Journal of Endourology

To evaluate the safety, feasibility, and outcomes of ureteroscopic (URS) lithotripsy for distal ureteral stones under patient-controlled sedation (PCS) in a large single-center cohort.

This retrospective observational study included 414 patients who underwent 429 URS lithotripsies under intravenous PCS with propofol and alfentanil between 2017 and 2023. Pre-, peri-, and postoperative variables were assessed, and outcomes were analyzed according to stone-free status using graded definitions. Grade A indicated complete stone-free status with no residual stones on postoperative CT, Grade B included Grade A with residual fragments ≤2 mm, and Grade C included Grades A and B with residual fragments measuring 2.1–4 mm.

The overall absolute stone-free rate was 95% (n = 406; Grade A); when relative stone-free definitions were applied, the rates were 95% (n = 408; Grade B) and 97% (n = 414; Grade C). The rate of complications (Clavien–Dindo ≥III) was 1%, and no adverse events occurred. The procedure was aborted in 1% of cases, and 99% of procedures were completed on an outpatient basis without anesthesiology support. Non-stone-free patients (5%) more frequently had multiple or larger stones and a history of stone disease, although no associations were identified with sedation volume or surgeon experience.

URS lithotripsy under PCS is safe and effective for distal ureteral stones, with a high stone-free rate and low complication rate, and may offer practical advantages in clinical practice.

TURP remains a cornerstone endourology procedure and a key training platform for transurethral endoscopic skills. The aim of this study is to develop a transurethral treatment (TUT) Step 2-Prostate curriculum using cognitive task analysis (CTA) and Delphi consensus using the European School of Urology (ESU) methodology.

An ESU expert working group performed CTA and structured TURP into 10 domains (equipment, patient preparation, resection technique, bleeding prevention, bleeding management, exit strategy, tips and tricks, postoperative care, TUR syndrome, and management of other intraoperative difficulties).CTA-derived statements were assessed in a two-round Delphi (1–9 Likert scale) with consensus defined as ≥80% agreement (7–9) and <10% disagreement (1–3).

Of 109 invited experts, 62 completed round 1 and 55 completed round 2. In round 1, 138 statements were evaluated and 116 (84.1%) reached consensus; after reevaluation of 23 statements in round 2, a total of 126/138 (92.7%) statements achieved consensus, and one statement was rejected. Consensus was highest for safety-critical steps and complication management, while lower agreement clustered around equipment choices and some postoperative practices.

A CTA-informed, Delphi-validated ESU TUT Step 2P curriculum was established, defining consensus-based core competencies for TURP and providing a structured foundation for simulation development, standardized teaching, and competency-based assessment.

This research explores the use of virtual reality (VR) as a tool to improve the consenting process for shockwave lithotripsy (SWL). We investigated how patients experienced VR and its impact on their understanding, emotions, and pain levels.

Patients attending clinic for their SWL treatment were prospectively recruited to experience a 3-minute-long VR animation. This animation outlined the SWL procedure based on the British and European urolithiasis guidelines and enabled visualization of urinary anatomy. Participants then responded to questionnaires, giving insight into their levels of understanding, emotional status, and pain.

Two hundred participants fully completed all the questionnaires. VR use significantly improved participants’ understanding and confidence in explaining the SWL procedure, alongside significantly reducing nervousness. Participants reported improvements in all positive emotions and reductions in all negative emotions. VR was rated as significantly more accessible and helpful based on patient-reported outcome measures than current resources, with 76% of participants reporting a strong preference for its inclusion in future treatment. Compared with previous SWL research, the mean postprocedural pain score (1.86) was lower, suggesting that VR may help to improve pain tolerance.

VR shows great potential to enhance the consenting process for SWL. VR interventions can improve patient understanding, strengthening informed consent. They can also enhance the consenting experience through reducing negative emotions such as anxiety, while improving positive emotions such as satisfaction. Because of altered emotional status and improved understanding, VR may also have a role in reducing pain perception, potentially providing a nonpharmacologic alternative to traditional analgesics.

Adequate bladder distention is critical for safe and efficient transurethral morcellation during endoscopic prostate enucleation. Traditional assessment methods are subjective and may compromise safety and efficiency. We evaluated the feasibility and impact of continuous intravesical pressure (IVP) monitoring using a handheld pressure meter during morcellation compared with conventional manual bladder assessment.

In this prospective, randomized pilot study, 30 patients undergoing transurethral morcellation after bipolar prostate enucleation were randomized 1:1 to continuous IVP monitoring with a handheld pressure meter (Group A) or manual suprapubic bladder assessment by a urology fellow (Group B). In Group A, morcellation was performed while IVP remained within a predefined safe range (15–60 mmHg), with pauses for pressure correction as needed. The primary outcome was the number of morcellation pauses. Secondary outcomes included morcellation time, morcellation efficiency (g/min), total operative time, hemoglobin deficit, complications, and functional outcomes (International Prostate Symptom Score, maximum urinary flow rate, and post-void residual) at 3 and 6 months.

Baseline characteristics were comparable between groups. Morcellation time was significantly shorter in Group A (8.9 ± 3.7 vs 13.3 ± 2.1 minutes; p = 0.0008), with fewer morcellation pauses (3.3 ± 0.7 vs 5.7 ± 1.2; p < 0.0001) and higher morcellation efficiency (9.9 ± 2.0 vs 5.9 ± 0.6 g/min; p < 0.0001). Enucleation time, total operative time, tissue weight, and hemoglobin deficit were similar. No bladder injuries or postoperative fever occurred. Functional outcomes at 3 and 6 months were comparable.

Continuous IVP monitoring using a handheld pressure meter during transurethral morcellation is feasible, reduces interruptions, and significantly improves morcellation efficiency without compromising safety or functional outcomes. This inexpensive technique may be a valuable safety adjunct, particularly for less experienced surgeons, and merits evaluation in larger randomized trials.

To characterize the etiology and clinical course of patients with subcapsular renal hematoma (SRH) in order to better understand and manage patients in the acute and chronic settings.

A natural language processing algorithm screened computed tomography and magnetic resonance imaging studies for “subcapsular renal hematoma” across 10 inpatient facilities from 2011 to 2021. Patients with at least three cross-sectional exams were included. Retrospective chart review assessed etiology, clinical course, and management of SRH.

A total of 105 patients with acute SRH were included. The underlying etiologies involved traumatic (21%), spontaneous (32%), and iatrogenic causes (47%). Three patients developed Page kidney with hypertension secondary to renin-angiotensin-aldosterone system activation. Notably, two of these patients had solitary kidneys, with one necessitating temporary hemodialysis and the other undergoing hematoma evacuation. Additionally, six patients developed infected hematomas; five required drainage by interventional radiology (IR), and one patient underwent nephrectomy. Angiography by IR was recommended in 21 patients, 17 of whom underwent renal artery embolization. One patient developed intractable pain, requiring operative hematoma evacuation. Another patient developed abdominal compartment syndrome requiring decompressive laparotomy. Repeat imaging was done within 1–10 months in 69 patients, with 11 (16%) demonstrating complete hematoma resolution. In 16 patients who had further imaging between 10 and 15 months, an additional 8 had resolved. The average time to complete resolution was 368 days.

Subcapsular hematoma is a rare finding, most commonly occurring after iatrogenic causes. In our series, roughly 1/3 (34%) of all hematomas require intervention, including hemodialysis, embolization, and nephrectomy. One third (33%) of spontaneous SRH required embolization, most commonly those with underlying renal masses. Three patients developed the Page kidney phenomenon, which was more common in patients with a solitary kidney.

The Glean^® Urodynamics System was developed to enable catheter-free, wireless assessment of lower urinary tract function for use in ambulatory urodynamic testing. This study assesses the performance of the Glean Urodynamics System relative to the Laborie Goby™ conventional urodynamics (UDS) system using a human bladder model.

Thirty Glean intravesical pressure sensors and 30 air-charged catheters were compared relative to a reference sensor. Three pressure simulations were conducted in the bench-top human bladder model (stepped, sinusoidal, and ramping) on each test device to evaluate rise and fall times, bandwidth, maximum error (accuracy), and linearity. Data are presented as means and standard deviations and compared using independent sample t-tests.

The Glean intravesical pressure sensors showed significantly faster rise time (0.104 seconds) and fall time (0.111 seconds) than the comparator (0.172 and 0.264 seconds, respectively; both, p < 0.001 between groups). The bandwidth of the Glean sensors more closely matched the tested maximum frequency of 5 Hertz (Hz) compared with the comparator (4.978 Hz vs 2.250 Hz; p < 0.001). The maximum error was significantly lower with the Glean sensors than the comparator (6.882 vs 21.549; p < 0.001). Linearity showed that both behaved linearly; however, the Glean sensors performed significantly better (p < 0.001 between groups).

Comparative testing demonstrated equivalent or better performance of the Glean Urodynamics System’s intravesical pressure sensors relative to a conventional UDS system’s air-charged catheters, including greater bandwidth, increased dynamic response, and reduced maximum error. These results support the superior performance of the Glean Urodynamics System for urodynamic monitoring over a conventional catheter-based UDS system.

Holmium laser enucleation of the prostate (HoLEP) has now emerged as a new, prostate-size-independent gold standard, largely because of its favorable side-effect profile compared with the previous surgical methods. In this minimally invasive procedure, tissue morcellator devices are used as an important part. This systematic review and meta-analysis compares the outcomes of the different commercial tissue morcellators used in HoLEP procedures.

Three electronic databases were searched (PubMed, Web of Science, and EMBASE) without date restrictions to find the studies evaluating morcellator device performance during HoLEP. After screening 1145 studies, 34 English, human-subject studies were included. Devices evaluated included Wolf Piranha, CyberBlade, Lumenis VersaCut, Hawk, DrillCut, and MultiCut morcellators. Two reviewers performed the study selection individually to reduce the probable bias. Extracted outcomes included perioperative parameters and complications among different commercial morcellator devices. The review was conducted with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

A total of 7211 patients were analyzed. Meta-analysis showed no statistically significant differences between morcellator systems in morcellation time (mean difference [MD] 1.02 minutes, 95% confidence interval [CI] –1.37 to 3.41), morcellation efficiency (MD 0.75 g/min, 95% CI: –0.46 to 1.97), or catheterization duration (MD 3.22 hours, 95% CI: –1.09 to 7.52). The intraoperative complication rate was low in all studies. Device malfunction (risk ratio [RR] 1.16, 95% CI: 0.23 to 5.70), bladder mucosal injury (RR: 0.85, 95% CI: 0.46 to 1.57), and bladder perforation (RR: 0.35, 95% CI: 0.10 to 1.25) did not differ significantly between devices. Cost data were limited to two studies and there was no significant cost advantage for any device.

Available evidence shows that commonly used morcellators have comparable operative performance, and safety during HoLEP. No device showed a consistent advantage compared with the others, suggesting that the morcellator choice might be done by surgeon’s preference, resource considerations, the health center’s policy, and the availability rather than performance differences.

To compare the efficacy of traditional double-layer suturing techniques vs an improved “cross-stitch” suturing technique (CST) in robot-assisted partial nephrectomy (RAPN) for localized renal cell carcinoma.

We retrospectively analyzed clinical data from patients who underwent RAPN at our center between August 2022 and January 2025. A total of 89 patients were ultimately included, including 58 in the double-layer suture group and 31 in the “cross-stitch” suturing technique group. To minimize selection bias, 1:1 propensity score matching (PSM) was performed to balance baseline characteristics between groups (matched covariates: age, body mass index, RENAL score, tumor size, tumor location, and growth pattern). In the matched cohort, a double robust estimation strategy was applied. Multivariate regression models were used to adjust for residual confounders, enabling comparison of perioperative indicators, early renal function changes, and postoperative complications between the two groups.

After PSM, 52 patients (26 in each group) were analyzed, and the clinical baseline characteristics of both patient groups achieved favorable matching, with significantly reduced differences in the distribution of covariates such as age, BMI, tumor size, radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, location score, tumor location, and growth pattern (standardized mean difference <0.1). Compared with the double-layer suturing group, the “cross-stitch” suturing technique group had a significantly shorter operative time (111.1 vs 133.4 minutes, p = 0.002) and warm ischemia time (WIT) (15.4 vs 20.5 minutes, p < 0.001). However, no statistically significant differences were observed between groups in estimated blood loss (p = 0.362), postoperative hospital stay (p = 0.349), positive margin rate (p = 0.932), postoperative complications (p = 0.315), or trifecta achievement rate (p = 0.07).

The modified CST was associated with shorter WIT and operative time and may be particularly suitable for localized renal tumors of moderate complexity. However, no significant differences were observed in postoperative renal function or trifecta after matching, and these findings should be interpreted with caution and require further validation.

Compare the long-term effectiveness of appendiceal interposition ureteroplasty (AIU) and appendiceal onlay ureteroplasty (AOU) in addressing complex proximal ureteral (CPU) strictures in children.

A retrospective review of patients who underwent minimally invasive AIU and AOU for CPU strictures between March 2010 and August 2020. Patients were stratified into two groups based on the surgical technique: AIU group (n = 11) and AOU group (n = 29). Baseline characteristics, perioperative variables, and follow-up data were assessed in both groups.

All procedures were completed effectively without the need for conversion. There were no significant differences for the AIU versus AOU groups in median age at operation (p = 0.686), disease side (p = 0.715), preoperative split renal function of the affected kidney (p = 0.906), type of surgical procedure (laparoscopy- vs robot-assisted, p = 0.498), and the mean stricture length (p = 0.166). Operation time was significantly longer in the AIU group (p < 0.001). There were no intraoperative complications, and the estimated blood loss (p = 0.579), postoperative hospital stay (p = 0.557), and Grade I–Ⅱ complications (AIU: 8/11 vs AOU: 18/29, p = 0.715) were similar between the two groups. At a median follow-up of 6 years, the success rates for the AOU group were significantly higher than the AIU group (96.6% vs 54.6%; p = 0.004).

AOU is a safe and effective technique for managing CPU strictures in children, whereas AIU is not recommended for pediatric patients because of its potential for decreased success rates over time, primarily because of complications such as anastomotic stenosis and progressive hydronephrosis.

Despite appropriate preoperative evaluation, some patients are diagnosed with clinically significant prostate cancer after Holmium laser enucleation of the prostate. Postoperative screening is challenging due to unreliable thresholds and nomograms. We developed a preoperative nomogram to predict clinically significant prostate cancer and a postoperative decision matrix for risk stratification. The secondary aim was to validate existing risk calculators.

A retrospective cohort of 857 patients was analyzed, of whom 773 were eligible. The primary outcome was the detection of clinically significant prostate cancer (csPCa) at 1 year postoperatively. A multivariate Cox regression analysis was performed. Performance was assessed with time-dependent receiver operating characteristic analysis, calibration plots, and decision curve analysis (DCA). Prostate Cancer Prevention Trial 2.0 and Memorial Sloan Kettering Cancer Center calculators were validated in 100 randomly selected patients. Postoperative surveillance used nadir prostate-specific antigen (PSA) and prostate-specific antigen reduction ratio (PRR).

csPCa was identified in 30 patients (3.9%). Independent predictors were age (hazard ratio [HR] 1.08, p = 0.001), PSA density (HR 1.54, p = 0.003), and family history (HR 5.62, p = 0.007). The area under the curve was 0.71 at 1 year for the preoperative model. DCA showed clinical utility above 5%. Standard calculators overpredicted risk (8.8% and 38.2% vs observed 2%). For postoperative surveillance, nadir PSA 1 ng/mL and PRR 50% cutoffs had negative predictive value of 97.9% and 98.4%, respectively.

We developed a preoperative nomogram for predicting csPCa within 1 year postoperatively. The postoperative surveillance decision matrix enables risk-adapted follow up.

Steerable Ureteroscopic Renal Evacuation (SURE), a novel technology utilizing the CVAC system, demonstrated promising outcomes for larger renal stones by enhancing stone clearance. This study aims to continuously monitor intrarenal pressure (IRP) during ureteroscopy with laser lithotripsy with CVAC system.

Patients undergoing ureteroscopic laser lithotripsy using the SURE technique at our institution were prospectively enrolled. IRP was measured using a 5F Pollack catheter in conjunction with a 12/14F ureteral access sheath. IRP values were recorded live and documented every minute. We defined 40 mm Hg as the IRP threshold.

Simultaneous placement of a 12/14-Fr access sheath and a Pollack catheter was feasible in 13/25 (52%) patients. Seven (53.8%) patients were nonstented. The mean preoperative stone size was 1.25 cm (interquartile range [IQR] 0.65–1.61). The mean IRP during the procedure was 17 mm Hg (IQR 12–23), with a maximum recorded IRP of 37 mm Hg (IQR 29–37). IRP briefly exceeded 40 mm Hg when fragments occluded the suction channel; the 1-minute recording interval did not capture this transient excursion, which resolved after the push–pull syringe maneuver. The stone clearance rate was 100% (IQR 93–100) based on computed tomography.

The SURE technique facilitates complete stone clearance while maintaining IRP within a safe range. IRP >40 mm Hg signaled clogs that resolved with push–pull syringe maneuver. We recommend activating push–pull syringe every minute to maintain patency. These findings support SURE as a safe and effective alternative to percutaneous nephrolithotomy in patients with moderate stone burden.

In animal models, sodium acetate has been shown to protect against acute kidney injury (AKI) via activation of the hypoxia-inducible factor pathway. We report our clinical experience with sodium acetate as an intraoperative renoprotective agent in patients undergoing robotic partial nephrectomy.

Retrospective review of a single-surgeon experience using intraoperative sodium acetate infusion (SAI; 150 mEq at 200 mL/h) during partial nephrectomies. Primary outcomes included rates of AKI as defined by established standardized criteria (i.e., KDIGO [Kidney Disease: Improving Global Outcomes], RIFLE [Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease]). Propensity score matching without replacement was used to balance baseline characteristics between groups. Subsequent association between SAI and AKI events was assessed using logistic regression analysis in the matched cohort.

Overall, SAI did not impact postoperative renal function based on serum creatine level or glomerular filtration rate. On logistic regression analysis of the matched cohort, the administration of intraoperative SAI was associated with a 58% and 61% lower odds of AKI on postoperative day 1 based on the RIFLE (p = 0.06, CI 0.17–1.03) and KDIGO (p = 0.05, CI 0.15–1.01) criterion for AKI, respectively. In the subset of patients who had pre-existing chronic kidney disease (CKD), SAI was associated with significantly lower rates of AKI using both the RIFLE (p = 0.01) and KDIGO (p < 0.05) criteria.

Perioperative SAI did not confer a statistically significant renoprotective effect for all patients undergoing partial nephrectomy. However, it may reduce the odds of postoperative AKI based on the RIFLE/KDIGO criterion, particularly in patients with pre-existing CKD. Further research is warranted to determine the clinical impact of sodium acetate as a renoprotective agent.

Clinical evidence directly comparing silicone-covered metallic ureteral stents with polymeric polyurethane Double-J stents for managing malignant ureteral obstruction remain limited. To evaluate the efficacy and safety of silicone-covered metallic stents compared with Double-J stents in patients with malignant ureteral obstruction.

This prospective, randomized, open-label, single-center, single-surgeon trial (January 2020–November 2023) enrolled 65 patients (76 ureters) with malignant ureteral obstruction. Patients were randomized 1:1 to receive either a silicone-covered metallic stent (n = 38) or a Double-J stent (n = 38). Patency rates at 6 months post-procedure were assessed as the primary end point. The secondary endpoints included technical success, patency rate, adverse event rate, and patient discomfort, which was measured using the Ureteral Stent Symptom Questionnaire.

The patency survival rate was significantly higher in the silicone-covered stent group (p = 0.0024), with the control group exhibiting a 5.621 times higher risk of occlusion at 6 months (95% confidence interval 1.588–19.899, p = 0.0074). Both groups had comparable adverse events and discomfort rates, although the silicone-covered stent group reported a superior global quality of life (QoL) at 3 and 6 months.

In patients with malignant ureteral obstruction, silicone-covered metallic stents demonstrated superior patency maintenance and global QoL scores compared with Double-J stents, with no significant difference in safety or patient satisfaction. These findings suggest that silicone-covered stents may be a viable alternative for enhancing long-term ureteral patency and patient QoL.

Percutaneous nephrolithotomy (PCNL) is the gold standard for treating large and complex renal calculi, but puncture path selection (papillary vs nonpapillary) remains a critical debate because of bleeding risk concerns. This systematic review and meta-analysis aimed to compare the safety and efficacy of nonpapillary vs papillary access in PCNL.

A comprehensive literature search was conducted in the PubMed, Embase, Web of Science, Wanfang, and China National Knowledge Infrastructure databases from inception to December 2025, supplemented by an unpublished dataset from our team’s ongoing clinical study. Eligible studies were comparative trials reporting postoperative hemoglobin drop, complication rate, stone-free rate (SFR), or operative time. Quality assessment was performed using the Cochrane Risk of Bias Tool 2.0 and the Newcastle–Ottawa Scale, with statistical analysis conducted in Stata 17.0.

A total of nine studies involving 1229 patients (787 in the papillary group and 442 in the nonpapillary group) were included. No significant differences were observed between nonpapillary and papillary access in terms of postoperative hemoglobin drop (mean difference [MD] = 0.159, 95% confidence interval [CI] = −0.365 to 0.683, p = 0.5519), overall complication rate (risk ratio [RR] = 0.949, 95% CI = 0.701 to 1.286, p = 0.7371), blood transfusion rate (RR = 0.835, 95% CI = 0.483–1.443, p = 0.5174), or SFR (RR = 0.970, 95% CI = 0.909–1.035, p = 0.3527). Although no significant overall difference in operative time was found (MD = −1.852, 95% CI = −6.745 to 3.040, p = 0.4580), subgroup analysis of prospective studies revealed that nonpapillary access was associated with a significantly shorter operative time (MD = −6.608, 95% CI = −11.573 to −1.643, p = 0.0091).

Nonpapillary access is a safe and effective alternative to papillary access for PCNL, with comparable bleeding risk, complication rate, and SFR, and potential efficiency benefits in standardized settings. Urologists can flexibly select the puncture path based on clinical scenarios, with Doppler ultrasound preferred for avoiding vascular-rich regions. Future large-scale randomized controlled trials with standardized protocols and studies on artificial intelligence-assisted fused-image-guided puncture are warranted to further optimize PCNL access strategies.