Flexible Ureteroscopies Research Articles

Antegrade Percutaneous Flexible Endoscopic Approach for the Management of Urinary Diversion-Associated Complications

We present our experience in the minimally invasive management of postoperative complications associated with urinary diversions using an ureteral access sheath (UAS) in an antegrade approach. From 2005 to 2011, 21 antegrade flexible ureteroscopies (F-URS) were performed in 17 patients with a urinary diversion. Urinary diversions in this population consisted of ileal conduits, orthotopic neobladders, catheterizable pouches, and an ureterosigmoidostomy in 9, 5, 2, and 1 patients, respectively. The most important reason for treatment was recurrent upper urinary tract infection. The indication for intervention was stone disease in 15 procedures and strictures in 6 cases. In two patients, "staged-therapy" was performed. Using UAS in an antegrade approach was the main concept. A nephrostomy tube was already in place in 14 (66.6%) procedures, which was the access route used. Successful puncture was performed in all other patients. Eighty percent of patients were rendered stone free after the first antegrade session. Moreover, all strictures were successfully managed by dilation. In two sequential procedures in a patient, there was an inability to perform stone treatment because of abnormal position of the ureter (kinked), which did not allow the ureterorenoscope to pass. All other procedures were uneventful. Postoperative complications were reported in four procedures. There was significant urinary tract infection in two patients as well as an obstructed nephrostomy tube in two patients. An antegrade endoscopic procedure using UAS in patients who present with stones or ureterointestinal stricture as late complications of urinary diversion is a feasible, well-tolerated technique, especially when using smaller access sheaths.

1824 INTERNATIONAL COOPERATION IN ENDOUROLOGY: PERCUTANEOUS AND FLEXIBLE URETEROSCOPIC TREATMENT OF LOWER POLE KIDNEY STONES

Introduction Lower pole kidney stones represent at time a challenge for the urologist. The gold standard treatment for intrarenal stones 2 cm is Percutaneous Nephrolithotomy (PCNL). The success rate of ESWL, however, decreases when it is employed for lower pole stones, and this is particularly true in the presence of narrow calices or acute infundibular angles. Studies have proved that ureteroscopy (URS) is an efficacious alternative to ESWL for lower pole stones <2 cm, but this is not reflected by either the European or the American guidelines. The aim of this study is to present the results of a large series of flexible ureteroscopies and PCNLs for lower pole kidney stones from high-volume centers, in order to provide more evidences on the potential indications of the flexible ureteroscopy for the treatment of kidney stones. Materials and Methods A database was created and the participating centres retrospectively entered their data relating to the percutaneous and flexible ureteroscopic management of lower pole kidney stones. Patients included were treated between January 2005 and January 2010. Variables analyzed included case load number, preoperative and postoperative imaging, stone burden, anaesthesia (general vs. spinal), type of lithotripter, access location and size, access dilation type, ureteral access sheath use, visual clarity, operative time, stone-free rate, complication rate, hospital stay, analgesic requirement and follow-up time. Stone-free rate was defined as absence of residual fragments or presence of a single fragment <2 mm in size at follow-up imaging. Primary end-point was to test the efficacy and safety of flexible URS for the treatment of lower pole stones; the same descriptive analysis was conducted for the PCNL approach, as considered the gold standard for the treatment of lower pole kidney stones. In this setting, no statistical analysis was conducted owing to the different selection criteria of the patients. Secondary end-point consisted in matching the results of stone-free rates, operative time and complications rate of flexible URS and PCNL in the subgroup of patients harbouring lower pole kidney stones between 1 and 2 cm in the higher diameter. Results A total 246 patients met the criteria for inclusion. There were 117 PCNLs (group 1) and 129 flexible URS (group 2). Ninety-six percent of cases were diagnosed by CT KUB scan. Mean stone burden was 175±160 and 50±62 mm2 for groups 1 and 2, respectively. General anaesthesia was induced in 100 % and 80% of groups 1 and 2, respectively. Pneumo-ultrasonic energy was used in 84% of cases in the PCNL group, and holmium laser in 95% of the cases in the flexible URS group. The mean operative time was 76.9±44 and 63±37 minutes for groups 1 and 2 respectively. There were 12 major complications (11%) in group 1 (mainly Grade II complications according to Clavidien classification) and no major complications in group 2. Mean hospital stay was 5.7 and 2.6 days for groups 1 and 2, respectively. Ninety-five percent of group 1 and 52% of group 2 required analgesia for a period longer than 24 hours. Intraoperative stone-free rate after a single treatment was 88.9% for group 1 and 79.1% for group 2. Overall, 6% of group 1 and 14.7% of group 2 required a second look procedure. At 3 months, stone-free rates were 90.6% and 92.2% for groups 1 and 2, respectively, as documented by follow-up CT KUB (22%) or combination of intra-venous pyelogram, regular KUB and/or kidney ultrasound (78%). In the subanalysis conducted comparing 82 vs 65 patients who underwent PCNL and flexible URS for lower pole stones between 1 and 2 cm, intreoperative stone-free rates were 88% vs 68% (p= 0.03), respectively; anyway, after an auxiliary procedure which was necessary in 6% of the cases in group 1 and 23% in group 2 (p=0.03), stone-free rates at 3 months were not statistically significant (91.5% vs 89.2%; p=0.6). Conversely, the patients undergoing PCNL maintained a higher risk of complications during the procedure, with 9 cases observed in this group versus 0 in the group of patients treated with URS (p=0.01) Conclusions These data highlight the value of flexible URS as a very effective and safe option for the treatment of kidney stones; thanks to the latest generation of flexible devices, this new technical approach seems to be a valid alternative in particular for the treatment of lower pole kidney stones less than 2 cm. In high-volume centres and in the hands of skilled surgeons, this technique can approach the stone-free rates achievable through PCNL in lower pole stones between 1 and 2 cm, with a very low risk of complications. Furthermore, the results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, with no difference detectable between the prone and supine position.

1284 A COMPARATIVE STUDY OF THE REQUIREMENT OF INTRODUCER SHEATHS FOR URETERIC ACCESS BETWEEN AN OLD GENERATION FIBRE-OPTIC FLEXIBLE URETEROSCOPE AND A NEW “CHIP ON THE TIP” DIGITAL FLEXIBLE URETEROSCOPE

You have accessJournal of UrologyTechnology & Instruments: Ureteroscopy1 Apr 20101284 A COMPARATIVE STUDY OF THE REQUIREMENT OF INTRODUCER SHEATHS FOR URETERIC ACCESS BETWEEN AN OLD GENERATION FIBRE-OPTIC FLEXIBLE URETEROSCOPE AND A NEW “CHIP ON THE TIP” DIGITAL FLEXIBLE URETEROSCOPE Zafar Maan, Tamer El-Husseiny, Konstantinos Moraitis, Junaid Masood, and Noor Buchholz Zafar MaanZafar Maan More articles by this author , Tamer El-HusseinyTamer El-Husseiny More articles by this author , Konstantinos MoraitisKonstantinos Moraitis More articles by this author , Junaid MasoodJunaid Masood More articles by this author , and Noor BuchholzNoor Buchholz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.855AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although the new generation “chip on the tip” digital flexible ureteroscopes provide significantly superior views and are likely to be more durable than the old generation fibre-optic flexible ureteroscopes, one area of concern might be their larger distal tip diameter as it houses the digital chip. This might necessitate more frequent use of an introducer sheath to gain entry into the ureter. This of course may increase the risk of ureteric injury, the need for placing a JJ stent and has cost implications. METHODS We only looked at the need for a sheath in order to gain access to the ureter in all patients undergoing flexible uretero-renoscopy over a period between June 2006 and January 2009. Patients were scoped with either an old generation fibre optic flexible ureteroscope (DUR-8, Elite, ACMI; Working Length= 65cm; Distal Tip Diameter=8.5F) or a new generation “chip on the tip” digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; Working Length=65cm; Distal Tip Diameter= 8.7F). The age and sex of the patients and indications for f-URS were noted and compared between the two groups. Any patients who had a pre-operative JJ stent in place were excluded from the study. RESULTS FO and LCD flexible ureteroscopies were performed in 157 cases over the time frame. Sheaths were used for access more frequently in LCD f-URS cases; 19 out of 77 LCD f-URS cases required a sheath for access (25%), compared to 6 out of 80 FO f-URS cases (7.5%). Student's t-test produced a significant difference between the two groups (p value 0.00174). The two groups were well matched in terms of age and sex as well as indications for f-URS (85% for upper ureteric and renal calculi, 10% diagnostic and 5% for renal pelvic transitional cell carcinoma fulgaration). The vast majority of f-URS were carried out for stone disease and the groups were well matched in terms of stone location and stone burden. Post-operative JJ stenting was required in 35 of the 77 patients in the digital f-URS group and in 31 out of 80 in the fibre-optic f-URS group. This was not significantly different and may due to reduced operating time as a result of the superior image quality. CONCLUSIONS A statistically significant increase in sheath use was observed in the new generation digital f-URS group despite an increase in the tip diameter of only 0.2F (8.7F VS 8.5F). Despite the obvious improvement in the images obtained and the likely better durability, the increased use of ureteric access sheaths may increase morbidity and expense. London, United Kingdom© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e497 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zafar Maan More articles by this author Tamer El-Husseiny More articles by this author Konstantinos Moraitis More articles by this author Junaid Masood More articles by this author Noor Buchholz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Blood Splash Injury: An Underestimated Risk in Endourology

Mucocutaneous and transconjunctival exposure are important portals for the transmission of blood-borne infections to surgeons and health-care workers. Despite this knowledge, few surgeons or their assistants wear protective equipment for procedures perceived to be affiliated with less risk. This study investigates the potential risk of mucocutaneous and transconjunctival blood splash injury during common laparoscopic and endourologic procedures undertaken using standard video endoscopy equipment. Masks combined with eye shields were consecutively collected from the surgeon, surgical assistant, and theater nurse after a variety of endourologic procedures over a 4-month period. These were analyzed macroscopically for visible blood droplets. Modern forensic techniques were then instituted to assess for nonvisible blood exposure. Eye shields from 118 procedures performed by five surgeons were collected. Two hundred and thirty-six masks were examined for visible and visually enhanced evidence of blood contamination. In total, 48.5% of surgeons' masks, 29.5% of assisting surgeons' masks, and 31.8% of scrub nurse masks were positive for either visible or visually enhanced blood contamination. In terms of evidence of blood splash, 84.2% of laparoscopic nephrectomies, 66.7% of pyeloplasties, and 58.3% of flexible ureteroscopies tested positive. Splash injuries remain commonplace, even with the use of video endoscopy equipment. Therefore, all health-care workers should be encouraged to wear eye and face protection when undertaking both endoscopic and laparoscopic urologic procedures. These observations may have broader implications relevant to all minimally invasive surgical procedures, because they demonstrate a much greater potential risk of blood-borne disease transmission during surgery than has been previously appreciated.

Ureteroscopy for Stone Treatment Using New 270° Semiflexible Endoscope: In Vitro, Ex Vivo, and Clinical Application

The use of flexible ureteroscopy for diagnosis and management of upper urinary tract diseases is limited both by loss of maximum active deflection through the inserted working probes and a high frequency of damage with consequent costs. A newly developed ureteroscope (Flex-X, Karl Storz) with a maximized angle of deflection was introduced to overcome these problems. The aim of our study was to compare this new ureteroscope with an established device in vitro, ex vivo, and in a clinical approach. Angles of maximum active deflection and maximum irrigation flow were measured for both scopes in vitro with an empty working channel and after introduction of different lithotripsy and stone extraction probes. In addition, the loss of maximum active deflection and broken optical fibers of the scopes were assessed after 100 flexible ureteroscopies in an ex-vivo pig cadaver model. The clinical performance of both ureteroscopes was evaluated in 32 patients for management of lower pole stones. The new ureteroscope displays highly improved deflection compared with the standard scope; deflection angles as much as 270 degrees with an empty working channel were achieved. Thin probes did not inhibit maximum deflection. Durability in ex vivotrials was high. Only minimal loss of maximum deflection and three broken optical fibers were observed. In clinical usage, a stone-free rate of 100% was achieved after 4 weeks. In three patients, the opening mechanism of a basket did not work with maximum deflection because of high friction. The new ureterorenoscope facilitates retrograde stone management and might diminish repair intervals. Further development of comparable devices will support flexible ureterorenoscopy as a standard stone management procedure.

Intrarenal manipulation of flexible ureteroscopes: a comparative study

To compare the relative ease of manipulation around a calyceal model in the hands of experienced ureteroscopists of four flexible ureteroscopes (FUs), as new-generation FUs provide exaggerated active deflection to facilitate intrarenal manipulation. Four FUs of <7.5 F were tested: the FlexVision U-500 (SF) (Stryker Endoscopy, San Jose, CA, USA), the Dur-8 Elite (D8E) (ACMI, Southborough, MA, USA), the Viper (Richard Wolf Medical Instruments, Vernon Hills, IL, USA) and the URF-P3 (Olympus Surgical, Orangeburg, NY, USA). Eight experienced ureteroscopists, each with a minimum of 100 flexible ureteroscopies over the preceding 3 years, assessed the FUs. The Mediskills calyceal model represents a moderately hydronephrotic collecting system, with a renal pelvic width of 2 cm, infundibular widths of 1 cm and infundibular lengths of 2 cm. The middle calyx infundibular angle was 80 degrees and the lower calyx infundibular angle was 100 degrees . The model does not allow for significant passive secondary deflection. The surgeons manoeuvred systematically around a four-point course, from the pelvi-ureteric junction, to anterior lower calyx, to anterior middle calyx, to posterior lower calyx, to posterior middle calyx, touching a metal sensor with an fulguration electrode, to trigger an automated signal at each calyx. The order of FU used by each surgeon was randomized. Each surgeon performed the course twice with each FU, ending with the first FU they started with, to diminish the impact of "learning the course". There were significant differences in the mean (sd) total time for manipulation through the four-point course, for the Viper, SF, D8E and URF-P3, at 29 (11), 37 (23), 38 (20) and 50 (24) s, respectively (P = 0.034). The URF-P3 took longer to reach the posterior lower pole, at 18.1 (14.5) s than the Viper, SF and D8E, at 6.3 (2.8) (P = 0.004), 6.6 (3.3) (P = 0.008) and 7.7 (4.9) (P = 0.008), respectively. The Viper was quicker to reach the posterior middle pole, at 7.3 (4.0) s, than the URF-P3, SF and D8E, at 14.9 (13.1) (P = 0.036), 14.7 (14.3) (P = 0.056) and 12.7 (14.0) s (P = 0.115), respectively. Subjectively, six of eight endoscopists stated that the Viper was the better FU for ease of manipulation, while five of eight stated that the URF-P3 was the most difficult. Notably, all eight endoscopists had more clinical experience with the URF-P3 than with the other three FUs tested. In a model of a moderately hydronephrotic kidney with long infundibulum and limited ability to perform passive secondary deflection, FUs with exaggerated active deflection outmanoeuvred the URF-P3. The Viper was better for manipulation in the hands of experienced endoscopists.