Definition of clinically insignificant residual fragments after percutaneous nephrolithotomy among urologists: a world-wide survey by EAU-YAU Endourology and Urolithiasis Working Group

INTRODUCTION The aim of this article was to evaluate the current perception of urologists as to what size is considered as a clinically insignificant residual fragment (CIRF). MATERIAL AND METHODS A survey was globally distributed to the members of the Endourological Society via SurveyMonkey. RESULTS A total of 385 participants responded to the survey on CIRF. Most participants considered 2 mm (29%) as CIRF threshold, followed by 3 mm (24%), 4 mm (22%), 0 mm (14%), 5 mm (8%) and 1 mm (3%). North American urologists considered CIRF to be smaller than urologists from Asia, Eurasia and South America, (p-values ≤0.001, 0.037 and 0.015 respectively). European urologists identified smaller CIRF in comparison to Asian urologists (p-value = 0.001). Urologists mainly using a pneumatic lithotripter accepted larger fragments as CIRF, compared to urologists mainly using ultrasonic devices or a combination of ultrasonic and pneumatic devices (p-value = 0.026 and 0.005 respectively). Similarly, urologists mainly performing X-Ray and ultrasound as post-operative imaging accepted larger fragments as CIRF in comparison to urologists mainly performing non-contrast computed tomography (p-value = 0.001). CONCLUSIONS What is considered as CIRF varies between urologist from different continents and seems to be associated with the lithotripter used and the post-operative imaging modality of preference to assess treatment success

Worldwide survey of flexible ureteroscopy practice: a survey from European Association of Urology sections of young academic urologists and uro-technology groups

Introduction To understand the current practice of flexible ureteroscopy (fURS), we conducted a worldwide survey among urologists with a special interest in endourology. Material and methods A 42-question survey was designed after an initial consultation with European Association of Urology young academic urologists (YAU) and uro-technology (ESUT) groups. This was distributed via the SurveyMonkey (R) platform and an ESUT meeting to cover practice patterns and techniques in regard to ureteroscopy usage worldwide. Results A total of 114 completed responses were obtained. A safety guidewire was reportedly used by 84.5% of endourologists, an access sheath was always or almost always used by 71% and a reusable laser fibre was used by two-thirds of respondents. While a combination of dusting and fragmentation was used by 47% as a preferred mode of intra-renal stone treatment, some used dusting (43%) or fragmentation with basketing (10%). Disposable scopes were only used by 40% and three quarters of them used it for challenging cases only. Antibiotic prophylaxis was limited to a single peri-operative dose by two-thirds (67%) of respondents. The procedural time was limited to between 1-2 hours by two-thirds (70%) of respondents and very rarely (7.4%) it exceeded 2 hours. The irrigation method varied between manual pump (46%), mechanical irrigation (22%) or gravity irrigation (27%). Conclusions Our survey shows a wide variation in the available endourological armamentarium and surgical practice amongst urologists. However, there seems to be a broad agreement in the use of peri-operative antibiotics, access sheath usage, method of stone treatment and the use of post-operative stent

Quercetin treatment against ischemia/reperfusion injury in rat corpus cavernosum tissue: a role on apoptosis and oxidative stress

Reactive oxygen metabolites play an important role in the ischemia/reperfusion (I/R)-induced tissue injury. This study was designed to investigate the possible protective effects of quercetin against I/R injury of the rat corpus cavernosum tissue. To induce I/R injury, abdominal aorta was clamped for 30 min and reperfused for 60 min. Quercetin (20 mg/kg) or vehicle was given before ischemia and just after reperfusion in the I/R group and in the sham-operated control group in which clamping was not performed. After decapitation, corpus cavernosum tissues were removed and either placed in organ baths or stored for evaluating biochemical parameters. Oxidative injury was examined by measuring lucigenin chemiluminescence (CL), nitric oxide (NO), malondialdehyde (MDA) and glutathione (GSH) levels, superoxide dismutase (SOD) and myeloperoxidase (MPO) activities and caspase-3 protein levels. In the I/R group, contractile responses to phenylephrine and relaxation responses to carbachol were impaired significantly compared with those in the control groups, while quercetin treatment in I/R group reversed both of the responses. On the other hand, increase in lucigenin CL, NO, MDA levels and MPO and caspase-3 activities and decrease in GSH levels and SOD activity in the cavernosal tissues of the I/R group were also significantly reversed by quercetin treatment. Furthermore, observed distorted morphology with ruptured endothelial cells and vacuolization in the cytoplasm of cavernosal tissues of I/R no longer persisted in the quercetin-treated I/R group. Thus, our results suggested that treatment with quercetin may have some benefits in controlling I/R-induced tissue injury through its anti-inflammatory, anti-apoptotic, and antioxidant effects

WhatsApp Use In The Evaluation of Hematuria

Introduction: The advancements in telemedicine provide the possibility to send photos of hematuria cases to professionals for further evaluation. We aimed to evaluate the inter-rater reliability of WhatsApp use in the evaluation of hematuria. Materials and methods: Between December 2014 and April 2016, 212 patients were evaluated prospectively for hematuria by 2 groups of urologists; Group A: in direct contact with patients for evaluation; Group B: blind urologist who had no access to the patients' data but received pictures via WhatsApp. Two photos of voided urine in a sterile container were taken and sent using WhatsApp. The opinions of Group A and B about the grade of hematuria were evaluated. Shapiro-Wilk test and Fleiss' kappa statistics were used for statistical analyses. Results: The median age of patients was 71 (min 22, max 96). The Group A urologists were in accordance in 96.22% of cases. Group B urologists had common opinions in 99.5% (n = 203) and there was almost perfect agreement between 2 groups (lambda = 0.992). The number of common opinions among blind urologists is more than the number of common opinions among the consultants. When further classification is performed as serious and non-serious hematuria, the rate of misdiagnosing serious cases is approximately 6.5-7%. However, using WhatsApp, the urologists can differentiate normal urine and any form of hematuria with 100% accuracy. Conclusion: It is possible to evaluate hematuria remotely and also reduce unnecessary costs of services for hematuria of mild clinical significance by using telemedicine. WhatsApp can provide valuable aid to tertiary hospitals where the urologist is not always present as well as in rural areas

Initial Content Validation Results of a New Simulation Model for Flexible Ureteroscopy: The Key-Box

Purpose: We sought to test the content validity of a new training model for flexible ureteroscopy: the Key-Box. Material and Methods: Sixteen medical students were randomized to undergo a 10-day training consisting of performing 10 different exercises aimed at learning specific movements with the flexible ureteroscope, and how to catch and release stones with a nitinol basket using the Key-Box (n = 8 students in the training group, n = 8 students in the nontraining control group). Subsequently, an expert endourologist (O.T.) blindly assessed skills acquired by the whole cohort of students through two exercises on ureteroscope manipulation and one exercise on stone capture selected among those used for the training. A performance scale (1-5) assessing different steps of the procedure was used to evaluate each student. Time to complete the exercises was measured. Mann-Whitney Rank Sum test was used for comparisons between the two groups. Results: Mean scores obtained by trained students were significantly higher compared with those obtained by nontrained students (all p < 0.001). All trained students were able to complete the two exercises on ureteroscope manipulation within 3 minutes, whereas two students (25%) were not able to finish the exercise on stone capture. Conversely, four (50%) and six (75%) nontrained students were not able to finish one out of the two exercises on ureteroscope manipulation and the exercise on stone capture, respectively. The mean time to complete the three exercises was 76.3, 69.9, and 107 and 172.5, 137.9, and 168 seconds in the trained and nontrained groups, respectively (all p < 0.001). Conclusions: The K-Box (R) seems to be a valid easy-to-use training model for initiating novel endoscopists to flexible ureteroscopy

Which Flexible Ureteroscopes (Digital vs. Fiber-Optic) Can Easily Reach the Difficult Lower Pole Calices and Have Better End-Tip Deflection: In Vitro Study on K-Box. A PETRA Evaluation

Background and Purpose: Modern flexible ureteroscopes (fURSs) have good deflection, but despite this, approaching an acute angled calix can still be difficult. The goals of our in vitro study were to assess the ability of the available modern fURSs to effectively access the sharp angled calices and to compare the end-tip deflection of the various fiber-optic and digital fURSs. Materials and Methods: Using a bench-training model for FURS (K-Box, Porge's-Coloplast), we tried to access an acute angled calix with nine different fURSs (BOA vision, COBRA vision, R. Wolf; FLEX X-2, FLEX Xc, K. Storz; LithoVue, Boston Scientific; URF-P5, URF-P6, URF-V, URF-V2, Olympus). Passing the fURSs through a ureteral access sheath (ReTrace, Porge's-Coloplast), the maximum end-tip deflection for every fURS was measured with the tip extended out from the sheath at 1, 2, 3, and 4 cm. Two ranking methods were designed for scoring the fURSs, one based on total ranking points and the other on total degrees of deflection. Results: While all fiber-optic fURSs (except URF-P6) were able to access the sharp angled calix, none of the digital fURSs (except FLEX Xc) reached the difficult angled calix. Similarly, all fiber-optic fURSs had better end-tip deflection compared with the digital fURSs, except FLEX Xc, which was as deflectable as the fiberoptic fURSs. The fURSs showed an end-tip deflection (median difference of almost 21 degrees) in favor of fiber-optic fURSs. Based on the scoring, the highest ranked fURS (best deflection) was FLEX X2 and the lowest ranked fURS (worst deflection) was URF-V2. Conclusions: Digital fURSs were less effective in accessing the sharp angled calix and they had lesser end-tip deflection compared with the fiber-optic counterparts. When approaching a difficult lower pole calix, it might be better to use a fiber-optic fURS

Different patterns of pelvic ureteral endometriosis. What is the best treatment? Results of a retrospective analysis

Objective. Endometriosis is an estrogendependent disease. The incidence of urinary tract endometriosis (UE) increased during the last few years and, nowadays, it ranges from 0.3 to 12% of all women affected by the disease. The ureter is the second most common site affected. The ureteral endometriosis is classified in extrinsic and intrinsic. The aim of this study is to individuate the best treatments for each subset of ureteral endometriosis. Materials and Methods. 32 patients diagnosed with surgically treated UE were retrospectively reviewed. The patients were divided into 3 subsets (intrinsic UE, extrinsic UE with and without obstruction). The patients with intrinsic UE (n = 10) were treated with laser endoureterotomy. The patients with extrinsic UE (n = 22) were divided in two subsets with (n = 16) and without (n = 6) hydronephrosis. All the patients underwent ureteral stenting, and resection and reimplantation was performed in the first group, and when the mass was >2.5 cm (n = 3) Boari flap was performed. Laparoscopic ureterolysis (shaving) was performed in the second group. Results. In the extrinsic subset of UE, we obtained an high therapeutic success (84%). Conversely, in the intrinsic subset there was a recurrence rate of the disease in 6/10 of the patients (60%). Conclusions. Ureterolysis seems to be a good treatment in extrinsic UE without obstruction. Resection and reimplantation allows excellent results in the extrinsic UE with obstruction. In the intrinsic subset, the endoureterotomy approach is inadequate

Temperature Changes Inside the Kidney: What Happens During Holmium:Yttrium-Aluminium-Garnet Laser Usage?

Introduction: The improvements in flexible ureteroscopes provide efficient access to the upper urinary tract and advancements in laser technology strengthens the endourologists' armamentarium. The endourologists must be aware of the advantages and the potential complications of these powerful technological equipments. Our aim is to demonstrate temperature evolution during laser use inside an artificial kidney model. Materials and Methods: We created a bench model using K-Box((R)) immersed into a saline-filled heating tank, which was used to obtain the needed temperature inside the cavity to provide different real-time situations. An endotracheal thermometer was placed inside. We used Olympus URF-P6 ureteroscope and Rocamed Holmium:yttrium-aluminium-garnet laser with two different fibers; 200 and 272m, at five different settings. Irrigation at room (24.5 degrees C) and body (36.5 degrees C) temperatures was used. We measured temperatures at 15th, 30th, and 45th seconds and 1st, 2nd, and 5th minutes of laser use with and without irrigation. We stopped measurements when temperature reached the upper limit of the endotracheal thermometer. Results: When irrigation was closed, with 272-m laser fiber, we reached the temperature limit more rapidly with saline tank at 36.5 degrees C than the tank at 24.5 degrees C. When irrigation was closed, with both fibers and regardless of tank temperature and laser settings, the system surpassed the maximum temperature limit. With 272-m laser fiber, the limit was reached as early as the 30th second. When the irrigation was open, we did not reach the maximum temperature limit regardless of tank temperature and laser setting. When two laser fibers were compared, the temperature increase was more pronounced with 272-m fiber, but the difference was not statistically significant. Conclusion: Laser use during flexible ureteroscopy may cause increased intrarenal temperatures. Rapid increases should be kept in mind when irrigation is closed. The irrigation seems to limit the temperature increase when used with any laser setting

Pictorial review of tips and tricks for ureteroscopy and stone treatment: an essential guide for urologists from PETRA research consortium

With an increase in the number of ureteroscopy (URS) procedures, URS is now performed more widely and is becoming a standard procedure for all urologists. There is also a rise in the complexity of these procedures and URS is now offered for treatment of stones as well as for diagnosis and treatment of urothelial tumours. We wanted to provide a 'pictorial review' of the 'tips and tricks' of URS, as the finer and technical details are often easier to understand and remember with images rather than through textual explanations