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INTRODUCTION: Although rare, guidewire fractures can occur during interventional procedures. In most cases, the fractured guidewire segment can be removed. PATIENT CONCERNS: We report the case of a 54-year-old woman who experienced a guidewire fracture during percutaneous nephrostomy (PCN) for percutaneous nephrolithotomy to remove renal stones. DIAGNOSIS: Nephrolithiasis. INTERVENTIONS: PCN and percutaneous nephrolithotomy. OUTCOMES: In this case, the remaining segment could not be removed and caused inflammation and infection. However, her symptoms improved with inpatient treatment. Therefore, she was discharged from the hospital and followed up for 5 years. CONCLUSION: When performing PCN to remove renal stones, the possibility of a guidewire fracture must be considered. If resistance or scraping is felt while handling the guidewire, then it should be replaced.

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PURPOSE: This study aimed to investigate the impact of nephrostomies on the outcome of total renal function (TRF) and split renal function (SRF) in patients with malignant pelvic tumors associated with upper urinary tract obstruction (UUTO). METHODS: Patients with pelvic tumors suffering severe unilateral hydronephrosis treated at our hospital from 2000 to 2022 were included. Data for nephrostomy placement, short- and long-term renal function, and radiological and nuclear imaging studies were collected. The TRF and SRF of patients who underwent nephrostomy were compared to those who did not. RESULTS: Seven patients were included (rhabdomyosarcoma: 5, ovarian germ cell tumor: 1, malignant rhabdoid tumor: 1). Nephrostomies were placed in four, which were successfully managed without severe infections. Estimated glomerular filtration rate (eGFR) was significantly improved at the end of treatment in patients with nephrostomy. In contrast, eGFR in patients who did not undergo nephrostomy was not improved. Nuclear imaging studies (renograms or renal scintigrams) revealed impaired SRF of the affected kidney compared to the contralateral kidney, even in patients whose eGFR was within normal levels. Notably, SRF showed a trend to improve over time in one patient treated with nephrostomy. CONCLUSION: Nephrostomy for UUTO caused by pelvic tumors may improve renal outcome.

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BACKGROUND: Renal calculi are one of the most frequent diseases in urology, and percutaneous nephrolithotomy (PCNL) being the gold standard for treating renal calculi larger than 2 cm. However, traditional rigid nephroscope cannot bend, presents significant limitations during PCNL. This study aims to develop a novel digital flexible nephroscope for PCNL and verify its safety and efficacy using 3D printed models and ex vivo porcine kidney models, providing new equipment for PCNL. METHODS: Based on the determined technical parameters, the novel digital flexible nephroscope was manufactured. First, 3D-printed model and ex vivo porcine kidney models were utilized to simulate the PCNL procedures. Then, the traditional rigid nephroscope and the novel digital flexible nephroscope were utilized to simulate the PCNL procedures on 10 ex vivo porcine kidneys for comparison. We observed and recorded the renal calyces visualized and accessed by both the traditional rigid nephroscope and the novel digital flexible nephroscope. RESULTS: In both the 3D printing and ex vivo porcine kidney models, the novel percutaneous digital flexible nephroscope smoothly entered the renal collecting system through the percutaneous renal tract. It freely changed angles to reach most target calyces, demonstrating significant advantages over the traditional rigid nephroscope. CONCLUSION: The successful development of the novel percutaneous digital flexible nephroscope allows it to be used either independently or as an adjunct in complex stone cases, providing more effective and safer surgical equipment for percutaneous nephrolithotomy.

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Background and Objectives: The European Association of Urology guidelines on urolithiasis highlight the limited evidence supporting the superiority of percutaneous nephrostomy (PCN) over retrograde ureteral stent placement for the primary treatment of infected hydronephrosis secondary to urolithiasis. We, therefore, conducted a systematic review and meta-analysis comparing the effects of PCN and retrograde ureteral stent in patients with severe urinary tract infections secondary to obstructive urolithiasis. Materials and Methods: Meta-analyses were performed to compare four outcomes: time for the temperature to return to normal; time for the white blood cell (WBC) count to return to normal; hospital length of stay; and procedure success rate. After a full-text review, eight studies were identified as relevant and included in our systematic review and meta-analysis. Results: No significant difference was detected between PCN and retrograde ureteral stenting for the time for the temperature to return to normal (p = 0.13; mean difference [MD] = -0.74; 95% confidence interval [CI] = -1.69, 0.21; I2 = 96%) or the time for the WBC count to return to normal (p = 0.24; MD = 0.46; 95% CI = -0.30, 1.21; I2 = 85%). There was also no significant difference between methods for hospital length of stay (p = 0.78; MD = 0.45; 95% CI = -2.78, 3.68; I2 = 96%) or procedure success rate (p = 0.76; odds ratio = 0.86; 95% CI = 0.34, 2.20; I2 = 47%). Conclusions: The clinical outcomes related to efficacy did not differ between PCN and retrograde ureteral stenting for severe urinary tract infection with obstructive urolithiasis. Thus, the choice between procedures depends mainly on the urologist's or patient's preferences.

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Background and Objectives: This study evaluated the efficacy and safety of temporary ureteral occlusion combined with urinary diversion using a single-access route created by inserting a balloon catheter through a pigtail nephrostomy drainage catheter. With this approach, we aimed to offer an alternative for patients with ureteral leaks who are suboptimal surgical candidates. Materials and Methods: This retrospective study included nine patients (eight of which were bilateral cases and one was unilateral, totaling seventeen cases) who underwent the surgery between September 2023 and March 2024. The method involved gaining percutaneous access to the pelvicalyceal system, inserting a 4-French Fogarty balloon catheter through a pigtail nephrostomy catheter, and inflating the balloon at the proximal or mid-ureter. Results: All 17 cases achieved technical successful with no major complications. The procedure effectively relieved symptoms associated with urinary leakage in most patients. However, the significant deflation of the balloon catheter occurred in five cases (29.4%), with three (17.6%) experiencing complete deflation. In these five cases, the final balloon size was 5.81 mm (range: 0-8.9 mm), confirming a 25.0% decrease in size from pre- to post-procedure. Ureteral occlusion was 28.3 d long on average (range: 8-57 d). All patients experienced symptom relief during temporary ureteral occlusion. Except for two patients lost to follow-up, three patients showed symptom improvement with only PCN and four patients underwent surgical closure of the fistula tract before or after balloon catheter removal. Conclusions: This study confirms that this approach is safe and effective.

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PURPOSE: To assess the safety and efficacy of super-mini PCNL (SMP, 14 Fr) when compared to standard PCNL (sPCNL, 24-30 Fr) in the management of renal calculi of size ranging from 1.5 to 3 cm. METHODS: From February 2021 to January 2022, a total of 100 patients were randomized to either SMP group or sPCNL group in a 1:1 ratio (50 in each group) using computer-generated simple randomization. Demographic data, stone characteristics, operative times, perioperative complications, blood transfusions, postoperative drop in haemoglobin, postoperative pain, duration of hospital stay and stone-free rates were compared between the two groups. RESULTS: Mean stone volume (2.41 cm2 vs 2.61 cm2) and stone-free rates (98% vs 94%, p = 0.14) were similar in both the SMP and sPCNL groups, respectively. The SMP group had significantly longer mean operative times (51.62 ± 10.17 min vs 35.6 ± 6.8 min, p = 0.03). Intraoperative calyceal injury (1/50 vs 7/50, p = 0.42) and mean postoperative drop in haemoglobin (0.8 ± 0.7 g/dl vs 1.2 ± 0.81, p = 0.21) were lower in the SMP group, but not statistically significant. SMP group showed significantly lower mean postoperative pain VAS scores (5.4 ± 0.7 vs 5.9 ± 0.9, p = 0.03) and mean duration of hospital stay (28.38 ± 3.6 h vs 39.84 ± 3.7 h, p = 0.0001). Complications up to Clavien grade 2 were comparable, with grade ≥ 3 complications higher in the standard group, but not statistically significant. CONCLUSION: Super-mini PCNL is equally effective as standard PCNL in treating renal calculi up to 3 cm, with significantly reduced postoperative pain and duration of hospital stay and lower risk of Clavien grade ≥ 3 complications, although with higher operative times.

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PURPOSE: To assess outcomes of bilateral single-session percutaneous nephrolithotomy (PCNL) with minimally invasive techniques in pediatric population. MATERIALS AND METHODS: From August 2015 to July 2021, 45 children (including 12 infants) were treated with bilateral single-session PCNL, which included miniPCNL (12-16-Fr) and Microperc (4.8-Fr). Patient, stone and operation-related characteristics, stone-free rate (SFR) and complication rate (CR) were compared using ANOVA. Independent predictors were determined using multivariate linear regression. RESULTS: The mean stone burden was 3.2 cm in sum diameter for both kidneys. For bilateral kidneys, the mean operative time was 61.6min and SFR was 93.3%; CR was 53.3%, of which complications of Clavien grade 1 and 2 accounted for 46.7%. Bilateral Microperc, bilateral miniPCNL and Microperc plus miniPCNL was performed in 19, 14 and 12 children respectively. Both irrigation volume and postoperative stay were less in groups with Microperc. Both SFRs and CRs were satisfactory for the three groups. Self-limiting hematuria represented the most common complication of all cases (33.3%), especially in groups with miniPCNL. The stone burden was the only independent predictor for operative time (P < .001) and the postoperative complication (P = .008). Children with older age (P = .009), higher body mass index (P = .016) or a higher stone burden (P < .001) received larger irrigated fluid volume. Microperc was associated with less irrigated fluid volume (P = .001). Children with Clavien grade 3 complications (P = .004) spent prolonged postoperative hospital stay. CONCLUSION: With favourable SFR and acceptable CR, bilateral single-session PCNL with minimally invasive techniques might be an effective and safe procedure for pediatric nephrolithiasis.

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To evaluate the performance of a mathematical model to drive preoperative planning between RIRS and MiniPerc (MP) for the treatment of renal stones between 10 and 20 mm. Patients with a renal stone between 10 and 20 mm were enrolled. A mathematical model named Stone Management According to Size-Hardness (SMASH) score was calculated: hounsfield units (HU) χ stone maximum size (cm)/100. Patients were divided into 4 groups: RIRS with score < 15 (Group A), RIRS with score ≥ 15 (Group B), MP with score < 15 (Group C), MP with score ≥ 15 (Group D). Cyber Ho device was always used. Stone free rate (SFR) was assessed after 3 months. Complication rate and need for auxiliary procedures were evaluated. Between January 2019 and December 2021, 350 patients were enrolled (87, 88, 82 and 93 in Groups A, B, C and D). Mean stone size was 13.1 vs 13.3 mm in Group A vs B (p = 0.18) and 16.2 vs 18.1 mm in Group C vs D (p = 0.12). SFR was 82%, 61%, 75% and 85% for Groups A, B, C and D. SFR was comparable between Groups C and D (p = 0.32) and Groups A and C (p = 0.22). SFR was significantly higher in Group A over B (p = 0.03) and in Group D over B (p = 0.02). Complication rate was 2.2%, 3.4%, 12.1%, 12.9% for Groups A, B, C, D. RIRS and MP are both safe and effective. The mathematical model with the proposed cut-off allowed a proper allocation of patients between endoscopic and percutaneous approaches.Registration number of the study ISRCTN55546280.

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INTRODUCTION: Obstructive uropathy encompasses various urinary tract obstructions, leading to changes in urine flow, kidney pressure, and impaired kidney function. Predicting renal recovery from obstructive uropathy, can be challenging and necessitates treatment, as in percutaneous nephrostomy (PNS) drainage. The choice of drainage method depends on patient-specific factors and local expertise. According to the data for the Republic of North Macedonia, in the register of the European Renal Association, in the last few years, there has been an increase in the percentage of patients with obstructive nephropathy from 7.6% to 8.9% who end up on a chronic hemodialysis program. Prompt relief from urinary tract obstruction is essential to preserve renal function and prevent complications. The aim of this study is to present our initial data analysis of recent experience in the use of nephrostomies as a method for temporary or long-term resolution of obstructive nephropathy, in terms of safety and success in preserving kidney function and reducing the number of patients on hemodialysis. MATERIALS AND METHODS: This study analyzed the medical records of 24 patients with obstructive uropathy who underwent PNS placement. Data were collected for the type and degree of obstruction from the ultrasonographic examination. A pig tail nephrostomy was used, with a dilator, guided under ultrasound and controlled with contrast and fluoroscope. Obstructive nephropathy was defined as an elevation of the serum creatinine > 109 µmol/L, before the intervention. Glomerular filtration rate (GFR) was calculated according to the formula CKD epi in ml/min. Each placement of the PNS was considered as an individual procedure and the data of 38 placed nephrostomies were analyzed. We compared the laboratory analyses from the day before (D0) PNS placement and on the seventh day (D7) after PNS placement. The reduction of values for red blood cells (RBC) and hemoglobin (Hb) baseline values from D0 to D7 and the need for transfusion after the procedure were defined as a complication-bleeding. The increase in total counts of the white blood cells (WBC) and C-reactive protein (CRP) from the baseline values from D0 to D7 were defined as a complication-infection. Standard statistical methods were used for data processing. RESULTS: Most patients, 17 (70%), had malignant disease as the cause of obstruction. Unilateral obstruction was more common, detected in 24 (63%) of procedures, with a high degree of hydronephrosis. Obstructive nephropathy, marked by elevated serum creatinine, was observed in 23 (60%) cases before PNS placement. Complications included bleeding and infection but did not result in any fatalities. When comparing the laboratory analysis before PNS placement (D0) and seven days later (D7), a statistically significant decrease in serum creatinine (225±161 vs. 162±145, p=0.005) and an increase in GFR (47±39 vs.59±34, p= 0.005) were observed. CONCLUSION: Percutaneous nephrostomy is a safe and effective treatment option for urinary tract obstruction, especially in patients with malignancies. Continuous monitoring is essential to assess long-term complications and the longevity of PNS functionality. This procedure offers a significant benefit in preserving renal function and minimizing the need for hemodialysis in these patients.

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PURPOSE: To evaluate the rate of and predictors of ureteral obstruction after mini-percutaneous nephrolithotomy (mPCNL) for kidney stones. METHODS: We analyzed data from 263 consecutive patients who underwent mPCNL at a single tertiary referral academic between 01/2016 and 11/2022. Patient's demographics, stone characteristics, and operative data were collected. A nephrostomy tube was placed as the only exit strategy in each procedure. On postoperative day 2, an antegrade pyelography was performed to assess ureteral canalization. The nephrostomy tube was removed if ureteral canalization was successful. Descriptive statistics and logistic regression models were used to identify factors associated with a lack of ureteral canalization. RESULTS: Overall, median (IQR) age and stone volume were 56 (47-65) years and 1.7 (0.8-4.2) cm3, respectively. Of 263, 55 (20.9%) patients showed ureteral obstruction during pyelography. Patients without ureteral canalization had larger stone volume (p < 0.001), longer operative time (p < 0.01), and higher rate of stones in the renal pelvis (p < 0.01) than those with normal pyelography. Length of stay was longer (p < 0.01), and postoperative complications (p = 0.03) were more frequent in patients without ureteral canalization. Multivariable logistic regression analysis revealed that stone volume (OR 1.1, p = 0.02) and stone located in the renal pelvis (OR 2.2, p = 0.04) were independent predictors of transient ureteral obstruction, after accounting for operative time. CONCLUSION: One out of five patients showed transient ureteral obstruction after mPCNL. Patients with a higher stone burden and with stones in the renal pelvis are at higher risk of inadequate ureteral canalization. Internal drainage might be considered in these cases to avoid potential complications.

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OBJECTIVE: This study was performed to investigate the learning curve of ultrasound-guided percutaneous nephrolithotripsy (PCNL) for the treatment of complex renal calculi. METHODS: Seventy-two patients with complex renal stones who underwent ultrasound-guided PCNL by the same operator from November 2016 to September 2020 were retrospectively analyzed. The learning curve of PCNL for complex renal stones was analyzed using multifactorial cumulative sum (CUSUM) analysis and best-fit curves. RESULTS: The CUSUM best-fit curve peaked at Case 36, which represented the minimum number of cumulative cases required to cross the learning curve for this surgical procedure. Accordingly, the learning curve was divided into a learning improvement period (36 cases) and a proficiency phase (36 cases). Compared with the learning improvement period, the proficiency phase was characterized by a shorter puncture time and operation time, a smaller drop in the hemoglobin level, and a lower postoperative complication rate. CONCLUSION: The learning curve of PCNL for the treatment of complex renal calculi can be divided into a learning improvement period and a proficiency phase, and the minimum cumulative number of cases is 36.

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BACKGROUND: The factors influencing fluid absorption in mini-percutaneous nephrolithotripsy (mini-PCNL) are still unknown. We aim to investigate the factors that influence irrigation fluid absorption during mini-PCNL. METHODS: A total of 94 patients who underwent mini-PCNL were included in this prospective study. The endoscopic surgical monitoring system (ESMS) was used to measure the volume of irrigation fluid absorbed during the procedure. Irrigating time, the total volume of irrigation fluid, stone size, S.T.O.N.E. score, hemoglobin, electrolyte levels, and postoperative complications were recorded. RESULTS: A significant correlation was observed between fluid absorption and the presence of postoperative fever, and based on this phenomenon, patients were divided into low and high fluid absorption groups. The serum creatinine level in the high fluid absorption group was significantly high (7 vs. 16.5, p = 0.02). Significant differences were observed between the low and high fluid absorption groups in terms of mean stone size (21.70 mm vs. 26.78 mm), presence of stone burden ≥ 800 mm2 (4% vs. 23%), S.T.O.N.E. score > 8 (4% vs. 38%), the fluid used > 18,596 ml (19% vs. 78%), irrigation time (55.61 min vs. 91.28 min), and perfusion rate (24% vs. 45%) (all p < 0.05). The rates of postoperative fever and SIRS in the high fluid absorption group were significantly high (p < 0.05). CONCLUSIONS: Mean stone size, presence of stone burden ≥ 800 mm2, S.T.O.N.E. score > 8, the fluid used > 18596 mL, irrigation time, and perfusion rate are risk factors of intraoperative fluid absorption in mini-PCNL.

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INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is considered the gold standard treatment for kidney stones greater than 20 mm. However, retrograde intrarenal surgery (RIRS) may achieve the same stone-free rate with repeated procedures, and potentially fewer complications. This study aimed to compare the efficacy and safety of PCNL and two-staged RIRS. EVIDENCE ACQUISITION: We conducted a systematic search in PubMed, Embase, Scopus, Cochrane, and Web of Science for studies comparing PCNL and RIRS for kidney stones greater than 20mm. The primary outcome is stone-free rate (SFR) of PCNL and RIRS (repeated once if needed). Secondary outcomes were SFR of PCNL versus RIRS (single procedure), operative time, hospital stay, need for auxiliary procedures, and complications. We performed a subgroup analysis for randomized trials, non-randomized trials, and patients with solitary kidney. We performed a trial sequential analysis for the main outcome. EVIDENCE SYNTHESIS: We included 31 articles, with 1987 patients in the PCNL and 1724 patients in RIRS. We confirmed the traditional result that after a single procedure PCNL has a higher SFR. We also found that comparing the SFR of PCNL and RIRS, repeated up to two times if needed, no difference in SFR was observed. Surprisingly, only 26% (CI95 23%-28%) of the patients required a second RIRS. In the trial sequential analysis, the last point of the z-curve was within futility borders. We observed that PCNL has a higher incidence of complications (RR=1.51; CI95 1.24, 1.83; P<0.0001; I2=28%), specifically CD2 (RR=1.82; CI95 1.30, 2.54; P=0.0004; I2=26%) and longer hospital stay (MD 2.57; 2.18, 2.96; P<0.00001; I2-98%). No difference was observed regarding operative time. CONCLUSIONS: RIRS repeated up to two times is equivalent to PCNL in terms of the SFR and may have the same safety.

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OBJECTIVES: Compared to other stone groups, anterior calyx stones are more challenging for endourologists to treat. This study aims to evaluate the differences between our latest technique and conventional techniques for treating anterior calyx stones in the lower pole. MATERIALS AND METHODS: Patients with isolated anterior lower pole calyx or complex lower pole stones with anterior calyx branching were included in the study. The first group included lower pole access, while the second group included percutaneous treatment through the middle or upper pole. In the first group, the posterior calyx or direct anterior calyx approach was utilised depending on whether the stone was isolated calyx, complex structure or calyx anatomy, while in the second group, percutaneous nephrolithotomy was performed through the middle or upper pole posterior calyx access. RESULTS: There were 37 patients in Group 1 and 25 patients in Group 2. Both groups were similar regarding patient age, sex, stone burden, and stone localisation (p > 0.05). When comparing operative and post-operative data between groups, it was found that the stone clearance rate, number of accesses, and haematocrit decrease were statistically superior in the second group (p: 0.003, p: 0.002, p: 0.018), with no significant difference in mean operative time, length of hospital stay, fluoroscopy time and pain score (p > 0.05). CONCLUSIONS: Percutaneous surgery utilising an access from a calyx distal to the stone may offer better clearance and lower morbidity rates for lower pole stones involving the anterior calyx.

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Ureteral involvement by a tumor is common, and both partial and complete obstructions can result in symptoms that are distressing and debilitating, especially in cancer patients for whom the resection of the primary tumor is not considered an option. Maintaining ureteric patency in these patients is a challenge. In addition, in cases where a patient has undergone nephroureterectomy due to primary transitional cell cancer, it becomes necessary to decompress the urinary tract to preserve the contralateral kidney from irreversible damage. This is possibly due to ureteral stenting, both retrograde and anterograde, and percutaneous nephrostomy (PCN). Since imaging plays an important role in the routine monitoring of stents, their more and more increasing use requires radiologists to be familiar with these devices, their correct position, their potential complications, and their consequences. The aim of this review is to offer a comprehensive review of the imaging features of some urinary stents and to show the complications encountered in cancer patients as a direct consequence of an invasive diagnostic or therapeutic procedure. Specifically, we focus on ureteral stents and PCN.

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The aim is to compare the efficacy and safety between single percutaneous nephrolithotomy (sPNL) and antegrade flexible ureteroscopy-assisted percutaneous nephrolithotomy (aPNL) for the treatment of staghorn calculi. A prospective randomized controlled study was conducted at the Second Hospital of Tianjin Medical University. A total of 160 eligible patients were included, with 81 in the sPNL group and 79 in the aPNL group. The study first compared the overall differences between sPNL and aPNL. Then, the patients were divided into two subgroups: Group 1 (with less than 5 stone branches) and Group 2 (with 5 or more stone branches), and the differences between the two subgroups were further analyzed. The results showed that aPNL had a higher stone-free rate (SFR) and required fewer percutaneous tracts, with a shorter operation time compared to sPNL (P < 0.05). Moreover, aPNL significantly reduced the need for staged surgery, particularly in patients with 5 or more stone branches. Moreover, there were no significant differences in the changes of hemoglobin levels and the need for blood transfusions between the sPNL and aPNL groups, and the incidence of multiple tracts was lower in the aPNL group. The two groups showed comparable rates of perioperative complications. We concluded that aPNL resulted in a higher SFR for staghorn calculi, and required fewer multiple percutaneous tracts, reduced the need for staged surgery, and had a shorter operative time than PNL alone, especially for patients with 5 or more stone branches. Furthermore, aPNL did not increase the incidence of surgical complications.

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OBJECTIVE: To assess safety, urinary symptoms, and feasibility of JJ stent removal with exteriorized threads through the percutaneous tract after percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Prospective, transversal, comparative, experimental, randomized 1-to-1 cohort study in 52 patients who underwent "tubeless" PCNL from October 2020 to November 2022. Group A with threads through the urethra and Group B through the percutaneous tract. The validated USSQ (Ureteral Stent Symptom Questionnaire) was applied in the Urology office a week after the procedure, and the JJ stent was withdrawn by pulling the threads. Hemoglobin and urine culture, and pre- and post-surgery were evaluated. RESULTS: There is a statistically significant difference in favor of group B when comparing urinary symptoms (p = 0.008), body pain (p = 0.009), and general condition (p = 0.042), mainly for non-urgency incontinence, frequency of analgesic use, and dysuria. There were significant differences between groups (p = 0.028, p = 0.026, p = 0.027, respectively). There is no association with urinary infections (p = 0.603) nor an increased risk of bleeding (p = 0.321). CONCLUSION: The removal of the JJ stent with exteriorized threads through the percutaneous tract after PCNL in the office is a feasible and safe procedure if it is removed before 8 days and has better tolerance regarding the urinary symptoms.

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BACKGROUND: To demonstrate the technical feasibility of percutaneous nephrolithotomy (PCNL) guided by 5G-powered robot-assisted teleultrasound diagnosis system (RTDS) in a complex kidney-stone (CKS) cohort and present our preliminary outcomes. PCNL is highly skill-required, which hinders it popularization in primary medical units of remote regions. We designed an innovative tele-assistance approach to make PCNL easy to be operated by inexperienced surgeons. METHODS: This was a prospective proof-of-concept study (IDEAL phase 1) on intraoperative tele-assistance provided by online urological experts via a 5G-powered RTDS. Total 15 CKS patients accepted this technology. Online experts manipulated a simulated probe to assist unskilled local operators by driving a patient-side robot-probe to guide and monitor the steps of access establishment and finding residual stones. RESULTS: Median total delay was 177ms despite one-way network-connecting distance > 5,800 km. No perceptible delay of audio-visual communication, driving robot-arm or dynamic ultrasound images was fed back. Successful tele-assistance was obtained in all cases. The first-puncture access-success rate was 78.6% with a one-session SF rate of 71.3% and without complications of grade III-V. CONCLUSIONS: The current technology based on 5G-powered RTDS can provide high-quality intraoperative tele-assistance, which has preliminarily shown satisfactory outcomes and reliable safety. It will break down a personal competence-based barrier to endow PCNL with more popular utilization. TRIAL REGISTRATION: The study was approved by ethics committee of the Xinjiang Kezhou People's Hospital and ethics committee of the First Affiliated Hospital of Nanjing Medical University and was registered on http://www.chictr.org.cn (ChiCTR2200065849, 16/11/2022).

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PURPOSE: This study aims to evaluate the safety and efficacy of ultrasound-guided balloon dilation compared to non-balloon dilation for percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A systematic review and meta-analysis were conducted by searching PubMed, EMBASE, and the Cochrane Library. Results were filtered using predefined inclusion and exclusion criteria as described and meta-analysis was performed using Review Manager 5.4 software. RESULTS: A total of six studies involving 1189 patients who underwent PCNL were included. The meta-analysis results demonstrated that compared to non-balloon dilation, balloon dilation was associated with reduced haemoglobin drop [mean difference (MD) = -0.26, 95% CI = -0.40 ~ -0.12, P = 0.0002], decreased transfusion rate [odds ratio (OR) = 0.47, 95% CI = 0.24 ~ 0.92, P = 0.03], shorter tract establishment time (MD = -1.30, 95% CI = -1.87 ~ -0.72, P < 0.0001) and shorter operation time (MD = -5.23, 95% CI = -10.19 ~ -0.27, P = 0.04). CONCLUSIONS: Overall, ultrasound-guided balloon dilatation offered several advantages in PCNL procedures. It facilitated faster access establishment, as evidenced by shorter access creation time. Additionally, it reduced the risk of kidney injury by minimizing postoperative haemoglobin drop and decreasing the need for transfusions. Moreover, it enhanced the efficiency of surgery by reducing the operation time. However, it is important to note that the quality of some included studies was subpar, as they did not adequately control for confounding factors that may affect the outcomes. Therefore, further research is necessary to validate and strengthen these findings.

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