ABSTRACT Purpose The aim of this meta-analysis is to assess the efficacy of extended dose of preoperative antibiotics to reduce infectious risk in patients undergoing percutaneous nephrolithotomy (PCNL). Materials and Methods A literature search for prospective case-control studies or randomized controlled trials was done. PICO framework was used. Population: adult patients that underwent to PCNL; Intervention: extended dose preoperative antibiotic prophylaxis before PCNL; Control: short dose preoperative antibiotic prophylaxis before PCNL; and Outcome: systemic inflammatory response syndrome (SIRS) or sepsis, fever after PCNL and positive intraoperative urine and stone culture. This meta-analysis was registered in PROSPERO database under the number: CRD42022359589. Results Three RCT and two prospective studies (475 patients) were included. SIRS/sepsis outcome was retrieved from all studies included. Seven days preoperative oral antibiotics for PCNL was a protective factor for developing SIRS/sepsis (OR 0.366, 95% CI 0.234 - 0.527, p < 0.001). There was no statistical association between seven-day use of antibiotics and fever (OR 0.592, 95% CI 0.147 – 2.388, p = 0.462). Patients who received seven days preoperative antibiotics had lower positive intraoperative urine culture (OR 0.284, 95% CI 0.120 – 0.674, p = 0.004) and stone culture (OR 0.351, 95% CI 0.185 – 0.663, p = 0.001) than the control group. Conclusion one week of prophylactic oral antibiotics based on local bacterial sensitivity pattern plus a dose of intravenous antibiotics at the time of surgery in patients undergoing PCNL reduces the risk of infection.

ABSTRACT Background: Endoscopic combined intrarenal surgery (ECIRS) has been used to treat complex kidney stones (1). The combined use of ultrasound (US) has the potential to improve safety and reduce radiation exposure, however, it is still underutilized (2). Objectives: Our objective is to describe, in a step-by-step manner, the ultrasound-guided ECIRS (USG ECIRS) technique, in order to facilitate learning by urologists. Materials and Methods: We describe the 10 standardized steps that we recommend to achieve a good outcome, based on our previous experience on a high-volume kidney stone center. We recorded a case of a 37-year-old female patient with complex bilateral kidney stones that underwent a left simultaneous combined retrograde and antegrade approach. The 10 described steps are: 1 - case evaluation with CT scan (3); 2 - preoperative care with antibiotics and tranexamic acid; 3 - warm-up and training with phantoms; 4 - patient positioning in Barts flank free position; 5 - retrograde nephroscopy with flexible ureteroscope; 6 - US and endoscopic guided puncture; 7 - tract dilation under endoscopic view; 8 - stone fragmentation; 9 - status free checking and 10, kidney drainage. Images were captured by external and internal cameras, promoting a complete understanding of the procedure. The patient has signed a written informed consent form. Results: Puncture was achieved under US guidance with one attempt. Another puncture was necessary in the lower pole, parallel to the initial puncture, due to a large fragment. Surgical time was 140 min. Stone-free status was verified by retrograde and antegrade view. Kidney drainage was done with ureteral stent on string, removed after 7 days. Hb drop was 1.1 Hb/dL. The first postoperative day CT scan showed no residual stones and no complications. The patient was discharged after the CT and urethral catheter removal. Conclusion: The USG ECIRS seems to be a very efficient and reproducible technique for the treatment of complex kidney stones. Its use should be widespread.

ABSTRACT Introduction: To demonstrate the entire surgeon's point of view of a prone split-leg (PSL) endoscopic guided percutaneous nephrolithotomy (ePCNL) recorded with a GoPro® camera for standardization of the essential technical steps towards a successful procedure (1). Materials and methods: A 40y.o female patient presented with right flank pain for three years. She had previously been submitted to shock wave lithotripsy without success. Non-contrast computed tomography (NCCT) revealed a 2cm stone in the renal pelvis with 1400HU and stone-to-skin distance of 11cm (Guy's Stone Score 1). PCNL approach was chosen for providing higher chances of stone-free after a single procedure. Informed consent was obtained. The PSL ePCNL was uneventful with a single access in a mid-pole. The surgeon had a Full HD GoPro Hero 4® camera mounted on his head, controlled by the surgical staff with a remote control. All essential surgical steps were recorded. Results: Operative time was 90 minutes. Hemoglobin drop was 0.7g/dL. The post-operative NCCT scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The camera worked properly and didn't cause any kind of discomfort to the surgeon. The quality of the recorded movie was excellent. Conclusion: By recording the surgeon's perspective of an endoscopic urological procedure, we were able to provide a comprehensive understanding of the surgical technique by assembling the endoscopic, fluoroscopic, and operative field views. The GoPro® camera proved to be an interesting tool to document surgical procedures without compromising outcomes and has great potential for educational purposes.

ABSTRACT COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties nondirectly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

RESUMO INTRODUÇÃO: Paciente com cálculos renais bilaterais e de grande volume são casos desafiadores para os endourologistas. A nefrolitotripsia percutânea bilateral simultânea (NLPbs) é um opção, entretanto esse procedimento pode ser acompanhado de morbidade importante. Uma alternativa é a NLP estagiada, operando um lado de cada vez. Aqui, nós comparamos o impacto da NLPbs e da NLP estagiada nas taxas de complicações e função renal. MÉTODOS: Pacientes que foram submetidos a NLPsb ou NLP stagiada com intervalo de até 6 meses foram pesquisados em nossa base de dados de cálculos renais prospectivamente coletada. Os grupos foram comparados em idade, gênero, índice de massa corpórea (IMC), comorbidades (classificação da Sociedade Americana de Anestesiologia – ASA), tamanho do cálculo, Classificação de Guys, taxa de pacientes livres de cálculos, função renal, perda sanguínea, taxa de transfusão, taxa de complicações e tempo de internação hospitalar. RESULTADOS: Vinte e seis paciente e 52 unidades renais foram incluídas. O tempo operatório médio foi de 134,7 min. Apenas 11.3% dos casos tiveram complicações, sendo todas menores (Clavien ≤ 2). No geral, a taxa de pacientes livres de cálculos foi de 61,5%. Comparando os grupos houve um tempo operatório significativamente maior no grupo NLPbs(172,5 vs. 126,3 min; p=0,016), assim como uma maior taxa de transfusão (12,5% vs. 5,6%; p=0.036). Não houve diferença significante nos níveis de creatinina entre os grupos. Em relação a taxa de doentes livre de cálculos houve uma proporção significativamente maior de pacientes livres de cálculos na NLP estagiada (64,9% vs. 43,8%; p=0,012). CONCLUSÃO: A NLPsb é um procedimento seguro, entretando quando comparada ao procedimento estagiado apresenta uma maior taxa de transfusão e uma menor taxa de pacientes livres de cálculos.

SUMMARY INTRODUCTION: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. METHODS: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. RESULTS: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). CONCLUSION: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.

ABSTRACT Purpose: Although the worldwide percutaneous nephrolithotomy (PCNL) practice pat- terns determined via a survey sent to members of the Endourological Society have been published, differences in PCNL practice patterns among Latin American urologists based on endourological or lithiasis training have not been published. To determine the PCNL practice patterns among Latin American urologists with and without training in endourology. Materials and Methods: The SurveyMonkey® web platform was used to develop a 27-item survey on PCNL for the treatment of renal stones, and the survey was sent via e- -mail and other electronic media to 2000 urologists from 15 Latin American countries. Endourology-trained (group 1) and nontrained urologists (group 2) were analyzed. The group results were compared using the chi-squared and Fisher's exact tests. SPSS version 20 for Windows was used for all analyses. Results: A total of 331 urologists responded to the survey (rate of 16.55%): 221 (66.7%) in group 1 and 110 (33.2%) in group 2). In groups 1 and 2, 91.9% and 63.2% performed PCNL, respectively: 85.1% and 58.5% used preoperative tomography, respectively; 12.7% and 4.7% used preoperative nephrolitometry nomograms, respectively: 45.2% and 32.1% used endoscopic combined intrarenal surgery, respectively: 68.3% and 38.7% used mul- tiple percutaneous tract realization, respectively: and 19.9% and 5.7% used minimally invasive PCNL, respectively (all p=0.0005). Conclusions: Statistically significant differences were observed in PCNL practice patterns of Latin American urologists with and without training in endourology. Specific training in endourology significantly influence the practice patterns of Latin American urologists.

ABSTRACT Objective: To compare the application time and the capacity of the nomograms to predict the success of Guy's Stone Score (GSS), S.T.O.N.E. Nephrolithometry (STONE) and Clinical Research Office of the Endourological Society nephrolithometric nomogram (CROES) of percutaneous nephrolithotomy (PCNL), evaluating the most efficient one for clinical use. Materials and Methods: We studied 48 patients who underwent PCNL by the same surgeon between 2010 and 2011. We calculated GSS, STONE and CROES based on pre-operative non-contrast computed tomography (CT) images and clinical data. A single observer, blinded to the outcomes, reviewed all images and assigned scores. We compared the application time of each nomogram. We used an analysis of variance for repeated measures and multiple comparisons by the Tukey test. We compared the area under the ROC curve (AUC) of the three nomograms two by two to determine the most predictive scoring system. Results: The immediate success rate was 66.7% and complications occurred in 16.7% of cases. The average operative time was 122 minutes. Mean application time was significantly lower for the GSS (27.5 seconds) when compared to 300.6 seconds for STONE and 213.4 seconds for CROES (p<0.001). There was no significant difference among the GSS (AUC=0.653), STONE (AUC=0.563) and CROES (AUC=0.641) in the ability to predict immediate success of PCNL. Conclusions: All three nomograms showed similar ability to predict success of PCNL, however the GSS was the quickest to be applied, what is an important issue for routine clinical use when counseling patients who are candidates to PCNL.

ABSTRACT We describe the use of the Uro Dyna-CT, an imaging system used in the operating room that produces real-time three-dimensional (3D) imaging and cross-sectional image reconstructions similar to an intraoperative computerized tomography, during a percutaneous nephrolithotomy and a contralateral flexible ureteroscopy in a complete supine position. A 65 year-old female patient had an incomplete calyceal staghorn stone in the right kidney and a 10mm in the left one. The procedure was uneventful and the intraoperative use of the Uro Dyna-CT identified 2 residual stones that were not found by digital fluoroscopy and flexible nephroscopy at the end of surgery, helping us to render the patient stone-free in one procedure, which was confirmed by a postoperative CT scan. Prospective studies will define the real role of the Uro Dyna-CT for endourological procedures, but its use seems to be a very promising tool for improving stone free rates and decreasing auxiliary procedures, especially for complex cases.

<title>ABSTRACT</title><sec><title>Purpose:</title><p>To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications.</p></sec><sec><title>Materials and Methods:</title><p>We reviewed our stone database searching for patients with solitary kidney who underwent PCNL from Jan-05 through Oct-13. Demographic data, stone characteristics, and intra- and postoperative outcomes were recorded. Spearman correlation was performed to assess which variables could impact on bleeding and surgical complications. Linear and logistic regressions were also performed.</p></sec><sec><title>Results:</title><p>Twenty-seven patients were enrolled in this study. The mean age and BMI were 45.6 years and 28.8Kg/m², respectively; 45% of cases were classified as Guys 3 (partial staghorn or multiple stones) or 4 (complete staghorn) – complex cases. Stone-free rate was 67%. Eight (29.6%) patients had postoperative complications (five of them were Clavien 2 and three were Clavien 3). On univariate analysis only number of tracts was associated with increased bleeding (p=0.033) and only operative time was associated with a higher complication rate (p=0.044). Linear regression confirmed number of access tracts as significantly related to bleeding (6.3, 95%CI 2.2-10.4; p=0.005), whereas logistic regression showed no correlation between variables in study and complications.</p></sec><sec><title>Conclusions:</title><p>PCNL in solitary kidneys provides a good stone-free rate with a low rate of significant complications. Multiple access tracts are associated with increased bleeding.</p></sec>