Some of Michel Foucault’s work focusses on an archeological and genealogical analysis of certain aspects of the medical episteme, such as ‘Madness and Civilization’ (1964/2001), ‘The Birth of the Clinic’ (1973) and ‘The History of Sexuality’ (1978/2020a). These and other Foucauldian works have often been invoked to characterize, but also to normatively interpret mechanisms of the currently existing medical episteme. Writers conclude that processes of patient objectification, power, medicalization, observation and discipline are widespread in various areas where the medical specialty operates and that these aspects have certain normative implications for how our society operates or should operate. The Foucauldian concepts used to describe the medical episteme and the normative statements surrounding these concepts will be critically analyzed in this paper.By using Foucault’s work and several of his interpreters, I will focus on the balance between processes of subjectification and objectification and the normative implications of these processes by relating Foucault’s work and the work of his interpreters to the current medical discipline. Additionally, by focusing on the discussion of death and biopower, the role of physicians in the negation and stigmatization of death is being discussed, mainly through the concept of biopower. Lastly, based on the discussion of panopticism in the medical discipline, this paper treats negative and positive forms power, and a focus will be laid upon forms of resistance against power. The discussed aspects will hopefully shed a different and critical light on the relationship between Foucault’s work and medicine, something that eventually can also be deduced from Foucault’s later work itself.

Introduction: Achieving a stone-free status during percutaneous nephrolithotomy (PCNL) is crucial to prevent additional morbidity or stone growth. Cone beam computed tomography (CBCT) in a hybrid operating room provides intraoperative imaging of the urinary tract, improving stone-free status assessment and enabling additional stone extraction. This study aimed to determine whether intraoperative CBCT leads to increased stone-free rates (SFR) after PCNL. Materials and Methods: We conducted a two-arm randomized trial involving adult patients undergoing PCNL at a tertiary referral center for complex kidney stone treatment. Intraoperative randomization took place when the kidney was deemed endoscopically stone free. Patients were assigned to either undergo an intraoperative CBCT scan or be placed in a control group, in which the procedure was ended without a CBCT scan. All patients underwent a low-dose noncontrast abdominal CT scan 4 weeks postoperatively. The primary outcome measure was the stone-free status evaluated by this scan. Results: This trial was prematurely terminated because of reaching the predefined criteria for superiority upon interim analysis, with 160 randomizations up to this point. SFR was 15% higher in the CBCT group (76% vs 61%, p = 0.04) using a 4-mm cut-off. With a 2-mm cut-off, the SFR difference was 14% (58% vs 44%, p = 0.08). Using a 0-mm cut-off, the difference was 9% (50% vs 41%, p = 0.27). Residual fragments were identified in 56% of CBCT scans, with additional extraction in 49% of these cases. No significant difference in 30-day postoperative complications was observed. Conclusion: Intraoperative CBCT during PCNL significantly increases single procedure SFR. Trial registration: Netherlands Trial Register (NTR) NL8168, ABR NL70728.042.19. Prospectively registered on 15 October 2019.

The current medical approach to erectile dysfunction (ED) consists of physiological, psychological and social components. This paper proposes an additional framework for thinking about ED based on phenomenology, by focusing on the theory of sexual projection. This framework will be complementary to the current medical approach to ED. Our phenomenological analysis of ED provides philosophical depth and illuminates overlooked aspects in the study of ED. Mainly by appealing to Merleau-Ponty’s Phenomenology of Perception, we suggest considering an additional etiology of ED in terms of a weakening of a function of sexual projection. We argue that sexual projection can be problematized through cognitive interferences, changes in the ‘intentional arc’, and modifications in the subject’s ‘body schema’. Our approach further highlights the importance of considering the ‘existential situation’ of patients with ED. We close by reflecting briefly on some of the implications of this phenomenological framework for diagnosis and treatment of ED.

Objectives: To assess the longer‐term impact of intraoperative cone‐beam computed tomography (CBCT) on stone‐related morbidity after percutaneous nephrolithotomy (PCNL), since intraoperative CBCT allows for the detection and removal of residual fragments during the same procedure, improving stone clearance and thereby potentially diminishing stone‐related morbidity.Patients and Methods: This study was a retrospective analysis of a previously conducted single‐centre randomised controlled trial at a tertiary complex endourology centre, in which patients were randomised intraoperatively to PCNL with intraoperative CBCT or conventional PCNL. We analysed 18‐month follow‐up data to assess differences in stone‐related events (SREs), including re‐interventions, emergency department visits, and hospital admissions. Stone‐free rates and time to stone recurrence, as determined by follow‐up CT scans, were also evaluated.Results: The CBCT group (n = 80) had a significantly lower detection rate of new or residual fragments >4 mm (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.38–0.97), with 29 (36%) cases during 18 months of follow‐up compared to 40 (50%) cases in the conventional PCNL group (n = 80). The restricted mean (standard deviation [SD]) time to fragment detection was 420 (44) days in the CBCT group vs 318 (53) days in the conventional PCNL group. In the CBCT group, 15 (19%) cases experienced 26 SREs, compared to 23 (29%) cases with 39 SREs in the conventional PCNL group. The restricted mean (SD) time to SRE was 499 (26) days for CBCT cases, compared to 447 (39) days for conventional PCNL cases. The rate of SREs did not decrease significantly when comparing CBCT‐PCNL to conventional PCNL (HR 0.61, 95% CI 0.32–1.17).Conclusion: This study found 10% fewer patients with SREs in the 18‐month period after PCNL with intraoperative CBCT compared to conventional PCNL. This difference is likely due to the notable increase in stone‐free rates following a single PCNL with intraoperative CBCT.

Background: Percutaneous nephrolithotomy (PCNL) often fails to achieve complete stone clearance with a single procedure. Residual fragments, irrespective of size, are associated with increased stone‐related morbidity and a higher likelihood of re‐intervention. Endoscopic combined intrarenal surgery (ECIRS), which integrates PCNL with retrograde ureterorenoscopy, may improve stone‐free rates and reduce morbidity. However, given the potential for increased risks and greater resource utilisation, a comprehensive randomised controlled trial is warranted. The ‘PRECISE’ trial is designed to compare ECIRS and PCNL in terms of efficacy, safety, stone‐related morbidity, and resource utilisation. Study Design: The PRECISE is a prospective, non‐blinded, randomised, parallel‐group, multicentre interventional trial involving patients eligible for percutaneous kidney stone surgery. Patients will be randomised in a 1:1 ratio to undergo either ECIRS or standard PCNL. Endpoints: The primary endpoint is the Grade A (0 mm) stone‐free rate on postoperative computed tomography (CT) at 4 weeks. Secondary radiological endpoints include Grade B (≤2 mm) and Grade C (≤4 mm) stone‐free rates at 4 weeks, stone volume reduction, 1‐year stone‐free rates, and radiation exposure. Additional outcomes include complications, operative duration, stone‐related events (SREs), health‐related quality of life (HRQoL), cost differences, cost‐effectiveness and environmental impact, assessed up to 5 years postoperatively. Patients and Methods: Adults (aged ≥18 years) eligible for percutaneous kidney stone surgery, where retrograde access is feasible, will be recruited. The main exclusion criteria comprise papillary calcifications, renal transplant procedures, and (suspected) pregnancy. A total of 350 patients (175 per arm) will be recruited. Follow‐up includes CT imaging with clinical consultations at 4 weeks and 1 year to evaluate radiological outcomes, complications, SREs, and HRQoL. Telephone interviews at 3 and 5 years will assess long‐term SREs and HRQoL. We aim to retrospectively evaluate cost differences, cost‐effectiveness, and environmental impact. Trial Registration: The PRECISE study: an investigation into combined kidney stone surgery, Dutch Trial Registry, NL‐009577.

Residual fragments (RFs) after percutaneous nephrolithotomy (PCNL) increase the risk of stone-related events (SREs) such as reinterventions and emergency department (ED) visits. Intraoperative cone-beam computed tomography (CBCT) facilitates detection and removal of RFs to improve stone-free rates and potentially reduce SREs. To determine whether the initial increase in surgical costs for CBCT in a hybrid operating room (OR) is offset by a reduction in overall expenses by minimizing SREs, we compared the total in-hospital health care costs of standard PCNL versus CBCT-PCNL over an 18-mo period. Data from a previous randomized controlled trial including 80 patients undergoing CBCT-PCNL and 80 undergoing conventional PCNL were analyzed. Procedural costs were calculated by multiplying operative duration by the Dutch reference price per minute, and adding disposable costs. Follow-up costs included costs for complications, SREs (reinterventions, ED visits, drainage, admissions), imaging, and consultations during 18 mo. Assuming utilization rates of 42% for a hybrid OR and 92% for a conventional OR and following reference prices, we calculated mean total costs per patient of €8725 for the CBCT group and €8564 for the control group, with a difference of €167. The 40.2% higher procedural costs for hybrid-OR PCNL were nearly offset by 38.3% lower follow-up, complication, and SRE costs. Limitations include the single-center design, incomplete cost standardization, and the exclusion of non-hospital costs such as productivity loss. While PCNL with CBCT in a hybrid OR increases operative costs, it lowers SREs and unplanned care expenses. Even at a significantly lower hybrid OR utilization rate, total health care costs remain comparable, so PCNL-CBCT can facilitate predictable resource use and efficient care, with potential benefits for patients and health care systems. A new technique using CT (computed tomography) scans during surgery may help in more complete extraction of kidney stone fragments. Our study shows that even though this procedure is more expensive, it reduces the need for postoperative appointments, scans, emergency department visits and additional operations.