Analysis of regional weather parameters in 2016, 2017, and 2018 and correlation with early ureteral whole stent encrustation

==inizio objective==

Early Whole Ureteral Stent Encrustation (EWUSE) is an uncommon adverse event.(1) Since we observed 5 EWUSE cases occurring all in a very short period after a scorching heat summer in year 2017, we considered weather condition as a possible external risk factor.

==fine objective==

==inizio methodsresults==

We indwelled a JJ ureteral stent (4.7 or 6 Fr), because of stone related hydronephrosis, in 51, 73 and 64 patients respectively in year 2016, 2017 and 2018. None EWUSE cases occurred in 2016, 5 in 2017 (6.8%), and 1 in year 2018 (1.5%). All the EWUSE cases brought the JJ during one or more summer months. All stents were removed before the limit of 180 days suggested by the producer. Stent material was Percuflex with HydroPlus™ coating produced by Boston Scientific. We did not consider patients with encrustation only on distal J that could be simply removed in the endoscopic office. Patients’ characteristics (age, sepsis, stone size and position, date of stent indwelling, number of weeks with stent) were considered and regional weather data of year 2016, 2017, and 2018 (obtained from archives available on weather’s internet sites) were analyzed.(2)
Common weather factors, that may interfere with human hydration, such as Temperature (maxim, medium and minimum) (Tmx, Tmd, Tmn) in Celsius (°C), Dew Point (DP) in °C, Relative Humidity (RH) in percent, Wind Velocity (WV) in km/h and Atmospheric Pressure (AP) in mbar were considered. RH is the ratio between amount of moisture in air to the maximum amount of water the air can absorb. DP is the temperature at which liquid first forms from a vapor. DP changes linearly for every given RH level.
Since in 2016 we did not register any EWUSE cases, we fixed as thresholds the average highest temperatures and the average lowest DP and RH, that were all happening in July 2016. We counted the days in each month with DP, RH inferior and Tmx, Tmd, Tmn superior to the thresholds.

==fine methodsresults==

==inizio results==

Summer weather condition of year 2016 and 2018 were similar. Interesting differences were found in summer 2017 for DP, RH, Tmx, Tmd, and Tmn showing that it was warmer and drier, and warmer and drier for a longer period.
Furthermore on August 2017 the temperature went on increasing and RH and DP decreasing comparing to the already hot and dry July 2017, while generally the apex of temperatures happens on July. Average Tmx in August 2017 was 3.5°C more than August 2016 and even 1.2°C more than July 2017).
In year 2017 the number of days with Tmx, Tmd, Tmn superior to our thresholds (31, 26, 21°C) were respectively: 8|9|9 days in June; 17|19|18 July; 15|21|20 August; 1|2|5 September. Which means that July and August 2017 had together 40 days with temperature higher than the thresholds and in those months for 13 days Tmx was over 35°C.
The number of days in 2017 with DP, RH inferior to our thresholds (16°C, 55%) were: 26|14 in June; 26|27 July; 26|27 August; 25|8 September. Which means that almost all July and August 2017 were under the thresholds for DP and RH, and almost all June and all September were with DP under the threshold.
While the analysis of WV, AP and patients’ characteristics did not show any interesting result.
The 5 EWUSE patients occurred in year 2017 had no metabolic factor causing stone formation, while the only EWUSE case of year 2018 had hyperuricemia has metabolic factor. Only 3 encrustation from the EWUSE cases were analyzed and all of them were brushite (Calcium hydrogen phosphate; CaHPO4.2H2O).

==fine results==

==inizio discussions==

In the recent years many articles are trying to correlate weather parameters to the incidence and prevalence of human diseases. Stone formation has a known multifactor etiology, an important role it has always been given do the income of daily water intake and the hydration status of the patient because highly concentrated salts and slow flow of urine in the collecting system facilitate precipitation of crystals and stone formation.(3)
“Stifling heat” is when both Temperature and RH are high. In this condition people suffer the heat and the sweat cannot evaporate easily from the body, because of the amount of moisture already present in the air.
“Scorching heat” is when, at a generally low RH, the Temperature is high and the DP is low. In this condition, in order to decrease the body temperature, the thermoregulation system induce sweating that immediately evaporate facilitating fast dehydration.

==fine discussions==

==inizio conclusion==

The 5 EWUSE patients (6.8% of the indwelled stent in year 2017, but also 28% of the indwelled stent in summer 2017) brought the stent during August and September 2017, and 3 of them also during July 2017, which were the months with the highest number of days with DP, RH and temperatures over the thresholds.
Results show that the “Scorching Heat” (high temperatures united with low RH and low DP) registered for so many days during summer 2017 acted as an external risk factor facilitating dehydration due to increased perspiration for thermoregulation.
Patients carrying stent should be advice to avoid condition that facilitate dehydration and increase water daily intake.

==fine conclusion==

==inizio reference==

1) Long-term complications of JJ stent and its management: A 5 years review. Ray RP, Mahapatra RS, Mondal PP, Pal DK. Urol Ann. 2015 Jan-Mar;7(1):41-5.
2) https://www.ilmeteo.it/portale/archivio-meteo
3) Seasonal Variation in the Frequency of Presentation with Acute Ureteral Colic and Its Association with Meteorologic Factors. Roche EC, Redmond EJ, Yap LC, Manecksha RP.J Endourol. 2019 Nov 21.

==fine reference==

THE „GREY ZONE“ OF 10-20 mm KIDNEY STONES: WHAT ABOUT THE EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY RESULTS?

==inizio objective==

Based on EAU guidelines the indication for the active removal of 10-20 mm is based on both endourological approach and ESWL.
Very often the choice of the treatment depends on the urologist or on the patients preferences. In some case the indications depends in the availability of instruments but, still the stone free rates and the complication rates of ESWL and endourological approaches, are confusing.
Worldwide the number of endourological procedures are increasing, in the treatment of renal stones, reporting high stone free rates and the question if the ESWL is competitive is still on debate

==fine objective==

==inizio methodsresults==

Material and Methods
We report our experience in a single Stone Center on 2856 out of 6477 patients with 10 – 20 mm urinary tract stones, using a lithotripter equipped with the EMSE type 220F-XXP.

From October 2001 till May 2019, 6477 patients were treated using the Dornier Lithotripter DLS II. We evaluated retrospectively the stone free rates and the complication rates on the group of patients (2856) with a 10-20 mm kidney stone. The inclusion criteria were patients with kidney stones for which ESWL were appropriate. All stone localization and chemical composition were included (whatever Hounsfield Unit).

==fine methodsresults==

==inizio results==

The overall “stone free rate” was equal to 85.0% ( 2430 out of 2856 patients)
after a single treatment. Based on the stone localizations, the 3 month stone free rates, were: in the pelvic stones group 1680 out of 1890 (88.8%) , for stones of the upper calyx 93 out of 112 patients (83.0%) , for medium calyx stones 58 out of 105 (55.2%), and for lower calyx stones 599 put of 749 (79.9%).
38 (1.4%) out of 2856 patients needed a post ESWL endourological approach to remove fragments blocked in the ureter and 3 patients underwent to double J insertion to treat a clinically evident subacapsular hematoma.

==fine results==

==inizio discussions==

The results showed a large stone free rates and lower complications rates in the 10-20 mm kidney stones. The evaluation of the results based on the localization indicates good results for lower calyx stones. Therefore, better results could be obtained by the evaluation of HU of the stones and following the best practice rules.

==fine discussions==

==inizio conclusion==

In such way, probably , the next guidelines must be redefine the treatment of choice of the “grey zone” of 10-20 mm kidney stones, maintain the leader role of ESWL in the treatment of urinary tract stones.

==fine conclusion==

==inizio reference==

==fine reference==

Clinical and psychological outcomes of patients undergoing Retrograde Intrarenal Surgery and Miniaturised Percutaneous Nephrolithotomy for kidney stones. A preliminary study Outcomes of surgery for kidney stones

==inizio objective==

Objective: To assess disease-specific and health-related QoL, anxiety and depression as well as satisfaction regarding RIRS and mPCNL intervention for kidney stones up to 2.5 cm. Secondarily, pain as well as perioperative and postoperative patient outcomes were evaluated.

==fine objective==

==inizio methodsresults==

60 consecutive patients with kidney stones of dimensions not exceeding 2.5 cm were enrolled in the study of which 30 underwent RIRS and 30 mPCNL 1. Perioperative characteristics (age, gender, body mass index (BMI), stone side and size, previous interventions for kidney stones and duration of hospitalization) and surgical outcomes (hemoglobin drop, stone-free rate, visual analogue scale (VAS), stenting time, size of UAS deployment, and postoperative complications) of patients were collected. Quality of life and psychological outcomes were evaluated using validated questionnaires. 2-3-4Regarding psychological outcomes, we found significant differences between the two groups regarding QoL domains of social functioning (p<0.05) and vitality (p<0.01). Furthermore, the RIRS group showed elevated anxiety and depression scores. Correlated to this data, also VAS pain scores were significantly lower in the mPCNL group compared with the RIRS group (p0.05). Significant differences between the mPCNL and the RIRS groups were found regarding stenting time (p=0.032) and duration of hospital stay (p0.05). Peri- and postoperative complications were not statistically different between the two groups (p>0.05). RIRS group reported higher anxiety and depression scores compared with the mPCNL group (3 [range 0-15] vs 15 [range 6-24], p<0.01). We found significant differences between the two groups in social (p<0.05) and vitality (p<0.01) scores. VAS pain score was significantly lower in the mPCNL group than in the RIRS one (p0.05). Likely, mPCNL would reach the success rate more precociously than RIRS as most of RIRS performers uses laser lithotripsy between 5 and 15W, using a dusting techniques reducing fragments to easily passible sandlike pieces. Instead, mPCNL may guarantee intraoperative stone clearance either by stone dusting or by fragments washed-out through Amplatz sheath . Validated Clavien-Dindo evaluation for complications did not reveal any statistically significant difference, while hospital stay was in favor for RIRS, as expected. In our experience, the length of stay is longer for the nephrostomy management in patients subjected to mPCNL, as patients remain hospitalized while the nephrostomy is still inserted. Instead, in tubeless or a totally tubeless patients hospitalization times are overlapping with those of the RIRS. Patients subjected to RIRS are discharged precociously even if they carry a stent because usually they do not require any specific support until stent removal. Stenting time was significantly different between the mPCNL and the RIRS group (7 days [range 4-5] vs 8 days [range 5-14.75], p=0.032). Since the complications and the success rate are similar, the surgical choice of switching from RIRS to mPCNL and viceversa may be proposed to patients during pre-operative counseling. Moreover, supine position modified according to Galdakao variant allows in the selected cases of kidney stones up to 2.5 cm, an easy, no time-consuming switch from retrograde to anterograde treatment and vice-versa when patients are unfit for one over the other technique.

==fine discussions==

==inizio conclusion==

These results open new scenarios in the treatment of kidney stones up to 2,5 cm when RIRS and mPCNL have interchangeable indications. Since in our experience complications and success rate are similar, the surgical choice of switching from RIRS to mPCNL in real-time and viceversa may be proposed to the patient in the preoperative counseling.

==fine conclusion==

==inizio reference==

1. Davis NF, Quinlan MR, Poyet C, et al. Miniaturised percutaneous nephrolithotomy versus flexible ureteropyeloscopy: a systematic review and meta-analysis comparing clinical efficacy and safety profile. World J Urol. 2018 Jul;36(7):1127-38. PubMed PMID: 29450733. Epub 2018/02/17.
2. Garcia SF, Cella D, Clauser SB, et al. Standardizing patient-reported outcomes assessment in cancer clinical trials: a patient-reported outcomes measurement information system initiative. J Clin Oncol. 2007 Nov 10;25(32):5106-12. PubMed PMID: 17991929. Epub 2007/11/10.
3. Penniston KL, Antonelli JA, Viprakasit DP, et al. Validation and Reliability of the Wisconsin Stone Quality of Life Questionnaire. J Urol. 2017 May;197(5):1280-8. PubMed PMID: 27889419. Epub 2016/11/28.
4. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70. PubMed PMID: 6880820. Epub 1983/06/01.
5. Heller GZ, Manuguerra M, Chow R. How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance. Scand J Pain. 2016 Oct;13:67-75. PubMed PMID: 28850536. Epub 2017/08/30.
6. de la Rosette JJ, Opondo D, Daels FP, et al. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol. 2012 Aug;62(2):246-55. PubMed PMID: 22487016. Epub 2012/04/11.

==fine reference==

Subcapsular renal hematoma after Retrograde Intra Renal Surgery (RIRS) and Holmium laser Litotripsy: a case report

==inizio objective==

We present a case report of subcapsular renal hematoma after Retrograde Intrarenal Surgery (RIRS) and literature review.

==fine objective==

==inizio methodsresults==

A 71-years-old female patient was diagnosed by abdominal contrast-enhanced computerized tomography (CT) scan with moderate dilatation of the upper left ureter, left hydronephrosis, left ureteral stone of 5 mm and 2 more left kidney stones of 5 and 7 mm in prior PCNL, performed in 2013. The patient presented with an history of diabetes and prior thyroidectomy. The patient was admitted to our hospital with negative uroculture to perform left ureteroscopy after written informed consent was obtained. During the procedure because of the stone migration into the kidney was observed, a RIRS procedure was performed, with Holmium lithotripsy, fragments removal and a double J stent placement. In the second post-operative day the patients complained of pain in the left lumber region and fever with development of uro-sepsis. The emergent abdominal CT Scan revealed a great sub-capsular renal hematoma of 8x11cm and a 14 mm perirenal fluid collection.

==fine methodsresults==

==inizio results==

The routine blood tests revealed normal hemoglobin level stable compared of preoperative levels. Vital signs, urine volume and routine blood tests were monitored. The case was managed in conservative manner with intravenous fluid intake, antibiotics, and FANS. The patients was discharged in tenth post-operative day with double J stent in place and antibiotics therapy. Outpatient ultrasonography after three months revealed subcapsular renal hematoma resolution. The double J stent was removed after three months.

==fine results==

==inizio discussions==

RIRS as a transurethral, minimally invasive and efficient procedure has become a regular operation for treatment of renal calculi. The postoperative complication rate of RIRS is low, with the most frequent complication being a fever, flank pain, hematuria, stein strasse, uro-sepsi. Complication rate varies from 0 to 25% ( 1 , 2 , 3, 4 , 5 ). Renal hematoma after RIRS lithotripsy using holmium laser is a rare complication. The physiologic intrarenal pressure is about 10 mmHg, although the minimum threshold pressure for pielo-venous and pielo-lynphatic reflux is about 30-45 mmHg ( 6 , 7 ). It was demonstrated that high intrarenal pressure is a clear risk factor for sepsis complication ( 8 ). Bleeding complications can occur owing to the lesion of laser on renal parenchima or due to calix avulsion. Moreover, parenchimal or fornix rupture due to high intrarenal pressure could occur during the procedure ( 9 , 10 , 11 ).

==fine discussions==

==inizio conclusion==

RIRS is a safe and affective procedure for renal stones with generally acceptable complication rate. Post-RIRS subcapsular hematoma is a rare but potentially serious complication. A high index of suspicion is needed when patients present with significant loin pain and fever after RIRS. The management of post-RIRS subcapsular hematomas could be conservative but needs to be customized for each patient.

==fine conclusion==

==inizio reference==

1. Cho SY. Current status of flexible ureteroscopy in urology. Korean J Urol. 2015;56:680–688.
2. Geavlete P, Multescu R, Geavlete B. Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014? Int J Urol. 2014;21:1076–1084.
3. Cakiroglu B. Comparison Of SWL and RIRS In Lower Calyceal Stones. Science Journal Of Clinical Medicine. 2013;2 166.
4. Cepeda M, Amón JH, Mainez JA, Rodríguez V, Alonso D, Martínez-Sagarra JM. Flexible ureteroscopy for renal stones. Actas Urol Esp. 2014;38:571–575.
5. Ho CC, Hee TG, Hong GE, Singam P, Bahadzor B, Md Zainuddin Z. Outcomes and Safety of Retrograde Intra-Renal Surgery for Renal Stones Less Than 2 cm in Size. Nephrourol Mon. 2012;4:454–457.
6. Jung H, Osther PJ. Intraluminal pressure profiles during flexible ureterorenoscopy. Springerplus. 2015;4 373.
7. Thomsen HS. Pyelorenal backflow. Clinical and experimental investigations. Radiologic, nuclear, medical and pathoanatomic studies. Dan Med Bull. 1984;31:438–457.
8. Wilson WT, Preminger GM. Intrarenal Pressures Generated During Deflectable Ureterorenoscopy. Journal Of Endourology. 1990;4:135–141.
9. Chen S, Xu B, Liu N, Jiang H, Zhang X, Yang Y, et al. Improved effectiveness and safety of flexible ureteroscopy for renal calculi (<2 cm): A retrospective study. Can Urol Assoc J. 2015;9:E273–E277.
10. Watanabe R, Inada K, Azuma K, Yamashita Y, Oka A. Case of renal subcapsular hematoma caused by flexible transurethral lithotripsy. Hinyokika Kiyo. 2013;59:565–568.
11. Campobasso D, Grande M, Ferretti S, Moretti M, Facchini F, Larosa M, Salsi P, Granelli P, Pozzoli GL, Frattini A. Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience. Minerva Urol Nefrol. 2018 Dec;70(6):617-623.

==fine reference==

PCNL closed circuit mini-Perc Clear Petra system: our experience

==inizio objective==

Percutaneous nephrolithotomy (PCNL) was at first indicated for larger renal stones. Technological progress allowed a significant improvement of the available equipment, mostly to miniaturize the devices. However, this should not affect the stone clearance. Many different techniques arised aiming to reduce the complications of PCNL. As it becomes less invasive, the indications are greatly expanded, and a growing number of patients will benefit from this procedure in the future. This explains the significance of knowing the technique in continual development in greater detail (1). Clear Petra System consist in a closed circuit with a continuous inflow and a suction-controlled outflow that permit a clear intraoperative vision. We present our experience with this procedure.

==fine objective==

==inizio methodsresults==

Ten consecutive patients (mean age 54 years) affected by renal stones varied between 25 to 35 mm were treated with mini-Perc clear Petra System at our institution. All patients were positioned in Valdivia Galdakao modified. A 16 Fr Clear Petra nephrostomy sheath and a 12 Fr nephroscope in all case were used. Lithotripsy were performed used Holimium Laser. Lapaxy was performed through the aspiration linked with the later arm of the sheath. No baskets were used. In all the patients double J ureteral stent and 8 Fr nephrostomy was positioned at the end of procedure. Mean RX exposition time during surgery was 90 sec (range 70-110 sec).

==fine methodsresults==

==inizio results==

Operation time varied from 60 to 90 minutes, mean 72 min. All patients were stone free at the end of the procedure. Routine blood test was performed in first post-operative day and in one patients we observed a decrease in hemoglobin level because of subcapsular hematoma, without necessity of transfusion. In one case we observed fever > 38°C, solved with antibiotic therapy. In all the other patients routine blood test was stable compared with preoperative. In all but one patients (fever case) nephrostomy was closed in the first post-operative day and removed in the second day. Mean Hospital stay was 3,7 days (range 3-6). After one month previous abdomen CT scan that demonstrated stone free, double J stent was removed in all patients. None patient required second look.

==fine results==

==inizio discussions==

The complications related to access might be the injury pleura and other visceral organs. The other complications are bleeding, infection and incomplete stone clearance (2). Complications such as perioperative bleeding, urine leak from nephrocutaneous fistula, pelvicalyceal system injury, and pain are individually graded as complications by various authors and are responsible for a significant variation in the reported overall PCNL complication rate. For this reasons comparison of morbidity between studies is almost impossible. Due to the latter, a universally accepted grading system specialized for the assessment of PCNL-related complications and standardized for each variation of PCNL technique is deemed necessary (3). Control intrarenal pelvic pressures could potential reduce the irrigation pressure-related complications (4)

==fine discussions==

==inizio conclusion==

A closed circuit PCNL clear Petra system could help the surgeon in several ways: the continuous aspiration guarantees a crystal clear vision along the procedure. The low intrarenal pressure is associated with less post-operative infective complications. The easy litholapaxy and the absence of fragments scatter may reduce operative time. Mini Perc clear Petra system is safe and effective in the treatment of large renal stone .

==fine conclusion==

==inizio reference==

1) Schoofs F, Celentano G, Abboudi H, Choong S, Iselin C, Wirth G. Evolution and miniaturization of percutaneous nephrolithotomy. Rev Med Suisse. 2019 Nov 27;15(673):2198-2201. French.
2) Ganpule AP, Vijayakumar M, Malpani A, Desai MR. Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surg. 2016 Dec;36(Pt D):660-664.
3) Kyriazis I, Panagopoulos V, Kallidonis P, Özsoy M, Vasilas M, Liatsikos E. Complications in percutaneous nephrolithotomy. World J Urol. 2015 Aug;33(8):1069-77.
4) Rawandale-Patil AV, Ganpule AP, Patni LG. Development of an innovative intrarenal pressure regulation system for mini-PCNL: A preliminary study. Indian J Urol. 2019 Jul-Sep;35(3):197-201.

==fine reference==

Supine Percutaneous Nephrolithotomy in Horseshoe Kidneys? Results of a Multicentric Study

==inizio objective==

To report on the outcomes of Percutaneous Nephrolithotomy (PCNL) in Horseshoe Kidneys (HSK) in 12 different institutions worldwide and evaluate the impact of positioning during surgery.

==fine objective==

==inizio methodsresults==

We performed a retrospective analysis of prospective databases, between 2008 and 2018, that included all PCNL in HSK. Pre, peri and postoperative data were collected and a subgroup analysis according the patient position was performed. Success rate was defined as absence of >4mm fragments on the control study. A p value =4mm. When analyzing surgeries according to the patient position, 67 patients (63.2%) were operated in prone and 39 (36.8%) in supine. Prone patients had a significantly higher BMI than supine group (30.1 vs 27.7, p=0.024). The transfusion, complication and immediate success rates between prone and supine groups were 4.5% vs 2.6% (p=0.99), 16.9% vs 18.4% (p=0.99) and 52.5 vs 69.2% (p=0.151), respectively. Surgical time was significantly higher for Prone group (126.5 vs 100 min, p=0.04). Upper pole was the preferred access in 80.3% of Prone group and in 43.6% in Supine group (p<0.001). Prone group had significantly more Clavien 2 complications than supine (p=0.013). Final success rate for prone and supine groups increased to 66.1 and 82.1% after 0.26 and 0.21secondary procedures respectively. There were no higher than Clavien 3 complications in this series.

==fine results==

==inizio discussions==

Our study shows that PCNL in HSK is a relatively low frequency procedure. However, it is a safe and effective treatment with a low rate of complications. Higher BMI and stone size impacted negatively outcomes and supine positioning was associated to a lower operative time.

==fine discussions==

==inizio conclusion==

Moreover, it breaks the paradigm that PCNL in HSK should only be done in prone positioning through the upper pole, since supine and prone groups had similar outcomes. Patient positioning during PCNL in HSK could be chosen according surgeon preference.

==fine conclusion==

==inizio reference==

1.​Weizer AZ, Silverstein AD, Auge BK, et al. Determining the incidence of horseshoe kidney from radiographic data at a single institution. J Urol. 2003;170(5):1722-1726.
2.​Pawar AS, Thongprayoon C, Cheungpasitporn W, Sakhuja A, Mao MA, Erickson SB. Incidence and characteristics of kidney stones in patients with horseshoe kidney: A systematic review and meta-analysis. Urol Ann. 2018;10(1):87-93.
3.​Raj GV, Auge BK, Assimos D, Preminger GM. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys. J Endourol. 2004;18(2):157-161.
4.​Kartal I, Cakici MC, Selmi V, Sari S, Ozdemir H, Ersoy H. Retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of stones in horseshoe kidney; what are the advantages and disadvantages compared to each other? Cent European J Urol. 2019;72(2):156-162.
5.​Gokce MI, Tokatli Z, Suer E, Hajiyev P, Akinci A, Esen B. Comparison of shock wave lithotripsy (SWL) and retrograde intrarenal surgery (RIRS) for treatment of stone disease in horseshoe kidney patients. Int Braz J Urol. 2016;42(1):96-100.
6.​Türk C, Petřík A, Sarica K, et al. EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis. Eur Urol. 2016;69(3):468-474.
7.​Assimos D, Krambeck A, Miller NL, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol. 2016;196(4):1153-1160.
8.​Li J, Gao L, Li Q, Zhang Y, Jiang Q. Supine versus prone position for percutaneous nephrolithotripsy: A meta-analysis of randomized controlled trials. Int J Surg. 2019;66:62-71.
9.​de Souza Melo PA, Vicentini FC, Beraldi AA, Hisano M, Murta CB, de Almeida Claro JF. Outcomes of more than 1 000 percutaneous nephrolithotomies and validation of Guy's stone score. BJU Int. 2018;121(4):640-646.
10.​Satav V, Sabale V, Pramanik P, Kanklia SP, Mhaske S. Percutaneous nephrolithotomy of horseshoe kidney: Our institutional experience. Urol Ann. 2018;10(3):258-262.
11.​Etemadian M, Maghsoudi R, Abdollahpour V, Amjadi M. Percutaneous nephrolithotomy in horseshoe kidney: our 5-year experience. Urol J. 2013;10(2):856-860.
12.​Osther PJ, Razvi H, Liatsikos E, et al. Percutaneous nephrolithotomy among patients with renal anomalies: patient characteristics and outcomes; a subgroup analysis of the clinical research office of the endourological society global percutaneous nephrolithotomy study. J Endourol. 2011;25(10):1627-1632.
13.​Sohail N AA, Abdelrahman KM, Bhatti KH. Supine percutaneous nephrolithotomy in horseshoe kidney. Journal of Taibah University Medical Sciences. 2017;12:261-264.
14.​Vicentini FC, Marchini GS, Mazzucchi E, Claro JF, Srougi M. Utility of the Guy's stone score based on computed tomographic scan findings for predicting percutaneous nephrolithotomy outcomes. Urology. 2014;83(6):1248-1253.
15.​Osther PJ, Razvi H, Liatsikos E, et al. Percutaneous nephrolithotomy among patients with renal anomalies: patient characteristics and outcomes; a subgroup analysis of the clinical research office of the endourological society global percutaneous nephrolithotomy study. J Endourol. 2011;25(10):1627-1632.
16.​Skolarikos A, Binbay M, Bisas A, et al. Percutaneous nephrolithotomy in horseshoe kidneys: factors affecting stone-free rate. J Urol. 2011;186(5):1894-1898.
17.​Shokeir AA, El-Nahas AR, Shoma AM, et al. Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys. Urology. 2004;64(3):426-429.
18.​Kuntz NJ, Neisius A, Astroza GM, et al. Does body mass index impact the outcomes of tubeless percutaneous nephrolithotomy? BJU Int. 2014;114(3):404-411.
19.​Zhou X, Sun X, Chen X, et al. Effect of Obesity on Outcomes of Percutaneous Nephrolithotomy in Renal Stone Management: A Systematic Review and Meta-Analysis. Urol Int. 2017;98(4):382-390.
20.​Tzou DT, Metzler IS, Usawachintachit M, Stoller ML, Chi T. Ultrasound-Guided Access and Dilation for Percutaneous Nephrolithotomy (PCNL) in the Supine Position: a step-by-step approach. Urology. 2019.
21.​Vicentini FC, Perrella R, Souza VMG, Hisano M, Murta CB, Claro JFA. Impact of patient position on the outcomes of percutaneous neprolithotomy for complex kidney stones. Int Braz J Urol. 2018;44(5):965-971.

==fine reference==

High-Frequency Dusting using a 120-W Holmium Laser during flexible ureteroscopy: a single-centre experience

==inizio abstract==

In this video to present a detailed report of our experience about Low Energy (LE)/High Frequency (HF) lithotripsy (settings 0.2-0.5J / 50-80Hz – 10-40W) by using a 120-W high-power Ho:YAG system and to propose our technique.
Our technique consists in 3 phases: 1) Contact Laser lithotripsy (LE/HF/LPW dusting – 0,5 J/50 Hz or 02 J/70 Hz in relation to stone Hardness), 2) Extraction of main fragments (both for treatment and for stone analysis), 3) Non-contact Laser lithotripsy (LE/HF/Short Pulse Width Pop Dusting – 0,5 J /80Hz). From December 2017 to January 2019 104 LE/HF/LPW RIRS had been performed in Cuneo Hospital. Follow-up was conducted with a CT scan performed at 3 months after RIRS and the procedure success was defined as stone-free or presence of ≤4 mm fragments (CIRF). All patients underwent a 3 months post-operative therapy with potassium citrate (3025,4 mg/100 ml/die) and magnesium citrate (1136,4 mg/100 ml/die). Overall success rate at 3 months CT scan was 88,5% (71,2% stone-free and 17,3% CIRF). Early post-operative complications were reported in 4,6%. The application of LE/HF/LPW RIRS for the treatment of renal stones seems to be safe and effective, in terms of positive success rate, low number of complications and reduced operative time.

==fine abstract==

RIRS PERFORMED IN SITU FOR LOWER POLE RENAL STONES: CAN WE ACHIEVE A GOOD OUTCOME?

==inizio abstract==

When performing RIRS for lower pole stones dislocation of the stone is usually suggested. The main reason of that is the high risk of ureteroscope damaging due the extreme and prolonged flexion. Less is known about real efficacy of lithotripsy if performed in situ. In this video to present a detailed report of our experience about the efficacy of RIRS with lithotripsy performed in situ in case of non dislocable stones or favorable anatomy.
RIRS performed in a single Center from 2011 to 2016 were retrospectively analyzed. Single stones ≤ 15 mm in the lower pole were selected. We created 2 groups: in group A stones were treated in situ, in group B stones were dislocated before before lithotripsy. Success was considerd in case of stone free or residual fragments ≤ 4 mm.
Complete data were available for 93 patients. Stones were treated in situ in 61 cases (group A) and after dislocation in 32 (group B). RIRS performed in situ for lower pole renal stones have a low success rate, even if the caliceal anatomy allows an easy access to the stone. Success rate is low for smaller stones as well. When the preoperative evaluation suggests poor chance of displacing, patient is informed about mini or Ultramini ECIRS.

==fine abstract==

Mini percutaneous nephrolithotomy (MiniPCNL) with ClearPetra™ Nephrostomy Sheath

==inizio abstract==

Percutaneous nephrolithotomy (PCNL) is the gold standard surgical modality in the management of large kidney stones. Recently, with raising popularity of PCNL procedures, multiple modifications were proposed to the surgical techniques and instrumentation. Reducing the gauge of the instrument reduces the morbidity associated with the procedure. There are many retrospective studies demonstrating safety and efficacy of different mini versions of PCNL.

The ClearPetra™ System is a new device designed for enhance the renal stones lithotripsy using a negative pressure aspiration. It improves stone clearance rate, reduces the intra-luminal pressure, prevents stone retropulsion, improves visual field, obviates the need of accessory device (baskets, forceps,…) and saves operating time.

In this video we show a case of miniPCNL procedure in a patient with a 3.5 cm left staghorn stone. The procedure was done with a modified 10-14 Ch access sheath with a suction-evacuation function and a Storz MiniNephroscope 12 Ch with a 3.5 Ch operative channel for stone Ho-laser lithotripsy.

==fine abstract==

Mini percutaneous nephrolithotomy (MiniPCNL) is the ideal solution for medium-sized renal calculi

==inizio abstract==

Percutaneous nephrolithotomy (PCNL) is the gold standard surgical modality in the management of large kidney stones. Recently, with raising popularity of PCNL procedures, multiple modifications were proposed to the surgical techniques and instrumentation. Reducing the gauge of the instrument reduces the morbidity associated with the procedure. There are many retrospective studies demonstrating safety and efficacy of different mini versions of PCNL.
The 16 Ch Miniperc tract offers low morbidity in terms of blood loss and maintains stone clearance comparable to larger 24 Ch tract size. It should be the ideal size used for medium (15 – 30mm) sized renal stones.

In this video we show a case of miniPCNL procedure in a patient with a 2.0 cm left pyelic stone, detailed step by step from the US-guided puncture to the exit strategy. The procedure was done through a 16 Ch Mini Amplatz cannula mounted on a 14 Ch metallic shaft dilator. A Storz MiniNephroscope 12 Ch with a 3.5 Ch operative channel is used for stone Ho-laser lithotripsy.

==fine abstract==