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Dear Stone fans. Welcome to this summer issue of Stone news. The platform to bring you closer to the most recent and relevant literature in urolithiasis.

As global warming is on a rapid rise (and summers are getting hotter every year) in this issue we will discuss the environmental impact of single use devices. We will also talk about the effects of theobromine, the promising molecule, for uric acid stones and finally we will give a shot glimpse to a very concise manuscript on intrarenal pressure. I hope this can be a great summer read for all of you.

img Cost and Environmental Impact of Disposable Flexible Cystoscopes Compared to Reusable Devices. Boucheron T, et al. J Endoruol 2022 img 2'
https://pubmed.ncbi.nlm.nih.gov/35703325/ img

As disposable devices are being increasingly used in endourology, their environmental impact has been questioned and criticized. Healthcare has an environmental impact as high as 5% of the total global impact and unfortunately there is little evidence regarding this subject, specially regarding specific instruments as the ones used in endourological surgery. This is a very interesting study comparing the environmental impact of reusable and single use cystoscopes. Almost 2000 cystoscopies were performed in a single center (1578 with reusable scopes and 550 with disposable devices). The authors revealed that the amount of waste generated by the reusable material was 800 g per procedure compared to 200 g per procedure for the single use scopes.

The study also revealed that to sterilize a reusable scope with a high grade disinfection process the amount of water used was 60L; Finally concluding that by using single use the waste generation could be reduced by 946.8 kg/year and water consumption by and 94.68 m3/year. This study shows how companies have to make clear green policies and studies to tackle this issue from the beginning as new instruments are developed.

Studies have to be made individually by instrument to assess their real impact. 

img Efect of theobromine on dissolution of uric acid kidney stones. Julia F. et al. World J. Urol 2022. img 2'
https://pubmed.ncbi.nlm.nih.gov/35689678/ img

Oral chemolysis can be recommended as an initial treatment option for uric acid stones. Also medical therapy is the cornerstone for prevention of such stones as they can be actively dissolved by achieving a urinary pH over 6. This in-vitro study compared the effects of theobromine and N-acetylcysteine on uric acid stones in artificial urine at a pH of 6.5. The experiment showed that N-acetylcysteine had a non-significant dissolution stones. On the other hand, theobromine significantly increased the dissolution rate of uric acid stones a 37.5%, being as good as giving both medications at the same time. This study revealed the possibility of including theobromine to the already known medical therapy (citrate or bicarbonate salts) as a new agent to treat or prevent uric acid stones and reduce the time to dissolve them.

This give us the opportunity to increase our strategies to keep helping our patients to avoid recurrences.

img Intrarenal Pressure: What Is Acceptable for Flexible Ureteroscopy and Percutaneous Nephrolithotomy? Doizi. S. Eur Urol Focus 2021 img 2'
https://pubmed.ncbi.nlm.nih.gov/33547026/ img

Intrarenal pressure is a hot topic nowadays. Specially as we have new armamentarium that could help us measure pressure during our procedures. We know that pressure is important and that high pressures is one of the main causes of complications in endourology. Although we have to acknowledge that our understanding of this issue is limited as we haven’t been able to measure pressure properly.

This mini-review explains in how pressure in endourology is a balance between our irrigation inflow and the outflow; And how all aspects regarding this two values have a role. For example, inflow depends on irrigations systems and the size of working channels as outflow depends on the size of access sheaths or the space between scopes and sheaths. For flexible ureteroscopy larger diameters of access sheaths have shown to decrease pressures at the cost of probably increased ureteral injuries and the caliber should be wisely chosen (usually the smallest possible is recommended). For PCNL decreased intrarenal pressures can be achieved by having a wide space between the sheath and the scope. For both surgeries low irrigation is always recommended. Finally, is worth mentioning that there are many limitations in the literature regarding this issue.

I hope the new devices can help us better understand this subject and allows to have more strategies to decrease complications.

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