ABSTRACT Introduction: Endoscopic Combined Intrarenal Surgery (ECIRS) has emerged as a promising technique for the management of large and complex kidney stones, potentially offering advantages over traditional Percutaneous Nephrolithotomy (PCNL). This study aims to evaluate best practices, outcomes, and future perspectives associated with ECIRS. Materials and Methods: A comprehensive PubMed search was conducted from 2008 to 2024, using MESH terms and the following key words: "ECIRS" and "Endoscopic Combined Intrarenal Surgery" The search yielded 157 articles, including retrospective cohort studies, two randomized controlled trials (RCTs), and four meta-analyses comparing ECIRS with PCNL. Most important findings were summarized regarding indications, patient positioning, kidney access, tract size, surgical outcomes, and complications. Results: ECIRS demonstrated higher stone-free rate, lower complication rate, and a reduced need for multiple procedures compared to traditional PCNL. Additionally, ECIRS has the potential to integrate new technologies to further enhance outcomes. Conclusion: ECIRS demonstrates significant advantages in the management of large kidney stones. Future research should focus on well-designed RCTs to provide robust evidence of its efficacy, safety, and cost-effectiveness, potentially establishing ECIRS as the first option treatment for complex kidney stones. Introduction (ECIRS stones PCNL . (PCNL) practices outcomes Methods 200 2024 words "ECIRS 15 articles studies RCTs, , (RCTs) metaanalyses meta analyses indications positioning access size complications Results stonefree stone free rate Additionally Conclusion welldesigned well designed efficacy safety costeffectiveness, costeffectiveness cost effectiveness, effectiveness cost-effectiveness (PCNL 20 202 1 (RCTs 2

ABSTRACT Introduction Ureteral stricture is often a consequence of urolithiasis or previous endourological procedures (1-3). Precisely delineating the stricture zone intraoperatively is crucial to minimize ureter shortening and target only the affected tissue (4, 5). Flexible ureteroscopy offers a significant advantage in this regard. Objective This video aims to demonstrate the step-by-step technique of flexible ureteroscopic guided laparoscopic ureteroplasty for treating ureteral stricture caused by urolithiasis and prior endourological interventions. Patient and Methods We present a case of a 36-year-old male with a history of urolithiasis and unsuccessful endourological treatments, including endoureterotomy and balloon dilation, diagnosed with re-stenosis of the proximal ureter of 1 cm through ureteroscopy and pyelography. He underwent a successful laparoscopic ureteroplasty. While the lead surgeon performed the laparoscopy, an assistant conducted the flexible ureteroscopy. Intraoperatively, using transillumination facilitated by the flexible ureteroscope, we can precisely identify the narrowed area, allowing for resection of only the damaged segment. Subsequently, we perform the end-to-end ureteroplasty, confirming its patency through the seamless passage of the ureteroscope. Upon completion, we employ a fat patch to safeguard the anastomosis. Results The patient was discharged on the third postoperative day. Double J stent was removed six weeks after surgery. Symptoms resolved. Renal function improved: eGFR 49 to 67 ml/min. Furthermore, improvement was observed in the DTPA scan, and a decrease in hydronephrosis was noted on the follow-up tomography. Conclusion Flexible ureteroscopy effectively identifies the stricture zone in laparoscopic ureteroplasty, enhancing surgical precision and outcomes. This approach is safe, effective, and reproducible, offering a valuable technique in the surgical treatment of ureteral strictures. 13. 13 3 . (1-3) 4, 4 (4 5. 5 5) regard stepbystep step interventions 36yearold yearold 36 year old treatments dilation restenosis re stenosis pyelography laparoscopy Intraoperatively ureteroscope area segment Subsequently endtoend end completion anastomosis day surgery resolved improved 6 mlmin ml min ml/min Furthermore scan followup follow up tomography outcomes safe effective reproducible strictures (1-3 ( (1- (1

ABSTRACT Background: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. Methods: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. Results: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. Conclusion: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies. Background procedures (PCNL URS, URS , (URS) Recently (ICT considered metaanalysis meta analysis fluoroscopicguided fluoroscopic guided Methods guidelines 2023 nonICTguided non procedure rate evaluated recommendations 95CI 95 randomeffects random effects data Results 53 32 103 (10 22 nonICT. nonICT . non-ICT) 84.5% 845 84 5 (84.5 414 41 4 41.4 respectively 30 3.61, 361 61 [3.61 12.72 1272 12 72 12.72] p<0.00001 p000001 0 00001 I2=0. I20 I I2=0 I2 I2=0) 326 6 32.6 126 12.6 OR 0.34 034 34 0.12,0.94 012094 94 [0.12,0.94] =0.04 004 04 48%, 48 48% 48%) differences Conclusion nephroscopy followup follow (URS 202 9 10 (1 2 non-ICT 84.5 8 (84. 41. 3.61 36 [3.6 12.7 127 1 7 p<0.0000 p00000 0000 32. 12. 0.3 03 0.12,0.9 01209 [0.12,0.94 =0.0 00 20 ( 84. (84 3.6 [3. p<0.000 p0000 000 0. 0.12,0. 0120 [0.12,0.9 =0. (8 3. [3 p<0.00 p000 0.12,0 012 [0.12,0. =0 [ p<0.0 p00 0.12, 01 [0.12,0 = p<0. p0 0.12 [0.12, p<0 0.1 [0.12 p< [0.1 [0. [0

ABSTRACT Purpose: The aim of this study is to perform a high-quality meta-analysis using only randomized controlled trials (RCT) to better define the role of postoperative antibiotics in patients undergoing percutaneous nephrolithotomy (PCNL). Materials and Methods: A literature search for RCTs in EMBASE, PubMed, and Web of Science up to May 2023 was conducted following the PICO framework: Population—adult patients who underwent PCNL; Intervention—postoperative antibiotic prophylaxis until nephrostomy tube withdrawal; Control—single dose of antibiotic during the induction of anesthesia; and Outcome—systemic inflammatory response syndrome (SIRS) or sepsis and fever after PCNL. The protocol was registered on the PROSPERO database (CRD42022361579). We calculated odds ratios (OR) and 95% confidence intervals (CI). A random-effects model was employed, and the alpha risk was defined as < 0.05. Results: Seven articles, encompassing a total of 629 patients, were included in the analysis. The outcome of SIRS or sepsis was extracted from six of the included studies, while the outcome of postoperative fever was extracted from four studies. The analysis revealed no statistical association between the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal and the occurrence of SIRS/sepsis (OR 1.236, 95% CI 0.731 – 2.089, p=0.429) or fever (OR 2.049, 95% CI 0.790 – 5.316, p=0.140). Conclusion: Our findings suggest that there is no benefit associated with the use of postoperative antibiotic prophylaxis until nephrostomy tube withdrawal in patients undergoing percutaneous nephrolithotomy (PCNL). We recommend that antibiotic prophylaxis should be administered only until the induction of anesthesia in PCNL. Purpose highquality high quality metaanalysis meta RCT (RCT PCNL . (PCNL) Methods EMBASE PubMed 202 framework Populationadult Population adult Interventionpostoperative Intervention Controlsingle Control single Outcomesystemic Outcome systemic (SIRS CRD42022361579. CRD42022361579 CRD (CRD42022361579) OR 95 CI. (CI) randomeffects random effects employed 005 0 05 0.05 Results articles 62 studies SIRSsepsis 1236 1 236 1.236 0731 731 0.73 2089 2 089 2.089 p=0.429 p0429 p 429 2049 049 2.049 0790 790 0.79 5316 5 316 5.316 p=0.140. p0140 p=0.140 140 p=0.140) Conclusion (PCNL 20 CRD4202236157 (CRD42022361579 9 (CI 00 0.0 6 123 23 1.23 073 73 0.7 208 08 2.08 p=0.42 p042 42 204 04 2.04 079 79 531 31 5.31 p014 p=0.14 14 CRD420223615 (CRD4202236157 0. 12 1.2 07 7 2.0 p=0.4 p04 4 53 3 5.3 p01 p=0.1 CRD42022361 (CRD420223615 1. 2. p=0. p0 5. CRD4202236 (CRD42022361 p=0 CRD420223 (CRD4202236 p= CRD42022 (CRD420223 CRD4202 (CRD42022 CRD420 (CRD4202 CRD42 (CRD420 CRD4 (CRD42 (CRD4 (CRD

ABSTRACT Purpose: to identify risk factors for urinary septic shock in patients who underwent percutaneous nephrolithotomy (PCNL). Materials and Methods: Data from PCNL procedures performed between January 2009 and February 2020 were retrospectively analyzed. The study included all patients over 18 years old with kidney stones larger than 15 mm who underwent PCNL. Patients who underwent mini-PCNL or combined surgeries, such as ureteroscopy or bilateral procedures, were not included in the study. Logistic regression was conducted to determine the risk factors for urinary septic shock within 30 days post-operation in patients who underwent PCNL. Results: Urinary septic shock was observed in 8 out of the 1,424 patients analyzed (0.56%). The presence of comorbidities, evaluated using the Charlson Comorbidity Index (CCI) (OR 1.46 [CI 95% 1.15-1.86], p=0.01), larger stones (41.0 mm [IQR 30.0-47.5 mm] vs. 24.0 mm [IQR 17.0-35.0 mm], OR 1.03 [CI 95% 1.01-1.06], p=0.04), and a positive preoperative urine culture (OR 8.53 [CI 95% 1.71-42.45], p <0.01) were shown to significantly increase the risk of postoperative urinary septic shock. Patients with a CCI > 2, larger stones (≥ 35 mm), and a positive preoperative urine culture were at even higher risk of urinary septic shock (OR 15.40 [CI 95% 1.77-134.21], p=0.01). Conclusion: Patients with larger stones, positive preoperative urine culture, and a higher CCI are at risk for urinary septic shock after PCNL. These findings are of utmost importance for optimizing the perioperative care of these patients to prevent life-threatening complications. Purpose . (PCNL) Methods 200 202 1 miniPCNL mini surgeries 3 postoperation post operation Results 1424 424 1,42 0.56%. 056 0.56% 0 56 (0.56%) comorbidities (CCI 146 46 1.4 CI 95 1.151.86, 115186 1.15 1.86 , 86 1.15-1.86] p=0.01, p001 p=0.01 01 p=0.01) 41.0 410 41 (41. IQR 30.047.5 300475 30.0 47.5 47 5 30.0-47. vs 240 24 24. 17.035.0 170350 17.0 35.0 17 17.0-35. mm, 103 03 1.0 1.011.06, 101106 1.01 1.06 06 1.01-1.06] p=0.04, p004 p=0.04 04 p=0.04) 853 53 8.5 1.7142.45, 1714245 1.71 42.45 71 42 45 1.71-42.45] <0.01 001 2 ≥ ( mm) 1540 40 15.4 1.77134.21, 17713421 1.77 134.21 77 134 21 1.77-134.21] p=0.01. Conclusion lifethreatening life threatening complications (PCNL 20 142 1,4 05 0.56 (0.56% 14 4 1. 9 151 1.151.86 11518 115 1.1 186 1.8 1.15-1.86 p00 p=0.0 41. (41 047 30.047. 30047 300 30. 475 47. 30.0-47 035 17.035. 17035 170 17. 350 35. 17.0-35 10 011 1.011.06 10110 101 106 1.01-1.06 85 8. 7142 1.7142.45 171424 171 1.7 4245 42.4 7 1.71-42.45 <0.0 00 154 15. 77134 1.77134.21 1771342 177 13421 134.2 13 1.77-134.21 1, 0.5 (0.56 1.151.8 1151 11 1.15-1.8 p0 p=0. (4 30.047 3004 30.0-4 17.035 1703 17.0-3 1.011.0 1011 1.01-1.0 714 1.7142.4 17142 42. 1.71-42.4 <0. 7713 1.77134.2 177134 1342 134. 1.77-134.2 0. (0.5 1.151. 1.15-1. p=0 30.04 30.0- 17.03 17.0- 1.011. 1.01-1. 1.7142. 1714 1.71-42. <0 771 1.77134. 17713 1.77-134. (0. 1.151 1.15-1 p= 1.011 1.01-1 1.7142 1.71-42 < 1.77134 1771 1.77-134 (0 1.15- 1.01- 1.714 1.71-4 1.7713 1.77-13 1.71- 1.771 1.77-1 1.77-

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. metaanalysis meta analysis PCNL. . (PCNL) casecontrol case done used Population Intervention Control Outcome SIRS (SIRS sepsis number CRD42022359589 CRD 475 (47 included SIRSsepsis OR 0366 0 366 0.366 95 0234 234 0.23 0527 527 0.527 0.001. 0001 0.001 001 sevenday day 0592 592 0.592 0147 147 0.14 2388 2 388 2.388 0.462. 0462 0.462 462 0.462) 0284 284 0.284 0120 120 0.12 0674 674 0.674 0.004 0004 004 0351 351 0.351 0185 185 0.18 0663 663 0.663 group infection (PCNL CRD4202235958 47 (4 036 36 0.36 9 023 23 0.2 052 52 0.52 000 0.00 00 059 59 0.59 014 14 0.1 238 38 2.38 046 0.46 46 028 28 0.28 012 12 067 67 0.67 035 35 0.35 018 18 066 66 0.66 CRD420223595 4 ( 03 3 0.3 02 0. 05 5 0.5 0.0 01 1 2.3 04 0.4 06 6 0.6 CRD42022359 2. CRD4202235 CRD420223 CRD42022 CRD4202 CRD420 CRD42 CRD4

SUMMARY OBJECTIVE: Mini-percutaneous nephrolithotomy is a recent advancement in the field of kidney stone treatment; however, its role has not been completely established. We aimed to compare the outcomes of initial Mini-percutaneous nephrolithotomy and flexible ureteroscopy. METHODS: A retrospective review of consecutive mini-percutaneous procedures was performed. Inclusion criteria were as follows: all percutaneous nephrolithotomy procedures performed with an access sheath up to 24Fr, kidney stone burdens up to 1550 mm3; and the presence of postoperative computed tomography (for control). The data collected for Mini-percutaneous nephrolithotomy procedures were paired 1:2 with patients treated with flexible ureteroscopy for stones between 100 and 1550 mm3, and with postoperative computed tomography for control. A 14Fr Mini-percutaneous nephrolithotomy set was used. The stone-free rate was defined as the absence of fragments on the control computed tomography, whereas success was limited to 2-mm residual fragments. Statistical analysis was performed using SPSS version 19. RESULTS: A total of 63 patients met the inclusion criteria (42 with flexible ureteroscopy and 21 with mini-percutaneous nephrolithotomy). Demographic data were comparable. The stone-free rate and success were similar between the groups (76.2 vs. 66.7%, p=0.42 and 90.5 vs. 85.7%, p=0.57). The complication rate was also similar (26.1 vs. 9.6%, p=0.188), but Mini-percutaneous nephrolithotomy had longer hospitalization and fluoroscopy time (p=0.001 in both). CONCLUSIONS: Our initial study of Mini-percutaneous nephrolithotomy showed that it is a promising procedure, with outcomes similar to flexible ureteroscopy, but with higher inpatient numbers and fluoroscopy times. A larger study population size and better equipment may improve the outcomes of mini-percutaneous nephrolithotomy.

ABSTRACT Flexible ureteroscopy is a well-established method for treatment of urinary stones but flexible ureteroscopes are expensive and fragile devices with a very limited lifetime. Since 2006 with the advent of digital flexible ureteroscopes a great evolution has occurred. The first single-use flexible ureteroscope was launched in 2011 and new models are coming to the market. The aim of this article is to review the characteristics of these devices, compare their results with the reusable devices and evaluate the cost-benefits of adopting single-use flexible ureteroscopes in developing countries. Materials and Methods: an extensive review of articles listed at PubMed and published between 2000 and 2021 was performed. Results: Single-use flexible ureteroscopes have a shaft with 65 to 68cm length and weight between 119 and 277g. Their deflection goes up to 300 degrees. Their stone-free rates vary between 60 and 95% which is comparable to reusable scopes and operative times ranges from 54 to 86 minutes which are lower when compared to reusable flexible scopes. Their costs vary between 800 and 3180 US dollars. Conclusion: single-use flexible ureteroscopes are lighter and have superior quality of image when compared to fiberoptic ones. There are no definite data showing a higher stone-free rate or less complications with the use of single-use flexible ureteroscopes. Each institution must perform a cost-benefit analysis before making the decision of adopting or not such devices depending on the local circumstances.