Haas CR, Knoedler MA, Li S, et al. Pulse-modulated holmium:YAG laser vs the thulium fiber laser for renal and ureteral stones: a single-center prospective randomized clinical trial. J Urol. 2023;209(2):374-383.

Special thanks to Drs Marcin Zuberek and Daniel Garvey at the University of Illinois at Chicago.

Urologists always welcome new technologies, especially if they improve patient outcomes and efficiency in the operating room. Laser technology revolutionized stone disease treatment. How does the new thulium laser compare to the holmium:YAG laser? In this randomized controlled trial of a bit over 100 patients, the authors sought to answer this question.

The primary outcome studied was the ureteroscopic time required to adequately fragment stones to 1 mm or less. Secondary outcomes included stone-free rate, complications, laser performance, patient quality of life, and laser efficiency. Ureteroscope time was not significantly different between the 2 laser modalities, with the pulse-modulated holmium:YAG laser and the thulium laser fiber both requiring close to a mean of 20 minutes. There were no significant differences in stone-free rate and complications between the 2 lasers.

It would seem from this study that there is no clear clinical advantage of one laser technology over the other for ureteroscopic stone management. The pulse-modulated holmium:YAG laser has been the gold standard for lithotripsy, while the thulium fiber laser offers certain technical advances such as higher absorption coefficient and smaller fiber diameter. Ultimately, the choice of which laser technology to employ is up to the urologist and their health care system. What this study supports is either choice will lead to equivalent excellent results.

Dutta R, Mithal P, Klein I, Patel M, Gutierrez-Aceves J. Outcomes and costs following mini-percutaneous nephrolithotomy or flexible ureteroscopic lithotripsy for 1-2–cm renal stones: data from a prospective, randomized clinical trial. J Urol. 2023;209(6):1151-1158.

Special thanks to Drs Jason Huang and Mahmoud Mima at the University of Illinois at Chicago.

Flexible ureteroscopy is the standard treatment for renal stones less than 2 cm, but is this the best treatment for midsized stones 1 to 2 cm in size? For these stones, flexible ureteroscopy can be extremely time-consuming and with lower stone-free rates. These authors conducted a prospective randomized trial comparing the efficacy and costs of flexible ureteroscopy and mini-percutaneous nephrolithotomy (mini-PCNL), a percutaneous approach employing a 16F access sheath half the diameter of a traditional nephrolithotomy access sheath.

This group evaluated the surgical and cost outcomes of just over 100 patients, half undergoing mini-PCNL and the other half ureteroscopy. The results were very persuasive. Mini-PCNL offered a significantly higher stone-free rate than ureteroscopy for midsized renal stones. This benefit came with no increase in surgical time or complications. As for economics from a urological perspective, while the direct cost of the surgery was higher, mini-PCNL resulted in higher revenue.

As medicine further tailors treatments to patients, mini-PCNL promises an increasing role in renal stone treatment. At this time, flexible ureteroscopy remains the standard for small to midsized renal stones, and adding mini-PCNL to our armamentarium increases our ability to adapt and offer patient-centered stone management.

Lenfant L, Pinar U, Roupret M, Mozer P, Chartier-Kastler E, Seisen T. Role of antimuscarinics combined with α-blockers in the management of urinary storage symptoms in patients with benign prostatic hyperplasia: an updated systematic review and meta-analysis. J Urol. 2023;209(2):314-324.

Special thanks to Drs Ahmad Hefnawy and Omer Acar at the University of Illinois at Chicago.

Antimuscarinics are frequently used in conjunction with α blockers in the management of urinary storage symptoms associated with benign prostate enlargement and related obstruction. This meta-analysis challenged this well-established practice and aimed to reevaluate the safety and efficacy of combining antimuscarinics with α blockers in patients with benign prostate enlargement.

The inclusion criteria were strict: out of almost 500 randomized controlled trials only 12 studies met them. Over 4,500 patients were included and divided into 2 well-balanced groups of a blocker with placebo vs α blocker with antimuscarinics. There was a small but statistically significant reduction in frequency, but there was no statistically significant improvement in urgency with the addition of antimuscarinics. As for safety, the risks of acute urinary retention, dry mouth, and constipation were significantly higher in patients who received antimuscarinics as adjunctive therapy, which translated into worse compliance.

Considering the marginal symptomatic improvement at the expense of side effects leading to discontinuation, we should revisit the idea of combining antimuscarinics with α blockers in the management of urinary storage symptoms from benign prostate enlargement and counsel our patients accordingly. How to identify the subset of patients who will benefit from adding antimuscarinic agents remains an open question.