Post-Ureteroscopic Lesion Scale Research Articles

Fluid absorption during flexible ureteroscopy with intelligent control of renal pelvic pressure: a randomized controlled trial.

To investigate fluid absorption and its influencing factors during flexible ureteroscopy with intelligent control of renal pelvic pressure (RPP). A total of 80 patients with upper urinary tract calculi underwent flexible ureteroscopy with intelligent control of RPP by pressure-measuring ureteral access sheath and were randomly divided into four groups. The RPP of Groups A, B, and C were set at -5, 0 and 5mmHg, respectively. Conventional flexible ureteroscopy with uncontrolled pressure served as control Group D. The perfusion flow rate was set at 100ml/min in the four groups, with 20 patients in each group. The fluid absorption was measured by 1% ethanol every 10min. Operation time, stone-free rate, and complications were recorded. Seventy-three patients were finally included in the RCT. The general and preoperative data of the patients were comparable between the groups. The fluid absorption of Groups A, B, and C was significantly less than that of Group D (P < 0.01). Fluid absorption and operation time were positively correlated, and the correlation coefficients R were 0.864, 0.896, 0.918, and 0.947, respectively (P < 0.01). The fluid absorption of patients with vomiting, fever and ureteral injury was greater than that of patients without complications in the four groups (P < 0.01). In different groups, fluid absorption was greater in patients with ureteral injury Post-Ureteroscopic Lesion Scale (PULS) 1-3 than in noninjured patients (P < 0.01). Flexible ureteroscopy with intelligent control of RPP effectively reduces the absorption of perfusion fluid. Operation time and ureteral injury are also key factors affecting perfusion fluid absorption. NCT05201599; August 11, 2021.

Post-Ureteroscopic Lesion Scale to determine ureteral wall damage, not so easy to employ

ObjectiveTo analyze the level of agreement of the Post-Ureteroscopy Lesion Scale (PULS) and the consequences on its application in clinical practice with more reliable statistical data than the one used in the original work. Methods14 URS and 14 micro-URS were performed in 14 female porcine model. All the procedures were video recorded and an anatomopathological analysis was performed in each ureter. Sixteen urologists (9 endourologists and 7 general urologists) and 4 residents evaluated the ureteral lesions according to the PULS, with degrees 0, 1 and ≥2. The agreement was calculated with percentages, Kendall’s W coefficient and the indicators Fleiss’ Kappa and Krippendorff’s Alpha, while the inter-rater agreement was calculated with Spearman’s correlation and Cohen’s Kappa. ResultsThe percent of agreement was 11.1%. The coefficients were likewise classified as low or very low, with the greatest agreement found among the inexperienced. Also, 50% of the raters did not agree with the rest. ConclusionsThe low inter-rater agreement, the specificity of the PULS and the clinical-pathological correlation suggests that this scale is not simple, and probably has a long learning curve.

Post-Ureteroscopic Lesion Scale: limitaciones en su aplicabilidad clínica

ObjectiveTo analyze the level of agreement of the Post-Ureteroscopic Lesion Scale (PULS) and the consequences on its application in clinical practice with more reliable statistical data than the one used in the original work. Methods14 URS and 14 micro-URS were performed in 14 female porcine model. All the procedures were video recorded and an anatomopathological analysis was performed in each ureter. Sixteen urologists (9 endourologists and 7 general urologists) and 4 residents evaluated the ureteral lesions according to the PULS, with degrees 0, 1 and ≥2. The agreement was calculated with percentages, Kendall's W coefficient and the indicators Fleiss’ Kappa and Krippendorff's Alpha, while the inter-rater agreement was calculated with Spearman's correlation and Cohen's Kappa. ResultsThe percent of agreement was 11.1%. The coefficients were likewise classified as low or very low, with the greatest agreement found among the inexperienced. Also, 50% of the raters did not agree with the rest. ConclusionsThe low inter-rater agreement, the specificity of the PULS and the clinical-pathological correlation suggests that this scale is not simple, and probably has a long learning curve.

MP05-10 NATURAL HISTORY OF URETERAL INJURY IN AN IN-VIVO PORCINE MODEL

You have accessJournal of UrologyCME1 Apr 2023MP05-10 NATURAL HISTORY OF URETERAL INJURY IN AN IN-VIVO PORCINE MODEL Sohrab N. Ali, Paul Piedras, Seyed Amiryaghoub M. Lavasani, Seyed Hossein H. Sharifi, Antonio R. H. Gorgen, Andrei D. Cumpanas, Yi Xi Wu, Zachary E. Tano, Pengbo Jiang, Roshan M. Patel, Jaime Landman, and Ralph V. Clayman Sohrab N. AliSohrab N. Ali More articles by this author , Paul PiedrasPaul Piedras More articles by this author , Seyed Amiryaghoub M. LavasaniSeyed Amiryaghoub M. Lavasani More articles by this author , Seyed Hossein H. SharifiSeyed Hossein H. Sharifi More articles by this author , Antonio R. H. GorgenAntonio R. H. Gorgen More articles by this author , Andrei D. CumpanasAndrei D. Cumpanas More articles by this author , Yi Xi WuYi Xi Wu More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003216.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteroscopy (URS) accompanied by passage of a ureteral access sheath (UAS) is a common procedure for the treatment of urolithiasis; however, the ureter may sustain an injury during UAS placement. The post-ureteroscopic lesion scale (PULS) is a validated scoring system for endoscopic detection of ureteral injury. PULS Grade 3 (perforation with less than 50% partial transection) and Grade 4 (greater than 50% partial transection) are considered severe injuries generally requiring prolonged stent placement. The natural history of these lesions if left unstented, is unknown. METHODS: Female Yorkshire pigs underwent ureteral sizing with Cook® urethral dilators (10-24 Fr) using a validated force sensor with forces limited to < 6 N; passage of the urethral dilators resulted in PULS Grade ≥3 in 13 ureters. These animals were excluded from the original study but were survived for another week without stent placement. On the seventh day, URS was performed to assess ureteral healing and PULS grade. Exact fisher test and Two-Tailed T-test were used to evaluate differences in PULS grade, location (proximal, mid, or distal) and number of dilator passages. RESULTS: Among thirteen PULS lesion Grades ≥3 (nine Grade-3 and four Grade-4) in 10 pigs, URS one week later revealed healing in ten ureters (77%) (nine Grade-0 and one Grade-2) (Figure 1); however, three ureteral strictures were noted, all associated with prior Grade-3 lesions (23%). In addition, there was no difference in the location of primary lesions becoming strictures (50% in proximal, 0% in medial and 33% in distal, p=0.2133). Ureters without stricture formation had a higher mean number of dilator passages compared to those that did not stricture, (5.2 vs 3.0, p=0.0374). CONCLUSIONS: Despite PULS 3 or 4 lesions, in the absence of ureteral stenting, the urothelium in 75% of ureters healed completely within a week. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e47 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab N. Ali More articles by this author Paul Piedras More articles by this author Seyed Amiryaghoub M. Lavasani More articles by this author Seyed Hossein H. Sharifi More articles by this author Antonio R. H. Gorgen More articles by this author Andrei D. Cumpanas More articles by this author Yi Xi Wu More articles by this author Zachary E. Tano More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-03 SAFE PASSAGE OF 16 FR URETERAL ACCESS SHEATHS

You have accessJournal of UrologyCME1 Apr 2023MP35-03 SAFE PASSAGE OF 16 FR URETERAL ACCESS SHEATHS Sohrab N. Ali, Amanda McCormac, Minh-Chau Vu, Andrew S. Afyouni, Mitchell O'Leary, Kathryn Osann, Michael Klopfer, Zachary E. Tano, Pengbo Jiang, Roshan M. Patel, Jaime Landman, and Ralph V. Clayman Sohrab N. AliSohrab N. Ali More articles by this author , Amanda McCormacAmanda McCormac More articles by this author , Minh-Chau VuMinh-Chau Vu More articles by this author , Andrew S. AfyouniAndrew S. Afyouni More articles by this author , Mitchell O'LearyMitchell O'Leary More articles by this author , Kathryn OsannKathryn Osann More articles by this author , Michael KlopferMichael Klopfer More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: During ureteroscopic stone therapy, the insertion of a 14 Fr ureteral access sheath (UAS) results in significant ureteral trauma in upwards of 20% of patients. In attempts to avert such injury, we developed a proprietary UAS force sensor. Our studies indicated that maintaining the force of insertion below 6 N would allow for non-injurious insertion of even a 16 Fr UAS. Herein, we sought to identify the clinical factors associated with the safe deployment of a 16 Fr UAS. METHODS: Two hundred and thirty-eight patients (250 renal units) were subject to having UAS insertion forces recorded. In each case, an attempt was made to initially pass a 16 Fr UAS; if 6 N was reached, the surgeon was advised to downsize to a 14 Fr UAS and if 6 N was again reached, the surgeon was advised to downsize to a 12 Fr UAS. A post-ureteroscopic lesion scale (PULS) was recorded for each case to assess for ureteral injury. Regression models were created to estimate the impact of adjusted variables on PULS value, 16 Fr UAS deployment, and maximum UAS insertion force. RESULTS: A 16 Fr UAS was deployed in 145 (58%) renal units with a mean maximum force of 5.5 N. Two renal units with high-grade ureteral injuries (PULS=3) were noted; however, in both cases, the safety threshold (6 N) was exceeded: 8.36 N and 8.91 N. Preoperative stents were strongly associated with successful passage of a 16 Fr UAS independent of tamsulosin (OR 3.184, p=0.002). Recently treated bacteriuria (OR 1.988, p=0.033), and preoperative antibiotics (OR 1.96, p=0.014) were also independent predictors of successful 16 Fr UAS deployment. Preoperative administration of tamsulosin was not found to be beneficial. CONCLUSIONS: Maintaining an insertion force of ≤ 6 N can avoid significant UAS associated ureteral injuries. Preexisting indwelling stents, recently treated bacteriuria, and preoperative antibiotics favored safe insertion of a 16 Fr UAS. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e469 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sohrab N. Ali More articles by this author Amanda McCormac More articles by this author Minh-Chau Vu More articles by this author Andrew S. Afyouni More articles by this author Mitchell O'Leary More articles by this author Kathryn Osann More articles by this author Michael Klopfer More articles by this author Zachary E. Tano More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR

You have accessJournal of UrologyCME1 Apr 2023MP35-02 CLINICAL MEASUREMENT OF MAXIMUM SAFE URETERAL DISTENSIBILITY USING A NOVEL FORCE SENSOR Amanda McCormac, Minh-Chau Vu, Andrew S. Afyouni, Zachary E. Tano, Sohrab N. Ali, Pengbo Jiang, Roshan M. Patel, Michael Klopfer, Jaime Landman, and Ralph V. Clayman Amanda McCormacAmanda McCormac More articles by this author , Minh-Chau VuMinh-Chau Vu More articles by this author , Andrew S. AfyouniAndrew S. Afyouni More articles by this author , Zachary E. TanoZachary E. Tano More articles by this author , Sohrab N. AliSohrab N. Ali More articles by this author , Pengbo JiangPengbo Jiang More articles by this author , Roshan M. PatelRoshan M. Patel More articles by this author , Michael KlopferMichael Klopfer More articles by this author , Jaime LandmanJaime Landman More articles by this author , and Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior clinical studies, using a novel UCI ureteral access sheath (UAS) force sensor have indicated that passage of a ureteral access sheath at <6 Newtons (N) results in no harm to the ureter. Armed with this information, we sought to define, for the first time, the natural distensibility of the human ureter using sequential urethral dilators in combination with the UCI force sensor while limiting the applied force to 6 N. METHODS: Seventy-five patients (46 females and 29 males) undergoing either ureteroscopy and/or percutaneous stone removal underwent ureteral sizing by passing a series of 35 cm long, urethral dilators in 2 Fr increments within the pre-defined force threshold limit of <6 N. After 6 N was attained, the size of the urethral dilator was recorded and then ureteroscopy was performed and a post-ureteroscopic lesion scale (PULS) was determined. Next, a similar sized UAS, up to 16 Fr was inserted as part of the planned procedure. A multivariable logistic regression analysis was performed assessing the impact of age, gender, tamsulosin, stents, and the combination of tamsulosin and stents on the ability to pass dilators >16 Fr. RESULTS: Among 75 patients, urethral dilators were successfully passed at the 6 N threshold in 37.3% at ≤12 Fr, 24% at 14 Fr, 24% at 16 Fr, and 14.6% at >18 Fr (18-24 Fr). The mean maximum dilator diameter was 14 Fr. Logistic regression revealed that preprocedural ureteral stenting favored passage of >16 Fr dilators (OR 15.47, 95% CI 1.44 – 166.86; p=0.024). Neither gender nor age were significant differentiators. The effect of tamsulosin alone was not statistically significant (OR 0.60, 95% CI 0.15 – 2.32; p=0.454). The interaction effect was not significant suggesting that the effect of stent plus tamsulosin did not differ from stent alone (OR for interaction = 1.85, range 0.089 – 38.63; p=0.690). CONCLUSIONS: The unstented human ureter can be safely sized to an average circumference of 14Fr; this increases to 16 Fr in the prestented ureter. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e468 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda McCormac More articles by this author Minh-Chau Vu More articles by this author Andrew S. Afyouni More articles by this author Zachary E. Tano More articles by this author Sohrab N. Ali More articles by this author Pengbo Jiang More articles by this author Roshan M. Patel More articles by this author Michael Klopfer More articles by this author Jaime Landman More articles by this author Ralph V. Clayman More articles by this author Expand All Advertisement PDF downloadLoading ...

Симультанная билатеральная ретроградная интраренальная хирургия c использованием тулиевого волоконного лазера.

Introduction. Urolithiasis is a common disease and up to 15% of patients have multiple kidney stones. Retrograde intrarenal surgery (RIRS) can be used in the surgical treatment of kidney stones because this method is highly effective. Patients with multiple kidney stones often necessitate several surgeries. In this study we our own experience of bilateral RIRS to analyze its effectiveness and safety. Materials and methods. From January 2021 to February 2022 the simultaneous bilateral RIRS were performed to 11 patients (7 man and 4 woman). The maximal size of stone was 21 mm (the average size of the right kidney was 15,0 mm ± 6,0 mm and the left kidney – 11,7 mm ± 4,3 mm). Average stone density was more than 1000 HU. The mean age of the patients was 57±13 years. Bilateral retrograde intrarenal surgery was performed simultaneously by two surgeons using flexible ureteroscopes using a SuperPulsed thulium fiber laser. The following parameters were assessed: surgical intervention time; stone free rate (SFR); degree of ureteral injury according to the post-ureteroscopic lesion scale (PULS); the need for drainage of the ureter in the postoperative period, assessment of the creatinine level, glomerular filtration rate (GFR) and C-reactive protein in the postoperative period; postoperative complications according to the Clavien-Dindo classification. Results and their discussion. The average duration of the surgery was 56±11 minutes. The SFR level was 90,9 %. At the final inspection of the ureters: on the right side injury Grade 0 according to the PULS scale was recorded in 10 patients, Grade 1 – in 2 patients; on the left side Grade 0 – in 9 patients, Grade 1 – in 2 patients. The surgery was completed with the installation of ureteral catheters in 10 and 9 cases on the right and left sides, respectively. Three surgical interventions ended with the installation of ureteral stents on one side or another. The level of creatinine and C-reactive protein in the postoperative period increased on average by 10.2±5.7 μmol/l and 1.8±0.6 mg/l, respectively. The GFR decreased by 7.2 ± 2.6 ml/min. A complication was registered in 1 patient – increased body temperature on the 1st day, stopped by antibiotic therapy (Clavien-Dindo II). Conclusions. Simultaneous bilateral RIRS using single-use flexible ureteroscopes and a SuperPulsed thulium fiber laser is a safe and effective procedure for patients with bilateral nephrolithiasis.

Comparison of retrograde intrarenal stone surgery with and without a ureteral access sheath using kidney injury molecule-1 (KIM-1) levels: a prospective randomized study.

The objective is to compare patients who underwent retrograde intrarenal surgery with and without a ureteral access sheath (UAS) using kidney injury molecule-1 (KIM-1) levels. We also examined the difference in kidney damage between standard and dual lumen UAS. Sixty patients diagnosed with kidney stones and scheduled for RIRS were randomized into three groups: RIRS without UAS (Group 1), 11Fr/13Fr Boston scientific Navigator™ UAS (Group 2), and 11Fr/13Fr dual lumen ClearPetra™ UAS (Group 3). Data were prospectively collected in consecutive patients. Urine KIM-1/Cr levels were measured preoperatively, at postoperative 4 h, and on a postoperative day 14. Stone size, location, number, pre- and postoperative stent use, operation time, stone-free rate (SFR), post-ureteroscopic lesion scale (PULS) grade, hospitalization duration, and complications were recorded. There was no significant difference in demographical parameters and preoperative KIM-1/Cr levels among the groups. Postoperative 4th-hour urine KIM-1/Cr levels were higher in patients without UAS than patients with UAS (1.86, 0.67, 0.63 Groups 1, 2, 3, respectively). In comparing group 1 with groups 2 and 3 separately, Group 1 had a statistically significantly higher value than both groups (p = 0.002, p = 0.001, respectively). According to UAS type, there was no significant difference between groups 2 and 3. The use of UAS during RIRS has been shown to reduce kidney injury in the evaluation with KIM-1. Different UAS types on kidney injury and which one can protect the kidneys more during the procedure; will be elucidated by prospective randomized studies involving larger patient groups and UAS types.

Average, and Maximum Ureteral Wall Thickness are Predictor Factor for Ureteroscopy Outcomes?

Objective: The aim of our study is to investigate the effect of average and maximum ureteral wall thicknesses measured by computed tomography before the operation on ureteroscopy results.Materials and Methods: This prospective study was conducted with 103 patients who underwent ureteroscopy for ureteral stones between July and December 2021. The maximum ureteral wall thickness in the region of the ureteral stone and the average of the ureteral wall thicknesses measured from the 3-6-9-12 lines were calculated by non-contrast computed tomography. The operation time, residual stone, double j insertion status, and intraoperative complication status were examined according to the average ureteral wall thickness and maximum wall thickness.Results: Of the 103 patients included in the study, 77 were male, and 26 were female. The mean age of the patients was 43.83±15.11 years. The mean stone length was 10.76±3.84 mm. The average ureteral wall thickness was 3.81±1.24 mm, while the maximum ureteral wall thickness was 4.9±1.8 mm. It was found that as the maximum, and average ureteral wall thickness increased, the operation time, residual stone, double insertion rate, and post-ureteroscopic lesion scale grade increased (p&amp;lt;0.05).Conclusion: Maximum and average ureteral wall thicknesses are predictive factors for ureteroscopy results.

The Impact of One Week of Pre-Stenting on Porcine Ureteral Luminal Circumference.

Objectives: Larger ureteral access sheaths (UASs) have the potential to improve ureteroscopic stone removal outcomes but are often avoided by surgeons because of concerns of ureteral injury. Using our novel UAS force sensor and previously defined force thresholds for ureteral injury, we sought to evaluate the impact of 1 week of stenting on the maximum safe dilation of ureteral luminal circumference. Methods: Twelve juvenile female Yorkshire pigs (24 ureters) were evaluated. The inner (i.e., luminal) circumference of each ureter was determined using Cook urethral dilators ranging from 8F to 24F in 2F increments, 37 cm in length. Each dilator was sequentially passed while applying the UAS force sensor to measure insertion force before and after 1 week of stent placement. Each ureter was randomized to receive either a 4.7F or 7.0F stent (20 cm). Maximum ureteral luminal circumference was defined as effective passage of the dilator to the ureteropelvic junction with ≤6 newtons (N) of force (the force threshold previously defined by porcine and clinical studies to avoid ureteral damage). After passage of the largest dilator at 6 N, flexible ureteroscopy was performed and a post-ureteroscopic lesion scale (PULS) was recorded. Results: After 1 week of stent placement, the median ureteral luminal circumference increased to 15F representing a mean increase of 3.8F ± 2.8F (p < 0.001). Twenty-one (88%) of the pre-stented ureters had an increase in luminal circumference, with 12 ureters (50%) dilated to ≥16F (p = 0.032), 6 ureters (25%) dilated to ≥18F, and in 2 cases a maximum size of 24F was recorded. The PULS grade was ≤2 in all cases, indicating no high-grade ureteral injuries. Laterality and stent size did not impact ureteral luminal circumference after pre-stenting (p = 0.232 and p = 0.337, respectively). Conclusions: One week of ureteral stenting resulted in nearly a 4F increase in the luminal circumference of porcine ureters.

Does Tamsulosin use before Ureteroscopy Increase the Success of the Operation?

To investigate the effect of preoperative tamsulosin use on the success and complications rates of ureteroscopy for ureteral stone removal. A randomised clinical trial. Department of Urology, Dursun Odabas Medical Center, Van Yuzuncu Yil University, Turkey, from December 2020 to June 2021. Patients were scheduled for ureteroscopy due to ureteral stones, and were randomly divided into two groups; 67 patients preoperatively were given 0.4 mg tamsulosin for 7 days and 70 patients were not given tamsulosin. Each patient's intraoperative surgical complications, preoperative and postoperative pain, postoperative fever, need for analgesia, stone-free rate, and double J ureteral stent (DJ) insertion rates were recorded and evaluated. A total of 137 patients, 103 (75.1%) males, and 34 (24.8%) females, were included. In 70 (51.1%) of these patients, the stone was on the right side, while in 67 (48.9%) the stone was on the left side. The stone was in the distal ureter in 47 (34.3%) patients, in the middle in 38 (27.7%) patients, and the proximal in 52 (37.9%) patients. The patients who were given tamsulosin had lower preoperative visual analog scale (p=0.02), operation time (p=0.003), post-ureteroscopic lesion scale (p=0.01), postoperative 24th-hour visual analog scale (p=0.03), fever (p=0.02), and analgesic need (p=0.04), while their rate of accessing the stone (p=0.02); and their stone-free rates (p=0.02) was higher. Preoperative tamsulosin use increases the success of the operation and reduces complications. Key Words: Tamsulosin, Ureteral calculi, Ureteroscopy.

A multicenter-based critical analysis of laser settings during intrarenal laser lithotripsy by the Turkish academy of urology prospective study group (ACUP study).

In this multicenter prospective study, we aimed to evaluate the use of holmium:yttrium-- aluminum-garnet laser during retrograde intrarenal surgery for kidney stones and the relationship between laser-related parameters and procedure-related perioperative parameters. The 769 patients whose laser setting parameters (fiber thickness, number of shots, frequency (max.), laser power (max.), and total energy) were completely registered were included in this study program. The intraoperative ureteral lesions were evaluated using postureteroscopic lesion scale (PULS) scores and the postoperative complications with the modified Clavien-Dindo classification system. The maximum levels of laser power and the frequency were used in the middle calyceal stones; the value of total energy consumed was found to be higher gain in cases with multiple stones (all parameters P < .05). There was a significant positive correlation among (mean number of shots [P < .001, r ¼ 0.46], frequency [P ¼ .009, r ¼ 0.1], maximum power [P < .001, r ¼ 0.11], total energy [P < .001, r ¼ 0.25]), anesthesia time (P < .001, r ¼ 0.42), surgery time (P < .001, r ¼ 0.47), and stone size. The mean number of shots increased (P < .001, r ¼ 0.25), and the frequency level decreased (P < .001, r ¼ -0.17) significantly with increasing Hounsfield unit (HU) values. Again, the mean number of shots and maximum laser power increased in correlation with the increasing hospitalization time (P ¼ .004, r ¼ 0.09 and P ¼ .02, r ¼ 0.07, respectively). In addition, it was observed that higher laser subparameter values and thicker fibers were used in PULS grade 2. As the stone size and HU values increased, laser-setting parameters were found to show significant variability. The increase in different parameters of the laser setting was found to be associated with longer anesthesia time, surgery time, and hospitalization period and increased risk of local trauma with PULS grade.

Ureteral access sheath-related injuries vs. post-operative infections. Is sheath insertion always needed? A prospective randomized study to understand the lights and shadows of this practice

ObjectiveTo compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion. Patients and methodsIn this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication. ResultsThe evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P = 0.03). ConclusionsUAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections. Clinical Trial Registration Number (ISRCTN registry number)55546280.

Lesiones relacionadas con la vaina de acceso ureteral frente a infecciones postoperatorias. ¿Es siempre necesaria la inserción de la vaina de acceso? Estudio prospectivo aleatorizado para comprender las luces y sombras de esta práctica

ObjectiveTo compare intraoperative ureteral injuries in RIRS with UAS insertion with the rate of postoperative infections after RIRS without UAS insertion. Patients and methodsIn this randomized trial, patients who received an indication for RIRS between January 2017 and December 2017 were divided into two groups. Group A had no UAS insertion and Group B had UAS insertion. Post-Ureteroscopic Lesion Scale (PULS) grading was performed after UAS or flexible ureteroscope removal. Proximal, middle and distal ureteral lesions were evaluated and compared according to the PULS scale. Additionally, patients in both groups were followed postoperatively to assess any infective complication. ResultsThe evaluation comprised 181 patients, 89 for group A and 92 for group B. Overall stone-free rate, clinically insignificant residual fragments, and final stone-free rate were 41.4%, 53.5%, and 95%, respectively. There were 33 (37.1%) patients with ureteral lesions in group A while 42 (45.6%) patients had ureteral lesions in group B, with no significant difference. On the other hand, the overall presence of postoperative infection rate was much higher for Group A (37.1% vs 16.3% P=.03). ConclusionsUAS insertion does not result in a higher number of ureteral injuries. UAS insertion during RIRS allows a lower rate of postoperative infections.Clinical Trial Registration Number (ISRCTN registry number): 55546280.

Can Urinary KIM-1 and NGAL Predict Management Endoscopic Surgery in Acute Unilateral Obstructive Stone Disease? Results from a Prospective Cohort Study

Introduction: Kidney injury molecule-1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) are the leading novel biomarkers used efficiently in acute kidney injury (AKI). The levels of these biomarkers increase especially in the early period of nephrotoxic and ischemic renal damage. In this study, we aimed to investigate the clinical importance of NGAL and KIM-1 biomarkers used in the effective evaluation of kidney functions in patients with acute unilateral obstructive stone disease (AUOSD) in the management of endoscopic surgery. Materials and Methods: We prospectively included patients who underwent endoscopic surgery due to AUOSD between January 2018 and December 2019. Urine KIM-1 and NGAL values of the patients were measured preoperative period, postoperative 4th h, and postoperative 7th day. The patients were evaluated according to the location and size of the stone, the degree of renal hydronephrosis, the duration of the operation, complications, and JJ stent placement. Results: The study enrolled 50 patients. Urinary KIM-1/Cr and urinary NGAL/Cr ratios were higher in postoperative 4th h than in others (p < 0.001). Also, we found that urinary KIM-1/Cr and urinary NGAL/Cr ratios with Grade 2 and higher hydronephrosis were statistically higher than Grade 0–1 hydronephrosis (p < 0.001 and p: 0.042, respectively). Additionally, a preoperative urinary KIM-1 value of 1.24 ng/mL had a sensitivity of 78% and a specificity of 63% to predict the presence of hydronephrosis. When urine KIM-1 and NGAL results were compared with surgery time, stone size and location, serum creatinine (sCr) value, and Post-Ureteroscopic Lesion Scale grade, the difference was not statistically significant. Postoperative 7th day NGAL/Cr and KIM-1/Cr ratios were statistically higher in those with JJ stents placed (p: 0.03 and p: 0.004, respectively). Conclusion: KIM-1 and NGAL can be used in our assessment of renal function in patients with AUOSD, even if sCr is normal. Also, these biomarkers can predict the presence of hydronephrosis. It can be helpful in determining the time of surgical treatment, as well as providing information in the follow-up of patients with JJ stents after treatment.

Determining the Safety Threshold for the Passage of a Ureteral Access Sheath in Clinical Practice Using a Purpose-Built Force Sensor.

Ureteral injury is a frequent complication of ureteral access sheath deployment. We sought to define the safe threshold of force for the passage of a ureteral access sheath using a novel ureteral access sheath force sensor. Ureteral access sheath-force sensor measurements were recorded in 210 renal units. A 16Fr ureteral access sheath was deployed initially based on a prior porcine study. If 6 N was reached, the surgeon was advised to downsize the 16Fr ureteral access sheath. In each case, a post-ureteroscopic lesion scale was recorded. Regression models were used to estimate the impact of adjusted variables on post-ureteroscopic lesion scale grade, 16Fr ureteral access sheath deployment, and peak force. A 16Fr ureteral access sheath was deployed in 127 (61%) renal units with a mean peak force of 5.7 N. Two high-grade ureteral injuries occurred; in both cases >6 N of force was recorded. Post-ureteroscopic lesion scale grade correlated directly with peak insertion force (p <0.01). Bacteriuria within 60 days of the procedure (OR 2.009, p=0.034), combination of preoperative stent plus oral tamsulosin (OR 2.998, p=0.045), and prior ipsilateral stone surgery (OR 2.13, p=0.01) were independent predictors of successful 16Fr ureteral access sheath deployment. Among patients with neither prior ipsilateral stone surgery nor preoperative stent, preoperative tamsulosin facilitated passage of a 16Fr ureteral access sheath (OR 2.750, p=0.034). Ureteral access sheath associated ureteral injury can be averted by limiting the insertion force to ≤6 N. Prior stone surgery, preoperative indwelling ureteral stent plus oral tamsulosin, and recently treated bacteriuria favored passage of a 16Fr ureteral access sheath. In the naïve, unstented patient, preoperative tamsulosin favored deployment of a 16Fr ureteral access sheath.

Üreter Taşı Hastalarında Postüreteroskopik Lezyon Skalası ile Emilen Irrigasyon Sıvısı Arasında Bağlantı Var Mı?

Objective: Post-Ureteroscopic Lesion Scale (PULS) is used to classify ureteral wall injury that occurs during ureteroscopy. In this study we presented the preliminary results of absorbed irrigation fluid volumes according to PULS grades. Material and Methods : Forty-four patients to whom 7F semirigid ureteoscopy was performed due to ureteral stone were included in the study. All patients received general anesthesia. Izotonic containing 1% ethanol was used as irrigation fluid. Ethanol concentration in venous blood was commenced to be measured at the start of irrigation use and was carried on at 15-minute intervals including the post-operative period in the recovery room. Absorbed fluid volume was calculated by using blood ethanol concentrations. Irrigation time, stone size and PULS grade were recorded. Results : Mean operation time was found to be 44.2 ± 19.9 minutes. Mean stone size was measured to be 12.7± 6 mm and mean irrigation fluid amount used was 1371±1262 ml. PULS grade of 0 was seen in 26 patients and that of 1 or more was seen in 18 patients. No patient had a PULS grade of 3 or 4. Mean absorbed fluid volume was measured to be 58 ± 50,6 ml. No significant correlation was found between PULS grade and mean absorbed fluid volume. Conclusion: Fluid absorption during URS is not correlated with the PULS grade. Semirigid URS is a safe treatment option for ureteral stone disease in terms of the level of irrigation fluid being absorbed.

Radiation exposure during retrograde intrarenal surgery (RIRS): a prospective multicenter evaluation

PurposeRetrograde intrarenal surgery (RIRS) may require extensive X-ray usage. We evaluated the impact of preoperative surgeon briefing regarding the inclusion and evaluation of fluoroscopy time (FT) and dose area product (DAP) in a multicenter study on the applied X-ray usage.MethodsA prospective multicenter study of 6 tertiary centers was performed. Each center recruited up to 25 prospective patients with renal stones of any size for RIRS. Prior to study´s onset, all surgeons were briefed about hazards of radiation and on strategies to avoid high doses in RIRS. Prospective procedures were compared to past procedures, as baseline data. FT was defined as the primary outcome. Secondary parameters were stone-free rate (SFR), complications according to the Clavien, SATAVA and postureteroscopic lesion scale. Results were analyzed using T test, chi-squared test, univariate analysis and confirmed in a multivariate regression model.Results303 patients were included (145 retro- and 158 prospective). Mean FT and DAP were reduced from 130.8 s/565.8 to 77.4 s/357.8 (p < 0.05). SFR was improved from 85.5% to 93% (p < 0.05). Complications did not vary significantly. Neither stone position (p = 0.569), prestenting (p = 0.419), nor surgeons’ experience (> 100 RIRS) had a significant impact on FT. Significant univariate parameters were confirmed in a multivariate model, revealing X-ray training to be radiation protective (OR − 44, p = 0.001).ConclusionsIncreased surgeon awareness of X-ray exposure risks has a significant impact on FT and DAP. This “awareness effect” is a simple method to reduce radiation exposure for the patient and OR staff without the procedures´ outcome and safety being affected.

Ureteral Access Sheath Deployment: How Much Force Is Too Much? Initial Studies with a Novel Ureteral Access Sheath Force Sensor in the Porcine Ureter

Introduction and Objectives: Ureteral injuries can occur during ureteral access sheath (UAS) deployment. The force exerted during deployment and the amount of force that results in ureteral injury is yet to be accurately quantitated. In this feasibility study, we developed and then tested a novel force-sensing device in our animal laboratory to identify the threshold force that results in a porcine ureteral injury. Methods: With Institutional Animal Care and Use Committee approval, we measured ureteral dilator and UAS deployment force using our proprietary University of California, Irvine Ureteral Access Sheath Force Sensor (UAS-FS). The exerted force was measured during deployment from the moment that the tip of the UAS was passed into the urethral meatus until it reached the renal pelvis; progression of the UAS along the ureter was monitored with fluoroscopy. Ureteroscopic evaluation was performed after deployment of each catheter/sheath ≥8F to assess for ureteral injury using the Postureteroscopic Lesion Scale (PULS). Results: Six juvenile Yorkshire female pigs (12 ureters) were studied. No injuries were detected when the deployment force was <4 Newtons (N), which was the case when the catheter/access sheath was ≤13F. Increasing UAS size >13F resulted in greater peak forces. In five of the pigs, ureters selected for 14F UAS deployment without previous sequential dilation were injured (PULS ≥3) at a mean threshold force of 4.84 N. Serial dilation had a higher threshold for PULS ≥3 at 5.56 N. Overall, injury of PULS ≥3 was routinely noted when the force applied exceeded 8.1 N. Conclusions: The UAS-FS reliably measured forces while deploying a UAS. Significant ureteral injury can routinely be avoided if the applied force is <4.84 N; PULS ≥3 routinely occurred when forces exceeded 8.1 N. Serial dilation may allow safe passage at higher deployment forces, as much as 5.56 N.

Risk Factors for Ureteral Damage in Ureteroscopic stone Treatment: Results of the German Prospective Multicentre Benchmarks of Ureterorenoscopic Stone Treatment-Results in Terms of Complications, Quality of Life, and Stone-Free Rates Project

Background: The Post-Ureteroscopic Lesion Scale (PULS) is a validated, standardised scale that classifies iatrogenic ureteral lesions during ureteroscopy (URS). Objective: To determine risk factors for the various PULS-grades caused by URS. Method: We prospectively investigated the independent influence of various risk factors in correlation with PULS-Grade 1+ and 2+ on 307 patients with ureterorenoscopic stone treatment from 14 German urologic departments. Results: The following are the outcomes of the study: 117 (38.4%) and 188 (61.6%) of the calculi (median stone size 6 mm) were found in the kidney or ureter; 70% and 82.4% underwent preoperative or postoperative ureteral stenting; 44.3 and 7.2% received laser or ballistic lithotripsy; 60% of the patients presented with PULS grade 1+ and 8% with PULS grade of 2+. Only intracorporal lithotripsy revealed a significant independent risk factor for PULS grade 1+ or 2+. Both laser and ballistic therapies raised the probability of PULS grade 1+ by the factors 3.6 (p < 0.001) and 3.9 (p = 0.021), respectively. The ORs in conjunction with PULS grade 2+ were 3.1 (p = 0.038) and 5.8 (p = 0.014) respectively. Neither endpoint exhibited a significant difference regarding the lithotripsic procedure (laser vs. ballistic). Conclusion: Intracorporal lithotripsy is associated with a significant increase in damage to the ureter; further research is needed to determine its long-term effects.