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INTRODUCTION: Percutaneous nephrolithotomy (PNL) is the treatment of choice for larger and complex renal calculi. First step in performing PNL is to obtain access to the renal cavity using either fluoroscopy or ultrasound (US) guidance or a combination of both. Which guiding method to choose is controversial? A systematic review of the literature was performed comparing image guidance modalities for obtaining access in PNL. Evidence acquisition and synthesis: A PubMed, Scopus and Cochrane search for peer-reviewed studies was performed using the keywords "ultrasound" AND "fluoroscopy" AND "Percutaneous nephrolithotomy". Eligible articles were reviewed according to PRISMA criteria. Two hundred and forty records were identified using the keywords. Of these twelve studies were considered relevant.RESULTS: US guidance seems to be associated with a slightly lower complication rate, which may be related to fewer puncture attempts needed for obtaining access and to better peri-renal organ visualization. On the other hand, US-guidance alone needs the adjunct of fluoroscopy in a significant number of cases for achieving access. Stone free rate (SFR) was comparable between groups. Using US for renal access unequivocally reduces radiation exposure.CONCLUSION: Current evidence indicates that both fluoroscopy and US guidance may be successfully used for obtaining percutaneous renal access. Combining the image-guiding modalities - US and fluoroscopy - seems to increase outcome in PNL both with regard to success in achieving access and reducing complications. Furthermore, including US in the access strategy of PNL reduces radiation exposure to surgeon and staff as well as patients.

In the original publication of the article, we inadvertently left the author Kay Thomas of the submission

To systematically assess the quality of videos on the surgical treatment of urinary stones available on YouTube using validated instruments. A systematic search for videos on YouTube addressing treatment options of urinary stones was performed in October 2019. Assessed parameters included basic data (e.g. number of views), the grade of misinformation reporting of conflicts of interest. Quality of content was analyzed using the validated DISCERN questionnaire. Data were analyzed using descriptive statistics. A total of 100 videos with a median of 26,234 views (1020–1,720,521) were included in the analysis. Of these, only 26 videos were rated to contain no misinformation and only nine disclosed potential conflicts of interest. Overall, the median quality of the videos was low (2 out of 5 points for DISCERN question 16). Videos uploaded by healthcare professionals and medical societies/organizations offered significantly higher levels of quality. In particular, the videos provided by the EAU achieved the highest rating with a median score of 3.0. The majority of videos concerning the surgical treatment of urinary stones have a low quality of content, are potentially subject to commercial bias and do not report on conflicts of interest. Videos provided by medical societies, such as the EAU, provide a higher level of quality. This highlights the importance of active recommendation of evidence-based patient education materials.

Miniaturization was the major trend in percutaneous nephrolithotomy in the past 15 years, aiming to lower tract-size-related complication rates while maintaining good stone-free-rates (SFR). Although there is some evidence that 18 Fr Mini-percutaneous lithotomy (PCNL) has comparable efficacy to conventional PCNL and a lower risk of bleeding, it is less clear whether further miniaturization led to an even better safety profile while maintaining good SFR. The present review evaluates the latest results on efficacy, safety, and feasibility of miniaturized techniques 14 Fr or less in PCNL.Recent literature of the last 2 years reported outcomes of different systems from 4.85 to 14 Fr. Most of these studies demonstrated good efficacy when comparing with RIRS or conventional PCNL. Limitations were a decrease in SFR for stone sizes more than 2 cm, a longer operative time and the likelihood of pathologic intrarenal pressure (IRP) with a higher risk of postoperative fever or sepsis.Miniaturization of PCNL is an innovative approach in order to lower complication rates and hospitalization time for therapy of renal stones. Limitations like longer OR time or higher IRP may limit the benefit of super miniaturized systems. Currently, the 18 Fr Mini-PCNL seems to be the most reliable solution for stones up to 25 mm, whereas RIRS remains the first choice in renal stones less than 10 mm.

Die zunehmende Digitalisierung stellt unsere Gesellschaft vor Herausforderungen und bietet zugleich eine Unmenge an Chancen. Sowohl Mensch als auch Maschine produzieren heutzutage eine grose Anzahl an Daten, die bisher noch ungenutzt und nicht miteinander verbunden sind.

There are two major steps of percutaneous nephrolithotomy (PNL): the puncture of the kidney and the subsequent dilatation to establish the percutaneous tract. Several concepts have been established: sequential dilators, telescope dilators, balloons and, most recently, single-step dilators. The choice is upon the surgeon and depends on personal preferences, costs as well the preferred access size. Potential advantages and disadvantages have been evaluated in multiple studies and meta-analyses, demonstrating that all of them provide good safety.

Conflicts of interest (COIs) can potentially introduce a risk of bias into the assessment of evidence and the formulation of recommendations for guidelines. It is essential that a systematic process for the disclosure and management of COIs is adopted to minimise potential bias in the guideline development process.

Purpose To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). Methods A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled “Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy” held in Copenhagen, Denmark, in September 2019. Results New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). Conclusion Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

Introduction: Urologists have to master a variety of techniques to be able to offer the most appropriate surgical stone treatment for each individual patient. Therefore, we performed a survey among board-certified Swiss urologists to assess the availability of the different surgical methods, the current practices of surgical treatment of urolithiasis and the adherence to evidence-based guideline recommendations in Switzerland. Methods: A 14-question survey assessed the working environment, equipment, perioperative settings and decision trees for specific stone scenarios. Data was analyzed using descriptive statistics and chi-square tests to determine differences between frequencies of answers. Results: Hundred and five members of Swiss Urology (38%) completed the survey. All treatment modalities are available for the majority of respondents. Ureterorenoscopy was found to have the highest availability (100%) and was the preferred choice in the majority of stone scenarios. A high adherence to the guidelines was found for the treatment of ureteral stones 10 mm (69% proximal, 94% distal). All respondents answered in accordance with the guidelines regarding the treatment of middle and upper pole stones 20 mm, and 63% for middle/upper pole stones >20 mm. Conclusion: This survey provides a detailed insight into current stone treatment practices in Switzerland. The full spectrum of urinary stone treatment options is available for the majority of Swiss urologists. The choice of treatment shows a high accordance with evidence-based guidelines and a preference for retrograde endoscopic surgery in the majority of stone scenarios.

Percutaneous nephrolithotomy (PCNL) is considered to be the first line of treatment for large renal stones. Though PCNL comes with higher morbidity, its efficacy is unbeaten by other minimally invasive modalities. However, potential complications, such as bleeding, occur. Improved skills and modifications of the procedure may reduce the probability of adverse outcomes. This article discusses the current trends and standards in PCNL technique with special focus on all important steps as positioning, access, instruments, dilation, disintegration, and exit, including outcomes, complication management, and training modalities.

INTRODUCTION: We evaluated a new digital single-use flexible ureteroscope, LithoVue™ with respect to deflection, image quality and maneuverability.METHODS: A prospective cohort study was conducted in eight tertiary reference centers in Europe in December 2015 and January 2016. All consecutive patients included underwent flexible ureteroscopy and were 18 years or older. Deflection and image quality pre- and post-use and maneuverability were rated with a Likert scale.RESULTS: A total of 40 procedures were performed (five per institution). The indication for FURS was treatment of renal stones in 92.5 % of the cases. Before LithoVue™ usage, the median measured upward and downward deflections were both 270°. Image quality was rated as "very good" in 65 % of cases and "good" in 30 %. Maneuverability was "very good" in 77.5 % and "good" in 17.5 %. At the final evaluation, median upward and downward deflections were both 270°. Image quality was still "very good" in 65 % of cases and "good" in 30 % with no significant difference compared with preoperative data (p = 1). Maneuverability was "very good" in 72.5 % and "good" in 17.5 %, with no significant difference compared with preoperative data (p = 0.92). Two LithoVue™ broke during surgery (5 %): one occurring in extreme deflection with acute infundibulopelvic angle and spontaneous loss of vision for the second one.CONCLUSION: The LithoVue™ displayed good image quality, active deflection and maneuverability. Further evaluation of surgical outcomes and cost analysis will help to present the best utility of this single-use FURS in current practice.

Background Urolithiasis is a widespread disease. Diagnostic imaging plays an important role in the evaluation and management of patients with suspected urolithiasis. Furthermore, modern imaging methods may provide information on stone location, size, fragility and composition aiding the urologist to determine the appropriate treatment modality. Purpose Based on the current literature and guidelines, this review reports on the various new and established diagnostic imaging modalities. Results Ultrasound should always be the initial imaging modality. Following ultrasound, noncontrast CT-principally using a low-dose protocol-is the imaging modality of choice in the evaluation of patients with acute flank pain and suspected urolithiasis. New imaging modalities like dual energy CT, Uro Dyna CT and digital tomosynthesis are currently under investigation but not yet part of daily clinical practice. Magnetic resonance imaging can be used to detect obstruction caused by urinary stones but is not a first-line imaging modality.

Purpose White light cystoscopy (WLC) is the standard procedure for visualising non-muscle invasive bladder cancer (NMIBC). However, WLC can fail to detect all cancerous lesions, and outcomes with transurethral resection of the bladder differ between institutions, controlled trials, and possibly between trials and routine application. This noninterventional study assessed the benefit of hexaminolevulinate blue light cystoscopy (HALC; Hexvix®, Ipsen Pharma GmbH, Germany) plus WLC versus WLC alone in routine use. Methods From May 2013 to April 2014, 403 patients with suspected NMIBC were screened from 30 German centres to perform an unprecedented detailed assessment of the additional detection of cancer lesions with HALC versus WLC alone. Results Among the histological results for 929 biopsy samples, 94.3 % were obtained from suspected cancerous lesions under either WLC or HALC: 59.5 % were carcinoma tissue and 40.5 % were non-cancerous tissue. Of all cancer lesions, 62.2 % were staged as Ta, 20.1 % as T1, 9.3 % as T2, 7.3 % as carcinoma in situ (CIS), and 1.2 % were unknown. Additional cancer lesions (+6.8 %) and CIS lesions (+25 %, p

We developed and validated the German version of the Ureteral Stent Symptoms Questionnaire (USSQ) for male and female patients with indwelling ureteral stents. The German version of the USSQ was developed following a well-established multistep process. A total of 101 patients with indwelling ureteral stents completed the German USSQ as well as the validated questionnaires International Prostate Symptom Score (IPSS) or International Consultation on Incontinence Questionnaire (ICIQ) and the Short Form Health Survey (SF-36). Patients completed questionnaires at 1 and 2–4 weeks after stent insertion and 4 weeks after stent removal. Statistical analyses were performed to assess the psychometric properties of the questionnaire. The German version of the USSQ showed good internal consistency (Cronbach’s α = .72–.88) and test–retest reliability [intraclass correlation coefficient (ICC) = .81–.92]. Inter-domain associations within the USSQ showed substantial correlations between different USSQ domains, indicating a high conceptual relationship of the domains. Except from urinary symptoms and general quality of life, German USSQ showed good convergent validity with the corresponding validated questionnaires. All USSQ domains showed significant sensitivity to change (p ≤ .001). The new German version of the USSQ proved to be a reliable and robust instrument for the evaluation of ureteral stent-associated morbidity for both male and female patients. It is expected to be a valid outcome measure in the future stent research.

Jeder 10. Bundesburger wird im Laufe seines Lebens zumindest einen Harnstein bilden. Die Diagnostik, Therapie und Nachsorge der Urolithiasis gehort daher zum taglich Brot aller Urologen in Klinik und Praxis, aber auch vieler anderer Fachdisziplinen wie Allgemeinmedizinern, Internisten, Nephrologen oder Padiatern. Wahrend Diagnostik und Therapie in den letzten 10 Jahren erhebliche Veranderungen erfahren haben, fristen die Moglichkeiten einer metabolischen Diagnostik und Sekundarpravention von Risikopatienten leider vielerorts – zu Unrecht – ein Schattendasein. Die vorliegende S2k-Leitlinie, welche erstmals aus einem interdisziplinaren Konsensusprozess hervorging, stellt die aktuellen Empfehlungen praxisnah dar und verwendet wann immer moglich Tabellen und Algorithmen, um ein rasches Nachschlagen bei der taglichen Arbeit zu erleichtern. Nicht zuletzt die Masnahmen zur Metaphylaxe werden hierdurch deutlich vereinfacht.

Context Imaging is essential for the diagnosis and the clinical decision-making process of patients with urinary stones. Objective To assess the benefits and limitations of various imaging techniques by specifically focusing on different phases of stone patients' management. Evidence acquisition PubMed and Web of Science databases were used to identify studies published in the last 10 yr on this argument. Search terms included ‘urolithiasis', nephrolithiasis', or ‘urinary stones' in combination (AND) with the terms ‘imaging', ‘computer tomography', ‘ultrasonography', ‘intravenous pyelogram', or ‘radiation exposure'. Study selection was based on an independent peer-review process of all the authors after the structured data search. Evidence synthesis Noncontrast-enhanced computer tomography (CT) provides the highest value of diagnostic accuracy for urinary stones. Stone composition can be specifically assessed through the use of dual-energy CT. When information about the anatomy of the renal collecting system is required or alternative pathologies are suspected, CT with contrast injection is recommended. Low-dose protocols allowed a drastic reduction of the effective dose administered to the patient, thus limiting the biological risk due to ionising radiations. Other strategies to contain the radiation exposure include the dual-split bolus dual energy CT and the adaptive statistical image reconstruction. Abdomen ultrasound may be a valid alternative as an initial approach since it does not change the outcome of patients compared with CT, and should be the imaging of choice in children and pregnant women. Conclusions Noncontrast-enhanced CT is the most accurate imaging technique to identify urinary stones. Abdomen ultrasound seems to be a valid alternative in the initial evaluation of urinary colic. New low-dose protocols and strategies have been developed to contain radiation exposure, which is a major issue especially in specific circumstances. Patient summary Noncontrast-enhanced computer tomography has been increasingly used for the diagnosis and management of urinary stones. Low-dose protocols as well as alternative imaging should be considered by clinicians in specific circumstances to minimise radiation exposure.

Ronney Abaza Mehran Abolbashari Ahmad Abolyosr Ashraf Abou-Elela Omar Aboumarzouk Jose Benito Abraham Peter Acher Alex Acosta-Miranda Samiran Adhikary Ramez Adrawis Anshuman Agarwal Mayank Agarwal Madhu Agrawal Sachin Agrawal Rajesh Ahlawat Tom Ahlering Hanjong Ahn Sascha Ahyai Murat Akand Naeem Akhter Joseph Akornor Yilmaz Aksoy Abdulla Al Naimi Azan Al Saadi Husain Alenezi Bachmann Alexander Samih Al-Hayek Gerasimos Alivizatos Erdal Alkan Ahmed Al-Kandari Peter Alken Khaled Al-Kohlany Mohamad Allaf Seth Alpert Hernan Altamar Bulent Altay Serkan Altinova Fatih Altunrende Mario Alvarez-Maestro Theodore Anagnostou Anastasios Anastasiadis James Anderson Kevin Anderson Sero Andonian Cassio Andreoni Yoichi Arai Marco Arap Athanasios Argyropoulos Angela Arlen Abdullah Armagan Noel Armenakas Don Arnold II Monish Aron William Aronson Nicola Arrighi Amir Arsanjani Murat Arslan Montserrat Arzoz John Asplin Mohamed Atalla Mutlu Ates Hammad Ather Ali Fuat Atmaca Fatih Atug Brian Auge Riccardo Autorino Timothy Averch Emin Aydur Ali Ayyildiz Abdel-Rahmene Azzouzi Richard Babayan Christian Bach Thorsten Bach Gopal Badlani Herman Bagga Demetrius Bagley Badrulhisham Bahadzor Mevlana Balbay D. Baldwin Gaurav Bandi Yige Bao Shivadev Bapat Caner Baran Eric Barret John Barry Jay Basillote Mehmet Baykara Selahattin Bedir Dina Bedretdinova Frank Begun Darren Beiko Jakob Ben-Chaim Karim Bensalah Brian Benway Aaron Berger Sara Best Akshay Bhandari Mahendra Bhandari Shiv Bhanot Sam Bhayani Naeem Bhojani Giampaolo Bianchi Hemant Bid Pierre Bigot JOURNAL OF ENDOUROLOGY Volume 29, Number 4, April 2015 a Mary Ann Liebert, Inc. Pp. 490–494 DOI: 10.1089/end.2015.1512

Purpose: Fluoroscopy is valuable in modern endourology. We present the results of a survey where compliance to radiation safety measures was tested according to surgical exposure, and level of understanding of the radiation rules and risks associated with it. Methods: A 52-item, anonymous questionnaire, structured by 6 ESUT/EULIS experts was distributed at 3 different endourological meetings during 2017–2018. Main aim was to evaluate level of knowledge on radiation physics and the protective measures taken against radiation exposure by participants. Fisher’s exact test, Kruskal–Wallis test and ROC curve were used for statistical analysis. Results: 211 responses were evaluated. Number of correct answers (median 7.00) differed significantly according to age (p = 0.001), working position (p = 0.005), working field (p < 0.001), number of semirigid (p < 0.001)/flexible URS (p < 0.001) and PNL (p < 0.001) performed per year. Physicians aged 50–60 years, consultants, academics and those who performed more procedures achieved higher scores. In our study 51.7% of responders used shields in the operating room, 89.6% wore lead aprons, 84.4% thyroid shields, while glasses and gloves were used by 14.7% and 8.1%, respectively. Age, working field and number of correct answers did not affect significantly the use of protection in contrast with endourology fellowship training, working position and lessons on radiation. Interestingly, residents, untrained endourologists and those who were provided with lessons on radiation were more compliant. Conclusions: Our study revealed that majority of modern urologists advocate radiation protection during endourology practice. Senior consultants and academic urologists performing a high volume of procedures seem to understand physics and rules of radiation use.

Urolithiasis is an urologist's daily business. This article provides an overview of the developments in the management of urinary stone disease since the 1970s. While conventional KUB X-rays and intravenous pyelography were standard imaging procedures in the past, computed tomography is the first choice today. Conservative treatments such as medical expulsive therapy were established to facilitate ureteral stone passage, but have come into discussion in the past few years. Fifty years ago, open stone surgery was the standard procedure to access renal stones. This has been superseded by minimally-invasive procedures ranging from percutaneous nephrolithotomy (PCNL) to extracorporeal shock-wave lithotripsy (ESWL) and ureteroscopy (URS), which is today's standard for most upper urinary tract stones. It would have been desirable if such enormous efforts and progress had been made in the evaluation of stone pathogenesis and the improvement of preventative measures. Unfortunately, the knowledge on stone formation has hardly improved compared to 1970.Die Urolithiasis ist das Brot-und-Butter-Geschäft des Urologen. Kaum eine urologische Praxis oder Klinik kann auf die Therapie von Harnsteinen verzichten. Dieser Artikel stellt die Entwicklungen der letzten 50 Jahre auf dem Gebiet der Urolithiasis dar. In der bildgebenden Diagnostik hat sich die Computertomografie gegenüber der konventionellen Röntgenbildgebung durchgesetzt. Konservative Therapien wie die „medical expulsive therapy“ (MET) hatten sich etabliert, sind aber zuletzt wieder in die Diskussion geraten. Die größten Fortschritte hat in den letzten 50 Jahren sicherlich die interventionelle Therapie gezeigt. War in den 70er-Jahren noch die offene Steinchirurgie der Therapiestandard, so hat sich diese bis heute vollständig zu Minimal-Invasivität gewandelt. Die Entwicklung der perkutanen Nephrolithotomie (PCNL), dann der extrakorporalen Stoßwellenlithotripsie (ESWL) und schließlich der Ureterrenoskopie (URS) ermöglichen heute individualisierte Therapiekonzepte, wobei die URS sicherlich das am häufigsten eingesetzte Verfahren ist. Wünschenswert sind die gleichen Fortschritte auf dem Gebiet der Steinmetabolik und -prävention, wo die diagnostischen Verfahren und Therapieempfehlungen keine wirkliche Entwicklung gezeigt haben.

Das Recycling der Fraktion

PURPOSE: To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers.METHODS: A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018.RESULTS: Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice.CONCLUSIONS: Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Zusammenfassung: Die Zunahme des medizinischen Wissens, technische Neuerungen gemeinsam mit demographischem Wandel stellen eine Herausforderung an die Neukonzeption von Leitlinien und klinischen Studien dar. Die vorliegende S2k-Leitlinie, die sich ausschlie ss lich mit Nieren- und Harnleitersteinen beschaftigt, soll die Behandlung von Harnsteinpatienten in Klinik und Praxis unterstutzen, aber auch Patienteninformationen zur Urolithiasis geben. Die zunehmende interdisziplinare Zusammenarbeit in der Steintherapie zeigt sich auch an der Anzahl beteiligter Fachgruppen und Arbeitsgemeinschaften in der Erstellung des neuen Leitlinienupdates. Die vorliegende, aus einem interdisziplinaren Konsensusprozess hervorgegangene S2k-Leitlinie stellt die aktuellen Empfehlungen praxisnah dar und gibt Entscheidungshilfen fur Diagnostik-, Therapie- und Metaphylaxema ss nahmen auf Basis von Expertenmeinungen und verfugbaren Evidenzgrundlagen aus der Literatur. Abstract: The increase of medical knowledge and technical innovations together with the demographic change represent a challenge for the new conception of guidelines and clinical studies. The present S2k guidelines, which are exclusively concerned with kidney and ureteral stones, should support the treatment of urolithiasis in hospitals and private practices and provide information on urolithiasis for patients. Increasing interdisciplinary collaboration in stone treatment is also demonstrated in the number of professional and working groups participating in the update of the new guidelines. The present S2k guidelines emerged from a consensus process and demonstrate the current recommendations in step with actual practice. They provide decision-making guidance for diagnostics, treatment and metaphylactic measures based on expert opinions and available published fundamental evidence from the literature.

The precise identification and detection of bladder tumours is a prerequisite for complete transurethral resection and, thus, the reduction of recurrence. White-light cystoscopy remains the gold standard and has been further improved by the introduction of digital HD techniques. New digital techniques such as narrow-band imaging (NBI) or the IMAGE 1 S-System have been introduced to better visualise suspicious areas. They are particularly valuable in the outpatient setting. However, fluorescence or photodynamic diagnostics (PDD) after instillation of hexaminolevulinic acid into the bladder is the only approach supported by good evidence. It is recommended by most guidelines in high-grade tumours or carcinoma in situ, while the value of NBI and the Image 1 S-System is under evaluation. Newer approaches include microscopic techniques such as optical coherence tomography, confocal laser endomicroscopy or molecular imaging. The combination of these methods with macroscopic imaging could be very promising.Die korrekte Detektion von Blasentumoren ist die Voraussetzung zur vollständigen Resektion und damit zur Reduktion von Rezidiven, aber auch zum korrekten Staging von fortgeschrittenen und high-grade Karzinomen. Die Weißlicht-Zystoskopie stellt den Goldstandard dar und konnte durch digitale HD-Zystoskopie weiter verbessert werden. Die weiteren Verfahren zur verbesserten Bildgebung etablieren sich schrittweise. Narrow Band Imaging und S-System könnten v. a. im ambulanten Setting einen Vorteil darstellen, da keine Kontrastmittel notwendig sind. Die fotodynamische Diagnostik hat sich bereits im klinischen Setting bei der TURB, zumindest bei high-grade Karzinomen etabliert und einen gesicherten Stellenwert in den Leitlinienempfehlungen. Die Kombination von diesen makroskopischen Verfahren mit mikroskopischer Bildgebung könnte die Diagnostik verbessern. Solche neueren Verfahren wie optische Kohärenztomografie oder Konfokale Laser Endomikroskopie sind derzeit in der klinischen Evaluation. Andere Techniken bis hin zur molekularen Bildgebung stellen spannende Konzepte dar, deren Weg in die Klink aber noch lang zu sein scheint.

Non-contrast enhanced computed tomography (NCCT) is widely used measuring stone size in patients with urolithiasis. We performed an evaluation of the accuracy of stone size measuring via NCCT. In an in-vitro study, we analyzed a total of 38 uric acid and 38 phantom stones. Within NCCT, we used different slice thicknesses (1.5 mm, 2.0 mm, and 3.0 mm) and kernel settings (bone and soft-tissue window). Maximal height, maximal length, and maximal width of each stone were measured on a picture archiving and communication system workstation. Blinded to these results, a second physician measured stone size in the same way using a caliper (real stone size). We used the Bland–Altman method for the analysis of agreement between the two measuring methods. The limit of agreement that was deemed clinical insignificant was ± 1.0 mm. All measurements via NCCT correlated significantly with the real stone size (p

Context Management of urinary stones is a major issue for most urologists. Treatment modalities are minimally invasive and include extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL). Technological advances and changing treatment patterns have had an impact on current treatment recommendations, which have clearly shifted towards endourologic procedures. These guidelines describe recent recommendations on treatment indications and the choice of modality for ureteral and renal calculi. Objective To evaluate the optimal measures for treatment of urinary stone disease. Evidence acquisition Several databases were searched to identify studies on interventional treatment of urolithiasis, with special attention to the level of evidence. Evidence synthesis Treatment decisions are made individually according to stone size, location, and (if known) composition, as well as patient preference and local expertise. Treatment recommendations have shifted to endourologic procedures such as URS and PNL, and SWL has lost its place as the first-line modality for many indications despite its proven efficacy. Open and laparoscopic techniques are restricted to limited indications. Best clinical practice standards have been established for all treatments, making all options minimally invasive with low complication rates. Conclusion Active treatment of urolithiasis is currently a minimally invasive intervention, with preference for endourologic techniques. Patient summary For active removal of stones from the kidney or ureter, technological advances have made it possible to use less invasive surgical techniques. These interventions are safe and are generally associated with shorter recovery times and less discomfort for the patient.

The prevalence of kidney stones is increasing worldwide. Asymptomatic non-obstructing kidney stones are increasingly detected as an incidental finding on radiologic imaging, which has been performed more frequently over the last decades. Beside the current interventional treatment modalities such as extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy (URS) and percutaneous nephrolithotomy (PNL), active surveillance of asymptomatic kidney stones has been a focus of discussion lately, not only for attending physicians, but even more so for patients. The current German and European guidelines recommend active surveillance for patients with asymptomatic kidney stones if no interventional therapy is mandatory because of pain or medical factors. Herein we review the current literature on risks and benefits of active surveillance of asymptomatic non-obstructing kidney stones.

PURPOSE: To prospectively evaluate the new Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) access sheath (UAS) which allows the use of a single wire to serve as both safety and working guide.MATERIALS AND METHODS: Between June and September 2014, adult patients from five European centers who underwent flexible ureteroscopy (fURS) for therapeutic and diagnostic purposes were included. The 12/14Fr Flexor©Parallel™ UAS was evaluated. Data were collected and examined by both univariate and multivariate analyses. The UAS material and usage characteristics were rated per case by the surgeons on a scale from very bad to very good.RESULTS: In total, 134 UASs were used in 67 male and 67 female patients. Fifty percent of ureters (67 patients) were pre-stented. Ninety percent of the procedures were therapeutic. The overall successful insertion rate was 94 %. Pre-stenting status was the only independent factor for a successful access sheath insertion: 98.5 % of the pre-stented patients had a successful UAS placement vs. 82 % of non-pre-stented (p = 0.001, C.I. 95 %: 1.2). Evaluation of the material and radiopacity was considered very good in over 90 % of cases. Release of the guidewire, hydrophilic coating, gliding of the endoscope and repeatability were considered very good in over 80 %. There were two (1.4 %) UAS malfunctions and one submucosal lesion reported.CONCLUSIONS: The use of the Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) with usage of a single guidewire in a prospective multicentric scenario was clinically applicable in the majority of cases. Pre-stenting increased the chance of a successful insertion from 82 to 98.5 %.

Nach ihrer Einfuhrung in den 1980er Jahren entwickelte sich die extrakorporale Stoswellenlithotripsie (ESWL) zum Goldstandard der Behandlung von Nieren- und Uretersteinen. Die zum Thema „Steintherapie“ innerhalb der letzten Dekade publizierten wissenschaftlichen Arbeiten suggerieren einen Paradigmenwechsel hin zu endourologischen Techniken. Anhand der vorliegenden Arbeit soll uberpruft werden, ob dieser Anschein der Ablosung des Goldstandards ESWL auch der reellen Versorgungssituation in Deutschland entspricht. Weiterhin soll die Behandlungsqualitat der ESWL in deutschen Kliniken erfasst werden. Unter Federfuhrung der Deutschen Gesellschaft fur Stoswellenlithotripsie (DGSWL) wurde ein Fragebogen an 306 urologische Kliniken in Deutschland verschickt. Der Fragebogen umfasst medizinische, technische und organisatorische Themenbereiche der Therapie von Nieren- und Uretersteinen. 99 Fragebogen (33 %) wurden beantwortet zuruckgesandt. Mit Ausnahme weniger Kliniken spielt die nicht-invasive ESWL weiterhin eine bedeutende Rolle im therapeutischen Spektrum, eine Ablosung als Goldstandard ist nicht in Sicht. Die ESWL wird an deutschen Kliniken mit hoher Qualitat praktiziert, fur deren Sicherung und weiteren Optimierung es einer Einhaltung von ESWL-Behandlungsstandards sowie einer strukturierten ESWL-Ausbildung bedarf.

Seit Mai 2015 steht die neue S2k-Leitlinie Urolithiasis zur Verfugung. Die ausfuhrliche Version erhalten Facharzte und Interessierte auf der Homepage der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. Fur URO-NEWS hat der Koordinator der Leitlinie die wichtigsten Neuerungen zusammengefasst.

Context An optimum metabolic evaluation strategy for urinary stone patients has not been clearly defined. Objective To evaluate the optimum strategy for metabolic stone evaluation and management to prevent recurrent urinary stones. Evidence acquisition Several databases were searched to identify studies on the metabolic evaluation and prevention of stone recurrence in urolithiasis patients. Special interest was given to the level of evidence in the existing literature. Evidence synthesis Reliable stone analysis and basic metabolic evaluation are highly recommended in all patients after stone passage (grade A). Every patient should be assigned to a low- or high-risk group for stone formation. It is highly recommended that low-risk stone formers follow general fluid and nutritional intake guidelines, as well as lifestyle-related preventative measures to reduce stone recurrences (grade A). High-risk stone formers should undergo specific metabolic evaluation with 24-h urine collection (grade A). More specifically, there is strong evidence to recommend pharmacological treatment of calcium oxalate stones in patients with specific abnormalities in urine composition (grades A and B). Treatment of calcium phosphate stones using thiazides is only highly recommended when hypercalciuria is present (grade A). In the presence of renal tubular acidosis (RTA), potassium citrate and/or thiazide are highly recommended based on the relative urinary risk factor (grade A or B). Recommendations for therapeutic measures for the remaining stone types are based on low evidence (grade C or B following panel consensus). Diagnostic and therapeutic algorithms are presented for all stone types based on the best level of existing evidence. Conclusion Metabolic stone evaluation is highly recommended to prevent stone recurrences. Patient summary In this report, we looked at how patients with urolithiasis should be evaluated and treated in order to prevent new stone formation. Stone type determination and specific blood and urine analysis are needed to guide patient treatment.

YAU Group; International audience; Short-term ureteric stents are commonly placed after ureteroscopy. The removal usually entails having a cystoscopy, but recently, endourologists have been using stents with extraction strings attached to them for ease of removal. We wanted to conduct a systematic review of literature looking at the outcomes of ureteric stents with extraction strings attached to them. Our objective was to investigate the use, morbidity, tolerability, complications, associated cost, and patient preference of stents with extraction strings attached to them. All studies in English language (between 1990 and 2015) where stents on extraction strings were either self-removed by patients or removed by physician were included. A total of eight studies (1279 patients) were included, of which 483 (38 %) patients had extraction strings for removal. There seemed to be no overall difference in pain scores or urinary symptoms between patients with and without extraction strings, but nearly 10 % of patients suffered stent dislodgement in the group with extraction strings attached. Overall stent dwell time was lower in patients who had their stents removed via extraction strings, and majority of them were able to remove their stents at home. Our study suggests that stents with extraction strings are easy for patient self-removal and can reduce the stent dwell time for patients, thus reducing the duration of morbidity and physical and financial burden to patients. However, this must be balanced against a risk of stent dislodgement and, hence, may not be a good option in all patients.

This chapter is about the think-aloud protocol and its application to player experience. It covers what the protocol is, when to apply it, how to conduct it, its pros and cons, and its variations. The chapter concludes with a discussion of think-aloud protocols with children and the considerations necessary when using child participants.

WOS: 000457123100013 PubMed ID: 30680241 Introduction We assessed the clinical performance of a new digital single-use flexible ureteroscope (UscopePU3022). Material and methods A prospective cohort study was carried out across 11 centers (July-Oct. 2017). The UscopePU3022 was assessed regarding ease of insertion; deflection, image quality, maneuverability and overall performance using either a visual analog* or Likert scale. Results A total of 56 procedures were performed in 11 centers (16 surgeons) with the indication being renal stones in 83%. The median score for ease of scope insertion was 10 (3-10). Intraoperative maneuverability was rated as 'good' in 38% and 'very good' in 52%. Visual quality was rated as 'poor or bad' in 18%, 'fair' in 37% and 'good very good' in 43%. Two scopes failed intraoperatively (4%). Preoperative and postoperative median upward and downward deflection was 270 degrees. Compared to standard flexible ureteroscopy (f-URS) maneuverability was rated as 'equivalent' in 30% and 'better' in 60%; visual quality was 'worse' in 38% and 'equivalent or better' in 62%; limb fatigue scores were 'better' in 86%; and overall performance was 'worse' in 55% and 'equivalent or better' in 45%. Conclusions UscopeTM3022 performed well with regards to maneuverability, deflection and limb fatigue and appears to be at least non-inferior to standard f-URS with regards to these parameters. Poor image quality is a concern for UscopePU3022 with it receiving a low overall performance rating when compared to standard f-URS. Despite this it scored highly when investigators were asked if they would use it in their practice if it was cost-effective to do so.

Harnsteine bei Kindern sind selten. Wenn sie vorkommen, liegen haufig metabolische Ursachen zugrunde, welche zu einer Rezidivsteinbildung fuhren konnen. Kinder mit Harnsteinen sind daher per Definition eine Hochrisikogruppe, weshalb nach dem ersten Steinereignis basierend auf der Steinanalyse eine erweiterte Stoffwechseldiagnostik erfolgen muss.

The simultaneous surgical management of ureteropelvic junction obstruction (UPJO) with concomitant renal stones has evolved the last 20 years; hence, the ideal minimally invasive technique is still controversial. Laparoscopic and robot-assisted laparoscopic operations allow precise surgical maneuvers and were thought to simplify the reconstruction steps of the procedure, especially in the treatment of complex cases with large stones. The aim of this study was to summarize the available perioperative and functional outcomes of minimally invasive available techniques. A non-systematic review of the literature was performed using a free-text protocol in the MEDLINE database. The terms used were "ureteropelvic junction obstruction," "renal calculi" and "renal stones." Furthermore, other significant relevant studies cited in the reference lists of the selected papers were also evaluated in the structure of this review. Currently, available evidence suggests that both laparoscopic and robotic-assisted techniques offer excellent surgical solutions in the field of UPJO reconstruction and renal stones removal. In the hands of experienced surgeons, laparoscopic and robotic pyeloplasty with concomitant stone removal is a safe procedure with high stone-free rates and UPJ patency. Minimally invasive pyeloplasty should constitute the first choice of treatment for concomitant renal stones and ureteropelvic junction obstruction.

Hintergrund Zahlreiche Studien zeigen, dass die Thuliumvapoenukleation (ThuVEP) der Prostata ein grosenunabhangiges, minimal-invasives Verfahren zur Therapie der benignen Prostatavergroserung darstellt. Bislang wurden alle Studien mit einem 2-µm-Thuliumlaser durchgefuhrt. Ziel der vorliegenden Arbeit war es, Komplikationen und fruhfunktionelle Ergebnisse zweier Thuliumlaser unterschiedlicher Wellenlangen bei Prostatavolumina > 80 ml zu evaluieren.

Following its introduction in 1980, shock wave lithotripsy (SWL) rapidly emerged as the first-line treatment for the majority of patients with urolithiasis. Millions of SWL therapies have since been performed worldwide, and nowadays, SWL still remains to be the least invasive therapy modality for urinary stones. During the last three decades, SWL technology has advanced in terms of shock wave generation, focusing, patient coupling and stone localization. The implementation of multifunctional lithotripters has made SWL available to urology departments worldwide. Indications for SWL have evolved as well. Although endoscopic treatment techniques have improved significantly and seem to take the lead in stone therapy in the western countries due to high stone-free rates, SWL continues to be considered as the first-line therapy for the treatment of most intra-renal stones and many ureteral stones.This paper reviews the fundamentals of SWL physics to facilitate a better understanding about how a lithotripter works and should be best utilized.Advances in lithotripsy technology such as shock wave generation and focusing, advances in stone localization (imaging), different energy source concepts and coupling modalities are presented. Furthermore adjuncts to improve the efficacy of SWL including different treatment strategies are reviewed.If urologists make use of a more comprehensive understanding of the pathophysiology and physics of shock waves, much better results could be achieved in the future. This may lead to a renaissance and encourage SWL as first-line therapy for urolithiasis in times of rapid progress in endoscopic treatment modalities.

Live surgical broadcasts (LSBs) are becoming increasingly popular in urological conferences. These activities can provide excellent training opportunities, as they allow the audience to view an operation conducted by world-renowned surgeons, and have the ability to interact with them in real time. However, several ethical considerations have been raised with this practice, which the participating surgeons and conference organisers must appreciate and address carefully. In this article we highlight the ethical considerations related to LSBs and advise on how these should be addressed. We also present the latest recommendations made by the European Association of Urology Live Surgery Committee and discuss alternatives to LSB.

Treatment of renal stones using flexible ureteroscopy (fURS) is increasingly common despite the poor evidence in literature supporting its use and indications. With this study, we wanted to investigate the current use and indication of fURS for the treatment of renal stones in the clinical practice across the European countries. A survey was conducted using an emailed questionnaire consisting of 21 items; 2,894 recipients were selected via the EAU membership database. The questionnaires were collected through the SurveyMonkey system and the data were processed with the SPSS statistical package. Frequencies, cross tabs and Pearson correlation coefficients were applied as appropriate. 1,168 questionnaires were collected (response rate 40.4 %). fURS was performed in 72.9 % of the respondents’ institutions, and 54.2 % of the respondents were performing the procedure. For 95 % of the users, fURS was considered first-line treatment, for stone of lower pole stone (45.9 %) and

Objective To evaluate the experience and views regarding live surgical broadcasts (LSB) among European urologists attending the European Association of Urology Robotic Urology Society (ERUS) congress in September 2012. Materials and Methods An anonymous survey was distributed via email inviting the participants of the ERUS congress with experience of LSB to share their opinions about LSB. The outcomes measured included; personal experience of LSB, levels of anxiety faced and the perceived surgical quality. The impact of factors, such as communication/team-working, travel fatigue and lack of specific equipment were also evaluated. Results In all, 106 surgeons responded with 98 (92.5%) reporting personal experience of LSB; 6.5% respondents noted ‘significant anxiety’ increasing to 19.4% when performing surgery away from home (P < 0.001). Surgical quality was perceived as ‘slightly worse’ and ‘significantly worse’ by 16.1% and 2.2%, which deteriorated further to 23.9% and 3.3% respectively in a ‘foreign’ environment (P = 0.005). In all, 10.9% of surgeons ‘always’ brought their own surgical team compared with 37% relying on their host institution; 2.4% raised significant concerns with their team and 18.8% encountered significantly more technical difficulties. Lack of specific equipment (10.3%), language difficulties (6.2%) and jet lag (7.3%) were other significant factors reported. In all, 75% of surgeons perceived the audience wanted a slick demonstration; however, 52.2% and 42.4% respectively also reported the audience wished the surgeon to struggle or manage a complication during a LSB. Conclusions A small proportion of surgeons had significantly heightened anxiety levels and lower perceived performance during LSB, which in a ‘foreign’ environment seemed to affect a greater proportion of surgeons. Various factors appear to impact surgical performance raising concerns about the appropriateness of unregulated LSB as a teaching method. To mitigate these concerns, surgeons' performing live surgery feel that the operation needs to be well planned using appropriate equipment; with many considering bringing their own team or operating from home on a video link.

The impact of renal anatomy on the success rate of flexible ureterorenoscopy (fURS) for lower pole stones is less clear than it is on shock wave lithotripsy, for which it is a recognized influence factor. We analyzed safety and efficiency of fURS using modern endoscopes for lower pole stones dependent on the collecting system's configuration.We retrospectively evaluated a consecutive sample of 111 fURS for lower pole stones at our tertiary care center between January 2010 and September 2012 from our prospectively kept database. All procedures were performed with modern flexible ureterorenoscopes, nitinol baskets, holmium laser lithotripsy, and ureteral access sheaths whenever needed. The infundibular length (IL) and width (IW) and infundibulopelvic angle (IPA) were measured and the data were stratified for stone-free status and complications classified by the Clavien-Dindo scale. Univariate and multifactorial statistical analyses were performed. Correlation of operation time (OR-time) with anatomical parameters was conducted.Ninety-eight (88.3%) of the 111 patients were stone free after a single fURS. On multifactorial analysis, the stone size and IL had significant influence on the stone-free rate (SFR) (p0.01), whereas IW did not. An acute IPA (30°) also had significant influence (p=0.01). The incidence of complications and OR-time were not influenced by the pelvicaliceal anatomy.fURS is a safe and efficient treatment option for lower pole kidney stones. A long infundibulum and a very acute IPA (30°) negatively affect the SFR. However, with second look procedures, a complete stone clearance is achievable even in case of unfavorable anatomic conditions. A narrow infundibulum has no negative effect while using modern endoscopes. The complication rate is not affected by the collecting system's anatomy.

Purpose: The Post-Ureteroscopic Lesion Scale (PULS) offers a simple grading system for the description of ureteral lesions after ureteroscopy. In this article, we present the results of a video-based multicenter evaluation of the inter-rater reliability of clinically important PULS grades 0-3. Methods: Video sequences at the end of ureteroscopy (final passage) were recorded for 100 consecutive patients at a single institution and assessed by experienced urologists (n = 20) and senior residents (n = 17) at 19 international centers. The cohort included only patients with lesions grades 0-3 (with grades 2 and 3 subsumed as 2 + since distinction is defined by an extravasation of contrast medium in fluoroscopy). The gradings were evaluated for inter-rater reliability and in terms of simplicity, validity, comprehensibility, reproducibility, and usefulness. Results: Overall, inter-rater reliability was high (Kendall's W = 0.69, p < 0.001) and was comparable between specialists (Kendall's W = 0.69, p < 0.001) and residents (Kendall's W = 0.71, p < 0.001). The matched ratings showed grade 0 in 43.0 % of patients and grades 1 or 2 + in 44.0 and 13.0 % of patients, respectively. Results of the questionnaires indicated a high degree of acceptance, with an overall rating of 1.76 (1.64-1.93 for different items, scale 1-6). Conclusions: Inter-rater reliability of the endoscopically assessable PULS was high among urologists with different levels of experience in different countries worldwide. The validated PULS system may be used for standardized reporting of ureteral lesions/injuries after ureteroscopy. In addition, PULS will enable more selective standardization of indications for postoperative DJ stenting based on the randomized controlled trials.

Context Extracorporeal shock wave lithotripsy (SWL) and ureteroscopy (URS), with or without intracorporeal lithotripsy, are the most common treatments for upper ureteric stones. With advances in technology, it is unclear which treatment is most effective and/or safest. Objective To systematically review literature reporting benefits and harms of SWL and URS in the management of upper ureteric stones. Evidence acquisition Databases including Medline, Embase, and the Cochrane library were searched from January 2000 to November 2014. All randomised controlled trials (RCTs), quasi-randomised controlled trials, and nonrandomised studies comparing any subtype or variation of URS and SWL were included. The primary benefit outcome was stone-free rate (SFR). The primary harm outcome was complications. Secondary outcomes included retreatment rate, need for secondary, and/or adjunctive procedures. The Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to assess nonrandomised studies. Grading of Recommendations Assessment, Development, and Evaluation was used to assess the quality of evidence. Evidence synthesis Five thousand-three hundred and eighty abstracts and 387 full-text articles were screened. Forty-seven studies met inclusion criteria; 19 (39.6%) were RCTs. No studies on children met inclusion criteria. URS and SWL were compared in 22 studies (4 RCTs, 1 quasi-randomised controlled trial, and 17 nonrandomised studies). Meta-analyses were inappropriate due to data heterogeneity. SFR favoured URS in 9/22 studies. Retreatment rates were higher for SWL compared with URS in all studies but one. Longer hospital stay and adjunctive procedures (most commonly the insertion of a JJ stent) were more common when primary treatment was URS. Complications were reported in 11 out of 22 studies. In eight studies, it was possible to report this as a Clavien-Dindo Grade. Higher complication rates across all grades were reported for URS compared with SWL. For intragroup (intra-SWL and intra-URS) comparative studies, 25 met the inclusion criteria. These studies varied greatly in outcomes measured with data being heterogeneous. Conclusions Compared with SWL, URS was associated with a significantly greater SFR up to 4 wk but the difference was not significant at 3 mo in the included studies. URS was associated with fewer retreatments and need for secondary procedures, but with a higher need for adjunctive procedures, greater complication rates, and longer hospital stay. Patient summary In this paper, the relative benefits and harms of the two most commonly offered treatment options for urinary stones located in the upper ureter were reviewed. We found that both treatments are safe and effective options that should be offered based on individual patient circumstances and preferences.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is usually performed worldwide with a rigid-only antegrade approach. Daily practice suggests that adding flexible nephroscopy and/or ureteroscopy to conventional rigid PNL might improve its efficacy and safety, but available evidence is weak. Appraisal of reliable outcomes of such PNL techniques would better guide intraoperative choices and optimize surgical results. Therefore our objective was to systematically review relevant literature comparing the outcomes of rigid-only PNL and combined flexible PNLs (adding flexible nephroscopy and/or flexible ureteroscopy) for the treatment of large and/or complex upper urinary tract calculi, with regard to efficacy and safety.EVIDENCE ACQUISITION: Ovid MedLine (R), PubMed, Scopus and Web of Science databases were searched in August 2016 to identify relevant studies. Article selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis criteria.EVIDENCE SYNTHESIS: Six articles reporting on 666 patients were included: two randomized controlled trials, two retrospective comparative studies and two case series > 50 patients (one prospective and one retrospective). A narrative synthesis of minor evidences was also prepared. The adjunct of flexible nephroscopy and/or ureteroscopy provided better stone-free rates (range 86.7-96.97%), through a single percutaneous access most of the times and in any position, reducing the need for second-look procedures. Safety of the combined flexible procedures was improved to a variable degree, with a consensual reduction of the mean hospital stay (range 5.1-7 days).CONCLUSIONS: The current evidence suggests that patients with large and/or complex urolithiasis might benefit from the adjunct of flexible nephroscopy and/or ureteroscopy to rigid PNL.