The Investigative Role of Statins in Ameliorating Lower Urinary Tract Symptoms (LUTS): A Systematic Review.

Previous data have shown that patients with metabolic syndrome (MetS) and lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) could be refractory to the medical treatment. In this context, the evidence suggests a role for statin use in LUTS/BPE patients. The present systematic review aimed to evaluate the impact of statins on the treatment of men with LUTS/BPE. This review has been registered on PROSPERO (CRD42019120729). A systematic review of English-language literature was performed up to January 2020 in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA statement) criteria. Retrieved studies had to include adults with LUTS connected to BPE treated with statins drugs for metabolic syndrome. After removing duplicates, a total of 381 studies were identified by the literature search and independently screened. Of these articles, 10 fit the inclusion criteria and were further assessed for eligibility. Data from our systematic review suggest that a long-term therapy with statins, at least 6 months, is required to achieve significant impacts on prostate tissue and LUTS. Moreover, besides statins' direct activity, the risk reduction of LUTS might be connected to the improvement of hypercholesterolemia and MetS. The role of statins for the treatment of LUTS/BPE may be beneficial; however, evidence from robust studies is not enough, and more clinical trial are required.

Thulium:YAG Versus Holmium:YAG Laser Effect on Upper Urinary Tract Soft Tissue: Evidence from an Ex Vivo Experimental Study.

Introduction: There are limited data regarding the effect of thulium laser (Tm:YAG) and holmium laser (Ho:YAG) on upper urinary tract. The aim of this study was to compare soft tissue effects of these two lasers at various settings, with a focus on incision depth (ID) and coagulation area (CA). Materials and Methods: An ex vivo experimental study was performed in a porcine model. The kidneys were dissected to expose the upper urinary tract and the block samples containing urothelium and renal parenchyma were prepared. The laser fiber, fixed on a robotic arm, perpendicular to the target tissue was used with a 100 W Ho:YAG and a 200 W Tm:YAG. Incisions were made with the laser tip in contact with the urothelium and in continuous movement at a constant speed of 2 mm/s over a length of 1.5 cm. Total energy varied from 5 to 30 W. Incision shape was classified as follows: saccular, triangular, tubular, and irregular. ID, vaporization area (VA), CA, and total laser area (TLA = VA + CA) were evaluated. Statistical analysis was performed using the SPSS V23 package, p-values <0.05 were considered statistically significant. Results: A total of 216 experiments were performed. Incision shapes were saccular (46%), triangular (38%), and irregular (16%) with the Ho:YAG, while they were tubular (89%) and irregular (11%) with the Tm:YAG. ID was significantly deeper with the Ho:YAG (p = 0.024), while CA and TLA were larger with the Tm:YAG (p < 0.001 and p < 0.005). Conclusion: ID was deeper with Ho:YAG, whereas CA and TLA were larger with the Tm:YAG. Considering surgical principles for endoscopic ablation of upper tract urothelial carcinoma, these results suggest that Tm:YAG may have a lower risk profile (less depth of incision) while also being more efficient at tissue destruction. Future in vivo studies are necessary to corroborate these findings.

Holmium laser for RIRS. Watts are we doing? / Laser holmium para ureteroscopia flexible retrograda. ¿Qué estamos haciendo?

OBJECTIVE: To review recent and relevant information regarding the use of high-power (HPL) and low-power (LPL) Holmium:YAG lasers (Ho:YAG) in retrograde intrarenal surgery (RIRS) for lithotripsy. METHODS: A PubMed/Embase search was conducted and recent and relevant papers on Ho:YAG for RIRS were reviewed. RESULTS: Settings for Ho:YAG are pulse energy (PE), pulse frequency (PF), and pulse width. Currently, the majority of LPL can also adjust pulse-width but cannot reach PF as high as HPL, however, the higher energy outputs reached by HPL are rarely useful in lithotripsy. Higher PE might enhance ablation but generates larger fragments and higher retropulsion. Pulse width does not affect energy output but delivers energy for a longer time-length. Dusting and basketing are complementary techniques. Dusting seeks to pulverize stones into particles ≤250 µm avoiding the use of instruments for stone retrieval, whereas in fragmenting, the stones are break into smaller pieces which are then retrieved. Dusting can prevent the use of supplies such as access sheaths and baskets and also prevent the complications related to their use. However, is not always feasible in clinical practice to fully ablate a stone into dust, then the use of this supplies and popcorn technique are helpful for rendering a patient stonefree. The energy gap between HPL and LPL is wide and leaves room for a mid-power laser classification, which can overcome the main drawback of LPL, the expenses of HPL, and still holding its versatility for other procedures beyond stones. CONCLUSIONS: HPL and LPL have similar effectiveness, but long-term cost-effectiveness comparisons are underexplored. Newer HPL would need to be compared to emerging technologies as the thulium fiber, and prove superiority to mid-power laser to determine how powerful is enough for Ho:YAG in the years to come.

OBJETIVO: El láser Holmio:YAG (Ho:YAG) es el de elección para litotricia en cirugía retrógrada intrarenal (RIRS). Los equipos láser de alto poder (HPL) y bajo poder (LPL) tienen diferentes características, por lo tanto, pueden tener diferente desempeño. En el presente trabajo tuvimos el objetivo de revisar evidencia sobre el uso de HPL y LPL en RIRS. MATERIAL Y MÉTODOS: Se realizó una búsqueda en PubMed/Embase y la información reciente y relevante sobre HPL y/o LPL en RIRS fue evaluada para una revisión monográfica. RESULTADOS: Los HPL y algunos LPL más recientes permiten al cirujano ajustar la duración del pulso, por lo tanto, al configurar un pulso largo, alta frecuencia y baja energía, se puede lograr una verdadera pulverización. Los LPL no pueden alcanzar la misma emisión de energía que los HPL. La retropulsión aumenta si la energía de pulso es mayor, entonces, se previene la retropulsión al incrementar la emisión total de energía mediante el incremento de la frecuencia. El costo de adquisión de los HPL es considerablemente mayor que el de los LPL, sin embargo, el costo a largo plazo pudiera ser similar pues los procedimientos pueden abaratarse al disminuir el uso de insumos para recuperar los litos, preservar la punta de las fibras reutilizables y disminuir el tiempo quirúrgico. CONCLUSIONES: La evidencia no favorece la efectividad de los HPL o LPL de modo abrumador. Ambos dispositivos son efectivos y seguros. No cabe duda de que los HPL alcanzan mayor emisión de energía que los LPL, pero los dispositivos de 50-80 Watts, tienen emisiones de energía que rara vez se alcanzan para litotricia y por lo tanto pudiera considerarse demasiada energía. A medida que nuevas tecnologías han surgido, la brecha entre LPL y HPL se amplía, dejando espacio para una clasificación de poder intermedio (36-55 Watts) y la comparación entre estos dispositivos sería más justa. Asimismo, los HPL aún necesitan ser contrastados en el escenario clínico, con las nuevas tecnologías disponibles, tal como la fibra de laser tulio.

Holmium laser for RIRS. Watts are we doing? / Laser holmium para ureteroscopia flexible retrograda. ¿Qué estamos haciendo?

OBJECTIVE: To review recent and relevant information regarding the use of high-power (HPL) and low-power (LPL) Holmium:YAG lasers (Ho:YAG) in retrograde intrarenal surgery (RIRS) for lithotripsy. METHODS: A PubMed/Embase search was conducted and recent and relevant papers on Ho:YAG for RIRS were reviewed. RESULTS: Settings for Ho:YAG are pulse energy (PE), pulse frequency (PF), and pulse width. Currently, the majority of LPL can also adjust pulse-width but cannot reach PF as high as HPL, however, the higher energy outputs reached by HPL are rarely useful in lithotripsy. Higher PE might enhance ablation but generates larger fragments and higher retropulsion. Pulse width does not affect energy output but delivers energy for a longer time-length. Dusting and basketing are complementary techniques. Dusting seeks to pulverize stones into particles ≤250 μm avoiding the use of instruments for stone retrieval, whereas in fragmenting, the stones are break into smaller pieces which are then retrieved. Dusting can prevent the use of supplies such as access sheaths and baskets and also prevent the complications related to their use. However, is not always feasible in clinical practice to fully ablate a stone into dust, then the use of this supplies and popcorn technique are helpful for rendering a patient stonefree. The energy gap between HPL and LPL is wide and leaves room for a mid-power laser classification, which can overcome the main drawback of LPL, the expenses of HPL, and still holding its versatility for other procedures beyond stones. CONCLUSIONS: HPL and LPL have similar effectiveness, but long-term cost-effectiveness comparisons are underexplored. Newer HPL would need to be compared to emerging technologies as the thulium fiber, and prove superiority to mid-power laser to determine how powerful is enough for Ho:YAG in the years to come

OBJETIVO: El láser Holmio:YAG (Ho:YAG) es el de elección para litotricia en cirugía retrógrada intrarenal (RIRS). Los equipos láser de alto poder (HPL) y bajo poder (LPL) tienen diferentes características, por lo tanto, pueden tener diferente desempeño. En el presente trabajo tuvimos el objetivo de revisar evidencia sobre el uso de HPL y LPL en RIRS. MATERIAL Y MÉTODOS: Se realizó una búsqueda en PubMed/Embase y la información reciente y relevante sobre HPL y/o LPL en RIRS fue evaluada para una revisión monográfica. RESULTADOS: Los HPL y algunos LPL más recientes permiten al cirujano ajustar la duración del pulso, por lo tanto, al configurar un pulso largo, alta frecuencia y baja energía, se puede lograr una verdadera pulverización. Los LPL no pueden alcanzar la misma emisión de energía que los HPL. La retropulsión aumenta si la energía de pulso es mayor, entonces, se previene la retropulsión al incrementar la emisión total de energía mediante el incremento de la frecuencia. El costo de adquisión de los HPL es considerablemente mayor que el de los LPL, sin embargo, el costo a largo plazo pudiera ser similar pues los procedimientos pueden abaratarse al disminuir el uso de insumos para recuperar los litos, preservar la punta de las fibras reutilizables y disminuir el tiempo quirúrgico. CONCLUSIONES: La evidencia no favorece la efectividad de los HPL o LPL de modo abrumador. Ambos dispositivos son efectivos y seguros. No cabe duda de que los HPL alcanzan mayor emisión de energía que los LPL, pero los dispositivos de 50-80 Watts, tienen emisiones de energía que rara vez se alcanzan para litotricia y por lo tanto pudiera considerarse demasiada energía. A medida que nuevas tecnologías han surgido, la brecha entre LPL y HPL se amplía, dejando espacio para una clasificación de poder intermedio (36-55 Watts) y la comparación entre estos dispositivos sería más justa. Asimismo, los HPL aún necesitan ser contrastados en el escenario clínico, con las nuevas tecnologías disponibles, tal como la fibra de laser tulio

Endourologic Treatment of Late Migration of Embolization Causing Nephrolithiasis in Two Patients.

Background: Selective renal artery angioembolization is the first treatment option in case of significant bleeding after percutaneous nephrolithotomy. Migration of embolization material into the collecting system is extremely rare. The treatment of this condition is not standardized, but manual extraction, ultrasound fragmentation, and holmium laser lithotripsy have been described. Case presentation: We report the laser extraction of these coils in two patients at our center with two different approaches: retrograde intrarenal surgery (RIRS) and endoscopic combined intrarenal surgery (ECIRS). They were young male patients aged 25 and 29 years at the time of surgery, and they were 2-5 years postembolization when they presented to our center for symptoms such as hematuria and passage of small stone fragments. The first patient was managed solely with RIRS, whereas the second patient required ECIRS because of significant bleeding after coil removal, which necessitated hemostasis using a resectoscope. Conclusion: For patients who present with recurrent stones or other symptoms such as pain, hematuria, or flank pain, the diagnosis of migrated embolization coils should be considered. Management can be via the retrograde or percutaneous approach, but in the setting of significant amount of migrated coils or significant bleeding after their removal, percutaneous access may allow more definitive hemostasis.