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When training resident surgeons to perform RALP, a dual-console system may improve intraoperative and perioperative outcomes. The dual-console may represent a safer, more efficient modality for robotic surgical education as compared to a single-console system.

We previously showed that nearly half the patients left with residual fragments (RFs) after URS experience a subsequent stone-related event (SE). We aimed to determine if a stone free state after URS is associated with a fewer SEs than those left with residual fragments.METHODS: After undergoing URS for renal and ureteral calculi between December 2015 and February 2017 167 patients (209 renal units, RUs) were prospectively enrolled. CT was obtained 6-8 weeks post-operatively. Patients were evaluated at subsequent office visits and/or contacted by phone to determine if a stone event attributable to the treated RU occurred. A stone event (SE) was defined as spontaneous stone passage, symptoms requiring emergency department (ED) visit, surgical intervention, or stone growth. Only patients with at least 12 months of follow-up were included for analysis. Kaplan Meier analysis, Chi-squared analysis, log rank test, and logistic regression were used to assess outcomes.RESULTS: Among the study group, 123 patients and 152 RUs met study criteria, including 57% (87 RUs) with residual fragments and 43% (65 RUs) who were rendered stone-free on post URS CT. Median overall follow-up was 29 months . The mean number of RFs per patient was 2.1 AE 1.5 and mean largest fragment size was 3.7 AE 2.0 mm. SE occurred in 47% (41/87) of RUs with RFs and 14% (9/ 65) of those that were stone free (p<0.001). Median time to SE was 33 months for those with RFs (CI 23-43) and 45 months in those who were stone free . The stone event-free survival was 68% in those with RFs and 98% in those stone free at 24 months (p<0.001) (Figure 1). Multivariate regression demonstrated stone-free status as a predictor of a stone event (OR 4.98, p<0.001), although residual fragment size and number were not.CONCLUSIONS: Attaining a stone-free state after URS with basket extraction reduces the rate of SEs in patients undergoing ureteroscopy.

INTRODUCTION AND OBJECTIVE:The in vitro effects of thulium fiber laser (TFL) for lithotripsy has been previously described. 1 We aim to describe the first North American clinical experience in the use of thulium laser lithotripsy in mini-PCNL.METHODS: A consecutive series of patients undergoing mini-PCNL with the TFL (Soltive TM , Olympus Surgical) at two institutions was reviewed. Mini-PCNL with 16.5F dilation/17.5 sheath was performed with Storz MIPS system. The TFL was utilized in all cases for lithotripsy. Dust, stone debris, and fragments were cleared in standard fashion through nephrostomy sheath. Visual and fluoroscopic stone clearance was confirmed for all patients. Operative technique and postoperative management were maintained at the institutional standard.RESULTS: Six patients underwent mini-PCNL with TFL. Five cases were unilateral and performed supine and one patient had a bilateral mini-PCNL in the prone position. Mean age was 51, mean BMI was 30. Mean Charlson Comorbidity Index was 1.3 and mean ASA score was 2.8. 3 of 7 renal units had a single primary stone vs. 4 of 7 with more than one significant stone. Mean stone volume in primary calculus was 4,940mm 3 . Laser energy settings ranged from 0.1-1.0J and rate ranged from 20-500Hz. Mean laser time was 18.1 minutes (range [ 0.9-28 min). Mean laser energy was 15.9kJ (range 1.6-64kJ). There were no intraoperative complications. 3 patients received stents, for a mean of 8 days. 2 of the 7 renal units had nephrostomy placed at end of case, both removed the next day. One patient had an extended 4 day hospital stay for treatment of bacteremia. Overall mean hospital stay was 1.6 days (range 1-4 days). Mean decrease in creatinine and hemoglobin were 0.1mg/dL and 1.0g/dL respectively. No blood transfusions were performed.CONCLUSIONS: In this initial North American cohort, the TFL has been shown to be promising as a safe and effective modality for clearance of calculi during mini-PCNL. Our group has noted synergy in the ability to clear stone when TFL is used in combination with supine mini-PCNL, in both fragmentation and dusting modes. Larger cohort and longer follow up is needed for further evaluation of this new technology.

Purpose: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery. Methods: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests. Results: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning. Conclusions: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one’s surgical team might allow for novel and safer approaches.

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