INTRODUCTION: The nutritional supplement called Fagolitos plus® contains hydroxycitric acid as main component, in addition to zinc, magnesium, vitamin A and vitamin B6. It is necessary to study new molecules as chemolytic treatment in calcium lithiasis or that facilitate its fragmentation with the help of other instrumental treatments.OBJECTIVE: The objective of this study is to evaluate the effectiveness of the combined treatment of Fagolitos plus® and extracorporeal lithotripsy in the fragmentation of the lithiasis.MATERIAL AND METHODS: Retrospective case-control study includes 88 patients with lithiasis. Group 1: Treated with 1 session of extracorporeal lithotripsy and Fagoliths plus®. Group 2: Treated with 1 session of extracorporeal lithotripsy. The variables analyzed were: Age, sex, body mass index, maximum diameter of the stone, area of the stone, hounsfield units of the stone measured by axial tomography, location of the stone, result after 1 session of extracorporeal wave lithotripsy. shock [complete fragmentation, partial fragmentation (presence of a fragment greater than 5 mm) and absence of fragmentation (same size of the lithiasis)], adverse effects that occurred after taking Fagolitos plus®, days of treatment with Fagolitos plus® and energy shock wave applied to lithiasis. Results were analyzed with SPSS 20.0, p≤0.05.RESULTS: The mean age of the patients included in the study is 53.81 ± 12.62 years in group 1 compared to 56.53 ± 12.37 years in group 2, p=0.31. According to the distribution by sex, there were no statistically significant differences (p=0.5), including 24 men and 24 women in group 1 and 23 men and 17 women in group 2. The mean of body mass index of the patients in group 1 was 28.39 ± 2.27 kg/m2 in group 1 versus 28.39 ± 3.03 kg/m2 in group 2, p=0.9. The maximum diameter of the stone was 11.5 ± 3.91 mm in group 1 compared to 13.15 ± 5.49 mm in group 2, p=0.1. The area of the lithiasis measured by tomography was 104.74 ± 70.56 mm2 in group 1 compared to 141.91 ± 80.95 mm2 in group 2, p=0.3. The Hounsfield units measured by tomography of the lithiasis in group 1 was 1061.98 ± 213.68 compared to 1143.15 ± 172.24 in group 2, p=0.06.Relation to fragmentation, complete fragmentation was observed in 66.7% of group 1 patients, compared to 41% of group 2 patients (p=0.02), between 20-30 days after the first session of Extracorporeal Lithotripsy evaluated by means of a simple X-ray of the Abdomen.CONCLUSIONS: The administration of Fagolitos plus®concomitant to extracorporeal lithotripsy could increase its effectiveness in lithiasis fragmentation, requiring clinical trials and prospective studies to confirm these findings.

OBJECTIVE: Aim of our study was to evaluate the effectiveness and safety of the preoperative placement of JJ stent compared to not doing in patients undergoing ureteroscopy for ureteral and kidney stone.MATERIALS AND METHODS: Prospective, observational, multicenter study. Adult patients, who underwent ureteroscopy treatment for ureteral and kidney stone, were recruited from August 2017 to March 2019, in 23 Argentine institutions. The variables analyzed included: demographic data, stone size and location, stone-free rate (SFR) and complications.RESULTS: 580 patients were included. 473 with ureteral stone (309 with and 164 without prior JJ stent) and 107 with kidney stone (77 with and 30 without prior JJ stent). The SFR was higher in the group with previous JJ stent, both in the treatment of ureteral stone (82.2% vs. 90.9%, OR 2.15 (1.17 to 3.96)), and in the treatment of kidney stone (73.3% vs. 89.6%, OR 3.14 (1.02 to 9.61)). No differences were established in the complication rate both in the treatment of ureteral stone (6.1 vs. 6.1%, OR 0.98 (0.45 to 2.19)) and in the treatment of kidney stone (6.7 vs. 5.2%, OR 0.76 (0.13 a 4.46)).CONCLUSIONS: The preoperative placement of JJ stent, increases SFR in the treatment of ureteral and kidney stone, but not decrease the complication rate.

INTRODUCTION: The Holmium laser is the most used energy source in flexible ureterrenoscopy (URSf). The Lumenis Pulse 120H® laser has a higher system energy, a higher energy per pulse and a higher repetition frequency in relation to other types of lasers, which offers advantages in the treatment of lithiasis.OBJECTIVE: To analyze the results that we have obtai-ned with the use of the Lumenis Pulse120H® laser in patients treated by intrarenal retrograde surgery (RIRS). As secondary objectives there are: the study of the de-mographic variables of the patients, the characteristics of the stones and the complications associated with the procedure.MATERIAL AND METHODS: An observational, retros-pective study of the first 26 patients treated by RIRS and Lumenis Pulse 120H® laser has been performed in our Service between August 2018 and February 2019. The size of the lithiasis was measured on the simple ra-diography and the CT, in addition, the volume of the lithiasis was calculated. For the realization of RIRS, 8.5 Fr digital flexible ureterorenoscope (Olympus®) and the Holmium Lumenis 120H® laser with 200 micron laser fibers from Lumenis® were used. Statistical analysis was performed with the SPSSv21 system.RESULTS: A total of 26 patients with renal lithiasis have been analyzed. The median age was 55.15 years (40.67-67.05). 57.7% of the patients had prior surgical treatment of lithiasis. Thirteen patients presented the litia-sis in the renal pelvis, ten in the Upper Calicial Group (GCS), fifteen in the Middle Calicial Group (GCM) and eighteen in the Lower Calicial Group (GCI). The median of the lithiasic volume was 1826.41 mm3. Our overall success rate was 80.8% (100% success in lithiasis less than 2 cm and 85.7% in lithiasis between 2-3 cm). Five patients presented complications, of which 4 were Cla-vien II and 1 Clavien IIIb. No significant results were found between the lithiasic size and the presence of complications (p = 0.128).CONCLUSIONS: The use of the Lumenis Pulse 120H® laser is an useful tool for the treatment of kidney stones by RIRS, due to his efficiency in the fragmentation and dusting, taking into account that very large lithiasic mas-ses require, in a high percentage of cases, more than one treatment session.

OBJECTIVE: The management of stone disease in renal abnormalities is a challenge for urologist due to its rarity. The aim of the current manuscript is to report our experience in Retrograde Intrarenal Surgery (RIRS) in 4 complex-abdnormal cases using the flexible videoureterorrenoscopy. MATERIAL AND METHODS: Data was prospectively collected and retrospectively analyzed regarding our first 100 RIRS for stone disease with flexible videoureterorrenoscope (FLEX-X 8.4 Fr- STORZ®) between 2017 and 2018. Four patients presented with renal anomalies and stone disease; one horseshoe kidney, polycystic kidney, a renal ectopia fused and a caliceal diverticulum. We analyzed demographic variables (age and gender), stone size, previous treatment received, clinical presentation, stone free rate and complication rate using Dindo-Clavien classification. RESULTS: 4 (4%) cases of renal stone disease associated to renal anomalies were identified. All procedures were ambulatory. The mean age was 56 years (43 to 65) being 3 male and 1 female. The average stone size was 16.25 mm (6 to 23). All cases represented recurrent stone disease, initially treated with a primary treatment such as extracorporeal shock wave or percutaneous lithotripsy. The mean surgical time was 57 minutes (43 to 79) and the stone free rate 100%. As complications, one patient presented low back pain at 48 hours after surgery, which did not yield with oral analgesics requiring intravenous treatment, although without admission (Clavien II). CONCLUSION: Retrograde intrarenal surgery for the management of renal stone in kidney anomalies is safe, feasible and effective. However; more cases and comparative studies with percutaneous and extracorporeal lithotripsy are needed to optimize treatment decision making.

OBJECTIVE: To evaluate the impact of a new renal lithiasis classification on the stone free rate. The new system would allow standarization of comparison between different series of percutaneous nephrolithotomy. MATERIAL AND METHODS: Patients undergoing NPCL between November 2011 and November 2016 were retrospectively analyzed. The stones were classified as simple (pelvic and/or calyceal stones that required a single access and/or use of a rigid nephroscope), complex (required the use of more than one percutaneous access and/or flexible instruments and/or combined access) and extremely complex (complete staghorn stones or anatomical alterations), according to the Ibarluzea-Llanes classification. Other variables analyzed were age, sex, diabetes, hypertension or taking anticoagulants, stones composition, placement of postoperative nephrostomy and surgical time. We performed a univariate and multivariate analysis using the chi-square or Fisher test and logistic regression.RESULTS: Sixty-nine procedures were included in 57 patients with a mean age of 51 years (13-84) and a mean follow-up time of 30 months. The stone free rate was 86%, 75% and 55% for a simple, complex or extremely complex stone, both at three months and a year. Only the stone type was associated with a worse stone free rate (p 0.03) with RR of 2.5 for a 95% CI.CONCLUSIONS: The Ibarluzea-Llanes clasification could be used as a new system for standarization of PCNL outcomes reporting.

OBJECTIVES: Extracorporeal shock wave lithotripsy is a minimally invasive therapeutic option for the treatment of renal-ureteral lithiasis. The aim of this study was to analyze the results and complications of shock wave extracorporeal lithotripsy treatment with the Dornier Gemini® Generator EMSE 220f-XXP device in patients with renal and ureteral lithiasis.MATERIAL AND METHODS: Retrospective study includ-ing 377 patients with renal or ureteral lithiasis with in-dication for treatment with extracorporeal shock wave lithotripsy. The following variables were analyzed, age, sex, body mass index, lithiasis size, lithiasis location, presence of urinary diversion, number of lithotripsy ses-sions, number of shock waves, fluoroscopy time, wave energy, applied focal energy coefficient, efficiency co-efficient, lithiasic fragmentation, lithiasic clearance, re-sidual lithiasis, presence of lithiasis and complications. The results were analyzed with SPSS 17.0 considering statistical significance p≤0.05.RESULTS: Of the 377 patients, 213 were men and 164 women, with a mean age of 51.28 ± 12.77 years. The mean size of the stones in maximum diameter was 11.77 ± 6.13 mm. Lithiasis fragmentation occurred in 81.9% of cases, with a percentage of residual lithiasis after the first session of 58.7% and a total or partial ex-pulsion rate of lithiasis fragments of 68.3%, with global success at the end of sessions of lithotripsy of 69.8%. The overall Efficiency Ratio was 0.42, higher in upper calyx 0.51 and lower in medium calyx 0.35, with sig-nificant differences (p<0.05). The only differences were found in relation to the success of lithotripsy treatment (75% versus 64.6%, p=0.02), according to lithiasis size (≤10 mm maximum diameter in comparison to >10 mm). In patients with a DJ catheter there is a higher percent-age of residual lithiasis (p=0.006).CONCLUSIONS: Treatment with extracorporeal lith-otripsy in small lithiasis and in well-selected patients obtains good results with a low rate of complications regardless of sex and body mass index.

OBJECTIVES: Studying the psychosocial sphere of patients who undergo any treatment allows to have more information about its repercussion and can help the choice of an appropriate and personalized treatment. Due to the absence of specific instruments at present, the objective is to design and validate a health questionnaire regarding the treatment received with ESWL.METHODS: It was carried out in 6 phases using a sam-ple of 50 patients treated with ESWL in 2015 in our center, whom we interviewed by telephone. In phase 1 the items were proposed based on bibliographic re-view, in phase 2 those that scored below 7 were elim-inated according to the evaluation from 0 to 10 on the items made by specialists. In phase 3, values of 1 to 5 were assigned to each item and those with corrected correlation more than 0.2 and not significant (p>0.05) discriminant power with U-Mann Whitney were elimi-nated. In phase 4 the reliability of the questionnaire was checked with two indexes (Cronbach’s alpha and two Guttman’s halves). In phase 5, the factor analysis with Varimax rotation was performed to calculate the con-struct validity and in stage 6, the scores were analyzed to establish reference values.RESULTS: 50 patients (32 men, 18 women). Median age 59 years (27-79). In phase 1, 35 items were pro-posed, 9 of which were eliminated in phase 2. The ini-tial questionnaire with 26 items was distributed, with 18 being eliminated in phase 3. The final questionnaire was formed with 8 items. In phase 4 the results of Cronbach’s alpha and Guttman’s two halves index were 0.44 and 0.323 respectively. In phase 5 after factor analysis, we found 4 factors with 2 items each (background, impact of the acute picture, post-treatment, quality of life) able to explain 71.19% of the variance. The median scores of the scale, extreme values and quartiles studied in phase 6 were respectively: P50: 17 (minimum-maximum 9-25), P25: 14 and P75: 20.CONCLUSIONS: The study carried out has provided a new instrument for assessing satisfaction after treatment with ESWL with adequate reliability and validity values. Future studies will be necessary to contrast its true clinical usefulness.

OBJECTIVE: To determine the lithogenic risk index and its evolution after treatment of paraguayan lithiasic patients. METHODS: This experimental study of temporal series included 28 lithiasic patients of both sexes that attended to the Instituto de Prevision Social in 2012. Basal evaluation included metabolic study and urinary saturation indexes determined by EQUIL software. With this data, a specific treatment was selected for each patient. The follow up included a medical consultation monthly and the metabolic evaluation after 6 month. The study was approved by an ethical committee.RESULTS: Basal evaluation showed hypocitraturia, hypercalciuria and hyperoxaluria in 50%, 46.4% and 14.3% of patients, whereas 42.9% showed diuresis lower than 2 L/day. Crystallization risk for calcium oxalate, sodium urate, hidroxiapatite and uric acid was observed in 1,3, 12 and 12 patients respectively. After treatment, a decrease in the frequency of hypercalciuria and hypocitraturia was observed, just like the urinary saturation risk for all types of crystals studied. Statistical analysis showed a significant variation of diuresis (p 0,0001) and uric acid urinary saturation (p 0,002) after treatment.CONCLUSIONS: The lithogenic risk factors more frequently detected were hipocitraturia and hypercalciuria. Therapeutic measures achieved the decrease of saturation risk indexes for all the crystals analyzed, registering significant effects in the increase of diuresis and uric acid saturation decrease. The use of software tools for the calculation of crystallization risk is an important innovation in Paraguay.

OBJECTIVE: Extracorporeal shock wave lithotripsy (ESWL) represents one of the most frequently used methods to treat urinary tract calculi. However, sometimes we do not obtain the fragmentation expected. The aim of this study is to evaluate the parameters that may influence ESWL final results, developing a classification for better patient’s selection and outcome optimization. METHODS: 270 patients with renal or ureteral stones were retrospectively reviewed after ESWL treatment, recording both clinical parameters (age, sex, location, laterality, body mass index [BMI]), and CT-Scan parameters (stone size and volume, skin-to-stone distance (SSD), mean and maximal stone density). Cutoff values were determined for each parameter based upon ROC curves, and final score (ESWL score) was calculated based on the number of parameters lower than the cutoff values.RESULTS: Of the 270 patients treated, 186 (68.8%) were considered as ESWL success, without significant differences between success and failure group.Parameters that showed significant difference after multivariate analysis were: size (cut off: 9.3 mm), volume (237.2 mm3), mean density (951 UH), SSD (133 mm) and BMI (26.9 kg/m2). AUC of ROC curve including all of these parameters, was 0.807. Stone free status was 17.6% for score 0, 25% (score 1), 48.8% (score 2), 74.1% (score 3), 86.3% (score 4) and 92.2% for score 5.CONCLUSIONS: Patient classification before ESWL treatment seems to allow us better selection, improving treatment success.

OBJECTIVE: Epidemiological data onurolithiasis in Spain have appeared in publicationsespecially local and regional level, with few referralsto Spanish national territory. The aim of this paper isto review and systematize the epidemiological datapublished on urolithiasis in Spain.METHODS: We reviewed publications in nationaland international scientific journals, meetings andconferences, and research reports (1977-2016).PubMed search (indexed papers) and manualbibliography search (not indexed works) wereperformed. Bibliometric data evaluated: Year ofpublication, geographic area, number of cases, sample type, study design and publishing format. Demographicsystematization of data: age, age and frequencydistribution by gender, family history, social stratum,profession, place of residence, ethnics, seasonality anddietary habits.RESULTS: Publications revised: 79 corresponding to 56main authors. Selected publications with original data:42 (2 composed by Part I and II, and 2 composedby paper and thesis), corresponding to 35 authors.Bibliometric and demographic data of all publicationsare displayed in tables, sorted by variables.CONCLUSIONS: The comprehensive review of studieson epidemiology in Spain constitutes a solid basis forfuture research about epidemiology of urolithiasis.

Urinary lithiasis is a prevalent disorder ofuncertain origin which provokes health problems throughpotential harm to the urinary system, renal parenchymaor the body as a whole, with a frequent trend to relapse.Historically urinary calculi have been studied andtreated as an isolated disease but nowadays we knowmore about their connection with other pathologicalentities. In a small percentage of patients, diseases likeprimary hyperparathyroidism, tubular renal acidosis,inflammatory bowel disease or bariatric surgery havea fairly well studied physiopathological link withkidney stones. However, papers have been publishedrecently describing connections between prevalentdiseases such as bone disease or metabolic syndromeand nephrolithiasis. Attempts to prevent or treat theseaffections can possibly influence the other´s prevalencesince their trend to increase is clear in western countries.

OBJECTIVES: The objective of this article is to show the current situation regarding two surgical techniques for the treatment of renal lithiasis, RIRS (Retrograde intrarenal surgery) and PCNL (Percutaneous nephrolithotomy), specially concerning the larger size stones. We perform a literature review on the topic and add the experience with both techniques at our center. Besides, we also analyze the role of RIRS in comparison with the percutaneous techniques in smaller size lithiasis. METHODS: We review the results obtained in the literature and our experience. We offer our opinion in reference to the indications of RIRS in these cases based on such review and our experience.RESULTS/CONCLUSIONS: RIRS is a safe and effective technique, with a similar success rate to PCNL if one assumes the possibility of retreatment in stones >2cm. Its low complication rate, fast postoperative recovery and short hospital stay make this technique a therapeutic alternative to PCNL in this type of patients.Compared with percutaneous techniques less invasive than classical 24 to 30 Ch. accesses (miniperc or microperc), RIRS offers a higher stone free rate. If we also consider that RIRS is associated with shorter hospital stay and lower bleeding risk, even without significant differences in the global complication rate we could consider RIRS as the first line endourological treatment in stones >2cm.

Renal lithiasis is one of the most commondisorders in modern society, constituting an importanthealth problem that associates a great economic burden.The nature of stone disease varies according to ageand sex, being also influenced by dietary and lifestylefactors, and climatic variations among others. In spite ofthe advances made in the management of this pathology,it continues being a disease with a high recurrence rate.In recent years, several studies have pointed out that itsprevalence is rising especially in developed countries.This increase seems to be fundamentally due to changesin dietary habits and lifestyle, although other factors suchas migratory flows from rural areas to major cities, and arise in global temperatures may also be involved.In the present article, we discuss the main factors thatseem to influence today the epidemiology of urinarylitiasis, as well as the aforementioned increase ofprevalence.

Miniaturized percutaneous nephrolithotomy(mini-PCNL) has increased in popularity in recentyears and is now widely used to overcome the therapeuticgap between conventional PCNL and less-invasiveprocedures such as shock wave lithotripsy (SWL) orflexible ureterorenoscopy (URS) for the treatment of renalstones. However, despite its minimally invasive nature,the superiority in terms of safety, as well as the similarefficacy of mini-PCNL compared to conventional procedures,is still under debate. The aim of this chapter is topresent one of the most recent advancements in termsof mini-PCNL: the Karl Storz “minimally invasive PCNL” (MIP). A literature search for original and review articleseither published or e-published up to December 2016was performed using Google and the PubMed database.Keywords included: minimally invasive PCNL; MIP.The retrieved articles were gathered and examined. Thecomplete MIP set is composed of different sized rigidmetallic fiber-optic nephroscopes and different sized metallicoperating sheaths, according to which the MIP iscategorized into extra-small (XS), small (S), medium (M)and large (L).Dilation can be performed either in one-step or with aprogressive technique, as needed. The reusable devicesof the MIP and vacuum cleaner efect make PCNL withthis set a cheap procedure. The possibility to shift froma small to a larger instrument within the same set (Matrioskatechnique) makes MIP a very versatile techniquesuitable for the treatment of almost any stone. Studies inthe literature have shown that MIP is equally effective,with comparable rates of post-operative complications,as conventional PCNL, independently from stone size.MIP does not represent a new technique, but rather acombination of the last ten years of PCNL improvementsin a single system that can transversally cover all availabletechniques in the panorama of percutaneous stonetreatment.

Micro-ureteroscopy is a novel techniquederived from the need to reduce the morbidity associatedwith conventional ureteroscopy. Reducing morbidity,we will be able to improve quality of life of patients, forexample, by shortening the times to elimination of thestones. In this article the authors intend to expose thedifferent applications of micro ureteroscopy as well asthe incipient scientific evidence on the topic.

OBJECTIVE: An update of the new treatment strategies in extracorporeal lithotripsy as a valid therapeutic alternative in the management of urinary calculi.METHODS: We performed a search and review of the most recent literature which responded to the terms “best practices”, “update”, “optimization”, “practice pattern” in lithotripsy. Only articles written in English or Spanish were selected. RESULTS: The use of a stepwise voltage ramping during extracorporeal lithotripsy with or without pause before the first rise of energy, a decreased delivery rates and the use of a higher number of shock waves per session are shown as alternatives to improve the effectiveness with optimum safety profile.CONCLUSIONS: Extracorporeal lithotripsy is still an effective and minimally invasive treatment, and it has an important role in the treatment of urolithiasis. New treatment strategies are being developed to increase the effectiveness with a similar safety profile.

The creation of the access is one of the main steps in percutaneous nephrolithotomy, the most complicated for many urologists and the one that limited most the universalization of the technique. From a purely technical point of view, it includes puncture of the excretory tract and dilatation of the percutaneous tract to end with the introduction of an Amplatz type working sheath. The objective of the puncture is to try to access the excretory system through the renal papilla, minimizing the risk of bleeding. The puncture may be guided by ultrasound, fluoroscopy, both, under endoscopic or laparoscopic control, by CT scan or MRI, or even by application of new technologies (Robotic, augmented reality, electromagnetic navigation,…). Due to the versatility and independence involved in having the ability to perform the renal puncture in the operative room, as well as its influence in the results of PCNL, it must be the urologist himself who performs this basic step of percutaneous surgery. The tract may be dilated by Alken type metallic dilators, semirrigid Amplatz type dilators or high pressure balloons. To date, there is no single ideal dilatation method, being the selection based on the endourologist´s experience and the knowledge of the advantages and limitations of each option.The objective of this review is to present the main methods for puncture guiding and tract dilatation for PCNL, as well as to provide technical details to improve its result.

Miniaturization in percutaneous surgeryhas seen its zenith in microperc. Technological advanceshave enabled us to treat renal lithiasis through a4.8 Ch. caliper percutaneous access. According topublished literature, the technique is reproducible andwhen applied to small and medium size renal lithiasishas a high success rate keepin a low complication rate.Its main advantage is the absence of tract dilatation,diminishing the bleeding risk inherent to percutaneousaccess, postoperative pain and hospital stay. Nevertheless,it presents a series of technical limitations: lowmaneuverability and versatility, impossible extraction ofsignificant fragments, limited vision and high intrarenalpressure. Does microperc have a place among proventechniques such as SWL, flexible ureteroscopy or minipercutaneoussurgery? In our article we try to answerthis question by reviewing the available literature, andreview all technical features, advantages and limitationsof the procedure at the same time.

Over the last 30 years, the treatment of urinary lithiasis has changed dramatically. With the advent of extracorporeal lithotripsy and the advances on ureterorenoscopy and percutaneous nephrolithotomy, the need to turn to open and laparoscopic/robotic surgery has diminished. The objective of this article is to review the different indications for open and/or laparoscopic treatment of urinary lithiasis, to achieve its complete elimination with the less invasive possible means and trying to minimize the number of secondary procedures as well as complications.

INTRODUCTION: The contribution of therapeutic ureteroscopy done by Perez Castro in 1980 varied the management algorithm for ureteral lithiasis worldwide. The techniques of Retrograde Ureteroscopy and transrenal antegrade ureteroscopy led to the abandonment of open surgery for the treatment of ureteral lithiasis. Only Shock wave lithotripsy has maintained similar success rates in selected cases.METHODS: Descriptive analysis of the semirigid and flexible ureteroscopy techniques performed in our department over the last 10 years giving detail on the technique and safety tips to increase the efficacy and efficiency of ureteroscopy. 4,533 semirigid ureterorenoscopies and 980 flexible ureterorenoscopies were performed between January 2005 and July 2016.RESULTS: We registered 82% lithiasis elimination on a single operation with a 1,8% overall complication rate for complications higher than Clavien III. We registered 108 urinary sepsis episodes with 2 deaths secondary to massive shock. One patient required supra-selective renal embolization due to renal rupture and hemorrhage after URS. Four patients have required open or laparoscopic surgical repair Five patients required nephrectomy due to absent function of the renal unit after URS and 2 for complete ureteral avulsion on ureteroscope extractionCONCLUSIONS: Semirigid ureterorenoscopy enables the elimination of ureteral lithiasis on a major ambulatory surgery regimen with an acceptable complication rate and a low rate of ancillary measures.Flexible ureteroscopy has resolved intrarenal lithiasis of up to 2 cm, being a substitute for percutaneous nephrolithotomy for these cases

Urolithiasis is a common disease with increasing prevalence worldwide and a lifetime- estimated recurrence risk of over 50%. Imaging techniques play a critical role in the initial diagnosis, follow-up and urological management of urinary tract stone disease. The are many useful tools for diagnosing urolithiasis, including conventional plain radiography, intravenous urography, ultrasonography, computed tomography and magnetic resonance imaging. All these techniques have their own individual roles to play and also their limitations. Radiological management will depend on the tools available at the center and on the characteristics of the patient. Non-contrast enhanced CT scan has high sensitivity and specificity, although concerns about radiation exposure and costs remain. It is essential to use computed tomography techniques that minimize radiation and to use alternatives like ultrasonography, or magnetic resonance imaging in pregnant patients and children. There is no evidence to support strong recommendations regarding the frequency and type of imaging for follow-up of patients with urolithiasis (treated or under observation). The objective of this article is to review the imaging pathway for comprehensive stone management.

The incidence and prevalence of lithiasicdisease in developed countries has increased over thelast years. Being diet one of the risk factors for urolithiasis,and having it evolved in conjunction with lifestyleover the last decades, such changes could explain theincrease in lithiasis case-load.In this article, we analyze how the exercise of the urologisthas been regarding the preventive role of diet in thelithiasis patient, what are the scientific evidences on therelationship of diet and lithiasis, and, on this base, whatgeneral dietetic recommendations we can give currentlyto our patients.

OBJECTIVE: To introduce an emerging technique termed ‘super-mini- percutaneous nephrolithotomy’ (SMP) and describe its application in practice. METHODS: We described the technique of SMP in the treatment of renal stones with emphasis on the material, indications, technique procedure, advantages, and results. RESULTS: SMP refers to a 7 Ch. nephroscope placed through a 10-14 Ch. metal access sheath with functions of both irrigation and suction-evacuation, to achieve stone fragmentation via laser or pneumatic lithotripsy. We reported our experience of this technique in 342 cases including 231 adults and 111 children. The mean stone size was 2.3 ± 0.9 cm resulted in 54.3 ± 27.7 min of mean operative time in adults, as well as 39.4 ± 26.2 min for stone size of 1.4 ± 0.5cm in children. In parallel, the initial stone-free rate (SFR) was 89.2% and 90.0% followed with a 94.4% and 95.5% of final SFR at 3 months in adults and children, respectively. No transfusions were needed in all patients. Tubeless was achieved in 93.9% and 100% of patients in adults and children respectively. The mean hospital stay was 2.3 ± 0.8 d and 2.7 ± 1.5 d respectively.CONCLUSIONS: SMP are suited for stones less than 2.5 cm in size. It is also suited for special situations such as pediatric moderate-sized stones, previously failed SWL or RIRS approaches. It has advantages of a shorter operative time and hospital stays, with a largely reduction use of drainage catheter after procedure. The indications of the SMP may also compete with those of SWL and RIRS.

Renal calculi are generally formed as a result of the combination of certain factors, some related to urine composition (concentration of lithogenic substances, deficiency of crystallization inhibitors, presence of heterogeneous nucleants) and others with renal morphology and anatomy (urinary tract stasis, low urodynamic efficiency cavities, morpho-anatomic deformations, renal papillary tissue lesions). In fact, the composition, macrostructure and microstructure of the calculus will clearly depend on the factors that have induced it. For this reason, the appropriate study and classification of the renal calculi simplifies the diagnosis and allows a more effective therapeutic approach since it can be oriented to directly correct the etiological factors responsible for stone formation. In this article, we review the main etiological factors involved in the formation of each type of calculus and the prophylactic measures that can be adopted for proper correction. The most frequent kidney stones have been classified into the following types: calcium oxalate monohydrate papillary calculi, calcium oxalate monohydrate non-papillary calculi, calcium oxalate dihydrate calculi, mixed hydroxyapatite/calcium oxalate calculi, carboxyapatite/hydroxyapatitecalculi, brushite calculi, struvite/carboxyapatite calculi, uric acid calculi, uric acid/calcium oxalate monohydrate calculi, and cystine calculi. Occasionally, however, the calculus is not available for study, in which case the only way forward is to use all available information (clinical history, life habits, radiological data), together with basic biochemical information, to identify and correct all etiological factors related to renal lithiasis that have been identified.

There are two basic pathways for formation of calcium based kidney stones. Most idiopathic calcium oxalate (CaOx) stones are formed in association with sub-epithelial plaques of calcium phosphate (CaP), known as Randall’s plaques, on renal papillary surfaces. Crystal formation and retention within the terminal collecting ducts, the ducts of Bellini, leading to the formation of Randall’s plugs, is the other pathway. Both pathways require supersaturation leading to crystallization, regulated by various crystallization modulators produced in response to changing urinary conditions. High supersaturation, as a result of a variety of genetic and environmental factors, leads to crystallization in the terminal collecting ducts, eventually plugging their openings into the renal pelvis. Stasis behind the plugs may lead to the formation of attached or unattached stones in the tubular lumen. Deposition of crystals on the plug surface facing the pelvic or tubular urine may result in stone formation on the Randall’s plugs. Kidneys of idiopathic stone formers may be subjected to oxidative stress as a result of increased urinary excretion of calcium/oxalate/phosphate and/or decrease in the production of functional crystallization inhibitors or in relation to co-morbidities such as hypertension, atherosclerosis, or acute kidney injury. We have proposed that production of reactive oxygen species (ROS) causes dedifferentiation of epithelial/endothelial cells into osteoblast type cells and deposition of CaP in the basement membrane of renal tubules or vessels. Growth, aggregation and melding of CaP crystals leads to the formation of plaque which grows by further calcification of interstitial collagen and membranous vesicles. Plaque becomes exposed to pelvic urine once the covering papillary epithelium is breached. Surface layers of CaP are replaced by CaOx through direct transformation or demineralization of CaP and mineralization of CaOx. Alternatively, or in addition, CaOx crystals nucleate directly on the plaque surface. Stone growth may also depend upon supersaturation in the pelvic urine, triggering further nucleation, growth and aggregation.

Flexible ureteroscopy is a highly resolving surgery which is able to solve most renal lithiasis of any Urology Department, with very low economic impact. It is a technique that has helped to continue treatment when SWL couldn´t, and also has reduced the number of percutaneous renal surgeries that we currently perform. In this paper, we try review three important features of the operation: Technique, minimal requirements that we need to perform this surgery in a Urology Department, and the different possibilities to treat the lithiasis with holmium laser. We want to show how to perform the surgery successfully and advise what instruments and other surgical materials we really need to purchase. It is totally proved that this is a minimal invasive technique, with reasonably low cost and highly effective.

Renal lithiasis is known for its high incidence and prevalence, but mainly for its morbidity and recurrence. Despite a good indication and appropriate surgical treatment, the essential problem, the origin of the formation of the stones, generally persists and it is not uncommon that patients suffer multiple treatments and discomfort secondary to ancillary measures normally used to prevent complications. It is widely known, for consistency, that a prophylactic treatment with general or, in a smaller group of patients, specific measures are appropriate to diminish recurrences. Nevertheless, prophylaxis is not usually used by many urologists and, on top of that, in the majority of those cases when it is taken into consideration, it is the patient who fails for inadequate treatment compliance. It is very important, in any of our conversations with the urinary lithiasis´ patient in relation with the disease, that the urologist provides a proper and detailed information about all its features, from diagnosis to active treatment and possible complications and, of course in those cases where prophylaxis is going to be essential to avoid new unpleasant episodes of pain and associated surgical interventions, emphasizing that improving his/her quality of life depends, to a great extent, on the patient himself. In this article, considering the existing evidence and personal experience, we intend to detail those behaviors we should take into consideration to facilitate the patient both therapeutic decisions and a positive attitude towards his/her disease, with the aim to control it in the best possible way.

Ultra mini PCNL (UMP) has been described as a less invasive technique of PCNL for the treatment of small to medium sized stones in attempt to reduce the surgical morbidity.OBJECTIVE: Evaluate prospectively the outcomes of UMP.METHODS: Single surgeon prospective concurrent cohort study of UMP in India.Effectiveness was assessed by stone-free rates, operative time, complications including transfusion, sepsis rates, length of stay and analgesic requirements. RESULTS: In 2013, data on 98 consecutive patients who underwent UMP was collected prospectively. Mean stone size (±SD) was 15.85 ± 4.53mm. The mean Hounsfield unit (HU) was 1105 ± 165HU. Access to the kidney was from the upper pole (8), interpolar (36) and lower pole (55) with no instances of failed access. Mean operating time was 54 minutes (range 28-120 minutes). The mean change in haemoglobin was -0.81g/dl and mean change in creatinine was 0.05mg/dl. No patients were transfused or suffered acute kidney injury. There were fiveClavien-Dindo complications (Grade I x4, IIIb x 1) with the most serious being a perinephric collection requiring intervention.Post-operative oral analgesia was sufficient in 89 patients (91%) with 9 patients (9%) requiring IM or IV analgesia. Median length of stay was 30 hours (IQR 10 hours). 13 patientshad nephrostomy drainage. 8 patients required a stent for one week. Intraoperatively, 98% of patients were stone free on fluoroscopy, which was 76% on day 1 post op ultrasound and 83% on CT at 1 month. Stone free was the absence of detectable calculi. CONCLUSIONS: UMP for 10-20mm stones appears to be effective and safe with few complications and a short length of stay. Further multicentre studies are required but if confirmed, UMP may be a valuable addition to the armamentarium of the endourologist.

OBJECTIVE: To describe the PCNL technique addressing those conditions that enable us to perform the procedure with maximum patient`s safety without losing focus on the objective of lithiasis resolution.METHODS: Based on our experience, accumulated with time, and the constant update of the endourological techniques we treat those issues in relation to PCNL from the efficiency, efficacy and effectiveness perspective. To consider them involves the successful performance of the technique, with complications prevention and taking cost-efficiency into account. The first one is in close connection to selection of the most adequate technique for each case, training and team work to achieve excellence. With meticulous preoperative preparation and procedure performance, on every single step of the operation, we will ensure an effective technique, avoiding complications. Efficiency comes from the two first and involves, in addition to perform a successful and safe procedure, that the procedure should be cost effective from the management point of view.CONCLUSIONS: PCNL offers the possibility of endoscopic extraction of renal lithiasis, regardless of its volume, density or site, but its success, safety and efficiency are closely linked to the possibility of establishment of an appropriate tract that enables manipulation and total extraction of the calculus.

Stone disease has afflicted mankindsince centuries; records from ancient civilisations ofIndia and Egypt have shown stones in human bodies.The scientific mind of humans has always made smartendeavours to remove the kidney stones. From largeinstruments made like the beaks of different animalsand birds in 600 BC (Indian civilisation) to extremelysophisticated and miniaturised endoscopic intrumentsof today the human race has travelled a long way.The theme has always been to remove the stones withminimal morbidity and mortality and with minimum painto the patient. The article takes you through the journeyof instruments used in 600 BC until today. The story ofinstrumentation is a symbiosis of the medical minds alongwith engineering advances. The story of miniaturisationcould not have moved further without the developmentof lasers, fiberoptics and sophisticated cameras. As thefield stands today, we remove more complex stones by larger endoscopic intervention and smaller stones byminiaturised instruments. The article discusses all themerits and shortcomings of various techniques: fromopen surgery to standard PCNL to Mini PCNL to Ultra-Mini PCNL to Micro-PCNL.

Risk factors should be evaluated in all patients with urinary lithiasis. The kind of evaluation, simplified or extended, depends on stone composition and, in patients with calcium lithiasis, on the clinical presentation. These studies are done in an outpatient regimen, are easy to perform and accessible for most laboratories. Patients with uric acid, infectious and cystine stones only require a selective more abbreviated evaluation. In calcium lithiasis we perform an extended metabolic evaluation in recurrent patients and also in single- episode patients when they have high recurrence risk. The extended evaluation has demonstrated to be cost- effective in patients with highly recurrent lithiasis. There is not enough clinical evidence yet on what would be the most convenient study methodology for a proper metabolic evaluation, and proposed clinical guidelines are mainly based on expert committee opinions. With these studies, we can diagnose systemic and renal diseases of lithogenic nature, and they also enable the adoption of precise prophylactic measures that achieve recurrence control in a great number of patients.

In this review, we analyze the etiopathogenic principles of urinary lithiasis formation. In the kidney, calcifications that may cause renal lithiasis are produced as a consequence of processes that injury the urothelium at the papilla and Bellini´s ducts. With the improvement of imaging techniques, mainly micro CT scan, it is possible to detect them and we may be able to anticipate to the formation of lithiasis. As we well know, there are different factors that influence the formation of the calculi depending on their composition. In calcium lithiasis it is key to review the modification of the categories of hypercalciuria, we currently distinguish two types instead of three, thanks to the fasting calcium/ creatinine ratio, differentiating absorptive hypercalciuria and fasting hypercalciuria. In the fasting hypercalciuria, it is important to emphasize the relationship between this factor and the loss of bone mineral density in patients with recurrent renal calcic lithiasis, so that in this kind of patients it is compulsory the study of bone metabolism by bone remodelling markers and bone densitometry. Regarding the other factors that participate in the formation of calcium lithiasis we should specially emphasize on hypercalciuria and its growing increase because of its relationship with obesity and metabolic syndrome, as well as hipocitraturia, present in an important percentage of patients and related in some cases with metabolic acidosis and osteopenia-osteoporosis too. In relation to uric acid lithiasis it should be highlighted that urinary pH is the most determinant factor and, therefore, its control and modifications would be paramount for prevention of this type of lithiasis. In the infectious lithiasis, the presence of germs that split urea is mandatory. They generate ammonia ions with the ability to injure the urothelium and to form magnesium ammonium phosphate lithiasis mainly. Regarding cystine lithiasis, rare, it was classically divided in three types and now passed to be classified in type A and B depending on the muted gene, and it is more useful to perform direct 24-hour urine measurement than screening tests which have low sensitivity. In general, we tried to give a comprehensive view of the various types of lithiasis emphasizing the most interesting clinical points for the urologist.

OBJECTIVE: To address various issues concerning the fate of residual fragments (and the patients carrying them), their detection, and current and future techniques to avoid them. METHODS: Narrative overview of the all relevant articles retrieved from Pubmed research together with the experiences of personal practice was conducted. RESULTS: Clinically insignificant residual fragments (CIRFs) are defined as asymptomatic, non-obstructing residual fragments smaller than 4 mm (1.6-8) or 5 mm. CIRFs can be diagnosed with either direct endoscopic vision or using imaging modalities including ultrasonography and computerized tomography. Although ultrasonography is radiation-free, the sensitivity and specificity is relatively low when compared to non-contrast computerized tomography. CONCLUSION: The best and the easiest way to deal with residual fragments is preventing their occurrence. Although asymptomatic residual fragments can be safely followed up, symptomatic fragments should be promptly treated. Several modifications and modalities are currently available to treat the fragments occurring after different treatment options.

OBJECTIVE: : To determine the importanceof fasting calcium/creatinine ratio in patients withcalcium stones and its relation with hypercalciuria andphospho-calcium metabolism.METHODS: Cross-sectional study including 143patients divided into two groups according to fastingcalcium/creatinine. Group 1: 66 patients (calcium/creatinine< 0.11); Group 2: 77 patients (calcium/creatinine> 0.11). A comparative study is performedbetween groups including phospho-calcium metabolismparameters and excretion of urinary lithogenic markers.Linear correlation studying calciuria and fasting calcium/creatinine was performed. SPSS 17.0 statistical analysissoftware was used, considering p≤0.05.RESULTS: It is noteworthy that group 2 had increased24 h urine calcium excretion in comparison to group1 (229.3 vs 158.1; p=0.0001) and calcium/citrate(0.47 vs 0.34; p=0.001). There is a positive andsignificant correlation between calcium levels in 24 h urineand fasting calcium/creatinine (R=0.455; p=0.0001)and a cutoff is set at 0.127 (sensitivity 72%, specificity66%) to determine hypercalciuria (>260 mg in 24 h).CONCLUSION: Increased fasting calcium/creatininedetermines increased 24 hours calcium excretion,although the sensitivity and specificity to determinehypercalciuria is not high.

OBJECTIVE: The aim of this study is toanalyze urine concentrations (mg/dl) of different lithogenicfactors in a sample of 24 h as a predictor of thesechanges rather than absolute values depend on the volumeof diuresis.METHODS: A total of 131 patients from the North AlmeriaHealth Management Area (Spain) with urinary calstonedisease in whom a metabolic study was indicatedwere included from June 2014 to May 2015. Theconcentrations of calcium, oxalate, uric acid, citrateand magnesium were measured in the urine, and thecalcium/citrate ratio was calculated. The classificationsused were: hypercalciuria (>260mg/24h), hyperuricosuria(>750mg/24h), hyperoxaluria (>40mg/24h),hypocitraturia (< 320mg/24h) and hypomagnesuria(< 35mg/24h). The statistical analysis was performedusing SPSS 17.0.RESULTS: A cut-off point of 12.55mg/dl, with a sensitivityof 90% and a specificity of 85% and a relative risk(RR) of 51.2 (13.9-188.4), was estimated for urinarycalcium. For oxalate the cut-off point was 1.86mg/dl,with a sensitivity of 91% and a specificity of 84% with anestimated RR of 67.2 (8.3-540.6). As regards the uric acidconcentration in urine, a cut-off point of 31.2mg/dl wasestimated, with a sensitivity of 85% and a specificity of70% and a RR of 12 (3.8-37.6). For citrate the cut-offpoint was 18.8mg/dl, with a sensitivity and specificityof 82% and 74%, respectively, with a RR of 13.7 (4.4-42.6). The cut-off point for magnesium was 2.26mg/dlwith a sensitivity of 95% and specificity of 78%, with aRR of 67.6 (11.4-398.3).CONCLUSION: The determination of urine concentrations,instead of absolute values, depends to a largeextent on urine output, appears to be useful when estimatingclassic metabolic alterations and should be takeninto account in the evaluation of patients with urinarystone disease.

OBJECTIVES: Treatment of calciumstones is based on diet and pharmacological measuressuch as the use of thiazides and other drugs. The aimof this study is to assess the effect of alendronate onhydrochlorothiazide on urinary calcium and bonemineral density in patients with calcium stones.METHODS: Prospective observational study involving77 patients with relapsing calcium stones divided into2 groups according to treatment received. Group 1: 36patients treated with alendronate 70 mg/week;Group 2: 41 patients treated with hydrochlorothiazide50 mg/day. All patients receive diet recommendationsand fluid intake. Studied and analyzed among othervariables were bone mineral density, bone turnovermarkers and calciuria before and after 2 years oftreatment. Statistical study with SPSS 17.0, statisticalsignificance p< 0.05.RESULTS: No statistically significant differences inthe distribution by sex or age of the patients betweengroups. In group 1 statistically a significant decreasewas observed in the b-crosslaps and improvement inbone mineral density, along with decreased urinarycalcium after 2 years of treatment. In Group 2 statisticallysignificant decrease in urinary calcium and fastingcalcium/creatinine was seen, along with improvement inbone mineral density after 2 years of treatment. In group 1,there is a more obvious and significant improvement inbone mineral density compared to 2 and b-crosslapsdecrease. However, in group 2 the decrease in urinarycalcium and calcium/creatinine was more significantthan in group 1.CONCLUSION: Treatment with thiazide decreasecalciuria and produces an improvement in bone mineraldensity, although not in the same range as treatment withalendronate.

OBJECTIVE: To determine the effect of a botanical formulation of Herniaria glabra, Agropyron repens, Equisetum arvense, and Sambucus nigra as a preventive agent in an experimentally induced nefrolithiasis model in rats.METHODS: Six groups of six Wistar male rats each were induced for nefrolithiasis by treatment with 0.75% ethylene glycol (EG) and 1% ammonium chloride for three days and then EG only for 15 days. One group was treated with placebo (control group) and the other groups (treated groups) were treated with 30 mg/Kg, 60 mg/Kg, 125 mg/Kg, 250 mg/Kgand 500 mg/Kg of the plant extract formulation (PEF). 24-h urine and water samples were collected one day before EG administration and at 7, 13 and 18 days to determine diuresis, crystalluria and urine biochemistry. The kidneys were removed for histological analysis. The phytochemical characterization of PEF and each of its component plant extracts was performed using gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry.RESULTS: Animals treated with 125 mg/Kg of the PEFhad statistically significantly lower calcium oxalate crystals deposits content compared to the control group. All PEF doses statistically significantly decreased the number of microcalcifications compared to the control group. Furthermore, the number of kidneys affected by subcapsular fibrosis was statistically significantly higher in control group than in treated groups with the PEF. The diuresis of the 125 mg/Kg and 500 mg/Kg PEF-treated groups was statistically significantly higher than that of the control group. A phytochemical analysis demonstrated the presence of flavonoids, dicarboxylic acids and saponins.CONCLUSION: Treatment with PEF prevents deposits of calcium oxalate crystals formation and of microcalcifications in the kidney, and reduces the risk of fibrosis subcapsular. 125 mg/Kg of PEF is the dose that has a greater effect on the studied parameters.