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Inoue T, Tanaka H, Masuda T, Iba A, Tambo M, Okada S, Hou T, Takazawa R, Izaki H, Hamamoto S, Fujisawa M. Japanese survey of perioperative complications and ureteral stricture after ureteroscopy with laser lithotripsy for upper urinary tract stones in multicenter collaborative study. Int J Urol 2024; 31:795-801. [PMID: 38622823 DOI: 10.1111/iju.15466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/31/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES This study aimed to investigate perioperative complications and the details of postoperative ureteral stricture after ureteroscopy with laser lithotripsy (URS-L) for upper urinary tract stones in Japan. METHODS Patient data on intra- and postoperative complications after ureteroscopy using URS-L were retrospectively collected from multiple centers in Japan between April 2017 and March 2020 with the cooperation of the Japanese Society of Endourology and Robotics. Data included the number of patients undergoing URS-L, number and type of intra- and postoperative complications, and detailed characteristics of postoperative ureteral stricture. RESULTS In total, 14 125 patients underwent URS-L over 3 years at 82 institutions. Annual URS-L numbers gradually increased from 4419 in 2017, to 4760 in 2018, and 4946 in 2019. The total complication rate was 10.5%, which was divided into intra-operative complications in 1.40% and postoperative complications in 9.18%. The annual incidences of intra- and postoperative complications were not significantly different from year to year (p = 0.314 and p = 0.112). Ureteral perforation, ureteral avulsion, and the intra-operative conversion rate were 1.35%, 0.03%, and 0.02%, respectively. Fever >38°C, septic shock, blood transfusion, and postoperative mortality were 7.44%, 0.81%, 0.07%, and 0.04%, respectively. Ureteral stricture occurred in 0.8% of cases. The median length of stricture site was 10.0 mm and the success rate of stricture treatment was 54.6%. CONCLUSION Although URS-L utilization has increased in Japan, the annual complication rate has remained steady. Although URS-L is a useful and less invasive procedure, devastating complications can still occur.
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Affiliation(s)
- Takaaki Inoue
- Department of Urology and Stone Center, Hara Genitourinary Hospital, Hyogo, Japan
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hirokazu Tanaka
- Department of Urology, Hyogo Prefectural Kakogawa Medical Center, Kakogawa, Japan
| | - Tomoko Masuda
- Department of Urology, Tokyo Metropolitan Police Hospital, Nakano-ku, Japan
| | - Akinori Iba
- Department of Urology, Rinku General Medical Center, Izumisano, Japan
| | - Mitsuhiro Tambo
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Shinsuke Okada
- Department of Urology, Gyotoku General Hospital, Chiba, Japan
| | - Terunobu Hou
- Department of Urology, Teikyo University, Chiba Medical Center, Chiba, Japan
| | - Ryoji Takazawa
- Department of Urology, Tokyo Metropolitan Otsuka Hospital, Toshima-ku, Japan
| | - Hirofumi Izaki
- Department of Urology, Tokushima Prefectural Central Hospital, Toshima-ku, Japan
| | - Shuzo Hamamoto
- Department of Nephro-Urology, Medical School, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Masato Fujisawa
- Division of Urology, Department of Surgery Related, Kobe University Graduate School of Medicine, Hyogo, Japan
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Berger JH, DiPina T, Alshara L, Batagello C, Heiman J, Large T, Sivalingam S, Sur RL, Krambeck A, Bechis SK. The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy. J Endourol 2023; 37:1174-1178. [PMID: 37675902 DOI: 10.1089/end.2023.0300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.
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Affiliation(s)
- Jonathan H Berger
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Thomas DiPina
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Luay Alshara
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carlos Batagello
- Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Joshua Heiman
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tim Large
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sri Sivalingam
- Glickman Urology and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Roger L Sur
- Department of Urology, University of California, San Diego, San Diego, California, USA
| | - Amy Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Seth K Bechis
- Department of Urology, University of California, San Diego, San Diego, California, USA
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Xu ZJ, Chen L, Li D, Xu CL, Chen FT, Tang QL, Shao Y. Ureteroscopic and flexible ureteroscopic lithotripsy: continuation or discontinuation of anticoagulant or antiplatelet drugs? A Chinese survey among urologists. Urolithiasis 2023; 51:39. [PMID: 36809516 DOI: 10.1007/s00240-023-01413-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/11/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To evaluate the management of antithrombotic drugs made by different urologists before ureteroscopic lithotripsy and flexible ureteroscopy in stone patients undergoing active anticoagulant or antiplatelet therapy. METHODS A survey was distributed to 613 urologists in China, which included personal work information and views on the management of anticoagulants (AC) or antiplatelet (AP) drugs during the perioperative period of ureteroscopic lithotripsy (URL) and flexible ureteroscopy (fURS). RESULTS 20.5% of urologists believed that AP drugs could be continued and 14.7% believed that AC drugs could be continued. 26.1% of the urologists who participated in more than 100 ureteroscopic lithotripsy or flexible ureteroscopy surgeries each year believed that AP drugs could be continued and 19.1% believed that AC drugs could be continued, compared with 13.6% (P < 0.01) and 9.2% (P < 0.01) of the urologists who performed less than 100 surgeries. Among the urologists with more than 20 cases undergoing active AC or AP therapy per year, 25.9% thought that AP drugs could be continued and 19.7% thought that AC drugs could be continued, compared with 17.1% (P = 0.008) and 11.5% (P = 0.005) of the urologists with less than 20 cases. CONCLUSION The decision on the continuation of AC or AP drugs before ureteroscopic and flexible ureteroscopic lithotripsy should be individualized. The experience in URL and fURS surgeries and in dealing with patients under AC or AP therapy is the influencing factor.
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Affiliation(s)
- Zi-Jie Xu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Chen
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Deng Li
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao-Liang Xu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei-Teng Chen
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi-Lin Tang
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Shao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Municipal Alliance in Urology, Shanghai, China.
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Zeng G, Traxer O, Zhong W, Osther P, Pearle MS, Preminger GM, Mazzon G, Seitz C, Geavlete P, Fiori C, Ghani KR, Chew BH, Git KA, Vicentini FC, Papatsoris A, Brehmer M, Martinez JL, Cheng J, Cheng F, Gao X, Gadzhiev N, Pietropaolo A, Proietti S, Ye Z, Sarica K. International Alliance of Urolithiasis guideline on retrograde intrarenal surgery. BJU Int 2023; 131:153-164. [PMID: 35733358 PMCID: PMC10084014 DOI: 10.1111/bju.15836] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS. MATERIALS AND METHODS After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided. RESULTS A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications. CONCLUSION The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.
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Affiliation(s)
- Guohua Zeng
- Department of Urology, Guangdong Key Laboratory of UrologyFirst Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Olivier Traxer
- GRC Urolithiasis No. 20, Sorbonne UniversityTenon HospitalParisFrance
| | - Wen Zhong
- Department of Urology, Guangdong Key Laboratory of UrologyFirst Affiliated Hospital of Guangzhou Medical UniversityGuangzhouChina
| | - Palle Osther
- Department of Urology, Vejle Hospital‐a part of Lillebaelt HospitalUniversity Hospital of Southern DenmarkVejleDenmark
| | | | - Glenn M Preminger
- Division of Urologic SurgeryDuke University Medical CenterDurhamNCUSA
| | | | - Christian Seitz
- Department of Urology, Comprehensive Cancer Center, Vienna General HospitalMedical University of ViennaViennaAustria
| | - Petrisor Geavlete
- Sanador HospitalBucharestRomania
- Department of UrologySf. Ioan Emergency Clinical HospitalBucharestRomania
| | - Cristian Fiori
- Division of Urology, Department of OncologyUniversity of TurinTurinItaly
| | | | - Ben H. Chew
- Department of Urologic SciencesUniversity of British ColumbiaVancouverBCCanada
| | - Kah Ann Git
- Department of UrologyPantai HospitalPenangMalaysia
| | - Fabio Carvalho Vicentini
- Departamento de Urologia, Faculdade de Medicina da Universidade de São Paulo – FMUSPHospital das ClínicasSão PauloBrazil
| | - Athanasios Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Marianne Brehmer
- Division of Urology, Department of Clinical Sciences, Karolinska InstitutetDanderyd HospitalStockholmSweden
| | | | - Jiwen Cheng
- Department of UrologyThe First Affiliated Hospital of Guangxi Medical UniversityNanningChina
| | - Fan Cheng
- Department of UrologyRenmin Hospital of Wuhan UniversityWuhanChina
| | - Xiaofeng Gao
- Department of UrologyChanghai HospitalShanghaiChina
| | - Nariman Gadzhiev
- Department of UrologySaint‐Petersburg State University HospitalSaint‐PetersburgRussia
| | | | | | - Zhangqun Ye
- Department of Urology, Tongji Medical College, Tongji HospitalHuazhong University of Science and TechnologyWuhanChina
| | - Kemal Sarica
- Department of Urology, Medical SchoolBiruni UniversityIstanbulTurkey
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Abedi G, Monga M. Flexible Ureteroscopy for Treatment of Upper Urinary Tract Calculus. J Endourol 2021; 35:S56-S61. [PMID: 34499545 DOI: 10.1089/end.2020.1018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The aim of this article is to illustrate a step-by-step guide to flexible ureteroscopy (URS) for treatment of upper urinary tract calculus. Preoperative evaluation of the patient with focus on comorbidities is paramount for the type of stone procedure to be performed. In this article, the steps of operating room setup, patient positioning, gaining access to the upper urinary tract, flexible URS, laser lithotripsy, basket extraction of stone fragments, and placement of a ureteral stent are described. The importance of clearance of the ureter before flexible URS in the case of pre-existing ureteral stone is also described.
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Affiliation(s)
- Garen Abedi
- Department of Urology, University of California, San Diego, La Jolla, California, USA
| | - Manoj Monga
- Department of Urology, University of California, San Diego, La Jolla, California, USA
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Ureteroscopy in Patients Taking Anticoagulant or Antiplatelet Therapy: Practice Patterns and Outcomes in a Surgical Collaborative. J Urol 2020; 205:833-840. [PMID: 33035142 DOI: 10.1097/ju.0000000000001416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE AUA guidelines recommend ureteroscopy as first line therapy for patients on anticoagulant or antiplatelet therapy and advocate using a ureteral access sheath. We examined practice patterns and unplanned health care use for these patients in Michigan. MATERIALS AND METHODS Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry we identified ureteroscopy cases from 2016 to 2019. We assessed outcomes and adherence to guidelines based on therapy at time of ureteroscopy: 1) anticoagulant: continuous warfarin or novel oral agent therapy; 2) antiplatelet: continuous clopidogrel or aspirin therapy; 3) control: not on anticoagulant/antiplatelet therapy. We fit multivariate models to assess anticoagulant or antiplatelet therapy association with emergency department visits, hospitalization and ureteral access sheath use. RESULTS In total, 9,982 ureteroscopies were performed across 31 practices with 3.1% and 7.8% on anticoagulant and antiplatelet therapy, respectively. There were practice (0% to 21%) and surgeon (0% to 35%) variations in performing ureteroscopy on patients on anticoagulant/antiplatelet therapy regardless of volume. After adjusting for risk factors, anticoagulant or antiplatelet therapy was not associated with emergency department visits. Hospitalization rates in anticoagulant, antiplatelet and control groups were 4.3%, 5.5% and 3.2%, respectively, and significantly increased with antiplatelet therapy (OR 1.48, 95% CI 1.02-2.14). Practice-level ureteral access sheath use varied (23% to 100%) and was not associated with anticoagulant/antiplatelet therapy. Limitations include inability to risk stratify between type/dosage of anticoagulant/antiplatelet therapy. CONCLUSIONS We found practice-level and surgeon-level variation in performing ureteroscopy while on anticoagulant/antiplatelet therapy. Ureteroscopy on anticoagulant is safe. However, antiplatelet therapy increases the risk of hospitalization. Despite guideline recommendations, ureteral access sheath use is not associated with anticoagulant/antiplatelet therapy.
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Complications of ureteroscopy: a complete overview. World J Urol 2019; 38:2147-2166. [DOI: 10.1007/s00345-019-03012-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 11/05/2019] [Indexed: 12/18/2022] Open
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Tran TY, Bamberger JN, Blum KA, Parkhomenko E, Thai J, Chandhoke RA, Gupta M. Predicting the Impacted Ureteral Stone with Computed Tomography. Urology 2019; 130:43-47. [PMID: 31029671 DOI: 10.1016/j.urology.2019.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/08/2019] [Accepted: 04/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate whether preoperative computed tomography (CT) findings could predict the presence of an impacted stone. Preoperative identification of an impacted ureteral stone may influence patient preparation and operative decisions. Factors predicting ureteral stone impaction have not been clearly identified. METHODS We identified all patients from June 2014 to July 2016 that underwent ureteroscopic treatment of an impacted ureteral stone. Patients that had ureteral prestenting or previous treatment for their stone were excluded. Noncontrast CT images were reviewed to calculate stone size, stone volume, degree of hydronephrosis (0-3), and Hounsfield units (HU) of the stone as well as the ureter distal and proximal to the stone. These were compared with a control group of patients that had nonimpacted stones. RESULTS Patients with impacted stones had a greater stone size, volume, HU of the ureter under the stone, HU under/above ratio, and degree of hydronephrosis on univariate analysis. Multivariate analysis demonstrated that HU under the stone was a significant predictor of ureteral stone impaction (odds ratio 1.17; 95% confidence interval 1.11-1.25). Distal ureteral density above 27 HU demonstrated a sensitivity of 85%, specificity of 85%, positive predictive value of 89%, and negative predictive value of 81% for ureteral stone impaction. CONCLUSION Impacted stones are associated with ureteral density cut-off value of 27 HU or greater. Measuring this value on preoperative noncontrast CT may help predict which patients are more likely to have impacted stones.
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Affiliation(s)
- Timothy Y Tran
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Urology, Providence VA Medical Center, Providence, RI
| | - Jacob N Bamberger
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Kyle A Blum
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Egor Parkhomenko
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Urology, Boston University School of Medicine, Boston, MA
| | - Julie Thai
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan A Chandhoke
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Mantu Gupta
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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Sharaf A, Amer T, Somani BK, Aboumarzouk OM. Ureteroscopy in Patients with Bleeding Diatheses, Anticoagulated, and on Anti-Platelet Agents: A Systematic Review and Meta-Analysis of the Literature. J Endourol 2018; 31:1217-1225. [PMID: 29048211 DOI: 10.1089/end.2017.0253] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Ureteroscopy (URS) is the most common surgical treatment of urolithiasis and can be problematic in patients with a bleeding diathesis. The intent of this review is to systematically review the literature to assess the safety and efficacy of ureteroscopic procedures in these groups of patients. METHODS The systematic review was performed according to the Cochrane diagnostic accuracy review guidelines. The search strategy was conducted to perform a comprehensive database search (1990-2017). A cumulative analysis was done and where applicable a comparative analysis between bleeding diathesis patients and those without. RESULTS Eight studies included were all published between 1998 and 2016 with the total number of participants with bleeding diatheses being 1109 with an age range of 18-97. Overall stone-free rate across the studies was 90.8% vs 86.2% in the control group. There was no significant difference in complications between the bleeding diathesis group and control group (N = 12,757, p = 0.07, 95% confidence interval [CI] 0.92, 6.02, I2 = 78%). Pooled analysis for bleeding-related complications shows a statistically significant difference favoring the control arm (N = 12,757, p ≤ 0.0001, 95% CI 1.81, 5.73, I2 = 0%). Pooled analysis for thrombosis shows no statistically significant difference between the bleeding diathesis group and the control arm (N = 118, p = 0.67, 95% CI 0.23, 9.86, I2 = 48%). CONCLUSION The use of URS with or without the holmium laser is a safe and efficient modality for treating patients with urolithiasis who also have a bleeding diathesis or are anticoagulated or on antiplatelet agents. However, this review would suggest that the increased risk of procedure related bleeding is not insignificant and a patient-centered approach should be taken with regards to continuing these agents or not correcting bleeding diatheses.
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Affiliation(s)
- Alaa Sharaf
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Tarik Amer
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Bhaskar K Somani
- 2 Department of Urology, University Hospital of Southampton NHS Foundation Trust , Southampton, United Kingdom
| | - Omar M Aboumarzouk
- 1 Department of Urology, Queen Elizabeth University Hospital , NHS Greater Glasgow and Clyde, Glasgow, United Kingdom .,3 EAU Young Academic Urologists-Endourology and Urolithiasis Working Group, European Assocication of Urology.,4 School of Medicine, Dentistry and Nursing, University of Glasgow , Glasgow, United Kingdom
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