Ureteroscopic Laser Research Articles

Modular flexible ureteroscope and Holmium laser lithotripsy for upper urinary calculi less than 2 cm: a report of 117 cases

Modular flexible ureteroscope and Holmium laser lithotripsy for upper urinary calculi less than 2 cm: a report of 117 cases

Rirs through Semi-Rigid Ureteroscope and Holmium Laser in the Treatment of Ureteral Stones Retropulsion

Retrograde displacement of ureteral stones into the renal cavities during ureteroscopic lithotripsy represents a frequent and adverse event that leads to additional procedures (ESWL, PCNL, Retrograde Intra-renal lithotripsy with flexible instruments, DJ stent placement and subsequent EWSL) to obtain full clearence of calculi. All these procedures require a further time of treatment. Between 1/2008 and 3/2009, a total of 48 patients harbouring proximal (21 cases) and distal (27 cases) ureteral stones underwent Holmium Laser lithotripsy. In 3 patients previous percutaneous nephrostomy was performed to drain the excretory way. In 12 cases (25%) stone retropulsion occurred; in 3 patients in the upper calix and in 5 in the renal pelvis. Only in 4 cases the stone migrated in the lower or medium calix. In 8 cases we attempted the immediate treatment of intrarenal displaced stones by advancing the semi-rigid instrument into the renal cavities. In 2 cases the treatment aborted because of the shortness of ureteroscope. The instillation of lubricating lidocaine jelly prevented in 3 cases furher displacement of stone. Washing with saline solution through nephrostomic catheter allowed an effective mobilization of stone and an easy lasertripsy RIRS was successful in 4 cases. When flexible devices or immediate ESWL are not available, rigid or semi-rigid retrograde lithotripsy with holmium laser immediately performed after ureteral stone displacement represents a safe and effective method to treat displaced stones. Several tricks are required to obtain a good stone-free rate.

347 SUPPLY COST SAVINGS FOR HIGH-VOLUME UROLOGIC PROCEDURES AT AN ACADEMIC MEDICAL CENTER

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2010347 SUPPLY COST SAVINGS FOR HIGH-VOLUME UROLOGIC PROCEDURES AT AN ACADEMIC MEDICAL CENTER James Dupree, Arshia Wajid, and Norm Smith James DupreeJames Dupree More articles by this author , Arshia WajidArshia Wajid More articles by this author , and Norm SmithNorm Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.413AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Over the past 20 years, there have been many efforts to reign in health care costs. Efforts are intensifying today, often focusing on hospital and physician costs. There is potential for surgeons to play a significant role in helping reduce supply costs while maintaining high quality patient care. We believe that increasing surgeons' understanding of surgical supply cost may be one method to safely reduce costs. METHODS We retrospectively reviewed the volume and supply cost data for all urologic procedures performed at our 897-bed, tertiary care academic medical center from September 2008 through August 2009. We identified the five highest volume urologic procedures and the five surgeons with the highest volume and median supply and disposable instrument cost for each of these procedures. We created a cost model to predict the supply cost saving that would occur if the profiled surgeons operated at the median supply cost. RESULTS We analyzed 1,075 cases including 321 open radical prostatectomies (RRP), 264 holmium laser ureteroscopies (laser URS), 189 robotic-assisted laparoscopic prostatectomies (RALP), 178 cystoscopy/ureteroscopies (URS), and 123 transurethreal resections of prostates (TURP). Total yearly supply cost for these procedures was $1,162,068. Table 1 describes the costs and potential savings for each procedure. Potential supply cost savings ranged from $21/case and $5,541/year for laser ureteroscopy, to $128/case and $24,189/year for RALP. The total potential supply cost savings for these five procedures is $78,376/year, a saving of 6.7%. For RALP, RRP, and laser ureteroscopy, the highest volume surgeons had the lowest median supply costs (data not shown). Table 1. Description of supply costs and supply cost savings ($) Procedure Mean cost/ case Median cost/ case Cost savings/ case Cost savings/ year RRP 392 312 75 24,009 Laser URS 896 984 21 5,541 RALP 3,194 3196 128 24,189 URS 528 454 69 12,355 TURP 830 734 100 12,282 CONCLUSIONS Small reductions in supply costs can have a large impact on yearly cost savings. From a sample of the five highest volume procedures and five highest volume surgeons, we have shown that operating at a median supply cost could save $78,376 per year. This is an underestimate of department-wide potential cost savings as these cases represented only 32% of 3405 total cases performed by the department. As a retrospective study, we have the advantage of avoiding the Hawthorne effect, where the act of observing subjects alters their behaviors. The next step will be analyzing how supply costs change now that surgeons know this data. Chicago, IL© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e138 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Dupree More articles by this author Arshia Wajid More articles by this author Norm Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Ureteric Stones

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4 mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10 mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

25: Delay in time to Nephroureterectomy for Patients Undergoing Ureteroscopic Biopsy and Laser Tumor Ablation of Upper Tract Transitional Cell Carcinoma Does not Impact Postoperative Disease Status

25: Delay in time to Nephroureterectomy for Patients Undergoing Ureteroscopic Biopsy and Laser Tumor Ablation of Upper Tract Transitional Cell Carcinoma Does not Impact Postoperative Disease Status

Management of ureteric stones.

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

Treatment of Proximal Ureteral Calculi: Holmium:Yag Laser Ureterolithotripsy Versus Extracorporeal Shock Wave Lithotripsy

We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.

TREATMENT OF DISTAL URETERAL STONES IN CHILDREN: SIMILARITIES TO THE AMERICAN UROLOGICAL ASSOCIATION GUIDELINES IN ADULTS

Purpose: The American Urological Association (AUA) published clinical guidelines for the treatment of ureteral calculi in adults and note that up to 98% of stones less than 5 mm. in diameter will pass spontaneously. Ureteroscopy and shock wave lithotripsy were acceptable treatment choices for stones less than 10 mm. in diameter in the distal ureter. We reviewed our management of distal ureteral stones in children to see if the AUA Guidelines for adults would apply.Materials and Methods: A total of 14 males and 19 females with a mean age of 12 years (range 0.5 to 17) required hospitalization in the last 6 years for distal ureteral obstruction due to stones. Excretory urography or computerized tomography was performed in all cases, and mean stone size was 4 mm. (range 1 to 15). When stones did not pass spontaneously most patients were treated with ureteroscopic laser lithotripsy.Results: There were 12 (36%) with a mean age of 11 years and a mean stone size of 2 mm. (range 1 to 3) who passed stones spontaneo...

Treatment of distal ureteral stones in children: similarities to the american urological association guidelines in adults.

The American Urological Association (AUA) published clinical guidelines for the treatment of ureteral calculi in adults and note that up to 98% of stones less than 5 mm. in diameter will pass spontaneously. Ureteroscopy and shock wave lithotripsy were acceptable treatment choices for stones less than 10 mm. in diameter in the distal ureter. We reviewed our management of distal ureteral stones in children to see if the AUA Guidelines for adults would apply. A total of 14 males and 19 females with a mean age of 12 years (range 0.5 to 17) required hospitalization in the last 6 years for distal ureteral obstruction due to stones. Excretory urography or computerized tomography was performed in all cases, and mean stone size was 4 mm. (range 1 to 15). When stones did not pass spontaneously most patients were treated with ureteroscopic laser lithotripsy. There were 12 (36%) with a mean age of 11 years and a mean stone size of 2 mm. (range 1 to 3) who passed stones spontaneously with intravenous hydration and narcotics. No child passed a stone 4 mm. or greater spontaneously in this series. Of 21 patients (64%) with a mean age of 12 years and a mean stone size of 5 mm. (range 1 to 15) 2 were treated with ureteral stents, 17 with ureteroscopic lithotripsy and 2 with shock wave lithotripsy. All patients were stone-free at the end of the procedures. The stone composition was predominantly calcium oxalate. Mean followup was 2 years. Similar to the AUA guidelines in adults, most stones less than 3 mm. in diameter in the distal ureter of children will pass spontaneously. Stones 4 mm or greater in the distal ureter are likely to require endosurgical treatment. Ureteroscopy and shock wave lithrotripsy have a high success rate for stones between 4 and 15 mm. in the distal ureter. Needle ureteroscope and laser lithotripsy have allowed more stones to be treated safely and effectively in smaller children.

Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness.

To determine the efficacy and costs of extracorporeal shock-wave lithotripsy (ESWL) compared with ureteroscopy (URS) in the treatment of mid- and lower ureteric calculi. The records of patients treated primarily by ESWL and URS were analysed retrospectively. Treatment with ESWL included 63 patients (42 men and 21 women, mean age 52 years, range 23-78, 19 mid- and 44 lower ureteric calculi). All patients received 4000 shock waves at a mean energy setting of 18.1 kV. URS was used in 105 patients, with a 7.2 F miniscope or the 7.1 F flexible scope. Stones were fragmented with a pulsed-dye laser lithotripter at 504 nm and a power of up to 130 mJ (mean 53 mJ) using a 200 or 320 microns fibre. All ureteroscopies were performed with the patient under general (n = 17) or spinal (n = 87) anaesthesia in a mean treatment duration of 34 min. Stones were located in the mid-ureter in 24 patients and in the lower ureter in 80. The outcome was assessed by stone-free rates, re-treatment rates, time to become stone-free, complication and costs. ESWL for mid- and lower ureteric calculi resulted in a success rate of 90% and 81%, respectively, compared with 96% and 99% for URS. However, patients treated with URS were stone-free within 2 days, whereas patients in the ESWL group required up to 4 months. The best results for ESWL were achieved with stones of < 50 mm2. The costs of URS were higher than those for ESWL. ESWL provides a noninvasive, simple and safe option for the management of mid- and lower ureteric calculi, provided that the stones are < 50 mm2; larger stones are best treated by URS.