Øyvind Ulvik

Objective: To explore differences and similarities in paediatric stone treatment between hospitals in the Nordic countries. Material and methods: A retrospective review of the medical records was performed for children receiving stone treatment in nine Nordic hospitals between January 2014 and December 2023. Variables of interest included diagnostic imaging, treatment modalities, complication rates and stone free rates (SFR). Results: Five hundred and sixty two treatments among 319 children were included; 117 girls and 202 boys with a median age of 10 years (interquartile range 5 – 14). Preoperative diagnostic imaging with computed tomography was performed in 442 cases (79%), and 120 patients (21%) were diagnosed with ultrasound, MRI or X-ray. In 150 cases (27%), stones treated were located in the ureter only and in 412 cases (73%) in the renal pelvis ± ureter. Ureteroscopic stone treatment (URS) was performed in 248 (44%), shock wave lithotripsy (SWL) in 242 (43%) and percutaneous lithotripsy (PCNL) in 72 cases (13%). The distribution of treatment modalities varied considerably between hospitals. URS treatments increased, and SWL procedures declined throughout the study period. A follow-up consultation was carried out in 505 cases (90%). Overall SFR after each session across treatment modalities and location was 49%. The SFRs after URS was 68%, SWL 30% and PCNL 61% and significantly higher after URS compared to SWL, p < 0.001. Postoperative complications leading to readmission occurred in 10% of patients. Conclusion: The study reveals differences in preferred treatment modalities and results between the hospitals. Standardising diagnostics, treatment and follow-up could improve outcomes for children with kidney stone disease.

Introduction: The need for immediate CT in patients with acute flank pain is debated. We aimed to study the diagnostic value and therapeutic impact of CT in these patients. Furthermore, to identify factors associated with intervention and determine who would benefit from acute imaging. Material and methods: A retrospective review was performed of patients with acute flank pain admitted to the emergency department at Haukeland University Hospital between June 2023-June 2024. In total, 289 patients with 319 referrals were included in the study. Results: A total of 142 women and 147 men, with a median age of 48 years (IQR 35–60) were registered. Acute CT was performed in 197 cases (62%), and a cause for flank pain was determined in 159 (81%). A ureteral stone was detected in 122 (62%). Acute ureteroscopy was performed in 48 (39%) of these, while 27 (22%) were drained with a JJ-stent or nephrostomy tube only. Irrespective of the cause for acute flank pain, 234 patients (73%) received conservative treatment only. Patients needing intervention had higher levels of CRP (52 vs 15 mg/L, p < 0.001) and creatinine (108 vs 87 μmol/L, p < 0.001) compared to those treated conservatively. 219 patients (69%) had CT at follow-up after 3–4 weeks. A persistent ureteral stone needing ureteroscopy was registered in 40 (19%). Conclusion: CT in patients with acute flank pain may be reserved for complicated cases with signs of infection, elevated CRP and creatinine levels. In uncomplicated cases, CT can safely be deferred until follow-up after 3–4 weeks.

Objective: Thulium fibre laser (TFL) offers a wide range of power settings during ureteroscopic (URS) lithotripsy, yet the impact of power selection on intraoperative laser‐use dynamics remains unclear. The objective of this study was to characterise differences in laser activation patterns between low‐power (LP) and high‐power (HP) TFL during sheathless URS. Materials and Methods: This was a predefined secondary analysis of intraoperative laser data collected during a randomised clinical trial comparing LP (0.4–0.6 J × 10 Hz; 4–6 W) and HP (0.4–0.8 J × 20–40 Hz; 16–18 W) TFL URS lithotripsy. Flexible URS was performed without a ureteral access sheath. Laser system logs provided time‐stamped activation and pause events with microsecond precision. Laser‐use dynamics were characterised using a predefined set of complementary metrics, including active laser time (ALT), laser operating time (LOT), total activation count, activation durations, pause durations and operator duty cycle (ODC = ALT/LOT). Group comparisons used Holm–Bonferroni–adjusted p values. Results: Data from 72 LP and 74 HP procedures were analysed. ALT was longer with LP (23 vs. 13 min; p < 0.001), whereas LOT was similar (31 vs. 30 min; p = 0.194). LP had a lower activation count (55 vs. 89; p < 0.001) and longer activations (median 24 s vs. 7 s; p < 0.001). Empirical cumulative distribution function analysis showed 89.4% of LP activations lasted ≤30 s compared with 97.2% for HP ( p < 0.001). Total pause time was shorter in LP (8 vs. 14 min; p < 0.001), resulting in a higher ODC (73% vs. 49%; p < 0.001). Conclusion: LP and HP TFL lithotripsy result in distinctly different laser‐use dynamics during sheathless URS. LP supported sustained, continuous lasing, whereas HP yielded fragmented activation requiring frequent pauses. Coupled with superior stone‐free outcomes in the parent trial, these findings suggest that preserving clear endoscopic visibility and more active lasing may be more impactful than increasing laser power.

Introduction: Ureteral strictures are a recognised late complication post ureteroscopy (URS). Most research on the pathology focuses on mechanisms of injury and preventative strategies. There is limited data describing follow up patterns and treatment outcomes. The aim was to evaluate the subsequent management and outcomes of de novo ureteral strictures post URS. Methods: Retrospective review was conducted of patients diagnosed with a de novo ureteral stricture post URS at a tertiary centre between 2014 and 2024. Eligible cases were identified by manual review of ICD-coded records (N13.0–N13.5), yielding 40 patients for analysis. Baseline and procedural data were summarised descriptively, and group comparisons were performed using the Mann–Whitney U and Fisher’s exact tests. Results: Among 40 patients (median age 69 years), most strictures were detected symptomatically (67.5%) and were located proximally or distally (each 43%). Median time to diagnosis was 3.8 months, and median follow-up was 4.3 years. Overall, 45% achieved successful resolution after a median of two procedures, while 15% underwent nephrectomy. Higher age-adjusted Charlson Comorbidity Index scores and older age were significantly associated with poorer outcomes, although interpretation is limited by the sample size. Stricture length and a history of stone impaction showed no significant associations. Conclusions: In this cohort, fewer than half of patients with de novo ureteral strictures following URS achieved lasting resolution despite multiple interventions. These findings highlight the potential clinical burden of this complication and support the importance of preventive strategies, timely detection and structured follow-up, while underscoring the need for further studies to better define long-term outcomes.

Objective: To compare operative time and clinical outcomes between high‐power (HP) and low‐power (LP) thulium fibre laser (TFL) ureteroscopic (URS) lithotripsy for renal stones. Patients and methods: Single‐centre, randomised trial (1:1) at Haukeland University Hospital, Norway. Adults undergoing day‐case URS for 8–25 mm renal stones were enrolled. A total of 150 cases were included. Patients were randomised to URS lithotripsy with TFL using HP (16–18 W, selected for thermal safety during sheathless URS) or LP (4–6 W). The primary endpoint was operative time. The secondary endpoints were stone‐free rate (SFR) on 3‐month non‐contrast computed tomography (Grade A: no residuals; Grade B: ≤2 mm; Grade C: ≤4 mm; Grade D: >4 mm), laser metrics, performance measures, and complications according to the Clavien–Dindo Classification. Groups were compared using appropriate parametric and non‐parametric tests (two‐sided α = 0.05). Results: A ureteric access sheath was not used in any case, reflecting routine practice at our centre. The operative time did not differ between arms: median (interquartile range) HP 48 (36–62) vs LP 54 (42–65) min ( P = 0.12). HP used more energy (12 vs 7 kJ, P < 0.001) with shorter active laser time (13 vs 24 min, P < 0.001), but laser operating time was similar. SFRs favoured LP compared to HP: Grade A, 63% vs 44% ( P = 0.02); Grade B, 77% vs 56% ( P = 0.008). The Grade C SFR was similar between arms. LP was also associated with better surgeon‐rated endoscopic visibility and fewer minor postoperative complications (11% vs 37%, P < 0.001). Major complications (Clavien–Dindo Grade ≥III) were uncommon and similar between arms. Conclusion: Using HP did not shorten the operative time. LP improved SFRs for Grade A/B and reduced minor postoperative morbidity, supporting LP as the default TFL strategy for sheathless URS lithotripsy.

Purpose To investigate the current thoughts and perspectives on kidney stone analysis amongst urologists and urology residents worldwide. Methods In October 2022 an online survey supported by the EULIS was circulated amongst urologists and urology residents worldwide. The survey was based on the current EAU guidelines regarding stone analysis and its role in urolithiasis management. Responses were collected until February 2023. Results The survey was completed by 351 urologists (75.4%) and 115 urology residents (24.7%). 49.1% of the participants stated that performing kidney stone analysis was of utmost importance in every patient. 91.8% were of the opinion that stone analysis changes KSD management. 62.3% of the participants declared to adhere to the guidelines. 44.7% aim to perform stone analysis in first-time stone formers. 1 out of 11 does not send stones for kidney stone analysis at all. Urologists that pursued an additional endo-urology sub-specialism performed stone analysis more frequently compared to those who were not endo-urologists. Conclusion Although majority of urologists consider stone analysis an essential part of kidney stone management, in reality the practice patterns regarding stone analysis deviate from the EAU guidelines. Our aim should be to bridge the knowledge gap regarding stone analysis, foster collaboration to streamline logistics regarding stone analysis and enhance the quality of care we provide for kidney stone patients.

Introduction: Ureteroscopy has become increasingly chosen as a treatment of choice for patients with kidney stone disease and laser as the energy source for stone lithotripsy is a key part of this. Our aim was to analyse a national database to evaluate the burden of adverse events related to laser fibers and laser machines.Methods: Search was performed of the Manufacturer User and Facility Device Experience (MAUDE) database in the United States for all events related to holmium laser fibers and holmium laser machines during ureteroscopy between 2012-2021. Information collected included the following: problem, timing, prolonged anaesthesia, early termination of procedure, injury and retained parts.Results: 699 holmium laser fiber events were reported and these had been manufactured by 13 different companies. The commonest problems were breakage outside the patient while in use (26.3%) and breakage of the laser fiber tip (21.2%). Manufacturers concluded root cause to be device failure in 8.9%. 29% of issues occurred before the laser had been activated. 5.2% of cases had to be cancelled as a result of an event. Significantly more injuries were sustained intra-operatively by operating staff compared to patients (6% vs. 0.2%, p < 0.001). All these injuries were superficial burns to the skin with the hand being the most affected body part (88.1%). Zero ocular injuries were reported. Only eight events were related to laser machines and all involved sudden hardware failure but no patient injury.Conclusions: Laser fibers are fragile. Most adverse events are due to operator error. Direct patient injury from laser fiber is scarce but operating staff should be aware of the risk of sustaining minor burns. Laser machines rarely incur problems and, in this study, did not result in any safety issues beyond need to abort the procedure due to lack of spare equipment.

Introduction: Kidney stones in pregnant is not a common emergency, but it is one that is extremely challenging to manage. There exists no previous survey, which maps the different practice patterns adopted. Our aim was to deliver a survey to evaluate the current status of practice patterns across different parts of the world regarding the management of stone disease in pregnancy. Methods: Through an iterative process, 19-item survey was devised. This contained the following five sections: (1) Demographics, (2) General items, (3) Diagnosis and Imaging, (4) Initial management, (5) Surgery. It was disseminated via social media and email chains. Results: A total of 355 responses were collected, and the majority (66.2%) reported no established hospital protocol for stones in pregnancy. Ultrasound was the most popular first line imaging choice (89.9%) but 8% would choose non-contrast CT. The latter was also chosen as second line choicer in 34.6% as opposed to magnetic resonance imaging. A large proportion (42.5%) had requested CT in pregnancy previously. With equivocal ultra sound results, only 19.4% would proceed to ureteroscopy (URS) but 40.9% would opt for CT. Twenty-four–48 hours were the most popular (37.6%) time period to observe before surgical intervention. Ureteral stent and nephrostomy were regarded as equally effective, and 6 weeks was most popular frequency for an exchange. Most do not use fetal heart rate monitoring intraoperatively. A total of 3.94% had previously performed percutaneous nephrolithotomy during pregnancy. Conclusion: Practice patterns vary widely for suspected kidney stones in pregnancy and use of CT appears increasingly popular. This includes when faced with equivocal ultrasound results and instead of proceeding to ureteroscopy. Most hospitals lack an established management protocol for this scenario.