Renal arterial embolization is a well-established treatment for renal trauma, with most reported complications occurring early after the procedure. We report a case of ureteral obstruction caused by migration of a renal embolization coil 25 years after blunt renal trauma, managed with initial ureteral stenting followed by elective ureteroscopic removal. This case highlights that embolization-related complications may present long after the original intervention and should be considered in patients presenting with renal colic and a remote history of renal embolization.

Introduction: To help understand and better meet the needs of its membership, the Endourological Society (ES) conducts an annual membership survey. The purpose of this article is to report the findings of the third annual census of the ES. Materials and Methods: A 39-question Qualtrics survey was distributed to ES members around the time of the 41 st World Congress of Endourology and Uro-Technology (WCET). Questions were divided into three categories including demographics, engagement, and the WCET. Responses were analyzed and are reported to facilitate the society’s ability to respond to the needs of its membership. Results: Of the 1730 dues-paying members of the ES, 458 questionnaire responses were obtained (26.5% response rate). The average age of respondents was 50.2 years, 91.5% were male, and 63% completed a fellowship. Of these, 59% of respondents were in academic practice spread across 64 different countries. The most common procedure performed by respondents was complex retrograde endoscopy (83%) followed by percutaneous nephrolithotomy (76%). The majority of respondents (89%) participated in clinical research. Most respondents (96.3%) felt that the ES had an impact on their professional development. Conclusions: The survey results demonstrate that the ES has a broad international involvement and has a significant impact on its members’ professional development. Importantly, the results also suggest avenues to increase impact by (1) encouraging broader participation including younger physicians; (2) prioritizing affordable and desirable meeting locations; (3) reducing session overlap; and (4) improving virtual connectivity and language services so that more members worldwide can participate in ES offerings.

Background/Aims:Current guidelines suggest that the indications for pelvic lymph node (LN) dissection (PLND) during radical prostatectomy (RP) should rely on nomograms predicting their involvement. Positron emission tomography/computed tomography (PET/CT) with prostate-specific membrane antigen (PSMA) radioligand is gaining acceptance as routine diagnostic test before RP in patients with intermediate/high-risk prostate cancer (PC). In this study, we examined the effect of preoperative PET/CT on the accuracy of the nomograms. Materials and methods:Patients with intermediate/high risk PC showing no extraprostatic disease on PET/CT-PSMA underwent RP with PLND and were followed postoperatively for at least 6 months. Patients with detectable (>0.1 ng/mL) postoperative prostate-specific antigen levels underwent re-evaluation with PET/CT-PSMA. Results:A total of 70 patients underwent RP for intermediate (34 patients) or high-risk disease (36 patients). According to the Partin, MSKCC, and Briganti 2012 nomograms, positive LNs were expected in 7, 13, and 12 patients, respectively. At PLND, 1 positive LN was found in a single patient (p < 0.05 compared with the expected number of patients from all nomograms). Postoperatively, 10 patients developed detectable prostate-specific antigen levels. One patient exhibited radioligand uptake that could indicate LN involvement. Considering these 2 patients as failures, the negative predictive value of PSMA-PET/CT for LN involvement was 97.1%. Conclusions:Preoperative PSMA-PET/CT with no extraprostatic uptake before RP in patients with intermediate to high-grade PC is highly accurate for ruling out LN involvement, superior to the routinely used nomograms. Its use induced stage migration, rendering predictive nomograms irrelevant.

Background: Percutaneous thermal ablation (TA), partial nephrectomy (PN), and active surveillance with delayed intervention in tumors smaller than 3 cm are the recommended treatments for small renal masses (SRMs). In this study, we investigated the post-operative course and the long-term oncological results of TA and PN, to identify the best candidates for each technology. Methodology: Patients with SRMs underwent either TA (77 patients) or PN (100 patients), according to surgeon and patient preferences. TA patients were significantly older (67.4 years ±0.2 vs. 60.0 years ±12, p < 0.01), sicker (Charlson comorbidity index of 0.85±36 vs. 0.39±0.94, p < 0.01), and their tumors were smaller by an average of 3 mm. Results: TA was associated with significantly shorter hospital stay (1.9 days ±0.4 vs. 5.5 days ±3.2, p < 0.01), smaller burden of treatment score (13.4 ± 6.7 vs. 26.9 ± 7.5, p < 0.01) and fewer complications. The 5-year recurrence-free survival rates after a single TA intervention and after PN were 83.5 % and 98.1 %, respectively (p < 0.01). The 5-year recurrence-free survival rate after TA was dependent on tumor diameter (100 % in tumors < 2.4 cm and 58.4 % in tumors 2.4–4 cm, p < 0.01) and independent of tumor diameter after PN. Conclusions: TA is an effective treatment for kidney tumors smaller than 2.4 cm. Compared to PN, it provides the benefits of shorter hospitalization, lower burden of treatment, fewer complications, and excellent recurrence-free status after a single intervention. This finding suggests that 2.4 cm and not 3 cm may be the preferred cutoff for converting from active surveillance to active treatment. PN is the preferred treatment for patients with tumors>2.4 cm.

Introduction: The prevailing view is that renal cell carcinomas (RCCs) are resistant to chemotherapy. However, it is essential to periodically reassess paradigms. When RCC is diagnosed concurrently with another malignancy, the latter typically assumes priority in treatment. This scenario provides a unique opportunity to observe the effects of systemic therapy on the RCC, without incurring additional costs or risks to the patient. Our study aimed to explore the response of several "old school" and modern anti-cancer systemic therapies on growth rate of otherwise untreated RCC. Methods: Twenty patients (average age 61.4 years, SD 10.0 years) were diagnosed with histologically confirmed RCC and another type of cancer. These included lymphomas (7 patients), lung adenocarcinoma, and breast cancer (4 patients each), leukemia (3 patients), and 4 patients with other types of malignancy. The cohort received 29 different systemic chemotherapeutic agents, including cyclophosphamide and doxorubicin (5 patients each), and prednisone, vincristine, and rituximab (4 patients each). The patients were monitored radiographically, focusing on RCC, without any RCC-specific treatments. Changes in RCC diameter on axial CT scans were recorded during the follow-up period. Results: The average RCC diameter on initial CT scans was 41.9 ± 25.1 mm. After an average follow-up of 28.9 ± 29.6 months, the RCC diameter increased in 14 patients (by an average rate of 7.3 ± 2.9 mm/year), while it remained stable or decreased in six patients. Notably, tumor size reductions were observed in patients treated with Tamoxifen and a combination of bevacizumab, docetaxel, and cisplatin. Conclusions: These results underscore the significant resistance of RCC to both traditional chemotherapies and newer treatments, many of which have not been specifically evaluated in the context of RCC. However, several agents demonstrated potential efficacy and merit further investigation. Nevertheless, no solid conclusion can be drawn regarding any specific agent using this methodology.

. The lamina propria (LP) of the urinary bladder lies between the urothelial mucosa and the muscularis propria. This complex stratum is composed of extracellular matrix, several cell types, and collagen types I and III fibers. LP invasion by urothelial carcinoma (progression from stage Ta to T1) is determinant of bladder cancer advancement. We attempted to characterize collagen fiber arrangement in the LP. This could enrich our understanding of this important layer and potentially provide clues for sub staging of the T1 bladder cancer. A total of 24 Masson trichrome-stained images of normal bladder, including 12,530 collagen fibers were quantitatively analyzed using the Dragonfly software. The LP was divided according to fiber orientation into superficial LP (SLP, 15% of the thickness) and the deep LP (DLP, 85% of the thickness). Collagen fiber geometry analysis demonstrated that the SLP fibers are more parallel to the urothelium with an average angle of 26 degrees +/- 23 degrees compared to 40 degrees +/- 26 degrees in the DLP (p=3.4x10-144), more packed (average distance to the closest fiber of 0.61 +/- 0.67 compared to 0.66 +/- 0.77, p=0.0001), and their aspect ratio is considerably longer (average of 1.93 +/- 0.12 compared to 0.20 +/- 0.11, p=2.84x10-8). No difference was found in fiber perimeter or Feret diameter. Thus, we conclude that bladder collagen fibers are arranged in two distinct layers: a dense-ordered SLP and a loose disorder DLP. This indicates that the physical barrier to cancer cell invasion probably lies in the SLP, immediately underneath the urothelium. Once this barrier is breached, the looser and disorganized DLP poses no remarkable obstacle. Thus, we believe that histology-based subdivisions of stage T1 are expected to fail in providing clinically meaningful prognostic information.

INTRODUCTION:Benign prostatic hyperplasia (BPH) is common in men over 50 years of age and often causes urinary tract obstruction, which can lead to urinary retention and reliance on a permanent catheter. In cases where medical treatment fails or it is contraindicated, surgical treatment is recommended. This study explored an alternative: prostatic artery embolization (PAE), evaluating its effectiveness in weaning patients off a catheter. METHODS:In this retrospective study, data was collected on patients who underwent PAE at our institution, by the same physician, from August 2018 to November 2023, to treat persistent urinary retention or had contraindications to catheter weaning. A statistical analysis was conducted. RESULTS:A total of 115 patients underwent PAE, 29 patients for weaning off a catheter. Their average age was 73.4 years (SD - 10.19). The average prostate volume was 167.44 grams (SD - 85.4). The majority, 62%, had significant comorbidities (ASA of 3-4). After PAE, 28 patients (97%) weaned off the catheter. The side effects were mostly mild (17%) with a Clavien-Dindo score of 1 to 2 and resolved spontaneously. More serious side effects were observed in two patients and included partial necrosis of the glans penis and renal failure. Both side effects resolved completely during follow-up. CONCLUSIONS:PAE is a good solution for weaning off a urethral catheter in patients with significant comorbidities. This procedure has a high success rate in catheter weaning and mostly mild and transient side effects.

INTRODUCTION:In recent decades, with improvement in therapy, men born with spina bifida (myelomeningocele) live longer and reach adulthood. This raises the question whether they develop age-related benign prostatic hyperplasia (BPH). We recently found that low spinal cord injuries reverse age-related prostatic growth, suggesting that continuous nervous system support is essential for sustaining BPH. OBJECTIVES:This study aimed to examine if patients born with spina bifida develop BPH as they age. METHODS:This was a multi-center study. The prostate volume (PV) of 24 spina bifida patients older than 35 years were documented from recent available imaging, or from ultrasound testing conducted as part of the research. Each patient's measured volume was compared to expected age-adjusted average volumes of healthy men. Additional clinical variables were collected. RESULTS:Patients' median age was 46 years, with a range of 35-61 years. The prostate volume of spina bifida patients was on average 18% smaller than age-expected volume (P<0.005). The most common level of injury was lumbar; however, no significant correlation was found between the level of injury and PV. Non-parametric statistical tests did not show a significant correlation between PV and other clinical variables, probably due to the small sample size. CONCLUSIONS:Spina bifida patients have smaller PV than age expected, and do not commonly develop BPH. This information is beneficial for clinicians counselling spina bifida patients. Moreover, it provides additional evidence of the nervous system's role in developing BPH and raises the possibility of finding a non-hormonal pharmacological intervention for reversing BPH.

INTRODUCTION:This special issue of 'Harefuah' presents original research papers and review articles that reflect recent developments and innovations in urological care in Israel and worldwide. The expanding urological challenges today relate to establishing innovative and evidence-based treatment approaches tailored to the unique needs of patients and the risk factors in the development of urological diseases. These enable proper explanation and acquisition of accurate knowledge by patients and their families regarding the disease, risk, treatment, and recommended follow-up. Promoting shared decision-making models regarding treatment course and planning personalized surgical interventions improves treatment outcomes and patient and family experience. The issue covers a wide range of urological topics, from treating benign prostatic hyperplasia, through innovations in the diagnosis and treatment of urological tumors, developments in endourology, to innovative solutions in urinary tract reconstruction. These articles reflect the extensive clinical and research activity in the field of urology in Israel and provide an up-to-date picture of future trends and technological developments expected to influence urological care in the coming years.

INTRODUCTION AND STUDY OBJECTIVE:Hysterosalpingography (HSG) is the standard imaging modality for diagnosing Müllerian structural abnormalities. However, its utility is limited in cases of complete obstruction of the Müllerian ducts. Ultrasonography and MRI often fall short in pinpointing the obstruction's location and extent, which can be critical for surgical planning. This report introduces antegrade genitography as a novel diagnostic approach for congenital obstructive Müllerian malformations, highlighting its potential to enhance diagnostic accuracy and guide patient management. METHODS:This retrospective case series describes three patients with Müllerian obstructive malformations. Using laparoscopic guidance, fluoroscopy, and ultrasound, we performed percutaneous puncture of the uterine cavity and contrast injection into it, followed by X-ray imaging to assess the obstruction's characteristics and location. RESULTS:Two adolescents (17 and 19 years) with primary amenorrhea and a newborn with oligohydramnios and urinary retention were included. In the two adolescent patients, antegrade genitography confirmed cervical agenesis by showing no contrast progression from the uterus to the cervical canal or vagina. The newborn was diagnosed with a high urogenital sinus and obstructed stenotic distal vaginal insertion into the bladder trigone. CONCLUSIONS:antegrade genitography proves to be a valuable diagnostic tool for patients with complete Müllerian obstructive malformations. We advocate its integration into clinical practice, emphasizing collaboration among urologists, gynecologists, and radiologists to optimize the management of patients with complex Müllerian malformations.

INTRODUCTION:Benign prostatic hyperplasia (BPH) is very common among men over 50 years of age. Most people suffering from BPH present symptoms of lower urinary tract (LUTS) of varying degrees of severity. The surgical treatment is an important and central step in the treatment of lower urinary tract symptoms caused by benign enlargement of the prostate. For many years, the most common surgical intervention for prostate up to 80 cc was transurethral resection of the prostate (TURP) and above this volume it was accepted to perform an open prostatectomy - RPP (Radical Perineal Prostatectomy) /SPP (Suprapubic Prostatectomy). In recent years, several minimally invasive methods have been developed to treat BPH. When choosing the appropriate treatment, several factors must be taken into account, including the prostate volume, the patient's medical condition, sexual function, the experience of the surgeon, and more. In this review, we examined five minimally invasive surgical approaches that have developed in recent years, while emphasizing the unique advantages and disadvantages of each approach, and highlighting the important tools in the hands of the treating urologist, alongside the traditional surgeries. This review is intended to give a broader armamentarium and a more accurate and personalized treatment for each patient. The variety of methods is suitable for the era of personalized medicine and allows the urologist to tailor treatment individually to each patient.

To develop a comprehensive scale that measures the three burden types of any treatment, including expected, unexpected (complications), and need for ancillary procedures. A panel of experts created a scale that assessed the burden of all aspects of treatment, including hospitalization, anesthesia, surgery, and follow-up. The total score is defined as the burden score (BS). BS was calculated retrospectively for patients in three clinical scenarios in urology, each with two acceptable treatment options: patients with a small renal mass (T1a) treated with either partial nephrectomy (PN, 139 patients) or percutaneous ablation (PA, 83 patients), patients with bladder cancer (stages T2-4a, N0, M0) treated with radical cystectomy (RC, 162 patients) or trimodal therapy (TMT, 88 patients), and patients with upper ureteral stones ≤ 10 mm treated with either ureteroscopy (137 patients) or extracorporeal shock-wave lithotripsy (SWL, 150 patients). Both PN and PA provided excellent oncological results (5-year recurrence-free survival ≥ 97

PurposeTo identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications.MethodsAfter literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified.ResultsTwenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely.ConclusionsLaser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Introduction and Objective: As part of the Endourological Society's (ES) initiative to continuously enhance the field of endourology, the second annual census was circulated after the World Congress of Endourology and Uro-Technology 2022 (WCET22). Methods: An anonymous survey was created using Qualtrics XM and was disseminated via email to all ES members (n = 1502) between October 4, 2022, and January 26, 2023. A total of 46 questions were included in the survey and covered different aspects, including demographics, practice patterns, satisfaction, impact of COVID-19, WCET22 attendance, and future opportunities. Results: A total of 404 (26.9%) ES members (91.8% male and 8.2% female), representing 63 different countries, participated in the survey. Fellowship-trained endourologists constituted 58.9% of respondents, and the most common practice setting was academic (55.2%). The most common practice scope was complex retrograde endoscopy (83.4%), followed by percutaneous nephrolithotomy (79.5%) and medical management of urolithiasis (72.5%). Work schedules were variable, with 51.1% working 40-60 hours/week and 35.3% working >60 hours/week. More than 80% were satisfied with t heir practice; however, 42.4% indicated that COVID-19 made satisfaction worse. Of the participants, 49.5% were satisfied with their compensation, and 7.3% plan to retire within the next 5 years. When asked about the future of endourology, 92.9% had a positive outlook. Of the respondents, only 36.8% attended WCET22, with the most chosen reason for attendance being an interest in learning new research and technology. For lack of attendance, the cost of travel and lodging was reported as a determining factor by 45.4%. Conclusion: These survey results report important trends within the field of endourology and demonstrate the robust outlook of ES members for the future. By demonstrating important practice patterns and member needs, this information can be used to improve the responsiveness of its members and to continually strengthen the ES.

Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts' experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

The aim of this study was to construct the sixth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the management of pediatric patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of literature in the PubMed database from January 1952 to December 2023. Each generated recommendation was graded using a modified GRADE methodology. Recommendations are agreed upon by Panel Members following review and discussion of the evidence. Guideline recommendations were developed that addressed the following topics: etiology, risk factors, clinical presentation and symptoms, diagnosis, conservative management, surgical interventions, prevention, and follow-up. Similarities in the treatment of primary stone episodes between children and adults, incorporating conservative management and advancements in technology for less invasive stone removal, are evident. Additionally, preventive strategies aiming to reduce recurrence rates, such as ensuring sufficient fluid intake, establishing well-planned dietary adjustments, and selective use pharmacologic therapies will also result in highly successful outcomes in pediatric stone patients. Depending on the severity of metabolic disorders and also anatomical abnormalities, a careful and close follow-up program should inevitably be planned in each pediatric patient to limit the risk of future recurrence rates.