ABSTRACT Introduction: The ureteral access sheath (UAS) is a medical device that enables repeated entrance into the ureter and collecting system during retrograde intrarenal surgery (RIRS). Its impact on stone-free rates, ureteral injuries, operative time, and postoperative complications remains controversial. Therefore, we performed a systematic review and meta-analysis comparing RIRS with versus without UAS for urolithiasis management. Purpose: To compare outcomes from retrograde intrarenal surgery (RIRS) for stone extraction with or without ureteral access sheath (UAS); evaluating stone-free rate (SFR), ureteral injuries, operative time, and postoperative complications. Materials and Methods: We systematically searched PubMed, Embase, and Cochrane Library in June 2024 for randomized controlled trials (RCTs) evaluating the efficacy and safety outcomes of UAS use in RIRS for urolithiasis treatment. Articles published between 2014 and 2024 were included. Pooled risk ratios (RRs) and mean differences (MDs) were calculated for binary and continuous outcomes, respectively. Results: Five RCTs comprising 466 procedures were included. Of these, 246 (52.7%) utilized UAS. The follow-up ranged from 1 week to 1 month. UAS reduced the incidence of postoperative fever (RR 0.49; 95% confidence interval [CI] 0.29–0.84; p=0.009), and postoperative infection (RR 0.50; 95% CI 0.30–0.83; p=0.008). There were no significant differences between groups in terms of SFR (RR 1.05; 95% CI 0.99–1.11; p=0.10), ureteral injuries (RR 1.29; 95% CI 0.95–1.75; p=0.11), operative time (MD 3.56 minutes; 95% CI −4.15 to 11.27 minutes; p=0.36), or length of stay (MD 0.32 days; 95% CI −0.42 to 1.07 days; p=0.40). Conclusion: UAS leads to a lower rate of post-operative fever and infection. However, UAS did not significantly reduce or increase the SFR or the rate of ureteral injuries during RIRS for patients with urolithiasis. The use of UAS should be considered to decrease the risk of infectious complications, particularly in those who may be at higher risk for such complications. Introduction (UAS RIRS. . stonefree free rates controversial Therefore metaanalysis meta analysis management Purpose (RIRS SFR, , (SFR) Methods PubMed Embase 202 (RCTs treatment 201 included RRs (RRs MDs (MDs respectively Results 46 these 24 52.7% 527 52 7 (52.7% followup follow up month RR 0.49 049 0 49 95 [CI 0.29–0.84 029084 29 84 p=0.009, p0009 p p=0.009 009 p=0.009) 0.50 050 50 0.30–0.83 030083 30 83 p=0.008. p0008 p=0.008 008 p=0.008) 1.05 105 05 0.99–1.11 099111 99 11 p=0.10, p010 p=0.10 10 p=0.10) 1.29 129 0.95–1.75 095175 75 p=0.11, p011 p=0.11 p=0.11) MD 356 3 56 3.5 minutes 415 4 15 −4.1 1127 27 11.2 p=0.36, p036 p=0.36 36 p=0.36) 032 32 0.3 days 042 42 −0.4 107 07 1.0 p=0.40. p040 p=0.40 40 p=0.40) Conclusion post However (SFR 20 2 52.7 5 (52.7 0.4 04 9 0.29–0.8 02908 8 p000 p=0.00 00 0.5 0.30–0.8 03008 0.99–1.1 09911 p01 p=0.1 1.2 12 0.95–1.7 09517 35 3. 41 −4. 112 11. p03 p=0.3 03 0. −0. 1. p04 p=0.4 52. (52. 0.29–0. 0290 p00 p=0.0 0.30–0. 0300 0.99–1. 0991 p0 p=0. 0.95–1. 0951 −4 −0 (52 0.29–0 029 0.30–0 030 0.99–1 099 p=0 0.95–1 095 − (5 0.29– 02 0.30– 0.99– 09 p= 0.95– ( 0.29 0.30 0.99 0.95 0.2 0.9

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 Introduction: We aim to publish our innovative modified biplanar 0-90 endoscopic guided puncture technique for percutaneous nephrolithotomy in supine recorded with a GoPro® camera for standardization of the technique. It solves drawbacks of the fluoroscopic technique, i.e., in kidneys with complex anatomy, it may be challenging to distinguish calyces as they are often superposed, and it does not allow for all benefits of a combined endoscopic approach (1, 2). Our technique shortens puncture and fluoroscopic time and is easy to teach and reproduce. Methods: A 77-year-old female patient had previous double J insertion due to an obstructing stone in the right distal ureter. She managed to pass the distal stone but remained with the double J and a 20mm stone (1300HU) in the right renal pelvis. The shared decision was for the actual standard of care (3, 4) endoscopic combined intrarenal surgery (ECIRS). The MiniECIRS started with flexible ureteroscopy and a posterior calix which gave direct access to the stone was chosen. The tip of the flexible scope was used to mark point A with the C-arm in the 0-degree position and line B in the 90-degree position. Puncture was fast and the MiniECIRS was uneventful with a single mid-pole access guided by the flexible scope. The surgeon had a Full-HD GoPro® camera mounted on his head, controlled by the surgical staff. All essential surgical steps were recorded. Results: The quality of the recorded movie was graded as excellent, and the camera did not cause any discomfort to the surgeon. Operative and X-Ray time were 120minutes and 2minutes (7.64mGy). Hemoglobin drop was 0.8g/dL. The post-operative day-1 computed tomography scan was stone-free. The patient was discharged 24h after surgery. Kidney stent was left with a string and removed after 5days. The patient remained asymptomatic and metabolic evaluation revealed a calcium oxalate stone, low urinary volume and hypocitraturia which were treated with potassium citrate and hydration. Conclusion: The Modified Biplanar (0-90 degree) Endoscopic-Guided Puncture Technique for Percutaneous Nephrolithotomy joins the reproducibility of the same technique under fluoroscopy with advantages regarding safety and efficiency of ECIRS. Introduction 090 0 90 0-9 GoPro ie i e i.e. anatomy superposed 1, 1 (1 2. 2 . 2) reproduce Methods 77yearold yearold 77 year old ureter mm 1300HU HU (1300HU pelvis 3, 3 (3 4 ECIRS (ECIRS) chosen Carm C arm 0degree degree 90degree midpole mid pole FullHD Full HD head staff Results excellent XRay X Ray minutes 7.64mGy. 764mGy mGy 7.64mGy 7 64mGy (7.64mGy) 08gdL gdL 8g dL g 0.8g/dL postoperative post operative day1 day day- stonefree. stonefree free. free stone-free h 5days days hydration Conclusion (0-9 EndoscopicGuided Endoscopic Guided 09 9 0- i.e ( (ECIRS (7.64mGy (0- (0

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.

ABSTRACT Purpose: The objective of this study is to evaluate the impact of a previous standard percutaneous nephrolithotomy (PCNL) on the outcomes of retrograde intrarenal surgery (RIRS). Materials and Methods: Outcomes of RIRS performed from January 2017 to January 2020 in adult patients with residual stone fragments ≤20mm after a standard PCNL (Post-PCNL) and symptomatic adult patients with kidney stones ≤20mm (Control) were prospectively studied. Stone-free rate (SFR) was evaluated on a postoperative day 90 non-contrast computed tomography. Surgical complications based on Clavien-Dindo classification during the 90 days of follow-up were recorded. Results: Outcomes of 55 patients and 57 renal units of the post-PCNL group were compared to 92 patients and 115 renal units of the control group. SFR was lower in post-PCNL group than in control (28/57, 49.1% vs. 86/115, 74.8%, p <0.001). Overall complications were more frequent in post-PCNL group (p=0.004). Infundibula strictures were identified and incised with laser in 15/57 (26.3%) renal units of the post-PCNL group. Thirteen renal units had infundibulum stricture at the site of previous percutaneous tract (13/15; 86.7%, p=0.004) and one renal unit had three infundibula strictures. Postoperative complications were not affected by the treatment of infundibula strictures (p=0.198). Conclusions: Previous standard PCNL significantly impairs the outcomes of RIRS. Infundibula strictures can be found in 26.3% of the patients with residual stone fragments after standard PCNL for large burden kidney stones. The main site of infundibulum stricture after standard PCNL is the infundibulum of the entry calyx.

ABSTRACT Purpose: to evaluate the effect of low-calorie diet on 24-hour urinary metabolic parameters of obese adults with idiopathic calcium oxalate kidney stones. Materials and Methods: Adult idiopathic calcium oxalate stone formers, with body mass index (BMI) ≥30kg/m2 and a known lithogenic metabolic abnormality, were submitted to low-calorie diet for twelve weeks. After enrolment, anthropometric measures, serum exams, 24-hour urinary metabolic parameters and body impedance were collected one month prior to dietary intervention and at the end of twelve weeks. Correlations between weight loss, waist circumference loss, fat loss and variation in 24-hour urinary lithogenic parameters and calcium oxalate urinary supersaturation (CaOx SS) as per Tiselius equation were analysed. Results: From January 2017 to January 2018, 39 patients were enrolled to participate in this study. Median (range) prescribed diet was 1300 (1100-2100) Kcal/day. Mean age was 51.7±11.0 (29-68) years old and 69.2% were female. 30.8% of the participants shifted from obesity to BMI <30kg/m2 and none to BMI <25kg/m2. A significant correlation was found between baseline 24-hour urinary oxalate and weight (p=0.018) and BMI (p=0.026). No correlation was found between variation of weight, waist circumference, fat mass and 24-h urinary stone risk factors or CaOx SS. Conclusions: Short-term modest weight loss induced by twelve weeks of low-calorie diet is not associated with a decrease of 24-hour urinary lithogenic parameters in idiopathic calcium oxalate stone formers. Calcium oxalate urinary stone formation is probably multifactorial and driven by other factors than weight.

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.

Resumo Contexto e objetivo: Cálculos de fosfato de amônio e magnésio (FAM), também conhecidos como cálculos de estruvita, estão associados à infecção urinária e ao comprometimento da unidade renal. O objetivo deste estudo é avaliar os fatores de risco metabólico-urinários para recorrência de cálculos renais em pacientes submetidos à nefrectomia devido a cálculo de FAM. Métodos: Revisamos retrospectivamente os prontuários de pacientes > 18 anos submetidos à nefrectomia total devido a cálculos de FAM puro e cálculos de oxalato de cálcio puro (OxCa) de julho de 2006 a julho de 2016. Os parâmetros metabólicos urinários foram avaliados através de exames de urina de 24 horas ≥ 3 meses após a nefrectomia. Os parâmetros metabólicos urinários e um novo evento relacionado à litíase foram comparados. Resultados: Vinte e oito e 39 pacientes foram incluídos nos grupos FAM e OxCa, respectivamente. As anormalidades em amostras de urina de 24 horas foram similares entre os grupos. A hipercalciúria ocorreu em 7,1 e 10,3% dos pacientes nos grupos FAM e OxCa, respectivamente (p = 0,66), enquanto a hipocitratúria esteve presente em 65,2 e 59,0% dos pacientes nos grupos FAM e OxCa, respectivamente (p = 0,41). Nenhuma diferença significativa em novos eventos foi encontrada entre os grupos FAM e OxCa (17,9 vs. 23,1%, respectivamente; p = 0,60). Conclusão: Uma avaliação de urina de 24 horas deve ser oferecida aos pacientes submetidos à nefrectomia devido a cálculos de FAM puro, a fim de detectar risco metabólico, melhorar o tratamento e prevenir a recorrência de cálculos.

Abstract Background and objective: Magnesium ammonium phosphate stones (MAP), also known as struvite stones, are associated with urinary infection and impairment of renal unit. The aim of this study is to evaluate the urinary metabolic risk factors for recurrence of renal calculi in patients submitted to nephrectomy due to MAP stones. Methods: We retrospectively reviewed the charts of patients > 18 years old submitted to total nephrectomy due to pure MAP stones and pure calcium oxalate (CaOx) stones from July 2006 to July 2016. Urinary metabolic parameters were assessed through 24-hour urine exams ≥ 3 months after nephrectomy. Urinary metabolic parameters and new event related to lithiasis were compared. Results: Twenty-eight and 39 patients were included in MAP and CaOx group, respectively. Abnormalities in 24-hour urine samples were similar between groups. Hypercalciuria occurred in 7.1 and 10.3% of patients in MAP and CaOx group, respectively (p = 0.66), whereas hypocitraturia was present in 65.2 and 59.0% of patients with MAP and CaOx group, respectively (p = 0.41). No significant difference in new events was found between MAP and CaOx groups (17.9 vs. 23.1%, respectively; p = 0.60). Conclusion: A 24-hour urine evaluation should be offered to patients submitted to nephrectomy due to pure MAP stones in order to detect metabolic risk, improve treatment, and prevent stone recurrence.

ABSTRACT Objectives Measurements of stone features may vary according to the non-contrast computed tomography (NCCT) technique. Using magnified bone window is the most accurate method to measure urinary stones. Possible differences between stone measurements in different NCCT windows have not been evaluated in stones located in the kidney. The aim of this study is to compare measurements of kidney stone features between NCCT bone and soft tissue windows in patients submitted to retrograde intrarenal surgery (RIRS). Materials and Methods Preoperative and 90th postoperative day NCCT were performed in 92 consecutive symptomatic adult patients (115 renal units) with kidney stones between 5 mm to 20 mm (< 15 mm in the lower calyx) treated by RIRS. NCCT were evaluated in the magnified bone window and soft tissue window in three axes in a different time by a single radiologist blinded for the measurements of the NCCT other method. Results Stone largest size (7.92±3.81 vs. 9.13±4.08; mm), volume (435.5±472.7 vs. 683.1±665.0; mm3) and density (989.4±330.2 vs. 893.0±324.6; HU) differed between bone and soft-tissue windows, respectively (p<0.0001) 5.2% of the renal units (6/115) were reclassified from residual fragments > 2 mm on soft tissue window to 0-2 mm on bone window. Conclusion Kidney stone measurements vary according to NCCT window. Measurements in soft tissue window NCCT of stone diameter and volume are larger and stone density is lesser than in bone window. These differences may have impact on clinical decisions.

ABSTRACT Objective To evaluate the effectiveness and outcomes of endovascular treatment of TRAS with PTA. Materials and Methods We searched our prospectively collected database looking at cases of TRAS between January 2005-December 2011. CCT was the gold-standart for diagnosis of TRAS. Parameters analysed comprised technical aspects, arterial blood pressure variation, and renal function. A minimum follow-up of 24 months was considered. Results Of the 2221 renal transplants performed in the selected period, 22 (0.9%) patients were identified with TRAS. Fourteen (63.6%) were male and mean age was 377±14.8years (12-69). Kidney graft was from deceased donnors in 20 (80%) cases. On doppler evaluation, mean blood flow speed after transplantation, at TRAS diagnosis and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p<0.001). For SBP and DBP, there was a significant difference between between pre-intervention and all post-treatment time points (p<0.001). After 1 month of the procedure, there was stabilization of the Cr level with a significant difference between mean Cr levels along time (p<0.001). After a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. Conclusions Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS, ensuring the functionality of the graft and normalization of blood pressure and renal function.

RESUMO Objetivo: investigar os fatores de risco de conversão para cirurgia aberta na nefrectomia laparoscópica (NL) para urolitíase. Métodos: foram revisados os dados de todos os pacientes maiores de 18 anos de idade submetidos à NL entre janeiro de 2006 e maio de 2013 em nossa Instituição. Índice de Charlson, escore ASA, função renal pela equação e estágio de MDRD (Modification of Diet in Renal Disease), achados de tomografia computadorizada (TC) pré-operatória, complicações pela classificação de Clavien-Dindo e taxa de conversão foram analisados. Determinaram-se os fatores de risco para conversão por meio de regressão logística. Resultados: oitenta e quatro pacientes foram submetidos à LN, sendo que 16 (19%) tiveram seu procedimento convertido para cirurgia aberta devido à forte aderência do hilo renal aos órgãos adjacentes. Outras causas associadas à conversão foram sangramento excessivo (n=6) e lesão do intestino grosso (n=3). Na análise univariada, cirurgia renal prévia, borramento da gordura perirrenal, abscesso renal, abscesso perirrenal, abscesso pararrenal, fístula, aderência ao fígado ou baço e aderência ao intestino foram associados à conversão. Na análise multivariada, abscesso pararrenal e aderência ao intestino foram fatores de risco significativos para a conversão. Conclusão: abscesso pararrenal e aderência ao intestino demonstrados na TC pré-operatória são fatores de risco de conversão para cirurgia aberta em LN por urolitíase.

ABSTRACT Objective: to investigate the risk factors for conversion to open surgery in laparoscopic nephrectomy (LN) for urolithiasis. Methods: we reviewed data on all patients over 18 years of age submitted to LN between January 2006 and May 2013 at our institution. We analyzed the Charlson's index, the ASA score, renal function by the equation and stage of MDRD (Modification of Diet in Renal Disease), preoperative computed tomography (CT) findings, complications by the Clavien-Dindo classification and conversion rate. We used logistic regression analysis to determine the risk factors for conversion. Results: eighty-four patients underwent LN, 16 (19%) sustaining convertion to open surgery due to the strong adhesion of the renal hilum to the adjacent organs. Other causes associated with conversion were excessive bleeding (n=6) and lesion of the large intestine (n=3). In the univariate analysis, previous renal surgery, perirenal fat blurring, renal abscess, perirenal abscess, pararenal abscess, fistula, adherence to the liver or spleen, and adherence to the intestine were associated with conversion. In the multivariate analysis, pararenal abscess and adherence to the intestine were significant risk factors for conversion. Conclusion: pararenal abscess and bowel adhesions demonstrated in the preoperative CT are risk factors for conversion to open surgery in LN due to urolithiasis.

ABSTRACT Objective: To show a video of a complete supine Percutaneous Nephrolithotomy (csPCNL) performed for the treatment of a staghorn calculus, from the surgeon's point of view. The procedure was recorded with a GoPro® camera, demonstrating the ten essential steps for a successful procedure. Materials and methods: The patient was a 38 years-old woman with 2.4cm of left kidney lower pole stone burden who presented with 3 months of lumbar pain and recurrent urinary tract infections. She had a previous diagnosis of polycystic kidney disease and chronic renal failure stage 2. CT scan showed two 1.2cm stones in the lower pole (Guy's Stone Score 2). She had a previous ipsilateral double J insertion due to an obstructive pyelonephritis. The csPCNL was uneventful with a single access in the lower pole. The surgeon had a Full HD GoPro Hero 4 Session® camera mounted on his head, controlled by the surgical team with a remote control. All of the mains steps were recorded. Informed consent was obtained prior to the procedure. Results: The surgical time was 90 minutes. Hemoglobin drop was 0.5g/dL. A post-operative CT scan was stone-free. The patient was discharged 36 hours after surgery. The camera worked properly and didn't cause pain or muscle discomfort to the surgeon. The quality of the recorded movie was excellent. Conclusion: GoPro® camera proved to be a very interesting tool to document surgeries without interfering with the procedure and with great educational potential. More studies should be conducted to evaluate the role of this equipment.

ABSTRACT Introduction To present the current practice patterns on percutaneous nephrolithotomy (PCNL) in a developing country. Materials and Methods A survey was offered to Brazilian urologists during the II International Endourology Symposium held in Sao Paulo, in 2015. The first seven questions were related to demographic data while the 20 remaining were directed to urologists who performed PCNL. Results From 250 participants, 100 replied to the survey, 81% performed PCNL and 60.4% of performers had been in practice for less than 15 years. Eighty-one percent were trained in the prone position and 64% in supine. PCNL was learned during the residency in 66.7% and 2.5% had fellowship training. Prone position was the preferred decubitus for simple or complex calculi, though for obese patients there was no difference. Younger surgeons prefer supine while older surgeons prefer prone. The access was obtained by the surgeon in all cases, 96.3% use fluoroscopy and 3.7% prefer ultrasonography. Forty-seven percent use ultrasonic lithotripters and 4.1% laser. For kidney drainage, 71.6% place a nephrostomy tube. Double J stent is left in 77%. The postoperative image method was CT for 50%. Colonic injury was reported by 25%, predominantly in the senior group without statistically difference between positions. Conclusions From a selected group of urologists, we observe that Brazilian urologists usually gain their own access for PCNL guided by fluoroscopy. They predominantly prefer the prone position, use fascial dilators, ultrasonic lithotripters and place a nephrostomy tube when exiting the kidney. Fellowship programs, ultrasonography, flexible nephoscopy and tubeless procedures could be encouraged.

ABSTRACT Purpose: To assess the public hospitalization rate due to stone disease in a large developing nation for a 15-year period and its association with socio-demographic data. Materials and Methods: A retrospective database analysis of hospitalization rates in the Brazilian public health system was performed, searching for records with a diagnosis code of renal/ureteral calculi at admission between 1998–2012. Patients managed in an outpatient basis or private care were excluded. Socio-demographic data was attained and a temporal trend analysis was performed. Results: The number of stone-related hospitalizations increased from 15.7%, although the population-adjusted hospitalization rate remained constant in 0.04%. Male:female proportion among hospitalized patients was stable (49.3%:50.7% in 1998; 49.2%:50.8% in 2012), though there was a significant reduction in the prevalence of male hospitalizations (−3.8%;p=0.041). In 2012, 38% of hospitalized patients due to stone disease had 40–59 years-old. The ≥80 years-old strata showed the most significant decrease (−43.44%;p=0.022), followed by the 20–39 (−23.17%;p<0.001) and 0–19 years-old cohorts (−16.73%;p=0.012). Overall, the lowest relative hospitalization rates were found for yellow and indigenous individuals. The number of overweight/obese individuals increased significantly (+20.6%), accompanied by a +43.6% augment in the per capita income. A significant correlation was found only between income and obesity (R=0.64;p=0.017). Conclusions: The prevalence of stone disease requiring hospitalization in Brazil remains stable, with a balanced proportion between males and females. There is trend for decreased hospitalization rates of male, <40 and ≥80 years-old individuals. Obesity and income have a more pronounced correlation with each other than with stone disease.