==inizio objective==

As described in many papers, metabolic syndrome is associated with a marked immune activation and the increased release of inflammatory mediators. These processes promote a low-grade chronic inflammatory state, silent and persistent over time. In presence of ureteral lithiasis, the ureteral wall could undergo changes related to an inflammatory state developing in an increasing of its thickness. Aim to our study is to evaluate if metabolic syndrome and ureteral wall thickness are predicting factor of “non spontaneous passage” of ureteral stones.

==fine objective==

==inizio methodsresults==

From January 2017 to February 2022, all patients hospitalized in our centre for renal colic due to ureteral stones were retrospectively collected. Among these patients, we have excluded all patients who needed immediate stenting/urs for urosepsis(fever> 38.0 ° C or hypothermia <36.0 ° C, tachycardia> 90 beats/ minute, tachypnoea> 20 breaths/minute, leucocytosis> 12 000 /l or leukopenia <4000/l), uretheral lithiasis Dmax >5mm, patients with AKI for bilateral stones or solitary kidney stones. We assessed the following parameters for each patient and divided them into the following categories: Metabolic Syndrome(Y/N), ureteral wall thickness(<2mm/≥2mm), c-reactive protein (<100/≥ 100). We have also created crosstabs for all the parameters considered for evaluation of “spontaneous stone passage” (yes/no). Logistic regression analysis was used to assess the association between spontaneous lithiasis passage, and all parameters evaluated. We assumed p <0.05 as statistical significance value ==fine methodsresults== ==inizio results== A total of 645 patients were enrolled in the study. After applying the exclusion criteria, we have created a cohort of 336 patients admitted to our division .Main characteristics of the cohort were described in Table 1. Metabolic Syndrome was found in 117 pts, ureteral wall thickness ≥2mm in 174 pts. At the logistic regression analysis for spontaneous lithiasis passage presence of metabolic syndrome (OR 3.64 CI 95% 1.53-8.66 p = 0.006) , an ureteral wall thickness ≥2mm (OR 5.31 CI95% 1.26-22.44 p = 0.023) were positively associated with non spontaneous stone passage. Elevated values of C-reactive proteine (OR 1.99 p = 0.40) was otherwise not positively associated. ==fine results== ==inizio discussions== ==fine discussions== ==inizio conclusion== Metabolic syndrome is currently one of the most common conditions in western population. The proinflammatory state, characterizing the syndrome, in presence of ureteral lithiasis can manifest itself as an increasing thickness of the ureteral wall and therefore lead to not spontaneous passage. Therefore, in patients with metabolic syndrome, ureteroscopy or ureteral stenting should be performed immediately. ==fine conclusion== ==inizio reference== ==fine reference==

==inizio objective==

Urolithiasis represents one the most frequent urologic pathologies in general population, with an estimated incidence risk of stone formation estimated around 11% in males and 7% in females (1,2).
Consequently, the incidence of the newly diagnosed bilateral stone disease is estimated in up to 15% of patients with new onset urolithiasis according to recent studies (3). Recent technological advances in endourology have led to an implementation of indications to retrograde intrarenal surgery (RIRS), which is become the preferred methodic for treatment of renal stones, with higher stone-free rate (SFR) compared to shock-wave lithotripsy (SWL ) (4). Recent literature points out the feasibility of single-session bilateral simultaneous endoscopic treatment (SBES) by means of contemporary supine percutaneous nephrolithotomy (PCNL) and RIRS. Aim of this study is to provide the results of a wide multicentric casistic of bilateral endoscopic stone treatment by means of single-session bilateral RIRS.

==fine objective==

==inizio methodsresults==

A retrospective analysis of all consecutive patients who had RIRS for stones between January 2015 and June 2022 in 21 international centers was performed. Inclusion criteria were age ≥18 years, stone(s) of any size and location located in both kidneys and deemed suitable for RIRS, surgery performed surgery in both sides. Exclusion criteria were pediatric cases, concomitant ureteral lithotripsy, RIRS done as a combined procedure for endoscopic combined intrarenal surgery, and surgery performed solely on one side. Stone size was calculated on the largest diameter. In the case of multiple stones, data from the largest stone were gathered. Lithotripsy was carried out either by HL (low-power ≤30W; high-power >30W) or TFL. Surgical time was estimated as the time from the start of cystoscopy to the placement of a bladder catheter. SFR was assessed 3 months after surgery according to the local standard of care with KUB X-Ray and/or ultrasound or non-contrast CT scan and was defined as absence of any RF ≤2 mm.

==fine methodsresults==

==inizio results==

During the study period, 1250 patients meet the inclusion criteria and were included in the analysis. There were 844 (67.5%) males. Median age was 48.0 (36-61) years. Pain was the most common symptom at presentation (59.8%) followed by hematuria and pain (22.5%). Roughly half of the patients (46.2%) were recurrent stone formers. More than half of the patients were presented (58.2%, bilaterally in 21.7%, and unilaterally in 36.5%). The most common reason for pre-stenting was routine practice (32.2%) followed by symptoms (28.5%). Pre-stenting lasted more than 14 days in 61.2% of patients. Most of the patients (94.7%) had normal bilateral renal/collecting systems. Median stone diameter was 10 mm on both sides and the pelvis was the most common stone location in both kidneys. Multiple stones were present in 45.3% and 47.9% of left and right kidneys, respectively.
Antibiotic prophylaxis was administered in 84% of cases. General anesthesia was performed in 1118 (89.4%) of patients. Multiple surgeons were involved in 204 (16.3%) procedures. Only 98 cases (7.8%) were performed sheathless, whereas the most common outer diameter of UAS was 12 Fr (29.8%). UAS was employed bilaterally in most of the cases (72.6%). A reusable ureteroscope was used in 56.9% of cases. Low-power HL was used in 41.4% of cases, followed by high-power HL (33.2%) and TFL (24.4%). A combination of techniques was the most common lithotripsy mode (71%). Surgery was stopped in only 85 (6.8%) cases and the most common reason was prolonged operation time (58.8%) followed by concern for sepsis (43.5%). Most patients had a stent positioned after RIRS (97.3%, bilaterally in 58.4%) mainly as a routine practice (86.2%). Median X-ray time was 78.0 (48-120) seconds. Median surgical time was 75.0 (55-90) minutes. On table, bilateral SFR was 64.1%. Regarding early postoperative complications, 134 (10.7%) patients had transient fever (Clavien 1), 69 (5.5%), fever/infection needing prolonged stay (Clavien 2), 25 (2%) sepsis requiring intensive care admission (Clavien 4b) and 16 (1.3%) required a blood transfusion (Clavien 2). Median hospital stay was 2 (1-2) days, whilst 241 (14.3%) patients were discharged within 24 hours of surgery. Analysis was available in 1045 stones and the most common composition was calcium oxalate monohydrate (45.8%) followed by calcium oxalate dihydrate (29.8%).
At 3-months follow-up, bilateral SFR was 73.0%, whereas unilateral SFR was 17.4%.
Female (OR 2.99 95% CI 1.18-7.55, p=0.02), kidneys anomalies (OR 5.3 95% CI 1.76-15.97, p<0.01) and surgical time (OR 1.02 95% CI 1.01-1.03, p<0.01) were factors associated with sepsis at multivariable analysis. Female (OR 1.81 95% CI 1.31-2.50, p<0.001), bilateral pre-stenting (OR 3.15 95% CI 1.16-8.56), p=0.03), use of high-power HL (OR 1.64 95% CI 1.16-2.33, p<0.01) and TFL (OR 3.40 95% CI 1.84-6.29, p<0.001) were predictors of bilateral SFR at multivariable analysis, whereas age (OR 0.98 95% CI 0.97-0.99, p<0.001), stone size (OR 0.95 95% CI 0.92-0.98, p<0.01 in left kidney; OR 0.96 95% CI 0.92-0.98, p<0.01 in right kidney) and surgical time (OR 0.99 95% CI 0.98-0.99, p<0.001) were less likely associated with SFR. ==fine results== ==inizio discussions== This is the first wide casistic of same session bilateral RIRS presented in Literature. All cases were performed in high-volume stone centers. As showed from intraoperative data, the procedure was feasible in the most part of cases and was interrupted in case of prolonged surgical time to minimize the risk of sepsis. The complication rate is comparable to wide series of single site ureteroscopies, also in terms of postoperative sepsis. According to multivariate analysis, better results in terms of SFR were achieved with new generations HL or TFL, demonstrating how much this procedure can be enhanced with new technologies (digital flexible URS, lasers, ureteral access sheath). ==fine discussions== ==inizio conclusion== Single-session bilateral RIRS represent a feasible treatment option for medium-sized bilateral renal stones in high-volume centers. Proper selection of patients and surgical expertise, extending surgery on the second side only when the first side was uneventful, are the key point to ensure a complete safety of the procedure. Those results should encourage a widespread adoption of this approach. ==fine conclusion== ==inizio reference== 1. Hesse A, Brändle E, Wilbert D, Köhrmann KU, Alken P. Study on the prevalence and incidence of urolithiasis in Germany comparing the years 1979 vs. 2000. Eur Urol. 2003 Dec;44(6):709-13. doi: 10.1016/s0302-2838(03)00415-9. 2. Scales CD Jr, Smith AC, Hanley JM, Saigal CS; Urologic Diseases in America Project. Prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160-165. doi: 10.1016/j.eururo.2012.03.052 3. Rapp DE, Wood NL, Bassignani M, Gergoudis L, Caulkins S, Kramolowsky EV. Clinical variables and stone detection in patients with flank pain. Can J Urol. 2016 Oct;23(5):8441-8445. PMID: 27705728. 4. Geraghty RM, Jones P, Somani BK. Worldwide Trends of Urinary Stone Disease Treatment Over the Last Two Decades: A Systematic Review. J Endourol. 2017 Jun;31(6):547-556. doi: 10.1089/end.2016.0895. ==fine reference==