Prospective Randomized Controlled Trial to Compare Dusting vs Fragmentation Using Thulium Fiber Laser in Retrograde Intrarenal Surgery.

Objective: To compare the dusting vs fragmentation modes with thulium fiber laser (TFL) in retrograde intrarenal surgery (RIRS) for upper tract stones using the same fixed low-power settings in both the arms. The primary objective was to compare the stone-free rate (SFR) and secondary objectives were to compare mean operating times, hospital stay duration, complication rates, need for secondary procedures, and laser efficacy. Materials and Methods: A prospective randomized trial, with patients having proximal ureteral or renal stones of 10-20 mm and planned for RIRS was done at a single institute. A total of 60 consecutively admitted patients with signed consent were included for randomization with 30 patients in each arm of dusting and fragmentation modes. Results: Median age in dusting and fragmentation arms of 41.5 and 45.5 years, median stone size of 10.45 and 12.25 mm, median stone volume of 351.6 and 490.7 mm3, and median stone density of 1263.5 HU in both arms with comparable hospital stay of median of 2 days in both arms. Lasing time was significantly lesser in the fragmentation group (20.5 minutes; interquartile range [IQR] 15.12-31.62) than in the dusting group (34.25 minutes, IQR 26.62-38.62, p < 0.001). Higher ablation speed for fragmentation mode (0.405 mm3/sec, IQR 0.337-0.635) than for dusting mode (0.17 mm3/sec, IQR 0.135-0.325, p < 0.001). SFRs and complication rates were comparable in both the arms. Conclusion: TFL in fragmentation mode has shorter lasing times and better laser efficacy than dusting mode with comparable minimal complications, SFRs, and hospital stay duration. Clinical Trial Registration number: CTRI050827.

Outcomes and predictors of clinical T1 renal mass (cT1) upstaged to pathological T3a (pT3a) after partial nephrectomy: A single-center experience.

OBJECTIVES: Clinical T1 (cT1) renal mass treated surgically has a good prognosis, but there is an upstaging risk that potentially threatens oncological outcomes after partial nephrectomy (PN). We aim to analyze and study the incidence, predictors, perioperative morbidity, and oncological outcomes of pT3a upstaging. METHODOLOGY: A retrospective study of 313 patients who underwent PN for cT1 renal mass at a single center from a single tertiary referral center between 2000 and 2021 was done. Demographic, perioperative, pathological, and outcome variables were reviewed. We compared these parameters between upstaged and non-upstaged groups. Multivariate logistic regression analysis was used to study preoperative variables associated with upstaging. RESULTS: Nineteen patients were upstaged to pT3a. Making an incidence of 6.1%. Upstaged tumors were bigger (5.02 cm vs. 4.08 cm, p = 0.004), had higher clinical stage T1b (84.2 vs. 40.5%, p < 0.001), had more tumors which were central location (21 vs. 3.4%, p < 0.001), had more endophytic and mesophytic tumors (15.8 vs. 5.8% and 52.6 vs. 9.5%, p < 0.001), and had higher R.E.N.A.L Nephrometry score (8.05 vs. 6, p < 0.001). Upstaged tumors had more operative times (227 vs. 203 min, p = 0.01), more postoperative complications (68.4 vs. 13.1%, p < 0.001), more major complications of Clavien Dindo Grade 3 and above (15.8 vs. 4.4%, p < 0.001). Age (OR 1.035, p = 0.034), Radiological tumor dimension (OR 1.578, p = 0.003), Radiological or Clinical stage (T1b) (9.19, p = 0.008), Higher Nephrometry score (Intermediate and High) (OR 6.184, p = 0.004) were preoperative predictors of upstaging. Oncological outcomes were comparable. CONCLUSION: Tumor upstaging was uncommon with more perioperative morbidity. Higher age, larger tumor size, higher tumor stage, and higher nephrometry scores were preoperative predictors of upstaging.

A randomized controlled trial comparing infectious complications using mini perc with and without suction for renal stones less than 3 cm in size.

The purpose was to do a study to compare infectious complications in patients operated for MiniPerc or Minimally invasive Percutaneous Nephrolithotomy (MPCNL) using MIP and MPCNL with suction using Shah Superperc sheath for medium-sized renal stones less than 3 cm in size. The primary objective of this study is to compare the infectious complications and the secondary objectives are to compare stone-free rates, complication rates and operative times. A prospective randomized controlled trial with patients having proximal ureteral and renal stones of 10-30 mm size and planned for MPCNL done at a single institute. A total of 80 consecutively admitted patients with written informed consent were included for randomization with 40 patients in each arm of MPCNL and suction MPCNL. The median age in MPCNL and suction MPCNL arms were 48 and 49 years, the median stone size of 15.45 and 16.7 cm, the Median stone volume of 1576.2 vs 1752 mm3, and the median stone density of 1258 and 1250 Hu, the median hospital stay of 3 days in both arms were comparable. Infectious complications were comparable in both arms. Operative time was significantly less in the suction MPCNL group (26.5 min-IQR 17-34.8) than in the MPCNL group (34.8 min-IQR 20-45), p = 0.021 and stone-free rates (SFR), were more in Suction MPCNL arm 97.5% than in MPCNL 87.5%, p = 0.04. Overall, the complication rates were comparable in both arms. Suction MPCNL procedure resulted in shorter operating times and more SFR than conventional MPCNL with comparable complication rates.

Initial experience of comparison between two slimmest single-use flexible ureteroscopes: Indoscope Sleek (Bioradmedisys™) Versus Uscope PU3033A (Pusen™): A single-center prospective study.

PURPOSE: A single-use digital flexible ureteroscope (fURS) has become a cost-effective alternative option to reusable fURS. The requirement of large-diameter access sheath for passage of 9.5 Fr single-use fURS has not always achieved in the first attempt in all cases leading to stage stone clearance. Recently, two slimmest single-use digital disposable fURSs have been introduced by Bioradmedisys™ and Pusen™ to mitigate the accessibility problem, without or with small size access sheath. Primary objective was to compare in vivo performance and surgical outcomes with two single-use fURS: 7.5Fr Indoscope (Bioradmedisys™, Pune, India) and 7.5Fr Uscope PU3033A (Pusen, Zhuhai, China). METHODS: 60 patients undergoing Retrograde Intrarenal Surgery (RIRS) with < 2 cm renal stones were prospectively randomized into: Group A (30 patients) for Indoscope and Group B (30 patients) for Uscope PU3033A. Pre-operative, intra-operative, and post-operative parameters were evaluated. In vivo visibility and maneuverability were rated on 5-point Likert scale by the operating surgeon. At one-month stone clearance was assessed with ultrasound and X-ray KUB. Data were analyzed using SPSS 23.0. RESULTS: Patient demographics and stone characteristics were comparable in both groups. Indoscope had significantly higher visibility (p < 0.05) than Uscope; however, the maneuverability scores were comparable between both the groups (p > 0.05). 28 patients in group A and 26 patients in group B achieved complete stone clearance (p = 0.38). Scope failure was observed in 1 case of group B (p = 0.31). CONCLUSION: We conclude that 7.5Fr Indoscope has better vision than 7.5Fr Uscope and the rest of in vivo performances were comparable with similar outcomes and complications among both scopes.

A multicentric non-randomized prospective observational study on the clinical efficiency of thulium fibre laser in large volume stones (> 1000 mm3).

PURPOSE: Our objective was to analyse the clinical efficiency of TFL in large volume stones during retrograde intrarenal surgery. MATERIALS AND METHODS: Patients with large volume renal stones (> 1000 mm3) operated at two different centres, from May 2020 to April 2021, were enrolled in this study. Retrograde intrarenal surgery was performed using 60W Superpulse thulium fibre laser™ (IPG Photonics, Russia). Demographic data, stone parameters, laser time, and total operating time were recorded, and laser efficacy (J/mm3) and ablation speed (mm3/s) were calculated. NCCT KUB was done at 3 months postoperatively to calculate stone-free rate. RESULTS: A total of 76 patients were included and analysed in the study. Mean stone volume was 1753.12 ± 1245.81 (1169.27-2193.25) mm3, mean stone density was 1104.46 ± 313.09 (875.00-1317.00) HU, mean laser time was 537.79 ± 689.89 (21.00-1080.00) sec, mean operating time was 43.38 ± 12.96 (35.00-51.25) min, mean laser efficacy was 20.30 ± 15.5 (8.88-25.57) J/mm3, and mean ablation speed was 1.32 ± 0.7 (0.82-1.64) mm3/sec. A strong positive correlation was found between the stone volume and ablation speed (r = 0.659, p = 0.000), and a moderate negative correlation was found between the stone volume and laser efficacy (J/mm3) (r = - 0.392, p = 0.000). With increasing volume of the stone, J/mm3 decreased significantly and ablation speed increased significantly (p < 0.001). Complications occurred in 21.05% (16/76) patients, most of which were Clavien grades 1-2. Overall SFR is 96.05%. CONCLUSION: Laser efficiency increases at higher stone volumes (> 1000 mm3), as less energy is required to ablate every mm3 of stone.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy.

PURPOSE: We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes. METHODS: This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications. RESULTS: Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area. CONCLUSION: The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

Stage Migration in Renal Malignancies in COVID Era: A Single-Center Analysis.

The COVID-19 disease, caused by SARS-CoV-2 virus, attained the status of a pandemic by March 2020. There was apprehension among patients suffering from renal malignancies about balancing cancer treatment and preventing COVID-19 infection transmission. We analyzed 184 patients with renal malignancies retrospectively, who presented to our institute over 2 years: 91 patients of renal malignancies in pre-COVID era (March 2019-Feb 2020) and 93 patients in COVID era (March 2020-Feb 2021). The parameters analyzed were age, tumor size, clinical presentation, clinical stage, pathological stage, nuclear grade, and presence of metastasis. Level of significance was kept at 95%, and p value <0.05 was considered significant. The age of patients was comparable in both groups (p: 0.381). Clinical presentation was also similar in both groups whereas there were more cases diagnosed during routine evaluation in pre-COVID era (p: 0.022). Tumor size was 5.84 ± 3.03cm vs. 7.10±3.83cm (p: 0.017) in pre-COVID vs. COVID era, respectively. Patients in COVID era had significantly higher clinical stage (p = 0.041), pathological stage (p =0.027), nuclear grade (p = 0.007), and presence of metastasis (p = 0.005) as compared to pre-COVID era. Patients, who underwent Nephron-sparing surgery, also had higher pathological stage in COVID era. COVID overshadowed the management of renal malignancies. There was a clear shift and stage migration in patients of renal malignancies in COVID era as compared to pre-COVID era, probably because of less routine health check-ups and patients deferring hospital visits due to fear of contracting COVID infection.

Robot-assisted versus conventional open kidney transplantation: a propensity matched comparison with median follow-up of 5 years.

BACKGROUND: RAKT is a relatively newer approach for kidney transplant and has to be proven against the established approach, OKT. RAKT may be beneficial in obese patients as described in literature. Hence, we compared pre-, intra- and postoperative parameters with one year follow-up of both approaches by propensity matching similar characteristics patients. METHODS: Data of 28 OKT and 28 RAKT propensity matched patients was collected during 2014 to 2022 through the institutional transplant registry. OKT and RAKT patients were propensity matched for confounding factors like donor age, eGFR, side along with recipient age, BMI and comorbidities. All graft kidneys were harvested laparoscopically. RESULTS: Both the groups were comparable in terms of recipient age and BMI, donor age, creatinine, BMI, eGFR and comorbidities. Total ischemia time (P<0.001) and postoperative day (POD) 1 creatinine (P<0.001) was significantly more in RAKT. However, postoperative 1 month (P=0.12), 3 months (P=0.60) and 1 year (P=0.10) creatinine was comparable in both approaches. Postoperative complications (P=0.90) including hemoglobin drop (P=0.72) were comparable in both the groups. The days to half the creatinine from preoperative values was significantly less in OKT group (P=0.009). Serum Tacrolimus levels at day 3 (P=0.08) and day 7 (P=0.112) were also comparable in both the groups. Graft survival was 78.5% in OKT group and 82.14% in RAKT group with median follow-up of 60 months in both the groups. CONCLUSION: In this comprehensive propensity matched analysis of RAKT with OKT, we conclude that RAKT has similar outcomes as OKT at 1 year and 5 years follow-up. CIT, TIT, time to half creatinine and POD 1 creatinine values were higher in RAKT group, but eventually have comparable outcomes at further follow-up. Thus, RAKT, a novel approach is non-inferior to established OKT approach. However, further larger trials are required.

Outcomes of Hem-o-Lok clip migration at vesico-urethral anastomotic site post-robotic-assisted laparoscopic radical prostatectomy: a single centre experience.

BACKGROUND: Robotic-assisted laparoscopic prostatectomy (RALP) is the most preferred intervention for the management of prostatic malignancy worldwide. Hem-o-Lok clips (HOLC) are widely used for haemostasis and lateral pedicle ligation. These clips are prone to migrate and lodge at the anastomotic junction as well as inside the bladder causing lower urinary tract symptoms (LUTS) secondary to bladder neck contracture (BNC) or bladder calculi. The objective of this study is to describe the incidence, clinical presentation, management, and outcome of HOLC migration. METHODOLOGY: Retrospective analysis of the database of Post RALP patients who developed LUTS secondary to HOLC migration was done. Cystoscopy findings, number of procedures required, number of HOLC removed intra-operatively, and follow-up of the patients was reviewed. RESULTS: The incidence of HOLC migration requiring intervention was 1.78% (9/505). The mean age of the patient, BMI, Pre-operative Serum PSA were 62.8 years, 27.8 kg/m2, and 9.8 ng/mL, respectively. The mean duration of appearance of symptoms due to HOLC migration was 9 months. Two patients presented with Haematuria and 7 presented with LUTS. Seven patients required a single intervention while 2 required up to 6 procedures for recurrent symptoms secondary to recurrent HOLC migration. CONCLUSION: HOLC use in RALP may present with migration and associated complications. HOLC migration is associated with severe BNC and may require multiple endoscopic interventions. Severe dysuria and LUTS not responding to medical management should be treated using an algorithmic approach and there should be a low threshold for performing cystoscopy and intervention in these cases to improve outcomes.

Single-use flexible ureteroscopes: Comparative in vitro analysis of four scopes.

Objective: Single-use flexible ureteroscopes (fURSs) have recently been introduced by different companies. Goal of this in-vitro study was to compare four fURSs. Methods: We performed in vitro analysis of Uscope 7.5 Fr and Uscope 9.5 Fr (Pusen Ltd., Zhuhai, China), LithoVue 9.5 Fr (LithoVue™, Boston Scientific, MA, USA), and Indoscope 9.5 Fr (Bioradmedisys™, Pune, India). Optical characteristics (image resolution, color representation, and luminosity) were compared at various distances of 10 mm, 20 mm, and 50 mm. Deflection and irrigation were evaluated with and without accessories. Results: Color perception was comparable for all scopes at 10 mm (p<0.05), while Lithovue 9.5 Fr was comparable with Indoscope 9.5 Fr at the distances of 20 mm and 50 mm. Both scopes were statistically better than both Uscopes at the distances of 20 mm and 50 mm. Image resolution powers were comparable amongst all fURSs at the distances of 10 mm and 20 mm (3.56 line pairs per millimeter [lp/mm]). However, Indoscope (3.56 lp/mm) was superior to LithoVue and Uscope scopes (3.17 lp/mm) at the distance of 50 mm. Luminosity at the distance of 10 mm was comparable for LithoVue and Uscope 9.5 Fr. However, at the distances of 20 mm and 50 mm, LithoVue had the highest luminosity while Uscope 7.5 Fr had the lowest one. Indoscope had lower luminosity than other 9.5 Fr scopes at all distances. With empty working channel and 200 µm laser fiber, Indoscope had the maximum deflection (285°). With basket, Uscope 7.5 Fr had the maximum loss of deflection (30°) while Indoscope had no deflection loss. With empty working channel, all scopes had comparable irrigation flow rates in both deflected and undeflected state. Similarly, with 200 µm laser or basket, irrigation flow rates were comparable in all scopes. Conclusion: Color representation was equivalent for Indoscope and LithoVue, while being better than Uscope 7.5 Fr and Uscope 9.5 Fr. Image resolution was comparable in all scopes at the distances of 10 mm and 20 mm. Beyond the distance of 10 mm, luminosity of LithoVue was the highest and that of Uscope 7.5 Fr was the lowest. Deflection loss was the minimum with Indoscope and the maximum with 7.5 Fr Uscope. Under all scenarios, irrigation flow rates were comparable in all scopes.

Can we predict the ancillary treatments after extracorporeal shockwave lithotripsy for renal and upper ureteral stones?

OBJECTIVE: To quantify the predictors for the ancillary treatments after extracorporeal shock wave lithotripsy (SWL) for renal and upper ureteral stones. MATERIALS AND METHODS: From January 2014 to January 2017, patients undergoing SWL using an electromagnetic lithotripter machine (Compact Delta; Dornier MedTech GmbH, Wessling, Germany) for renal and upper ureteral stones ≤ 20 mm were retrospectively reviewed. All patients underwent CT urography prior to SWL. The cohort was subdivided into three groups according to stone attenuation values in Hounsfield Units (HU). Group I; HU < 500 (n = 20), group II; HU 500-1000 (n = 51) and group III; HU ≥ 1000 (n = 180). The parameters included for multivariate analysis were stone size, location, multiplicity, stone attenuation value, number of shocks and stone clearance rate by 3 months. The ancillary treatments were ureteroscopy (URS), ureteral stenting and hospital readmission for pain or fever. RESULTS: A total of 251 patients were included in the study. The overall SWL success rate was 92.4%. Mean stone size was 10.9 ± 2.1, 11.6 ± 3 and 11.4 ± 3.6 mm and mean stone attenuation values were 364 ± 125, 811 ± 154 and 1285 ± 171 HU for groups I, II and III respectively. The stone clearance rates by 3 months were 96%, 92% and 88.4% for groups I, II and III respectively. On subgroup analysis, group III required ancillary treatments in 70% of patients whereas group I, II, did not require any ancillary treatments. On multivariate analysis, stone multiplicity, stone location (lower calyceal stones) and HU were independent significant predictors for the need for ancillary treatments after SWL (p values < 0.05). CONCLUSIONS: Patients with stone attenuation value (HU) > 1000, multiple stones and/or lower calyceal stones have higher risk to necessitate ancillary treatments after SWL. These patients would likely benefit from upfront endoscopic lithotripsy for treating symptomatic renal or upper ureteral stones.

Supine Percutaneous Nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) has evolved many a fold and was originally described in supine position by Valdivia et al. In this position, the direction of the tract is posterior and thus preserves a low pressure in the renal pelvis, and thereby reduces the risk of fluid absorption and allows spontaneous clearance/washout of fragments by gravity-directed flow of fluid. Supine PCNL is feasible in most situations. It is an important tool for patients who have musculoskeletal abnormalities precluding prone positioning. It gives the surgeon a simultaneous opportunity to do flexible ureteroscopy. Mobility of the kidney may make the puncture difficult. Suctioning of the dust using the suction sheath in supine PCNL makes the procedure more effective.

Laparoscopic ureteric reimplantation versus robotic-assisted laparoscopic ureteric reimplantation for lower ureter pathology: Single-institutional comparative study.

OBJECTIVE: To compare and analyze the results of laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation at our tertiary institute. MATERIALS AND METHODS: We retrospectively reviewed data of adult patients who underwent laparoscopic ureteric reimplantation and robotic-assisted ureteric reimplantation between January 2000 and December 2020. Data were analyzed for 19 patients in the laparoscopic group and 47 patients in the robotic group. The data were compared in both the groups. RESULTS: The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics and demographic data including age, gender, laterality, Charlson comorbidity index, and BMI were comparable in both the groups. The time range from previous surgeries to presentation varied from 7 days to 5 years. There is statistically significant difference between the operative time in the laparoscopic (224.23 ± 76.61 min) and robotic groups (187.06 ± 52.81 min) (p = 0.027). There is statistically significant difference between the hospital stay also between the two groups (9.07 ± 2.75 vs. 6 ± 1.65 days p-0.001). There were no differences in the complication rate and postoperative outcomes in both the groups. Mean length of follow-up was 28 ± 25.5 (2-108) months and 20.57 ± 19.91 (2-96) months in both the groups, respectively. The success rates in terms of symptomatic improvement, decrease in hydronephrosis, and improved drainage in the laparoscopic and robotic groups were 94.73% and 95.45%, respectively, which were statistically not significant. CONCLUSIONS: Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in clinical outcomes. Robotic-assisted laparoscopic ureteric reimplantation is feasible, safe, and faster with excellent outcomes, decreased hospital stay, and minimal complications.

Outcome of post-COVID-19 fungal pyelonephritis: A single Indian tertiary center experience.

Introduction: COVID-19 pandemic is associated with secondary opportunistic fungal infections. These have an aggressive course with a high mortality rate. We present our experience of seven cases of post-COVID-19 fungal pyelonephritis. Methods: An observational study over a period of 8 months of May to December 2021 was carried out at our tertiary care hospital, including all patients with features of fungal pyelonephritis in post-COVID-19 setting. The patient demographics, details of previous COVID-19 infection, details of present admission and management were collected. The endpoints were either discharge from the hospital or death. Results: Seven patients were included. Mean age of presentation was 42 years (range: 20-63 years, standard deviation ± 14.2). Male-to-female ratio was 6:1. One patient was diabetic. Two patients were asymptomatic, one had mild infection, and four patients had severe COVID-19 infection as per National Institute of Health criteria. In the present admission, all patients had symptomatic pyelonephritis with laboratory parameters showing elevated D dimer, C reactive protein, and total leukocyte counts. In all seven patients, ultrasound of kidney ureter bladder region showed bulky kidney, color Doppler showed main renal arterial thrombosis in two patients, segmental arterial thrombosis in another patient. Computed tomography scan was suggestive of changes of pyelonephritis in all patients with multiple renal hypodense areas. All patients required nephrectomy with biopsy suggestive of changes of necrotizing fungal inflammation. Three patients expired. Conclusion: Management of post-COVID-19 fungal pyelonephritis should be aggressive and suspicious laboratory and imaging findings should be treated by early nephrectomy.

Initial Safety and Feasibility of Steerable Ureteroscopic Renal Evacuation: A Novel Approach for the Treatment of Urolithiasis.

Background: There is a need to reliably render urolithiasis patients completely stone free with minimal morbidity. We report on the initial safety and feasibility with steerable ureteroscopic renal evacuation (SURE) in a prospective study using basket extraction as a comparison. Materials and Methods: A pilot randomized controlled study was conducted comparing SURE with basket extraction postlaser lithotripsy. SURE is performed using the CVAC™ Aspiration System, a steerable catheter (with introducer). The safety and feasibility of steering CVAC throughout the collecting system under fluoroscopy and aspirating stone fragments as it was designed to do were evaluated. Fluoroscopy time, change in hemoglobin, adverse events through 30 days, total and proportion of stone volume removed at 1 day, intraoperative stone removal rate, and stone-free rate (SFR) at 30 days through CT were compared. Results: Seventeen patients were treated (n = 9 SURE, n = 8 Basket). Baseline demographics and stone parameters were not significantly different between groups. One adverse event occurred in each group (self-limiting ileus for SURE and urinary tract infection for Basket). No mucosal injury and no contrast extravasation were observed in either group. The CVAC catheter was steered throughout the collecting system and aspirated fragments. There was no significant difference in fluoroscopy time, procedure time, change in hemoglobin, or stone removal rate between groups. SURE removed more and a greater proportion of stone volume at day 1 vs baskets (202 mm3 vs 91 mm3, p < 0.01 and 84% vs 56%, p = 0.022). SURE achieved 100% SFR at 30 days vs 75% for baskets, although this difference was not statistically significant (p = 0.20). Conclusions: This initial study suggests SURE is safe, feasible, and may be more effective in stone removal postlaser lithotripsy compared to basketing. More development is needed, and larger clinical studies are underway.

High-Power Holmium with MOSES Technology or Thulium Fiber Laser in MiniPerc with Suction: A New Curiosity.

Purpose: To present initial clinical comparison between high-power holmium laser with MOSES technology (HPH-M) and thulium fiber laser (TFL) during mini-percutaneous nephrolithotomy (PCNL) for renal calculi with specific emphasis on fragmentation efficiency, fragment size distribution, and stone-free rates (SFRs). Materials and Methods: Between August 2018 and December 2019, we performed mini-PCNL for renal calculi <3 cm using HPH-M (Lumenis, Israel) or TFL (Urolase SP, IPG Photonics). Data were collected prospectively in our institutional stone registry. Propensity score matching (1:1) was performed using stone size and density as predictors resulting in matched cohort of 51 patients in each group. Mini-PCNL with active suction sheath was standard across all patients. Primary end-point was SFR at immediate postprocedure and 1 month using CT/kidney, ureter, and bladder radiograph. Stone fragments were retrieved and segregated to assess proportion of dust (<1 mm), small (1-3 mm), and large (>3 mm) fragments. Result: Both groups were comparable in terms of stone size (p = 0.74), volume (p = 0.17), and density (p = 0.69). SFR at 48 hours was 78.43% in HPH-M group and 68.63% in TFL group. Patients with residual fragments were completely clear at 1 month. Lasing time (678.6 vs 551.95 seconds; p = 0.17), stone fragmentation rate (4.6 vs 5.2 mm3/s; p = 0.23), and total laser energy (21.9 vs 16.3 KJ; p = 0.09) were comparable in both arms. Both groups produced similar dusting (46.8 vs 46.41%; p = 0.93). TFL produced a greater proportion of fragments >3 mm (36% vs 22.68%, p = 0.002). On subset analysis based on stone density, all outcome parameters were comparable except a shorter total operative time with TFL (p ≤ 0.05). Conclusion: HPH-M and TFL showed similar SFR. Within constraints of the laser fiber size and energy settings, both modalities were equivalent in terms of fragmentation efficiency and proportion of dusting across stone densities.

The clinical outcomes of laser with suction device in mini-percutaneous nephrolithotomy.

OBJECTIVE: To evaluate the safety, efficacy and feasibility of laser with suction device in mini-percutaneous nephrolithotomy (mini-PCNL). METHODS: A retrospective study was conducted including 200 patients who underwent mini-PCNL for renal stones. All patients underwent PCNL using Electro-Medical Systems laser. In addition to the laser in 100 patients, a suction device was used (laser with suction [LWS]). In the other 100, suction device was not used (laser with no additional suction [LOS]). Mini-PCNL was performed using standard technique and Karl Storz minimally invasive PCNL-medium system was used. Primary end point was stone clearance. RESULTS: Both the groups were comparable in terms of demographic data. Mean stone size was 15.24±5.90 mm and 16.16±5.53 mm in LWS and LOS, respectively. Mean Hounsfield unit of stone was 1285.64 and 1206.79 in LWS and LOS, respectively. Operative time was less in LWS group (56.89±19.65 min) as compared to LOS (62.01±28.81 min). At one-month follow-up, radiological complete clearance was 96% in LWS and 92% in LOS. On subgroup analysis of stones larger than 18 mm, the clearance rate was in favour of LWS (85.7% vs. 100%) and also the need for nephrostomy placement was less in LWS group. CONCLUSIONS: LWS device is safe and efficacious when used with mini-PCNL. For stones greater than 18 mm, it has a better stone free rate as compared to using no suction.

Superselective angioembolization in posttraumatic pseudoaneurysm of corpora cavernosa presenting as acute urinary retention.

Pseudoaneurysm of corpora cavernosa is rare and its presentation as acute urinary retention has not been reported in the literature so far. We report a 47-year-old gentleman who presented with acute urinary retention. Doppler ultrasound revealed pseudoaneurysm of corpora cavernosa at bulbar urethra region with 2 feeder vessels with turbulent flow inside. Selective internal pudendal artery angiogram was done and two feeder arteries from bilateral pudendal arteries were confirmed. Trans perineal thrombin & fibrinogen instillation and selective coil embolization of left internal pudendal artery were done, leading to complete obliteration of pseudoaneurysm and alleviation of patient's symptoms.

Super-mini percutaneous nephrolithotomy (SMP) vs retrograde intrarenal surgery (RIRS) in the management of renal calculi ≤ 2 cm: a propensity matched study.

OBJECTIVE: To compare the effectiveness and safety of Super-Mini PCNL (SMP) and Retrograde Intrarenal Surgery (RIRS) in the management of renal calculi ≤ 2 cm. PATIENTS AND METHODS: A prospective, inter-institutional, observational study of patients presenting with renal calculi ≤ 2 cm. Patients underwent either SMP (Group 1) or RIRS (Group 2) and were performed by 2 experienced high-volume surgeons. RESULTS: Between September 2018 and April 2019, 593 patients underwent PCNL and 239 patients had RIRS in two tertiary centers. Among them, 149 patients were included for the final analysis after propensity-score matching out of which 75 patients underwent SMP in one center and 74 patients underwent RIRS in the other. The stone-free rate (SFR) was statistically significantly higher in Group 1 on POD-1 (98.66% vs. 89.19%; p = 0.015), and was still higher in Group 1 on POD-30 (98.66% vs. 93.24%, p = 0.092) SFR on both POD-1 and POD-30 for lower pole calculi was higher in Group 1 (100 vs. 82.61%, p = 0.047 and 100 vs 92.61% p = 0.171). The mean (SD) operative time was significantly shorter in Group 1 at 36.43 min (14.07) vs 51.15 (17.95) mins (p < 0.0001). The mean hemoglobin drop was significantly less in Group 1 (0.31 vs 0.53 gm%; p = 0.020). There were more Clavien-Dindo complications in Group 2 (p = 0.021). The mean VAS pain score was significantly less in Group 2 at 6 and 12 h postoperatively (2.52 vs 3.67, 1.85 vs 2.40, respectively: p < 0.0001), whereas the mean VAS pain score was significantly less in Group 1 at 24 h postoperatively (0.31 vs 1.01, p < 0.0001). The mean hospital stay was significantly shorter in Group 1 (28.37 vs 45.70 h; p < 0.0001). CONCLUSION: SMP has significantly lower operative times, complication rates, shorter hospital stay, with higher stone-free rates compared to RIRS. SMP is associated with more early post-operative pain though.