Stone Basket Research Articles

V9-04 DIRECT VISUALIZATION PERCUTANEOUS NEPHROLITHOTOMY WITHOUT FLUOROSCOPY

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) remains a challenging procedure associated with significant potential for patient morbidity. In an attempt to decrease the morbidity of PCNL, we have developed a novel technique employing direct visualization with ureteroscopy to decrease ambiguity associated with fluoroscopy guidance, while eliminating ionizing radiation exposure. In this video, we demonstrate PCNL techniques that obviate the need for fluoroscopy. METHODS: This video demonstrates fluoroless PCNL in a 56 year-old female with large left renal stone burden (>4 cm). The patient was positioned prone and split-leg. Utilizing visual and tactile cues, a super-stiff and standard guidewire were placed from below using a flexible cystoscope. Using flexible ureteroscopy, the ideal calyx for access was selected. Under ultrasound guidance, an access needle was placed into the selected calyx, which was directly visualized on ureteroscopy. With the aid of a stone basket, an access wire was pulled into the ureter to allow for subsequent exchange to a super-stiff guidewire. Under direct visualization with the ureteroscope, the balloon and access sheath were positioned. The ureteroscope was left with the tip occluding the ureteropelvic junction to prevent distal migration of fragments. Stone comminution was accomplished with an ultrasonic lithotripter. Stone-free status was assured intraoperatively using a combination of flexible nephroscopy and ureteroscopy. A nephrostomy tube and multipurpose angled ureteral catheter were placed under direct vision ureteroscopically to conclude the procedure. RESULTS: Operative time was 4 hours 36 minutes. Estimated blood loss was <50 mL. On post-operative day one, a 15 mAs low-dose CT (<1 mSv) demonstrated stone-free status. CONCLUSIONS: This technique combines the methods of many pioneering endourologic surgeons in a unique way to perform PCNL under direct visualization. We believe this technique offers significant promise both by eliminating uncertainties encountered when operating under fluoroscopic guidance and reducing the risk of radiation exposure to patients and operating room staff.

Percutaneous retrieval of PICC fractures via the femoral vein in six cancer patients.

To investigate the feasibility and safety of the interventional technique of retrieving the fractured peripherally inserted central catheter (PICC) segments within the vessels via the femoral vein. From July 2007 to January 2012, we performed percutaneous retrieval of PICC fractures in six cancer patients who accepted chemotherapy via PICC. The fractures occurred during the traction of the catheter and were diagnosed with chest plain film radiography and/or computed tomography. The patients included four cases of ovarian cancer, one case of breast cancer and one case of cervical cancer. The fractures were retained in the vessels of the patients for 1 to 10 days. According to the location of the ends of the PICC fractures, three methods were employed using the most commonly used interventional devices in the digital subtraction angiography suite. The PICC fractures were located in the subclavian vein, superior vena cava, right atrium, right ventricle or pulmonary arteries. During the procedures, a goose neck snare, pigtail catheter and stone basket catheter were used individually or in combination. The PICC fractures were removed successfully in all six patients via unilateral or bilateral femoral vein access. No major complications occurred during the operation or the follow-up period of 7 to 10 days. Via femoral vein access, PICC fractures could be removed with common interventional instruments such as a goose snare, basket catheter and pigtail catheter. The interventional retrieval is a safe, convenient and minimally invasive method for the removal of PICC fractures.

Stone formation from nonabsorbable clip migration into the collecting system after robot-assisted partial nephrectomy.

We describe a case in which a Weck Hem-o-lok clip (Teleflex, Research Triangle Park, USA) migrated into the collecting system and acted as a nidus for stone formation in a patient after robot-assisted partial nephrectomy. The patient presented 2 years postoperatively with left-sided renal colic. Abdominal computed tomography scan showed a 10 millimeter renal calculus in the left middle pole. After using laser lithotripsy to fragment the overlying renal stone, a Weck Hem-o-lok clip was found to be embedded in the collecting system. A laser fiber through a flexible ureteroscope was used to successfully dislodge the clip from the renal parenchyma, and a stone basket was used to extract the clip.

Concomitant Treatment of Ureteropelvic Junction Obstruction and Renal Calculi With Robotic Laparoscopic Surgery and Rigid Nephroscopy

The treatment of ureteropelvic junction obstruction (UPJO) and concomitant calculus poses a technically challenging situation. We present our experience with using rigid nephroscopy for renal calculi removal during robot-assisted pyeloplasy (RAP) for UPJO. From December 2010 to November 2012, 25 patients with UPJO had RAP at our institution; 9 of those had concurrent renal calculi, which were simultaneously treated with rigid nephroscopy. For stone extraction, a rigid ureteroscope was passed through an assistant trocar under laparoscopic vision directly into a previously created pyelotomy. The stones were extracted using a rigid grasper or stone basket through the rigid ureteroscope. For the removal of the stones within the upper and lower calyces, the rigid ureteroscope was introduced into the incised renal pelvis through robotic trocars if the "assistant trocar" route failed. Complete stone clearance was achieved in 8 of 9 patients. Residual calculi in 1 patient were removed with a single session of extracorporeal shock wave lithotripsy. At the mean follow-up of 10.2 months, no patients had obstruction or recurrent stones. The mean operative time was 187.1 minutes, which was 40.9 minutes longer than the mean operative time in patients without renal calculi. There was no significant difference in blood loss, hospital stay, complications, and success rates between patients with and without renal calculi. Our data suggest that the use of a concomitant rigid nephroscope and RAP is a safe and feasible option for the treatment of UPJO complicated with renal calculi.

Extracorporeal lithotripsy endoscopically controlled by ureterorenoscopy (LECURS): a new concept for the treatment of kidney stones—first clinical experience using digital ureterorenoscopes

To evaluate the feasibility and usefulness of extracorporeal lithotripsy endoscopically controlled by simultaneous flexible ureterorenoscopy (LECURS) and combined with Holmium laser lithotripsy for kidney stones surgery. Retrograde flexible ureteroscopy allowed stone visualization and intrarenal relocation when possible. Extracorporeal schock wave lithotripsy (ESWL) was performed under direct vision allowing constant focal zone adjustment for optimal stone fragmentation. Holmium laser lithotripsy was used simultaneously when necessary. Post-operative assessment included ultrasound at day one and abdominal CT scan 3 weeks later to evaluate for residual fragments. Six patients with kidney stones were recruited including 3 with relative contraindication to ESWL. One patient had a stone beyond an infundibular stenosis and 2 had multiple stones in a horseshoe kidney with an uretero-pelvic junction (UPJ) stricture. A 100 % stone fragmentation rate was obtained. Post-operative ultrasound was normal in 5 patients and showed slight peri-renal infiltration in the other. One patient developed an obstructive pyelonephritis requiring antibiotics and changing a double J to a ureteral catheter. No other complications were noted. Three patients (50 %) were stone free after LECURS. Three patients underwent a second-look procedure for small (<3 mm) retained residual fragments. No damage was seen with the digital ureteroscopes, laser fibers or stone baskets. This initial experience with LECURS has shown to be feasible and safe. This opens the opportunity for further evaluation of this approach in order to improve outcomes of both approaches.

The Use of a Ureteric Stone Basket for Removing Loose Bodies at Hip Arthroscopy

We present the use of a ureteric stone basket for arthroscopic removal of loose bodies from the hip joint. The technique is easy to perform and reduces the time required for loose body retrieval while minimizing the risk of iatrogenic damage to the cartilage surfaces of the joint.

Hollow steel tips for reducing distal fiber burn-back during thulium fiber laser lithotripsy

The use of thulium fiber laser (TFL) as a potential alternative laser lithotripter to the clinical holmium:YAG laser is being studied. The TFL's Gaussian spatial beam profile provides efficient coupling of higher laser power into smaller core fibers without proximal fiber tip degradation. Smaller fiber diameters are more desirable, because they free up space in the single working channel of the ureteroscope for increased saline irrigation rates and allow maximum ureteroscope deflection. However, distal fiber tip degradation and "burn-back" increase as fiber diameter decreases due to both excessive temperatures and mechanical stress experienced during stone ablation. To eliminate fiber tip burn-back, the distal tip of a 150-μm core silica fiber was glued inside 1-cm-long steel tubing with fiber tip recessed 100, 250, 500, 1000, or 2000 μm inside the steel tubing to create the hollow-tip fiber. TFL pulse energy of 34 mJ with 500-μs pulse duration and 150-Hz pulse rate was delivered through the hollow-tip fibers in contact with human calcium oxalate monohydrate urinary stones during ex vivo studies. Significant fiber tip burn-back and degradation was observed for bare 150-μm core-diameter fibers. However, hollow steel tip fibers experienced minimal fiber burn-back without compromising stone ablation rates. A simple, robust, compact, and inexpensive hollow fiber tip design was characterized for minimizing distal fiber burn-back during the TFL lithotripsy. Although an increase in stone retropulsion was observed, potential integration of the hollow fiber tip into a stone basket may provide rapid stone vaporization, while minimizing retropulsion.

A novel technique of percutaneous stone extraction in choledocholithiasis after cholecystostomy.

To evaluate the technical feasibility and clinical efficacy of percutaneous common bile duct stone extraction via cystic duct after percutaneous cholecystostomy. Twenty-five consecutive patients with choledocholithiasis underwent percutaneous stone extraction under conscious sedation. The stones were extracted through the 12-Fr sheath using Wittich nitinol stone basket under fluoroscopic guidance via cystic duct after percutaneous trnas-hepatic cholecystostomy. Common bile duct stones were successfully removed in 22 of the 25 patients (88%) by this new technique. The causes of failure in three patients were bile leakage, hematoma of the gallbladder and failure of cystic duct cannulation. Cystic duct injury during this procedure did not occur and there was no post-procedure mortality. The mean period of indwelling catheter was 8.7±4.6 days and the mean duration of hospitalization was 13.4±5.9 days. Percutaneous commmon bile duct stone extraction via the cystic duct through percutaneous cholecystostomy route is effective and feasible for treating choledocholithiasis.

Endoscopic removal of an intraventricular primitive neuroectodermal tumor: retrieval of a free-floating fragment using a urological basket retriever

The endoscopic resection of intraventricular tumors represents a unique challenge to the neurological surgeon. These neoplasms are invested deep within the brain parenchyma and are situated among neurologically vital structures. Additionally, the cerebrospinal fluid system presents a dynamic pathway for resected tumors to be mobilized and entrapped in other regions of the brain. In 2011, the authors treated a 3-year-old girl with a third ventricular mass identified on stereotactic brain biopsy as a WHO Grade IV CNS primitive neuroectodermal tumor. After successful neoadjuvant chemotherapy, endoscopic resection was performed. Despite successful resection of the tumor, the operation was complicated by mobilization of the resected tumor and entrapment in the atrial horn of the lateral ventricle. Using a urological stone basket retriever, the authors were able to retrieve the intact tumor without additional complications. The flexibility afforded by the nitinol urological stone basket was useful in the endoscopic removal of a free-floating intraventricular tumor. This device may prove to be useful for other practitioners performing these complicated intraventricular resections.

1.2 French stone retrieval baskets further enhance irrigation flow in flexible ureterorenoscopy

Ureterorenoscopy (URS) has revolutionized upper urinary tract stone therapy. However, the size of the working channel and the stone baskets limit irrigation flow as well as vision. This study determined further improvements of irrigation flow, deflection capacities and impairments of breaking resistance in a new 1.2 French (F) ultra-miniaturized basket. Irrigation measurements were performed in semirigid URS (semiURS, working channel 5F) and in flexible URS (flexURS, 3.6F) in 0°, 90° and 270° deflection with 1.2F, 1.8F, 1.9F and 2.2F baskets and compared with empty channel. Breaking strength of 1.2F, 1.8F and 1.9F baskets were evaluated using a material testing machine. Tested baskets affected irrigation in semiURS and flexURS (p < 0.05). Mean ± SEM (standard error of the mean) for semiURS flow rates counted 197.1 ± 2.0, 140.9 ± 1.6, 111.1 ± 1.5, 98.0 ± 1.3 and 77.1 ± 0.9 ml/min for empty channel, 1.2F, 1.8F, 1.9F and 2.2F baskets (p < 0.05). Using unbent flexURS flow rates of 44.2 ± 0.4, 20.4 ± 0.2, 5.9 ± 0.1, 5.4 ± 0.1 and 1.5 ± 0.1 ml/min for empty channel, 1.2F, 1.8F, 1.9F and 2.2F baskets, were observed (p < 0.05). The 1.2F versus 2.2F basket showed a 13.6-fold increase in flexURS irrigation (p < 0.05), while only the 2.2F basket reduced deflection by 20.3 %. The breaking strength decreased with a reduced basket size (1.2F: 6.4 ± 0.46 vs. 1.8F: 16.8 ± 2.79 vs. 1.9F: 32.2 ± 2.74 N, p < 0.05). Ultra-miniaturized baskets of 1.2F ensured a sufficient irrigation flow as needed for high quality vision in URS stone management. However, miniaturization of the 1.2F basket resulted in a reduced breaking strength compared with larger sized devices which in turn may hamper stone removal by an increased vulnerability.

Damage of Stone Baskets by Endourologic Lithotripters: A Laboratory Study of 5 Lithotripters and 4 Basket Types

Background. In some cases, the ureteral stone is simultaneously stabilized by a stone basket when endourologic lithotripsy is performed. This stabilization can be either on purpose or by accident. By accident means that an impaction in the ureter occurs by an extraction of a stone with a basket. A stabilization on purpose means to avoid a retropulsion of the stone into the kidney during lithotripsy. At this part of the operation, stone baskets have been frequently damaged. This severing of wires can lead to ureteral trauma because of hook formation. Material and Methods. In a laboratory setting, the time and the pulse numbers were measured until breaking the wires from four different nitinol stone baskets by using five different lithotripsy devices. The endpoint was gross visibledamage to the wire and loss of electric conduction. Results. The Ho:YAG laser and the ultrasonic device were able to destroy almost all the wires. The ballistic devices and the electrohydraulic device were able to destroy thin wires. Conclusion. The operating surgeon should know the risk of damagefor every lithotripter. The Ho:YAG-laser and the ultrasonic device should be classified as dangerous for the basket wire with all adverse effects to the patient.

Measurement of Stone Diameter with Three Sizes of Automatically Fixating Stone Baskets

Background: Complications after endoscopic retrieval of kidney and ureter stones are obviously related to the size of the stones as well as the experience of the surgeon and other factors. During the procedure it is sometimes difficult for surgeons to estimate stone size and therefore give prognostic advises. The visual perception of the stone size depends on the shape, colour, distance to the renoscope and dilatation of the ureter. This is the so-called binding problem, because shape, color and direction of motion are processed separately by different population of optical neurons. In order to establish a better prognostic rational especially for less experienced surgeons, we established an intra operative semi-quantitative measurement of the stone size supported by a stone basket. Materials and Methods: We modified the tipped, nitinol stone baskets from the company Urotech with diameters of 2.5, 3.0 and 4 FR. The handle of this basket has a spring mechanism, which automatically closes the basket and provides a predefined fixation force of the stones within the basket. On the handle we established a non-linear scale in mm by grabbing standardized balls or standardized screws. Result: The scales are nonlinear because of the nonlinear relation between the diameter of the stone and the distance of the slider. Also the scales differ in between the basket size, because of the different strain conditions due to the different wire sizes and materials or the spring and basket. Conclusion: This scale could be an important orientation for a surgeon during endourological procedures to estimate stone sizes. After further clinical experience a semi-quantitative visualization like green, yellow and red colors could help to predict potential complications due to large stone sizes. Finally it could bevery interesting for other disciplines like gastroenterology.

Migration of a Hem-o-Lok Clip to the Ureter Following Laparoscopic Partial Nephrectomy Presenting With Lower Urinary Tract Symptoms

We report a case of ureteral migration of a surgical clip after partial nephrectomy in which the clip was misdiagnosed as a ureteral stone. A 37-year-old woman had undergone laparoscopic partial nephrectomy of right renal cell carcinoma at another hospital 2 years previously. Postoperatively, she had gradually acquired lower urinary tract symptoms. Then, she complained of sudden right flank pain for a week. A plain X-ray and enhanced abdominopelvic computed tomography scan were performed. A 0.5 cm×1.0 cm right upper ureteral opacity with borderline hydronephrosis was seen but could not be found on the X-ray. Ureteroscopy revealed a medium-sized Hem-o-Lok clip on the right upper ureter that was removed with a stone basket. We concluded that a Hem-o-Lok clip used for collecting system sealing had migrated to the ureter and had been misdiagnosed as a ureteral stone on a computed tomography scan.

A new set of instruments for laparoscopic pyeloplasty: development and assessment

Objective To overcome some difficulties and technical challenges encountered during pure laparoscopic pyeloplasty,we designed a set of new instruments and assessed them using porcine model.Methods According to the ideas from the surgeons,our medical engineer designed three new instruments,including the right angle laparoscopy scissors,the petal-shape ureter dilator and the guide tube.Four experienced laparoscopic experts were involved in a no survival porcine study to assess the help of these new instruments.Four experiments were conducted on live pigs that weighed 22 to 25 kg at the same time.After general anesthesia was administered,transperitoneal ureteroureterostomy was performed using standard laparoscopic instruments,including placing the double J stent anterograde.Then,the opposite lateral was done by the same surgeon plus these new devices for side-by-side comparative analysis.All experts were interviewed to assess these new instruments by the questionnaire based on the visual analog scale (VAS) from 1 (none) to 10 (very much).Results The procedures were all technically successful.The right angle laparoscopy scissors and the guide tube were accepted by all participants and the Help Scores was 6.75 and 4.25 respectively,at the same time the New Difficulty Score 1.25 and 1.75.However,the petal-shape ureter dilator got 1.50 Help Score and 6.50 New Difficulty Score,these surgeons made a negative comment and one of surgeons recommended the stone basket more suitable.Conclusion The right angle laparoscopy scissors and the guide tube may be helpful to minimize some difficulties in pure laparoscopic pyeloplasty.The petal-shape ureter dilator needs improvement. Key words: Laparoscopy; Pyeloplasty ; Instrument; Pig

Preventing stone retropulsion during intracorporeal lithotripsy

Several studies of ureteroscopic treatment for ureteral stones have reported that most stone clearance failures can be attributed to stone fragment retropulsion. Stone retropulsion can result in increased operative time and cost-resulting from the need to change from the semi-rigid ureteroscope to a flexible instrument to chase migrated calculi-and additional procedures to treat residual migrated fragments are often required. The degree of migration depends mainly on the energy source used for lithotripsy; pneumatic and electrohydraulic lithotripters are associated with a greater degree of retropulsion than lasers. Different stone-trapping strategies and devices have been developed to minimize stone migration. Novel devices include the Lithovac(®) suction device, the Passport(™) balloon, the Stone Cone(™), the PercSys Accordion(®), the NTrap(®), and stone baskets such as the LithoCatch(™), the Parachute(™), and the Escape(®). Some authors have also reported on the use of lubricating jelly and BackStop(®) gel (a reverse thermosensitive polymeric plug); these devices are instilled proximal to the stone prior to the application of kinetic energy in order to prevent retrograde stone migration.

Could titanium oxide coating from a sol-gel process make stone baskets more resistant to laser radiation at 2.1 μm?

BackgroundStone baskets could be easily destroyed by Holmium:YAG-laser at an endourologic treatment, with respect to this, we try to improve the resistance by coating them with a titanium oxide layer. The layer was established by a sol–gel-process.Materials and methodsSix new baskets (Equadus, Opi Med, Ettlingen, Germany) were used: 1.8 Ch. with 4 wires (diameter 0.127 mm). Three baskets were coated with a layer of titanium oxide established by a sol–gel process at the BioCerEntwicklungs GmbH in Bayreuth (~100 nanometres thickness). The lithotripter was a Holmium:YAG laser (Auriga XL, Starmedtec, Starnberg, Germany). 10 uncoated and 10 coated wires were tested with 610 mJ (the minimal clinical setting) and 2 uncoated and 2 coated wires were tested with 110 mJ. The wires were locked in a special holding instrument under water and the laser incident angle was 90°. The endpoint was gross visible damage to the wire and loss of electric conduction.ResultsOnly two coated wires resisted two pulses (one in the 610 mJ and one in the 110 mJ setting). All other wires were destroyed after one pulse.ConclusionThis was the first attempt at making stone baskets more resistant to a Holmium:YAG laser beam. Titanium oxide deposited by a sol–gel-process on a titanium-nickel alloy did not result in better resistance to laser injuries

Residual Fragments Following Ureteroscopic Lithotripsy: Incidence and Predictors on Postoperative Computerized Tomography

Residual fragments following ureteroscopy for calculi may contribute to stone growth, symptoms or additional interventions. We reviewed our experience with ureteroscopy for calculus disease to define the incidence and establish factors predictive of residual fragments. Records associated with 667 consecutive ureteroscopic lithotripsy procedures for upper urinary calculi were reviewed. In 265 procedures (40%) computerized tomography was done between 30 and 90 days postoperatively. They comprised the study group. Residual fragments were defined as any residual ipsilateral stone greater than 2 mm. Included in the study were 121 men and 127 women with a mean age of 47 years. Mean target stone diameter was 7.6 mm. The stone location was the kidney in 30% of cases, ureter in 50%, and kidney and ureter in 20%. Residual fragments were detected on computerized tomography after 101 of 265 procedures (38%). Pretreatment stone size was associated with residual fragments at a rate of 24%, 40% and 58% for stones 5 or less, 6 to 10 and greater than 10 mm, respectively (p <0.001). Additionally, stone location in the kidney (p <0.001) or the kidney and ureter (p = 0.044), multiple calculi (p = 0.003), longer operative time (p = 0.008) and exclusive use of flexible ureteroscopy (p = 0.029) were associated with residual fragments. In a multivariate model only pretreatment stone diameter greater than 5 mm was independently associated with residual fragments after ureteroscopy (diameter 6 to 10 and greater than 10 mm OR 2.03, p = 0.03 and OR 3.74, p = 0.003, respectively). Of patients who underwent ureteroscopic lithotripsy for calculi 38% had residual fragments by computerized tomography criteria, including more than 50% with stones 1 cm or greater. Such data may guide expectations regarding the success of ureteroscopy in attaining stone-free status.

1835 EQUIPMENT USE DURING URETEROSCOPY: IS THERE A DIFFERENCE BETWEEN TERTIARY CARE CENTERS AND COMMUNITY HOSPITALS?

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20121835 EQUIPMENT USE DURING URETEROSCOPY: IS THERE A DIFFERENCE BETWEEN TERTIARY CARE CENTERS AND COMMUNITY HOSPITALS? Justin Friedlander, Bin Xu, Zhamshid Okhunov, Cristina Sison, Brian Duty, Nikhil Waingankar, Zeph Okeke, and Arthur Smith Justin FriedlanderJustin Friedlander New Hyde Park, NY More articles by this author , Bin XuBin Xu Shanghai, China, People's Republic of More articles by this author , Zhamshid OkhunovZhamshid Okhunov New Hyde Park, NY More articles by this author , Cristina SisonCristina Sison Manhasset, NY More articles by this author , Brian DutyBrian Duty New Hyde Park, NY More articles by this author , Nikhil WaingankarNikhil Waingankar New Hyde Park, NY More articles by this author , Zeph OkekeZeph Okeke New Hyde Park, NY More articles by this author , and Arthur SmithArthur Smith New Hyde Park, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1923AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We sought to investigate whether there exists a difference in disposable equipment usage during ureteroscopy between tertiary (TH) and community hospitals (CH). METHODS We performed a retrospective review of ureteroscopy procedures for calculus disease at two tertiary care centers and two community hospitals from January through October 2010. Cases were identified by procedural code for ureteral calculus. Variables under examination included patient demographics, surgeon training level, hospital setting, clinical stone characteristics, instruments and materials used, and clinical outcomes. Cost data for disposable equipment was obtained from health system billing records. Mann-Whitney and Chi-square tests were used to analyze continuous and categorical variables, respectively. Multivariable regression analysis was performed. RESULTS Of the 318 procedures evaluated, 80.8% (257) were performed at TH versus 19.2% (61) performed at CH. There was no difference in mean stone size, procedures treating more than 1 stone, mean operating room time, use of more than 1 wire during a procedure, or mean disposable equipment cost (TH 861.30 vs CH 802.30, p=0.91) between the two groups. Significant differences were found between TH and CH for Holmium laser use (65.4% vs 49.2%, p=0.03), balloon dilator use (31.5% vs 73.8%, p<0.0001), ureteral access sheath use (27.6% vs 4.9%, p<0.0001), dual lumen catheter use (22.2% vs 1.6%, p<0.0001), use of stone baskets (95.7% vs 86.9%, p=0.015), and the presence of a stent in place prior to definitive ureteroscopy (26.9% vs 14.8%, p=0.049). The stone-free rate for TH was 91.4% versus 86.9% at CH, this was not statistically significant (p=0.32). Multivariable regression analysis revealed that stone size (p <0.001) and the presence of a stent at the time of ureteroscopy (p=0.0006) were significantly associated with cost of disposable equipment charged. CONCLUSIONS We found no difference in cost of disposable equipment used during ureteroscopy between TH and CH. TH demonstrated more frequent use of the Holmium laser, ureteral access sheaths, dual lumen catheters, and stone baskets, whereas CH demonstrated more frequent use of ureteral balloon dilation. Stone-free status was greater at TH than CH; however, this did not reach statistical significance. Table 1. Descriptive Statistics and Equipment Usage Tertiary Care Hospitals (TH) Community Hospitals (CH) p-value Mean stone size (in mm) 6.48 6.41 0.98 Patients with stone size ≥ 7 mm 60.3%(155/257) 62.3%(38/61) 0.88 More than 1 stone treated 24.9%(64/257) 21.3%(13/61) 0.62 Stone location Kidney 10.1%(26/257) 1.6%(1/61) Ureter 85.6%(220/257) 93.4%(57/61) Both kidney and ureter 4.3%(11/257) 4.9%(3/61) Mean OR time (in minutes) 47.22 45.90 0.95 Mean disposable equipment cost (in US dollars) 861.30 802.30 0.91 Use of more than 1 wire 53.3%(137/257) 49.2%(30/61) 0.57 Holmium laser use 65.4%(168/257) 49.2%(30/61) 0.03 Balloon dilator use 31.5%(81/257) 73.8%(45/61) <0.0001 Ureteral access sheath use 27.6%(71/257) 4.9%(3/61) <0.0001 Dual lumen catheter use 22.2%(57/257) 1.6%(1/61) <0.0001 Anti-retropulsion device use 3.9%(10/257) 8.2%(5/61) 0.18 Stone basket use 95.7%(246/257) 86.9%(53/61) 0.015 Stent in place before ureteroscopy 26.9%(69/257) 14.8%(9/61) 0.049 Stent after ureteroscopy 91.4%(235/257) 96.7%(59/61) 0.28 © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e742 Peer Review Report Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Friedlander New Hyde Park, NY More articles by this author Bin Xu Shanghai, China, People's Republic of More articles by this author Zhamshid Okhunov New Hyde Park, NY More articles by this author Cristina Sison Manhasset, NY More articles by this author Brian Duty New Hyde Park, NY More articles by this author Nikhil Waingankar New Hyde Park, NY More articles by this author Zeph Okeke New Hyde Park, NY More articles by this author Arthur Smith New Hyde Park, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1707 URONET™: A NOVEL DEVICE FOR MANAGING PATIENTS WITH BLADDER AND RENAL STONES

INTRODUCTION AND OBJECTIVES: For patients treated for large bladder and renal stones, open lithotomy, percutaneous approach and transurethral cystolithalapaxy have been the standard of care. Complete removal of these stones is paramount to eliminate stone burden and to help prevent stone recurrence. We describe our experience with a new device for evacuation of large bladder stones by percutaneous cystolithalapaxy and staghorn renal stone(s) removal by percutaneous nephrolithotomy (PCNL). METHODS: We treated 20 patients who presented with bladder stones (10) and/or renal stones (12). The mean stone burden was 6 cm and 3 cm for bladder and renal stones, respectively. The mean age of patients was 56 years with male predominance of 9:1 in the bladder stone group and parity of gender with 5:5 ratio for renal stones. Extraction of stones following cystoscopy/laser lithotripsy (7), percutaneous cystolithalapaxy (2) or stone manipulation (1) of bladder stones and percutaneous nephrolithotomy (12) for renal stones were performed with the UroNetTM (US Urology, Cleveland, Ohio). Stones were extracted using the 5.4F or 9.6F UroNetTM mesh (3.0cm x 1.25cm) device for percutaneous cystolithalapaxy or PCNL, respectively. RESULTS: The smaller UroNetTM device was ideal for removal of bladder stones and the larger device successfully removed stones within the kidney. The UroNetTM was ideal for removal of stones between 2-10mm in size and the softer, sludge-like stones. In one patient undergoing a PCNL procedure, extraction of 108 renal stones was completed with 25 passages of the UroNetTM. Smaller particles were extracted by aspiration techniques. All patients had successful treatment of stones without any complications. Stone composition included Calcium Oxalate (9), Calcium Phosphate (5), Struvite (2), Uric Acid Stones (3) and mixed type stones (3). CONCLUSIONS: The UroNetTM is a safe, reliable and efficient disposable device to remove multiple stone fragments with each passage of the device. The limited passage of instruments helps minimize trauma to the bladder, urethra and kidney during cystolithalapaxy and PCNL procedures. More efficient stone extraction also decreased operative and anesthesia times. Prospective studies are currently underway to compare classic stone baskets to the UroNetTM.

Acute Postoperative Pain after Ureteroscopic Removal of Stone: Incidence and Risk Factors

PurposeUreteroscopic removal of stones (URS) has been widely used to treat ureteral stones because it is comparatively safe, has a high success rate, and enables patients to rapidly return to their daily routines. However, some patients experience pain after URS, but the incidence of acute post-URS pain remains largely unknown. This study aimed to investigate the incidence of acute postoperative pain after URS and the associated risk factors.Materials and MethodsData for 143 consecutive patients who underwent URS from June 2008 to December 2010 were collected. After excluding 8 patients who developed intraoperative complications, the patients were divided into two groups according to postoperative pain on the first postoperative day. Acute postoperative pain was defined as a pain score greater than 4 on a visual analogue pain scale (normal range, 0 to 10). Various factors were analyzed to identify the risk factors that could predict acute postoperative pain after URS.ResultsThe stone-free rate without URS intraoperative complications was 95.5%. A total of 21 (14.6%) patients experienced postoperative pain on the first postoperative day. Young age, psychiatric illness, history of urinary tract infection, use of a stone basket, large stone size, and prolonged operation time were identified as risk factors for acute postoperative pain.ConclusionsThe incidence of acute postoperative pain is not that low and should not be overlooked, because it is associated with postoperative complications that could result in an unscheduled hospital admission or visit. Active pain control should be contemplated after URS in young patients and in those with a history of urinary tract infection, psychiatric illness, large stone size, and prolonged operation time.