Purpose:To compare Holmium: YAG laser settings for popcorn lithotripsy and evaluate the impact of MOSES modulation across stone-density groups. Materials and Methods:An in vitro bench model was used with synthetic gypsum stones prepared at three density levels (low, intermediate, and high: mean attenuation was 574, 945, and 2067 HU, respectively). For each trial, five fragments (2.8-3.3 mm) were treated using popcorn technique with Holmium: YAG laser and 272 µm fiber during a 2 min run under standardized irrigation. Five laser settings (0.3 J/80 Hz, 0.5 J/40 Hz, 1.0 J/20 Hz, 1.0 J/30 Hz, and 1.5 J/20 Hz) were tested with and without MOSES mode: each setting-by-modulation condition was repeated six times. The primary endpoint was percent mass reduction; secondary endpoints were residual fragment counts 1-2 and > 2 mm. Results are presented as mean ± SD, and ANOVA was used for comparison. Results:In the low-density group, percent mass reduction was highest overall (65%-86%), with 1.0 J/30 Hz achieving the greatest reduction, MOSES provided no additional benefit (p = 0.6). In the intermediate-density group, the greatest mass reduction was achieved with 1.0 J/30 Hz with MOSES (51% ± 5.9%), and MOSES effects were setting-dependent, and at 1.0 J/30 Hz MOSES reduced total residual fragments (5.3 vs 8.0, p = 0.04). In the high-density group, 1.0 J/30 Hz with MOSES achieved the highest mass reduction (71.5% ± 12.1%) and was associated with improved outcomes (p = 0.037). Secondary analyses of residual fragments generally paralleled these findings. Conclusions:In this in vitro popcorn lithotripsy model, 1.0 J/30 Hz provided the most consistent performance across density groups. MOSES modulation did not improve outcomes in low-density stones but was associated with improved efficiency in intermediate- and high-density stones.

Placenta accreta spectrum (PAS) is a high-risk obstetric condition associated with hemorrhage, urologic injury, and peripartum hysterectomy. Rising cesarean delivery rates continue to increase its prevalence. Variation in surgical management and limited multidisciplinary involvement may contribute to adverse maternal outcomes. To evaluate whether the implementation of a multidisciplinary team (MDT) protocol for PAS was associated with improved perioperative outcomes. This retrospective cohort study included 417 women diagnosed with PAS from 2011 to 2022 at a tertiary center. In 2019, a structured MDT protocol was adopted, incorporating standardized imaging, preoperative conference, routine bilateral ureteral catheter (UC) placement, and on-site urologic support. Outcomes of MDT-managed patients (n = 108) were compared with pre-MDT patients (n = 309). Multivariable logistic regression and generalized linear models adjusted for maternal age, gravidity, prior cesarean delivery, placenta previa, PAS grade, surgical urgency, gestational age, and year of delivery. After adjustment, MDT care was associated with lower odds of urologic injury (aOR 0.34; 95

Purpose:To evaluate the effect of different connector types and commonly used endourologic devices on irrigation fluid flow through the working channel of a flexible ureteroscope. Methods:Irrigation flow was measured under a 200-cm H2O pressure head using three connector types (Tuohy-Borst, UroLok, and Check-Flo) and a standard Y-set connection. Instruments tested included Piranha biopsy forceps, Segura hemisphere basket, Glidewire guidewire, and two laser fibers (200 μm and 365 μm). Each condition was repeated six times. Descriptive statistics were calculated, and one-way ANOVA was used to assess differences between groups. Results:With an empty channel, the standard Y-set connection achieved the highest mean flow (115.8 ± 4.3 mL/min), followed by Tuohy-Borst (113.0 ± 1.6), UroLok (100.2 ± 1.3), and Check-Flo (80.4 ± 0.5) (p < 0.001). Inserting instruments markedly reduced flow. The Piranha forceps and Glidewire guidewire produced the largest reduction (∼96-97%). A larger instrument diameter or the absence of a smooth coating significantly reduced flow across all connectors. With small-caliber instruments, connector design played a greater role: relative flow reduction was greatest with Tuohy-Borst (50.6%) and lowest with Check-Flo (38.0%). In absolute terms, UroLok yielded the highest median flow with laser fibers (38.7 mL/min), followed by Tuohy-Borst (37.5 mL/min) and Check-Flo (34.7 mL/min). Conclusion:Both connector choice and instrument size significantly affect irrigation flow in flexible ureteroscopy. Large-diameter instruments almost abolish flow regardless of connector, whereas with smaller instruments, connector design influences performance. These findings emphasize the importance of selecting optimal connector-instrument combinations to maintain intraoperative visibility.

Endoscopic management offers acceptable oncologic control in select patients with upper tract urothelial carcinoma (UTUC) while preserving renal function. Adjuvant intracavitary treatment with chemotherapy or Bacillus Calmette-Guérin (BCG) has been proposed to reduce recurrence risk. We aimed to evaluate the impact of adjuvant intracavitary treatment on ipsilateral UTUC recurrence following endoscopic management. We queried a multi-institutional cohort of patients who underwent endoscopic management for UTUC. Treatment groups were defined as no instillation, single post-operative instillation, or multiple instillations. Ipsilateral UTUC recurrence-free survival (RFS) was estimated using Kaplan-Meier curves and Cox proportional hazards models evaluated factors associated with recurrence. A total of 599 renal units, of which 43 received single instillation and 86 multiple instillations, in 334 patients treated endoscopically for UTUC were analyzed. The median follow-up time for patients without recurrence was 12 months (IQR 4–33). Multiple adjuvant instillations of any intracavitary treatment were associated with a significantly improved RFS (HR 0.52, 95

PURPOSE:Obstructing ureteral stones with urinary tract infection (UTI) represent a urological emergency requiring prompt decompression to prevent sepsis-related morbidity and mortality. Although percutaneous nephrostomy (PCN) is a widely used drainage method, the optimal timing for its insertion remains unclear. This study explored the association between the timing of PCN insertion and clinical outcomes. PATIENTS AND METHODS:A retrospective review of 744 patients who underwent PCN insertion for ureteral stones and UTI between 2011 and 2023. Patients were grouped by time-to-drainage from emergency department arrival: Immediate (<6 hours, n = 241), early (6-24 hours, n = 232), and delayed (>24 hours, n = 271). Infectious status was assessed at presentation, before, and after PCN insertion. Primary outcomes were sepsis, septic shock, and intensive care unit (ICU) admission rates. Multivariable analysis identified predictors of non-immediate drainage. RESULTS:In the immediate drainage group, sepsis rate decreased following PCN insertion (61.4% pre-PCN vs 45.2% post-PCN, p = 0.03), whereas septic-shock rates remained unchanged (23.7% vs 23.2%, p = 0.6). In the early drainage group, sepsis remained unchanged (59.1% vs 59.5%, p = 0.11) after PCN insertion, whereas septic shock increased (12.9% vs 31%, p < 0.001). A similar pattern was observed in the delayed group, with unchanged sepsis (38.7% vs 36.9%, p = 0.14) but increased septic shock rates (7% vs.15.5%, p = 0.001) following PCN insertion. Immediate drainage was associated with shorter hospitalization, fewer ICU admissions, and earlier stone treatment (all p < 0.001). Predictors of non-immediate drainage included night-shift arrival (odds ratio [OR]: 4.846, p < 0.001), female gender (OR: 1.917, p = 0.002), elevated creatinine (OR: 1.262, p = 0.011), and older age (OR: 1.009, p = 0.018). CONCLUSION:Decompression with PCN within 6 hours is associated with significantly improved infectious and clinical outcomes in patients with obstructed, infected kidneys caused by ureteral stones.

BACKGROUND:Segmental ureterectomy (SU) is a kidney-sparing alternative to radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) localized to the ureter, yet contemporary comparative data are limited. We aimed to evaluate perioperative, functional, and pathology-adjusted oncologic endpoints between SU and RNU using propensity-score matching. METHODS:We retrospectively reviewed UTUC patients treated at a tertiary referral center (2008-2025), identifying SU (n = 81) and RNU (n = 259) cases. To reduce confounding, we performed 1:1 propensity-score matching on age, gender, comorbidities, and baseline eGFR, yielding 92 matched patients (46 pairs). Because 8 pairs showed no residual malignancy (pT0) on final pathology, the primary adjusted analysis was restricted to 38 pairs (n = 76), with the full 46-pair cohort retained for sensitivity analysis. Primary endpoints were DFS, CSS, and OS. Secondary endpoints included perioperative outcomes, renal function, intravesical recurrence-free survival, and metastasis-free survival. Time-to-event outcomes were analyzed using paired Cox models adjusted for definitive pathological grade and stage, and Kaplan-Meier estimated as secondary analysis. RESULTS:The median follow-up for the matched cohort was 37.1 months (IQR: 14.2-69.0). Baseline tumor characteristics were comparable except for tumor location, with a higher prevalence of nondistal tumors in the RNU group (P < 0.001). In the primary analysis (pathology-adjusted) paired-Cox regression estimated DFS and CSS were similar between SU and RNU (HR 0.63, 95% CI 0.23-1.69, P = 0.358 and HR 0.57, 95% CI 0.2-1.54, P = 0.275, respectively). The adjusted OS was also comparable (HR 0.49, 95% CI 0.16-1.51, P = 0.213), alongside all secondary oncologic endpoints (P > 0.05). In the sensitivity analysis, oncological endpoints did not differ between the groups. Renal function preservation favored SU, with median ΔeGFR +8.8 vs. RNU -11.95 ml/min/1.73 m² (P < 0.001). CONCLUSIONS:SU significantly improved renal preservation without compromising intermediate-term, pathology-adjusted oncologic endpoints vs. RNU. These findings support SU as a kidney-sparing option in selected patients, including those with high-grade disease, adverse features (CIS, LVI, ≥pT2), and nondistal tumors. Further work should refine patient selection and post-SU surveillance.

BACKGROUND:Double-J stents are commonly inserted following ureteroscopy and stone lithotripsy, potentially leading to various urinary and pain-related symptoms and affecting patients' quality of life. This study aimed to compare the impact of soft and firm silicone stents on stent-related symptoms in patients undergoing ureteroscopy and stone lithotripsy. METHODS:After receiving institutional ethical committee approval (SMC 0119-23), we conducted a prospective, randomized, single-blinded trial between 2023-2024. Patients undergoing ureteroscopy and stone lithotripsy were randomized into two groups: those receiving a soft polymer stent (Universa®, Cook Medical, Bloomington, IN, USA) or a firm polymer stent (Percuflex®, Boston Scientific, Marlborough, MA, USA). Symptoms were assessed using the Ureteral Stent Symptoms questionnaire (USSQ), completed upon stent removal, 14 days postoperatively. The primary outcome was the USSQ index score, with secondary outcomes including individual USSQ domain scores. RESULTS:A total of 120 patients completed the questionnaire. The soft-stent group (N.=60) demonstrated significantly lower USSQ index scores (26 vs. 73, P<0.001) and improved outcomes across all USSQ sub-domains (P<0.001) compared to the firm-stent group. A multiple regression model confirmed that using firm stent material independently resulted in higher USSQ index scores (P<0.001) relative to soft stent. Intraoperative and postoperative complication rates were similar between groups. CONCLUSIONS:Using soft ureteral stents results in fewer stent-related symptoms compared to firm stents, offering superior quality of life while maintaining a comparable safety profile. Based on these findings, when placing a ureteral stent following ureteroscopy and stone lithotripsy, a soft stent is recommended.

Abstract Introduction Ureteral injuries during gynecologic surgery are uncommon (0.1%–2.5%) but may result in significant morbidity, including strictures, hydronephrosis and the need for additional interventions. This study evaluates the effectiveness of retrograde endoscopic management in treating iatrogenic ureteral injuries. Materials and Methods A retrospective review was conducted on women diagnosed with ureteral injury post‐gynecologic surgery between 2010 and 2024 at a single institution. Patients were categorized into two groups: those treated with retrograde endoscopic interventions and those managed with non‐endoscopic approaches (percutaneous nephrostomy and/or surgical reconstruction). The endoscopic group was further divided into early (<3 months post‐injury) and late interventions. Outcomes assessed at ≥3 months of follow‐up included treatment success, long‐term complications and the need for further interventions. Results Of 42 patients, 29 (69%) underwent endoscopic treatment and 13 (31%) received non‐endoscopic management. Among endoscopically treated patients, early intervention achieved an 80% success rate, significantly higher than the 33% observed with late intervention (p = 0.03). All non‐endoscopic patients initially received percutaneous nephrostomy, and 12 (92.3%) required definitive surgical repair. Endoscopic treatment was associated with reduced operative time and shorter hospital stays. Given the rarity of ureteral injuries, the cohort represents one of the largest single‐centre experiences focused on this specific population. Conclusions Early retrograde endoscopic management is a safe and effective approach for treating ureteral injuries after gynecologic surgery. Timely diagnosis and intervention significantly improve outcomes. Non‐endoscopic patients were more complex cases, often unsuitable for endoscopy, which may account for outcome differences. Intraoperative retrograde ureterography and stenting should be considered whenever there is suspicion of ureteric injury, whereas postoperative endoscopic realignment or endoscopic management of ureteric strictures should be performed by appropriately trained urologists. Further prospective studies with larger cohorts and longer follow‐up are warranted to refine optimal clinical pathways and long‐term management strategies.

PURPOSE:Endoscopic management offers renal-sparing approaches for upper tract urothelial carcinoma (UTUC). We sought to characterize the impact of endoscopically managing UTUC on kidney function and identify predictors of renal function decline. METHODS:We queried a multi-institutional cohort of endoscopically managed UTUC. Estimated glomerular filtration rate values 12 months after endoscopic treatment were assigned according to the National Kidney Function Kidney Disease Outcomes Quality Initiative (KDOQI) chronic kidney disease (CKD) stages. Loss of kidney function was defined as an increase by at least one CKD stage. Severe loss was defined as an increase by at least 2 CKD stages or development of CKD stage 3b-5. RESULTS:A total of 339 patients (521 interventions) were included. 113 patients (33.3%) experienced loss of kidney function and 75 (22.1%) experienced severe loss of kidney function. In multivariable logistic regression, high grade tumor (OR 2.29, 95% CI 1.23-4.33) and renal pelvic location (OR: 2.64, 95% CI 1.32-5.54) were significantly associated with loss of kidney function on a per-patient level. We observed similar results on a per-intervention analysis, with higher odds for kidney function loss for high grade tumor (OR 2.03, 95% CI 1.23-3.35) and renal pelvic location (OR 1.76, 95% CI 1.01-3.08). CONCLUSION:Despite preservation of the renal unit, one-third of patients undergoing endoscopic management of UTUC experience loss of kidney function. High-grade tumors and renal pelvic location were associated with adverse renal function outcomes.

Segmental ureterectomy (SU) is an established kidney-sparing strategy for upper tract urothelial carcinoma (UTUC), yet few studies have compared the standard open approach to the emerging robotic modality. We performed a clinical outcome and safety evaluation of robotic-assisted SU compared to the traditional open approach. In this retrospective study of 53 patients (40 open, 13 robotic) treated between 2008 and 2025, we assessed perioperative, functional, and oncological parameters. Regarding safety endpoints, robotic SU demonstrated a favorable profile with no significant difference in postoperative complication rates compared to open surgery (15.4

Achieving renal access during percutaneous nephrolithotomy is challenging, with a complication rate of 10–20

INTRODUCTION:Pelvic kidney is a congenital anomaly whereby the kidney fails to ascend to its normal anatomical location during early embryonic development. This, in turn, makes traditional surgical approaches for renal calculi challenging. AIMS:To summarize our experience with robotic-assisted pyelolithotomy (RPPK) for pelvic kidney stones. METHODS:A retrospective review of patients who underwent RPPK between 2014 and 2023 was conducted. Demographic data, stone characteristics (size and density), operative details, and postoperative outcomes were collected and analyzed. RESULTS:Four patients underwent RPPK between 2014 and 2023, three of whom were male. The mean age was 51.2 years (range: 45-54), BMI was 26.6 (22.3-32.2). All patients had a right-sided pelvic kidney. Two patients had previously undergone a failed attempt for ureteroscopy and laser lithotripsy. Stone diameter was 27.7 mm (17-35 mm) and estimated density was 1207.5 HU (905-1500 HU). Mean operative time was 265 minutes (200-323 minutes), while time from incision to closure was 142.2 minutes (95-225 minutes). No ureteral stent or surgical drain were left at the conclusion of the procedures. Upper urinary tract correction was not involved in any of the cases. Blood loss was negligible. The length of hospital stay was 2.2 days. No immediate complications were recorded within one week and one-month post-surgery. Mean follow-up length was 7.5 months (3-13 months). CONCLUSIONS:RPPK is safe and effective in the management of pelvic kidney stones. The challenging renal anatomy, as well as stone size and density are not obstacles when it comes to the robotic approach in comparison to other fragmentation methods.

PURPOSE OF REVIEW:Upper tract urothelial carcinoma (UTUC) is a rare yet aggressive malignancy, representing 5-10% of urothelial cancers. While radical nephroureterectomy (RNU) has traditionally offered excellent oncological control, it compromises renal function. Recent advancements have shifted the paradigm toward kidney-sparing strategies in select cases. This review highlights innovations in UTUC diagnosis and conservative management, focusing on emerging imaging techniques, noninvasive biomarkers, and minimally invasive treatments. RECENT FINDINGS:Advances in multiparametric MRI and radiomics have improved diagnostic accuracy and risk stratification. Moreover, noninvasive biomarkers - including circulating tumor DNA, microRNAs, and urinary methylation assays - provide promising tools for early detection and surveillance. Kidney-sparing approaches such as endoscopic laser ablation and segmental ureterectomy have demonstrated comparable oncologic outcomes in low-risk patients. Moreover, topical therapies, including intracavitary treatments like UGN-101, offer a promising minimally invasive option. SUMMARY:The conservative management of UTUC is evolving, driven by advancements in imaging, molecular diagnostics, and minimally invasive treatments. While kidney-sparing approaches are increasingly utilized in low-risk patients, further prospective studies are needed to validate their efficacy.