Welcome to 'the rock show' Evaluating paradigms in stone treatment

Kidney stone disease is a prevalent and recurrent urological condition. This doctoral thesis critically examines four paradigms relevant to the quality, safety, and sustainability of modern kidney stone treatment: radiation exposure during ureterorenoscopy, kidney stone analysis, evaluation of ureterorenoscopes and perceived surgical workload.
Fluoroscopy use and radiation safety among urologists in Belgium and the Netherlands were investigated. Despite mandatory training and widespread implementation of the ALARA principle, substantial variability persisted in awareness and application of radiation protection measures. Furthermore, operator-controlled imaging was evaluated and showed significantly reduced fluoroscopy time compared with radiographer-controlled imaging.
Furthermore, endoscopic stone recognition was evaluated as a potential adjunct to conventional stone analysis. Visual identification of stone composition during ureterorenoscopy demonstrated limited diagnostic accuracy and low intra-observer agreement. In parallel, the influence of time and ex vivo storage conditions on stone characteristics was assessed, showing no significant effect on the accuracy of X-ray diffraction or morpho-constitutional analysis.
A third part of this doctoral thesis systematically reviewed the current methods for evaluating flexible ureterorenoscopes. In the absence of a universally accepted standard, the TULIP-tool was developed to support structured and reproducible assessment of technical performance, image quality, manoeuvrability, durability, and ergonomics.
Finally, perceived surgical workload across endourological procedures was evaluated. Workload was generally low compared with other surgical disciplines, but differed between procedures, with the highest workload during percutaneous nephrolithotomy and the lowest during extracorporeal shockwave lithotripsy.
These findings advance safer, more standardized, and sustainable endourological stone care for patients and surgical teams.