Holmium Laser Incision Research Articles

Holmium Laser Incision of Ejaculatory Duct (HoLIED): Surgical Procedure

Introduction: Ejaculatory duct obstruction is a well-known cause of infertility and many other symptoms, such as hematospermia and lower urinary tract symptoms. Diagnosis is made based on the medical history and a series of imaging tests identifying the obstructed ducts. Transurethral resection of the ejaculatory ducts is the mainstay treatment to release the obstruction. In this step-by-step surgical video, we will describe a novel technique using the holmium laser to incise the ejaculatory ducts in a patient with chronic lower urinary tract symptoms, hematospermia, and persistent urethral discharge. Materials and Methods: A pelvic MRI was obtained in workup of the above issues and identified a complex ejaculatory duct cyst. The patient consented for Holmium Laser Incision of Ejaculatory Duct. A holmium laser fiber was used through a 24F rigid cystoscope to unroof the ejaculatory duct cyst, resulting in the drainage of a dark brown fluid. Following unroofing of the cyst, the ejaculatory ducts were identified using a 17F rigid cystoscope and a 16F Foley catheter was inserted. Results: The Foley catheter was removed on POD1, and the patient was able to void. His symptoms improved progressively with time and antibiotics. A repeat MRI was obtained several months postoperatively and showed the resolution of the cystic lesion. Conclusion: Holmium Laser Incision of Ejaculatory Duct is safe and feasible procedure allowing to treat ejaculatory duct obstruction without increased risk of complications.

Effect analysis of ureteroscope holmium laser incision in treatment of parapelvic MRI cyst

ObjectiveTo investigate the safety and efficacy of flexible ureteroscopy in treating parapelvic cysts. MethodsFrom June 2017 to June 2019, 21 cases of parapelvic cysts were treated by flexible ureteroscopy with holmium laser incision in our hospital. The average diameter of the cyst was (6.1 ± 1.6) cm. All patients were treated with flexible ureteroscopy with holmium laser incision and drainage of the cyst wall, and 4.7F ureteral stent was indwelling for 3 months after operation. The patients were followed up for an average of 2 years to observe the clinical efficacy and safety. ResultsThe intraoperative blood loss and postoperative pain scores of the observation group were significantly better than those of the control group, the operation time and hospitalization time of the observation group were significantly shorter than those of the control group, and the postoperative recurrence rate of the observation group was significantly lower than that of the control group, with statistically significant differences (P < 0.05). ConclusionThe incision and drainage of the parapelvic cyst under a flexible ureteroscope can effectively reduce the intraoperative bleeding and postoperative pain of patients, and the postoperative recovery is fast, there is less recurrence, it is safe and reliable, and it is worthy of promotion.

Transurethral columnar balloon dilation of the prostate combined with holmium laser incision for bladder neck contracture in day-surgery mode.

The study aimed to investigate the clinical effect of transurethral columnar balloon dilation of the prostate combined with holmium laser in the treatment of bladder neck contracture (BNC). This retrospective study included 41 patients with BNC, who had been treated with transurethral columnar balloon dilation and holmium laser in our hospital from June 2020 to June 2022. Admission, operation, and discharge of all the patients were completed in 24h. The patients' satisfaction, postoperative complications, and chronic pain after operation were followed up. Clinical parameters, such as International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL), and post-void residual volume (PVR) in pre-operation, 1month and 6months after operation were recorded. All patients underwent the operations successfully. Six patients experienced urge incontinence and one patient experienced recurrence of BNC after 12months. At 1month and 6months after the operation, IPSS, QoL, PVR, and Qmax of the patients were significantly better than those before the operation (P < 0.05). Transurethral columnar balloon dilation of the prostate combined with holmium laser can effectively treat BNC with simple performance and satisfactory clinical effects. It is a minimally invasive treatment that can be conducted by simple day surgery.

Clinical Effect of Flexible Ureteroscope and Laparoscope in the Treatment of Parapelvic Cyst.

Objective Comparing the clinical effect of flexible ureteroscope and laparoscope in the treatment of parapelvic cyst. Method A total of 82 patients with parapelvic cyst who underwent surgical treatment in our hospital from May 2019 to May 2020 were selected. Patients were randomly divided into a control group and an observation group; the control group underwent laparoscopic parapelvic cyst topical decompression; the observation group underwent transurethral flexible ureteroscope holmium laser incision and drainage of parapelvic cyst. The intraoperative (operative time, intraoperative blood loss, and ventilation time), postoperative (time of getting out of bed, pain score, and length of hospital stay), and recurrence were compared between the two groups. Results (1) The operative time and intraoperative blood loss in the observation group were significantly better than those in the control group (P < 0.05), while the ventilation time had no significant difference (P > 0.05). (2) The pain score and length of hospital stay in the observation group were better than those in the control group (P < 0.05). There was no significant difference in the time of getting out of bed (P > 0.05). (3) There was no serious infection or bleeding in either group. The observation group had no recurrence, and the postoperative recurrence rate was 0. There were 11 cases of recurrence in the control group, and the postoperative recurrence rate was 26.83%. The postoperative recurrence rate of the observation group was significantly lower than that of the control group, with statistical significance (χ2 = 4.604, P < 0.05). Conclusion Flexible ureteroscope for the treatment of parapelvic cyst could effectively reduce the operative time, intraoperative blood loss, and pain; in addition, the postoperative recovery was fast and the recurrence is rare, which was worth popularizing.

Clinical efficacy of intraoperative real time ultrasound-assisted flexible ureteroscopic holmium laser incision and internal drainage in the treatment of parapelvic cysts

ObjectiveThis study aims to investigate the efficacy and safety of intraoperative real time ultrasound-assisted flexible ureteroscopic holmium laser incision and internal drainage in the treatment of parapelvic cysts, and to review recently published relevant literature.MethodThis is a retrospective study in which the clinical data of 47 patients who underwent flexible ureteroscopic holmium laser incision and internal drainage of parapelvic cysts in our center from March 2017 to March 2021 were retrospectively analyzed. A literature search was conducted to review and summarize relevant reports on endoscopic treatment of parapelvic cysts published in the past 10 years.ResultsAmong 47 patients with parapelvic cysts who underwent flexible ureteroscopic holmium laser incision and internal drainage, 12 (25.53%) cases had a typical cyst wall bulging into the collecting system under flexible ureteroscope. As the cyst wall was thin and translucent in these cases, ultrasound was not used during the operation. The cysts of the remaining 35 patients were located with the aid of intraoperative real time ultrasound, and all underwent successful operation. No serious surgical complications occurred after surgery. The patients were followed up for 12–24 months after operation. The cyst in one case was observed larger than its original size before operation, so recurrence was considered. In another two cases, the diameters of the cysts were more than half of their original diameters before operation. Thus, the efficacy was poor in the three cases. For the remaining 44 cases, there was no obvious cyst observed or the diameter of the cysts was less than half their preoperative level.ConclusionThe approach of ultrasound-assisted flexible ureteroscopic holmium laser incision and internal drainage in the treatment of parapelvic cysts is safe and effective, which helps to solve the problem of localization of atypical parapelvic cysts on endoscopic findings.

Ultrasonography-assisted flexible ureteroscope for the treatment of parapelvic renal cysts: A comparison between the 1470-nm diode laser and the holmium laser.

The present study aimed to compare the efficacy and safety of a flexible ureteroscopic holmium laser incision with flexible ureteroscopic 1470-nm diode laser incision for the treatment of parapelvic renal cysts. The current study collected and analysing the clinical data of 90 independent renal cysts cases retrospectively, including 43 renal cysts cases that received holmium laser surgery (holmium laser group) and 47 renal cysts cases that received 1470-nm diode laser surgery (1470-nm diode laser group). Each group was divided into a thin-walled cyst subgroup and thick-walled cyst subgroup according to cyst wall thickness. Intracapsular hematoma was significantly lower in the 1470-nm diode laser group compared with the holmium laser group (0/47 vs. 4/43; P=0.048). The incision diameter in the 1470-nm diode laser group was significantly larger than the holmium laser group in the thick-walled parapelvic renal cysts subgroup [1.70(1.50,1.90) vs. 1.30(1.25,1.70) cm; P=0.007]. The renal cystic diameter of the two groups was markedly reduced one and six months after surgery. The difference was non-significant in the diameter of the renal cyst in the thin-walled cysts subgroups between the two laser groups 6 months after surgery (1.01±0.38 vs. 1.03±0.53 cm; P=0.454). However, the diameter of the renal cyst in the thick-walled cysts subgroup treated with the 1470-nm diode laser was significantly lower compared with the thick-walled cysts subgroup treated with the holmium laser 6 months after surgery (1.21±0.57 vs. 1.88±0.94 cm; P=0.002). The results demonstrated that the use of a 1470-nm diode laser or holmium laser surgery under a flexible ureteroscope is a safe and effective treatment for parapelvic renal cysts. For thick-walled parapelvic renal cysts, the 1470-nm diode laser appears to exhibit a lower postoperative recurrence rate and better long-term postoperative effects due to its improved haemostatic effect and larger intraoperative incision diameter.

Efficacy and Complication of Flexible Ureteroscopic Holmium Laser Incision for Simple Renal Cysts: A Retrospective Study.

Objective: The aim of this research was to verify the efficacy and complication of flexible ureteroscopic holmium laser incision for simple renal cysts (SRCs). Patients and Methods: We retrospectively reviewed 116 patients who not only had done flexible ureteroscopic holmium laser incision or laparoscopic decortication for SRC in our institution but also had sufficient data: preoperative information and >1-year follow-up records. The following variables were recorded: age, gender, side, cyst size, location (upper pole, lower pole, and interpolar), blood loss, operative duration, complications during and after surgery, pathology report, and presence or absence of flank pain. The primary endpoint was the efficacy of the treatment; secondary endpoints were safety, pain, and the resolution of other complications. All patients underwent radiologic imaging of the kidneys with a repeated CT, before the operation, 3 and 12 months after surgery. If there were no cysts on the most recent imaging, we defined it as a radiologic success. Results: No statistically significant difference in the background variable in patients of group A (64 patients, flexible ureteroscopic holmium laser incision) and group B (52 patients, laparoscopic decortication) was found, including age, gender, cyst's side, cyst's location, and cyst size before the operation. There were less blood loss by surgeons' evaluation and shorter operative duration (p < 0.001) in group A. In group A, there were three patients who had failed in the first time of operation (two patients failed to place flexible ureteroscope through ureter because of ureteral stricture, and one patient was unable to find the renal cyst in the view of flexible ureteroscope), and no severe postoperative complication was observed. The number of postoperative radiologic failure was five at 3 months and three at 12 months in group A, whereas all the procedures were completed laparoscopically, and no conversion was necessary for group B. But there was one patient who had obvious hematuresis for 1 month after the operation and then it was resolved spontaneously at 3 months. There was only one patient who had a radiologic failure in group B, with the cyst of ∼2 cm at 3 months, and his cyst cannot be seen in CT imaging at 12 months without further treatment. There was no statistically significant difference in the rate of effective operation and complication between the two groups. Conclusion: The operation of flexible ureteroscopic holmium laser incision for SRC had the advantages of less blood loss, short operation time, with a similar rate of operative success and radiologic success after the operation, compared with the process of laparoscopic decortication. It was a good option for urologists to deal with endogenous renal cysts.

The use of laser as a therapeutic modality as compared to TURP for the small prostate ≤40 mL: a collaborative review.

In the last decade therapeutic options for patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE) have constantly increased. Although transurethral resection of the prostate (TURP) is still considered the surgical gold standard, different lasers and advanced techniques have been introduced as alternatives to TURP. A non-systematic Medline/Pubmed literature search was performed with different combination of terms including: "BPH," "M-TURP," "B-TURP" "bladder outlet obstruction," "YAG laser," "Diode laser," "Potassium titanyl phosphate," "KTP," "bladder outlet obstruction" (BOO), "BOO in small prostate". Only studies reporting prostate volume ≤40 cc were considered for this review. Current evidence on the use of laser as a therapeutic modality as compared to TURP reported similar functional results of bipolar-TURP, Thulium laser and Greenlight. For prostate gland ≤40 cc, HoLEP can be technically more difficult while Holmium-TUIP seems to be a valid option but with a higher rate of retrograde ejaculation which is considerably higher than the rate in electrocautery series. The diode laser showed excellent intra-operatively haemostasis with clear endoscopic vision and durable improvements in functional results, but may produce greater passive thermal energy conduction that can cause scrotal edema and anal pain. However, conclusions need to be drawn after median to long term evaluation of patients and consideration of the economic implications, coupled with the potential for reducing morbidity. Evidence acquisition from the literature showed that mini-invasive surgeries, including Greenlight laser and Holmium laser incision represent valid alternatives to TURP in prostate ≤40 g. We reported effective results of laser therapy as therapeutic modalities as compared to TURP for the small prostate ≤40 mL, both for enucleation and excision or cauterization, however cost effective of laser in the current literature are still scarce and it should be implemented.

Comparision of ureteroscopy with holmium laser combined balloon expansion and pure balloon expansion for the treatment of ureteral stricture

Objectives To compare safety and efficacy of ureteroscopy with holmium laser combined balloon expansion with pure balloon expansion for the treatment of ureteral stricture. Methods Retrospective analysis of 45 cases of patients with ureteral stricture in our hospital from January 2010 to January 2015 were performed. All patients were divided into observation group(n=25) and the control group(n=20) according to the different methods.25 patients in observation group were given balloon dilatation combined Wolf 9 rigid ureteroscope with holmium laser incision for ureteral stricture, and 20 patients in control group were given pure balloon expansion for ureteral stricture, the efficacy were compared of the two treatment methods. Results 25 patients in observation group finished surgery successfully.Followed-up for 1~19 months after the operation, 2 cases of reccurence of ureteral stricture, 2 cases of hydronephrosis and no obvious postoperative bleeding, urinary fistula and the complications were found.The effective rate of operation was 84.00% in observation group and success rate was 55.00% in control group.20 patients underwent ureteral stricture balloon expansion who were followed up 1~19 months after operation, 4 cases of reccurence of ureteral stricture, no obvious change in 5 cases of hydronephrosis, no obvious postoperative bleeding, urinary fistula and the complications were found. There was statistically significant difference between the two groups(P<0.05). Conclusions Ureteroscopy with holmium laser combined balloon expansion cound be the preferred treatment for ureteral stricture because of little injury and complication, safety, and complete cure.It is to be worth spread. Key words: Ureteral Obstruction; Lasers, Solid-State; Ureteroscopes

Research of holmium laser incision combined with X-ray guided balloon dilation in treatment of ureterostenosis under ureteroscope

Objectives To explore the efficacy of holmium laser incision combined with X-ray guided balloon Dilation in treatment of ureterostenosis under ureteroscope. Methods A total of 49 patients with ureteric stenosis were analyzed retrospectively in our hospital from February 2008 to January 2015.All the patients were treated by a combined therapy. Results All patients were successfully completed surgery, except for 5 cases who developed fever(over 38.5℃), others had no complication.After one year of follow-up, 42 patients were totally cured, 5 patients were improved, and 2 patients with upper ureter circuity were inefficient. Conclusions The holmium laser incision combined with X-ray guided balloon Dilation in treatment of ureterostenosis under ureteroscope is effective and have a broad clinical prospects. However, in patients with upper ureter circuity, it should be cautiously used. Key words: Ureteral Obstruction; Lasers, Solid-State; Ureteroscopes

Endoscopic Treatment of Vesicourethral Stenosis after Radical Prostatectomy: Outcomes and Predictors of Success

We describe patency outcomes and predictors of success for the endoscopic treatment of vesicourethral stenosis after radical prostatectomy. A retrospective review identified 142 patients who underwent endoscopic treatment for vesicourethral stenosis after radical prostatectomy during a 10-year period. Clinical parameters examined were treatment modality, prior endoscopic treatment, age, concurrent radiotherapy, body mass index 35 kg/m(2) or greater, diabetes and smoking. The primary outcome measure was absence of stenosis (less than 16Fr) on followup cystoscopy. Treatment modalities were divided into 5 groups of holmium laser incision, cold knife incision, electrocautery incision, dilation or UroLume® stent. Descriptive statistics as well as univariate and multivariate logistic regression were performed. A total of 142 patients required 292 endoscopic treatments for a mean of 2.1 treatments per patient. The success rate of a single endoscopic treatment was 44.2%. However, 91% of the patients were ultimately treated successfully with endoscopic measures with a mean followup of 9.7 months. On multivariate analysis treatment modality (OR 0.65, 95% CI 0.52-0.80, p <0.001), prior failed treatment (OR 0.86, 95% CI 0.74-0.99, p=0.04) and smoking (OR 0.55, 95% CI 0.34-0.97, p=0.04) were associated with failure, while age (p=0.85), diabetes (p=0.25), radiotherapy (p=0.68) and body mass index 35 kg/m(2) or greater (p=0.92) were not. Compared to holmium laser incision all modalities except UroLume were associated with treatment failure. Most patients with vesicourethral stenosis after radical prostatectomy are treated successfully with endoscopic modalities but often require multiple procedures. Unlike anterior urethral strictures, in this specific scenario the use of repeat endoscopic treatments appears justified. Holmium laser incision may be more successful compared to other endoscopic modalities.

Clinical outcome of treating intractable hematospermia using holmium laser incision through a ureteroscope.

Clinical outcome of treating intractable hematospermia using holmium laser incision through a ureteroscope.

The evaluation of tissue mass loss in the incision line of prostate with benign hyperplasia performed using holmium laser and cutting electrode.

IntroductionThe aim of this study is to compare the changes in the incision line of prostatic adenoma using a monopolar cutting electrode and holmium laser, as well as the assessment of associated tissue mass and volume loss of benign prostatic hyperplasia (BPH).Material and methodsThe material used in this study consisted of 74 preparations of prostatic adenoma obtained via open retropubic adenomectomy, with an average volume of 120.7 ml. The material obtained cut in vitro before fixation in formaldehyde. One lobe was cut using holmium laser, the other using a monopolar cutting electrode. After the incision was made, tissue mass and volume loss were evaluated. Thermocoagulation changes in the incision line were examinedunder light microscope.ResultsIn the case of the holmium laser incision, the average tissue mass loss was 1.73 g, tissue volume loss 3.57 ml and the depth of thermocoagulation was 1.17 mm. When the monopolar cutting electrode was used average tissue mass loss was 0.807 g, tissue volume loss 2.48 ml and the depth of thermocoagulation was 0.19 mm.ConclusionsWhere holmium laser was used, it was observed that the layer of tissue with thermocoagulation changes was deeper than in the case of the monopolar cutting electrode. Moreover, it was noticed that holmium laser caused bigger tissue mass and volume loss than the cutting electrode.

Management of Anastomotic Stricture After Artificial Urinary Sphincter Placement in Patients Who Underwent Salvage Prostatectomy

To report on a safe endoscopic management technique for the treatment of an anastomotic stricture (AS) in patients with an artificial urinary sphincter (AUS). Five patients with a history of salvage prostatectomy after radiation therapy that developed an AS after AUS placement were treated with a rigid ureteroscope and a Holmium YAG (Ho: YAG) laser to incise the AS. The AUS was opened and deactivated but not decoupled or removed during the procedure. The rigid ureteroscope allowed complete control of the laser fiber to incise the stricture at the 3 and 9 o' clock positions and then circumferentially. There were no intraoperative complications and the mean operative time was 42.6 minutes. Of the 5 patients who underwent holmium laser incision of an AS after AUS placement, none developed AUS malfunction or required device replacement. No patients reported worsening of urinary incontinence after treatment. Two patients required repeat holmium laser incision for AS recurrence. Using a rigid ureteroscope and a holmium laser to incise an AS after AUS placement seems to be a safe management option that does not damage the AUS or result in worsening incontinence. This treatment strategy provides an endoscopic alternative to using open surgical technique to uncouple or remove the AUS while treating the AS.

V332 HOLMIUM LASER INCISION OF BLADDER NECK FOR POST-PROSTATECTOMY BLADDER NECK STENOSIS

You have accessJournal of UrologyMale Voiding Dysfunction (BPH & Incontinence) & Infection1 Apr 2010V332 HOLMIUM LASER INCISION OF BLADDER NECK FOR POST-PROSTATECTOMY BLADDER NECK STENOSIS Hemendra Shah Hemendra ShahHemendra Shah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.397AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bladder neck stenosis is an inherent long term complication of prostatectomy for bladder outlet obstruction. We present our experience with Holmium laser incision of post-prostatectomy bladder neck stenosis. To the best of our knowledge, there is no information on the outcome of this procedure in the literature. METHODS Retrospective review of 11 patients with post-prostatectomy bladder neck stenosis who underwent bladder neck incision with holmium laser at our institute from May 2003 to June 2008 was performed. All patients had an ascending urethrogram & cystoscopy to diagnose bladder neck stenosis. The procedure was performed using 550 μ laser fiber at 100 W holmium laser energy. Initially incision was taken at 5 and 7o clock position and deepened till all fibrous tissue is cut. Later on the fibrous tissue is resected using the holmium laser. An additional 12 o clock &/or 6o clock incision is take to completely release all the fibrous tissue. The remaining residual fibrous tissue is vaporized. All patients had a per urethral catheter for 1 day. Patients demographic and perioperative data was analyzed to know the safety and efficacy of the procedure. Follow-up data was obtained to know early outcome of surgery. Digital video clips from previously recorded Holmium laser incision of post-prostatectomy bladder neck stenosis were edited into a video describing the steps of procedures. RESULTS The primary procedure for prostatectomy was open prostatectomy (1); TURP (7) and HoLEP (3). All patients presented with recurrent bladder outlet obstruction after initial prostatectomy. The mean interval between prior prostatectomy and presentation was 1.9 years (3 months – 9 years). The mean pre-prostatectomy prostate size (available in 8 patients) was 34.8 gm (11- 72 gm). The mean preoperative AUA symptom score, maximum uroflow rate and post-void residual urine were 24, 7.2 ml/sec and 112 ml respectively. There were no major intraoperative or post-operative complications. At mean follow-up of 21 months, no patients had recurrent bladder neck stenosis. The mean postoperative AUA symptom score, maximum uroflow rate and post-void residual urine during last available follow-up were 7, 19.8 ml/sec and 33 ml respectively. CONCLUSIONS Holmium laser bladder neck incision is associated with favorable early postoperative outcome. Mumbai, India© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e132 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hemendra Shah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

First Digital Flexible Ureterorenoscope: Initial Experience

Flexible ureterorenoscopy is a minimally invasive procedure that is rapidly gaining popularity as a treatment for patients with upper urinary tract lithiasis. One of the main drawbacks is the limited visualization imposed by fiberoptic technology in an endoscope, often only 7 to 8F and the fragility of fiber-based optics in a flexible endoscope. We report our initial experience with digital flexible URS and holmium laser lithotripsy using digital image capture in three patients. Two patients had upper tract calculi (1 cm lower pole calculus and 8 mm caliceal diverticular stone, respectively), and one patient underwent diagnostic URS. After basket capture and intrarenal relocation of the lower pole stone, complete stone destruction was achieved. Similarly, the caliceal diverticular stone was destroyed after holmium laser incision of the caliceal diverticulum. Remarkable improvement in image quality was observed throughout the procedures in comparison with current fiberoptic image acquisition. Minor image interference was noted during fluoroscopic screening, which increased slightly during laser activation. The first digital flexible ureterorenoscope provided excellent image quality and zoom capability, with a substantial improvement compared with fiberoptic technology. It does not require a separate light source and is an important step for the continued evolution of flexible URS as a therapeutic modality for upper urinary tract pathology.

Retrograde Endopyelotomy: A Comparative Study of Hot-Wire Balloon and Ureteroscopic Laser

This study compared the immediate and long-term results and complications of hot-wire balloon endopyelotomy and ureteroscopic holmium laser endopyelotomy. Between March 1994 and January 2002, 64 patients with a primary (N = 52) or secondary (N = 12) ureteropelvic junction obstruction underwent retrograde endopyelotomy using either a fluoroscopically guided hot-wire balloon incision (N = 27) or a ureteroscopically guided, direct-vision holmium laser incision (N = 37). This study group included 46 women and 18 men aged 13 to 79 years (mean 38.9 years). The indications and contraindications to a retrograde approach were identical in each group and included documented functionally significant evidence of obstruction, no upper-tract stones, obstruction <2 cm, and no radiographic evidence of entanglement of crossing vessels at the ureteropelvic junction. Immediate and long-term outcomes were obtained from a prospective registry, with success defined as resolution of symptoms and radiographic relief of obstruction as determined by follow-up with intravenous urography, diuretic renography, or both. Follow-up ranged from 39 to 133 months (mean 75.6 months). Length of hospital stay, indwelling stent duration, and long-term success rates (77.8% v 74.2% in the hot-wire balloon and holmium-laser group, respectively) were equivalent. However, two patients in the hot-wire balloon group developed bleeding necessitating transfusion and selective embolization of lower-pole vessels. No patient in the ureteroscopic group suffered a major complication. These two alternatives for retrograde endopyelotomy provide comparable success rates for similarly selected patients. However, because significant hemorrhagic complications developed with greater frequency in those treated with the hot-wire balloon, our preference is for a ureteroscopic approach, as it allows direct visual control of the incision and thus, a lower risk of significant bleeding.

The use of endoluminal ultrasonography for preventing significant bleeding during endopyelotomy: evaluation of helical computed tomography vs endoluminal ultrasonography for detecting crossing vessels

To evaluate, in a prospective study, the efficiency of helical computed tomography (CT) and endoluminal ultrasonography (ELUS) for detecting significant crossing vessels, a major cause of bleeding complications when treating patients with pelvi-ureteric junction (PUJ) obstruction, and to compare our results using ELUS with those of an earlier multicentre study (not using ELUS), to see whether the complication rate decreased. The study included 27 patients with a PUJ who had isotope renography, intravenous urography, helical CT and ELUS before surgery. Depending on the findings of ELUS, patients were treated with a pure lateral Acucise incision (Applied Medical, Irvine, CA, USA) an Acucise with changed cutting direction, or (later) a laparoscopic pyeloplasty. ELUS detected 15% more crossing vessels than helical CT; 16 patients had Acucise (seven lateral, nine other cutting direction), eight were treated with a laparoscopic pyeloplasty and three with other procedures. By contrast with earlier reports and as a consequence of using ELUS, there was no bleeding, vs 16% in the study not using ELUS. The success rate of 73% of the endourological approach is comparable with previous reports. ELUS is more sensitive in detecting relevant crossing vessels than helical CT and therefore the use of ELUS can better prevent bleeding complications. ELUS can also improve the success rate by helping in selecting the correct treatment. Because it is minimally invasive and safe, ELUS combined with Acucise (or other possible endourological techniques, like holmium laser incision) should be the first choice of treatment for PUJ stenosis.

The role of endourology in ureteropelvic junction obstruction.

Endopyelotomy has benefited from abundant confirmatory investigations, and significant progress in different technical modalities has occurred. Retrograde techniques, including the Acucise (Applied Medical, Laguna Hills, CA) cutting balloon and the ureteroscopic Holmium laser incision, are becoming preferred approaches while the other modalities retain their specific indications. Long-term results and potential complications have been carefully studied and reported. Better identification of risk factors has prompted precise preoperative investigations and allowed for careful patient selection, leading to improved results. These results approach those of open pyeloplasty, but with minimal morbidity.