Use of artificial intelligence for sepsis risk prediction after flexible ureteroscopy: a systematic review / Uso da inteligência artificial na predição do risco de sepse pós-ureteroscopia flexível: uma revisão sistemática

ABSTRACT Introduction: flexible ureteroscopy is a minimally invasive surgical technique used for the treatment of renal lithiasis. Postoperative urosepsis is a rare but potentially fatal complication. Traditional models used to predict the risk of this condition have limited accuracy, while models based on artificial intelligence are more promising. The objective of this study is to carry out a systematic review regarding the use of artificial intelligence to detect the risk of sepsis in patients with renal lithiasis undergoing flexible ureteroscopy. Methods: the literature review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The keyword search was performed in MEDLINE, Embase, Web of Science and Scopus and resulted in a total of 2,496 articles, of which 2 met the inclusion criteria. Results: both studies used artificial intelligence models to predict the risk of sepsis after flexible uteroscopy. The first had a sample of 114 patients and was based on clinical and laboratory parameters. The second had an initial sample of 132 patients and was based on preoperative computed tomography images. Both obtained good measurements of Area Under the Curve (AUC), sensitivity and specificity, demonstrating good performance. Conclusion: artificial intelligence provides multiple effective strategies for sepsis risk stratification in patients undergoing urological procedures for renal lithiasis, although further studies are needed.

RESUMO Introdução: a ureteroscopia flexível é uma técnica cirúrgica minimamente invasiva utilizada para o tratamento de litíase renal. A urosepse pós-operatória é uma complicação rara, mas potencialmente fatal. Os modelos tradicionais utilizados para prever o risco dessa condição apresentam precisão limitada, enquanto modelos baseados em inteligência artificial são mais promissores. O objetivo desse estudo é realizar uma revisão sistemática a respeito do uso de inteligência artificial para detecção do risco de sepse em pacientes com litíase renal submetidos à ureteroscopia flexível. Métodos: a revisão de literatura está de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A busca com palavras-chave foi realizada no MEDLINE, Embase, Web of Science e Scopus e resultou no total de 2.496 artigos, dos quais 2 se enquadraram nos critérios de inclusão. Resultados: os dois estudos utilizaram modelos de inteligência artificial para predizer o risco de sepse após utereroscopia flexível. O primeiro teve uma amostra de 114 pacientes e foi baseado em parâmetros clínicos e laboratoriais. O segundo teve uma amostra inicial de 132 pacientes e foi baseado em imagens de tomografia computadorizada no pré-operatório. Ambos obtiveram boas medidas de Area Under the Curve (AUC), sensibilidade e especificidade, demonstrando boa performance. Conclusão: a inteligência artificial fornece múltiplas estratégias eficazes para estratificação do risco de sepse em pacientes submetidos a procedimentos urológicos para litíase renal, ainda que mais estudos sejam necessários.

Learning curve of semi-rigid ureteroscopy for small calculi: how many cases are necessary? / Curva de aprendizado em ureteroscopia semi-rígida em cálculos de pequenas dimensões: quantos casos são necessários?

ABSTRACT Introduction: semi-rigid ureteroscopy is the procedure of choice for the treatment of ureterolithiasis, but it requires a learning curve to be performed safely. Objective: To describe an estimate of the learning curve for performing semi-rigid ureterorenolithotripsy in patients with small-sized ureterolithiasis and to estimate the minimum number of procedures necessary to safely perform the surgical procedure. Methods: this is a prospective study evaluating the learning curve of a resident of urology in the first 60 semirigid ureteroscopies in patients with ureterolithiasis up to 1cm. The patients were divided into three groups: Group I one to twenty surgeries, Group II twenty one to forty surgeries and Group III forty one to sixty surgeries. The surgeries were recorded and analyzed by two urologists experienced in endourology. A qualitative analysis was performed based on a previously validated tool and a quantitative analysis. Results: all qualitative variables had significant variation between Groups I and II (p<0.001), and between Groups I and III (p<0.001). There was a difference in time to access the ureter, passage of a double J catheter and total operative time between Groups I and II (p<0.001) and Groups I and III (p<0.001). Conclusion: after 40 cases there seems to be little increase in both quantitative as well as qualitative evaluation in surgical performance for performing semi-rigid ureterolithotripsy safely in calculations up to 1cm.

RESUMO Introdução: ureteroscopia semi-rígida é o procedimento de escolha para o tratamento da ureterolitíase, mas necessita de uma curva de aprendizado para ser executada com segurança. Objetivo: descrever uma estimativa da curva de aprendizado para realização da ureterorrenolitotripsia semi-rígida em pacientes com ureterolitíase de pequena dimensão e estimar o número mínimo de procedimentos necessários para realizar o procedimento cirúrgico com segurança. Métodos: trata-se de um estudo prospectivo avaliando a curva de aprendizado de um residente de urologia nas primeiras 60 ureteroscopias semi-rígidas em pacientes com ureterolitíase até 1cm. Os pacientes foram divididos em três grupos: Grupo I uma a vinte cirurgias, Grupo II vinte e uma a quarenta cirurgias e Grupo III quarenta e uma a sessenta cirurgias. As cirurgias foram gravadas e analisadas por dois urologistas experientes em endourologia. Foi feita uma análise qualitativa baseada em uma ferramenta previamente validada e uma análise quantitativa. Resultados: todas as variáveis qualitativas tiveram variação significativa entre os Grupos I e II (p<0.001), e entre os Grupos I e III (p<0.001). Houve diferença no tempo para acesso ao ureter, passagem de cateter duplo J e tempo operatório total entre os Grupos I e II (p<0.001) e nos Grupos I e III (p<0.001). Conclusão: após 40 casos parece haver pouco incremento tanto na avaliação quantitativa bem como na avaliação qualitativa em performance cirúrgica para a realização de ureterolitotripsia semi-rígida com segurança em cálculos de até 1cm.

The learning curve for retrograde intrarenal surgery: A prospective analysis / A curva de aprendizado em cirurgia retrógrada intrarrenal: Uma análise prospectiva

ABSTRACT Introduction: retrograde intrarenal surgery (CRIR) is an evolving tool. Its learning curve is not well established, despite the common use of flexible ureteroscopes today. Our aim is to estimate the number of procedures needed for one to perform RIRS consistently. Material and Methods: a urology resident had his first 80 RIRS for nephrolithiasis analyzed quantitatively and qualitatively. The procedures were divided into 4 groups containing 20 surgeries each (I to IV), according to their order, for comparison. Results: there was no difference in stone sizes between groups. All qualitative variables varied significantly between groups (p<0.001), except between III and IV. In the quantitative analysis, there was a difference between groups I and IV in time for double-J catheter placement (p=0.012). There was an increasing difference in sheath placement time (p<0.001) and in total operative time (p=0.004). The time fot stone treatment (p=0.011) was significant only between groups I, II and III. There was difference in total sheath time only between groups I and III (p=0.023). Stone free status did not change between groups. Discussion: the differences between the qualitative and quantitative variables show the relation between number of surgeries performed and proficiency in the procedure. Intergroup comparisons show sequential optimization of parameters. Conclusions: we found that 60 is a reasonable number of surgeries to be performed in order to reach the plateau of RIRSs learning curve.

RESUMO Introdução: a cirurgia retrógrada intrarrenal (CRIR) é ferramenta em evolução. Sua curva de aprendizado não está bem estabelecida, apesar do uso comum dos ureteroscópios flexíveis atualmente. O objetivo é estimar o número de procedimentos necessários para se realizar CRIR consistentemente. Material e Métodos: Um residente de urologia teve suas primeiras 80 CRIR para tratamento de nefrolitíase analisadas quantitativa e qualitativamente. Os procedimentos foram divididos em 4 grupos contendo 20 cirurgias cada (I a IV), de acordo com sua ordem, para comparação. Resultados: Não houve diferença nos tamanhos dos cálculos entre grupos. Todas as variáveis qualitativas apresentaram variação significativa entre os grupos (p<0,001), exceto entre III e IV. Na análise quantitativa houve diferença entre os grupos I e IV no tempo de colocação do cateter duplo J (p=0,012). Houve uma diferença crescente no tempo de colocação da bainha (p<0,001) e no tempo operatório total (p=0,004). O tempo para o tratamento do cálculo (p=0,011) foi significativo apenas entre os grupos I, II e III. Houve diferença no tempo total de bainha apenas entre os grupos I e III (p=0,023). Taxa livre de cálculos não se alterou entre os grupos. Discussão: as diferenças observadas entres as variáveis qualitativas e quantitativas evidenciam a relação entre o número de cirurgias realizadas e a proficiência no procedimento. As comparações intergrupo mostram otimização sequencial dos parâmetros. Conclusões: estima-se que 60 é um número razoável de cirurgias para que se atinja o platô da curva de aprendizado.

Distintos enfoques adoptados por los médicos para tratar la nefrolitiasis en pediatría: estudio basado en una encuesta / Different approaches among physicians to treat pediatric stone disease: a survey-based study

Introducción. Los pediatras, cirujanos y subespecialistas, como urólogos y nefrólogos pediátricos, participan en el diagnóstico y tratamiento de la nefrolitiasis pediátrica. El objetivo fue determinar los enfoques de distintas disciplinas y evaluar las diferencias en sus protocolos de diagnóstico y tratamiento habituales.Población y métodos. Cuestionario administrado a participantes de sesiones sobre nefrolitiasis en congresos nacionales en 2017 para evaluar las rutinas de diagnóstico y tratamiento de la nefrolitiasis entre distintas especialidades (cirujanos y pediatras) y subespecialidades (nefrólogos pediátricos y urólogos pediátricos).Resultados. Se analizaron 324 cuestionarios de 88 pediatras, 121 urólogos, 23 cirujanos pediátricos, 54 nefrólogos pediátricos y 38 urólogos pediátricos. Ambos grupos coincidieron en la necesidad de una evaluación metabólica. Para los cálculos ureterales distales ≥6 mm, los cirujanos preferían una ureteroscopía; los pediatras, una litotricia por ondas de choque (LOC) (p < 0,001); y los subespecialistas, una ureteroscopía (p = 0,636). Para los cálculos en la parte inferior de los cálices renales < 1 cm, los cirujanos y los subespecialistas preferían la LOC y los pediatras, la hidratación (p < 0,001; p = 0,371). Para los cálculos de entre 1,1 cm y 2 cm, los cirujanos preferían la cirugía retrógrada intrarrenal (CRIR) y la LOC, y los pediatras, la LOC (p = 0,001). Para los cálculos más grandes, los cirujanos y subespecialistas preferían la nefrolitotomía percutánea (NLP) y los pediatras, la LOC (p = 0,458; p = 0,001).Conclusión. Existen diferencias entre las disciplinas que participan activamente en el diagnóstico y tratamiento de la nefrolitiasis

Introduction. Pediatricians, surgeons and subspecialties as pediatric urology and nephrology are involved in the diagnosis and treatment of pediatric renal stone disease (RSD). The aim of this study was to determine diagnostic and treatment approaches, of different disciplines, and to assess differences in their routine diagnostic and treatment protocols.Population and methods. A questionnaire was designed and administered to the participants of the RSD sessions in national congresses of all disciplines in 2017 to evaluate the diagnostic and treatment routines of specialties (surgeons and pediatricians) and subspecialties (pediatric nephrologists and pediatric urologists) for RSD. Results. A total, of 324 questionnaires were analyzed, from 88 pediatricians (27 %), 121 urologists (37 %), 23 pediatric surgeons (7 %), 54 pediatric nephrologists (17 %), and 38 pediatric urologists (12 %). Both groups agreed on the necessity of metabolic evaluation. For distal ureter stones that were ≥ 6 mm; surgeons preferred ureteroscopy (URS), pediatricians preferred shock wave lithotripsy (SWL) (p < 0.001) and subspecialties preferred URS for the treatment (p = 0.636). For lower calix stones less than 1 cm surgeons and subspecialists preferred SWL, while pediatricians preferred hydration (p < 0.001, p = 0.371). For the stone between 1.1 and 2 cm, surgeons preferred intrarenal surgery (RIRS) and SWL, pediatricians preferred SWL (p = 0.001). For larger stones, surgeons and subspecialists preferred percutaneous nephrolithotomy (PCNL), and pediatricians preferred SWL (p = 0.458 p = 0.001). Pediatric urologist chose low-dose computerized tomography as a diagnostic radiologic evaluation (p = 0.029).Conclusion. There are differences between the disciplines who take an active role in diagnosis and treatment of RSD.

Vantagens custo-efetivas da utilização de ureteroscópios flexíveis descartáveis em comparação com o uso de ureteroscópios flexíveis reprocessáveis / Cost-effective advantages of using disposable flexible ureteroscopes versus using reprocessable flexible ureteroscopes

Objetivo: Analisar o custo-efetividade da utilização de ureteroscópios flexíveis descartáveis em comparação com o uso de ureteroscópios flexíveis reprocessáveis. Métodos: Revisão integrativa de literatura realizada nos bancos de dados SciELO, LILACS e MEDLINE, utilizando os descritores "ureteroscopia", "resistência à flexão", "marketing", "análise de custo-benefício" e "esterilização", cujo objeto trata das vantagens custo-efetivas da utilização do ureteroscópio flexível descartável. Resultados: Trinta e cinco artigos foram encontrados, sendo quatro utilizados no estudo. Além disso, características de sete modelos de ureteroscópios flexíveis comercializados no Brasil mais conhecidos atualmente foram apresentadas. Os resultados foram baseados na análise conjunta dos artigos selecionados e características dos modelos de flexíveis apresentados e discutidos em duas categorias: a evolução dos ureteroscópios flexíveis e marketing mix ­ ureteroscópios flexíveis de uso único. Conclusão: Apesar da escassez de pesquisas que se aprofundem em custos de utilização de um ureteroscópio flexível de uso único, comparado a um reprocessável, são notórios os benefícios advindos das inovações agregadas a esses dispositivos, dando retorno positivo tanto para o profissional que faz seu uso deles quanto para o paciente, fazendo-se necessário analisar mais profundamente a possibilidade de migração da "cultura" de uso de ureteroscópios flexíveis reprocessáveis para os descartáveis

Objective: To analyze the cost-effectiveness of using disposable flexible ureteroscopes versus using reprocessable flexible ureteroscopes. Methods: Integrative literature review conducted in the SciELO, LILACS and MEDLINE databases, using the descriptors ureteroscopy, flexion resistance, marketing, cost-benefit analysis, and sterilization, whose object deals with the cost-effective advantages of using the flexible ureteroscope disposable. Results: Thirty-five articles were found and four were used in the study. In addition, characteristics of seven models of flexible ureteroscopes commercialized in Brazil, that are currently better known, were presented. The results were based on a joint analysis of the selected articles and characteristics of the flexible models presented, and discussed in two categories: the evolution of flexible ureteroscopes; and marketing mix - flexible single-use ureteroscopes. Conclusion: Despite the scarcity of research that deepens the costs of using a flexible single-use ureteroscope when compared to a reprocessable one, the benefits arising from the innovations added to these devices are notorious, giving a positive return both to the professional who uses it and to the patient, making it necessary to further analyze the possibility of migration from the "culture" of using flexible reprocessable ureteroscopes to disposable ones

Mirabegron Role in Urolithiasis Management: What you should Know / Rol del mirabegrón en el manejo de la urolitiasis: Lo que usted debe saber

The purpose of the present study was to develop a narrative review of the available evidence of mirabegron efficacy in three scenarios: as a medical expulsive therapy; as a medical treatment to increase a successful access to stones before ureteroscopy, and management of double-J stent-related symptoms. Only two original studies have evaluated its use as a medical expulsive therapy, with contradictory results in terms of stone expulsion rate; however, both demonstrated a better pain control in the mirabegron group. One randomized controlled trial (RCT) found a higher successful access to ureteral stones when mirabegron was administered 1 week before the ureteroscopy. And two RCTs demonstrated its efficacy in diminishing discomfort related with double-J stent. There is a promising role for the use of mirabegron in the arsenal of urolithiasis treatment, even as a medical expulsive therapy, before ureteroscopy surgery, to increase the successful access to the stones and after the placement of ureteral catheter to reduce the related symptoms. However, larger-scaled prospective double-blinded RCTs are needed before it can be used with these purposes in the clinical scenario.

El propósito de este trabajo fue desarrollar una revisión narrativa de la literatura describiendo la evidencia disponible sobre la eficacia del mirabegrón en tres escenarios: como terapia médica expulsiva, como tratamiento médico antes de la ureteroscopia para incrementar el acceso exitoso al cálculo, y en el manejo de los síntomas asociados con el uso de catéter doble J. Solo dos estudios originales han evaluado su uso como terapia médica expulsiva, con resultados contradictorios en términos de tasa de expulsión del cálculo; sin embargo, ambos demostraron mejor control del dolor en el grupo de mirabegrón. Un estudio aleatorizado multicéntrico encontró un aumento en el acceso exitoso al cálculo durante la ureteroscopia cuando el mirabegrón era administrado una semana antes del procedimiento. Adicionalmente, dos estudios aleatorizados controlados demostraron eficacia del medicamento para disminuir los síntomas relacionados con el catéter doble J. El uso del mirabegrón como parte del arsenal del tratamiento para urolitiasis tiene un rol prometedor, tanto en la terapia médica expulsiva como antes de la ureteroscopia, para aumentar la posibilidad de acceder exitosamente al cálculo, y en pacientes con catéter doble J, para disminuir los síntomas asociados. Sin embargo, se requiere estudios más grandes, prospectivos, doble ciegos y aleatorizados antes de que podamos utilizarlo con estos fines en un escenario clínico.

Validación de un modelo simulado inanimado basado en impresión 3D de ureterorrenoscopía flexible / Validation of an inanimate simulated model based on flexible ureterorenoscopy 3D printing

Resumen Objetivo: Establecer validez aparente, de contenido y constructo, de un programa de simulación de ureterorrenoscopía flexible. Materiales y Método: Se desarrolló un modelo de simulación de silicona para ureterorrenoscopía flexible, en el cual se establecieron 8 marcas de colores en los distintos cálices. Para la validación, se reclutaron urólogos expertos y residentes de urología con experiencia variable en este procedimiento. Se separaron en 3 grupos: G1 para residentes sin experiencia en ureteroscopía, G2 para residentes con experiencia variable y G3 para urólogos expertos. Se les solicitó realizar una navegación completa del modelo, en un tiempo máximo de 600 segundos. Al finalizar, cada participante contestó una encuesta respecto a la utilidad y realismo del modelo. Además, se midió tiempo total, número de puntos encontrados y cantidad de veces de reingreso a los cálices para validación de constructo. Resultados: 15 personas participaron en la evaluación. Se obtuvo una mediana de 8,6 puntos para la utilidad del modelo y 6,75 puntos para el realismo de este. Los tiempos totales de navegación fueron 504, 293 y 133 segundos para G1, G2 y G3 respectivamente (p = 0,02). De las 8 marcas, se encontraron en promedio 5,1, 6,6 y 7,3 (p = 0,18), presentando un promedio de 9,5, 3,8 y 1,3 reintentos de exploración de los cálices en los respectivos grupos (p = 0,11). Conclusiones: Se establece validez aparente y contenido para un modelo de ureterorrenoscopía flexible. El programa de simulación de ureterorrenoscopía flexible establecido, permite diferenciar novatos de expertos en cuanto a reducción en los tiempos de navegación.

Aim: To establish the face, content, and construction validity of a flexible ureterorenoscopy simulation program. Materials and Method: A simulation model for flexible ureterorenoscopy was developed using silicone on which eight colored marks were marked on the calyxes. For validation, expert urologists and residents with varying amounts of experience in this procedure were recruited. They were separated into three groups: 1) G1 for residents without experience in ureteroscopy; 2) G2 for residents with variable experience; and 3) G3 for expert urologists. They were asked to perform a full navigation of the model in a maximum time of 600 sec. At the end, each participant answered a survey regarding the usefulness and realistic nature of the model. In addition, total time, number of marks found, and times of re-entry to the calyxes were measured. Results: A median of 8.6 points was obtained for the utility of the model and 6.75 points for its realistic nature. The total navigation times were 504, 293, and 133 seconds for G1, G2, and G3, respectively (p = 0.02). Of the eight marks, an average of 5.1, 6.6, and 7.3, (p = 0.18) were found with an average of 9.5, 3.8, and 1.3 exploration reattempts at the chalices in the corresponding groups (p = 0.11). Conclusions: Face and content validity was established for this simulation model of flexible ureterorenoscopy. This flexible ureterorenoscopy simulation program allowed us to differentiate the level of expertise in terms of reduction in navigation time.

Factores predictores del estado libre de cálculos en la primera ureteroscopia flexible con litotricia láser / Predictors of stone-free status in the first flexible ureteroscopy with laser lithotripsy

Resumen Introducción: La ureteroscopia flexible con litotricia láser (URSLL) es una modalidad mínimamente invasiva de tratamiento quirúrgico de cálculos renales. La selección inadecuada de pacientes para este procedimiento genera un desbalance de costo-efectividad. Objetivo: Conocer los factores predictores de estado libre de litos en un solo tiempo quirúrgico en pacientes sometidos a URSLL. Método: Cohorte retrospectiva de pacientes sometidos a URSLL. Se realizó un análisis univariado y multivariado (regresión logística) de los predictores de estado libre de cálculos en la primera URSLL, global y categorizado por sexo. Resultados: EL estado libre de cálculos en la primera URSLL fue de 73.62 %. Los predictores de estado libre de cálculos en hombres fueron edad y tamaño, densidad y multiplicidad del cálculo; en las mujeres, el índice de masa corporal y la multiplicidad del cálculo. Conclusiones: Los factores pronósticos de estado libre de cálculos en la primera URSLL son distintos en hombres y mujeres. Las mujeres con obesidad y sobrepeso probablemente tengan cálculos de fácil fragmentación y extracción asociados con ácido úrico.

Abstract Introduction: Flexible ureteroscopy and laser fragmentation (FURSL) is a minimally invasive modality for surgical treatment of renal stones. Inadequate selection of patients for this treatment generates a cost-effectiveness unbalance. Objective: To know the stone-free rate predictors in a single surgical time in patients undergoing FURSL. Method: Retrospective cohort of patients undergoing FURSL. Global and gender-categorized univariate and multivariate (logistic regression) analyses were performed to identify stone-free predictors at first FURSL. Results: Stone-free rate at first FURSL was 73.62%. Predictors in males were patient age and stone size, density and multiplicity; in females, body mass index and multiplicity of stones. Conclusions: Stone-free rate predictors at first FURSL are different in males and females. Women with overweight and obesity probably have easy-to-fragment and easy-to-extract stones associated with uric acid.

Ureteroscopia con litotripsia para el tratamiento de la litiasis ureteral inferior: casuística del Servicio de Urología del Hospital Luis Vernaza en el período 2015 ­ 2017 / Ureteroscopy with lithotripsy for the treatment of lower ureteral lithiasis: case reports from Urology Department of the Luis Vernaza Hospital in the period 2015 - 2017

En Ecuador la litiasis renal y del uréter causan alrededor de diez mil egresos hospitalarios a nivel nacional. La endolitotomía ha tenido una transición de la litotripsia balística al láser. Objetivo Comparar los datos quirúrgicos y tasa de éxitos de ureteroscopias semirrígidas usando litotripsia balística o laser. Diseño Estudio retrospectivo Lugar y sujetos Un total de 137 pacientes con litiasis ureteral distal, atendidos en el Hospital Luis Vernaza de Guayaquil-Ecuador, entre enero 2015 y junio 2017. Mediciones principales Datos clínicos de los pacientes, ubicación y dimensión del cálculo, tiempo quirúrgico, complicaciones y tasa de éxitos. Resultados Los pacientes (39.3% hombres y 60.7% mujeres) tuvieron una edad media de 52.4 ± 2.1 años. La mayoría tuvieron cólico nefrítico (77.0%), por litiasis en uréter inferior (izquierdo [45.8%] o derecho [38.7%]) o uréter medio (izquierdo [8.9%] o derecho [6.0%]). Hasta el 90% de los casos fueron de cálculos únicos. Los pacientes fueron tratados con láser (n=50) o con litotripsia balística (n=87). En el grupo de láser, la dimensión del cálculo fue mayor (12.6 ± 1.29 vs. 11.5 ± 0.8 mm; p=0.001), el procedimiento quirúrgico tuvo más duración (66.9 ± 7.4 vs. 58.8 ± 5.3 minutos; p=0.001) y hubo más tiempo postoperatorio previo al egreso (2.22 ± 0.57 vs. 1.7 ± 0.2 días; p=0.001). La taza libre de litiasis fue similar en ambos grupos (98.0% vs. 91.9%; p=ns). Las complicaciones fueron pocas (n=14; 10.2%) y en igual frecuencia con ambas técnicas, pero hubo más casos de retropulsión del cálculo con la litrotripsia balística (n=7) que con el láser (n=1). Conclusión La endolitotomía láser tiene mayores beneficios en cuanto al tamaño del cálculo que puede ser tratado y pocos eventos de retropulsión. La litotripsia balística tuvo mejor tiempo quirúrgico y menos días de egreso postoperatorio. No obstante, la tasa de éxitos aparentemente es similar con ambas técnicas.

Uso de cateter doble J en ureteroscopias por litiasis ureteral / Use of double catheter J in ureteroscopies by ureteral litiasis

RESUMEN Se presenta serie prospectiva no randomizada de pacientes tratados con Ureteroscopia por litiasis ureteral. Se compara el uso de catéter doble J para evaluar diferencia en complicaciones postoperatorias. Se incluyen finalmente a 110 pacientes que cumplen con el seguimiento. Se observa diferencia significativa entre ambos grupos en relación a la presencia de colico renal post operatorio a favor del grupo sin cateter 33 por ciento v/s 0 por ciento . Las complicaciones menores son más frecuentes en el grupo con catéter. La mayoría de los pacientes tolero el catéter a pesar de las molestias. Se aconseja su uso paradisminuir esta complicación.(AU)

ABSTRACT: We present a non-randomized prospective series of patients treated with Ureteroscopy due to ureteral lithiasis. The use of a double J catheter is compared to evaluate the difference in postoperative complications. Finally, 110 patients who comply with the follow-up are included. A significant difference was observed between both groups in relation tothe presence of post-operative renal colic versus the group without catheter 33 pertcent v / s 0 pertcent . Minor complications are more frequent in the catheter group. Most patients tolerated the catheter despite the discomfort. Its use is advised to reduce this complication.(AU)

Ureteroscopía rígida retrógrada en el tratamiento de la litiasis urinaria / Rigid Retrograde Ureteroscopy in the Treatment of Urinary Lithiasis

Introducción: la ureteroscopía constituye, en la actualidad, una de las principales opciones de tratamiento para la litiasis renoureteral. Objetivo: describir los resultados del tratamiento, mediante ureteroscopía rígida retrógrada, en una serie de pacientes con litiasis del tracto urinario superior. Métodos: estudio observacional, descriptivo, longitudinal y prospectivo, en una muestra de 53 pacientes con litiasis renal o ureteral, que recibieron tratamiento mediante ureteroscopía rígida retrógrada. Las variables estudiadas fueron: edad, sexo, localización de la litiasis, modalidad de litotricia realizada, técnicas complementarias empleadas y complicaciones presentadas. Los resultados fueron analizados mediante estadística descriptiva. Resultados: prevalecieron los pacientes de la sexta década de la vida. El promedio de edad fue de 50,2 años con predominio del sexo masculino, con 36 pacientes, para un 67,9 por ciento. La litiasis preponderante fue la ureteral con 67,9 por ciento, y la mayoría localizadas en su porción distal con un tamaño de entre 10 y 20 mm. La modalidad de litotricia más utilizada fue la neumática en 46 pacientes (86,8 por ciento). La técnica complementaria más usada fue la litofragmentación (96,2 por ciento). Presentaron complicaciones 8 enfermos (15 por ciento), y todas en grados II y III de la clasificación de Clavien-Dindo. Conclusiones: la ureteroscopía rígida retrógrada, complementada con otros procederes endourológicos, constituye una modalidad terapéutica eficazy segura para el tratamiento de la litiasis renoureteral, y con un bajo índice de complicaciones(AU)

Introduction: Ureteroscopy is at present, one of the main treatment options for renal and ureteral lithiasis. Objective: To describe the results of the treatment, by rigid retrograde ureteroscopy, in a series of patients with upper urinary tract lithiasis. Methods: observational, descriptive, longitudinal and prospective study, in a sample of 53 patients with renal or ureteral lithiasis, who received treatment by rigid retrograde ureteroscopy. The variables studied were: age, sex, location of lithiasis, lithotripsy modality performed, complementary techniques used and complications presented. The results were analyzed by descriptive statistics. Results: Patients of the sixth decade of life predominated. The average age was 50.2 years with predominance of males, with 36 patients, for 67.9 percent. The predominant lithiasis was the ureteral with 67.9 percent, and most located in its distal portion with a size between 10 and 20 mm. The most used lithotripsy modality was pneumatic in 46 patients (86.8 percent. The most used complementary technique was lithofragmentation (96.2 percent). There were complications in 8 patients (15 percent), and all in grades II and III of the Clavien-Dindo classification. Conclusions: Rigid retrograde ureteroscopy, complemented with other endourological procedures, constitutes an effective and safe therapeutic modality for the treatment of renoureteral lithiasis, and with a low rate of complications(AU)

Is a safety guidewire needed for retrograde ureteroscopy? / Fio guia de segurança é necessário na ureteroscopia?

Summary Introduction: It is generally advised to have a safety guidewire (SGW) present during ureteroscopy (URS) to manage possible complications. However, it increases the strenght needed to insert and retract the endoscope during the procedure, and, currently, there is a lack of solid data supporting the need for SGW in all procedures. We reviewed the literature about SGW utilization during URS. Method: A review of the literature was conducted through April 2017 using PubMed, Ovid, and The Cochrane Library databases to identify relevant studies. The primary outcome was to report stone-free rates, feasibility, contraindications to and complications of performing intrarenal retrograde flexible and semi-rigid URS without the use of a SGW. Results: Six studies were identified and selected for this review, and overall they included 1,886 patients where either semi-rigid or flexible URS was performed without the use of a SGW for the treatment of urinary calculi disease. Only one study reported stone-free rates with or without SGW at 77.1 and 85.9%, respectively (p=0.001). None of the studies showed increased rates of complications in the absence of SGW and one of them showed more post-endoscopic ureteral stenosis whenever SGW was routinely used. All studies recommended utilization of SGW in complicated cases, such as ureteral stones associated with significant edema, ureteral stricture, abnormal anatomy or difficult visualization. Conclusion: Our review showed a lack of relevant data supporting the use of SGW during retrograde URS. A well-designed prospective randomized trial is in order.

Resumo Introdução: O uso de fio guia de segurança (FGS) costuma ser recomendado para a realização de ureteroscopia para prevenir e solucionar complicações durante o procedimento. Seu uso, porém, aumenta a força necessária para manipular o aparelho endoscópico dentro da luz ureteral e, atualmente, existe uma carência de dados consistentes que indiquem o uso do FGS em todos os procedimentos. Método: Uma revisão da literatura foi realizada em abril de 2017 utilizando as ferramentas PubMed, Ovid e The Cochrane Library para identificar estudos relevantes. O desfecho primário da análise foi reportar taxas de resolução dos cálculos, viabilidade, contraindicações e complicações relacionadas ao não uso do FGS. Resultados: Seis estudos foram incluídos na análise, totalizando 1.886 pacientes, nos quais foi realizada ureteroscopia semirrígida ou flexível sem o uso do FGS no tratamento de cálculos renais ou ureterais. Somente um estudo relatou taxa livre de cálculos com ou sem FGS, sendo 77,1 e 85,9%, respectivamente (p=0.001). Todos os estudos mostraram não haver aumento da taxa de complicação na ausência do FGS e um deles relatou aumento de estenose ureteral pós-endoscopia no grupo que utilizou o FGS. Todos os estudos recomendam o uso do FGS em casos complicados, como cálculos ureterais associados a edema de mucosa, estenose ureteral, anomalias anatômicas ou dificuldade de visualização do cálculo. Conclusão: Nossa revisão mostrou que faltam dados relevantes para justificar o uso do FGS durante a ureteroscopia.

Desarrollo de un checklist para la técnica de nefroureterolitototomía endoscópica flexible en un modelo simulado mediante el método de delphi modioficado / Development of a checklist for the technique of flexible endoscopic nephroureterlithotomy in a simulated model by the modifiet delphy method

Introducción: La simulación en medicina está cobrando cada vez mayor importancia, principalmente en el área quirúrgica, ya que nos otorga la posibilidad de lograr el aprendizaje de forma segura, bajo ambiente controlado y reproducible. Nuestro objetivo es establecer una pauta estructurada de realización de ureteroscopía flexible para un procedimiento simulado de nefro-ureterolitotomía endoscópica.Material y métodos. Se utilizó el método de Delphi modificado. Se contactó vía correo electrónico a cinco urólogos a los cuales se les envió un checklist para la evaluación de la técnica del procedimiento de 1 a 7, agregando comentarios. Basado en esto, se modifica el checklist en 2 oportunidades, hasta lograr el consenso.Resultados. Se obtiene una la versión definitiva del checklist. Esta consta de 20 puntos, con una media que fluctúa entre 5,6 y 7, y una mediana entre 6 y 7. El coeficiente de Cronbach para establecer su consistencia interna es de 0,86.Conclusión. Se establece un listado estándar para la realización de nefro-ureterolitotomíaendoscópica flexible utilizando el método de Delphi modificado.(AU)

Introduction: The simulation in medicine is becoming increasingly important, mainly in the surgical area, because it gives us the possibility to achieve learning safely, in a controlled and reproducible environment. Our objective is to establish a structured guideline of flexible ureteroscopy for a simulated endoscopic nephro ureterolithotomy procedure.Material y Methods. The modified Delphi method was used. Five urologists were contacted via email, a checklist was sent for the evaluation of the procedure technique from 1 to 7, adding comments. Based on this, the checklist is modified 2 times, until consensus is reached.Results. A final version of the checklist is obtained. It consists in 20 points, with a mean that fluctuates between 5.6 and 7, and a median between 6 and 7. The Cronbach coefficient to establish its internal consistency is 0, 86.Conclusion. A standard list is established using the modified Delphi method for the performance of flexible endoscopic nephro-ureterolithotomy.(AU)

Manejo ureteroscópico y litotripcia láser en la ureterolitiasis / Ureteroscopic treatment of urolithiasis with the holmium laser

Introducción: El desarrollo de la ureteroscopia semirigida y flexible ha permitido un accesso más fácil a los cálculos del tracto urinario. Analizamos el uso de la ureteroscopía semirigida para el manejo de la urolitiasis en una institución de Santiago.Material y métodos. La ureteroscopia semirigida fue realizada a 139 pacientes entre Febrero 2009 y Marzo 2011. Ubicación de litiasis, detalles de tratamiento, resultado postoperatorio y complicaciones fueron registradas. Los procedimientos fueron realizados bajo anestesia regional y general. Para la fragmentación de la litiasis se utilizó el láser HO: YAG holmium yag.Los resultados fueron analizados en forma retrospectiva.Resultados. 139 pacientes fueron sometidos a tratamiento ureteroscópico para litiasis ureterales. Fueron sometidos 33 pacientes a ureteroscopia proximal y 106 pacientes a ureteroscopia distal, respectivamente. La tasa libre de cálculo global fue de 86.33 por ciento, con una tasa de éxito proximal y distal de 71.88 por ciento y 94.33 por ciento respectivamente.Conclusión. El tratamiento ureteroscópico de las litiasis ureterales resulta en una tasa libre de cálculo elevada con baja morbilidad.(AU)

Introduction: The development of semi-rigid and flexible ureteroscopes has permitted an easier Access to calculi through the urinary tract. We analyzed the use of semi-rigid ureteroscopy for the managment of urolithiasis at a single institution.Intervention: Ureteroscopy was performed according to study protocol and current local clinical practice.Material y Methods. Ureteroscopic Stone treatment was attempted in 139 patients between february 2009 and march 2011. Stone location, treatment details, postoperative outcome and complication were recorded. The procedures were performed under regional and general anesthesia. For Stone fragmentation we used the HO: YAG, holmium yag laser under direct vision of calculi. Preoperative, operative, and postoperative data were retrospectively analyzed.Results. 139 patients receive ureteroscopic tretament for ureteral stones. 33 and 106 patients underwent proximal and distal ureteroscopy, respectively. Global stone free rate was 86.33 pertcent, with a proximal and distal success rate of 71.88 pertcent and 94.33 pertrcent.Conclusion. Ureteroscopic treatment of ureteral stones resulted in elevated stone­free rates and low morbidity.(AU)

Percutaneous treatment of complex biliary stone disease using endourological technique and literature review / Tratamento percutâneo da litíase biliar complexa intra-hepática com técnica endourológica e revisão da literatura

Most biliary stone diseases need to be treated surgically. However, in special cases that traditional biliary tract endoscopic access is not allowed, a multidisciplinary approach using hybrid technique with urologic instrumental constitute a treatment option. We report a case of a patient with complex intrahepatic stones who previously underwent unsuccessful conventional approaches, and who symptoms resolved after treatment with hybrid technique using an endourologic technology. We conducted an extensive literature review until October 2012 of manuscripts indexed in PubMed on the treatment of complex gallstones with hybrid technique. The multidisciplinary approach with hybrid technique using endourologic instrumental represents a safe and effective treatment option for patients with complex biliary stone who cannot conduct treatment with conventional methods.

A maioria das doenças litiásicas das vias biliares necessita de tratamento cirúrgico. No entanto, em casos especiais, que não permitem o acesso tradicional das vias biliares por via endoscópica, a abordagem multidisciplinar com técnica híbrida, que utiliza instrumentais endourológicos, apresenta-se como uma opção no tratamento. Relatamos aqui o caso de um paciente com litíase de via biliar complexa com múltiplas abordagens prévias, sem sucesso no tratamento com métodos convencionais, resolvido com abordagem híbrida com tecnologia endourológica. Realizamos uma extensa busca na literatura de artigos relacionados ao tratamento de litíase biliar complexa com técnica híbrida publicados no PubMed até outubro de 2012. A abordagem multidisciplinar com técnica híbrida, utilizando instrumental endourológico, representa uma opção segura e eficaz no tratamento de pacientes com litíase complexa de via biliar com impossibilidade de tratamento com métodos convencionais.

Instilación intravesical de levobupivacaína para el manejo del dolor y síntomas urinarios en pacientes portadores de catéter doble J / Intravesical instillation of levobupivacaine for pain management andurinary symptoms in patients with ureteral double J stent

La instalación de catéteres ureterales tipo Doble J o “pigtail” es una práctica habitual en urología, el principal problema de su instalación radica en que gran parte de los pacientes presentan diferentes tipos de molestias en relación a su uso. Existen algunas alternativas de tratamiento médico que han probado ser efectivas en disminuir parcialmente estos síntomas; sin embargo, pocos estudios han evaluado la posibilidad de terapias locales, y estos reclutaron pocos pacientes por lo que no pudieron demostrar grandes diferencias.

The use of Double J ureteral stents or also called “pigtail” is common practice in urology; the main problem with its use is that a large number of patients develop discomfort with indwelling stents. To diminish them there are medical treatments that have been proven useful, however, few studies have assessed local therapies, and this studies include a small number of patients.

Desarrollo de un checklist de tareas específicas para el procedimiento ureterolitotomía endoscópica / Development of a task-specific checklist for endoscopic reterolithotomy

En el último tiempo, en la urología, ha ganado terreno la cirugía endoluminal que es menos invasiva pero técnicamente más compleja que la cirugía abierta. Esto sumado a la menor exposición a procedimientos prácticos de los residentes ha puesto la alerta en la necesidad de establecer mecanismos de evaluación objetivos de las competencias técnicas para garantizar la seguridad de los pacientes. El objetivo de nuestro trabajo fue desarrollar un checklist de tareas específicas para la evaluación del procedimiento ureterolitotomía endoscópica. MATERIALES Y MÉTODOS: Para el desarrollo del checklist se utilizó el método de Delphi modificado que busca consenso entre expertos a través de la evaluación y revisión sucesiva de un formulario y el análisis estadístico de las respuestas. RESULTADOS: Con la participación de ocho urólogos expertos en procedimientos endourológicos de distintas instituciones del país se obtuvo un checklist de 23 ítems para el procedimiento ureterolitotomía endoscópica. CONCLUSIÓN: Se describe y presenta el desarrollo de un checklist de tareas específicas para el procedimiento ureterolitotomía endoscópica que permitirá la evaluación de residentes tanto en el laboratorio de simulación como en el pabellón quirúrgico.

In the last years, endoluminal surgery, a less invasive but technically more complex procedure, has gained ground in urology over open surgery. The reduction on exposure to practical procedures of residents has added an alert on the need to establish a mechanism for objective assessment of technical skills to ensure patients safety. The aim of this study was develop a tasks-specific checklist in order to assess resident performing endoscopic ureterolithotomy. MATERIALS AND METHODS: The modified Delphi method was used for the development of the checklist. This technic tries to find a consensus among experts through the evaluation and subsequent revision of a questionnaire and the statistical analysis of the responses. RESULTS: Eight endourologists procedures experts from different institutions of the country participate on this study helping to develop a 23-item checklist for ureterolithotomy endoscopic procedure. CONCLUSIONS: We describe and present the development of a tasks-specific checklist for ureterolithotomy endoscopic that will allow the evaluation of residents in both simulation laboratory and surgical ward.

Litotricia extracorpórea versus ureterolitectomía endoscópica para el manejo de litiasis de uréter distal. Costos asociados. Experiencia del Hospital Militar de Santiago / Extracorporeal shock wave lithotripsy versus endoscopic ureterolithectomy for management of distal ureteral stones. Associated costs. Experience the Military Hospital of Santiago

INTRODUCCIÓN: La ureterolitiasis distal (UD) es una patología prevalente. Su tratamiento quirúrgico es con litotricia extracorpórea(LEC) o ureteroscopía (URS), ambas con tasa libre de cálculo (TLC) sobre 90% y mínimas complicaciones. El objetivode este trabajo es comparar la TLC luego de la primera intervención y su costo asociado. Además, comparar el costo totaltratándolos con LEC o URS. PACIENTES Y MÉTODOS: Estudio descriptivo comparativo, que muestra el costo económicode LEC vs URS para tratamiento de UD entre 2009 y 2013. Se incluyeron 107 pacientes; 47 URS y 60 LEC. Se analizaronnúmero de días hospitalizados, necesidad de reintervención y costo total de atención médica. Los costos se ajustaron alvalor actual de la prestación. Se describió la TLC en ambos procedimientos. Se obtuvo el costo total de hospitalizacióny se compararon las variables de interés. RESULTADOS: l tamaño de litiasis fue 8.21mm versus 7.39mm para URS y LEC,respectivamente (p=0.24). Luego de la primera intervención, la TLC fue 97.8% para URS y 80% para LEC (p=0.007). En LEC,12 pacientes requirieron retratamiento elevando la TLC a 95%, (p=0.13). Se instaló catéter JJ en 53.1% y 18.3% para URS yLEC, respectivamente (p<0.001). El costo de honorarios médicos, insumos y derecho a pabellón, es $460.838 para URS y$1.243.075 para LEC. El número de días de hospitalización post procedimiento fue 1.6 y 1.71 días para URS y LEC, respectivamente(p=0.86). En relación con los costos totales, la LEC en promedio, es un 132% más cara respecto a la URS (p<0.001)...

INTRODUCTION: Distal ureterolithiasis (UD) is a common disorder. Its treatment is surgical either with extracorporeal lithotripsy(LEC) or ureteroscopy (URS), both with a stone free (TLC) over 90% and minimal complications. The aim of this studyis to compare the TLC after the rst intervention and its associated cost. Also, compare the total costs of treatment with LECor URS. PATIENTS AND METHODS: A comparative descriptive study, which shows the economic cost of LEC vs UD URS fortreatments performed between 2009 and 2013. 107 patients were included; 47 URS and 60 LEC. Number of hospitalizationdays, reoperation and total cost of care were analyzed. Costs were adjusted to present charges for the same procedures. TLC was described in both proceedings. The total cost of hospitalization was obtained and the variables of interest werecompared. RESULTS: Stone size was 8.21mm versus 7.39mm URS and LEC, respectively (p = 0.24). After the rst intervention,TLC was 97.8% for URS and 80% for LEC (p = 0.007). In LEC, 12 patients required retreatment raising the TLC to 95% (p = 0.13).JJ catheter was installed in 53.1% URS and 18.3% LEC, respectively (p <0.001). The cost of medical supplies, operation roomand physician fees was $460.838 for URS and $1.243.075 for LEC. The number of hospitalization days post procedure was1.6 and 1.71 days for URS and LEC, respectively (p = 0.86). In relation to total costs, LEC is on average, 132% more expensivewhen compared to URS (p <0.001)...

Uso rutinario del dispositivo antimigratorio Accordion para prevenir la retropulsión de cálculos ureterales durante la litotripsia intracorpórea con laser Holmium: ¿se justifica su uso? / Routine use of Accordion® antimigratory device for preventing the retropulsion of ureteral stones during intracorporeal lithotripsy with holmium laser: is it justified?

Evaluar el impacto del dispositivo Accordion® (Percsys, Palo Alta, CA) en la prevención de la migración de cálculos ureterales. Materiales y Métodos: Un total de 68 pacientes con cálculos ureterales fueron evaluados en este estudio caso-control. 34 fueron destinados al grupo I (grupo Accordion®) y 34 al grupo II (grupo control). Como objetivo primarios se evaluó la diferencia en tiempo de fragmentación durante el procedimiento. Objetivos secundarios evaluados fueron el tiempo operatorio total, tasa de éxito en la fragmentación del cálculo, requerimiento de catéter ureteral posterior al procedimiento y complicaciones perioperatorias. Resultados: Ambos grupos de pacientes resultaron comparables en término de variables demográficas y características de la litiasis. El tiempo de fragmentación intraoperatoria fue similar entre los grupos (25 minutos en el grupo I vs 24 minutos en el grupo II; p=0,94). No fue encontrada ninguna diferencia estadísticamente significativa en tiempo operatorio total (45 minutos en el grupo I vs 50 minutos en el grupo II; p =0,67) o tasa de éxito en la fragmentación (100 por ciento grupo I vs 97 por ciento grupo II). El análisis multivariado demostró una disminución significativa en la necesidad de instalación de catéter doble J al término del procedimiento con el uso de Accordion durante la ureteroscopía (OR 0.24; CI 0,07-0,90; p=0.034).Conclusión: Ambos grupos en nuestro estudio se comportaron de manera similar con respecto a los resultados inmediatos de la ureteroscopía. La disminución en la necesidad de instalación de un catéter doble J y el costo asociado a éste constituyen un argumento a favor de utilizar el dispositivo Accordion®...

To evaluate the impact of Accordion® (Percsys, Palo Alto , CA) device in preventing stone migration. Methods: A total of 68 patients with ureteral stones were evaluated in this case control study, 34 in group I (Accordion group) and 34 in group II (control group) . As primary outcome we evaluated difference in fragmentation time during the procedure. Secondary outcomes were total operative time, stone free rates, postoperative ureteral catheter requirement and perioperative complications. Results: Both groups of patients were comparable in terms of demographics variables and stone characteristics. Intraoperative fragmentation time was similar between groups (25 minutes for group I vs 24 minutes for group II; p=0,94). No statistically significant difference were found in total operative time (45 minutes for group I vs 50 minutes for group II; p =0,67) or stone free rates (100 percent group I vs 97 percent group II). Multivariate model showed a significant decrease in the need to install a double J catheter at the end of the procedure with the use of Accordion during ureteroscopy (OR 0.24; CI 0,07 -0,90; p=0.034).Conclusions: Both groups in our study behaved similarly with respect to immediate outcome of ureteroscopy. The decrease in the installation of double J stent and the cost associated with it constitutes an argument in favor of the use of Accordion device...

Técnica combinada de LEC con ureteroscopía flexible en cálculo de gran tamaño en cáliz inferior / ESWL technique combined with Flexible ureteroscopy in big lower calyx stones

El tratamiento del cálculo del caliz inferior es controversial. Los resultados del tratamiento de los cálculos caliciarios mayores de 1 cm especialmente en el cáliz inferior son no óptimos con la Litotripsia extracorpórea . Debido al avance en los ureteroscopios flexibles es que iniciamos una experiencia para obtener pacientes libres de cálculos residuales. Se presentan 15 pacientes con cálculos mayores de 1 cm. que fueron operados en una sola sesión aplicando primero Litotripsia extracorpórea hasta fragmentar el cálculo y luego extraer los fragmentos residuales con ureteroscopio flexible. En 14 de 15 pacientes el control demostró ausencia de caculos residuales. Esta experiencia demuestra la eficacia de la combinación de ambos métodos sin complicaciones. Debe evaluarse la relación costo beneficio de esta técnica en el objetivo de dejar a los pacientes libres de cálculos.

Treatment of lower caliz’ Stone is controversial. Greater than 1 cm and especially in the low caliz witht he extracorporeal lithotripsy is bad. Because of advances in flexible ureteroscopes is to begin an experience for patients with big stones in the low caliz. We present 15 patients with stones larger than 1 cm who were operated in a single session using extracorporeal lithotripsy to fragment first calculating and then extract the residual fragments with ureteroscoip flexible. In 14 of 15 patients showed Stone free. This report demonstrates the effectiveness of the combination of both methods without complications. Must evaluate the cost benefit of this technique in order to make patients stone free.