Lifestyle factors are key aspects of a patient's overall health. Smoking, alcohol consumption and physical exercise are known to be cardiovascular risk factors and have been linked to a wide variety of diseases, including cancer. This systematic review assessed whether smoking, alcohol consumption and physical activity have any role in patients with stone disease. The authors analyzed 14 of 4921 studies identified by a database search. Conflicting results were found on the impact of physical activity. While some studies linked physical activity to a reduction in risk of stone disease, others revealed an increased risk, probably due to dehydration associated with over-exercising (>30 min/day), as previously studied in marathon runners. It is also good to remember that the opposites of over-exercise, namely immobilization and a sedentary lifestyle, also entail a higher risk of stone disease and metabolic syndrome. Some authors suggested that alcohol intake may be protective for the diuretic effect although it was observed to increase hypercalciuria, uric acid levels and renal oxidative stress. Smoking seems to have a role in stone disease as it increases vasopressin levels (antidiuretic) and also metallic elements in urine and serum cadmium (which are linked to urolithiasis). It also increases renal oxidative stress and may accelerate chronic kidney disease, which is a risk factor for stone disease.

Overall, beyond basic metabolic study and therapy based on urine pH modification, this review indicates that moderate exercise should be recommended with good hydration and that smoking should be avoided. And even if no clear effect was demonstrated regarding the impact of alcohol on urolithiasis, it should be recommended that people avoid or moderate alcohol consumption in view of the effect on overall health quality. Of course, the same consideration applies to smoking.

One of the main concerns during stone surgery has been the significant risk posed to urologists by radiation exposure (RE). This study reviews the ALARA (“As Low As Reasonably Achievable”) principle and describes strategies to reduce RE when performing endourological procedures.

It is to be noted that the authors’ fluoroscopy time reduces RE by 24%. A checklist to reduce RE has been described, based on consideration of fundamental aspects such as checking of preoperative images, use of leaded aprons, lowering of the X-ray tube and use of pulsed fluoroscopy, implementing such a checklist could reduce fluoroscopy times by 67%.

Several strategies to reduce RE during RIRS and PCNL have been described, involving the use of gentle maneuvers and replacement of surgical steps commonly guided by fluoroscopy with endoscopy. Compatibility with the ALARA principle is ensured by avoiding fluoroscopy or by giving just seconds of fluoroscopy only when necessary. Also, it has been described how the ALARA principle can be implemented through the use of all the technology and techniques available during PCNL, such as endovision and ultrasound-guided punctures and dilations.

Radiation-free endourology has been described in pediatric patients, who are more sensitive to radiation, with great efficacy and reduced complications. Finally, it is important to bear in mind that reduction in RE should not be achieved at the expense of poorer results or increased complications, so if in doubt, please use fluoroscopy to ensure a safe and effective procedure. Nowadays the aim is always to implement the ALARA principle whenever possible to avoid unnecessary risks.

Obstructive pyelonephritis is one of the few surgical emergencies in urology. Usually patients require decompression, and a double J stent or a nephrostomy tube is placed, based on diverse variables. Although it seems that neither one of these options is better than the other, in this paper surgeons placed more nephrostomies as the severity of sepsis increased (6% in patients without sepsis vs 30% in those with severe sepsis). The objective of the study was to look at the timing of decompression and assess whether delayed decompression is an independent predictor of in-hospital mortality.

Using the US National Inpatient Sample, 311,100 patients were identified over a 5-year period. Although the overall risk of mortality was low, it increased as sepsis severity increased, ranging from 0.2% in nonseptic decompressed patients to 13.6% in patients with septic shock who did not undergo decompression. Non-decompression increased the odds of death, the odds ratio rising from 2.14 to 3.18 (p<0.001).

In the study, two groups were studied for comparison: a prompt decompression group with a mean time until decompression of 0.42 days and a delayed decompression group with a mean time until decompression of 3.08 days. It was seen that delayed decompression significantly increased the odds of death by 29% (OR 1.29, 95% CI 1.03-1.63, p=0.032), with a 7% increase in the odds of death per day of delay. Factors that increased the odds of delay included weekend emergencies and, sadly, nonwhite race and lower income. On the other hand, knowing that the patient had a kidney stone, female sex, private insurance and increased severity of sepsis were associated with decreased odds of delay. As a conclusion, we need to be aware that urologists must promptly identify patients with obstructive pyelonephritis and avoid delays in decompression.