Therapeutic Ureteroscopy Research Articles

MP40-10 SURVIVAL OUTCOMES OF UPPER TRACT UROTHELIAL CARCINOMA PATIENTS TREATED WITH THERAPEUTIC ENDOSCOPIC MANAGEMENT

You have accessJournal of UrologyCME1 May 2022MP40-10 SURVIVAL OUTCOMES OF UPPER TRACT UROTHELIAL CARCINOMA PATIENTS TREATED WITH THERAPEUTIC ENDOSCOPIC MANAGEMENT Wesley Yip, Peter Reisz, Amy Tin, Nicole Benfante, Eugene Cha, Eugene Pietzak, Ari Hakimi, and Jonathan Coleman Wesley YipWesley Yip More articles by this author , Peter ReiszPeter Reisz More articles by this author , Amy TinAmy Tin More articles by this author , Nicole BenfanteNicole Benfante More articles by this author , Eugene ChaEugene Cha More articles by this author , Eugene PietzakEugene Pietzak More articles by this author , Ari HakimiAri Hakimi More articles by this author , and Jonathan ColemanJonathan Coleman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002600.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical nephroureterectomy for upper tract urothelial carcinoma (UTUC) is associated with significant morbidity and renal dysfunction. Interest has increased in endoscopic, kidney-sparing treatment options. We aim to characterize the survival outcomes of UTUC patients treated with therapeutic ureteroscopy (tURS) at our institution. METHODS: We retrospectively reviewed all patients treated for UTUC with tURS, defined as two or more URS with therapeutic intent to eradicate all visible tumor. Kaplan-Meier figures were created for three outcomes, including progression-free (PFS), metastasis-free (MFS), and cancer-specific survival (CSS). Progression was defined as converting from negative or low to high-grade disease on follow-up URS, proceeding to systemic therapy, or undergoing ureterectomy/nephroureterectomy. The association between each outcome and certain risk factors at diagnostic URS (tumor grade/size/multiplicity, carcinoma in situ, and variant histology) was assessed by univariable Cox proportional hazard regression models. RESULTS: 89 patients underwent tURS between 2010 and 2021. Median age was 70 years (IQR 62, 78), the majority were male (69%), and with clinical Ta disease (81%). 33 (37%) patients underwent tURS at the same time as their initial diagnostic URS. Among the remaining 56 patients, the median time from diagnostic to therapeutic URS was 10 weeks (IQR 5, 21). 43 patients progressed, 5 patients developed metastases, and 3 patients died from disease. Median follow-up among patients who did not progress was 2.1 years. Of the patients who progressed, 12 (28%) had high-grade disease on follow-up URS, 4 (9.3%) underwent systemic therapy, 26 (60%) underwent nephroureterectomy, and 1 (2.2%) underwent ureterectomy. Kaplan-Meier estimated one-year and three-years PFS were 68% (95% CI 58%, 79%) and 58% (95% CI 48%, 70%), respectively (Figure 1). Kaplan-Meier estimated 5-year MFS and CSS were 91% (95% CI 83%, 100%) and 96% (95% CI 91%, 100%), respectively. CONCLUSIONS: Endoscopic management is an efficacious treatment option for highly selected UTUC patients based on PFS. A proportion of patients may proceed to salvage therapies; however, metastases and death from disease are rare. Source of Funding: Thompson Family Foundation, Ruth L. Kirschstein National Research Service Award T32CA082088 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e677 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wesley Yip More articles by this author Peter Reisz More articles by this author Amy Tin More articles by this author Nicole Benfante More articles by this author Eugene Cha More articles by this author Eugene Pietzak More articles by this author Ari Hakimi More articles by this author Jonathan Coleman More articles by this author Expand All Advertisement PDF DownloadLoading ...

Therapeutic ureteroscopy for urolithiasis in children younger than 60months of age.

The management of urinary tract calculi has evolved dramatically in children with the development of smaller and more durable endoscopic equipment. The indications for therapeutic ureteroscopy in children have significantly expanded with the availability of smaller caliber endoscopes and Holmium:YAG laser. In this paper, we review our experience of the management of urolithiasis and report outcomes of therapeutic ureterorenoscopy (URS) in children younger than 60months. We retrospectively reviewed the inpatient, outpatient records, and imaging data of our hospital, of all children ≤ 60months of age undergoing URS for the treatment of urinary stones. During the study period; 77 children, mostly male (70.1%) presenting with a single calculus and a mean age of 28.97 ± 2.44months underwent therapeutic URS. A majority of children (71.4%) had lower or mid-ureteric calculi. Pre URS double J (DJ) stenting was necessary for 21 (27.2%) children. A total of 24 (31.1%) children needed ureteric dilatation before the ureteroscopy. Post URS DJ stenting was necessary in 41 (53.2%) children. Stents were retrieved within 10days of the procedure. Stone clearance rate following a single-stage URS procedure was 94.8%, and 4 (5.2%) children needed additional shockwave lithotripsy (SWL) to achieve stone clearance. Overall complication rate including hematuria and fever was 12.9% (10 patients). Therapeutic ureterorenoscopy in the management of ureteric and selective renal pelvic calculi is safe and effective. It can be considered as the first-line therapy in young children.

Adjuvant Single-Dose Upper Urinary Tract Instillation of Mitomycin C After Therapeutic Ureteroscopy for Upper Tract Urothelial Carcinoma: A Single-Centre Prospective Non-Randomized Trial.

Purpose: To address the safety and feasibility of adjuvant single-dose upper urinary tract instillation of mitomycin (ASDM) immediately after therapeutic ureteroscopy for upper tract urothelial carcinoma (UTUC) and to compare urothelial (ipsilateral or bladder) recurrence rates in the ASDM group and controls. Materials and Methods: Between April 2015 and August 2018, 52 patients affected by UTUC were treated by endoscopic ablation, of whom 26 were selected for ASDM. Clinical and perioperative data and 30-day complications were recorded. Urothelial recurrence-free survival (URFS) was evaluated with second-look ureteroscopy (URS) and CT scan/URS every 6 months. Results: ASDM was administered through a Single-J (19/25, 76%) or a Double-J (6/25, 24%) in 25/26 (96%) patients. Median follow-up was 18 months (IQR 10-29). The urothelial recurrence rate was 23.5% and 55.5% in the ASDM group and controls, respectively (p = 0.086). Mean URFS was 28.8 months in the ASDM group vs 18.8 months in controls (log-rank p = 0.067). On multivariate Cox regression, ASDM was associated with a 7.7-fold lower risk of urothelial recurrence (HR = 0.13; 95% CI 0.03-0.65; p = 0.01). Clavien grade ≤II complications occurred in 32% (8/25) and 30.7% (8/26) of the ASDM and control group, respectively (p = 0.9). Two Clavien III complications occurred in the ASDM group: bladder hematuria after concomitant transurethral resection of bladder and obstructive kidney failure in a single-kidney patient. Conclusions: ASDM was well tolerated after therapeutic URS. It appears to reduce the risk of urothelial recurrence in patients affected by low-grade UTUC without bladder tumor. Therefore, its use should be evaluated.

SC321 - Immediate upper urinary tract instillation of mitomycin C after therapeutic ureteroscopy for upper tract urothelial carcinoma

SC321 - Immediate upper urinary tract instillation of mitomycin C after therapeutic ureteroscopy for upper tract urothelial carcinoma

743 - Adjuvant single-dose upper urinary tract instillation of mitomycin-C after therapeutic ureteroscopy for upper tract urothelial carcinoma: Preliminary results

743 - Adjuvant single-dose upper urinary tract instillation of mitomycin-C after therapeutic ureteroscopy for upper tract urothelial carcinoma: Preliminary results

Early complications of diagnostic and therapeutic ureteroscopy

Objective: The aim of this study is to report early complications of diagnostic and therapeutic ureteroscopy and to grade each complication according to modified Clavien classification system (MCCS). Materials and Methods: Through a prospective study conducted from March to September 2017, all patients who underwent diagnostic and therapeutic semirigid ureteroscopy were evaluated. The procedure was performed by different surgeons. The recording data included patient demographics, ureteroscopy site (left, right, or bilateral), aim of ureteroscopy (diagnostic or therapeutic), operative time, additional intervention, stone-free rate, double J stent placement, and complications which were graded according to the modefied clavien classification system with their management. Results: One hundred and fifty patients were included in the study. The average age was 39.9 years and male-to-female ratio 2.3/1. The number of patients who underwent right, left, and bilateral ureteroscopy was 74 (49.3%), 64 (42.3%), and 12 (8%), respectively, so the overall number of ureteroscopy procedures was 162. Diagnostic ureteroscopy was done in 20 (13.3%) patients and therapeutic ureteroscopy in 130 (87.7%). Complications occurred in 37.3% of patients. According to MCCS, Grade I, II, IIIa, IIIb, IVa, IVb, and V complications were detected in 40 (26.6%), 6 (4%), 10 (6.7%), 14 (9.3), 0 (0.0%), 2 (1.3%), and 0 (0.0%) of cases, respectively. Conclusion: Ureteroscopy becomes the prevailing procedure for different ureteral pathologies mainly stones with a good safety and efficacy. It is important to adopt a precise classification system for reporting the complications of ureteroscopy. Most of the complications are of low grade and they are amenable to conservative management. The complications of ureteroscopy will continue to decline as the ureteroscopic technology evolved.

Ureteroscopie Retrograde: Expérience de l’Hôpital Général Grand Yoff de Dakar

ObjectiveTo present the results of the ureteroscopy at the GrandYoff General Hospital (Hoggy) in Dakar (Senegal). Subjects and methodsThis is a descriptive study of 91 ureteroscopy procedures performed at the Urology department of Grand Yoff General Hospital from January 2012 to December 2013. The variables of the study were indication, age, type of ureteroscopy associate or no laser, results of lithotripsy. ResultsSeven diagnostic ureteroscopy and 84 therapeutic ureteroscopy were done. The average age of the patients was 44.7 years+- 13,9 years. Semi-rigid ureteroscope was used in 43 cases, flexible ureteroscope in 15 cases and rigid ureteroscope in 9 cases. The location of the stones was renal pelvis in 30 cases, upper ureter in 28 cases, distal ureter in 13 cases, calix in 10 cases and middle ureter in 3 cases. The number of laser (Nd:Yag) fragmented stones was 87. Complications were dominated by false passages in 8 cases. The overall success of endoscopic treatment was 85.7%. ConclusionThe current practice of endoscopic treatment for upper urinary tract stone is quite challenging to the urologist practising in sub- Sahara Africa. The effectiveness and lesser morbidity of laser lithotripsy has made it the treatment of choice for upper urinary tract stones.

Indications, outcome and complications of ureteroscopy, at Gezira Hospital for renal diseases and surgery, Sudan: a seven years ‘experience

Background: Ureteroscopy (rigid and flexible) with irrigating and working channels have expanded the capability of the urologist to diagnose and treat most abnormalities of the upper tracts. Objective: This study was conducted as a part of holistic auditing to the services provided by Gezira Hospital for Renal Disease and Surgery (GHRD&S), and specifically to evaluate ureteroscopy done in GHRD&S with emphasis on the indications, outcome and complications. Methods: Across-sectional- hospital-based study was adopted. All patients who underwent ureteroscopy since the inauguration of the hospital from 2005-2011 were included. Results: The total number of patients satisfying the inclusion criteria was 472 with a mean age of 40.6 years. Male to female ratio was 1.46:1. The mean hospital stay was 2.74 days.The commonest indication for ureteroscopy was ureteric stone amounting (74%) to a tangible share of ureteric stenting or removal as indication were found in (56.8%) . and therapeutic ureteroscopy for (92.3%). Ureteric stricture was not uncommon (24%). The success rate of therapeutic ureteroscopy was (93.7%) with definite correlation to the site of pathology been (91.75%), (92.3 %) and (87.5%) for the lower, mid and upper ureter respectively. The complications recorded were bleeding (3.3%), penetration (2.5 %), post-operative colic (13%) and infection (0.4%). Mortality rate was zero Conclusion: Because the experience of ureteroscopy in GHRD&S was auspiced by regular training from the SIU the outcome is really comparable to the literature. Keywords: Ureteroscopy, Gezira Hospital for Renal Disease and Surgery, Wad Medani, Success and safety

MP73-19 URETEROSCOPY SIMULATION - A SYSTEMATIC REVIEW OF CURRENT TRAINING MODALITIES

You have accessJournal of UrologyStone Disease: Evaluation III1 Apr 2014MP73-19 URETEROSCOPY SIMULATION - A SYSTEMATIC REVIEW OF CURRENT TRAINING MODALITIES Oliver Brunckhorst, Abdullatif Aydin, Hamid Abboudi, Muhammad Khan, Prokar Dasgupta, and Kamran Ahmed Oliver BrunckhorstOliver Brunckhorst More articles by this author , Abdullatif AydinAbdullatif Aydin More articles by this author , Hamid AbboudiHamid Abboudi More articles by this author , Muhammad KhanMuhammad Khan More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2372AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Various simulation models are available for training and assessment of ureteroscopy and they are a common adjunct to OR training. This systematic review aims to: 1. Identify the available simulators for diagnostic and therapeutic ureteroscopy; 2. Explore the evidence for their effectiveness using the characteristic criterion; and 3. Recommend a curriculum based on the available literature. METHODS This study was performed using the guidelines set out by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A literature search was performed using the PubMed, EMBASE and Cochrane Library Databases for research articles describing the validation and training of simulators in ureteroscopy. RESULTS 20 out of a 527 potentially relevant articles were included. Three high-fidelity bench models are available. The Uro-Scopic Trainer has proven face, construct and concurrent validity whilst the Scope Trainer has undergone content, construct and predictive validity. The Adult Ureteroscopy Trainer, has demonstrated face, content and construct validity. The URO mentor is the one virtual reality system available. Extensive validation via ten studies shows face, content, construct, concurrent and predictive validity. All but the Adult Ureteroscopy Trainer have an established educational impact proven. A cost effective non-commercially available low-fidelity model has demonstrated educational impact comparable to its high fidelity counterpart at teaching novices at 185 times less the price. Additionally three studies have described the use of porcine ex-vivo models for training, however validation studies are lacking. With current levels of evidence the simulators could now be incorporated into a formalised curriculum for validation. However, small sample sizes coupled with the lack of randomised controlled studies leaves room for further investigation. Cost-effectiveness and non-technical skills of ureteroscopy simulations requires further scrutiny. CONCLUSIONS Simulators need rigorous validation to justify the high cost associated with them and current models require strengthening of evidence. The next step for the ureteroscopy simulators is incorporation into a formalized and validated curriculum integrated with a non-technical skills aspect. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e872 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Oliver Brunckhorst More articles by this author Abdullatif Aydin More articles by this author Hamid Abboudi More articles by this author Muhammad Khan More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1063 PREDICTIVE FACTOR FOR FEBRILE URINARY TRACT INFECTION AFTER URETEROSCOPIC PROCEDURES

You have accessJournal of UrologyInfections/Inflammation of the Genitourinary Tract: Kidney & Bladder (I)1 Apr 20131063 PREDICTIVE FACTOR FOR FEBRILE URINARY TRACT INFECTION AFTER URETEROSCOPIC PROCEDURES Masafumi Kita, Masaki Watanabe, Kazumi Hashizume, Tatsuya Iwata, Seiji Matsumoto, and Hidehiro Kakizaki Masafumi KitaMasafumi Kita Asahikawa, Japan More articles by this author , Masaki WatanabeMasaki Watanabe Asahikawa, Japan More articles by this author , Kazumi HashizumeKazumi Hashizume Asahikawa, Japan More articles by this author , Tatsuya IwataTatsuya Iwata Asahikawa, Japan More articles by this author , Seiji MatsumotoSeiji Matsumoto Asahikawa, Japan More articles by this author , and Hidehiro KakizakiHidehiro Kakizaki Asahikawa, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.649AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Febrile urinary tract infection (f-UTI) is a major complication associated with ureteroscopic procedures and, in some cases, leads to a life-threatening event. However there have been few reports investigating factors influencing the prevalence of f-UTI after diagnostic and therapeutic ureteroscopy. The aim of this study is to clarify predictive valuables of f-UTI related to ureteroscopic procedures. METHODS A retrospective review of the medical records of 215 consecutive patients undergoing ureteroscopic procedures was performed. These cases were divided into two groups: transurethral lithotripsy (TUL) group (112 cases, 66 males and 46 females, mean age 63.2±1.3 years) and ureteroscopic investigation (USI) group (103 cases, 56 males and 47 females, mean age 69.1±1.3 years). Risk factors for f-UTI were evaluated using univariate and multivariate analysis. RESULTS Mean operating time was 81.8±3.9 min in TUL group and 26.5±1.6 min in USI group. Prevalence of f-UTI was 11.6% in TUL group and 13.6% in USI group. Univariate analysis revealed that the presence of preoperative bacteriuria (p<0.001), renal stone (p=0.013), use of access sheath during lithotripsy (p=0.025), history of f-UTI (p=0.032) and operating time (p=0.008) had a significant relationship with f-UTI in TUL group. Multivariate logistic regression analysis revealed that operating time and preoperative bacteriuria were risk factors for f-UTI after TUL (Table1). In USI group, there was no single factor that had a significant relationship with f-UTI. However, among cases of USI group, those with both positive preoperative bacteriuria and persistent hydronephrosis after ureteroscopy had more than 2.5 times larger risk for f-UTI compared with other cases. CONCLUSIONS The reason why there were no significant risk factors for f-UTI in USI group might be explained by considerably short operating time compared to TUL group. When TUL is to be performed, reducing operating time is an important factor to prevent postoperative f-UTI especially in those cases with positive bacteriuria and renal stone. Table 1. univariate and multivariate analysis of factors elicitting f-UTI after transurethral lithotripsy univariate analysis univariate analysis multivariate analysis multivariate analysis OR P value OR P value age 1.03 .192 - - sex 0.56 .324 - - size of calculi 1.05 .141 - - preoperative ESWL 0.35 .328 - - preoperative bacteriuria 14.10 .001 16.70 .001 history of f-UTI 4.73 .012 - - ranal stone 0.22 .02 - - diabetes mellitus 0.43 .436 - - access seath 3.65 .032 - - perforation 0.67 .71 - - postoperative ureteral stenting 1.14 .872 - - operating time 1.02 .012 1.02 .018 ESWL: Extracorporeal shock wave lithotripsy, OR: odds ratio © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e436 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Masafumi Kita Asahikawa, Japan More articles by this author Masaki Watanabe Asahikawa, Japan More articles by this author Kazumi Hashizume Asahikawa, Japan More articles by this author Tatsuya Iwata Asahikawa, Japan More articles by this author Seiji Matsumoto Asahikawa, Japan More articles by this author Hidehiro Kakizaki Asahikawa, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictive Value of Current Imaging Modalities for the Detection of Urolithiasis During Pregnancy: a Multicenter, Longitudinal Study

We determined the optimal imaging study by which to diagnose and treat pregnant patients with suspected urolithiasis. A retrospective, multicenter study was performed to determine the comparative accuracy of imaging modalities used before the surgical management of suspected urolithiasis in pregnant patients. Patients with a clinical suspicion of urolithiasis were evaluated with directed imaging including renal ultrasound alone, renal ultrasound and low dose computerized tomography, or renal ultrasound and magnetic resonance urography. When indicated, patients underwent therapeutic ureteroscopy. The rate of negative ureteroscopy was determined and the positive predictive values of the imaging modalities were calculated. A total of 51 pregnant patients underwent ureteroscopy. The mean age of the cohort was 27 years. Mean gestational age was 24.4 weeks. Of the women 24 (47%) underwent renal ultrasound and low dose computerized tomography, 22 (43%) underwent ultrasound alone, and 5 (10%) underwent renal ultrasound and magnetic resonance urography. Negative ureteroscopy occurred in 7 of the 51 patients (14%). The rate of negative ureteroscopy among patients who underwent renal ultrasound alone, renal ultrasound and low dose computerized tomography, and renal ultrasound and magnetic resonance urography was 23%, 4.2% and 20%, respectively. The positive predictive value of computerized tomography, magnetic resonance and ultrasound was 95.8%, 80% and 77%, respectively. The rate of negative ureteroscopy was 14% among pregnant women undergoing intervention in our series. Of the group treated surgically after imaging with ultrasound alone, 23% had no ureteral stone, resulting in the lowest positive predictive value of the modalities used. Alternative imaging techniques, particularly low dose computerized tomography, offer improved diagnostic information that can optimize management and obviate unnecessary intervention.

Prevalence and management of complications of ureteroscopy: a seven-year experience with introduction of a new maneuver to prevent ureteral avulsion.

To evaluate the prevalence and type of rigid ureteroscopy complications and suggest a new method for ureteral avulsion prevention. Between March 2002 and March 2009, we retrospectively evaluated 2955 patients who had undergone diagnostic or therapeutic ureteroscopy for asymptomatic hematuria, migrated ureteral stent, or transurethral lithotripsy. They were enrolled from four hospitals in Ahvaz, Iran. Complications were encountered in 241 (8%) patients, including transient hematuria (4.2%), mucosal erosion (1.4%), stone migration (1.3%), ureteral perforation (1.2%), and fever and/or sepsis (1.0%). Ureteral avulsion occurred in 6 (0.2%) patients. Mostly, complications were managed conservatively, using ureteral stenting. Ureteral avulsions were managed using a new technique. In our series, the complication rate is comparable with the literature. A new technique was used in case of ureteroscope entrapment in the ureter, to lessen the occurrence of ureteral avulsion.

Hydroflotation Magnetic-Aided Endolumenal Navigation—Preliminary Platform in Ex-Vivo Setting for the Next Paradigm in Minimally Invasive Urologic Surgery

Navigation of endolumenal devices, such as image rendering capsules, have been described for diagnostic purposes in the animal, and more recently, human models. In urology, the ureter is a prime lumenal structure that often needs to be explored for diagnostic and therapeutic purposes. A novel device using a flotation mechanism in a water-filled environment was developed and its navigation achieved with magnetic-aided guidance. The device was tested for propulsion and real-time control in the ex-vivo setting. An endolumenal bionic worm (EBW) with a magnetic core was developed and introduced into synthetic lumens (SL) and supermarket chicken lumenal structures. The latter involved the gastrointestinal lumenal tissue of supermarket chickens; ie, the ex-vivo equivalent of a ureteral substitute lumen (USL). Navigation was graded by achievement of the EBW in propulsion to premarked sites, ability to remain static when necessary, and trauma to the USL. The structures were observed under the microscope for breech after the exercises. Navigation was observed in 10 SLs and 10 USLs. The EBW was successfully steered using the magnetic guidance system with hydroflotation. Observation of endolumenal surfaces did not reveal evidence of trauma in either model. Hydroflotation magnetic-aided endolumenal navigation (HMAEN) of a microdevice was achieved endolumenally with targeted real-time control and with no observed trauma to the structures. HMAEN could potentially be used to guide devices like the EBW to permit diagnostic and therapeutic ureteroscopy including biopsy of ureteral and renal pelvis lesions, thus ushering in the platform for the next paradigm in endolumenal urologic procedures.

THE EFFECT OF FAT AND NON-FAT COMPONENTS OF THE SKIN-TO-STONE DISTANCE ON SHOCKWAVE LITHOTRIPSY SUCCESS

It is the nature of endoscopy to begin with diagnostic applications and then to progress with improvements in technology to therapeutic applications. Retrograde upper urinary tract endoscopy has similar origins. In regard to ureteroscopy, it began with Victor Marshall24 who first described in 1964 the use of a flexible fiberscope placed in the ureter to visualize an obstructing calculus. The therapeutic ureteroscopy of today is based on treating the stone burden by converting it to small passable fragments.4, 23 This progression in technology has continued with the development of new endoscopes and various forms of energy that can be used not only for lithotripsy but also to treat upper tract tumors and ureteral stricture disease.9, 21Current treatment of upper tract calculi is based on focusing shock waves onto a stone and fragmenting it into more easily passable pieces (i.e., Extracorporeal Shockwave Lithotripsy [ESWL]) or on direct endoscopic inspection and conversion of the stone burden into fine dust and small fragments with intracorporeal lithotripsy. Shock wave lithotriptors also have evolved, requiring less anesthesia, in part, because of smaller focal zones and lower delivered energy. With these changes, the indications for treatment have narrowed. Large stones, those associated with high-grade ureteral obstruction, and those for which fluoroscopic localization is difficult, are best treated endoscopically.6 If there is poor fragmentation noted with shock wave lithotripsy, conversion to endoscopic techniques also has a significantly higher success rate with minimal morbidity.19 There has been recent debate on whether most upper tract stones would be treated better in a retrograde endoscopic way, in which there is more certainty of proper fragmentation and clearance.The current treatment algorithm used for those patients with moderately sized, uncomplicated upper urinary tract calculi is based on ESWL monotherapy performed under intravenous sedation. All other stones would represent more complex presentations and should be treated endoscopically.18 If there is a greater anesthetic requirement than intravenous sedation for the shock wave treatment or if placement of a ureteral catheter is required to drain a completely obstructed upper urinary tract, the more definitive endoscopic treatment can be considered rather than pursuing shock wave lithotripsy.The techniques and instrumentation currently used for retrograde ureteroscopic lithotripsy are presented in this article. A large series of ureteroscopic treatments performed with current small-diameter endoscopes also are reviewed. A large, prospectively accrued database of upper urinary calculi treated ureteroscopically with the Holmium laser also is presented to highlight the techniques.

Ureteroscopic management of urological complications after renal transplantation

To determine the feasibility, safety and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. We reviewed 1560 consecutive renal allografts performed between June 1989 and February 2002. A total of 28 patients (1.8%) had indications for an endoscopic procedure on the allograft ureter, as follows: obstructive ureteral calculi with a history of failed extracorporeal shock-wave lithotripsy, n=6; suspected ureteral stricture, n=3; upwardly migrated ureteral stents, n=9; and ureteral stricture at the ureteroneocystostomy site, n=10. Ureters were anastomosed to the bladder using the Leadbetter-Politano and Lich-Gregoire methods in six and 22 cases, respectively. Ureteroscopies were performed with a semi-rigid 9.8 F Wolf ureteroscope. Identification of the ureteral orifice and insertion of a guide-wire into it was successful in 19 cases (68%). If we exclude the 10 patients with ureteral stricture, ureteroscopy was successful in 13/18 cases (72%). Four ureteral calculi (67%) were removed with the ureteroscope. Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at the ureteroneocystostomy site (40%) underwent successful ureteral dilatation and double-J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications (one urinary leakage and one symptomatic urinary tract infection) occurred and were managed conservatively. Ureteral endoscopy is a safe and effective method for the management of urological complications after renal transplantation. This procedure can be considered the first choice, in preference to percutaneous and antegrade modalities.

Bilateral same-session ureteroscopy: its efficacy and safety for diagnosis and treatment.

To report the results of bilateral same-session ureteroscopy in patients with bilateral pathologies in urinary system. From among nearly 3000 patients who had undergone diagnostic or therapeutic ureteroscopy in our center, 23 (13 females and 10 males) were treated with bilateral same-session ureteroscopy. Pathologies included bilateral ureteral stone in 19, hematuria of unknown etiology in 3, and bilateral obstructive uropathy in 1. Hospital and follow-up records of the patients were reviewed in this study. Of 19 patients with bilateral ureteral stone, 11 had anuria and increased serum creatinine. Ureteroscopy was successful in 9, and the stones were fragmented. Ureteroscopy insertion was not successful in 1, and in 1 another, upper ureteral stone was pushed into the Kidney. Six patients had normal urine output and normal serum creatinine. In 5 of them, ureteroscopy was done and the stones were fragmented, but due to ureteral stricture, ureteroscopy was impossible in 1. In 2 patients with oliguria and increased serum creatinine, bilateral ureteral stones were extracted successfully. Of 3 patients with hematuria of unknown origin, 2 had normal ureteroscopy, and 1 had a small non-opaque stone that was extracted successfully. In 1 patient with obstructive uropathy and the diagnosis of obstructive megaureter, bilateral ureteroscopy was done and bilateral ureteral stents were placed. Finally, from 23 patients, 21 had successful bilateral same-session ureteroscopy. Postoperative complications included pyrogenic infection in 2 and gross hematuria in 4, all of which were resolved with medical treatment. Bilateral same-session ureteroscopy is an appropriate therapeutic and diagnostic option, with its own specific indications. It can reduce hospital stay, prevent multiple anesthesias, and alleviate the costs. We recommend this approach in patients with bilateral ureteral pathologies, provided that they are amenable to ureteroscopy.

Correlation of ureteroscopic appearance with histologic grade of upper tract transitional cell carcinoma

Objectives To correlate urologists' impressions of the tumor grade of upper tract tumors at ureteroscopy with the histologic findings after biopsy or resection. Methods A retrospective review of all patients who underwent diagnostic or therapeutic ureteroscopy for upper tract transitional cell carcinoma (TCC) between 1992 and 2002 was performed. Only patients who had proven TCC with a descriptive narration of the urologists' impressions of tumor grade and a representative pathologic specimen were included. The urologist's impression of tumor grade was reported as low or high grade according to the operative report and was correlated with the histologic grade. A total of 40 tumors met inclusion criteria. Results Ureteroscopy classified 28 tumors as low grade, 10 as high grade, and 2 as benign. The histologic findings of the 28 tumors believed to be low grade on ureteroscopy showed that 20 (71%) were grade 1-2, and of the 10 tumors believed to be high grade, 8 (80%) were actually grade 3-4. The overall accuracy of ureteroscopy in predicting the tumor grade of upper tract TCC was 70%. The benign-appearing lesions proved to be malignant. Conclusions The urologists' impressions of tumor grade on ureteroscopy were relatively good. However, visual assessment alone was inaccurate in 30% of the cases in our series. Therefore, we believe that biopsies remain essential for accurate grading of upper tract TCC. Therapeutic decisions should not be based solely on visual ureteroscopic assessment of tumor appearance.

The role of ureteroscopy in the treatment of renal transplantation complications.

To determine the feasibility, safety, and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. We reviewed 1560 consecutive renal allografts have been preformed between June 1989 and February 2002.Twenty-eight patients (1.8%) had indication for endoscopic procedure on allograft ureter. Six patients had obstructive ureteral calculi with a history of failed ESWL, 3 had suspected ureteral stricture, 9 had upward migrated ureteral stents and 10 had ureteral stricture at ureteroneocystostomy site. Ureters were anastomosed to bladder using Leadbetter- Politano and Lich-GreGoire methods in 6 and 22 cases, respectively. Ureteroscopies were performed with semi rigid 9.8F wolf ureteroscope. Identifying and introducing the ureteral orifice was successful in 19(68%) cases. If we exclude 10 patients with ureteral stricture, ureteroscopy was successful in 13 out of 18 (72%). Four ureteral calculi (67%) were removed with ureteroscope.Seven out of nine migrated stents (78%) were retrieved. Four patients with ureteral stricture at ureteroneocystostomy site (40%) had successful ureteral dilatation and double J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications including one urinary leakage and one symptomatic urinary tract infection occurred that were managed conservatively. Ureteral endoscopy was safe and effective method for management of urological complications after RT (renal transplantation). This procedure can be considered as the first choice compared with percutaneous and antegrade modalities.

Outpatient ureteroscopy: predictive factors for postoperative events

Objectives. To identify risk factors that can predict the postoperative events of outpatient ureteroscopy. Methods. The data of 329 consecutive patients who underwent outpatient ureteroscopy from January 1996 to July 2000 were analyzed. Patient selection for outpatient surgery was based solely on their general medical status and social factors. Eighty-three percent of the procedures were therapeutic ureteroscopy. The reported postoperative events included sleep disturbances, postoperative pain score, emesis, unplanned admission, and other complications. These were compared with the various patient and operative factors. Multivariate analysis was performed to identify the predictive factors for different postoperative events. Results. The overall success rate of ureteroscopic access to the pathologic site was 99.7%. Most of the therapeutic ureteroscopy performed was ureteroscopic lithotripsy (93%), with a stone-free rate of 91%. Ninety-seven percent of the operations were completed within 90 minutes, and 98% of patients were fit for discharge within 5 hours. Female patients reported more symptoms on the way home (25.8% versus 16%, P = 0.047) and more postoperative emesis (14.4% versus 2.1%, P <0.001). The postoperative pain score on day 1 was higher if the operation had lasted more than 60 minutes (2.4 versus 1.5, P = 0.002). Patients who received postoperative stenting had a higher postoperative pain score on day 3 (1.1 versus 0.4, P <0.001) and a higher complication rate compared with those who required no postoperative stenting (16.8% versus 4%, P <0.001). No predictive factors for unplanned admission were identified. Conclusions. Ureteroscopy can be successfully performed in an outpatient setting. Although the early postoperative pain was associated with nature of the operation (which could not be changed), the subsequent postoperative pain and complications were associated with ureteral stenting, which could be reduced by selective stenting. Unplanned admissions could not be predicted.

Porcine Urinary Tract as a Training Model for Ureteroscopy

Objectives: Endourological procedures as ureteroscopy require an advanced level of skills. To facilitate the training of the proper technique, simulators are helpful. Nonbiological models, useful to learn the basic steps, do not represent the clinical situation in an ideal way. We therefore looked for a biological but nevertheless easily available model. Methods: The complete urinary tract is dissected off the retroperitoneal organ package of freshly slaughtered pigs. Results: The porcine urinary tract model allows for training all aspects of diagnostic and therapeutic ureteroscopy including lithotripsy and stenting in a way which is almost identical to the clinical situation in humans. Conclusions: The porcine urinary tract model is an ideal ex vivo model. Concerning ‘tissue feeling’ and anatomic relations, it is superior to nonbiological simulators. Nevertheless, it is quite easily available and inexpensive. In training courses, we have used it with great success.