Faculty Bibliography

INTRODUCTION/UNASSIGNED:BPH/male LUTS is a prevalent condition in the aging male population with multifactorial pathophysiology. Pharmacotherapy remains the cornerstone of treatment in patients who fail conservative treatment. 5-α-Reductase inhibitors (5-ARIs) are the only class of medication shown to reduce the risk of acute retention and BPH-related surgery and, thus, are commonly used along with other "short acting" medications in combination treatments. AREAS COVERED/UNASSIGNED:Combination treatments with α-blockers and 5-ARIs have been investigated extensively in high quality trials that prove the long-term efficacy of such treatments with acceptable rates of side effects. Combination treatments involving 5-ARIs and other classes of medications (anticholinergics, b3 agonists, PDEI) have been shown to be beneficial in the short term and but studies with longer follow-up periods are required to fully establish their role. EXPERT OPINION/UNASSIGNED:A-blocker/5-ARI combination treatment is a reasonable approach for patients with male LUTS/BPH who are at increased risk of disease progression or have incomplete response to monotherapies. Other combination treatments with 5-ARIs and PDEI or anticholinergics/β-3 agonists can be tried based on predominant symptoms or side effect profile, but patients should be informed about the lack of long-term data.

BACKGROUND AND OBJECTIVE/UNASSIGNED:Elevated intrarenal pressure (IRP) may increase the risk of complications in patients undergoing ureteroscopy. As there is limited clarity on a threshold value for high IRP, how to manage high IRP, or which patients are at greater risk of complications due to high IRP, we used the Delphi methodology to understand expert opinion in this area. METHODS/UNASSIGNED:The Delphi process comprised two online surveys and an in-person meeting. During the in-person meeting, areas of disagreement and consensus were explored. Consensus statements were developed and voted on to determine the level of consensus. The study was granted a waiver by HML IRB Research and Ethics (reference number 2193). KEY FINDINGS AND LIMITATIONS/UNASSIGNED:O. CONCLUSIONS AND CLINICAL IMPLICATIONS/UNASSIGNED:Any IRP above normal physiological levels should be considered high. High IRP during ureteroscopy is a concern for patient safety. It is important to understand links between high IRP, patient characteristics, and complications. We call for additional research to better understand these risks and to inform refinements to clinical practice. PATIENT SUMMARY/UNASSIGNED:A group of experts were asked their opinion on pressure within the kidney (intrarenal pressure, IRP) during a procedure called ureteroscopy (URS), when a narrow telescope is passed through the bladder and into the tube connected to the kidney. Statements that the panel agreed on were developed. These statements show that there is a concern about high IRP during URS as it may be linked to a higher risk of complications for the patient. More research is needed to better understand high IRP and its link to patient outcomes.

Informed consent is a cornerstone of ethically acceptable surgical interventions. Traditional methods primarily rely on verbal explanations by clinicians and, at times, the use of supplementary resources such as information leaflets. In the modern era, novel tools have emerged to facilitate and enhance the consent process. Examples include multimedia, 3D models, virtual and augmented reality, quick response codes, and artificial intelligence technologies such as large language models. This narrative review provides an overview of these aids, discussing their potential advantages and limitations. In addition, the influence of social media on the consent process is explored.

PURPOSE/OBJECTIVE:The SMART Stone Multidisciplinary Team (MDT) recommendations aim to provide guidance on the role of the MDT in the early identification, referral and assessment of adult high-risk recurrent kidney stone formers to advance patient care. METHODS:Recommendations were developed by the expert Steering Committee (SC) comprising of three Urologists, one Nephrologist, and two Biochemists/Geneticists from the UK, Spain, Germany, and Italy. These recommendations were voted on by invited specialists via an online survey to determine their level of agreement, from 'strongly agree' to 'strongly disagree'. With an agreement threshold set at ≥ 70%, the SC reviewed the survey results, additional comments, and any areas of disagreement before finalizing the recommendations. RESULTS:A total of 44 recommendations were developed by the SC designed to support the set-up of an ideal MDT. Thirteen core recommendations were chosen as being highest priority and were voted on by 29 invited specialists from 19 countries across Europe, Canada, East Asia, South/Southeast Asia, and the Middle East. All 13 core recommendations reached the ≥ 70% agreement threshold. The remaining 31 recommendations were voted on by those specialists who opted-in to partake in the extended questionnaire. Fifteen specialists provided their responses from 14 different countries. All 31 recommendations reached the ≥ 70% agreement threshold. CONCLUSIONS:An ideal MDT process can achieve comprehensive, high-quality, and coordinated patient care, which is especially useful for patients with complex stone diseases. A high level of agreement was reached in areas relating to the implementation of an ideal MDT in identifying high-risk stone formers.

PURPOSE/OBJECTIVE:A novel larger 5.1Fr working channel flexible ureteroscope for Direct-In-Scope Suction (DISS) has recently been introduced. However, the optimal stone dust size for successful evacuation without working channel blockage is currently unknown. METHODS:In vitro assessment of the PU400A 9.2Fr ureteroscope (Zhuhai Pusen Medical Technology Co., Ltd, China) was performed with BegoStone particle sizes ≤ 2000 μm (size range 1000-2000 μm), ≤ 1000 μm (500-1000 μm), ≤ 500 μm (250-500 μm), ≤ 250 μm (125-250 μm) and ≤ 125 μm (63-125 μm), in a kidney calyx model. This was conducted with an empty working channel, and with occupancy by 150 μm Olympus, 200 μm Quanta, 270 μm Dornier laser fibers. Primary outcome was complete suction-evacuation without working channel blockage. Secondary outcome was evacuation speed for particle sizes that did not have blockage. RESULTS:/s respectively (ANOVA = p < 0.001). CONCLUSION/CONCLUSIONS:The 5.1Fr working channel DISS ureteroscope allows a stone particle size limit of 250 μm to be suction-evacuated without blockage, even with laser fiber occupancy. With a laser fiber, a smaller 150 μm fiber size allows better particle evacuation speeds. Urologists should therefore aim for a dust particle size of ≤ 250 μm in routine DISS with the 5.1Fr working channel ureteroscope, for effective intraoperative stone evacuation.

Our aim was to compare hand radiation exposure using leaded vs. regular latex surgical gloves in endourological procedures. We conducted a single-center prospective comparative study between January 2017 and December 2020. Surgeon 1 wore leaded surgical gloves, while Surgeon 2 voluntarily wore regular latex surgical gloves. A ring badge and chest dosimeters were used to estimate hand and whole-body scattered radiation dose in all endourological stone procedures (ureteroscopy (URS), retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL)). We found that Surgeon 1 and 2 performed a mean of 158 (SD 15.2) and 158 (SD 15.1) procedures/year, respectively, for a total of 1,092 between 2017 and 2020 between the two surgeons (696 URS/RIRS and 396 PCNL). The overall mean hand annual radiation exposure dose for Surgeon 1 and 2 was 2.87 mSv (SD 1.3) and 14.89 mSv (SD 7.87), respectively (p = 0.027), which corresponds to a mean of 0.02 (SD 0.02) and 0.1 mSv (SD 0.1) per procedure (p < 0.001). The estimated annual scattered radiation was 0.0012 and 0.0016, respectively (p = 0.63). We concluded that the use of leaded gloves in endourological stone procedures showed a significant reduction of radiation dose per year and per procedure compared to regular latex gloves; no increase in whole-body scattered radiation was detected with their use. We believe that the use of leaded gloves may be recommended, especially in urologists who dedicate most of their practice to endoscopic stone surgery. Further studies are needed to define whether these gloves could increase patient radiation exposure.

INTRODUCTION/UNASSIGNED:The treatment of kidney stone disease (KSD) has evolved significantly with the introduction of minimally invasive endourological techniques. Advancements in technology, particularly the transition from fibreoptic to digital and single use systems and the development of smaller-diameter instruments, has improved intraoperative view and efficacy in stone treatment. The miniaturization in single-use scopes represent a recent innovation, offering potential benefits, especially in challenging cases. However, there is limited evidence on their safety and clinical outcomes. This study aims to evaluate the efficacy and safety of stone treatment using a single-use 7.5 Fr flexible ureteroscope. MATERIAL AND METHODS/UNASSIGNED:Consecutive patients with urinary stones undergoing flexible ureteroscopy with a 7.5 Fr single-use flexible ureteroscope across five tertiary endourology centers were included. Data on patient demographics, stone characteristics, intra- and postoperative outcomes were prospectively collected and analyzed. Procedures were performed by experienced endourology surgeons following standard protocols. RESULTS/UNASSIGNED:) and mean Hounsfield units of 1087.4 (SD ±384.9). 36 (72%) had multiple stones and a bilateral FURS was performed in 9 cases (18%). 24 patients (48%) had a preoperative stent inserted. A ureteral access sheath was used in 22 (44%) cases and 46 (92%) patients had a postoperative stent inserted. The median operative time was 60min (IQR: 53-90), 32 patients (64%) were stone free after the first procedure (SFR for <2 cm and ≥2 cm stones was 85.2% and 36.2% respectively), perioperative and postoperative complications (Clavien ≤II) were observed in 3 patients (6%). CONCLUSIONS/UNASSIGNED:This multicentric study demonstrates the safety and efficacy of using the 7.5Fr single-use flexible ureteroscope for urinary stone treatment. While the results are promising, larger studies are needed to validate these findings further.