Journal of Endourology

To determine the incidence, risk factors, and clinical predictors of subcapsular renal hematoma (SRH) and perirenal hematoma (PRH) after ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) using a structured multilevel evidence synthesis (Rare Events Valuation through Evidence-based And Layered synthesis [REVEAL] framework).

A systematic review and multilevel analysis were conducted according to PRISMA and a registered protocol (PROSPERO CRD420251085350). Literature searches (2000–2025) identified studies reporting SRH/PRH after URS/RIRS. A three-step framework was applied: meta-analysis (MA) of incidence using generalized linear mixed-effects models; MA of risk factors from comparative studies; and individual patient data (IPD) synthesis from case series and reports, followed by prognostic model development and nomogram construction.

Fifteen studies, including 23,258 patients and 74 hematomas, were included. The pooled incidence of SRH/PRH was 0.42% (95% confidence interval: 0.22–0.79%), with slightly higher rates after RIRS (0.8%) compared with URS (0.4%). Stone size, longer operative time, hydronephrosis, and elevated intrarenal pressure were associated with increased risk. IPD analysis of 54 patients identified fever as the strongest predictor of unsuccessful conservative management. A multivariable model incorporating age, fever, hematoma length, hemoglobin drop, and time to presentation achieved strong discrimination and was translated into a prognostic nomogram to estimate individualized risk.

SRH and PRH are rare but clinically significant complications of URS and RIRS. Using the REVEAL framework, we integrated heterogeneous evidence, identified technical and clinical risk factors, and developed the first prognostic tool for individualized risk stratification. Validation in multicenter prospective studies is required before clinical implementation.

Endoscopic combined intrarenal surgery (ECIRS) has emerged as a significant advancement in the management of patients with a high stone burden or large, complex stones. This technique has been reported to improve the stone-free rate (SFR) while reducing complications commonly associated with percutaneous nephrolithotomy (PCNL). However, most available evidence comes from single-center studies with relatively small cohorts. We conducted a systematic review and meta-analysis to compare perioperative outcomes between the two procedures.

A systematic search of PubMed, Embase, and Scopus databases was conducted to identify both randomized and nonrandomized studies comparing ECIRS and PCNL. Primary outcomes included SFR after a single session, need for ancillary treatments, and major complications (Clavien–Dindo grade ≥3). Secondary outcomes were transfusion rates, operative time, and hospital stay. Random-effects models were applied when heterogeneity was high (I² > 50%). Results were expressed as odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs).

Fifteen studies (12 retrospective and 3 randomized) involving 1988 patients were included. A significantly higher SFR (OR 3.02, 95% CI: 2.40–3.80; p < 0.001) and a lower need for ancillary procedures (OR 0.20, 95% CI: 0.13–0.31; p < 0.001) were observed with ECIRS. Similarly, a lower rate of major complications (OR 0.58, 95% CI: 0.34–0.97; p = 0.03) and transfusions (OR 0.49, 95% CI: 0.28–0.88; p = 0.01) also favored ECIRS. Operative time (MD −9.25 minutes, 95% CI: −16.82 to −1.67; p = 0.01) and hospital stay (MD −1.61 days, 95% CI: −2.54 to −0.69; p = 0.0006) were significantly longer in the PCNL group.

ECIRS achieved higher single-session SFRs without increasing major complications or transfusion rates. This technique may also reduce operative time and hospital stay, particularly when performed by experienced endourologists. Given that most included studies were retrospective, further randomized trials are required to strengthen the evidence base and better define the clinical role of ECIRS.

Iatrogenic ureteral injuries following ureterorenoscopic (URS) stone surgery are significant complications that can occur despite the preserved structure of the urinary tract. This study aimed to evaluate the demographic characteristics, types of injuries, timing of diagnosis, and outcomes of treatment methods in patients with iatrogenic ureteral injury after URS.

Patients with iatorogenic ureteral injury during URS were included based on retrospective data collected from 19 centers across Turkey between November 2010 and December 2022. Demographics, location, and grade of injury, time of diagnosis, and success rates of endourological or reconstructive surgical interventions were analyzed. Surgical success was defined as the absence of postoperative complications and no need for further surgical intervention.

Of the 105 patients, 65 were males and 40 females, with a median age of 48 years (20–86). Injuries occurred in the distal ureter in %60, mid-ureter in %18.1, and proximal ureter in %21.9 of cases. Laceration accounted for %64.7 of the injuries, whereas %35.3 occurred during laser use. Diagnosis was made intraoperatively in %21 and postoperatively in %79 of patients, with a median time to postoperative diagnosis of 30 days (1–720). Higher body mass index was associated with lower primary surgical success (p = 0.049). The most common initial treatment was ureteral stent placement. Reconstructive surgeries had lower rates of secondary interventions or complications compared to endourological procedures (p = 0.045). Among patients necessitating a second surgery, those who underwent reconstructive surgery had significantly lower tertiary intervention or complication rates (p < 0.001). Nephrectomy was required in six patients because of renal atrophy.

Early diagnosis is crucial in iatrogenic ureteral injuries after URS. Elevated BMI may negatively affect surgical outcomes. Although endourological approaches are commonly used initially, reconstructive surgeries offer more durable outcomes, especially in severe injuries or failed primary treatments, underscoring the need for individualized management strategies.

Endourologic procedures for ureteral/renal stones traditionally rely on fluoroscopic guidance. The necessity of fluoroscopy for safe and effective stone treatment remains controversial.

To perform a systematic review and meta-analysis to evaluate intraoperative, perioperative, and postoperative outcomes of fluoroless vs fluoroscopy-guided endourologic procedures for kidney and/or ureteral stones.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, we searched PubMed, Cochrane Central Register, and Scopus on 13^th November 2025. Inclusion criterion comprised randomized trials comparing fluoroless with fluoroscopy-guided ureteroscopy (URS) or percutaneous nephrolithotripsy (PCNL). Binary outcomes were assessed using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% confidence interval (CI), and p-values. Continuous variables were pooled using the inverse variance of the mean difference with a random effect. Statistical significance was set at p < 0.05.

Eighteen randomized studies were included: 7 URS studies (1119 patients) and 11 PCNL studies (1370 patients). For PCNL, fluoroless ultrasound-guided techniques demonstrated superior safety with significantly lower overall complications (OR 0.57, 95% CI 0.42–0.78, p = 0.0004), minor complication- (OR 0.60, 95% CI 0.41–0.86, p = 0.006), and major complication- rates (OR 0.52, 95% CI 0.30–0.88, p = 0.02) compared with fluoroscopy-guided approaches. Stone-free rates (SFRs) were equivalent between groups (OR 1.03, 95% CI 0.77–1.38, p = 0.83). For URS, fluoroless approaches showed comparable overall complications (OR 1.08, 95% CI 0.81–1.45, p = 0.60), major complications, SFR (OR 0.89, 95% CI 0.65–1.19, p = 0.47), and reintervention rates. Flexible fluoroless URS demonstrated fewer minor complications (OR 2.09, 95% CI 1.43–3.06, p < 0.0001). Mean surgical time increased minimally for fluoroless URS (1.60 minutes, p = 0.03).

Fluoroless ultrasound-guided PCNL demonstrates superior safety with maintained efficacy compared with fluoroscopy-guided techniques. Fluoroless URS shows equivalent safety and efficacy with minimal operative time differences. These findings support transitioning from fluoroscopy-dependent to fluoroscopy-optional endourology, aligning with radiation safety principles while maintaining optimal patient outcomes.

Pediatric nephrolithiasis continues to pose a substantial clinical challenge in pediatric urology because of its elevated recurrence rate and elevated morbidity with risk of end-stage renal failure. The management of pediatric nephrolithiasis involves dietary modification, pharmacological therapy, and urological intervention, with the choice of treatment guided by stone size, location, and composition.

To evaluate the efficacy and safety of mini-percutaneous nephrolithotomy (mini-PCNL) and extracorporeal shock wave lithotripsy (SWL) for the management of renal stones measuring 1–2 cm in pediatrics.

This prospective, randomized comparative research was conducted at the Department of Urology, Al-Azhar University Hospital, Assiut, Egypt, between December 2022 and November 2024. Sixty children with single renal stones were enrolled, with 30 undergoing SWL and 30 receiving mini-PCNL.

Mini-PCNL achieved a significantly elevated stone-free rate (SFR, 93.33%) in contrast with SWL (33.33%) (p < 0.001). The SWL group also showed a higher rate of auxiliary approaches and retreatment. Overall complication rates were comparable.

Mini-PCNL is more effective than SWL for managing renal stones measuring 10–20 mm in children aged 6 months to 6 years. It provides an elevated SFR and lowers the likelihood of retreatment and hospital readmission, with a comparable safety profile.

To evaluate the effects of renal parenchymal thickness (RPT) and tract length (TL) on the stone-free rate (SFR) and complications in pediatric patients who underwent minimally invasive percutaneous nephrolithotomy (mini-PCNL).

The data of pediatric age group (<18 years) patients who underwent mini-PCNL between 2017 and 2025 in our clinic, which is a tertiary referral center, were retrieved. Eighty patients were included in this study. SFR was determined using low-dose nonenhanced CT in all patients 1 month after procedure. Stone-free status was defined as the complete absence of stones, and the presence of any stone fragment, regardless of size, was defined as residual stone.

The mean stone diameter was 22.8 mm, and the mean stone burden was 402 mm². Although 46.3% of the stones were located only in the renal pelvis, 32.5% were staghorn. Mean RPT was 13.6 ± 5.0 mm, TL was 33.0 ± 10.5 mm, and RPT/TL ratio was 0.42 ± 0.13. Complications occurred in 27.5% of the patients. No major (grade 4–5) complications were observed in any patient. After mini-PCNL, stone-free status was achieved in 65% of patients. The mean diameter of residual stone was 3.4 ± 5.9 mm. When comparing patients who were stone free and those with residual stones, RPT (p = 0.059), TL (p = 0.315), and RPT/TL ratio (p = 0.563) were similar between groups. When patients with and without complications were compared, no statistically significant difference was found between the two groups in RPT (p = 0.084), TL (p = 0.589), and RPT/TL ratio (p = 0.723).

Mini-PCNL appears to be an effective and safe surgical technique that can be applied in pediatric patients with kidney stones, regardless of RPT and TL; however, prospective multicenter studies are necessary to confirm our results in a larger number of patients.

Participation in a clinical trial has been shown to influence medical adherence. We compared postoperative imaging completion and office visit attendance between patients enrolled in the Pediatric KIDney Stone (PKIDS) Trial and those who were not at two participating institutions. We hypothesized that study enrollment would improve adherence to postoperative follow-up.

A retrospective review of patients (8–21 years) undergoing kidney stone surgery during the PKIDS study period was performed at two geographically different PKIDS institutions. Medical records were reviewed for completed imaging and follow-up office visits. The primary outcome was postoperative imaging acquisition within 8 weeks of surgery in alignment with the PKIDS protocol. Secondary outcomes included imaging acquisition by 16 weeks and postoperative office visit attendance by 8 and 16 weeks. Multivariable logistic regression assessed factors influencing adherence.

A total of 181 patients were included: 120 PKIDS vs 61 non-PKIDS. 51.9% of patients completed imaging at 8 weeks. PKIDS enrollment was not associated with imaging acquisition at 8 weeks or any secondary outcomes on univariate or multivariable analyses. A higher national Area Deprivation Index percentile (i.e., higher neighborhood-level deprivation) was associated with lower imaging acquisition on multivariable analysis (Odds ratio [OR] 0.98, 95% confidence interval [CI]: 0.97–0.99, p = 0.03). Conversely, private insurance was associated with higher attainment of imaging (OR 2.36, 95% CI: 1.09–5.12, p = 0.03) and office visit attendance within 16 weeks (OR: 3.08, 95% CI: 1.42–6.69, p < 0.01). There were no variables associated with 8-week postoperative office visits.

PKIDS trial enrollment was not associated with increased adherence to postoperative follow-up in two geographically different PKIDS sites. This study supports the generalizability of the PKIDS study to non-PKIDS participants and future use of the PKIDS dataset to examine determinants of postoperative care in pediatric kidney stone disease.

A 24-hour urine collection is central to the metabolic evaluation and prevention of nephrolithiasis. Despite its widespread use, methodological inconsistencies in data reporting and analysis limit the reliability, reproducibility, and clinical utility of findings. We aim to review and evaluate how 24-hour urine parameters are reported, analyzed, and interpreted in nephrolithiasis research.

We conducted a methodological review of 264 studies involving 450,624 patients with nephrolithiasis. Data extraction covered urine collection protocols, parameter reporting, units used, statistical methods, and missing data handling.

Retrospective cohort studies comprised 42.8% of included articles; cross-sectional and prospective cohort studies made up 25.0% and 19.3%, respectively. Only 6.8% (18/264) of studies reported power calculations, and 40.9% (108/264) provided reference ranges. Calcium was the most frequently reported parameter (93.9%), followed by citrate (87.5%), oxalate (86.7%), and uric acid (84.1%). Supersaturation indices were reported in 44.3% of studies. Reporting formats varied: continuous units were used in 94.7% for supersaturation, 91.7% for calcium/creatinine ratio, and 77.9% for calcium. Most common units were mg/day (e.g., calcium: 78.9%) and mmol/day (e.g., sodium: 56.9%). Regarding statistical analysis, 72.3% of studies used t-tests or Mann–Whitney U tests, 39.4% used chi-square tests, and only 21.6% used multivariate regression. Missing data were handled by complete case analysis in 71.2% of studies, while 27.7% did not report their approach.

There is significant variability in how 24-hour urine data are reported and analyzed across nephrolithiasis studies. This inconsistency undermines evidence synthesis, limits external validation, and obstructs the integration of advanced tools like artificial intelligence. We recommend creating a standardized reporting checklist to improve the rigor, reproducibility, and clinical relevance of future research.

To critically appraise the Radius, Exophytic/endophytic, Nearness of tumor to collecting system or sinus, Anterior/posterior, Location relative to polar lines (R.E.N.A.L.), Preoperative Aspects and Dimensions Used for an Anatomical classification (PADUA), and Radius, Position, iNvasion of sinus (RPN) nephrometry systems with respect to their classification of tumor complexity for surgical planning in robot-assisted partial nephrectomy (RAPN) and to compare their statistical validity, methodological rigor, and predictive performance.

A structured synthesis of published evidence identified large multicenter series, prospective cohorts, and meta-analyses from 2009 to 2025 that evaluated the predictive accuracy, methodological design, and clinical relevance of these systems. Key evaluation domains included statistical validation, anatomical parameter selection, and correlation with surgeon-perceived difficulty in RAPN.

Both the R.E.N.A.L. and PADUA scores were developed using empirically selected parameters and have historically been validated based on their correlation with perioperative outcomes. However, evidence in the literature now shows that such correlations are inconsistent and often clinically irrelevant in RAPN. In contrast, the RPN score was developed using a statistically modeled approach, reflecting the real-world surgical difficulty of RAPN as perceived by experienced robotic surgeons.

Current evidence does not support the continued use of R.E.N.A.L. and PADUA scores as validated tools in RAPN. The RPN score, with its statistically validated, anatomy-based methodology and alignment with surgical difficulty, represents a scientifically superior and clinically practical alternative for standardizing tumor complexity in RAPN.

To perform a systematic review and meta-analysis to assess the incidence of acute urinary retention (AUR)/failure to void after transurethral surgeries for benign prostatic enlargement, comparing Ablation, Enucleation, and Resection (TURP) techniques.

A systematic literature search was performed on October 13, 2025 using Cochrane Central Register of Controlled Trials, PubMed, and Scopus. We only included randomized studies comparing monopolar TURP (M-TURP) or bipolar TURP (B-TURP) vs Ablation vs Enucleation procedures. Incidence of AUR/failure to void following the index surgery was evaluated using the Cochran–Mantel–Haenszel method and reported as risk ratio (RR), 95% confidence interval (CI), and p values. Statistical significance was set at p < 0.05.

A total of 61 studies were included, with 1497 patients in the Enucleation, 2512 patients in the Ablation, and 4007 patients in the TURP groups. The pooled incidence of AUR/failure to void was 3.7% (72/1944 patients) after M-TURP, 3.0% (47/1553 patients) after B-TURP, 9.0% (226/2512 patients) after Ablation, and 2.4% (36/1497 patients) after Enucleation. Meta-analysis showed no significant difference between Enucleation and TURP (RR 0.90, 95% CI 0.61–1.32, p = 0.59; I² = 0%) in AUR/failure to void rate. Conversely, Ablation was associated with a significantly higher incidence of AUR/failure to void compared with TURP (RR 1.79, 95% CI 1.38–2.31, p < 0.001; I² = 22%). Subgroup analyses revealed that this difference persisted for diode laser (RR 4.53, 95% CI 1.24–16.47), monopolar electrovaporization (RR 3.24, 95% CI 1.90–5.55), and Neodymium (Nd):YAG laser/RR 2.61, 95% CI 1.54–4.42) ablation techniques. No significant difference was found between M-TURP, B-TURP, and Enucleation, and between B-TURP and Ablation. Conversely, AUR/failure to void incidence favored M-TURP over Ablation (RR 1.88, 95% CI 1.40–2.52, p < 0.001).

Enucleation procedures demonstrate comparable safety to TURP regarding postoperative AUR/failure to void, whereas Ablation procedures are associated with a significantly higher incidence of postoperative retention events, particularly with energy modalities such as monopolar electrocautery, diode, and Nd:YAG lasers.