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

Objective: To develop a user friendly system (S.T.O.N.E. Score) to quantify and describe stone characteristics provided by computed axial tomography scan to predict ureteroscopy outcomes and to evaluate the characteristics that are thought to affect stone free rates. Materials and Methods: The S.T.O.N.E. score consists of 5 stone characteristics: (S)ize, (T)opography (location of stone), (O)bstruction, (N)umber of stones present, and (E)valuation of Hounsfield Units. Each component is scored on a 1-3 point scale. The S.T.O.N.E. Score was applied to 200 rigid and flexible ureteroscopies performed at our institution. A logistic model was applied to evaluate our data for stone free rates (SFR). Results: SFR were found to be correlated to S.T.O.N.E. Score. As S.T.O.N.E. Score increased, the SFR decreased with a logical regression trend (p < 0.001). The logistic model found was SFR=1/(1+e^(-z)), where z=7.02-0.57*Score with an area under the curve of 0.764. A S.T.O.N.E. Score ≤ 9 points obtains stone free rates > 90% and typically falls off by 10% per point thereafter. Conclusions: The S.T.O.N.E. Score is a novel assessment tool to predict SFR in patients who require URS for the surgical therapy of ureteral and renal stone disease. The features of S.T.O.N.E. are relevant in predicting SFR with URS. Size, location, and degree of hydronephrosis were statistically significant factors in multivariate analysis. The S.T.O.N.E. Score establishes the framework for future analysis of the treatment of urolithiasis.

Purpose The purpose of this study is to determine if body mass index (BMI) and stone skin distance (SSD) affect stone free rate (SFR) in obese and morbid obese patients who underwent flexible URS for proximal ureteral or renal stones < 20 mm. Materials and Methods A retrospective chart review was performed of consecutive patients that underwent flexible URS. Inclusion criteria were: proximal ureteral stones and renal stones less than 20 mm in the preoperative computed tomography (CT). SFR were then compared according to SSD and BMI. Results A total of 153 patients were eligible for this analysis, 49 (32.02%) with SSD < 10 cm and 104 (67.97%) with SSD ≥ 10 cm. The mean stone size was 10.5 ± 6.4 mm. The overall SFR in our study was 82.4%. The SFR for the SSD < 10 and ≥ 10 were 79.6% and 83.7% respectively (p = 0.698) and for BMI < 30, ≥ 30 and < 40 and ≥ 40 were 82.9%, 81.7% and 90.9% respectively. Regression analysis showed no affect between BMI or SSD regarding SFR. Conclusion Ureteroscopy should be considered as a first-line of treatment for renal/proximal stones in obese and morbid obese patients. URS may be preferable to SWL in obese patients independently of the SSD, BMI or the location of proximal stones.

Purpose To report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the management of patients with indication for inguinal lymphadenectomy. Surgical Technique: VEIL was applied in all patients using the oncological landmarks (the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly). A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle. A second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO2 at 5-15 mmHg. The final trocar was placed 2 cm proximally and 6 cm laterally from the first port. Results: A total of 5 VEIL procedures in 3 patients were performed. Two patients underwent simultaneous bilateral VEIL while another underwent simultaneous bilateral surgery with VEIL on the right and open lymphadenectomy on the left side due to an enlarged node. All laparoscopic procedures were successfully performed without conversion and maintained the oncological templates. One lymphocele occurred in the patient who underwent the open procedure. None of the patients presented with skin necrosis after the procedure. Mean number of nodes retrieved was 6 from each side and 2 patients presented with positive inguinal nodes. After one year of follow-up no recurrences were observed. Conclusion: Simultaneous lymphadenectomy procedures are feasible. Improvement in operative and anesthesia time could decrease the morbidity associated with inguinal lymphadenectomy while maintaining the oncological principles.

INTRODUCTION: The objective of our study is to present the first Brazilian cryoablation experience in the treatment of low and intermediate risk localized prostate cancer using 3rd generation cryoablation and real-time biplanar transrectal ultrasonography. MATERIALS AND METHODS: Ten Brazilian patients underwent primary cryoablation for localized prostate cancer between October 2010 and June 2011. All patients consented for whole gland primary cryotherapy. The procedures were performed by 3rd generation cryoablation with the Cryocare System® (Endocare, Irvine, California). Preoperative data collection included patient demographics along with prostate gland size, Gleason score, serum prostate specific antigen, and erectile function status. Operative and post-operative assessment involved estimated blood loss, operative time, complications, serum PSA level, erectile function status, urinary incontinence, biochemical disease free survival (BDFS), and follow-up time. RESULTS: All patients in the study successfully underwent whole gland cryoablation. The mean of: age, prostate size, PSA level, and Gleason score, was 66.2 years old; 40.7g; 7.8ng/mL; and 6 respectively. All patients were classified as low or moderate D'Amico risk (5 low and 5 moderate). Erectile dysfunction was present in 50% of patients. The estimated blood loss was minimal, operative time was 46.1 minutes. All patients that developed erectile dysfunction post-treatment responded to oral or intracavernosal medications with early penile rehabilitation. All patients maintained urinary continence by the end of a 10 months evaluation period and none had biochemical relapse within the mean follow-up of 13 months (7-15 months). CONCLUSION: Our initial experience shows that cryoablation is a minimally invasive option for the treatment of localized prostate cancer. Short term data seems to be promising but longer follow-up is necessary to verify oncological and functional results.

INTRODUCTION: We present the initial experience of a novel surgical chair for laparoscopic pelvic surgery, the ETHOS TM (Bridge City Surgical, Portland, OR). MATERIALS AND METHODS: The ETHOS chair has an adjustable saddle height that ranges from 0.89 to 1.22 m high, an overall width of 0.89 m, and a depth of 0.97 m. The open straddle is 0.53 m and fits most OR tables. We performed 7 pelvic laparoscopy cases with the 1st generation ETHOS TM platform including 2 laparoscopic ureteral reimplantations, 5 laparoscopic pelvic lymphadenectomies for staging prostate cancer in which one case involved a laparoscopic radical retropubic prostatectomy, performed by 2 different surgeons. RESULTS: All 7 pelvic laparoscopic procedures were successful with the ETHOS TM chair. No conversion to open surgery was necessary. Survey done by surgeons after the procedures revealed minimal stress on back or upper extremities by the surgeons from these operations even when surgery was longer than 120 minutes. Conversely, the surgical assistants still had issues with their positions since they were on either sides of the patient stressing their positions during the procedure. CONCLUSION:The ETHOS chair system allows the surgeon to operate seated in comfortable position with ergonomic chest, arms, and back supports. These supports minimize surgeon fatigue and discomfort during pelvic laparoscopic procedures even when these procedures are longer than 120 minutes without consequence to the patient safety or detrimental effects to the surgical team.