Luis Llanes Gonzalez

Background: Retrograde intrarenal surgery (RIRS) is a well-established minimally invasive technique for the management of renal stones. However, intraoperative physiological and anesthetic events during the procedure remain poorly characterized, particularly in the context of newer technologies such as suction-assisted systems. Objective: The objective of this study is to evaluate the occurrence of intraoperative anesthetic and physiological adverse events during suction-assisted RIRS and to assess its safety profile. Methods: We conducted a prospective, single-center observational sub-analysis of the “Trifecta factors in ureteroscopy” project. A consecutive cohort of 30 patients undergoing RIRS with suction ureteral access sheaths (sUAS) between August 2025 and January 2026 was analyzed. Baseline demographics, stone characteristics, and intraoperative anesthetic parameters—including airway pressure, Bispectral Index (BIS), and hemodynamic events—were prospectively recorded. Primary endpoints included intraoperative fever, sustained tachycardia, blood pressure alterations, and anesthetic complications. Results: The cohort had a mean age of 56.4 years with an equal gender distribution. Mean stone size was 12.9 mm, and mean operative time was 50.3 min. Intraoperative monitoring demonstrated stable anesthetic conditions, with a mean airway pressure of 16.3 cmH₂O and a mean BIS of 42.6. No major anesthetic complications or significant blood pressure fluctuations were observed. Minor intraoperative events included fever in 10% of cases and sustained tachycardia in 6.7%. No cases of intraoperative anesthetic instability were recorded. Conclusions: Within this descriptive cohort, suction-assisted RIRS under general anesthesia demonstrated a favorable safety profile with stable intraoperative parameters, though larger comparative studies are required to confirm these preliminary findings.

Background/Objectives: The study aimed to find out if the patients without a reTURBT, due to changed protocol in our centre because of the COVID-19 pandemic, had presented higher rates of relapse or progression compared to patients treated by standard reTURBT protocol. Methods: A prospective study was conducted including 43 patients with high-risk T1 non-muscle invasive bladder cancer diagnosed between March 2020 and June 2021. Patients were divided into two groups: those who underwent reTURBT and those who did not, due to limitations during the COVID-19 pandemic. All patients received intravesical BCG induction therapy and were followed for 3 years. The institutional research ethics committee approved the study. Results: A total of 43 patients were included, 17 (39.5%) underwent reTURBT and 26 (60.5%) did not. No significant differences were observed in tumour characteristics between groups. Recurrence occurred in 43.8% of the reTURBT group and 15.4% of the non-reTURBT group. Tumour progression to T2G3 was observed only in the reTURBT group. Survival analysis showed no significant differences in recurrence-free survival between groups (p = 0.299). Conclusions: Omitting reTURBT in carefully selected patients did not result in significantly worse oncological outcomes; however, due to the small sample size, the study is underpowered and these findings should be interpreted with caution. Early BCG administration in the non-reTURBT group may have contributed to favourable recurrence-free survival. However, further prospective studies are needed to confirm these findings and define optimal criteria for safely omitting reTURBT.

Aim: To present state of the art on the management of urinary stones from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024.Options of treatment: The surgical treatment modalities of renal and ureteral stones are well defined by the guidelines of international societies, although for some index cases more alternative options are possible. For 1.5 cm renal stones, both m-PCNL and RIRS have proven to be valid treatment alternatives with comparable stone-free rates. The m-PCNL has proven to be more cost effective and requires a shorter operative time, while the RIRS has demonstrated lower morbidity in terms of blood loss and shorter recovery times. SWL has proven to be less effective at least for lower calyceal stones but has the highest safety profile. For a 6mm obstructing stone of the pelviureteric junction (PUJ) stone, SWL should be the first choice for a stone less than 1 cm, due to less invasiveness and lower risk of complications although it has a lower stone free-rate. RIRS has advantages in certain conditions such as anticoagulant treatment, obesity, or body deformity.Technical issues of the surgical procedures for stone removal: In patients receiving antithrombotic therapy, SWL, PCN and open surgery are at elevated risk of hemorrhage or perinephric hematoma. URS, is associated with less morbidity in these cases. An individualized combined evaluation of risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. Pre-interventional urine culture and antibiotic therapy are mandatory although UTI treatment is becoming more challenging due to increasing resistance to routinely applied antibiotics. The use of an intrarenal urine culture and stone culture is recommended to adapt antibiotic therapy in case of postoperative infectious complications. Measurements of temperature and pressure during RIRS are vital for ensuring patient safety and optimizing surgical outcomes although techniques of measurements and methods for data analysis are still to be refined. Ureteral stents were improved by the development of new biomaterials, new coatings, and new stent designs. Topics of current research are the development of drug eluting and bioresorbable stents.Complications of endoscopic treatment: PCNL is considered the most invasive surgical option. Fever and sepsis were observed in 11 and 0.5% and need for transfusion and embolization for bleeding in 7 and 0.4%. Major complications, as colonic, splenic, liver, gall bladder and bowel injuries are quite rare but are associated with significant morbidity. Ureteroscopy causes less complications, although some of them can be severe. They depend on high pressure in the urinary tract (sepsis or renal bleeding) or application of excessive force to the urinary tract (ureteral avulsion or stricture).Diagnostic work up: Genetic testing consents the diagnosis of monogenetic conditions causing stones. It should be carried out in children and in selected adults. In adults, monogenetic diseases can be diagnosed by systematic genetic testing in no more than 4%, when cystinuria, APRT deficiency, and xanthinuria are excluded. A reliable stone analysis by infrared spectroscopy or X-ray diffraction is mandatory and should be associated to examination of the stone under a stereomicroscope. The analysis of digital images of stones by deep convolutional neural networks in dry laboratory or during endoscopic examination could allow the classification of stones based on their color and texture. Scanning electron microscopy (SEM) in association with energy dispersive spectrometry (EDS) is another fundamental research tool for the study of kidney stones. The combination of metagenomic analysis using Next Generation Sequencing (NGS) techniques and the enhanced quantitative urine culture (EQUC) protocol can be used to evaluate the urobiome of renal stone formers. Twenty-four hour urine analysis has a place during patient evaluation together with repeated measurements of urinary pH with a digital pH meter. Urinary supersaturation is the most comprehensive physicochemical risk factor employed in urolithiasis research. Urinary macromolecules can act as both promoters or inhibitors of stone formation depending on the chemical composition of urine in which they are operating. At the moment, there are no clinical applications of macromolecules in stone management or prophylaxis. Patients should be evaluated for the association with systemic pathologies.Prophylaxis: Personalized medicine and public health interventions are complementary to prevent stone recurrence. Personalized medicine addresses a small part of stone patients with a high risk of recurrence and systemic complications requiring specific dietary and pharmacological treatment to prevent stone recurrence and complications of associated systemic diseases. The more numerous subjects who form one or a few stones during their entire lifespan should be treated by modifications of diet and lifestyle. Primary prevention by public health interventions is advisable to reduce prevalence of stones in the general population. Renal stone formers at "high-risk" for recurrence need early diagnosis to start specific treatment. Stone analysis allows the identification of most “high-risk” patients forming non-calcium stones: infection stones (struvite), uric acid and urates, cystine and other rare stones (dihydroxyadenine, xanthine). Patients at “high-risk” forming calcium stones require a more difficult diagnosis by clinical and laboratory evaluation. Particularly, patients with cystinuria and primary hyperoxaluria should be actively searched.Future research: Application of Artificial Intelligence are promising for automated identification of ureteral stones on CT imaging, prediction of stone composition and 24-hour urinary risk factors by demographics and clinical parameters,...

Background: Radical prostatectomy by lateral approach allows performing a prostatectomy through a buttonhole, with direct access to the seminal vesicle and fully sparing the anterior pubovesical complex. Our aim is to show the results of reproducing the technique of robotic radical prostatectomy by lateral approach, in terms of intraoperative, postoperative, oncological and functional parameters. Methods: We analyzed 513 patients submitted to robotic radical prostatectomy by lateral approach from January 2015 to March 2021, operated on by two surgeons in our institution. The oncological and functional results of both surgeons were compared. Results: When comparing both surgeons, the rate of positive surgical margins (PSM) was 32.87% and 37.9% and significant surgical margins (PSM > 2 mm) were 5.88% and 7.58% (p = 0.672) for surgeon 1 and surgeon 2, respectively. Immediate continence was 86% and 85% and sexual potency at one year 73% and 72%, with a similar rate of complications for surgeon 1 and 2. Conclusions: Radical prostatectomy by the lateral approach technique with preservation of the anterior pubovesical complex is reproducible and offers good oncological and functional results.

Urothelial tumour of the upper urinary tract is a rare neoplasm, but unfortunately, it has a high recurrence rate. The reduction of these tumour recurrences could be achieved by the intracavitary instillation of adjuvant chemotherapy after nephron-sparing treatment in selected patients, but current instillation methods are ineffective. Therefore, the aim of this in vitro study is to evaluate the cytotoxic capacity of a new instillation technology through a biodegradable ureteral stent/scaffold coated with a silk fibroin matrix for the controlled release of mitomycin C as an anti-cancer drug. Through a comparative study, we assessed, in urothelial carcinoma cells in a human cancer T24 cell culture for 3 and 6 h, the cytotoxic capacity of mitomycin C by viability assay using the CCK-8 test (Cell counting Kit-8). Cell viability studies in the urothelial carcinoma cell line confirm that mitomycin C embedded in the polymeric matrix does not alter its cytotoxic properties and causes a significant decrease in cell viability at 6 h versus in the control groups. These findings have a clear biomedical application and could be of great use to decrease the recurrence rate in patients with upper tract urothelial carcinomas by increasing the dwell time of anti-cancer drugs.

Purpose:To assess the prostate cancer (PCa) detection accuracy of transperineal prostate biopsy using mpMRI/Ultrasound Fusion Targeted Biopsy (TBX) and Micro-Ultrasound (micro-US) during the same p...

Objective To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. Materials and methods We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. Results Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667–0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. Conclusions Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS

HoLEP represents an excellent treatment option for benign prostatic hyperplasia. Recently, ‘en bloc’ techniques resulting in improved visualization, shorter surgical times, and easier recognition of the dissection plane have been described. In this paper we describe the ‘En bloc’ HoLEP technique with early apical release.