Cumulative Stone Size Research Articles

Semi-closed-circuit vacuum-assisted mini percutaneous cystolithotomy (vamPCL) in the pediatric population: Initial experience of a novel technique in native and augmented bladders.

Bladder stones (BS) in children are a rare condition and represent 1-5% of all urinary tract stones. With advances in miniaturized endoscopes and intracorporeal lithotripters, percutaneous cystolithotomy has been demonstrated to be an effective, safe and quick technique, despite the longer operative time. This limitation may be overcome by a semi-closed-circuit vacuum-assisted technology (vamPCL), characterized by a continuous inflow and a suction-controlled outflow (ClearPetra®). To assess the safety and efficacy of a vamPCL characterized by continuous inflow and suction-controlled outflow to treat bladder stones in pediatric patients with native or augmented bladder. From January 2021 up to December 2023, we prospectively collected variables on consecutive vamPCL procedures (Fig.) The stone-free rate (SFR) was defined as absence of stones or residual fragment <5mm diagnosed with ultrasound. Six patients with a median age of 139 months (55-212) were recruited for the study. Three patients (50%) with the initial diagnosis of extrophy-epispadia complex had an augmented bladder, whereas of the remaining three (50%) with an initial diagnosis of anorectal malformation two had an augmented bladder. All patients had a Mitrofanoff conduit opening on the right flank, except for one (16%) with umbilical access. The mean cumulative stone size was 24mm±14,2. The mean operating time was 78,3min±14,7. One procedure was interrupted after 90min due to the overall size (>50mm). Stone removal was achieved only via suction in all cases. All vamPCL procedures were completed without intraoperative complications. Fever for 24h (1/6; 16%) was the only post-operative complication. The mean stay of the suprapubic catheter was 3.4 days±1,5 and of the trans-Mitrofanoff catheter was 9.3 days±4,5. The SFR was confirmed in all the cases with US performed after 2 months. Only one male patient (16%) had recurrent stones after 8 months and he is waiting for second surgery. Mean follow-up was 7.2 months±9,4. In the present study we demonstrated that vamPCL is safe and feasible in selected cases especially in those with augmented bladder. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. To our knowledge, this manuscript is the first to present the use of the ClearPetra® for the treatment of bladder stones. The vamPCL seems to be sustainable, safe and feasible for bladder stones treatment in selected children.

Flexible ureteroscopy with and without ureteral access sheath in treatment of large renal stones: a randomized controlled study

BackgroundIn flexible ureteroscopy (FURS), the ureteral access sheath (UAS) is extensively used due to its superior stone-free rates and reduced intrarenal pressure. However, it may cause damage to the ureteral wall and increase surgery costs. Therefore, we aimed to compare the safety and effectiveness of FURS with and without UAS in treating renal stones.MethodsThis randomized controlled trial included 84 patients with upper ureteric and kidney stones undergoing FURS. Patients were randomized into two equal groups: Group I FURS treated with UAS and Group II FURS treated without UAS as a control group.ResultsOperative time was significantly delayed in Group I 69.52 ± 14.52 min as opposed to Group II 63.1 ± 9.69 min (p = 0.019). Cumulative stone size exhibited significantly greater values in Group I than Group II (p value < 0.001). The need for ancillary procedures was significantly higher in Group I than in Group II (p value = 0.047). Preoperative and postoperative stent, complications, renal colic pain, urinary tract infection, and length of stay were insignificantly different among the two groups.ConclusionsPerforming FURS without utilizing UAS appears safe and requires fewer additional procedures. Another benefit is the reduction in surgical duration and avoiding ureteral complications.

Rigid ureteroscopic lithotripsy with a pressure-controlling ureteral access sheath for complex steinstrasse

ObjectiveTo evaluate the safety and efficacy of rigid ureteroscopic lithotripsy with a pressure-controlling ureteral access sheath (PC-UAS) for complex steinstrasse.MethodsThirty-one consecutive patients (male: 18; female: 13) with steinstrasse were enrolled, six of whom had concurrent kidney stones. The mean cumulative stone size was 2.7 ± 1.3 cm. The patients were treated with rigid ureteroscopic lithotripsy using a PC-UAS. The cavity pressure parameters were set as follows: control value at -15 mmHg to -2 mmHg, warning value at 20 mmHg, and limit value at 30 mmHg. The infusion flow rate was set at 150–200 ml/min. A holmium laser (550 μm) was used to powderize the stone at 2.0–2.5 J/pulse with a frequency of 20–30 pulses/s. Analyses included cavity pressure, operative time, stone-free rates, and complications.ResultsAmong the 31 patients, 29 were successfully treated with PC-UAS, with nine requiring adjunctive flexible ureteroscopy for stone migration to the kidney. Two procedures were converted to percutaneous nephrolithotomies due to failure of sheath placement. The cavity pressure of all 29 patients was well-maintained below 20 mmHg, with clear vision. The mean operative time was 48.2 ± 17.7 min. No complications, such as ureteral perforation, mucosal avulsion, or hemorrhage, occurred. Two cases of Clavien-Dindo grade I complications occurred. No major complications (Clavien-Dindo grade II–V) occurred. The mean postoperative hospitalization time was 1.7 days. The stone-free rates 1 day and 1 month after surgery were 93.1% and 96.6%, respectively. One patient with residual stones underwent extracorporeal shockwaves.ConclusionsRigid ureteroscopic lithotripsy with PC-UAS can effectively control the cavity pressure, shorten the operation time, and improve the efficiency of broken stones, thus reducing the complication rate.

A machine learning approach using stone volume to predict stone-free status at ureteroscopy.

To develop a predictive model incorporating stone volume along with other clinical and radiological factors to predict stone-free (SF) status at ureteroscopy (URS). Retrospective analysis of patients undergoing URS for kidney stone disease at our institution from 2012 to 2021. SF status was defined as stone fragments < 2mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments > 2mm at XR KUB or US KUB at 3months follow up. We specifically included all non-SF patients to optimise our algorithm for identifying instances with residual stone burden. SF patients were also randomly sampled over the same time period to ensure a more balanced dataset for ML prediction. Stone volumes were measured using preprocedural CT and combined with 19 other clinical and radiological factors. A bagged trees machine learning model with cross-validation was used for this analysis. 330 patients were included (SF: n = 276, not SF: n = 54, mean age 59.5 ± 16.1years). A fivefold cross validated RUSboosted trees model has an accuracy of 74.5% and AUC of 0.82. The model sensitivity and specificity were 75% and 72.2% respectively. Variable importance analysis identified total stone volume (17.7% of total importance), operation time (14.3%), age (12.9%) and stone composition (10.9%) as important factors in predicting non-SF patients. Single and cumulative stone size which are commonly used in current practice to guide management, only represented 9.4% and 4.7% of total importance, respectively. Machine learning can be used to predict patients that will be SF at the time of URS. Total stone volume appears to be more important than stone size in predicting SF status. Our findings could be used to optimise patient counselling and highlight an increasing role of stone volume to guide endourological practice and future guidelines.

First worldwide report on safety and efficacy of using small 7.5 Fr scope for pediatric ureteroscopy: prospective pilot series from Europe.

Although pediatric urolithiasis remains relatively uncommon, its global prevalence is on the rise. Technological advances have led to miniaturization of instruments especially in the form of single use scopes. As the evidence on the use of small single use ureteroscopes in children is scarce, we have conducted a pilot two-center study to analyze the outcomes of pediatric patients treated with the Pusen 7.5 Fr single use scopes at our institutions. This study included consecutive pediatric patients with urinary stones treated with the small Pusen 7.5 Fr single use ureteroscope. The study was conducted at two large European tertiary endourology centers that specialize in pediatric kidney stone management. Patient data and outcomes were prospectively collected, and analysis was performed regarding patient demographics, stone parameters, as well as stone free rate (SFR), operating time, and complications. In this pilot study, 26 patients were included with a median age of 12 years (7.0-16.0) and a male to female ratio of 14:12. The mean cumulative stone size was 15.15 mm (SD ±11.1) and multiple stones were present in 9 (34.6%) patients. Pre-operative stent, access sheath and post-operative stent usage was done in 12 (46.2%), 23 (88.5%) and 13 (50%) patients respectively. The median operative time was 47 minutes (IQR: 40.0-63.8). Following the initial procedure 24 (92.3%) patients were stone free, while no intra or postoperative complications were observed. Our study demonstrates that the use of the small 7.5 single use ureteroscope is safe and efficient for the treatment of urinary stones in pediatric patients with high stone-free rates and no complications noted in our series. While this might become a standard of care in future, to confirm and validate our findings further studies with larger cohorts are warranted.

Ureteroscopy and lasertripsy with pop dusting using high power holmium laser for large urinary stones > 15mm: 6.5-year prospective outcomes from a high-volume stone center.

Ureteroscopy and stone lasertripsy (URSL) is a recognized technique for treatment of urinary tract stones. Holmium:Yag laser has been successfully used for this purpose for the last two decades. More lately, pulse modulation with Moses technology and high power lasers have been introduced with the result of faster and more efficient stone lasertripsy. Pop dusting is a two-stage combined treatment using a long pulse Ho:YAG laser, initially in contact mode with the stone 'dusting' (0.2-0.5J/40-50Hz) followed by non-contact mode 'pop-dusting' (0.5-0.7J/20-50Hz). We wanted to look at the outcomes of lasertripsy for renal and ureteric stones using a high-power laser machine. Over a period of 6.5years (January 2016-May 2022), we prospectively collected data for patients undergoing URSL for stones larger than 15mm treated using high power Ho:YAG laser (60W Moses or 100W laser). Patient parameters, stone demographics and outcomes of URSL were analyzed. A total of 201 patients, underwent URSL for large urinary stones. In 136 patients (61.6%) stones were multiple and the mean single and cumulative stone size was 18mm and 22.4mm respectively. A pre- and post-operative stent was placed in 92 (41.4%) and 169 (76%) respectively. The initial and final stone free rate (SFR) were 84.5% and 94% respectively and 10% patients underwent additional procedure to achieve stone free status. 7 (3.9%) complications were recorded, all related to UTI/sepsis, with 6 Clavien II and 1 Clavien IVa complication. Dusting and pop-dusting has shown to be successful and safe with the ability to treat large, bilateral or multiple stones with low retreatment and complication rates.

Role of Ureteroscopy (URS) and Stone Treatment in Patients with Recurrent UTIs: Outcomes over a 10-Year Period.

Background. The study aimed to assess whether the eradication of kidney stones might result in a substantial reduction in the onset of recurrent UTIs. Methods. We selected all the patients who underwent ureteroscopy (URS) for stone disease between 2012 and 2021, with either a history of recurrent UTIs (rUTIs), urosepsis or pre-operative positive urine culture (UC). Data included patient demographics, microbiological data, stone parameters, stone-free and infection-free rates (SFR and IFR, respectively) at follow-up, defined as fragments <2 mm at imaging and the absence of symptoms and urine-culture-proven UTI. Results. Overall, 178 patients were selected. The median age was 62 years. The median cumulative stone size was 10 mm (7-17.25), and the commonest locations were the lower pole (18.9%) and proximal ureter (14.9%). The overall stone-free rate at follow-up was 89.3%. The IFR at 3 months was 88.3%. As follow-up duration increased, the IFR reduced to 85.4%, 74.2%, 68% and 65% at 6, 12, 18 and 24 months, respectively. Patients who had infection recurrence were more likely to present stone persistence or recurrence compared to those who were infection-free at follow-up (20% vs. 4.4%, p = 0.005). Conclusions. SFR after URS is a significant predicting variable for the likelihood of infection-free status at follow-up in patients with an rUTI or positive UC at the time of URS.

MP16-08 DISTINGUISHING CHARACTERISTICS OF CHILDREN WITH PRIMARY HYPEROXALURIA TYPE 1 IN PEDSNET

You have accessJournal of UrologyCME1 Apr 2023MP16-08 DISTINGUISHING CHARACTERISTICS OF CHILDREN WITH PRIMARY HYPEROXALURIA TYPE 1 IN PEDSNET Gregory Tasian, Kimberley Dickinson, Julia Schuchard, Grace Park, Nicole Marchesani, Akanksha Mittal, Nathan Cheng, Christina Ching, David Chu, Ryan Walton, Karyn Yonekawa, Caroline Gluck, Kathleen Kan, William DeFoor, Kyle Rove, and Christopher Forrest Gregory TasianGregory Tasian More articles by this author , Kimberley DickinsonKimberley Dickinson More articles by this author , Julia SchuchardJulia Schuchard More articles by this author , Grace ParkGrace Park More articles by this author , Nicole MarchesaniNicole Marchesani More articles by this author , Akanksha MittalAkanksha Mittal More articles by this author , Nathan ChengNathan Cheng More articles by this author , Christina ChingChristina Ching More articles by this author , David ChuDavid Chu More articles by this author , Ryan WaltonRyan Walton More articles by this author , Karyn YonekawaKaryn Yonekawa More articles by this author , Caroline GluckCaroline Gluck More articles by this author , Kathleen KanKathleen Kan More articles by this author , William DeFoorWilliam DeFoor More articles by this author , Kyle RoveKyle Rove More articles by this author , and Christopher ForrestChristopher Forrest More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003236.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Primary hyperoxaluria type 1 (PH1) is an ultra-rare disorder of hepatic overproduction of oxalate that causes early onset kidney stones, chronic kidney disease, and systemic oxalosis. We sought to identify defining clinical characteristics of children with PH1 in order to develop approaches that facilitate its early diagnosis. METHODS: We determined the association between patient-level characteristics of PH1 in a case-control study conducted between January 2009 and August 2021 in PEDSnet, a clinical research network of eight pediatric health systems in the United States. We matched each patient with confirmed PH1 to 4 control patients with kidney stone disease not due to PH1 by sex and PEDSnet site at date of diagnosis (cohort entrance date). We obtained patient characteristics and diagnostic test results occurring before to less than 6 months after cohort entrace from a centralized query of the data pooled from the electronic health records and from manual chart review at each PEDSnet site. Differences in patient characteristics and diagnostic test results between patients were compared using paired tests as appropriate for the distribution of and type of data. RESULTS: The study sample included 37 patients with PH1 and 147 controls. Compared to patients with kidney stone disease not due to PH1, patients with PH1 were younger, were less likely to have immobility, had a higher percentage of stone comprised of calcium oxalate monohydrate, and had a lower eGFR measured within 6 months of cohort entrance (Table 1). There were no statistically significant differences in prevalent diagnosis of failure to thrive, cumulative stone size on ultrasound, nephrocalcinosis on ultrasound or CT, or echocardiography results. CONCLUSIONS: In this study, children with PH1 were characterized by presentation before adolescence, absence of immobility, high percentage of calcium oxalate monohydrate stone composition, and decreased eGFR at diagnosis. If validated in external populations, these consortium of characteristics may enable a strong clinical suspicion for PH1 diagnosis, facilitating confirmatory testing, and facilitating initation of targeted therapeutics. Source of Funding: Alnylam Pharmaceuticals © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e205 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Tasian More articles by this author Kimberley Dickinson More articles by this author Julia Schuchard More articles by this author Grace Park More articles by this author Nicole Marchesani More articles by this author Akanksha Mittal More articles by this author Nathan Cheng More articles by this author Christina Ching More articles by this author David Chu More articles by this author Ryan Walton More articles by this author Karyn Yonekawa More articles by this author Caroline Gluck More articles by this author Kathleen Kan More articles by this author William DeFoor More articles by this author Kyle Rove More articles by this author Christopher Forrest More articles by this author Expand All Advertisement PDF downloadLoading ...

Prospective Comparison of Thulium and Holmium Laser Lithotripsy for the Treatment of Upper Urinary Tract Lithiasis

BackgroundLithotripsy with holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the current gold standard for treating stones of the upper urinary tract (UUT). The recently introduced thulium fiber laser (TFL) has the potential to be more efficient and as safe as Ho:YAG. ObjectiveTo compare the performance and complications between Ho:YAG and TFL for UUT lithotripsy. Design, setting, and participantsThis was a prospective single-center study of 182 patients treated between February 2021 and February 2022. In a consecutive approach, laser lithotripsy was performed via ureteroscopy with Ho:YAG for 5 mo, and then with TFL for 5 mo. Outcome measurements and statistical analysisOur primary outcome was stone-free (SF) status at 3 mo after ureteroscopy with Ho:YAG versus TFL lithotripsy. Secondary outcomes were complication rates and results regarding the cumulative stone size. Patients were followed at 3 mo with abdominal imaging (ultrasound or computed tomography). Results and limitationsThe study cohort comprised 76 patients treated with Ho:YAG laser and 100 patients treated with TFL. Cumulative stone size was significantly higher in the TFL than in the Ho:YAG group (20.4 vs 14.8 mm; p = 0.01). SF status was similar in both groups (68.4% vs 72%; p = 0.06). Complication rates were comparable. In subgroup analysis, the SF rate was significantly higher (81.6% vs 62.5%; p = 0.04) and the operative time was shorter for stones measuring 1–2 cm, whereas the results were similar for stones <1 cm and >2 cm. The lack of randomization and single-center design are the main limitations of the study. ConclusionsTFL and Ho:YAG lithotripsy are comparable in terms of the SF rate and safety for the treatment of UUT lithiasis. According to our study, for a cumulative stone size of 1–2 cm, TFL is more effective than Ho:YAG. Patient summaryWe compared the efficiency and safety of two laser types for the treatment of stones in the upper urinary tract. We found that stone-free status at 3 months did not significantly differ between the holmium and thulium lasers.

Non-Papillary Access for the Percutaneous Antegrade Treatment of Renal and Ureteral Stones

ObjectiveTo evaluate the feasibility and success of medial non-papillary percutaneous access for the antegrade treatment of different locations of ureteral stones, with and without concomitant renal stones. MethodsWe performed an analysis of prospectively collected data of 72 patients, being subjected to percutaneous antegrade ureterolithotripsy. Stones located anywhere in the ureter with or without concomitant renal stones were included. A 12Fr, 22Fr, or 30Fr percutaneous tract dilation was performed based on the size of the stone pelvicalyceal system. Perioperative and demographic parameters were gathered and evaluated. The Lithoclast Trilogy (EMS Medical, Nyon, Switzerland) High-power holmium laser devices Cyber Ho 150 (Quanta System, Samarate, Italy) or MOSES Pulse 120H (Lumenis Ltd, Yokneam, Israel) were used for lithotripsy. ResultsThe average age and cumulative stone size of the patients were 57.9 ± 27.1 years and 24.2 ± 5.4 mm, respectively. The mean manipulation time was 36.9 ± 14.8 minutes. The mean hospitalization time was 2.5 ± 0.5 days and the average hemoglobin loss was 1.02 ± 0.18 gr/dL. The stone-free rate after percutaneous antegrade ureterolithotripsy was 95.8 % (69 patients), while the overall complications rate was 5.6 %, with 3 cases of fever and one case of prolonged hematuria that were treated conservatively. ConclusionNon-papillary percutaneous antegrade ureterolithotripsy is a safe and reliable technique for the treatment of patients with ureteral stones, with or without the co-existence of renal stones. A high stone-free rate of 95.8% was reported at 1-month after the surgery carrying a weighted risk of developing postoperative complications.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PurposeProlonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation.MethodsA retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times.ResultsCompared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03–23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95–23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89–27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year.ConclusionsTFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

A multi-institutional experience of Micro-percutaneous Nephrolithotomy (MicroPERC) for renal stones: Results and feasibility of day case surgery.

To report the multi-institutional outcomes of Microperc for nephrolithiasis and to assess its feasibility in outpatient care. We retrospectively identified all adult patients who underwent Microperc for renal stones at three centres between May 2015 and March 2021. Interventions were performed by three Surgeons. One Surgeon adopted a "one-way" strategy and all Microperc were performed on an outpatient basis, while the other two Surgeons provided inpatient monitoring for at least one day after surgery. The primary endpoint was same-day discharge after Microperc without emergency department visits or unplanned readmission within 30 days of the procedure. The secondary endpoints included treatment outcomes and the 30-day complication rate. Out of 72 consecutive patients included, 32 patients (44.4%) had same-day discharge. Median Charlson score (1 [0-2]) and cumulative stone size (15 [12-20] mm) were comparable between both groups. At one month post procedure, 32 patients (44.4%) were stone free and 23 patients (32%) had residual micro-fragments<3mm, conferring an overall success rate of 76.4% (inpatient Microperc group: 77.5% vs outpatient Microperc group: 75%, P=1). Analysis of the 30-day complication rate showed similar results between the two groups (Clavien I-II: 18.1%, Clavien≥III: 4.1%). After outpatient care, the rate of immediate admission and unplanned readmission was 12.5% (n=4), mainly due to urinary tract infection. In this multi-institutional study, we report that outpatient Microperc is feasible in selected patients with no significant impact on postoperative outcome.

Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in the pediatric population: the initial experience of two tertiary referral centers.

Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study was to assess the safety and feasibility of semi-closed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients. From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra® (Well Lead Medical Co., Ltd., Guangzhou, China) access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~120-150 cmH<inf>2</inf>O) by a 200 Ml plastic stone collector. Pre-, intra- and postoperative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments >4 mm with either ultrasound or kidney, ureter, and bladder X-ray. Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Postoperative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €). The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Clinical Impact of the Institution of Moses Technology on Efficiency During Retrograde Ureteroscopy for Stone Disease: Single-Center Experience.

Objective: To evaluate the clinical benefits of Moses technology compared with the regular mode with the Lumenis® Pulse™ P120H holmium laser during ureteroscopy for stone disease. Patients and Methods: An IRB-approved database of patients with urolithiasis was analyzed for ureteroscopies from January 2020 to December 2020 at an outpatient surgery center. Patients who underwent ureteroscopy with the Lumenis Pulse P120H holmium laser system with the Moses or regular mode were included. Patient characteristics and stone parameters were collected. Operative room parameters were compared, including procedural time, fragmentation/dusting time, lasing time, and total energy used. Complication rates and stone-free rates were also analyzed. Univariate analysis and multiple analysis of covariance controlling for cumulative stone size were performed. Patients with staged procedures were excluded. Results: Of 197 surgical cases, 176 met the inclusion criteria. Moses was utilized in 110 cases and regular mode in 66. There was no difference in cumulative stone size between Moses and regular modes (11.8 ± 7.9 vs 11.6 ± 9.2 mm, p = 0.901). Procedural time (43.5 ± 32.1 vs 39.8 ± 24.6 minutes, p = 0.436), fragmentation/dusting time (20.5 ± 25.3 vs 17.1 ± 16.1 minutes, p = 0.430), lasing time (7.5 ± 11.1 vs 6.7 ± 7.9 minutes, p = 0.570), and total energy used (5.1 ± 6.7 vs 3.8 ± 4.8 kJ, p = 0.093) were also similar. Complications (6.4% vs 6.1%, p = 0.936) and stone-free rates (52.3% vs 65.3%, p = 0.143) did not differ. Conclusion: At our institution, Moses technology did not significantly change the procedural time, fragmentation/dusting time, lasing time, or total energy used. Moreover, there were no differences in complications or stone-free rates. There may be technical benefits to the Moses technology not captured in this analysis.

Doppler-Assessed Ureteric Jet Frequency: A Valuable Predictor of Ureteric Obstruction.

Objectives: To compare ureterovesical jet frequency in non-obstructed versus obstructed ureter secondary to ureteric stone using ultrasonography in patients presenting with ureteral stones.Study design: Cross-sectional prospective study.Place of study and duration: Urology Department, The Kidney Centre Post Graduate Training Institute from May 16 to November 15, 2019.Methods: This study included 97 patients having presented in the emergency department with acute renal colic and were diagnosed as having ureteral stones on a non-contrast-enhanced computed tomography (NCCT). The ureteric jet frequency was measured by Doppler ultrasonography by our radiologist with the Hitachi Aloka F-37 ultrasound machine after they underwent CT. Patients were asked to drink 750-1000 ml of liquids 15-20 minutes before their ultrasonographic examination of both kidneys, ureters, and urinary bladder. The kidney size (length and width) and presence/absence of hydronephrosis were evaluated by grayscale ultrasound. Then, with the help of color Doppler ultrasonography, the frequency of the ureteric jet was recorded.Results: The patient's mean age was 46.66 ± 3.21 years ranging from 37 to 56 years. There were 58 (59.8%) male and 39 (40.2%) female cases. The mean cumulative stone size was 9.77 ± 2.65 mm. According to stone location, 44 (45.4%) cases had upper ureteric, 24 (24.7%) cases had mid ureteric, and 29 (29.9%) cases had lower ureteric stone. The mean obstructive side jet frequency was 0.70/min ± 0.49, and the non-obstructive side jet frequency was 2.89/min ± 1.29 (P < 0.05).Conclusions: The mean obstructive side jet frequency was 0.70 ± 0.49/min, which, if we compare to the non-obstructed normal ureter, is significantly less. Hence, color Doppler ultrasonography can be helpful to patients who were previously diagnosed with ureteral stones on NCCT to see if their stone has passed. This can be a very cost-effective modality especially in resource-poor countries where repeat CT can be very expensive. The results from this study can also be used in a specific population (i.e., pregnancy) where the use of imaging modalities that involve ionizing radiation is prohibited.

MP10-16 DOES THE USE OF MOSES TECHNOLOGY INCREASE EFFICIENCY DURING FLEXIBLE URETEROSCOPY FOR STONE DISEASE? SINGLE CENTER EXPERIENCE

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I (MP10)1 Sep 2021MP10-16 DOES THE USE OF MOSES TECHNOLOGY INCREASE EFFICIENCY DURING FLEXIBLE URETEROSCOPY FOR STONE DISEASE? SINGLE CENTER EXPERIENCE Margaret Knoedler, Shuang Li, Sara Best, Sean Hedican, Kristina Penniston, and Stephen Nakada Margaret Knoedler Margaret Knoedler More articles by this author , Shuang LiShuang Li More articles by this author , Sara BestSara Best More articles by this author , Sean HedicanSean Hedican More articles by this author , Kristina PennistonKristina Penniston More articles by this author , and Stephen NakadaStephen Nakada More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001983.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The objective of this study was to evaluate the efficiency of Moses technology compared to the regular mode during flexible ureteroscopy for stone disease. Moses technology has been shown to improve stone fragmentation both in vitro and in vivo, but it is unclear if this translates into improved efficiency in the operating room. METHODS: An IRB approved database of patients with upper tract stones was analyzed for ureteroscopies from January 1, 2020 to December 31, 2020. Patients who underwent flexible ureteroscopy with the Lumenis Pulse P120H holmium laser system with the regular or Moses mode were included. Patient characteristics including age, gender, BMI, diabetes, hypertension, gout, chronic urinary tract infection, chronic kidney disease, bowel disease and cumulative stone size were evaluated. Outcome measures included procedural time, laser time, total energy used, laser efficiency (laser time per stone size), complication rate and stone free rate. Univariate analysis with chi squared and MANCOVA controlling for cumulative stone size and comorbidities were performed. Patients were excluded if they had a staged procedure. RESULTS: Of the 200 surgical cases, 184 met the inclusion criteria. Moses was utilized in 114 cases and the regular mode in 70 cases. There was no difference in the cumulative stone size between the Moses and regular mode (11.6±7.4 vs 10.5±8.4 mm, p=0.314). Procedural time (44.5±33.6 vs 38.5±23.8 min, p=0.282), laser time (7.3±11 vs 6.6±8.2 min, p=0.927), total energy used (4.9±6.7 vs 3.7±4.9 kJ, p=0.373), and laser efficiency (4.7±6.5 vs 5.5±9.8 mm/min, p=0.501) were also similar between the two groups. Complications (6.1% vs 5.7%, p=0.906) and stone free rates (67.4% vs 70.4%, p=0.712) did not differ between the two. CONCLUSIONS: At our institution, Moses technology did not demonstrate a significant change in procedural time, laser time, total energy used or laser efficiency. Moreover, there was no difference in complications or stone free rate. There may be other technical benefits to Moses technology not captured in this analysis. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e174-e174 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Margaret Knoedler More articles by this author Shuang Li More articles by this author Sara Best More articles by this author Sean Hedican More articles by this author Kristina Penniston More articles by this author Stephen Nakada More articles by this author Expand All Advertisement Loading ...

MP18-13 ENDOUROLOGY FOR STONES DURING COVID-19

INTRODUCTION AND OBJECTIVE: Guidelines for endourological procedures during COVID-19 have suggested to defer nonobstructed stones, while obstructed/ infected stones should be considered emergencies.1,2 In our centre, screening protocols (as per Ministry of Health's guidelines)3 were implemented with prioritization strategies so that elective care could safely continue, albeit at deescalated rates. COVID or septic patients underwent decompression with stent or nephrostomy insertion, while non-COVID and non-septic patients underwent primary ureteroscopy (URS) or retrograde intrarenal surgery (RIRS). All interventions were done only by consultants, and surgical precautions such as donning of personal protective equipment were undertaken.4 We aim to report the outcomes of endourological surgery for stone disease in our centre during COVID. METHODS: We conducted a prospective review of all endourological surgeries for stones in our centre between 23 Jan and 31 Aug 2020, when all non-necessary surgeries were deferred. RESULTS: 201 surgeries were performed on 159 patients (93 emergencies, 108 electives)- 36 (17.9%) stent insertions, 116 (57.7%) URS and 49 (24.4%) RIRS. 34 patients were females and 125 males. Median age of patients was 50, with 37% ≥ 60. 31 patients were ASA ≥ 3. None were COVID positive. Mean single stone size was 8.17 mm (1-38) and cumulative stone size was 10.63 mm(1-84). 44 patients had multiple stones. The index stone location was proximal ureter in 111 (55.2%), mid ureter 19 (9.45%), distal ureter 67 (33.3%), renal 4 (1.99%). 55 (27.4%) procedures were carried out due to previously stented stones, 10 (4.98%) bilateral obstruction/ single kidney, 77 (38.3%) failed MET/ persistently symptomatic stone, 16 (7.96%) intractable colic, 14 (6.96%) AKI, and 20 (9.95%) sepsis. 166 (66.6%) patients had stent inserted post operatively- 15 with threads that precluded the need for scope guided removal. 27 (10.8%) had a ureteric catheter that was removed prior to discharge. The overall stone free rate was 97.4%;95 (59.7%) were stone free with 1 procedure. 60 (37.7%) required staged procedures. An average of 1.41 procedures/ patient was needed to be stone free. 2 (0.99%) patients had Clavien Dindo Grade III complications. 9 (4.48%) were readmitted- 7 for UTI and 1 for stent symptoms. Median length of stay was 2 days (0- 43). CONCLUSIONS: Our centre demonstrated favourable outcomes in patients undergoing endourological surgery for stone diseases during COVID by following strict screening protocols and surgical precautions. The results support the continuation of endourological surgery with the proposed framework in regions with similar COVID trends.

Safety and Outcomes of using ureteric access sheath (UAS) for treatment of Pediatric renal stones: Outcomes from 2 tertiary endourology centers

ObjectiveTo look at the safety and outcomes of using ureteral access sheath (UAS) for pediatric renal stones. The use of UAS is variable in urological practice with very little clinical work on their use in pediatric kidney stone disease. Patients and MethodsData was retrospectively collected from 2 large European tertiary endourology centers for all pediatric patients (≤16 years) with renal stones who underwent flexible ureteroscopy and lasertripsy (FURSL) via UAS. Data was collected on patient details, stone demographics and clinical outcomes of the FURSL procedure. ResultsForty-eight patients with a mean age of 10.7 years were treated with FURSL for a mean single and cumulative stone size of 10.4 mm and 15 mm respectively, with two-third having multiple stones and stones in the lower pole. The initial and final stone free rate (SFR) was 66.7% and 100% respectively with 1.3 procedures/patient. One patient each had intra-operative grade 1 ureteric injury and post-operative UTI, with no other injuries or complications noted. Over a mean follow-up of 17 months, no other complications were noted. ConclusionUreteral access sheath is safe for treatment of pediatric renal stones with excellent outcomes and are especially useful for larger or multiple stones. While there does not seem to be any medium-term sequalae, to avoid risk of ureteral injury, we would suggest using the smallest size sheath possible. We would argue these procedures are best done in specialist high-volume endourology units for optimal results.

Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in the pediatric population: the initial experience of two tertiary referral centers

Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study was to assess the safety and feasibility of semi-closed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients. From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra® (Well Lead Medical Co., Ltd., Guangzhou, China) access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~120-150 cmH<inf>2</inf>O) by a 200 Ml plastic stone collector. Pre-, intra- and postoperative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments >4 mm with either ultrasound or kidney, ureter, and bladder X-ray. Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Postoperative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €). The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Non papillary mini-percutaneous nephrolithotomy: early experience.

This study aims to evaluate the non-papillary puncture for mini-PCNL in terms of safety and efficacy. A total number of 32 patients were subjected to mini-PCNL by the performance of non-papillary punctures over 6months. One-step track dilation to 22 Fr took place in all cases. An 18 Fr nephroscope (Slender, Karl Storz GmbH, Germany) and an ultrasound lithotripter (Lithoclast Master, EMS S.A, Switzerland) with 9.9 Fr probe was used. Demographics and perioperative data are prospectively collected from an institutional board-approved database and the presented data were retrospectively collected. The average cumulative stone size was 23.53 ± 6.6mm. Mean operative time was 44.6 ± 13.44min and primary stone-free rate after PCNL was 96% and 85.7% for single and multiple access, respectively. Second access was performed in seven cases, all of which had multiple stones. Mean hemoglobin drop was 1.23 ± 0.88gr/dL. The patients stayed 2.56 ± 0.98days in the hospital. Overall complication rate was 9.37%, without encountering any severe bleeding complication. Using non-papillary access for mini-PCNL did not result in significant blood loss and need for transfusions. The respective data were directly comparable to contemporary literature and the safety of mini-PCNL by a non-papillary approach could be advocated.