a comprehensive review of survey trends in urology, aiming to provide insight into changes in publication in the new millennium. Surveys in healthcare allow for a better understanding of the knowledge, attitudes, and practice patterns as well as gaps in healthcare systems. Material and methods A comprehensive review of all “surveys in urology answered by urologists” was performed through the PubMed and Scopus databases, according to the SPICE framework. Included surveys were divided according to the subject: “Uro-oncology”, “Urolithiasis”, “Mental health” “Resident training”, and “Miscellaneous”. Publications were then divided into 2 main periods: Period-1 (2000–2011) and Period-2 (2012–2023). Results A total of 361 surveys have been published since 2000, with a significant overall increasing trend in the recent decade (p <0.001). A significantly increasing focus is seen for publications on resident training (n = 86; +660%; p = 0.003), mental health (n = 31; +650%; p = 0.001), urolithiasis (n = 40; +371%; p = 0.002), and uro-oncology (n = 94; +230%, p ≤0.001). In subanalysis, the largest increase in publications was noted for surveys on radical prostatectomy (+175%, p = 0.024), surgical treatment of urolithiasis (+320%, p = 0.040), quality of resident education (+483%, p <0.001), and personal satisfaction with resident training (+500%, p = 0.005). Conclusions Over the decades, surveys have served as an effective interactive tool for urologists to engage and investigate different aspects of practice and training across sub-specialties. In modern times, better evaluation tools integrated with AI will provide a bigger platform for urologists to use surveys as part of their armamentarium to address and evaluate not only clinical practices but also emotional challenges, training needs, and inequalities that hinder progress in urology. [ABSTRACT FROM AUTHOR]

Introduction Urethral stricture disease is considered one of the more functionally bothersome aspects of urological conditions. The management of such disease is also traditionally managed with urethroplasty, or in severe cases, reconstruction. With the rise of artificial intelligence (AI) playing its part in diagnostics and treatment of urological conditions, we sought to determine its use case in urethral conditions in today’s era of advanced surgical care. Material and methods A comprehensive literature search was performed to identify literature on advances in diagnosis and management of urethral strictures. Publications in English were selected, whilst studies that were case reports, abstracts only, reviews, or conference posters were excluded. Results Twelve studies were finalised for review. Conventional neural networks and computational fluid dynamics implemented in retrograde urethrography reduced false positive and negative rates of urethral stricture diagnosis. Four-detector row computed tomography and magnetic resonance imaging voiding with virtual urethroscopy are also emerging imaging combination options for identification, offering decreased duration needed for diagnosis and increased correlation with intraoperative findings of urethral stricturing. For tissue re-engineering for urethral strictures, the role of 3-dimensional bioprinting of both autologous and allogenic sources has been on the rise, with promising findings of sustained tissue viability demonstrated in several in vitro animal studies and showing potential for expansion into human utilisation. Conclusions Advances in detection and management of urethral strictures have steadily been increasing its capacity, especially with the rise in artificial AI-driven learning algorithms and more accurate objectivity. Further studies are awaited to validate the use case of AI models in fields of urethral stricturing disease. [ABSTRACT FROM AUTHOR]