OBJECTIVE: To assess laser-tissue interactions through ablation, coagulation, and carbonisation characteristics in a non-perfused porcine kidney model between three pulsed lasers: holmium (Ho): yttrium-aluminium-garnet (YAG), thulium fiber laser (TFL), and pulsed thulium (p-Tm):YAG.
METHODS: A 150-W Ho:YAG, a 60-W TFL, and a 100-W p-Tm:YAG lasers were compared. The laser settings that can be set identically between the three lasers and be clinically relevant for prostate laser enucleation were identified and used on fresh, unfrozen porcine kidneys. Laser incisions were performed using stripped laser fibers of 365 and 550 μm, set at distances of 0 and 1 mm from the tissue surface at a constant speed of 2 mm/s. Histological analysis evaluated shape, depth, width of the incision, axial coagulation depth, and presence of carbonisation.
RESULTS: Incision depths, widths, and coagulation zones were greater with Ho:YAG and p-Tm:YAG lasers than TFL. Although no carbonisation was found with the Ho:YAG and p-Tm:YAG lasers, it was common with TFL, especially at high frequencies. The shapes of the incisions and coagulation zones were more regular and homogeneous with the p-Tm:YAG laser and TFL than with Ho:YAG laser. Regardless of the laser used, short pulse durations resulted in deeper incisions than long pulse durations. Concerning the distance, we found that to be effective, TFL had to be used in contact with the tissue. Finally, 365-μm fibers resulted in deeper incisions, while 550-μm fibers led to wider incisions and larger coagulation zones.
CONCLUSIONS: Histological analysis revealed greater tissue penetration with the p-Tm:YAG laser compared to the TFL, while remaining less than with Ho:YAG. Its coagulation properties seem interesting insofar as it provides homogeneous coagulation without carbonisation, while incisions remained uniform without tissue laceration. Thus, the p-Tm:YAG laser appears to be an effective alternative to Ho:YAG and TFL lasers in prostate surgery.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is a common urological condition affecting aging men worldwide. Among the treatment options available for BPH, transurethral resection of the prostate (TURP) is the gold-standard invasive intervention. To reduce the TURP-related non-negligible morbidity, loss-of-ejaculation rate, hospitalization, blood loss and catheterization time several laser techniques have been developed, such as the Thulium Laser Enucleation of the Prostate (ThuLEP). To investigate the efficacy outcomes of the ThuLEP as a treatment option for benign prostatic hyperplasia (BPH) we performed a retrospective observational study at Moriggia Pelascini Hospital (Como, Italy) between January 2015 and September 2018.
METHODS: We included 265 patients who underwent ThuLEP at a specific hospital between defined dates. Data on various parameters, including post-void residue volume, peak urinary flow rate (Qmax), International Prostate Symptom Score (IPSS) for urinary symptoms, IPSS Quality of Life (QoL) score, and International Index of Erectile Function (IIEF) score for erectile dysfunction, were collected at baseline and follow-up.
RESULTS: The analysis revealed significant improvements in voiding efficiency, urinary flow, urinary symptoms, quality of life, and erectile function following ThuLEP. Furthermore, certain baseline characteristics, such as post-void residue, peak urinary flow rate, age, prostate volume, and aspirin usage, were found to influence treatment outcomes.
CONCLUSIONS: Despite the study\'s limitations, these findings contribute to understanding ThuLEP\'s effectiveness in managing BPH and can aid in making informed clinical decisions for patient care. Prospective studies with longer follow-up periods are recommended to validate and extend these results.

OBJECTIVE: To assess the impact of endoscopic stone surgeries on renal perfusion and blood flow in children.
METHODS: Children who underwent percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), ureterorenoscopy (URS), endoscopic combined intrarenal surgery (ECIRS) were included to the study. Renal Doppler ultrasonography (RDUS) was performed one day before the operation, and on the postoperative 1st day and 1st month. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured, and resistive index (RI) was calculated with the (PSV-EDV)/PSV formula. RDUS parameters were compared before and after surgery and between ipsilateral and contralateral kidneys.
RESULTS: A total of 45 children with a median age was 8 (2-17) years were included (15 (33.3%) girls, 30 (66.7%) boys). PCNL was performed in 13 children (28.9%), RIRS 11 (24.4%), URS 12 (26.7%), and ECIRS 9 (20%). There was no significant difference in renal and segmental PSV, EDV and RI values of operated kidney in the preoperative, postoperative periods. There was no significant difference between RDUS parameters of the ipsilateral and contralateral kidneys in preoperative or postoperative periods. PSV and EDV values were significantly higher in the 1st postoperative month in the group without preoperative DJ stent than in the group with DJ stent (p = 0,031, p = 0,041, respectively). However, RI values were similar. The mean RI were below the threshold value of 0.7 in each period.
CONCLUSIONS: RDUS parameters didn\'t show a significant difference in children. Endoscopic surgeries can be safely performed in pediatric stone disease.

OBJECTIVE: To characterize and compare in vitro the surfaces of ureteral stents (STENTS) before utilization.
METHODS: Our in vitro experiment included six unused STENTS models: three double-pigtail with side orifices (ImaJin and Stenostent [Coloplast©,France], TriaSoft [BostonScientific©,USA]), two double-pigtail without side orifice (Vortek-TumorStent [Coloplast©,France], Urosoft-TumorStent [Bard-Angiomed©,Germany]) and one single-pigtail (J-Fil [Rocamed©,Monaco]). STENTS were made of polyurethane except for ImaJin (silicone). For all STENTS, four parts of the stent were specifically analyzed under high-resolution scanning electron microscopy (HR-SEM,FEI-XL40 [Philips©,France]): surface core, lateral orifice, ureteral loop, and black marking surface. Each experiment was repeated with three different samples from three different stents. STENTS analysis included multiple imperfection searches, defined as irregularities>10μm.
RESULTS: All STENTS presented imperfections with no discernible differences. Imperfections were mainly located on the stent loop and on the lateral orifice. For STENTS without side orifice (J-Fil, Urosoft) imperfections were also reported, on the beveled cut as well as the distal loop orifice. Marking surfaces examinations found defects in the Urosoft and imperfections in the ImaJin and Stenostent. The Triasoft presented a better smoothness on marking surfaces compared to other STENTS. Additional matter was reported on the loop distal orifice for J-Fil and ImaJin but all STENTS presented irregular cross-sectional aeras.
CONCLUSIONS: All ureteral stents are not perfectly smooth even before utilization. Imperfections were noticed regardless to stent composition or shape, and could play a role in the incrustation phenomenon, is association with inner irregularities, infection, and urine composition. Both manufacturing and material could have an impact on the stent external surface\'s smoothness.
METHODS:

Purpose: The aim of this study is to evaluate the possible benefits of using video consent in the preoperative ureteroscopy (URS) consent process. Material and Methods: Prospective randomized trials took place at two Italian tertiary-care centers from March 2022 to September 2022. Patients were randomly assigned to two groups: Group A (standard verbal/written informed consent) and Group B (informed consent supported by video). We investigated the impact of both types of informed consent on patient anxiety levels using the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire both pre- and post-consent. In addition, using the Visual Analogue Scale, analysis of the effect of informed consent on postoperative pain and the number of calls for assistance during hospitalization as secondary outcomes was done. To assess the satisfaction level related to the whole process, patients were asked to rate their experience on a scale of 1-10, with 1 indicating \"not satisfied\" and 10 indicating \"completely satisfied.\" Results: Overall, 166 patients were randomized 1:1 in each group. The multivariable regression model demonstrated that video-assisted informed consent significantly increased the difference between post- and pre-consent STAI with a reduced level of anxiety. The video-assisted informed consent significantly predicted the number of assistance calls during hospitalization. Conclusions: Video consent for ureteroscopies is a valid tool to improve procedure awareness and satisfaction. Video consent is able to reduce procedure-related patient anxiety and postoperative assistance calls, thus proving to be useful in obtaining better-informed consent for endourological procedures.

OBJECTIVE: The question of best surgical treatment for lower urinary tract symptoms (LUTS) due to benign prostate hyperplasia (BPH) remains controversial. We compared the outcomes of aquablation and holmium laser enucleation of the prostate (\"HoLEP\") in a prospective cohort.
METHODS: Patients with BPH underwent aquablation or HoLEP according to their preference between June 2020 and April 2022. Prostate volume (\"PV\"), laboratory results, postvoid residual volume, uroflowmetry, IPSS, ICIQ-SF, MSHQ-EjD, EES and IIEF were evaluated preoperatively and at three, six and 12 months postoperatively. We also analyzed perioperative characteristics and complications via the Clavien Dindo (\"CD\") classification.
RESULTS: We included 40 patients, 16 of whom underwent aquablation and 24 HoLEP. Mean age was 67 years (SD 7.4). Baseline characteristics were balanced across groups, except the HoLEP patients\' larger PV. IPSS fell from 20.3 (SD 7.1) at baseline to 6.3 (SD 4.2) at 12 months (p < 0.001) without differences between aquablation and HoLEP. HoLEP was associated with shorter operation time (59.5 (SD 18.6) vs. 87.2 (SD 14.8) minutes, p < 0.001) and led to better PV reduction over all timepoints. At three months, aquablation\'s results were better regarding ejaculatory (p = 0.02, MSHQ-EjD) and continence function (p < 0.001, ICIQ-SF). Beyond three months, erectile, ejaculatory, continence function and LUTS reduction did not differ significantly between aquablation and HoLEP. CD ≥ grade 3b complications were noted in six patients in aquablation group while only one in HoLEP group (p =  < 0.01).
CONCLUSIONS: While aquablation revealed temporary benefits regarding ejaculation and continence at three months, HoLEP was superior concerning operation time, the safety profile and volumetric results.

OBJECTIVE: To compare stent-related symptoms (SRS) in patients with double J (DJ) undergoing substitution with a pigtail suture stent (PSS) after ureteroscopy (URS), through the Ureteral Stent Symptom Questionnaire (USSQ).
METHODS: Patients with DJ undergoing URS for stone treatment were enrolled in this prospective multicenter longitudinal study. The USSQ was submitted thrice: 2 weeks after DJ, 2 weeks after PSS and 4 weeks after PSS removal (baseline).
METHODS: to compare Urinary Symptom Index Score and the rate of patients with pain 2 weeks after DJ and PSS. Secondary endpoints: to compare other USSQ scores and single answers 2 weeks after DJ and PSS, and DJ and PSS USSQ scores with baseline.
RESULTS: 93 patients were enrolled. 2 weeks Urinary Symptom Index Score (p < 0.001) and the percentage of patients complaining of pain (60.2% vs 88.2%, p < 0.001) were significantly in favour of PSS compared to DJ. 2 weeks scores were significantly improved with PSS compared to DJ: Pain Index (p < 0.001), VAS (p < 0.001), General Health Index (p < 0.001) and Work Performance Index (p < 0.001). All urinary symptoms were significantly decreased with PSS, including renal pain during micturition and pain interfering with life. Pain Index Score (p = 0.622) and VAS (p = 0.169) were comparable to baseline with PSS, while differed with DJ.
CONCLUSIONS: Patients undergoing DJ substitution with PSS after URS report a significant decrease of SRS. Urologists may consider positioning PSS after URS in pre-stented patients to reduce the impact of SRS.

UNASSIGNED: The aims were to describe a software-based reconstruction of the patient-specific kidney cavity intraluminal appearance via a head-mounted device and to estimate its feasibility for training novices.
UNASSIGNED: In total, 15 novices were recruited. Each novice was shown a three-dimensional reconstruction of a patient\'s computed tomography scan, whose kidney was printed. They then joined the surgeon in the operating room and assisted them in detecting the stone during flexible ureteroscopy on the printed model. Then, each participant did a 7-day virtual reality (VR) study followed by virtual navigation of the printed kidney model and came to the operating room to help the surgeon with ureteroscope navigation. The length of the procedure and the number of attempts to find the targeted calyx were compared.
UNASSIGNED: With VR training, the length of the procedure (p = 0.0001) and the number of small calyces that were incorrectly identified as containing stones were significantly reduced (p = 0.0001). All the novices become highly motivated to improve their endourological skills further. Participants noticed minimal values for nausea and for disorientation. However, oculomotor-related side effects were defined as significant. Five specialists noticed a good similarity between the VR kidney cavity representation and the real picture, strengthening the potential for the novice\'s education via VR training.
UNASSIGNED: Virtual reality simulation allowed for improved spatial orientation within the kidney cavity by the novices and could be a valuable option for future endourological training and curricula.

BACKGROUND: Due to the radiation exposure for the urology staff during endourology, our aim was to evaluate the trends of radiation protection in the operation room by endourologists from European centers and to estimate their annual radiation.
METHODS: We conducted a multicenter study involving experienced endourologists from different European centers to evaluate whether the protection and threshold doses recommended by the International Commission on Radiation Protection (ICRP) were being followed. A 36-question survey was completed on the use of fluoroscopy and radiation protection. Annual prospective data from chest, extremities, and eye dosimeters were collected during a 4-year period (2017-2020).
RESULTS: Ten endourologists participated. Most surgeons use lead aprons and thyroid shield (9/10 and 10/10), while leaded gloves and caps are rarely used (2/10 both). Six out of ten surgeons wear leaded glasses. There is widespread use of personal chest dosimeters under the apron (9/10), and only 5/10 use a wrist or ring dosimeter and 4 use an eye dosimeter. Two endourologists use the ALARA protocol. The use of ultrasound and fluoroscopy during PCNL puncture was reported by 8 surgeons. The mean number of PCNL and URS per year was 30.9 (SD 19.9) and 147 (SD 151.9). The mean chest radiation was 1.35 mSv per year and 0.007 mSv per procedure. Mean radiation exposure per year in the eyes and extremities was 1.63 and 11.5 mSv.
CONCLUSIONS: Endourologists did not exceed the threshold doses for radiation exposure to the chest, extremities and lens. Furthermore, the ALARA protocol manages to reduce radiation exposure.

UNASSIGNED: Observational studies on the association of endourological procedures with renal parenchymal damage are lacking. This randomized trial examined the effect of standard percutaneous nephrolithotomy (sPCNL) in comparison with miniaturized-PCNL (mini-PCNL) and retrograde intrarenal surgery (RIRS) for nephrolithiasis treatment on novel biomarkers of renal injury.
UNASSIGNED: Seventy-five patients were randomized in a 1:1:1 ratio to receive sPCNL, mini-PCNL and RIRS for nephrolithiasis. The ratios of neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1) and interleukin-18 (IL-18) normalized for urinary creatinine (Cr) were calculated from urine samples collected at baseline (2-h preoperatively) and at 2-, 6-, 24- and 48-h postoperatively. Two-way mixed analysis of variance (ANOVA) for repeated measurements was used to evaluate the effects of type of procedure and time on studied biomarkers.
UNASSIGNED: Between baseline and 2-h postoperatively, no significant differences were observed in NGAL/Cr changes between sPCNL [median (interquartile range) 9.46 (4.82-14.9)], mini-PCNL [12.78 (1.69-25.24)] and RIRS [6.42 (2.61-23.90)] (P = .902). Similarly, no between-group differences were observed for KIM-1/Cr (P = .853) and IL-18 (P = .980) at 2 h, and all biomarkers at any time-point postoperatively. Within-groups, significant increases from baseline were noted for NGAL/Cr (sPCNL, P < .001; mini-PCNL, P < .001; RIRS, P = .001), KIM-1/Cr and IL-18/Cr at 2 h; progressively lower increases from baseline were noted in all groups for KIM-1/Cr and IL-18/Cr at 6-, 24- and 48-h postoperatively. As such, a significant effect of time but not of type of procedure was evidenced with two-way mixed ANOVA. No significant between-group differences were observed in acute kidney injury incidence and complications.
UNASSIGNED: The endourological procedures under study are associated with similar patterns of early tubular injury, detected by novel biomarkers, which is largely reduced within 48 h and no changes in glomerular function.