Assessment of Holmium:YAG, Pulsed-Thulium:YAG and Thulium Fiber Lasers for Urinary Stone Ablation. In Vitro Study.

Objective: To evaluate the ablation speed (AS), laser efficiency and direct thermal lesions during urinary stone lithotripsy with the current available laser technologies: Holmium:YAG (Ho:YAG), pulsed-Thulium:YAG (p-Tm:YAG) and thulium fiber laser (TFL) in vitro using different laser settings. Materials and Methods: Ho:YAG, p-Tm:YAG, and TFL laser system were used in an in vitro ureteral model with a volume of 125 mm3 Begostone. The following parameters were tested across all laser devices: 0.6J/10 Hz (6 W), 0.6 J/20 Hz (12 W), 1.5 J/10 Hz (15 W), and 1.5 J/20 Hz (30 W), employing short pulse width for all lasers and long pulse width for Ho:YAG and p-Tm:YAG. Ten participants conducted the experimental setup during 3-minutes laser on time, combining the laser technology, settings, and pulse widths, with a total of 20 different combinations. The efficiency, AS and ureteral damage resulting from each intervention were analyzed. Results: p-Tm:YAG and TFL demonstrated significantly higher efficiency compared with Ho:YAG (0.049 ± 0.02 Δgr/KJ and 0.042 ± 0.01 Δgr/KJ vs 0.029 ± 0.01 Δgr/KJ; p < 0.05). In all laser sources, as the power increases, the AS also increases (p < 0.05). Furthermore, only at high-energy settings (1.5 J) higher frequency led to increase AS (p < 0.05). Both, p-Tm:YAG and TFL exhibited higher AS compared to Ho:YAG (0.64 ± 0.33 Δgr/s and 0.62 ± 0.31 Δgr/s vs 0.44 ± 0.22 Δgr/s; p < 0.05). Regarding ureteral injuries, as the power increases, there is a higher chance of ureteral damage (p = 0.031). No differences were observed between laser technologies (p = 0.828). Conclusions: Both, p-Tm:YAG and TFL exhibited superior performances during laser lithotripsy compared with Ho:YAG, as they demonstrated higher efficiency and ablation speed. Thermal damage did not appear to be associated with specific laser equipment, but higher grades of lesions are described by increasing power.

Steady-state versus burst lasing techniques for thulium fiber laser.

OBJECTIVE: To evaluate the stone ablation rate and direct thermal damage from thulium fiber laser (TFL) lithotripsy using continuous (C) and burst (B) lasing techniques on an in vitro ureteral model. METHODS: The TFL Drive (Coloplast, Humlebaek, Denmark) was used in an in vitro saline-submerged ureteral model. Ten participants, including five junior and five experienced urologists, conducted the experimental setup with 7 different settings comparing two lasing techniques: steady-state lasing (0.5 J/10 Hz = 5W for 300 s and 0.5 J/20 Hz = 10W for 150 s) and burst, intermittent 5 s on/off lasing (0.5 J/20 Hz, 0.5 J/30 Hz, 0.5 J/60 Hz, 0.1 J/200 Hz, and 0.05 J/400 Hz) with a target cumulative energy of 1500 J using cubic 125 mm3 phantom BegoStonesTM. Ureteral damage was graded 1-3 based on the severity of burns and holes observed on the surface of the ureteral model. RESULTS: The were no significant differences in stone ablation mass neither between C and B lasing techniques, nor between expertise levels. At C lasing technique had only mild ureteral lesions with no significant differences between expertise levels (p: 0.97) or laser settings (p: 0.71). At B lasing technique, different types of thermal lesions were found with no expertise (p: 0.11) or setting (p: 0.83) differences. However, B laser setting had higher grade direct thermal lesions than C (p: 0.048). CONCLUSION: Regarding efficacy, C and B lasing techniques achieve comparable stone ablation rates. Safety-wise, B lasing mode showed higher grade of direct thermal lesions. These results should be further investigated to verify which of the lasing mode is the safest in vivo. Until then and unless proven otherwise, a C mode with low frequency should be recommended to avoid ureteral wall lesions.

Social media and urology: The good, the bad and the ugly.

Social media (SoMe) is now a core part of modern-day life with increased use among both patients and urologists. The interplay of SoMe between these two parties is complex. From a patient perspective, SoMe platforms can serve as educational tools as well as communication portals to support networks and patient communities. However, studies report the educational value of content online is often poor and may contain misinformation. For urologists, SoMe can lead to research collaborations, networking and educational content but areas of concern include the potential negative impact SoMe can have on mental health and sharing of patient images without appropriate consent. This review serves to provide an overview of the interaction between SoMe and urology practice and provide practical guidance to navigating it.

Temperature profile during endourological laser activation: introducing the thermal safety distance concept.

PURPOSE: To examine temporal-spatial distribution of heat generated upon laser activation in a bench model of renal calyx. To establish reference values for a safety distance between the laser fiber and healthy tissue during laser lithotripsy. METHODS: We developed an in-vitro experimental setup employing a glass pipette and laser activation under various intra-operative parameters, such as power and presence of irrigation. A thermal camera was used to monitor both temporal and spatial temperature changes during uninterrupted 60-second laser activation. We computed the thermal dose according to Sapareto and Dewey's formula at different distances from the laser fiber tip, in order to determine a safety distance. RESULTS: A positive correlation was observed between average power and the highest recorded temperature (Spearman's coefficient 0.94, p < 0.001). Irrigation was found to reduce the highest recorded temperature, with a maximum average reduction of 9.4 °C at 40 W (p = 0.002). A positive correlation existed between average power and safety distance values (Spearman's coefficient 0.86, p = 0.001). A thermal dose indicative of tissue damage was observed at 20 W without irrigation (safety distance 0.93±0.11 mm). While at 40 W, irrigation led to slight reduction in mean safety distance (4.47±0.85 vs. 5.22±0.09 mm, p = 0.08). CONCLUSIONS: Laser settings with an average power greater than 10 W deliver a thermal dose indicative of tissue damage, which increases with higher average power values. According to safety distance values from this study, a maximum of 10 W should be used in the ureter, and a maximum of 20 W should be used in kidney in presence of irrigation.

Current Perspectives on Endourological Ex Vivo Stone Interventions in Kidney Transplantation: A Systematic Review.

OBJECTIVE: To conduct a systematic review (SR) of literature to assess the existing evidence concerning the success and complications of endourological ex vivo stone surgeries. METHODS: Eligible studies for inclusion focused on investigating the success and/or complications related to endourological ex vivo surgeries in donors with nephrolithiasis. A SR was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search included databases of Web of Science, PubMed, and Scopus and only article in English were included. Studies published between 2002 and 2023 included in this SR. RESULTS: After screening 1726 abstracts, this SR included 16 studies with a total of 209 patients. The mean stone size was 5.6 mm and majority of kidneys contained single stones, located in the lower calyx. After ex vivo endourological stone surgeries, the average stone-free rate was found to be 95.4%. The mean duration of ex vivo surgery was 17.3 minutes. Regarding intraoperative complications, two patients (1%) experienced mucosal injuries during pneumatic lithotripsy. As for postoperative complications, two patients (1%) experienced vascular complications. In terms of urological complications, hematuria was observed in 24 patients (11.5%), while one patient (0.5%) experienced clot formation in renal pelvis. Seven patients (3.3%) had urinary tract infections, and three patients (1.4%) developed urolithiasis during the follow-up. Additionally, one patient (0.5%) experienced complete occlusion of ureteroneocystostomy and required revision. CONCLUSION: Given the advancements in current technology and techniques, endourological ex vivo stone surgeries are increasingly recognized as an effective and safe option for donors with nephrolithiasis. TRIAL REGISTRATION: This systematic review was registered under the protocol registration number CRD42024538384/PROSPERO.

Management of deceased and living kidney donor with lithiasis: a multicenter retrospective study on behalf of the renal transplant group of the Spanish urological association.

BACKGROUND: To maximize the availability of suitable grafts and ensure effective management, several reports have demonstrated successful outcomes when using kidney grafts with urolithiasis. This multicenter study reports on the management and long-term outcomes of kidney transplantation using renal grafts with lithiasis. METHODS: Retrospective data from three Spanish hospitals were analyzed for kidney transplants involving grafts with nephrolithiasis performed between December 2009 and August 2023. The study included adult patients, excluding those with incomplete records. It evaluated stone characteristics, complications, and outcomes in recipients and in living kidney donors. RESULTS: Out of 38 analyzed kidney transplants, 57.9% were cadaveric and 42.1% were from living kidney donors. Most diagnoses were incidental during donor evaluation, with an average stone size of 7.06 mm. After follow-up (median 26 months), all recipients but one had functioning grafts, and there were no stone recurrences in both recipients and living kidney donors. Conservative management was adopted in 28 cases, while 10 cases required ex-vivo flexible ureterorenoscopy for stone removal. Following conservative management, 5 patients needed additional treatments for stone-related events. CONCLUSIONS: Kidneys with lithiasis can be considered for transplantation in selected cases, resulting in good functional outcomes with no stone recurrence in recipients or living donors.

Illumination matters part I: comparative analysis of light sources and illumination in flexible ureteroscopy-fundamental findings from a PEARLS analysis.

PURPOSE: Illumination characteristics of flexible ureteroscopes have been evaluated in air, but not in saline, the native operative medium for endourology. The aim was to evaluate light properties of contemporary ureteroscopes in air versus saline, light distribution analysis, and color temperature. METHODS: We evaluated the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, and OTU WiScope using a 3D printed black target board in-vitro model submerged in saline. A spectrometer was used for lux and color temperature measurements at different opening locations. RESULTS: Illuminance was higher in saline compared to air (5679 vs. 5205 lx with Flex-Xc, p = 0.02). Illuminance in saline differed between ureteroscopes (ANOVA p < 0.001), with highest for the Flex-Xc at 100% brightness setting (5679 lx), followed by Pusen 9.2F (5280 lx), Flex-X2s (4613 lx), P7 (4371 lx), V3 (2374 lx), WiScope (582 lx) and finally Pusen 7.5F (255 lx). The same ranking was found at 50% brightness setting, with the highest ureteroscope illuminance value 34 times that of the scope with lowest illuminance. Most scopes had maximum illuminance off center, with skewness. Three scopes had two light sources, with one light source for all other scopes. Inter-scope comparisons revealed significant differences of color temperature (ANOVA p < 0.001). CONCLUSION: The study demonstrates the presence of inhomogeneous light spread as well as large differences in illumination properties of ureteroscopes, possibly impacting on the performance of individual scopes in vivo. Additionally, the study suggests that future studies on illumination characteristics of flexible ureteroscopes should ideally be done in saline, and no longer in air.

Illumination matters Part III: Impact of light obstruction on illuminance from flexible ureteroscopes - a comparative PEARLS analysis.

PURPOSE: Artifacts from poor ureteroscopes' light design with shadowing and dark areas in the field of view have been reported. The aim was to quantify effects of light obstruction in a kidney calyx model. METHODS: We evaluated a series of contemporary flexible ureteroscopes including the Storz Flex-Xc and Flex-X2s, Olympus V3 and P7, Pusen 7.5F and 9.2F, as well as OTU Wiscope using an enclosed 3D-printed pink in vitro kidney calyx model submerged in saline, where the field of light was intentionally partially obstructed alternatively at 12, 3, 6, and 9 o'clock. A color spectrometer was used for illuminance measurements at a 45° opening position in the background of the model. RESULTS: Overall and mean background illuminance for each obstructive situation were significantly different between scopes for both 50% and 100% brightness settings (ANOVA p < 0.001). At 50% brightness setting, almost all scopes had their highest and lowest background illuminance with the 6 o'clock and 3 o'clock obstructive situation, respectively. At 100% brightness setting, these became 6 o'clock and 12 o'clock obstructive situations. Considering each obstructive situation individually, the Flex-Xc was consistently the scope with highest background illuminance and the Pusen 7.5F the lowest. Background illuminance for each obstructive situation varied significantly for each scope individually, with the greatest range of variability for Pusen 7.5F and V3. CONCLUSIONS: Illuminance performance of ureteroscopes within an obstructed calyx model differ significantly for various obstructive situations. Urologists should be aware of this to help guide their choice of ureteroscope.

A historical comparison of thulium fiber laser systems for stone lithotripsy: navigating toward safe and effective parameters.

INTRODUCTION AND OBJECTIVES: Medical device companies have introduced new TFL machines, including Soltive (Olympus, Japan), Fiber Dust (Quanta System, Italy), and TFLDrive (Coloplast, France). The primary objective of this study is to compare our initial clinical experiences with TFL using those devices. Through this historical comparison of Thulium Fiber Laser systems for stone lithotripsy, we aim to advance our understanding and approach toward achieving safe and effective TFL parameters. MATERIALS AND METHODS: The data for this comparative analysis were extracted from three distinct prospective series that were previously published, outlining our initial clinical experience with the Soltive (Olympus, Japan), FiberDust laser (Quanta System, Italy), and TFLDrive laser (Coloplast, France). Parameters such as stone size, stone density, laser-on time (LOT), and laser settings were meticulously recorded. Additionally, we assessed critical variables such as ablation speed (expressed in mm3/s) and Joules/mm3 for each lithotripsy procedure. RESULTS: A total of 149 patients were enrolled in this study. Among them, 120 patients were subjected to analysis concerning renal stones. Statistically significant differences were observed in the median (IQR) stone volume: 650 (127-6027) mm3 for TFLDrive, 1800 (682.8-2760) mm3 for Soltive, and 1125 (294-4000) mm3 for FiberDust (p: 0.007); while there were no differences regarding stone density among the groups. Significant variations were identified in median (IQR) pulse energy, frequency, and total power. The Soltive group exhibited lower energy levels (0.3 J vs. 0.6 J, p: 0.002) but significantly higher pulse frequency (100 Hz vs. 17.5 Hz, p: 0.003) and total power (24 W vs. 11W, p: 0.001) compared to the other groups. Laser-on time showed no substantial differences across all three groups. Additionally, a statistically significant difference was observed in median J/mm3, with the TFLDrive group using higher values (24 J/mm3, p: 0.001), while the Soltive group demonstrated a higher median ablation speed of 1.16 mm3/s (p: 0.001). The overall complication rate remained low for all groups, with comparable stone-free rates. CONCLUSION: By reducing pulsed frequency, we improved laser efficiency, but smaller volumes lead to decreased efficiency due to increased retropulsion and fragment movement. Further studies are needed to identify and establish the appropriate laser settings for this new technology.

Endourological Management of Ureteral Stricture in Patients with Renal Transplant: A Systematic Review of Literature.

Purpose: To analyze the utility and outcomes of available endourologic options to treat ureteral stricture after kidney transplantation (KT). Methods: A systematic review was carried out for all English language articles from 2000 to 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standards using EMBASE, MEDLINE, SCOPUS, Google scholar, and Cochrane library. The search term combination for the string was follows: [(Ureteral stricture) OR (ureter stenosis) OR (ureteral stenosis) OR (Stricture ureter) OR (Narrowing ureter) OR (Ureter restriction) OR (ureteral restriction) OR (ureteral narrowing) OR (ureteral obstruction) OR (ureter obstruction) OR (obstructing ureter) OR (obstructive ureter) OR (narrow ureter) OR (ureteral narrow)] AND [(kidney transplant) OR (transplanted kidney) OR (transplant) OR (transplantation)] AND [(management) OR (Robotic) OR (laser) OR (stent) OR (dilatation) OR (dilation) OR (endoscopic) OR (endourological) OR (Urologic) OR (laparoscopic) OR (surgery) OR (treatment)]. Case reports, review articles, animal and laboratory studies were excluded. Risk of bias assessment was conducted using the RoB 2 and ROBINS-I tools. Results: A total of 1102 relevant articles published from 2000 to 2023 were found. After screening of titles and abstracts, a total of 19 articles were included in our systematic review. Ureteral stent/nephrostomy placement, balloon dilatation (ureteroplasty) with or without laser was used as initial approaches whereas follow-up and success rate were analyzed among other parameters. Conclusions: The management of ureteral strictures after KT is challenging and selecting the most appropriate treatment is crucial for successful outcomes. Our review suggests that, an endourologic management is a safe option with good long-term outcomes, especially in short and early strictures.

Patient Perspectives on Kidney Stone Surgery: A Content Analysis of Instagram Posts by Patients Versus Surgeons.

Background: Both clinicians and patients use social media to post about health care issues such as kidney stone disease, but their perspectives may differ. Objective: To evaluate content and themes regarding kidney stone surgery shared by patients and urologists on Instagram. Design setting and participants: A search was performed on Instagram using the term "kidney stone surgery". The first 100 posts from individuals who were clearly identified as a patient were assessed. We also assessed 100 posts from self-identified urologists. Outcome measurements and statistical analysis: A previously published system was applied as a framework for categorizing the information collected. Outcomes of interested included pain, recovery, and costs. Results and limitations: Some 71% of the patients were female and most of their posts (52%) were shared postoperatively. The most common themes covered in patient posts were the need for multiple operative sessions (45%), pain (43%), and recovery (42%). Other themes included activities of daily life (18%), return to work (11%), nervousness (16%), stent issues (31%), stent on a string (5%), diet and prevention (9%), gratitude for health care services (10%), disease recurrence (18%), and costs (10%). Some 94% of the urologists were male and their posts covered the following domains: recovery (11%), stent issues (3%), pain (1%), stent on a string (1%), gratitude for health care services (1%), and recurrence 1%. Among the posts from urologists, 79% included self-promotion and 52% covered new technology. Overall, 10% contained false information. The majority of the posts with surgical images had no clear statement regarding patient consent (97%). Conclusions: Kidney stone surgery can affect many areas of a patient's quality of life. Most of the posts shared by patients were negative. Posts shared by urologists do not reflect the same themes. Moreover, there appears to be poor adherence to European Association of Urology recommendations regarding online professional conduct. Patient summary: Many patients use social media to share their experiences of kidney stone surgery. Posts are largely related to quality-of-life issues and are mostly negative. While urologists also use social media, the content they post on professional accounts is mostly focused on new technology and career promotion.

Laser Ablation Efficiency, Laser Ablation Speed, and Laser Energy Consumption During Lithotripsy: What Are They and How Are They Defined? A Systematic Review and Proposal for a Standardized Terminology.

CONTEXT: Laser performance for lithotripsy is currently reported using units of measurement such as J/mm3, mm3/J, mm3/s, s/mm3, and mm3/min. However, there are no current standardized definitions or terminology for these metrics. This may lead to confusion when assessing and comparing different laser systems. OBJECTIVE: The primary objective was to summarize outcome values and corresponding terminology from studies on laser lithotripsy performance using stone volume in relation to time or energy. The secondary objective was to propose a standardized terminology for reporting laser performance metrics. EVIDENCE ACQUISITION: A systematic review of the literature was conducted using the search string ("j*/mm3" OR "mm3/j*" OR "mm3/s*" OR "s*/mm3" OR "mm3/min*" OR "min*/mm3" AND "lithotripsy") on Scopus, Web of Science, Embase, and PubMed databases. Study selection, data extraction, and quality assessment were performed independently by two authors. EVIDENCE SYNTHESIS: A total of 28 studies were included, covering holmium:yttrium-aluminum-garnet (Ho:YAG), MOSES, and thulium fiber laser (TFL) technologies. Laser energy consumption values reported for the studies ranged from 2.0 - 43.5 J/mm3in vitro and from 2.7 - 47.8 J/mm3in vivo, translating to laser ablation efficiency of 0.023 - 0.500 mm3/J and 0.021 - 0.370 mm3/J, respectively. Laser ablation speeds ranged from 0.3 - 8.5 mm3/s in vivo, translating to lasing time consumption of 0.12 - 3.33 s/mm3. Laser efficacy ranged from 4.35 - 51.7 mm3/min in vivo. There was high heterogeneity for the terminology used to describe laser performance for the same metrics. CONCLUSIONS: The range of laser performance metric values relating stone volume to energy or time is wide, with corresponding differing terminology. We propose a standardized terminology for future studies on laser lithotripsy, including laser ablation efficiency (mm3/J), laser ablation speed (mm3/s), and laser energy consumption (J/mm3). Laser efficacy (mm3/min) is proposed as a broader term that is based on the total operative time, encompassing the whole technique using the laser. PATIENT SUMMARY: We reviewed studies to identify the units and terms used for laser performance when treating urinary stones. The review revealed a wide range of differing units, outcomes, and terms. Therefore, we propose a standardized terminology for future studies on laser stone treatment.

Pulsed thulium:YAG laser-ready to dust all urinary stone composition types? Results from a PEARLS analysis.

PURPOSE: To evaluate whether stone dust can be obtained from all prevailing stone composition types using the novel pulsed thulium:YAG (p-Tm:YAG), including analysis of stone particle size after lithotripsy. METHODS: Human urinary stones of 7 different compositions were subjected to in vitro lithotripsy using a p-Tm:YAG laser with 270 µm silica core fibers (Thulio®, Dornier MedTech GmbH®, Wessling, Germany). A cumulative energy of 1000 J was applied to each stone using one of three laser settings: 0.1 J × 100 Hz, 0.4 J × 25 Hz and 2.0 J × 5 Hz (average power 10 W). After lithotripsy, larger remnant fragments were separated from stone dust using a previously described method depending on the floating ability of dust particles. Fragments and dust samples were then passed through laboratory sieves to evaluate stone particle count according to a semiquantitative analysis relying on a previous definition of stone dust (i.e., stone particles ≤ 250 µm). RESULTS: The p-Tm:YAG laser was able to produce stone dust from lithotripsy up to measured smallest mesh size of 63 µm in all seven stone composition types. Notably, all dust samples from all seven stone types and with all three laser settings had high counts of particles in the size range agreeing with the definition stone dust, i.e., ≤ 250 µm. CONCLUSION: This is the first study in the literature proving the p-Tm:YAG laser capable of dusting all prevailing human urinary stone compositions, with production of dust particles ≤ 250 µm. These findings are pivotal for the broader future implementation of the p-Tm:YAG in clinical routine.

Living donor-gifted allograft lithiasis: surgical experience after bench surgery stone removal and follow-up.

This study presents the surgical experience and long-term outcomes of living donor kidney transplantations involving asymptomatic kidney stones, using ex vivo flexible ureterorenoscopy (f-URS) during bench surgery for stone removal. Out of 1743 living kidney donors assessed between January 2012 and October 2022, 18 (1%) were diagnosed with urolithiasis. Among them, 12 donors were rejected, and 6 were accepted for kidney donation. Stone removal was successfully performed using f-URS during bench surgery, with no immediate complications or acute rejections observed. The study analyzed six living kidney transplants, of which 4 (67%) donors and three recipients were female, and 4 (67%) donors were blood-related to the recipient. The median age for donors and recipients was 57.5 and 51.5 years, respectively. The stones, primarily located in the lower calyx, had a median size of 6 mm. The median cold ischemia time during surgery was 41.6 min, and ex vivo f-URS ensured complete stone removal in all cases. After a median follow-up of 120 months, the remaining grafts were functioning well, and no urinary stone recurrence was observed in either the recipients or living donors. The findings suggest that bench f-URS is a safe approach for managing urinary stones in kidney grafts, providing good functional outcomes without stone recurrence in selected cases.

Retrograde intrarenal surgery for stones associated with renal anomalies: caliceal diverticulum, horseshoe kidney, medullary sponge kidney, megacalycosis, pelvic kidney, uretero-pelvic junction obstruction.

PURPOSE OF REVIEW: Nowadays, due to the increase of imaging diagnosis, we identify easily renal anomalies, and we can choose between a wide range of armamentarium to treat symptomatic stones in those challenging cases. However, there is a lack of evidence and consensus on its use. The aim of this narrative review is to collect all the available data about safety and efficacity of retrograde intrarenal surgery (RIRS) in the treatment of kidney stones associated to a renal anomaly. RECENT FINDINGS: Renal anomalies are uncommon findings and even more if it has to be associated with renal stones. After a literature review of the past 2 years, there are a small number of studies that compare the outcomes in patients who have been treated with minimally invasive modalities and they are mainly focus on RIRS. SUMMARY: It is of extreme importance to know the advances on the stone treatment in anomalous kidneys. With the development of new laser technologies, RIRS is becoming a more interesting technique with high success rate and safety. Further studies are needed to make an accurate statement about the adequate surgical technique for each renal anomaly and also, clinical trials using new laser technologies.

Robotic Retrograde Intrarenal Surgery: A Journey from "Back to the Future".

The introduction of robotics has revolutionized surgery. Robotic platforms have also recently been introduced in clinical practice specifically for flexible ureteroscopy. In this paper, we look at the robotic platforms currently available for flexible ureteroscopy, describing their advantages and limitations. The following robotic platforms are discussed: Roboflex Avicenna®, EasyUretero®, and ILY® robot. Finally, potential future advancements in this field are presented.

Risk of Sepsis in Retrograde Intrarenal Surgery: A Systematic Review of the Literature.

Context: Nowadays, urolithiasis has become a highly prevalent disease. Recent studies indicate that retrograde intrarenal surgery (RIRS) is becoming more popular among surgical treatments due to the preference of patients and providers. This minimally invasive procedure results in high stone-free rates and relatively low morbidity; however, complications resulting from infection can still occur, including acute urinary tract infection, systemic inflammatory response syndrome, and sepsis. Objective: To identify the independent risk factors for sepsis following RIRS, as well as general risk factors that may contribute to this life-threatening complication in the pre- and intraoperative periods. Evidence acquisition: A literature review was conducted in April 2020 using the Medline, Scopus, and Cochrane databases. We searched the references of included papers. Evidence synthesis: We screened 2306 manuscripts and selected 13 for inclusion. The sepsis rate ranged from 0.5% to 11.1%, and the septic shock rate ranged from 0.3% to 4.6%. All selected studies mentioned risks for sepsis and/or infective complications (including sepsis), but only four of them addressed independent risks for urosepsis. These independent risk factors were stone size, high irrigation pressure, prolonged stent dwelling time (>30 d), sepsis as an indication for stent insertion, female gender, positive intraoperative bladder urine culture, longer surgical time, and diabetes mellitus. Conclusions: RIRS is associated with a low sepsis rate, according to the latest evidence. However, given that this is a serious life-threatening complication, knowing its potential risk factors is extremely important. Patient summary: In this report, we looked at the outcome of sepsis after planned retrograde intrarenal surgery for stone disease in patients with and without comorbidities. This information may be useful for colleagues in their daily practice.

Glossary of pre-settings given by laser companies: no consensus!

INTRODUCTION: Since the construction of the first laser, many companies around the world have contributed to the development of new lasers technologies. To be user-friendly, some companies have developed a pre-setting mode in their laser devices. We aimed to review and compare all laser companies' pre-settings (PS) already established in the market. MATERIALS AND METHODS: An online search of holmium:YAG (Ho:YAG) and thulium fiber laser (TFL) devices was carried out. Manual and PS mode, pulse width and pulse modulation technology data were collected. The PS parameters were collected directly from the brochure devices or by asking the companies consulting agents. RESULTS: Thirty-nine laser devices were analyzed (33 Ho:YAG and 6 TFL). The power range varies from 15 to 152 W and 35 W to 60 W for Ho:YAG and TFL, respectively. PS are present in 66% of Ho:YAG lasers and the 33% of TFL. Long-pulse modes can be modified in 12 Ho:YAG and 1 TFL lasers. The median (IQR) PS for dusting stones with Ho:YAG laser is 0.4 J (0.2-1), 21.5 Hz (5-120), and 10 W (1.5-28) for energy, frequency and power, respectively; for Ho:YAG fragmentation is 0.8 J (0.3-5), 10 (3-15) Hz and 5 (1.5-50) W for energy, frequency, and power, respectively; and for popcorn is 0.8 J (0.4-1.2), 10 Hz (6-15) and 5 W (4-18) for energy, frequency, and power, respectively. Dusting and fragmentation mode of Rocamed MH01 and EMS LaserClast 35 are programmed according to the stone type. Most of these settings do not depend on the size of the fiber being used nor the location and type of stone. For TFL, the pre-sets are divided in bladder stone, dusting, fine dusting, fragmentation, and ureteral stone. CONCLUSION: There is a huge variability regarding pre-sets offered by companies because there is no consensus. Pre-sets should provide a range to work efficacy and safety.

Moses and Moses 2.0 for Laser Lithotripsy: Expectations vs. Reality.

Moses technology was born with the aim of controlling the Moses effect present in every single Ho:YAG laser lithotripsy. The capacity to divide the energy pulse into two sub-pulses gained popularity due to the fact that most of the energy would be delivered in the second pulse. However, is this pulse modulation technique really better for endocorporeal laser lithoripsy? A review of the literature was performed and all relevant clinical trials of Moses 1.0 and 2.0, as well as the lab studies of Moses 2.0 carried out up to June 2022 were selected. The search came back with 11 clinical experiences (10 full-text clinical trials and one peer-reviewed abstract) with Moses 1.0 and Moses 2.0, and three laboratory studies (peer-reviewed abstracts) with Moses 2.0 only. The clinical experiences confirmed that the MT (1.0) has a shorter lasing time but lower laser efficacy, because it consumes more J/mm3 when compared with the LP Ho:YAG laser (35 W). This gain in lasing time did not provide enough savings for the medical center. Additionally, in most comparative studies of MT (1.0) vs. the regular mode of the HP Ho:YAG laser, the MT did not have a significant different lasing time, operative time or stone-free rate. Clinical trials with Moses 2.0 are lacking. From what has been published until now, the use of higher frequencies (up to 120 Hz) consumes more total energy and J/mm3 than Moses 1.0 for similar stone-free rates. Given the current evidence that we have, there are no high-quality studies that support the use of HP Ho:YAG lasers with MT over other lasers, such as LP Ho:YAG lasers or TFL lasers.