Stone Extraction Research Articles

Optimizing stone harvesting in miniaturized-PCNL: a critical examination of renal access angles, technology, and the role they play in operative efficiency.

Stone retrieval can be a laborious aspect of percutaneous nephrolithotomy (PCNL). A unique phenomenon of mini-PCNL is the vortex-effect (VE), a hydrodynamic form of stone retrieval. Additionally, the vacuum-assisted sheath (VAS) was recently developed as a new tool for stone extraction. The purpose of our study is to investigate the impact of renal access angle (as a surrogate for patient positioning) on stone retrieval efficiency and compare the efficiency among methods of stone retrieval. A kidney model was filled with 3mm artificial stones. Access to the mid-calyx was obtained using a 15Fr sheath. Stones were retrieved over three minutes at angles of 0°, 25°, and 75° utilizing the VE, VAS, and basket. Stones were weighed for comparison of stones/retraction and stones/minute. Trials were repeated three times at each angle. Renal access angle of 0° was associated with increased stone retrieval for both the VE and VAS (p < 0.05). The VE was the most effective method for stones retrieved per individual retraction at an angle of 0° (p < 0.005), although when analyzed as stones retrieved per minute, the VE and VAS were no longer statistically different (p = 0.08). At 75°, none of the methods were statistically different, regardless if analyzed as stones per retraction or per minute (p = 0.20-0.40). Renal access angle of 0° is more efficient for stone retrieval than a steep upward angle. There is no difference in stone retrieval efficiency between the VE and VAS methods, although both are superior to the basket at lower sheath angles.

High-volume post-obstructive choleresis (biliary hyperproduction) with acute kidney injury after choledochotomy, gallstones extraction, and T-tube drainage, successfully treated with octreotide

Only several cases of postprocedural choleresis (biliary hyperproduction) were reported, and guidance on management is scarce, although an application of octreotide was anecdotally described. We herein present a rare post-obstructive choleresis complicated with acute kidney injury due to dehydration, successfully treated with an off-label application of octreotide. A 58-year-old female, following cholecystectomy and choledochotomy with numerous stones extraction, developed excessive bile loss via a T-tube complicated with acute kidney injury. Despite aggressive fluid replacement, the patient continued to deteriorate, prompting a trial of subcutaneous octreotide 0.1 mg three times per day over five days. Therapy yielded a rapid decline in bile production with improved diuresis and normalizing kidney function. The patient was discharged with a ligated T-tube, which we removed a month later. The followup was unremarkable, with normalized laboratory findings and symptom-free. Early use of octreotide could help resolve complicated biliary hyperproduction; however, further research is required to determine the risks and benefits of such an approach.

Advanced skills for general surgeons and carving out a niche: Endoscopic retrograde cholangiopancreatography in regional Australia.

The provision of high-quality healthcare in rural Australian hospitals has necessitated general surgeons to take up the challenge and expand their expertise to advanced endoscopy techniques including endoscopic retrograde cholangiopancreatography (ERCP). This study examines the utility of ERCP in a regional setting especially in decreasing patient transfers and associated costs while achieving exceptional safety by measuring key indicators of safety and efficacy. A single-centre retrospective cross-sectional cohort review in a rural Queensland hospital of patients who underwent ERCP (emergent and elective) from January 2019 until July 2022. Standardized international ERCP performance indicators were collected and compared to benchmark literature values including the rate of cannulation, stone extraction, successful stent placement, and post-ERCP pancreatitis. The majority of the ERCP performance indicator benchmarks were met. 100% of patients had an appropriate indication for the procedure and consent. 98.95% successful CBD cannulation with only 14.14% requiring multiple attempts. 92.22% successful stone retrieval with 100% stent placement, well above guideline targets. The post-procedural complication rate was 6.81% (2.09% pancreatitis; 1.05% pancreatitis; 1.05% duodenal perforation). Antibiotic prophylaxis adherence was identified to require improvement (12.57%). High-quality ERCP procedures can be performed in a regional hospital by general surgeons in a safe and cost-effective manner, significantly decreasing the costs associated with patient transfer. This study reflects strong evidence for consistently achieving international ERCP performance benchmarks and the provision of high-quality healthcare by a regional hospital and provides a strong argument for increasing access to ERCP in rural and remote hospitals.

Cohort analysis of relevant factors for negative emotions during the perioperative period in choledocholithiasis patients treated with ERCP and the impact on prognosis.

Endoscopic retrograde cholangiopancreatography (ERCP) is an emerging option in the management of common bile duct stones and has a high success rate for biliary stone extraction. However, due to the lack of knowledge and understanding of this technique, some patients often experience varying degrees of anxiety and depression. There is little research on the factors associated with negative emotions. This study aimed to investigate the risk factors for negative emotions in choledocholithiasis patients treated with ERCP and the impact on prognosis to provide a reference for improving patients' prognosis. We analyzed the data of 364 patients with choledocholithiasis treated with ERCP at our hospital between July 2019 and June 2022. Patients' emotional state was assessed using the SAS and SDS scales. The t-test and chi-square test were used to analyze the relationship between patients' negative emotions and prognosis. The patient's prognosis was assessed at one month postoperatively using the SF-36 scale. Binary logistic regression and multiple linear regression were used to analyze the independent risk factors for negative emotions and prognosis in patients. In this study, the prevalence of anxiety was 10.4%, the prevalence of depression was 8.8% and the prevalence of negative emotions was 15.4%. Binary logistic regression analysis showed that gender [odds ratio (OR) =0.379, P=0.023], fertility status (OR =0.164, P=0.032), monthly household income (OR =0.180, P=0.001) and so on were independent risk factors for the anxiety. Fertility status (OR =0.173, P=0.038), marital status (OR =0.210, P=0.043), TBIL on the first postoperative day (OR =1.079, P=0.002) and so on were independent risk factors for depression. Multiple linear regression analysis revealed that the presence of negative emotions (P=0.001) was an important risk factor for prognosis. Patients with choledocholithiasis treated with ERCP are prone to anxiety, depression and other psychological disorders. Therefore, clinical work should not only focus on the patient's condition, but also pay attention to the patient's family situation and emotional changes, and give timely psychological counselling and prevent complications, reduce the patient's suffering and improve the patient's prognosis.

Single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy: a technical review.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy is technically challenging. For example, scope insertion, selective cannulation, and intended procedures, such as stone extraction or stent placement, can be difficult. Single-balloon enteroscopy (SBE)-assisted ERCP has been used to effectively and safely address these technical issues in clinical practice. However, the small working channel limits its therapeutic potential. To address this shortcoming, a short-type SBE (short SBE) with a working length of 152 cm and a channel of 3.2 mm diameter has recently been introduced. Short SBE facilitates the use of larger accessories to complete certain procedures, such as stone extraction or self-expandable metallic stent placement. Despite the development in the SBE endoscope, various steps have to be overcome to successfully perform such procedure. To improve success, the challenging factors of each procedure must be identified. At the same time, endoscopists need to be mindful of adverse events, such as perforation, which can arise due to adhesions specific to the surgically altered anatomy. This review discussed technical tips regarding SBE-assisted ERCP in patients with surgically altered anatomy to increase success and reduce the risk of adverse events associated with ERCP.

Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones.

Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones. Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated. The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 (P=0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant. FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.

Ureteropelvic junction obstruction and renal calculi: Simultaneous treatment by robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy. Technique description and early outcomes.

Ureteropelvic junction obstruction (UPJO) and renal calculi are associated in 20 to 30% of cases and treatment is mandatory. The simultaneous surgical management is a therapeutic challenge that is still a source of controversy. We describe our technique combining robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy (fURS), assessing the feasibility of simultaneous treatment through an original technique. This single centre series reports our initial experience with 12 patients. From January 2014 to September 2018, 12 patients underwent robot-assisted laparoscopic pyeloplasty with simultaneous fURS for UPJO and renal calculi. Mean age was 46 years (24-68). 92% had multiple renal stones and the mean cumulative stone diameter was 31,3mm. Robot-assisted pyeloplasty was performed with peroperative transcutaneous retrograde fURS through a ureteral access sheath introduced in an incision on the bassinet through a subcostal trocar. Stone extraction was performed using a basket. All patients underwent surgery successfully, achieving UPJ repair and complete stone extraction. Mean operating time was 92,5min (85-110). All reported Clavien-Dindo complications were grade 1. Non-contrast enhanced abdominal CT performed 1 month after surgery confirmed the absence of residual stones in all patients. Mean follow-up time was 10 months with no recurrence of UPJO. This small series confirms the feasibility with good surgical results of concomitant robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde fURS stone extraction. No major complications were observed. This technique is easily reproducible but requires 2 experienced urologists to be achieved in a contained operative time.

Gallbladder perforation following peroral cholangioscopy‐guided lithotripsy: A case report

Peroral cholangioscopy-guided lithotripsy is highly effective in clearing difficult bile duct stones. It can cause adverse events, such as cholangitis and pancreatitis; however, gallbladder perforation is extremely rare. Herein, we describe the case of a 77-year-old woman who developed gallbladder perforation following peroral cholangioscopy -guided lithotripsy. She was referred to our hospital to treat multiple large bile duct stones. She underwent peroral cholangioscopy-guided lithotripsy because of conventional lithotripsy failure. After a cholangioscope was advanced into the bile duct, saline irrigation was used for visualization. Electronic hydraulic lithotripsy was performed, but it took time for fragmentation because the calculus was hard. The 2-h endoscopic procedure did not completely remove the stone, and treatment was discontinued after placing a biliary plastic stent and nasobiliary tube. After the endoscopic procedure, she started experiencing right hypochondrial pain, which worsened the next day. Computed tomography showed a gallbladder wall defect in the gallbladder fundus with pericholecystic fluid. She was diagnosed with gallbladder perforation and underwent emergency surgery. A perforation site was found at the gallbladder fundus. Open cholecystectomy, choledochotomy, and extraction of residual bile duct stones were performed. The patient was discharged 9 days post-surgery without any complications. The saline irrigation used for visualization may have caused a surge in intra-gallbladder pressure, resulting in gallbladder perforation. Therefore, endoscopists may need to conserve irrigation water during peroral cholangioscopy-guided lithotripsy.

PD45-07 THULIUM FIBRE VERSUS MOSES LASER LITHOTRIPSY FOR RETROGRADE INTRARENAL SURGERY: IS THERE A CLEAR WINNER? OUTCOMES FROM THE FLEXOR STUDY

You have accessJournal of UrologyCME1 Apr 2023PD45-07 THULIUM FIBRE VERSUS MOSES LASER LITHOTRIPSY FOR RETROGRADE INTRARENAL SURGERY: IS THERE A CLEAR WINNER? OUTCOMES FROM THE FLEXOR STUDY Ee Jean Lim, Khi Yung Fong, Danielle Castellani, Olivier Traxer, Bhaskar Kumar Somani, Ben Chew, and Vineet Gauhar Ee Jean LimEe Jean Lim More articles by this author , Khi Yung FongKhi Yung Fong More articles by this author , Danielle CastellaniDanielle Castellani More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Bhaskar Kumar SomaniBhaskar Kumar Somani More articles by this author , Ben ChewBen Chew More articles by this author , and Vineet GauharVineet Gauhar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003358.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Currently two technologies, super pulsed thulium fibre laser (TFL) and the Moses laser using the holmium fibre (HLM) are most effective for lithotripsy by flexible ureteroscopy(f-URS) for renal stones. The primary aim of our study is to compare and contrast the outcomes of these two laser technologies in our cohort of 2075 patients enrolled in the FLEXible ureteroscopy Outcomes Registry (FLEXOR) project .Our secondary aim is to evaluate if either technology was superior in stone free rate(SFR) and complications. METHODS: Patients who underwent f-URS for renal stones between January 2018 and August 2021 were retrospectively analysed. Patients aged<18 years, ureteral stones, concomitant bilateral procedures, or musculoskeletal abnormalities were excluded .Kolmogorov-Smirnov test was used to check data distribution for normality. Continuous data presented as mean and standard deviation and categorical data as absolute numbers and percentages. Analyses repeated after propensity score matching (PSM) to adjust for bias. One-to- one matching for age, gender, stone location, single/multiple stone, and HU estimated. Univariate logistic regression analysis was performed to evaluate factors for SFR from PSM population. Multivariable assessment done and estimated as odds ratio (OR) and 95% confidence interval (CI), and p-value. RESULTS: Before PSM matching, there were 508 patients in the HLM and 1567 in the TFL groups. The population in the TFL group were significantly younger (mean age 46.44±14.01 years), larger stone diameter (14.35±7.37 mm p<0.001), single stones (65.6% vs 42.5%, p<0.001) and stones located in the pelvis (46.4% vs 17.1%, p<0.001).Mean stone density was significantly higher in HLM group (1115±386 vs 1068±331 HU, p=0.016). Mean lasing time was significantly longer with HLM (29.40±14.25 vs 20.90±16.47 minutes, p=0.01) and longer total surgical time in TFL (73.41±51.14 vs 61.03±29.47 minutes, p<0.001).TFL group experienced more infective complications. SFR was significantly higher in the TFL group (89.9% vs 61.6%, p<0.001). There were 297 patients in each group after PSM matching. Pure dusting was performed in 5.7% of the HLM group compared with 28.8% in TFL group. A larger proportion of patients required stone extraction in the HLM group compared to the TFL group. (89.2% vs 40.5%, p<0.001). Lasing time did not differ significantly. Total operation time was significantly longer in the TFL group (74.75±51.38 vs 62.42±29.98 minutes, p<0.001). There were 11 patients who had sepsis in the TFL group and none in the HLM group (p=0.002). SFR was significantly higher with TFL (84.8% vs 56.6%, p<0.001). CONCLUSIONS: In our global study TFL was the winner with significantly higher SFR and a better laser for treating renal stones by dusting especially in larger stones A higher rate of sepsis cautions its careful use. MOSES laser lithotripsy is equally effective for fragmentation and extraction but need for ancillary treatment for RF was higher and urologists should counsel patients accordingly. Source of Funding: NIL © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1165 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ee Jean Lim More articles by this author Khi Yung Fong More articles by this author Danielle Castellani More articles by this author Olivier Traxer More articles by this author Bhaskar Kumar Somani More articles by this author Ben Chew More articles by this author Vineet Gauhar More articles by this author Expand All Advertisement PDF downloadLoading ...

MP75-15 ASSESSING FACTORS CONTRIBUTING TO DISPARITIES IN KIDNEY STONE MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP75-15 ASSESSING FACTORS CONTRIBUTING TO DISPARITIES IN KIDNEY STONE MANAGEMENT Marvin A. Meza Jarquín, Ram S. Basak, David F. Friedlander, Gopal L. Narang, and Davis P. Viprakasit Marvin A. Meza JarquínMarvin A. Meza Jarquín More articles by this author , Ram S. BasakRam S. Basak More articles by this author , David F. FriedlanderDavid F. Friedlander More articles by this author , Gopal L. NarangGopal L. Narang More articles by this author , and Davis P. ViprakasitDavis P. Viprakasit More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003349.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Studies suggest that there is a disproportionately increasing prevalence of kidney stone disease among African American and Hispanic patients in the United States. Furthermore, evidence indicates that disparities exist in the workup, management, and surgical interventions of different diseases based on race, ethnicity and socioeconomic status, among other variables. We sought to explore the potential non-clinical factors that could lead to disparities in the management of patients with symptomatic nephrolithiasis at a tertiary care center serving a mixed urban and non-urban population. METHODS: We retrospectively analyzed consecutive non-established adult patients presenting with symptomatic unilateral nephrolithiasis requiring definitive ureteroscopic stone extraction at a single institution between October 2019 and September 2021. The primary endpoint was time in days from the date of referral to the date of definitive treatment. Other variables included patient demographics, clinical characteristics, need for preoperative decompression, referral source, treatment date in relation to the COVID-19 pandemic, and Area Deprivation Index (ADI) ranking, a validated measure of neighborhood adversity related to education, employment, housing, and income. RESULTS: Of 398 included patients, the mean age was 53 years, 55% female and 75% Caucasian. 47% had private insurance, 40% had government assistance and 13% were uninsured. The majority (73%) of referrals were from the emergency department. 10% of patients had a urinary tract infection on presentation. Renal obstruction was present in 77% of patients with 40% requiring preoperative decompression. The overall mean time from referral to surgery was 29 days (IQR 15-36). Factors associated with significantly longer time to surgery included Hispanic identity (40 days IQR 12-68, p=0.0098) compared to other ethnicities, Medicaid insurance (36 days IQR 17-55, p=0.012) compared to other payer groups and patients within the highest tertile ADI (most disadvantaged) ranking (+8 days, p=0.022) compared to those in the lowest tertile (most advantaged). CONCLUSIONS: In our cohort we demonstrated several non-clinical factors that resulted in a delay to definitive treatment in symptomatic kidney stone patients including Hispanic identity, Medicaid insurance, and most disadvantaged ADI ranking. Recognition of such disparities is the first step to help delineate and eliminate the barriers delaying the care of these vulnerable patients. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1086 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marvin A. Meza Jarquín More articles by this author Ram S. Basak More articles by this author David F. Friedlander More articles by this author Gopal L. Narang More articles by this author Davis P. Viprakasit More articles by this author Expand All Advertisement PDF downloadLoading ...

Dual-energy CT kidney stone characterization-can diagnostic accuracy be achieved at low radiation dose?

To assess the accuracy of low-dose dual-energy computed tomography (DECT) to differentiate uric acid from non-uric acid kidney stones in two generations of dual-source DECT with stone composition analysis as the reference standard. Patients who received a low-dose unenhanced DECT for the detection or follow-up of urolithiasis and stone extraction with stone composition analysis between January 2020 and January 2022 were retrospectively included. Collected stones were characterized using X-ray diffraction. Size, volume, CT attenuation, and stone characterization were assessed using DECT post-processing software. Characterization as uric acid or non-uric acid stones was compared to stone composition analysis as the reference standard. Sensitivity, specificity, and accuracy of stone classification were computed. Dose length product (DLP) and effective dose served as radiation dose estimates. A total of 227 stones in 203 patients were analyzed. Stone composition analysis identified 15 uric acid and 212 non-uric acid stones. Mean size and volume were 4.7mm × 2.8mm and 114 mm3, respectively. CT attenuation of uric acid stones was significantly lower as compared to non-uric acid stones (p < 0.001). Two hundred twenty-five of 227 kidney stones were correctly classified by DECT. Pooled sensitivity, specificity, and accuracy were 1.0 (95%CI: 0.97, 1.00), 0.93 (95%CI: 0.68, 1.00), and 0.99 (95%CI: 0.97, 1.00), respectively. Eighty-two of 84 stones with a diameter of ≤ 3mm were correctly classified. Mean DLP was 162 ± 57mGy*cm and effective dose was 2.43 ± 0.86mSv. Low-dose dual-source DECT demonstrated high accuracy to discriminate uric acid from non-uric acid stones even at small stone sizes. • Two hundred twenty-five of 227 stones were correctly classified as uric acid vs. non-uric acid stones by low-dose dual-energy CT with stone composition analysis as the reference standard. • Pooled sensitivity, specificity, and accuracy for stone characterization were 1.0, 0.93, and 0.99, respectively. • Low-dose dual-energy CT for stone characterization was feasible in the majority of small stones < 3mm.

Предикторы успеха выполнения уретеролитотрипсии.

Urolithiasis is one of the most common diseases seen by urologists. In 28% of patients with kidney stones, the disease is symptomatic. The benefits of ureteral stone extraction include minimal invasiveness, a shorter postoperative recovery time, and a favourable safety profile. Aim: to compare and evaluate the relationship between the density of the ureter, the density of the calculus, its localization and the value of the creatinine level and predicting the success of ureterolithoextraction. Materials and methods. In total, 125 ureteral lithotripsy procedures were performed (42 in women and 83 in men). Initially, the patients were divided into two groups. In the first group, ureteral stone extraction was performed in 97 patients. The second group included 28 patients with ureteral stent placement, without ureteral lithotripsy. In percentage terms, the increase in mean calculus size in the groups (10%) was less significant than the increase in ureter density under the calculus (65%). Results. There was no relationship between the ureter density under the calculus and the residence time of the calculus in the ureter. However, there is a relationship between the residence time of the calculus and the anatomical narrowing of the ureter, which may affect the success of the procedure. Elevated creatinine levels in the group with initial ureteral stent placement may indicate impaired urine passage from the kidney. Conclusions. Routine measurement of the ureter density under the calculus during MSCT may be an additional parameter in determining the surgical treatment method.

Endoscopic retrograde contact electro-impulse lithotripsy and lithotomy

The paper presents clinical observation of a patient with cholelithiasis and so-called “difficult” choledocholithiasis. Considering the developed complications – mechanical jaundice and purulent cholangitis, as well as large operative risk, it was decided to refrain from open surgical intervention. Traditionally-performed endoscopic stone extraction did not provide any success. Contact electro-impulse lithotripsy and lithotomy were performed. This enabled choledocholithiasis and cholangitis to be eliminated, bile ducts patency to be restored, and ensured the possibility of safe elective surgical intervention for chronic calculous cholecystitis.

Nephrolithiasis in related kidney donors

Introduction. Long-term results of renal transplantation from living donors are much better than the results of cadaveric transplantations. Recently, because of the shortage of living donors, some centers have started using kidneys from living donors with asymptomatic stones as a potential solution for the problem. However, the optimal surgical solution for such situations has not yet been developed.Aim. To evaluate our obtained transplantation results of using the kidneys from living donors with nephrolithiasis and compare them with the literature data.Material and methods. In the period from 2012-2021, renal transplantations in our clinic were done in three patients from related donors with stones in the kidney. One donor underwent mini-percutaneous lithotripsy one month prior to nephrectomy. The other two underwent simultaneous retrograde lithotripsy and laparoscopic donor nephrectomy. In these cases a holmium or thulium laser was used for the destruction of calculi. All donors underwent laparoscopic retroperitoneal nephrectomy.Results. All stones were successfully removed. There were no surgical complications in donors during and after procedures. Warm ischemia time did not exceed 3.5 minutes. The general length of hospital stay was 10 days in case of predonation stone removal surgery and 6 and 4 days in the cases of simultaneous procedures, respectively. All grafts were transplanted to related recipients. One of the recipients was treated with hemodialysis before transplantation, the other one with peritoneal dialysis. The third recipient underwent preemptive transplantation (before the start of dialysis). The graft function in all cases was immediate. During the follow-up period (9-57 months), no signs of nephrolithiasis were seen in either donors, or recipients.Conclusions. Consideration of potential donors with stones in one kidney might increase the number of living donor renal transplantation. Simultaneous RIRS and laparoscopic donor nephrectomy can be considered as an alternative to sequential operations or ex vivo stone extraction. The presented technique is reproducible, safe and was not associated with an increased length of hospital stay.

Combined interventions on pancreatic ducts with external fistulas

The present paper describes clinical observation of successful treatment of a patient with chronic calcifying pancreatitis complicated by an external pancreatic fistula. Abdominal surgery after laparotomy and cholecystectomy had to be limited to bursoomentostomy due to the bleeding tissues and severe blood loss. Combined endoscopic intervention through the external pancreatic fistula was used for the treatment. The performed interventions included stone extraction in Wirsung’s duct, dilation and stenting of the distal stricture of the pancreatic duct. The fistula closed, a pain-free period lasted for 3 years. Similar transfistula interventions were performed in 7 patients with chronic pancreatitis and external pancreatic fistulas, lithiasis in Wirsung's duct (n = 5) and pancreatic duct strictures (n = 6). A total of 17 procedures were performed, 7 of 8 fistulas were closed. Complications developed in 3 observations, no lethal outcome was registered.Conclusion. Transfistula interventions in pancreatic ducts with combined X-ray guidance, oral and transfistula endoscopy can be used to remove stones, dilate strictures and restore natural passage of pancreatic secretions as an independent treatment or preparation for planned abdominal surgery.

Comparing endoscopic ultrasound-guided antegrade treatment and balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography in the management of bile duct stones in patients with surgically altered anatomy: A retrospective cohort study.

Endoscopic ultrasound-guided antegrade treatment (EUS-AG) and balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) have emerged as useful procedures for managing bile duct stones (BDS) in patients with surgically altered anatomy. However, the comparison between these two procedures has not been well studied. The aim of our study was to compare the clinical outcomes of EUS-AG and BE-ERCP for managing BDS in patients with surgically altered anatomy. The database was retrospectively evaluated at two tertiary care centers to identify patients with surgically altered anatomy who underwent either EUS-AG or BE-ERCP for BDS. Clinical outcomes were compared between the procedures. The success rate of each procedure was evaluated in three steps: endoscopic approach, biliary access, and stone extraction. Among the 119 identified patients, 23 had EUS-AG, and 96 had BE-ERCP. The overall technical success rates of EUS-AG and BE-ERCP were 65.2% (15/23) and 69.8% (67/96), respectively (P= .80). The comparison of each step between the procedures EUS-AG versus BE-ERCP was as follows: endoscopic approach, 100% (23/23) versus 88.5% (85/96) (P= .11); biliary access, 73.9% (17/23) versus 80.0% (68/85) (P= .57); stone extraction, 88.2% (15/17) versus 98.5% (67/68) (P= .10). The overall adverse event rate was 17.4% (4/23) versus 7.3% (7/96) (P= .22). Both EUS-AG and BE-ERCP are effective and relatively safe procedures in the management of BDS in patients with surgically altered anatomy. The challenging steps of each procedure might be different, which could help decide which one to use to manage BDS in patients with surgically altered anatomy.

Three Dimensional Printing Technology Used to Create a High-Fidelity Ureteroscopy Simulator: Development and Validity Assessment (Rein-3D-Print-UroCCR-39)

ObjectiveTo create and assess the validity of a high-fidelity, three dimensional (3D) printed, flexible ureteroscopy simulator resulting from a real case. MethodsA patient's CT scan was segmented to obtain a 3D model in .stl format, including the urinary bladder, ureter and renal cavities. The file was printed and a kidney stone was introduced into the cavities. The simulated surgery consisted of monobloc stone extraction. Nineteen participants split into 3 groups according to their level (6 medical students, 7 residents and 6 urology fellows) performed the procedure twice at a 1-month interval. They were rated according to a global score and a task-specific score, based on an anonymized, timed video recording. ResultsParticipants demonstrated a significant improvement between the 2 assessments, both on the global score (29.4 vs 21.9 points out of 35; P < .001) and the task-specific score (17.7 vs 14.7 points out of 20; P < .001) as well as procedure time (498.5 vs 700 seconds; P = .001). Medical students showed the greatest progress for the global score (+15.5 points (mean), P = .001) and the task-specific score (+6.5 points (mean), P < .001). 69.2% of participants considered the model as visually quite realistic or highly realistic and all of them judged it quite or extremely interesting for intern training purposes. ConclusionOur 3D printed ureteroscopy simulator was able to enhance the progress of medical students who are new to endoscopy, whilst being valid and reasonably priced. It could become part of a training program in urology, in line with the latest recommendations for surgical education.

A novel non-slip banded balloon catheter for endoscopic sphincteroplasty: an ex vivo and in vivo pilot study

Endoscopic balloon sphincteroplasty is an established procedure for the extraction of bile duct stones. However, the balloon often slips during the inflation process, and its length is an impediment if the distance between the papilla and scope is limited and/or the stone is located close to the papilla. This animal experimental study aimed to evaluate the feasibility of a novel short non-slip banded balloon measuring 15–20 mm in length for sphincteroplasty. The ex vivo component of this study was conducted using porcine duodenal papilla. Miniature pigs were subjected to endoscopic retrograde cholangiography in the in vivo component. The technical success of sphincteroplasty without any slippage was the primary outcome of the study and was compared between cases managed with the non-slip banded balloon (non-slip balloon group) and conventional balloon (conventional balloon group). The technical success rate of the ex vivo component, i.e., absence of any slippage, was significantly higher in the non-slip balloon group than in the conventional balloon group with the 8-mm (96.0% vs. 16.0%, P < 0.001) and 12-mm diameter balloons (96.0% vs. 0%, P < 0.001). The technical success rate of endoscopic sphincteroplasty without slippage in the in vivo component was significantly higher in the non-slip balloon group than in the conventional balloon group (100% vs. 40%, P = 0.011). No immediate adverse events were observed in either group. The slippage rate was significantly lower with sphincteroplasty using a non-slip balloon, despite the balloon length being considerably shorter than that of conventional balloons, demonstrating its potential utility in difficult cases.

A78 BILIARY STENT USE IN ERCP: A QUALITY ASSURANCE STUDY ASSESSING ADHERENCE TO CLINICAL GUIDELINES AND COST OUTCOMES

Abstract Background A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy. Purpose To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost. Method A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes. Result(s) A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%). Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000. Conclusion(s) Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Life cycle assessment of stone buildings in the Taihang mountains of Hebei province: Evolution towards cleaner production and operation

The building sector has gained significant attention due to its remarkably high energy consumption and greenhouse gas emissions. In China's rural areas, stone is a popular building material, but there are unprecedented demands to improve the life-cycle performance of stone buildings. It is essential to preserve the original architectural features while evolving towards a cleaner production and operation. This study implements a field survey in the Taihang Mountains of Hebei province. The improvement of stone extraction methods and the evolution of three stone wall styles are collected and developed. Thermal transmittances of three stone walls are measured and modeled. A cradle-to-grave life cycle assessment is conducted, and the results are compared to show their environmental performance in the embodiment and operation phases. Their life cycle inventories, including stone extraction, are developed. One representative building style sample is developed for the cooling and heating energy requirement simulation in the DesignBuilder. Based on the inventories, conducting life cycle impact assessment shows various environmental profiles in their whole life cycles. From the outcomes, the stone cladding wall (SCW) outperforms the other stone walls in both the embodiment and operation phases. However, its relatively high cost is a challenge for an individual house owner. This study proves the SCW is more sustainable, providing a basis for the choice of stone wall style in the future construction.