Hello and welcome to the Stone News, a newsletter where we discuss every two months the most recent and relevant studies in stone disease.

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Hello Stone Fans! For this edition I want you to imagine a world where kidney stone surgery is a breeze with less pain, are we ready for Totally Tubeless Percutaneous Nephrolithotomy? Also imagine fighting with efficiency of a high-speed vacuum cleaner, is suction flexible and navigable sheaths what it promises? Ready to learn more? Let’s get started!

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When performing PCNL, the initial tendency was to leave a post-operative nephrostomy for drainage and hemostasis. A tendency that has declined thanks to the increased use of Mini-PCNL, usually ending as a tubeless procedure(t-PCNL), meaning only with a double J stent. Nephrostomy tubes may be uncomfortable for patients and t-PCNL continue to have the stent related complications. Totally tubeless PCNL (tt-PCNL) emerged as a technique leaving no external or internal drainage tubes, improving hospital stays, analgesia requirements, and post-operative pain. 

In this very interesting review of five comparative studies involving 442 patients indicated that tt-PCNL had similar or better peri-operative and post-operative outcomes compared to other PCNL techniques, including shorter hospital stays, lower pain scores, and comparable complication rates. The shift to ambulatory tt-PCNL shows promise but requires further validation. Obesity doesn't significantly affect tt-PCNL outcomes, and hemostatic agents used in the nephrostomy tract can shorten hospital stays without increasing complications. The authors described the tt-PCNL procedure that involves specific criteria for patient selection and hemostasis management. Overall, tt-PCNL offers reduced morbidity and improved recovery compared to standard and tubeless PCNL, although careful patient selection is crucial to minimize risks.

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Despite advances in retrograde intrarenal surgery (RIRS), residual fragments remain a significant issue, with 21.7% of patients in the FLEXOR registry study having residual fragments and over half requiring additional interventions. This study explored the efficacy of a flexible and navigable sheath (FANS) in improving outcomes for RIRS. Conducted across 25 centers globally, the study involved 394 patients with normal renal anatomy and aimed to achieve a high stone-free rate while minimizing complications. The median age of participants was 49 years, and most presented with pain as the primary symptom. Procedures primarily used general anesthesia, disposable scopes, and thulium fiber lasers. The median operative time was 49 minutes, and the most common lithotripsy strategy was fragmentation with suction evacuation.

The study found that FANS use led to a 57.4% zero-fragment state rate, with an overall single-stage SFS rate of 97.2% when with residuals <2mm, indicating no need for reintervention. Complications were minimal, with no cases of sepsis and a low rate of readmission for stent symptoms. The use of FANS improved the ability to navigate and suction fragments effectively, contributing to the high SFS rate and low complication rates. The study concluded that FANS could significantly enhance RIRS outcomes and may represent a game-changing innovation in the field, potentially setting a new standard for RIRS procedures.

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The article discusses the increasing awareness of risks associated with ionising radiation in clinical settings, particularly in the endoscopic treatment of upper urinary tract stones using image guidance. While previous studies have examined occupational radiation exposure to the whole body, eyes, and extremities of urologists, this study focuses on gonadal exposure and the protective effect of X-ray gowns. Radiation effects are categorized as deterministic, resulting from cell death at high doses, and stochastic, leading to late effects such as cancer with no threshold dose.

The study collected data over six months in 2020, noting reduced case numbers due to COVID-19. Urologists wore protective gear and dosimeters to measure radiation exposure. The results showed significant dose reduction to the gonads by using a lead skirt that has to cover the linear x-rays coming from the tube which is usually undertable. Annual absorbed dose estimates indicated no risk of radiation-induced temporary or permanent sterility. The study emphasizes the importance of the ALARA principle (keeping radiation exposure as low as reasonably achievable) and suggests that while current protective measures are effective, future studies should explore the benefits of urology-specific X-ray protective gowns.