Urolithiasis

Boyke SoebhaliIndonesia Speaker Updates on Pharmacological Therapy for UrolithiasisUrolithiasis, a prevalent and recurrent urological condition, requires a multifaceted approach combining pharmacological, dietary, and surgical interventions. Recent advancements in pharmacological therapy emphasize personalized treatment based on stone composition, metabolic profiles, and patient-specific risk factors. For calcium oxalate stones, the most common type, thiazide diuretics remain first-line therapy to reduce urinary calcium excretion, while potassium citrate is recommended to increase urinary citrate levels, inhibiting stone formation. Dietary modifications, such as reduced oxalate intake and adequate calcium consumption, are adjunctive measures. In primary hyperoxaluria (PH), novel RNA interference (RNAi) agents like lumasiran and nedosiran significantly lower urinary oxalate levels, offering promising alternatives for patients unresponsive to pyridoxine. Uric acid stones are managed with urinary alkalinization using potassium citrate or sodium bicarbonate to maintain a pH >6.0, enhancing uric acid solubility. Xanthine oxidase inhibitors (allopurinol, febuxostat) are reserved for hyperuricemic patients. Cystine stones, though rare, require alkalinization and thiol-based drugs (tiopronin) to improve cystine solubility. Struvite stones, associated with urease-producing infections, necessitate antibiotics and urinary acidification (e.g., L-methionine) alongside surgical removal. Emerging therapies like theobromine show potential in inhibiting uric acid crystallization, while phytate demonstrates inhibitory effects on calcium salt aggregation. Medical expulsive therapy (MET) with alpha-blockers (tamsulosin) remains effective for distal ureteral stones (5–10 mm), reducing time to expulsion and need for surgery. However, MET efficacy diminishes for proximal stones or those >10 mm, necessitating surgical intervention. Future directions include optimizing RNAi therapies for hereditary stone diseases and integrating smartphone apps to enhance treatment adherence. A tailored, evidence-based approach combining pharmacological and lifestyle interventions is crucial for reducing recurrence and improving patient outcomes.Suction PCNL vs Suction RIRS? Do We Have a WinnerThe management of renal stones has evolved with the introduction of suction-assisted techniques in both percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS). Suction PCNL, including mini-PCNL and flexible mini-PCNL (F-mPCNL), utilizes negative pressure to improve stone clearance and reduce intrarenal pressure, while suction RIRS employs vacuum-assisted ureteral access sheaths (V-UAS) or direct in-scope suction (DISS) to enhance fragment removal and minimize infectious complications. Recent studies highlight that suction PCNL achieves superior stone-free rates (SFRs) in a single session, particularly for stones >2 cm, with SFRs ranging from 93.8% to 95.1% compared to 77.8%–87.9% for suction RIRS. However, suction RIRS offers advantages in reduced invasiveness, shorter hospital stays (1–3 days vs. 2–5 days for PCNL), and lower complication rates (e.g., bleeding, transfusion needs). For infectious stones, suction RIRS with V-UAS demonstrates lower postoperative infection markers (CRP, PCT) and fewer febrile complications than PCNL . Operative times vary, with suction PCNL often being faster for large stones (47–82 min) but requiring fluoroscopy, while suction RIRS avoids tract-related risks but may necessitate staged procedures for stones >2 cm. Cost-effectiveness analyses favor suction PCNL due to fewer retreatments, though RIRS reduces radiation exposure.

Yi-Yang LiuTaiwan Speaker Complex Renal Stone: PCNL or RIRS or Combination?Mini-percutaneous nephrolithotomy (mini-PCNL) provides stone-free rate (SFR) 85 to 95 % in children with complex burdens, and recent systematic reviews report overall complications < 7 % and transfusion requirements ≈3 % when tracts ≤18 Fr are used. Its drawbacks are the need for percutaneous access, risk of bleeding, and potential parenchymal scarring, especially when multiple tracts are required. Retrograde intrarenal surgery (RIRS) avoids renal puncture and shows the lowest incidence of high-grade complications (<1 %); contemporary series in preschool children describe initial SFRs of 60–78 %, with secondary procedures needed in up to one-third of cases because of narrow, tortuous ureters. Pre-stenting, staged dilation and longer operative time can offset its minimally-invasive appeal for stones ≥2 cm. Endoscopic combined intrarenal surgery (ECIRS) merges an antegrade mini-PCNL channel with simultaneous flexible ureteroscopy. The first multicenter pediatric series and a 2024 comparative study confirm SFRs of 75–92 %, shorter hospital stay and lower fluoroscopy or transfusion risk than standalone PCNL despite treating more complex stones. Its limitations are the need for two skilled teams, specialized equipment and the Galdakao-modified supine Valdivia position, which lengthen setup and raise costs. In summary, mini-PCNL remains the most efficient monotherapy for large or staghorn calculi; RIRS is ideal when bleeding risk or unfavorable percutaneous windows predominate; ECIRS offers the best compromise between clearance and morbidity where resources and expertise allow. Individualized, anatomy-based algorithms and further pediatric RCTs are still required. ECIRSIn this session, we will demonstrate the technique about Totally-X-ray free ultrasound guided endoscopic combind intrarenal surgery in Galdakao modified supine Valdivia position.A Critical Appraisal on Percutaneous NephrolithotripsyPercutaneous nephrolithotripsy (PCNL) has evolved from a uniform prone, fluoroscopy-guided, large-tract technique into a precision endourological platform that emphasizes patient-tailored positioning, radiation-free puncture, miniaturized tracts, energy-efficient lasers and nascent robotic–AI augmentation. Contemporary evidence affirms that stone-free rates now approach a plateau, making safety metrics—bleeding control, infection prevention and intrarenal pressure modulation—the key differentiators among modern approaches. Miniaturized optics, suction-regulated sheaths and thulium-fiber or dual-wavelength laser consoles have collectively reduced hemoglobin loss and postoperative sepsis while preserving clearance efficacy. Future success will hinge on harmonizing technological innovation with rigorous evidence so that every incremental advance translates into measurable gains for both efficacy and safety in stone surgery.Echo guide Puncture in Supine PCNL: Tips and Tricks for an Efficient and Safe ProcedureMastery of ultrasound-guided supine PCNL begins with precise anatomical orientation. Color-Doppler mapping pinpoints the target calyx, which is punctured transpapillary with an echogenic-tip needle after artificial hydronephrosis is produced by retrograde ureteroscopic irrigation. A hydrophilic, floppy-tip yet stiff-shaft guidewire is then advanced through the needle, allowing atraumatic navigation of the collecting system under ureteroscopic visualization. Balloon dilation—used in place of sequential dilators—prevents guidewire dislodgement. When necessary, a through-and-through guidewire from flank skin to urethral meatus may be created to secure renal access. Finally, antegrade nephroscopy along this coaxial tract confirms unobstructed entry, provides panoramic inspection, and optimizes lithotripsy efficiency—all without fluoroscopy. Collectively, these steps deliver reliable access, eliminate radiation, and streamline stone clearance in a single, ergonomically favorable supine position.

Takaaki InoueJapan Speaker New Advancement on Retrograde Intrarenal SurgeryRetrograde intrarenal surgery (RIRS) has dramatically grown up around world for stone management. Why has RIRS been getting popullar and increasing nowadays?. The reaseon are absoulutely "Technological development with collaborated engineering comapny" and " Global communicaton and collaboration in Endourology". Endourology has still been improving and expanding more and more. Thereby, many novel devices and machine are launching faster. We, urologists should catch up this faster trend and acquire these knowledge for our clinical use. However, most of urologists can not catch up it. Therefore, I will share you all these novel chage of mind and tech-knowledge of stone field in this session. Do We Need Augmented Reality for Renal Stone Management?What is Augmented reality and Vertual reality in medicine?. The paradigm shift of medicine which includes AI, Robotics, VR, and AR etc named Digital transformation has been still emerging. Of course, these shift is gradually permeating in stone field. Especially, in terms of VR, AR, we wonder if this kind of DX is useful in stone management. if so, how do we use it in clinical practice? Today, I will talk these future role in stone management, and expectation. Which Laser for RIRS: Pulsed Thulium YAG Laser We can use three kind of laser such as Holumium YAG, Thulium YAG, and Thulium fiber laser for stone management. Which lase are best option for stone patients? I will talk about featurs and advantage of pulsed-Thulium YAG laser. There are two kinds of p-Tm;YAG laser machine nowadays. P^Tm;YAG has unique characteristics as laser wave. Therefore, this laser would be able to use Stone, BPH, UTUC. Especially, p-Tm YAG laser can utilize for Stone ablation, fragmentingand and UTUC ablation, shock wave. We will share our experoence and thoughts. New Advancement on Retrograde Intrarenal Surgery