OBJECTIVE: To compare the outcomes of retrograde flexible ureteroscopy (fURS) with retroperitoneal laparoscopic ureterolithotomy (RLU) for large proximal ureteric stones.
METHODS: A prospective randomised trial was conducted from January 2018 through December 2022 including patients with impacted proximal ureteric stones of 15-25 mm. Patients underwent fURS or RLU. Primary outcome was the stone-free rate. Demographic data, stone features, and complications rates were also compared between groups.
RESULTS: A total of 64 patients were enrolled, 32 in each group. The mean impacted stone time was similar between groups, as well as stone size (17 mm) and stone density (>1000 Hounsfield Units). The ureteric stone-free rates between the two groups (93.7% in fURS vs 96.8% in RLU; odds ratio [OR] 0.72, 95% confidence interval [CI] -1.72 to 3.17; P = 0.554), and overall success rates, which take into account residual fragments in the kidney (84.3% in fURS vs 93.7% in RLU; OR 1.02, 95% CI -0.69 to 2.74; P = 0.23), were similar. Operative time was also not statistically significantly different between groups (median 80 vs 82 min; P = 0.101). There was no difference in hospital length of stay. Retropulsion rate was higher with fURS (65.6% vs 3.1%; p < 0.001). Residual hydronephrosis (34.3% each group) and complication rates did no differ according to treatment.
CONCLUSIONS: Flexible URS and RLU are both highly efficient and present low morbidity for large impacted proximal ureteric stone treatment. RLU is not superior to fURS.

UNASSIGNED: Indocyanine green (ICG) is a visible near-infrared fluorescent dye. Several studies have reported its benefit in identifying important anatomical structures, tissue vascularization, and sentinel lymph nodes in the case of tumors. Studies have shown that ICG is critical and safe in gynecologic surgeries. However, research on how ICG dye can help surgeons in laparoscopic surgeries correctly identify the course of the ureter has yet to be further investigated.
UNASSIGNED: This cross-sectional study enrolled 62 gynecology attending and resident surgeons who were asked to identify the course of the ureter on images of laparoscopic surgeries. The results were then compared with images in which ICG dye highlighted the course of the ureter. The purpose of this study was to detect the ability of surgical assistants and residents to adequately identify the course of the ureter in laparoscopic pelvic surgeries.
UNASSIGNED: No statistically significant differences were found in terms of year of residency, years of experience, number of laparoscopic procedures attended, and correct identification of ureter course. ICG proved useful in identifying the correct ureteral trajectory.
UNASSIGNED: ICG can be a valuable tool to improve the correct identification of ureters and improve surgical outcomes.

BACKGROUND: Ureteric injury (UI) is an infrequent but serious complication of colorectal surgery. Prophylactic ureteric stenting is employed to avoid UI, yet its efficacy remains debated. Intraoperative indocyanine green fluorescence imaging (ICG-FI) has been used to facilitate ureter detection. This study aimed to investigate the role of ICG-FI in identification of ureters during colorectal surgery and its impact on the incidence of UI.
METHODS: A retrospective cohort study involving 556 consecutive patients who underwent colorectal surgery between 2018 and 2023 assessed the utility of routine prophylactic ureteric stenting with adjunctive ICG-FI. Patients with ICG-FI were compared to those without ICG-FI. Demographic data, operative details, and postoperative morbidity were analyzed. Statistical analysis included univariable regression.
RESULTS: Ureteric ICG-FI was used in 312 (56.1%) patients, whereas 43.9% were controls. Both groups were comparable in terms of demographics except for a higher prevalence of prior abdominal surgeries in the ICG-FI group. Although intraoperative visualization was significantly higher in the ICG-FI group (95.3% vs 89.1%; p = 0.011), the incidence of UI was similar between groups (0.3% vs 0.8%; p = 0.585). Postoperative complications were similar between the two groups. Median stent insertion time was longer in the ICG-FI group (32 vs 25 min; p = 0.001).
CONCLUSIONS: Ureteric ICG-FI improved intraoperative visualization of the ureters but was not associated with a reduced UI rate. Median stent insertion time increased with use of ureteric ICG-FI, but total operative time did not. Despite its limitations, this study is the largest of its kind suggesting that ureteric ICG-FI may be a valuable adjunct to facilitate  ureteric visualization during colorectal surgery.

OBJECTIVE: This study investigated the effect of administering tamsulosin before surgery on the successful insertion of a 12/14 French (F) ureteral access sheath (UAS) during the procedure, as well as the impact of preoperative and postoperative tamsulosin use on symptoms related to the ureteral stent.
METHODS: This study was a randomized, single-center, double-blinded, placebo-controlled trial involving 200 patients who underwent unilateral retrograde intrarenal surgery. Patients received either tamsulosin (0.4 mg) or placebo 1 week before surgery until stent removal. Patients were randomly assigned to one of four groups. Group 1 received tamsulosin throughout the study period. Group 2 received tamsulosin before surgery and placebo after surgery. Group 3 received placebo before surgery and tamsulosin after surgery. Group 4 received placebo before and after surgery. The USSQ (Ureteral Stent Symptom Questionnaire) was completed between postoperative days 7 and 14 immediately before stent removal.
RESULTS: A total of 160 patients were included in this analysis. Their mean age was 55.0±11.0 years, and 48 patients (30.0%) were female. In the group that received preoperative tamsulosin, the success rate of 12/14F UAS deployment was significantly higher than that of the preoperative placebo group (88.0 vs. 75.3%, p=0.038). Preoperative and postoperative tamsulosin did not significantly alleviate symptoms related to the ureteral stent.
CONCLUSIONS: Our results revealed that preoperative administration of tamsulosin improved the success of larger-sized UAS, whereas preoperative and postoperative tamsulosin use did not significantly alleviate symptoms related to ureteral stents.

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:

OBJECTIVE: To investigate the effect of oral theophylline on stent-related syndrome (SRS) after Double-J insertion.
BACKGROUND: Double-J stent is widely using in many urological procedures. Infection, hematuria, and discomfort are some of common complication after stenting. Theophylline is a dimethylated xanthine that inhibits phosphodiesterase and blocks adenosine receptors. To relaxing effect of theophylline on smooth muscles and its effects on the urinary system, it seems it could reduce complications after inserting Double-J stent especially ureteral stent syndrome.
METHODS: In this double-blind placebo-controlled randomized clinical trial, 67 patients were enrolled. Mean (SD) age of control and theophylline group was 51.8 (12.5) and 43.9 (10.4) years old, respectively. Patients were randomized into two groups of control and theophylline. All patients were stenting with silicon Double J. Theophylline group received 100 mg of theophylline, twice daily for 30 days, while control group received placebo. Stent symptoms were assessed by questionnaire and urine culture was performed before stent removal at removal day. Statistical analysis was performed using Chi-squared test and t test with P < 0.05 considered significant. Logistic regression models were fitted, crudely and adjusted for age and sex.
RESULTS: Of 67 eligible patients, 60 completed the study. Theophylline significantly decreased percentages of gross hematuria (P < 0.001), dysuria (P < 0.001), and urinary frequency (P < 0.001). Microscopic hematuria (P = 0.042) and chills (P = 0.042) also decreased after theophylline.
CONCLUSIONS: Theophylline could be an effective and safe choice for reducing SRS among patients undergoing Double-J stent insertion.

BACKGROUND: This study aimed to evaluate the intrarenal pelvic pressure in endoscopic combined intrarenal surgery using an artificial kidney model.
METHODS: An artificial kidney model was created using the Urovac evacuator™. Four sizes of nephrostomy sheaths (MIP-L: 25/26 Fr, MIP-M: 16.5/17.5 Fr, MIP-S: 11/12 Fr, MIP-XS: 8.5/9.5 Fr) and two sizes of ureteral access sheaths (12/14 Fr and 10/12 Fr) were installed into the model. For each combination of nephrostomy and ureteral access sheath, renal pelvic pressure was measured with and without insertion of the retrograde flexible ureteroscope. Irrigation from the nephroscope was adjusted to 40-160 mmHg using an automatic irrigation device, and the irrigation of the ureteroscope was by spontaneous dripping at 80 cmH2O. Conditions were measured six times, and the renal pelvic pressure was compared in different conditions.
RESULTS: Without ureteroscope insertion through the ureteral access sheath, the renal pelvic pressure never exceeded 30 mmHg. Meanwhile, when the ureteroscope was inserted, the renal pelvic pressure increased as the nephrostomy sheath and ureteral access sheath became narrower and as the irrigation pressure increased. Intrarenal pelvic pressure exceeded 30 mmHg when the irrigation pressure was increased in 12/14 Fr ureteral access sheath when MIP-XS was used, and in 10/12 Fr ureteral access sheath when MIP-XS and MIP-S were used.
CONCLUSIONS: The use of a thin nephrostomy sheath in endoscopic combined intrarenal surgery can lead to increased intrarenal pelvic pressure. Although our results are from an artificial kidney model, special care is suggested to be required when using a retrograde flexible ureteroscope simultaneously in treatment of patients.

Diagnostic reference levels (DRLs) and achievable doses (ADs) provide guidance to optimise radiation doses for patients undergoing medical imaging procedures. This multi-centre study aimed to compare institutional DRLs (IDRLs) across hospitals, propose ADs and multi-centric DRLs (MCDRLs) for four common x-ray examinations in Sri Lanka, and assess the potential for dose reduction. A prospective cross-sectional study of 894 adult patients referred for abdomen anteroposterior (AP), kidney-ureter-bladder (KUB) AP, lumbar spine AP, and lumbar spine lateral (LAT) x-ray examinations was conducted. Patient demographic information (age, sex, weight, BMI) and exposure parameters (tube voltage, tube current-exposure time product) were collected. Patient dose indicators were measured in terms of kerma-area product (PKA) using a PKAmeter. IDRLs, ADs, and MCDRLs were calculated following the International Commission on Radiological Protection guidelines, with ADs and MCDRLs defined as the 50th and 75th percentiles of the median PKAdistributions, respectively. IDRL ranges varied considerably across hospitals: 1.42-2.42 Gy cm2for abdomen AP, 1.51-2.86 Gy cm2for KUB AP, 0.83-1.65 Gy cm2for lumbar spine AP, and 1.76-4.10 Gy cm2for lumbar spine LAT. The proposed ADs were 1.82 Gy cm2(abdomen AP), 2.03 Gy cm2(KUB AP), 1.27 Gy cm2(lumbar spine AP), and 2.21 Gy cm2(lumbar spine LAT). MCDRLs were 2.24 Gy cm2(abdomen AP), 2.40 Gy cm2(KUB AP), 1.43 Gy cm2(lumbar spine AP), and 2.38 Gy cm2(lumbar spine LAT). Substantial intra- and inter-hospital variations in PKAwere observed for all four examinations. Although ADs and MCDRLs in Sri Lanka were comparable to those in the existing literature, the identified intra- and inter-hospital variations underscore the need for dose reduction without compromising diagnostic information. Hospitals with high IDRLs are recommended to review and optimise their practices. These MCDRLs serve as preliminary national DRLs, guiding dose optimisation efforts by medical professionals and policymakers.

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.

OBJECTIVE: To evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones.
METHODS: We analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient\'s demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization.
RESULTS: Overall, median (IQR) age and stone volume were 56 (47-65) years and 1.7 (0.8-4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time.
CONCLUSIONS: One out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.