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Intrahepatic biliary stone disease is a difficult condition to treat, due to anatomical complexity of biliary tract, association with colestasis, and high recurrence rates, with potential short- and long-term complications, such as cholangitis and secondary biliary cirrhosis. Removal of biliary stones via intraductal access can be achieved endoscopically or percutaneously, with preference for cholangioscopy-guided laser lithotripsy in complex cases. The surgical approach, despite its prolonged results, is a more invasive and risky procedure. The authors present a case of cholangioscopy with percutaneous laser biliary lithotripsy as an option for the treatment of intrahepatic biliary stone disease associated with biliary stricture following biliodigestive anastomosis due to bile duct injury following cholecystectomy, a safe and effective alternative with low morbidity and satisfactory outcomes in follow-up.

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The new pulse modality Vapor-Tunnel™ (VT) consists of a very long pulse that uses the minimum peak power, causing the energy to pass through a previously created vapor channel or tunnel. The first part of the pulse creates a vapor channel, whereas the remaining energy is discharged immediately after, passing straight through the previously created tunnel. The aim of this study is to compare the dusting efficacy between Ho:YAG laser with long pulse and Ho:YAG laser with VT for non-complex kidney stones. A retrospective comparative study of 236 patients who underwent retrograde intrarenal surgery using Ho:YAG laser (long pulse vs. VT) was performed. Stone size, stone density, laser settings, laser emission time, and total operative time were recorded. We also assessed the lithotripsy efficacy (J/mm3). The stone-free rate was defined as the absence of stone fragments in a non-contrast abdominal computed tomography 4 weeks after the procedure. A total of 118 patients were included in each group. There was no significant difference in age, gender, and body mass index. Median stone volume (737 mm3 vs. 636 mm3) and stone density (788 HU vs. 656 HU) were higher in the VT group. Total energy used (14.5 J vs. 18.2 J), the laser emission time (20 min vs. 26 min), and the total operative time (79.5 min vs. 95 min) were significantly lower in the VT group. The stone-free rate was comparable between both groups (74.5% for VT and 66.1% for the long-pulse group, p = 0.15). When we evaluated the efficacy of laser lithotripsy, a significantly lower difference was obtained in the VT group (median 12.5 J/mm3 vs. median 23.1 J/mm3). The VT pulse modality was associated with decreased laser time and operative time. Additionally, it increased lithotripsy efficacy compared to Ho:YAG long pulse laser, but with a comparable free-stone rate.

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INTRODUCTION: Thulium Fiber Laser (TFL) is the most modern technology to treat nephrolithiasis and ureterolithiasis in endourology. Although there are a lot of new studies coming up, we still don't have data on how this laser works in some rare diseases.Cystinuria is the most common genetic nephrolithiasis disorder (1), known for its recurrent lithiasis (2). Our main goal in this video is to show a successful case of cystine calculi treated with Thulium Fiber Laser (Laser Fiber Dust/Quanta System™). Cystinuria is the most common genetic nephrolithiasis disorder (1), known for its recurrent lithiasis (2). MATERIALS AND METHODS: A 25 years-old male, cystinuric, presented with a CT scan, showing a 10mm stone on the right side and two calculi 6 and 7 mm on the left side, all located in the lower calyx. Bilateral flexible ureteroscopy was done using a reusable digital flexible ureteroscope. Starting on the left side, we repositioned the stone from the lower to the upper calyx, using a tipless front opening basket. Lithotripsy was performed using TFL. Settings were 100 Hz (frequency) and 100 mJ (energy) for dusting.  Popcorn technique was also used, setting the laser at 100Hz and 200 mJ, obtaining good dusting. On the right side, lithotripsy was performed in the inferior calyx, also resulting in "snowstorm". Procedure time was 120 minutes. RESULTS: The postoperative was uneventful. Follow up CT showed a 3 mm residual fragment in the right kidney. CONCLUSION: This video demonstrates the treatment of bilateral cystine calculi with Thulium Fiber Laser. Reasonable procedure time and excellent dusting results are encouraging, pointing towards great improvements in endourology.

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OBJECTIVES: To compare the dusting efficiency and safety with basketing for treating renal stones ≤ 2 cm during flexible ureteroscopy (fURS). MATERIALS AND METHODS: This study included 218 patients with renal stones ≤ 2 cm treated with fURS. Among them, 106 patients underwent dusting, and 112 patients underwent fragmentation with basket extraction. All patients were followed up for 3 months postoperatively. The operating time, lasing time, stone-free rate (SFR) and complication rate were compared. RESULTS: The mean stone size in the dusting group was 1.3 cm, whereas 1.4 cm in the basketing group. The mean operative time was significantly lower in the dusting group than in the basketing group (43.1±11.7 minutes VS 60.5±13.4 minutes, P < 0.05), but the lasing time was significantly longer for the dusting group than for the basketing group (17.7±3.9 minutes VS 14.1±3.6 minutes, P < 0.05). SFR was significantly higher in the basketing group immediately after the operation and follow-up after 1 month (76.8% vs 55.7%, P= 0.001 and 88.4% vs 78.3%, P = 0.045). However, the SFR was similar for both groups (88.8% in the dusting group vs. 90.2% in the basketing group) after 3 months postoperatively. There was no statistical difference in the complication rates between the two groups. CONCLUSIONS: Dusting has advantages in shortening the operation time and reducing the operation cost, but the lasing time was longer compared with the basketing. Although there is no difference in long-term effect, basketing is superior to dusting in terms of short-term SFR. Moreover, dusting should be avoided in some special cases and basketing a better choice. Both techniques are effective for the treatment of renal stones ≤ 2 cm and choice depends on patient demographic and stone characteristics.

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PURPOSE: To compare two-shift operation mode and single player mode different impact on surgical results and operator comfort in flexible ureteroscopic holmium laser lithotripsy for renal calculi larger than 1.5cm. MATERIALS AND METHODS: From december 2017 to december 2018, 92 patients with renal calculi admitted to Qilu Hospital and were treated through fl exible ureteroscopy. They were randomized in two-shift group (n=50) and single player group (n=42). The operative time, blood loss, hospitalization stay after operation, residual fragments (≥4mm) rate, fragmentation speed, postoperative complications and operator's fatigue score were compared. RESULTS: There was no significant difference between two groups regarding age, gender, illness side, stone size, blood loss, operative time, postoperative hospitalization stay, complications, etc (p >0.05). The fragmentation speed was 44.5±20.0mm3/min in two-shift group compared with 34.2±17.3mm3/min in single player group (p=0.037). Residual fragments (≥4mm) rate after fi rst surgery was 18% in two-shift group, while the residual fragments (≥4mm) rate was 40.5% after first surgery in single player group (p=0.017). The total fatigue score of two-shift group was 8.4 compared to 29.9 in single player group (p <0.001). CONCLUSION: In flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm, two-shift operation mode can raise the fragmentation speed and stone clearance rate, as well as signifi cantly lower operator's fatigue level and improve operator's comfort.

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ABSTRACT Purpose: To compare two-shift operation mode and single player mode different impact on surgical results and operator comfort in flexible ureteroscopic holmium laser lithotripsy for renal calculi larger than 1.5cm. Materials and Methods: From december 2017 to december 2018, 92 patients with renal calculi admitted to Qilu Hospital and were treated through flexible ureteroscopy. They were randomized in two-shift group (n=50) and single player group (n=42). The operative time, blood loss, hospitalization stay after operation, residual fragments (≥4mm) rate, fragmentation speed, postoperative complications and operator's fatigue score were compared. Results: There was no significant difference between two groups regarding age, gender, illness side, stone size, blood loss, operative time, postoperative hospitalization stay, complications, etc (p >0.05). The fragmentation speed was 44.5±20.0mm3/min in two-shift group compared with 34.2±17.3mm3/min in single player group (p=0.037). Residual fragments (≥4mm) rate after first surgery was 18% in two-shift group, while the residual fragments (≥4mm) rate was 40.5% after first surgery in single player group (p=0.017). The total fatigue score of two-shift group was 8.4 compared to 29.9 in single player group (p <0.001). Conclusion: In flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm, two-shift operation mode can raise the fragmentation speed and stone clearance rate, as well as significantly lower operator's fatigue level and improve operator's comfort.

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ABSTRACT Objectives To evaluate the efficacy of a novel decision aid (DA) in improving the patients' level of knowledge and decreasing decisional conflicts while deciding for SWL vs. RIRS in case of a symptomatic renal stone <2 cm. Materials and Methods In this prospective randomized study patients were randomized to receive either standard informing process (group 1, n=57) or DA (group 2, n=58). Level of knowledge was assessed with a questionnaire of 10 questions before and after patient informing process. Level of decisional conflict was assessed with a previously validated scoring system. Logistic regression analysis was performed to identify factors associated with adequate level of knowledge. Results Level of knowledge increased significantly in both groups after patient informing process. The increase was significantly more prominent in group 2 (p=0.045). Percentage of patients with adequate knowledge was also higher in group 2 (56.1%vs.74.1%, p=0.04). Mean decisional conflict scale score (higher score indicates higher decisional conflict level) was also significantly higher in group1 (14.7±14.5 vs. 10.1±13.7, p=0.045). Multivariate logistic regression analysis revealed higher education level (college degree) and use of DA as factors associated with adequate level of knowledge. Conclusions In the current study, The DA was shown to have a positive impact on level of knowledge and diminish the level of decisional conflict for patients with a symptomatic non-lower pole renal stone <20 mm. We recommend development and use of DAs for particular clinic scenarios to aid in education of patients and shared decision making process in stone disease clinics.

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OBJECTIVES: To evaluate the efficacy of a novel decision aid (DA) in improving the patients' level of knowledge and decreasing decisional conflicts while deciding for SWL vs. RIRS in case of a symptomatic renal stone < 2 cm. MATERIALS AND METHODS: In this prospective randomized study patients were randomized to receive either standard informing process (group 1, n=57) or DA (group 2, n=58). Level of knowledge was assessed with a questionnaire of 10 questions before and after patient informing process. Level of decisional conflict was assessed with a previously validated scoring system. Logistic regression analysis was performed to identify factors associated with adequate level of knowledge. RESULTS: Level of knowledge increased significantly in both groups after patient informing process. The increase was significantly more prominent in group 2 (p=0.045). Percentage of patients with adequate knowledge was also higher in group 2 (56.1%vs.74.1%, p=0.04). Mean decisional conflict scale score (higher score indicates higher decisional conflict level) was also significantly higher in group1 (14.7±14.5 vs. 10.1±13.7, p=0.045). Multivariate logistic regression analysis revealed higher education level (college degree) and use of DA as factors associated with adequate level of knowledge. CONCLUSIONS: In the current study, The DA was shown to have a positive impact on level of knowledge and diminish the level of decisional conflict for patients with a symptomatic non-lower pole renal stone < 20 mm. We recommend development and use of DAs for particular clinic scenarios to aid in education of patients and shared decision making process in stone disease clinics.

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INTRODUCTION: Flexible ureteroscopy and laser fragmentation (FURSL) is a minimally invasive modality for surgical treatment of renal stones. Inadequate selection of patients for this treatment generates a cost-effectiveness unbalance. OBJECTIVE: To know the stone-free rate predictors in a single surgical time in patients undergoing FURSL. METHOD: Retrospective cohort of patients undergoing FURSL. Global and gender-categorized univariate and multivariate (logistic regression) analyses were performed to identify stone-free predictors at first FURSL. RESULTS: Stone-free rate at first FURSL was 73.62%. Predictors in males were patient age and stone size, density and multiplicity; in females, body mass index and multiplicity of stones. CONCLUSIONS: Stone-free rate predictors at first FURSL are different in males and females. Women with overweight and obesity probably have easy-to-fragment and easy-to-extract stones associated with uric acid.

INTRODUCCIÓN: La ureteroscopia flexible con litotricia láser (URSLL) es una modalidad mínimamente invasiva de tratamiento quirúrgico de cálculos renales. La selección inadecuada de pacientes para este procedimiento genera un desbalance de costo-efectividad. OBJETIVO: Conocer los factores predictores de estado libre de litos en un solo tiempo quirúrgico en pacientes sometidos a URSLL. MÉTODO: Cohorte retrospectiva de pacientes sometidos a URSLL. Se realizó un análisis univariado y multivariado (regresión logística) de los predictores de estado libre de cálculos en la primera URSLL, global y categorizado por sexo. RESULTADOS: EL estado libre de cálculos en la primera URSLL fue de 73.62 %. Los predictores de estado libre de cálculos en hombres fueron edad y tamaño, densidad y multiplicidad del cálculo; en las mujeres, el índice de masa corporal y la multiplicidad del cálculo. CONCLUSIONES: Los factores pronósticos de estado libre de cálculos en la primera URSLL son distintos en hombres y mujeres. Las mujeres con obesidad y sobrepeso probablemente tengan cálculos de fácil fragmentación y extracción asociados con ácido úrico.

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