Journal of Endourology

To explore the value of vessel wall MRI (VW-MRI) in the preoperative assessment of T3 renal-cell carcinoma (RCC) with varying degrees of longitudinal venous system invasion.

Patients with RCC with pathological T3 stage between January 2016 and December 2023 were included in this retrospective study. All the patients underwent contrast-enhanced CT (CECT), conventional MRI (con-MRI) or VW-MRI. Images were independently and blindly evaluated at 4-week intervals by three readers. The pathological features reported in the pathological report, combined with clinical data, were used as the reference standards. The incremental value was calculated using net reclassification improvement (NRI) and integrated discrimination improvement.

Eighty-two T3 RCC patients (median age, 65 years) were enrolled. The accuracy of T staging in CECT (n = 59), con-MRI (n = 49), and VW-MRI (n = 30) was 69.5%, 71.4%, and 93.3%, respectively. VW-MRI had a statistically incremental value for CECT in the preoperative evaluation of T3a–c stages (T3a: NRI = 0.066, p = 0.04. T3b: NRI = 0.085, p = 0.02. T3c: NRI = 0.178, P = 0.02), especially in renal pelvicaliceal invasion (NRI = 0.154, p = 0.04) and vena cava wall invasion (NRI = 0.263, p = 0.01). Besides, statistically significant preoperative incremental effects were obtained in the assessment of T3a-c stages (T3a: NRI = 0.264, p = 0.01. T3b: NRI = 0.373, p = 0.03. T3c: NRI = 0.202, p = 0.045), renal vein invasion (NRI = 0.630, p = 0.03), and vena cava wall invasion (NRI = 0.185, p = 0.02) when added VW-MRI into con-MRI. VW-MRI changed 24% (4/27) of the previous CECT and con-MRI-based surgical plan.

VW-MRI added a preoperative value for evaluating T stage of T3 RCC, especially in the evaluation of renal vein invasion and vena cava wall invasion.

We aim to compare the clinical outcomes of radical nephroureterectomy with bladder cuff removal (RNU) and segmental resection with ureteral reimplantation (RR) in Chinese patients with distal ureteral urothelial carcinoma.

A retrospective analysis of medical records was performed for 922 patients found to have distal ureteral cancer, defined as below the level of the iliac vessels, with 747 patients who underwent RNU and 175 who underwent RR included in the final analysis. The primary endpoints included clinical outcomes and changes in the estimated glomerular filtration rate (eGFR). Survival analysis was conducted using the Kaplan–Meier method, and propensity score matching (PSM) was utilized to mitigate selection bias between the two surgical approaches.

After PSM, the Kaplan–Meier survival curves demonstrated significant associations between surgical approach and both local recurrence-free survival (LRFS) and bladder recurrence-free survival (BRFS), but no significant differences were found in cancer-specific survival (CSS) and overall survival (OS). There were no significant differences in metastasis-free survival and contralateral recurrence-free survival between the two groups. Multivariate Cox regression analysis identified RR as an independent predictor of poorer outcomes for LRFS and BRFS. In addition, a significant increase in eGFR was observed following RR, whereas a significant decrease was noted after RNU.

RR is associated with equivalent CSS and OS compared with RNU, even in the context of high-risk distal ureteral cancer, and results in improved postoperative eGFR, whereas the potential of RR to increase the risk of local tumor recurrence and intravesical recurrence requires clinical consideration.

The KangDuo Surgical Robot-1500 (KD-SR-1500) is a newly developed surgical robot. We aim to evaluate the feasibility and efficiency of the KD-SR-1500 system for robot-assisted radical prostatectomy (RARP).

This prospective, multicenter, single-arm clinical study was conducted among 18–75-year-old patients with suspected T1-2N0M0 prostate cancer scheduled for RARP. The perioperative and follow-up data were prospectively recorded. Early oncologic outcomes were assessed according to surgical margin status and prostate-specific antigen (PSA) at 6 weeks after surgery. Continence was defined as no more than one pad daily. Ergonomics were assessed with the National Aeronautics and Space Administration task load index (NASA-TLX). Perioperative complications were recorded according to the Clavien–Dindo classification.

A total of 31 patients were involved in the trial. One patient with severe abdominal adhesion withdrew from the trial. All surgeries were performed successfully without any conversion or secondary surgery due to surgical complications. The median docking time and console time were 3.8 (3.3–5.2) and 104.6 (80.0–145.6) minutes, with a median estimated blood loss of 50 (20–100) mL. Positive surgical margin was observed in 6 (20%) patients. One (3.4%) patient experienced PSA persistence at 6 weeks after surgery. The urinary continence rate was 75.9% (22/29) at 4 weeks after catheter removal. There were no major complications (grade ≥ III) or equipment-related adverse events. The mean NASA-TLX score was 23.9 ± 11.7.

The KD-SR-1500 is feasible and effective for the management of T1-T2 prostate cancer.

To analyze the association of patient characteristics on operating room (OR) times for robotic-assisted partial nephrectomies (RAPNs).

In total, 248 consecutive RAPNs were performed by a single surgeon from October 2018 to August 2022. Data were collected on the following patient factors: sex, age, race, weight, body mass index (BMI), diabetes, hypertension (HTN), tumor side, tumor mass, and American Society of Anesthesiologists (ASA) score. Total fixed OR times were evaluated as the sum of in-room time to anesthesia-release time (IRAT), anesthesia-release time to cut time (ARCT), close time to wheels out time (CTWO), and in-room time to cut time (IRAT + ARCT). Total variable OR times were defined as cut time to close time (CTCT). Total operative time was defined as wheels into wheel out (WIWO).

Median OR time was 265 minutes (interquartile range [IQR]: 247–298 minutes) for WIWO, 191 minutes (IQR: 170–225 minutes) for CTCT, and 75 minutes (IQR: 68–83 minutes) for total fixed time. There was a significant increase in WIWO with the following patient variables: male sex (18.0 minutes, 95% confidence interval [CI]: 6.3–29.7 minutes), weight (5.6 minutes, 95% CI: 2.8–8.4 minutes), BMI (14.3 minutes, 95% CI: 4.2–24.4 minutes), HTN (15.1 minutes, 95% CI: 3.7–26.5 minutes), pathology tumor size (cm) (6.4 minutes, 95% CI: 2.2–10.6 minutes), and ASA score (13.8 minutes, 95% CI: 3.1–24.4 minutes). Sex, age, BMI, weight, HTN, and pathology tumor size significantly impacted CTCT (P < 0.05). Total fixed OR time was only affected by ASA score (P = 0.02).

Patient variables significantly affect total OR time and variable OR time. These variables do not impact total fixed OR times, confirming fixed OR time as a viable OR efficiency point.

To test whether the contemporary robot-assisted nephroureterectomy (RNU) is associated with more favorable in-hospital outcomes than historical RNU, relative to the same endpoints in open NU (ONU).

Within the National Inpatient Sample (2008–2019), we identified RNU and ONU patients. Multivariable logistic and Poisson regression models were fitted.

Of 8032 NU patients, historical (2008–2013) vs contemporary (2014–2019) proportions were 776 (41%) vs 1104 (59%) for RNU and 3719 (60%) vs 2433 (40%) for ONU. The rates of RNU have increased over time (2008–2019; Δ absolute: +18%; p < 0.001). Contemporary RNU patients exhibited significantly better in-hospital outcomes in 6 of 12 comparisons vs historical that ranged from −54% for genitourinary complications to −12% for median length of stay (LOS). Contemporary ONU patients also exhibited significantly better in-hospital outcomes in 11 of 12 comparisons vs historical that ranged from −67% for blood transfusions to −26% for gastrointestinal complications. When historical RNU was compared with historical ONU, RNU in-hospital outcomes were better in 7 of 12 comparisons that ranged from −61% for median LOS to −16% for postoperative complications. Conversely, when contemporary RNU was compared with contemporary ONU, RNU in-hospital outcomes were only better in 2 of 12 comparisons: −25% cardiac complications and −13% for median LOS.

The magnitude of in-hospital outcomes categories improvement between historical vs contemporary was two-fold more pronounced in ONU (11 improved categories) than in RNU (6 improved categories). Few outcome benefits remained (two categories only) when contemporary RNU was compared with contemporary ONU.

To evaluate the efficacy and safety of a novel tip-flexible suction ureteral access sheath (NTFS-UAS) combined with flexible ureteroscopic lithotripsy (FURS) for treating kidney stones ≥30 mm in a large cohort.

The clinical data of 206 patients with renal calculi ≥30 mm treated by NTFS-UAS combined with FURS from June 2021 to September 2023 were analyzed retrospectively. The outcomes under investigation encompassed demographic information, stone-related characteristics, operative time, stone-free rates (SFRs), and postoperative complications.

The median operation duration was 110 minutes (interquartile 84.00–146.25 minutes). Immediate and 1-month SFRs were 83.98% and 85.44%, respectively. Multivariate analysis revealed five risk factors independently affecting stone clearance rate: stone size (≥50 mm, odds ratio [OR] = 3.826, p = 0.039), stone number (multiple: OR = 8.745, p = 0.015), stone location (multiple calyces: OR = 10.371, p = 0.045; lower calyx: OR = 9.615, p = 0.047), severe hydronephrosis (OR = 8.338, p = 0.002), and the Resorlu-Unsal scoring system (RUSS) score (6–7: OR = 10.829, p = 0.009; 4–5: OR = 4.223, p = 0.008). The incidence of Clavien–Dindo grade II–III complication was 5.82%. Positive preoperative urine culture (OR = 9.533, p = 0.012) and RUSS score (6–7: OR = 25.678, p = 0.026; 4–5: OR = 11.444, p = 0.038) were identified as the most important variables that may contribute to the development of high-grade postoperative complications.

NFTS-UAS combined with FURS achieved satisfactory outcomes with good efficacy and safety for treating large renal stones ≥30 mm, and it can be utilized as an effective treatment option for patients having contraindications or preference against percutaneous nephrolithotomy. In addition, clinical factors, such as stone size, severe hydronephrosis, positive preoperative urine culture, and RUSS stone score that likely affected the outcomes of NFTS-UAS, should be fully taken into account when the surgeon performing FURS using NFTS-UAS.

This study aims to assess the outcomes of ultrasonography (US)-guided minimally invasive percutaneous nephrolithotomy (PCNL) in the treatment of pediatric urolithiasis.

A retrospective analysis was conducted on 176 patients with pediatric renal and upper ureteral lithotripsy who underwent PCNL between August 2006 and July 2022. The cohort comprised 110 men and 66 women, with ages ranging from 6 months to 16 years. Postoperative stone clearance was evaluated using kidney, ureter, and bladder radiograph or US, categorizing stones less than 4 mm as clear. Postoperative complications were graded according to the Clavien–Dindo classification, with grades I and II considered minor and III and IV classified as major.

Among the patients, 152 underwent unilateral renal operation, whereas 24 underwent bilateral renal operation. The average operation duration was 67.41 minutes (range: 15–195 minutes). The mean duration of nephrostomy tube removal was 3.79 days, and the mean postsurgical hospital stay was 5.97 days. A total of 146 patients experienced a decrease in hemoglobin concentration post operation, with an average drop of 10.57 g/dL (range: 0.5–37.8 g/dL). Initial stone-free rate (SFR) was achieved in 85.5% (171/200) of cases, and the final SFR was 92.50% (185/200). The postoperative rate of minor complications was 8.54% (17/199), whereas major complications occurred in 12.06% (24/199) of cases. During the 6-month to 11-year follow-up period, 19 patients presented with combined stones, and of these 4 presented with ipsilateral stone recurrence who underwent PCNL treatment. Calcium oxalate was identified as the most common stone component.

US-guided minimally invasive PCNL demonstrated excellent SFR and an acceptable complication rate in the management of pediatric urolithiasis. Furthermore, it offers the advantage of minimizing potential risks associated with radiation exposure during the procedure.

Encrustation significantly affects the lifespan of Allium stents. Currently, there is no established treatment for Allium ureteral stent encrustation. This study introduces a method for treating these encrustations using a flexible ureteroscopy (F-URS) combined with a novel ultra-flexible ureteral access sheath (UF-UAS).

We retrospectively analyzed patients treated for Allium stent encrustation with UF-UAS from January 2022 to January 2024. Patients with transplanted kidneys were excluded. The UF-UAS features a 10 cm ultra-flexible distal segment, allowing passive deflection beyond 270° during F-URS. This segment, devoid of wire reinforcement, is made of a silicone composite for optimal pliability. The primary endpoints focused on complications such as damage and migration of the Allium stent.

A total of 15 consecutive patients (4 men) underwent the procedure. The cohort included 3, 9, and 3 patients with Allium stents measuring 6, 8, and 10 cm, respectively. Mean preoperative stent dwell time was 19.9 months. Preoperative urine cultures were positive in seven patients. Mean operative time was 33.8 minutes. Three patients (20.0%) required a Double-J stent postoperatively. No instances of Allium stent damage were observed. One patient with ≤2 mm fragments and one patient with 2.1–4 mm fragments within the renal. One patient experienced a 1.5 cm Allium migration one day postoperatively. At 3 months, no Allium migration and increased hydronephrosis were observed.

The novel UF-UAS facilitated the effective and safe removal of stones, encrustations, and biofilms from Allium ureteral stents. This method may extend the stent lifespan and reduce the need for stent exchanges.

Iatrogenic lesions of the distal ureter represent a frequent and feared complication of abdominal surgery that is traditionally managed by ureteral reimplantation. The aim of this systematic review (SR) is to summarize the published literature on the role of minimally invasive ureteroureterostomy (UU) in the surgical treatment of non-neoplastic distal ureteral lesions.

We performed a comprehensive literature search on PubMed, Embase, and Cochrane CENTRAL including published peer-reviewed studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The intra-, peri-, and postoperative outcomes as well as the safety profile and the success rates of minimally invasive UU are presented.

Seven retrospective studies with 116 patients were included in this SR. If the basic principles of the ureteral reconstructive procedure are followed, both laparoscopic and robotic UU are feasible, safe, and with a success rate ranging between 81.8% and 100%, depending on the definition of success. A single comparative study documented a significant difference in operative time and length of hospitalization in favor of robotic UU. The success of both laparoscopic and robotic UU has been mainly evaluated in the short and intermediate follow-up.

Minimally invasive UU may represent a viable treatment option for the treatment of non-neoplastic distal ureter pathology such as iatrogenic injuries or radiotherapy-induced stenosis. Larger, prospective studies adopting a standard definition of the postoperative success are required to affirm UU as a first-line option in the management of benign distal ureteral lesions.

To evaluate the efficacy of preserving urethral mucosa around verumontanum in all directions and at the prostatic apex on antegrade ejaculation preservation and early postoperative continence in patients undergoing transurethral resection of the prostate (TURP).

A randomized controlled trial was conducted in our tertiary center on patients scheduled for TURP. Patients were randomly allocated into two equal groups. Group A represented the control group who underwent conventional TURP, while Group B represented the ejaculation-sparing TURP. Patients were followed up for 3 months postoperatively to evaluate the voiding parameters and the preservation of antegrade ejaculation.

A total of 106 patients were evaluated in our study. Both groups were comparable regarding improvement in voiding parameters. Antegrade ejaculation was preserved in 44 patients (83%) of Group B compared with 10 patients (18.9%) in Group A with a highly statistically significant difference (p < 0.001). Early postoperative urge urinary incontinence was lower in group B (5.7%) compared with (20.8%) in group A, with a statistically significant difference (p = 0.02). Other perioperative parameters were compared between both groups.

The ejaculation-sparing technique adopted in our study showed a promising result for preserving antegrade ejaculation following TURP with a success rate of 83%. Additionally, there was a lower incidence of early postoperative urge urinary incontinence.

Excessive kidney mobility is an underestimating challenge for surgeons during retrograde intrarenal surgery (RIRS) and extracorporeal shock wave lithotripsy (ESL). There is no technique approved as a gold standard procedure for reducing excessive kidney mobility. The study aimed to uncover predictive factors for determining excessive renal mobility by utilizing clinicodemographic characteristics and noncontrast computed tomography (NCCT) data.

The patients were categorized into two groups based on the presence of excessive renal mobility. Patients were scanned with a 16-channel, multislice NCCT, and images were captured utilizing a 16 × 1.25 mm collimation, 5 mm slice thickness. Many parameters including the origin angle of the renal artery, renal artery, vein length, diameter, the area and length of the psoas muscle, and perirenal and pararenal fatty tissue were measured on the images and analyzed. The data were analyzed using multivariate logistic regression, and the receiver operating characteristic curve model and we used predictive modeling based on three significant parameters.

Between May 2023 and May 2024, a total of 140 patients with and without excessive renal mobility enrolled into study. After multivariate analysis, increasing renal vein length and renal artery origin angle results in higher renal motility (odds ratio [OR]: 0.982; 95% confidence interval [CI]: 0.966–0.998; p = 0.030 and OR: 0.973; 95% CI: 0.948–0.999; p = 0.044; respectively). It also observed that an increase in tidal volume led to a reduction in renal mobility (OR: 1.015; 95% CI: 1.007–1.024; p = 0.001). Predictive modeling was designed based on these outcomes. This predictive modeling accurately estimates the presence of excessive renal mobility with improved 59% specificity and 65% sensitivity (p < 0.001, area under the curve 0.757; CI: 0.671–0.843).

Physicians may predict the presence of excessive renal mobility via the predictive modeling mentioned in the current article. They may perform manipulations to reduce kidney mobility prior to ESL and RIRS.

Several diagnostic and therapeutic endoscopic urological procedures, such as stent placement, ureteroscopy, and bladder stone lithotripsy, can be performed in a hospital, an ambulatory surgery center, in the office with IV sedation, or in the office using only topical anesthesia. The potential benefits of performing procedures in the office setting using topical anesthesia include efficiency and cost reduction. The potential harms are failure to achieve the desired outcome and patient pain. The purpose of our study was to assess the feasibility, safety, pain tolerance, and cost-effectiveness of advanced office endourological procedures.

All patients from September 2022 to July 2023 undergoing certain office-based endoscopic procedures under topical anesthesia, including ureteral stent placement for obstruction, ureteral stent exchange, ureteroscopy with laser lithotripsy, ureteroscopy with tumor ablation, laser ablation of multifocal bladder tumors, laser lithotripsy of bladder stones, nephrostomy tube exchange, and ureteral catheterization for chemotherapy instillation or retrograde ureteropyelography, were prospectively enrolled and evaluated. At the end of every procedure, visual analog scale (VAS) score and procedure location preference were assessed. Complications and facility costs were also assessed.

A total of 80 endoscopic procedures were performed, including 11 bladder procedures, 9 ureteroscopies, and 60 stent and nephrostomy procedures. The mean VAS pain score for bladder procedures was 2.4, ureteroscopy procedures 3.9, and stent and nephrostomy procedures 3.3. Patients undergoing bladder and stent/nephrostomy procedures unanimously expressed a preference for the in-office setting. The office setting was also largely preferred in the ureteroscopy procedure cohort (77.8%). There were eight postprocedure calls and two ED visits. One complication and one failed stent placement occurred. Procedure cost savings ranged from $5,309 to $6,009.

Performing certain endoscopic urological procedures in an office setting with only the use of topical anesthesia is feasible, safe, well tolerated, and cost-effective when compared with performing these procedures in the operating room or with general anesthesia.

To develop and validate a high-fidelity, nonbiohazardous simulator model for the ultrasound-guided percutaneous nephrolithotomy procedure.

We employed a systematic framework based on Delphi consensus and modern education theory to design a simulation model. Twelve expert surgeons provided input through a hierarchal task analysis and identified procedural tasks, anatomical landmarks, and potential errors. These were translated into engineering deliverables by a team of biomedical engineers and surgical educators. A prototype was developed using three-dimensional printing and hydrogel molding, followed by expert validation through recorded simulations and subsequent multicenter trails with 48 participants.

A hydrogel prototype with realistic anatomical features was created using results from the Delphi process. It received positive feedback in areas such as anatomy, procedural fidelity, and education effectiveness, with overall high satisfaction ratings. Validation studies showed a significant difference in performance between novices and experts. Residents demonstrated significant skill improvement and retention after repeated simulations.

The developed simulator provides a realistic, effective training tool for urologic education, addressing the need for safer and more accessible surgical training modalities.