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

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Welcome to the winter edition of Stone News! 

This season, we're diving into three groundbreaking studies that could reshape the way we approach stone disease.

First, we'll challenge conventional thinking with a look at how urology can adopt more sustainable practices—because even in the OR, small changes can have a big environmental impact. Next, we’ll uncover fascinating insights from an analysis of 42,519 urinary stones (yes, you read that right!) and explore what these findings mean for patient care. Lastly, we’ll examine an exciting randomized controlled trial exploring the potential of fluoroscopy-free RIRS—paving the way for innovation with reduced radiation risks.

These studies offer fresh perspectives and practical takeaways to elevate care for your stone patients. So grab a cup of coffee, get cozy, and enjoy this edition of Stone News!

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The article emphasizes the urgent need to integrate sustainability into urological practices to address the healthcare sector's substantial environmental impact, which contributes 8.5% of greenhouse gas emissions in the U.S. Hospitals generate six million tons of waste annually, with urological practices playing a significant role. Neglecting sustainability exacerbates climate change, leading to health issues like increased urolithiasis and infertility.

The Key Recommendations are: Adopt Sustainable Practices: Use reusable instead of disposable items, such as surgical drapes and incontinence pads, to significantly reduce waste and emissions. Minimize Resource Use: Avoid unnecessary procedures like routine ureteral stenting and optimize operating room supplies through preference cards and inventory control. Advocate for Industry Changes: Push for reduced packaging and recyclable medical products. Leverage Telehealth: Virtual consultations reduce carbon emissions tied to travel and facility usage. Transition to Biodegradable Materials: Research into bioplastics for urological devices can reduce their environmental footprint.

The Benefits of These actions align with sustainability principles (e.g., reduce, reuse, recycle) and have shown promising results, such as reducing carbon emissions by 99% for virtual conferences and saving significant resources through reusable materials. With institutional support and individual commitment, the urology field can lead the way toward a greener healthcare system. This is a call to action for all practitioners to make sustainability a core element of their mission, starting with small but impactful changes like reducing single-use items.

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Urolithiasis is a common condition worldwide with a recurrence rate of 50% over 10 years, significantly affecting patients' quality of life and increasing the risk of chronic kidney disease. Proper analysis of urinary stones is critical for diagnosis, treatment and prevention of recurrence. While many studies focus on single-component stones, most urinary stones are mixed, consisting of two or more components, which are often overlooked in smaller studies.

In this study, stones were analysed using Fourier Transform Infrared (FTIR) spectroscopy, the gold standard for determining stone composition. Stone composition: 73% of the stones were mixed and almost all (over 90%) were combinations of calcium components (COM-COD, COM-CA, COD-CA or COM-COD-CA).

Interestingly, as the authors noted: "The treatment of mixed stones such as COM-CA, COD-CA and COM-COD-CA can be challenging because therapy for calcium oxalate stone disease includes urinary alkalinisation, whereas urinary acidification is indicated for CA stones". In these cases, we may need to use new therapies that can inhibit calcium-based crystallisation without altering urinary pH, such as phytate (e.g. Lit-Control^® pH Balance from Devicare).

The study also reported that men had a higher incidence of single-component stones (male to female ratio: 3:1) than multi-component stones (1:1 for four-component stones). Stone complexity (more components) was inversely associated with age, suggesting that gender and age differences in stone formation may have different pathophysiological mechanisms. Identifying all components in mixed stones is crucial for personalised treatment and prevention strategies to reduce recurrence.

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RIRS has become increasingly popular due to its minimally invasive nature, early patient discharge, low complication rates, and high success rates. Traditionally, RIRS uses fluoroscopy for guidance, but this exposes patients and surgeons to ionizing radiation, increasing cancer risk. To address this, a randomized controlled trial compared radiation-free (RF) RIRS to radiation-usage (RU) RIRS for safety and efficacy. The trial involved 128 patients with ≤20 mm kidney stones across five centers, d ivided into RF and RU groups. Both procedures achieved similar stone-free rates (78% RF vs. 80% RU) and low complication rates. Ureteral injuries were comparable, with no significant differences in high-grade injuries. RF RIRS employed semirigid ureteroscopes for guidewire placement, ureteral access sheath (UAS) insertion, and double-J stent placement without fluoroscopy, ensuring safety and precision through direct visualization. While RF RIRS avoids radiation exposure, it requires experienced surgeons and semirigid ureteroscopes. The study concludes that RF RIRS is a viable, noninferior alternative to RU RIRS for uncomplicated stones.