BACKGROUND:Single-injection erector spinae plane blocks (ESPB) provide analgesia after percutaneous nephrolithotomy (PCNL) but are limited in their duration. A continuous ESPB involving local anesthetic administered via a perineural catheter may extend analgesia duration. This study hypothesized that adding a continuous ESPB to a single-injection ESPB after outpatient PCNL would decrease pain severity and/or opioid consumption over the first 2 postoperative days (dual primary outcomes). METHODS:Preoperatively, adults undergoing PCNL had an ultrasound-guided perineural catheter inserted at the eighth transverse process after saline injection. Bupivacaine 0.25% with epinephrine (20 ml) was manually injected via the catheter for all participants who were subsequently randomly allocated to one of two postoperative treatments: active with bupivacaine 0.25% or placebo with normal saline. An automatic intermittent bolus of 21 ml was delivered every 4 h using a portable infusion pump for approximately 57 h. RESULTS:During the first 2 postoperative days, the median [interquartile range] average daily pain intensity as measured with the numeric rating scale for active (n = 25) was 3.5 [2.0, 4.5] compared with 3.0 [1.3, 4.5] for placebo (n = 25; estimated difference, 0.25; 95% CI, -1.0 to 1.5; P = 0.538). Cumulative oxycodone consumption during this same period was 10 [0, 25] mg for active versus 15 [0, 30] mg for placebo (estimated difference, 0; 95% CI, -15 to 5; P = 0.358). During this period, the maximum daily pain for active was 7.0 [4.3, 8.0] compared with 6.5 [5.5, 8.0] for placebo ( P = 0.754). Sleep disturbances the second night were 0 [0, 1] for both groups ( P = 0.423). During the day after surgery, pain interference with physical and emotional functioning was 10 [0, 33] for active and 8 [23, 48] for placebo as measured with the Brief Pain Inventory ( P = 0.587). CONCLUSIONS:This investigation failed to identify benefits of adding a continuous ESPB to a single-injection ESPB after PCNL.

OBJECTIVES:The objective of this study is to characterize the impact of stone disease on sexual quality of life (QoL). As a secondary end point, we identified predictors of reduced sexual QoL to identify characteristics of stone patients who may benefit from sexual counseling. SUBJECTS/PATIENTS AND METHODS:A multicentric cross-sectional study in eight centers across North America was carried out from July 2022 to March 2024. Patients with a history of kidney stones were recruited. Patients taking medication affecting erectile or ejaculatory function were excluded. Participants filled out the Wisconsin Quality of Life questionnaire to assess stone disease burden. Indicators of sexual QoL included the Sexual Distress Scale, the Global Measure of Sexual Satisfaction, and either the Male Sexual Health Questionnaire or Sexual Function Questionnaire to evaluate sexual function in men and women, respectively. We examined the impact of kidney stone events on indicators of sexual QoL. RESULTS:A total of 202 patients, including 70% (142/202) men and 30% (60/202) women, were recruited. The mean age was 53 (standard deviation [SD] 13) with men averaging 7 (SD 13) stone events and women 10 (SD 32). Men had good erectile (12/15) and ejaculatory (28/35) function. Women had low levels of sexual arousal (16/40), enjoyment (14/30), and orgasm (7/15). Men with worse erectile function demonstrated a significant association with increased frequency of kidney stone disease: 2-5 stone events (β = 2.95, CI [0.92-4.98], p = 0.005), 6-10 events (2.64 [0.64-5.22], p = 0.045), and more than 10 events (3.75 [0.80-6.70], p = 0.014). Both men (28/35) and women (25/35) had good sexual satisfaction and low sexual distress (5/20 and 6/20), respectively. CONCLUSION:This is the first study investigating sexual QoL among kidney stone formers. Both men and women had good satisfaction and low distress. Women had low sexual desire and arousal outcomes. Urologists may help in screening for these forms of dysfunction upon the diagnosis of kidney stones to better address their needs. Men reported worse erectile function with an increase in stone burden; however, this association may not be causal.

Introduction: Existing studies link kidney stone treatment to reduced recurrent urinary tract infections (UTIs); however, these studies are limited by their retrospective design and/or lack of comparison group. The present study assesses a prospective observational cohort of patients with recurrent UTIs who selected observation or intervention for management of their non-obstructing kidney stones to assess for impact on UTI recurrence. Methods: From 2020−2025, patients with non-obstructing kidney stones and recurrent UTIs were prospectively enrolled at four centers. After shared decision-making, participants underwent observation or surgical intervention. The primary outcome was UTI recurrence at 12 months post-enrollment, defined as presence of urinary tract symptoms with positive urine culture. The study was powered to detect a 50% reduction in the rate of UTI recurrence between the groups at 12 months. Results: Among 94 patients recruited, followup data at 12 months was available for 21 observation and 46 intervention patients. There were more staghorn stones in the intervention group (15.2% vs. 0%), and the median stone size was larger (13.5 vs. 6 mm). At 12 months, 81% (n=17) in the observation group and 54% (n=25) in the intervention group had a symptomatic UTI recurrence (p=0.06, non-significant). The subgroup (n=17) of stone-free intervention patients had fewer UTI recurrences compared to the observation group (odds ratio 0.12, 95% confidence interval 0.02−0.66). Causation cannot be confirmed due to the observational nature of the study. Conclusions: For patients with recurrent UTIs and stones, surgical intervention is not associated with decreased risk of UTI recurrence at 12 months overall; however, patients who were stone-free after intervention had significantly fewer UTI recurrences on subgroup analysis.

INTRODUCTION:Ureteral stent placement after ureteroscopy is a major contributor to patient morbidity. We sought to evaluate postoperative complications and quality of life (QoL) metrics comparing individuals receiving ureteral stent placement vs. stent omission after ureteroscopy. METHODS:A multicenter, randomized controlled trial was performed among patients undergoing ureteroscopy and laser lithotripsy for non-obstructing renal stones with up to 1.5 cm in total stone diameter. Ureteral access sheath use and laser technique were at the discretion of the surgeon. At case end, if no ureteral injury was observed, patients were randomized to stent placement or stent omission. Primary outcome was the 30-day occurrence of emergency department visits, unanticipated provider visits, or hospitalization. Secondary outcomes included QoL measured by the Wisconsin Stone Quality of Life (WISQOL) and the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference surveys, opiate use, and abnormal imaging findings at followup. RESULTS:Of 103 patients enrolled with mean (standard deviation [SD]) stone diameter 9.6 mm (4.5), 74 were randomized to stent placement (n=36) or stent omission (n=38). Ureteral access sheaths were used in 83% and 61% of patients in the stented and unstented groups, respectively. There was no difference in rate of 30-day complications between stent and stent omission cohorts (8% vs. 11%, absolute risk difference -2%, 95% confidence interval [CI] -15%, 11%, p=0.75). Stent omission showed better adjusted pre- vs. post-surgery WISQOL scaled score (16.7, 95% CI 3.1, 30.4, p=0.02) and PROMIS 6a t-score (-8.5, 95% CI -15.3, -1.6, p=0.02). No differences between groups were observed in the cumulative opiate use, ability to return to work, symptomatic urinary tract infection, or abnormal imaging findings at followup. CONCLUSIONS:Compared to ureteral stent placement, stent omission after ureteroscopy for renal stones appears to be feasible and suggests improved short-term patient-reported outcomes in selected patients. This study was limited by small sample size, and future larger studies are needed.

Ureteroscopic laser lithotripsy results in heat generation, raising concern for thermal injury. As laser platforms evolve, comparative assessment of their thermal profiles is increasingly important. This study presents the first comparative evaluation of temperature generation using three contemporary systems: pulsed thulium: YAG (Tm: YAG; Dornier Thulio), thulium fiber laser (TFL; Olympus SOLTIVE), holmium: YAG with pulse modulation (MOSES 2.0; Boston Scientific MOSES 2.0) using manufacturer-recommended dusting settings in an ex vivo porcine kidney model. Eighteen porcine kidney–ureter units were implanted with renal pelvic temperature probes and Bego stones. Specimens were randomized to one of three lithotripsy systems (n = 6 per group; one MOSES specimen excluded). A flexible ureteroscope was introduced via a 35 cm 10/12Fr ureteral access sheath, followed by 10 min of near-continuous dusting using 200 μm fibers (0.3 J/50Hz for TFL and Tm: YAG; 0.3 J/60 Hz for MOSES 2.0). Pressurized irrigation was maintained at 100-150mmHg. Outcomes included absolute temperature change, total energy delivered, and temperature increase normalized to energy (°C/kJ). The greatest mean temperature rise was observed with TFL (8.13 ± 1.96 °C), followed by pulsed Tm: YAG (4.12 ± 1.26 °C) and MOSES 2.0 (3.32 ± 1.84 °C). TFL demonstrated significantly greater heat generation than Tm: YAG (p = 0.0031) and MOSES 2.0 (p = 0.0010). When temperature was adjusted for energy delivery, TFL (1.09 ± 0.30 °C/kJ) surpassed both Tm: YAG (0.47 ± 0.14 °C/kJ; p = 0.0007) and MOSES 2.0 (0.31 ± 0.18 °C/kJ; p = 0.0001). No specimen exceeded temperatures of 43 °C. In this ex vivo setting, TFL was associated with higher heat generation relative to both pulsed Tm: YAG and MOSES 2.0; however, all systems remained below accepted thermal safety thresholds under the tested conditions (43 °C).

Purpose: Postoperative sepsis is a known complication of ureteroscopy, but whether intrarenal pressure (IRP) is indicative of postoperative sepsis remains unclear. Pyelovenous backflow is believed to occur when pressure exceeds 30 mmHg. Despite this, IRP is not routinely monitored during ureteroscopy. The present pilot study was designed to evaluate the relationship between IRP during ureteroscopy and postoperative sepsis. Materials and Methods: Patients undergoing ureteroscopy for kidney stones ( N = 100, 34% male, M = 56 years of age) had IRP continuously measured using the COMET™ II Pressure Guidewire. Three phases of ureteroscopy were identified: baseline (30 seconds before ureteral access sheath placement), post-access sheath placement, and treatment of the kidney stone. Data were analyzed using analysis of variance, odds ratio, risk ratio, and diagnostics statistics at p < 0.05. Results: The 12 patients that developed postoperative sepsis had significantly higher median baseline ( p < 0.04) and treatment phase ( p < 0.02) pressures than non-sepsis patients. The median baseline and treatment phase IRP above 30 mmHg were associated with twice the odds and twice the risk of sepsis compared to cases below this threshold, though these results were not statistically significant. IRP above the 30 mmHg threshold conferred accuracy for 84% of cases at baseline, with relatively high specificity (0.93) and high negative predictive values (0.89), but poor sensitivity (0.17) and positive predictive values (0.25). Older age ( p < 0.03) and history of sepsis ( p < 0.02) were also associated with postoperative sepsis risk. Conclusions: The present study found that baseline IRP was a significant predictor of sepsis following ureteroscopy for nephrolithiasis. These findings suggest that continuous IRP measurement during URS might prove valuable in predicting sepsis risk and may open new avenues for sepsis research.

OBJECTIVE:To evaluate postoperative outcomes after a minimal approach of water vapor thermal therapy (WVTT; Rezum, Boston Scientific, Marlborough, MA), defined as 1 treatment per prostate lobe, among men with benign prostatic hyperplasia. METHODS:We performed a multi-institutional retrospective review of patients who underwent WVTT from 2018 to 2022. Propensity score matching was utilized to generate patient cohorts based on number of treatments per lobe (1 per lobe, including median lobe if present [minimal group], vs ≥2 per lobe [nonminimal group]) matched for age, body mass index, and preoperative prostate volume. Primary outcome was postoperative complications and storage phase symptoms beyond 30days. We then conducted a non-propensity score matching independent t test to analyze differences in International Prostate Symptom Score (IPSS), uroflowmetry, and surgical retreatment rate postoperatively. RESULTS:146 patients were included, with 73 in each arm. The nonminimal group had their median lobe treated more frequently (P=.021) and experienced higher postoperative de-novo retention (P=.009) and urinary tract infection (P=.003) rates. On multivariate analysis, increasing number of treatments (hazard ratio 1.3, P=.039) and median lobe treatment (hazard ratio 4.7, P=.008) were significant risk factors for postoperative storage phase symptoms. Mean IPSS and uroflowmetry parameters were similar at 1, 3, 6, and 12months postoperatively. Surgical retreatment rates were comparable at 2years (3% vs 1%; P=.444). CONCLUSION:Minimal approach to WVTT is associated with decreased postoperative complications with comparable IPSS, maximum flow rate, and surgical retreatment rate. Further studies are needed to investigate longer term outcomes.

Background:Little is known regarding medical retreatment rates after water vapor thermal therapy (WVTT; Rezum, Boston Scientific, Marlborough, MA, USA) for benign prostatic hyperplasia (BPH). We sought to identify incidence and predictors of medical retreatment for symptomatic recurrence among this population. Methods:We performed a single institution retrospective review of patients who underwent WVTT by a single surgeon from July 2018 to January 2024. We excluded patients with prostate volume >80 cc. Primary outcome was medical retreatment, defined as initiation or resumption of any BPH medication following WVTT. Results:We identified 155 patients with mean age 67.4±10.3 years and prostate volume 46.4±13.6 cc. Forty-eight (31%) patients underwent medical retreatment within mean follow up of 19.5 months. Mean time to retreatment was 9.8 months. Alpha blockers were the most commonly restarted medication (40.5%), followed by daily tadalafil (25.5%) and 5-alpha reductase inhibitors (10.6%); 23.4% of patients restarted multiple medications. Preoperative use of alpha blockers (95.8% vs. 84.1%; P=0.04), 5-alpha reductase inhibitors (39.6% vs. 23.4%; P=0.04) and daily tadalafil (35.4% vs. 15.0%; P=0.004) significantly predicted medical retreatment. At 3 months, International Prostate Symptom Scores (IPSS) total (15.5±7.9 vs. 9.8±6.1, P=0.002) and quality of life (QoL) (3.2±1.6 vs. 2.4±1.5, P=0.05) were significantly higher in the medical retreatment group. Surgical retreatment within 3 years occurred in 9.7% of the cohort, with nonsignificant higher rates in the medical retreatment group (12.5% vs. 8.4%, P=0.43). Conclusions:Nearly one-third of patients undergo medical retreatment after WVTT, often within the first year. Early symptom trajectory, preoperative medication use, and close follow-up may help identify patients at risk and improve long-term outcomes.

Objective: To develop and validate a high-fidelity, nonbiohazardous simulator model for the ultrasound-guided percutaneous nephrolithotomy procedure. Methods: We employed a systematic framework based on Delphi consensus and modern education theory to design a simulation model. Twelve expert surgeons provided input through a hierarchal task analysis and identified procedural tasks, anatomical landmarks, and potential errors. These were translated into engineering deliverables by a team of biomedical engineers and surgical educators. A prototype was developed using three-dimensional printing and hydrogel molding, followed by expert validation through recorded simulations and subsequent multicenter trails with 48 participants. Results: A hydrogel prototype with realistic anatomical features was created using results from the Delphi process. It received positive feedback in areas such as anatomy, procedural fidelity, and education effectiveness, with overall high satisfaction ratings. Validation studies showed a significant difference in performance between novices and experts. Residents demonstrated significant skill improvement and retention after repeated simulations. Conclusions: The developed simulator provides a realistic, effective training tool for urologic education, addressing the need for safer and more accessible surgical training modalities.

Decreasing radiation exposure in renal colic management involves revisiting diagnostic, intraoperative, and postoperative practices. One approach is a shift in procedural standards from intraoperative fluoroscopy to ultrasonography. Despite the increased implementation of ultrasound in urology, the ultrasound visibility or echogenicity of various stents is not well-studied. Silicone stents, traditionally considered less radiopaque, pose challenges during placement under fluoroscopy due to their reduced visibility. However, a shift to ultrasound-based guidance can levels the playing field, as silicone stents demonstrate comparable echogenicity to stents made from other materials. This study aims to evaluate and quantify the echogenicity of different ureteral stents on the market, with a focus on silicone stents, which traditionally have been considered less radiopaque yet potentially advantageous for less patient discomfort. We conducted a simulation study using five different brands of ureteral stents in an ex-vivo porcine bladder model. We measured the mean grey intensity to quantify echogenicity of each stent. After comparing the echogenicity of individual stents, we grouped stents based on materials and diameters and performed T-tests. We established that ureteral stents can demonstrate good visibility inside porcine bladder under ultrasound. Upon further investigation, we found that diameter is the most important variable in determining the measured echogenicity of ureteral stents. 8 Fr ureteral stents have higher measured echogenicity than the Sensor wire and 6 Fr stents. Stent materials also play a role in the measured echogenicity of ureteral stents. With the same diameter, silicone is measurably more echogenic than polyurethane. This study describes a novel quantitative assessment of ureteral stent echogenicity, which can guide the development of novel echogenic stents and provide a benchmark for existing stents. In addition, it suggests that ultrasonography may facilitate the placement of silicone stents, which historically have been more difficult to visualize with fluoroscopy.