Ureteral Access Research Articles

A novel flexible vacuum-assisted ureteric access sheath in retrograde intrarenal surgery.

A novel flexible vacuum-assisted ureteric access sheath in retrograde intrarenal surgery.

Identification of the Risk Factors for the Failure of Ureteral Access Sheath Placement.

Purpose Insertion of a ureteral access sheath (UAS) may fail in some patients in retrograde intrarenal surgery (RIRS), and this study aimed to seek preoperative risk factors for the failure of 12/14F UAS placement. Methods We retrospectively analyzed 260 consecutive patients who underwent RIRS between May 2020 and March 2022 at our institution. Data on patient and stone characteristics and several computed tomography (CT)-based measurements were collected and compared between the success and failure UAS placement groups. Results Twenty-nine (11.2%) patients failed to insert the UAS. Age, gender, height, weight, stone side, stone location, length of history, and computed tomography (CT)-based parameters were not significant differences between the two groups. Univariate logistic regression analyses showed sex (female/male) (odds ratio: 0.287 and 95% CI [0.107, 0.722], p=0.013), length of history 15–31 days (odds ratio: 0.315 and 95% CI [0.102, 0.974], p=0.045), length of history >31 days (odds ratio: 0.202 and 95% CI [0.051, 0.805], p=0.023), and diameter of the ipsilateral common iliac artery (odds ratio: 1.285 and 95% CI [1.018, 1.623], p=0.035) were associated with UAS placement. Conclusion Our study indicated that males, the short length of history, and the short diameter of the ipsilateral common iliac artery were the risk factors for the failure of UAS placement.

Ureteral Access Sheaths and Its Use in the Future: A Comprehensive Update Based on a Literature Review.

Ureteral access sheaths (UASs) are part of urologist’s armamentarium when performing retrograde intrarenal surgery (RIRS). Recently, the world of RIRS has changed dramatically with the development of three game-changers: thulium fiber laser (TFL), smaller size single use digital flexible ureterosopes and intraoperative intrarenal pressure (IRP) measurement devices. We aimed to clarify the impact of UASs on IRP, complications and SFRs and put its indications in perspective of these three major technological improvements. A systematic review of the literature using the Medline, Scopus and Web of Science databases was performed by two authors and relevant studies were selected according to PRISMA guidelines. Recent studies showed that using a UAS lowers IRP and intrarenal temperature by increasing irrigation outflow during RIRS. Data on the impact of a UAS on SFRs, postoperative pain, risk of infectious complications, risk of ureteral strictures and risk of bladder recurrence of urothelial carcinoma after diagnostic RIRS were inconclusive. Prestenting for at least one week resulted in ureteral enlargement, while the influence of pre-operative administration of alpha-blockers was unclear. Since TFL, smaller single use digital ureteroscopes and devices with integrated pressure-measuring and aspiration technology seemed to increase SFRs and decrease pressure and temperature related complications, indications on the use of a UAS may decrease in the near future.

Does the Novel Thulium Fiber Laser Have a Higher Risk of Urothelial Thermal Injury than the Conventional Holmium Laser in an In Vitro Study?

Introduction and Objective: The novel thulium fiber laser (TFL) has been shown to break stones more rapidly than the holmium:YAG laser (HL). However, some evidence suggests that the TFL generates more heat. The purpose of this study is to compare ureteral temperatures generated by these lasers during ureteroscopic laser lithotripsy in a benchtop model. Methods: A 1-cm BegoStone was manually impacted in the proximal ureter of a three-dimensional printed kidney-ureter model and submerged in 35.5°C saline. Lithotripsy was performed using a 7.6F flexible ureteroscope and a 200 μm laser fiber without a ureteral access sheath. The Dornier 30 W HL, Olympus 100 W HL, and Olympus 60 W TFL were compared. A needle thermocouple to measure temperature was inserted 2 mm from the laser tip. Irrigation was maintained at 35 cc/minute at room temperature using the Thermedx FluidSmart System. Intraluminal temperature was continuously recorded for 60 seconds of laser activation. Five trials were performed for each of four different power settings: 3.6, 10, 20, and 30 W. Analysis of variance and Mann-Whitney U tests were performed with p < 0.05 considered significant. Results: Intraureteral fluid temperature increased as laser power settings increased for all lasers (p < 0.05). The TFL generated higher average ureteral fluid temperatures than the Dornier and Empower HL at all power settings tested (p < 0.001). The maximum temperature for the TFL was higher than the Dornier and Empower HL at all power settings tested (p < 0.001), except at 20 W with the Empower HL. At 30 W, the TFL exceeded 43°C, the threshold for tissue damage. Conclusions: The TFL generated more heat at all settings tested. Supraphysiologic ureteral temperatures may be generated with extended use at high energy settings and low irrigation rates. Understanding the heat generation properties of both lasers could help improve the safety of ureteroscopic laser lithotripsy.

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.

Retrograde intrarenal lithotripsy in completely bedridden children with severe physical disabilities

Pediatric urolithiasis is often associated with a metabolic disease or with a complication of steroid or antiepileptic agent use. Children who are on long-term bed rest or bedridden are also said to be at risk for urinary stone formation. Here we report two cases of compromised completely bedridden children with renal stones who achieved stone-free status without any complications through detailed intraoperative management. The patient in case 1 is an 8-year-old compromised bedridden boy with epilepsy, chromosomal abnormalities, and ulcerative colitis. In case 2, the patient is a 9-year-old compromised bedridden girl with hypoxic-ischemic encephalopathy and epilepsy. Both children had recurrent urinary tract infections (UTIs), and lithotripsy was planned for multiple renal stones. The patients were expected to be at high risk of developing a postoperative febrile UTI because they are compromised completely bedridden children. A 9.5/11.5-Fr ureteral access sheath was inserted, and lithotripsy was performed. The irrigation flow rate during lithotripsy was frequently adjusted and aspiration of intrarenal saline as necessary so as not to increase intrarenal pressure, with the aim of preventing postoperative febrile UTI. Stone-free status was achieved in both cases, without any intra and postoperative complications. • Long-term bed rest or Bedridden children are at high risk of urinary stone formation. • Bedridden children are high risk of developing febrile urinary tract infections. • Adjustment of irrigation flow rate is essential during retrograde intrarenal lithotripsy.

Sheathed flexible retrograde intrarenal surgery without safety guide wire for upper urinary tract stones.

To assess the success rate and intraoperative complications of flexible ureterorenoscopy (f-URS) in patients with upper urinary tract (UUT) stones using a ureteral access sheath (UAS) without a safety guide wire (SGW). Between April 2010 and March 2022, 464 renal units in patients with renal stones with and without concomitant ureteral stones (UUT), underwent ureterorenoscopy by one surgeon, and UAS was used in all of them. The primary endpoint was the stone-free rate (SFR). SFR was defined as no residual fragments at all. The following characteristics were examined: age, sex, laterality, renal/ureteral stones, stone diameter, SFR, Hounsfield unit, auxiliary procedures, double-J stent insertion, and intraoperative complications. This study was retrospective, with all the data recorded prospectively. Patients with residual stones were scheduled for the 2nd RIRS. The Clavien-Dindo classification was used to report complications. The mean patient age was 52.9 years. The mean stone size was 13.1 mm. Lower pole, upper and middle calyces, renal pelvis and ureteral stones were found in 51.5% (239), 34.9% (162), 18.3% (85) and 46.9% (218) of cases, respectively. The mean diameter was 8.1 mm, 8 mm, 12.5 mm and 8.1 mm for the lower pole, upper and middle calyces, renal pelvis and ureteral stones, respectively. The single- and second-session SFRs were 90% and 100%, respectively. The mean number of procedures per renal unit was 1.1. Ureteral double-J stents were inserted in 45.7% (212) of patients. In 96 cases, a stent was placed before surgery. Postoperative complications were minor, with no avulsion or perforation of the ureters; readmission and insertion of a DJ stent occurred in one patient. Ureteral stricture developed in one patient (0.2%) and needed treatment with laser ureterotomy. f-URS is a safe and effective mode of surgical management of renal and simultaneous renal and ureteral calculi using the ureteral access sheath without a safety guide wire. A guide wire should not be routinely used in these cases.

Retrograde Intrarenal Surgery (RIRS) for upper urinary tract stones in children below 12 years of age: A single centre experience.

Retrograde Intra Renal Surgery (RIRS) is a minimally invasive surgical modality for the treatment of renal stones. We evaluated the efficacy of RIRS in children below aged 12 years of age in the form of stone-free rate (SFR), complications and the feasibility of the procedure. This retrospective study included all children ≤ 12 years of age, with upper urinary tract stones single or multiple ≤ 15 mm in size who underwent RIRS between February 2019 to November 2021. RIRS was performed with 7.5 Fr flexible ureterorenoscope over the guidewire, the stones were dusted with Laser and the ureteral stent was left after RIRS. All patients had the post-procedure stent removed within 3 weeks after checking for residual stones with X-ray and ultrasonography of Kidney-Ureter-Bladder (USG-KUB). Follow-up USG KUB was done at 4 months. 15 patients included in our study met the inclusion criteria. The mean age was 8.7 ± 2.8 years, the mean stone size was 11.26 ± 2.14 mm and 26.6 % had multiple stones. Retrograde access failure was noted in 36.3 % in non stented patients. The mean operative time was 72.6 ± 20 minutes, fluoroscopy time was 4.4 ± 0.9 minutes and the mean LASER time was 26 ± 3.9 minutes. The mean hospital stay was 2.8 ± 0.9 days. Ureteral access sheath (UAS) was used in one patient. Conversion to mini PCNL was done in one pre stented patient due to access failure and one patient had a second look RIRS for residual stone. No major complications were noted except onr patient who had sepsis. The stone-free rates were 93.3% after primary RIRS and 100% after second look RIRS. RIRS is a feasible, safe procedure for pediatric upper urinary stones with excellent stone-free rates and a low rate of complications.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PurposeProlonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation.MethodsA retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times.ResultsCompared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03–23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95–23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89–27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year.ConclusionsTFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

Primary impact of simultaneous use of double devices through one-working channel when performing flexible ureteroscope with ureteral access sheath for single ureteral stone: In bench and retrospective clinical study.

This study aimed to compare the simultaneous use of two devices versus a single device through a single working channel in flexible ureteroscopy using a ureteral access sheath for single ureteral stones. In a bench study, the time to (i) set laser fiber, (ii) exchange laser fiber and nitinol basket through working channel, and (iii) pull out the device from working channel were measured 10 times in each step. In a clinical study, 156 patients who underwent flexible ureteroscopy with a ureteral access sheath for a ureteral stone in middle and upper ureter between April 2019 and November 2021 were assessed. One device was used at a time for 79 patients (S-Group) and two were simultaneously used for 77 (D-Group). Surgical outcomes and complications were compared. In the bench study, the mean time to change from laser fiber to basket and from basket to laser fiber through the working channel were 26.1 ± 3.7 s and 23.6 ± 2.0 s (p = 0.084), respectively, which were significantly longer than the laser setup time (p < 0.001). In the clinical study, although the stone-free rate was not significantly different between the groups (S-Group 89.8%, D-Group 93.5%; p = 0.412), the median operation time was significantly shorter (p < 0.001) and the rate of postoperative stenting was significantly lower (p = 0.002) in the D-Group. There were no significant between-group differences in intra- and post-operative complications. The simultaneous use of two devices through a single working channel is safe and could help save the time needed to exchange the laser fiber and nitinol basket.

A Practical Guide for Intra-Renal Temperature and Pressure Management during Rirs: What Is the Evidence Telling Us.

Introduction: One of the main limitations of Ho:YAG lithotripsy is represented by its advancement speed. The need for faster lithotripsy has led to the introduction of high-power laser equipment. This general trend in increasing Ho:YAG lithotripsy power has certain points that deserve to be considered and analyzed. The objective is to carry out a narrative review on intrarenal temperature and pressure during ureteroscopy. Methods: A literature search using PUBMED database from inception to December 2021 was performed. The analysis involved a narrative synthesis. Results: Using more power in the laser correlates with an increase in temperature that can be harmful to the kidney. This potential risk can be overcome by increasing either the irrigation inflow or outflow. Increasing irrigant flow can lead to high intrarenal temperature (IRP). The factors that allow the reduction of intrarenal pressure are a low irrigation flow, the use of a ureteral access sheath of adequate diameter according to the equipment used, and the occupation of the working channel by the laser or basket. Conclusion: To maintain a safe temperature profile, it has been proposed to use chilled irrigation fluid, intermittent laser activation or to increase irrigation flow. This last recommendation can lead to increased IRP, which can be overcome by using a UAS. Another option is to use low power laser configurations in order to avoid temperature increases and not require high irrigation flows.

The dilemma of 12/14F ureteral access sheath (UAS) usage: a case control study

BackgroundThe insertion of a ureteral access sheath (UAS) is a frequent procedure during flexible ureteroscopy (fURS) to facilitate kidney stone treatment. The aim of this study was to investigate the influence of 12/14 French (F) UAS on fURS outcomes.MethodsWe performed a retrospective monocentric analysis of fURS procedures conducted at the Department of Urology (University Hospital Schleswig–Holstein, Lübeck, Germany) for kidney stone treatment via lithotripsy or basket stone retrieval between September 2013 and June 2017. Uni- and multivariate analyses were done with the help of RStudio (Version 1.0.136) software.ResultsIn total, 283 consecutive fURS were analyzed. UAS was applied in 98 cases (34.63%). The insertion of UAS was preferred in cases with multiple kidney stones and larger median maximal stone diameter (p < 0.05). UAS usage correlated with elevated radiation exposure in seconds (94 vs. 61; p < 0.0001), prolonged operation time in minutes (99 vs. 66, p < 0.0001), length of hospital stay over 48 h (LOS, 22.49% vs. 10.81%; p = 0.015), more frequent postoperative systemic inflammatory response syndrome (SIRS, 13.27% vs. 4.32%; p = 0.013) and lower postoperative stone-free rates (60.20% vs. 78.92%; p = 0.0013). Moreover, we conducted uni- and multivariate subgroup analysis for cases with multiple kidney stones (≥ 2) and comparable stone burden; UAS was inserted in 48.3% of these cases (71/147). On multivariate logistic regression, UAS insertion was statistically associated with prolonged operation time in minutes (101 vs. 77; p = 0.004). No statistical differences regarding radiation exposure, stone-free rates, postoperative SIRS rates or LOS were noted between UAS and non-UAS patients with multiple kidney stones of similar size (p > 0.05).Conclusions12/14F UAS does not seem to improve overall outcomes in fURS for kidney stones. In patients with multiple kidney stones it may be associated with elevated operation time without a clear benefit in terms of improved stone-free status or reduced perioperative complication rate. Further prospective randomized studies to specify the indications for UAS usage are urgently needed.

IJU this issue

This issue of International Journal of Urology contains two Review Articles, 13 Original Articles, three Urological Notes, nine Editorial Comments, one Letter to the Editor, and three Author's Replies. Prostate biopsy is one of the most frequently performed urological procedures. Despite being generally safe and well-tolerated, it is sometimes associated with complications including acute bacterial prostatitis especially in transrectal approach. In the last decade, an increased number of fluoroquinolone-resistant and extended-spectrum beta-lactamase-producing Escherichia coli have been reported in cases of acute prostatitis. In the Review Article by Acosta et al. (Okayama, Japan), the authors emphasized the clinical value of the isolation of these pathogens from rectal bio-flora samples, which can be easily obtained through the fingertip of a sterile glove or a cotton swab, with selective media before transrectal prostate biopsy. As the authors described, this preventive measure may allow us to offer a tailored prophylactic treatment that benefits patients and reduces the economic burden for the hospital. The treatment paradigm for metastatic renal cell carcinoma (mRCC) has been dramatically changed by the introduction of immune checkpoint inhibitors (ICIs). Recent clinical trials have demonstrated the survival advantages of several kinds of the first-line ICI combination therapy compared with sunitinib, suggesting that substantial improvements in survival for patients with mRCC could be achieved during the ICI era compared with the tyrosine kinase inhibitor (TKI) era. Besides the advancement of systemic anticancer therapy, surgical resection of the primary tumor or metastases remains an important option in the management of mRCC although the clinical implications of these surgeries have changed in the TKI era. In the Review Article by Naito et al. (Yamagata, Japan), the authors provided an excellent overview about cytoreductive nephrectomy, metastatectomy, and radiotherapy for metastatic lesions in the ICI era. At present, this topic has minimal evidence and further investigations are needed. This review will give some hints to the readers for tomorrow's practice. A difficult ureter (DU) is defined as a ureter that requires prestenting because a ureteroscope or a ureteral access sheath needed for treatment cannot be inserted during retrograde intervention. In the Original Article by Waseda et al. (Tokyo, Japan), the authors focused on risk factors and predictive models for ureteral difficulty during retrograde ureteroscopic lithotripsy in clinical practice. It is meaningful and important to predict DU prior to surgery because the presence or absence of DU is related to the success of the procedure. Interestingly, the absence of stone history was the greatest risk factor for developing DU, followed by age 45 years or younger and renal stones only. As the authors suggested, preoperative assessment of the risk of DU may be helpful in the informed consent for patients requiring retrograde lithotripsy. Surgical resection of RCC with inferior vena cava (IVC)–tumor thrombus (TT) is the standard of care for nonmetastatic patients and confers long-term survival. However, it is a technically challenging procedure with a high risk of morbidity (40–50%) and mortality (5–10%). One of the serious complications is intraoperative tumor embolism (iTE) of pulmonary artery. Currently, there is no consensus on whether it is optimal to perform thrombectomy before kidney mobilization (“thrombus first”) or vice versa (“thrombus last”). In the Original Article by Ishiyama et al. (Tokyo, Japan), the authors compared these two techniques focusing on iTE prevalence and other early surgical outcomes in 130 patients with RCC and IVC-TT. In this retrospective study, there were four cases (3.1%) of iTE, all from the thrombus-last group. Additionally, those who underwent the thrombus-first technique experienced shorter operation time, smaller estimated blood loss, fewer complications, and shorter in-hospital stay. “Thrombus-first” approach may be preferred when performing nephrectomy and caval thrombectomy under open procedures. Unfortunately, the limited space does not allow me to introduce all the articles. However, all the papers are interesting, informative, and well-illustrated. I hope you enjoy this issue of International Journal of Urology. None declared.

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.

MP17-09 OUTCOMES AND LESSONS LEARNT FROM PRACTICE OF RETROGRADE INTRARENAL SURGERY (RIRS) IN A PAEDIATRIC SETTING OF VARIOUS AGE GROUPS: A GLOBAL STUDY ACROSS 8 CENTRES

You have accessJournal of UrologyCME1 May 2022MP17-09 OUTCOMES AND LESSONS LEARNT FROM PRACTICE OF RETROGRADE INTRARENAL SURGERY (RIRS) IN A PAEDIATRIC SETTING OF VARIOUS AGE GROUPS: A GLOBAL STUDY ACROSS 8 CENTRES Ee Jean Lim, Olivier Traxer, Yesica Quiroz Madarriaga, Daniele Castellani, Khi Yung Fong, Vinson Wai Shun Chan, Anna Bujons Tur, Amelia Pietropaolo, Deepak Ragoori, Anil Shrestha, Chandra Mohan Vaddi, Tanuj Paul Bhatia, Mriganka Mani, Patrick Juliebø-Jones, Stephen Griffin, Esther García Rojo, Mariela Corrales, Cagri Akin Sekerci, Yiloren Tanidir, Jeremy Yuen-Chun Teoh, Vineet Gauhar, and Bhaskar Kumar Somani Ee Jean LimEe Jean Lim More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Yesica Quiroz MadarriagaYesica Quiroz Madarriaga More articles by this author , Daniele CastellaniDaniele Castellani More articles by this author , Khi Yung FongKhi Yung Fong More articles by this author , Vinson Wai Shun ChanVinson Wai Shun Chan More articles by this author , Anna Bujons TurAnna Bujons Tur More articles by this author , Amelia PietropaoloAmelia Pietropaolo More articles by this author , Deepak RagooriDeepak Ragoori More articles by this author , Anil ShresthaAnil Shrestha More articles by this author , Chandra Mohan VaddiChandra Mohan Vaddi More articles by this author , Tanuj Paul BhatiaTanuj Paul Bhatia More articles by this author , Mriganka ManiMriganka Mani More articles by this author , Patrick Juliebø-JonesPatrick Juliebø-Jones More articles by this author , Stephen GriffinStephen Griffin More articles by this author , Esther García RojoEsther García Rojo More articles by this author , Mariela CorralesMariela Corrales More articles by this author , Cagri Akin SekerciCagri Akin Sekerci More articles by this author , Yiloren TanidirYiloren Tanidir More articles by this author , Jeremy Yuen-Chun TeohJeremy Yuen-Chun Teoh More articles by this author , Vineet GauharVineet Gauhar More articles by this author , and Bhaskar Kumar SomaniBhaskar Kumar Somani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002550.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We aim to analyse and report the practice, outcomes and lessons learnt from a global series of retrograde intrarenal surgery (RIRS) in a paediatric multicentre series. METHODS: Retrospective review of anonymised pooled data gathered globally from 8 centres in paediatric patients (≤18 years of age) who had renal stones and underwent RIRS from 2015 to 2020 was performed. Patient demographics, perioperative parameters, stone characteristics, complications and stone-free rate (SFR) were analysed. Residual fragments(RFs) were defined as a single fragment >2mm or multiple fragments. Our cohort was stratified by age into 3 groups : ≤5 years (Group A), 5-10 years (Group B) and ≥10 years (Group C). T-test and Mann–Whitney were used for continuous variables. Categorical data between groups were analysed using the χ2 test. RESULTS: 314 patients were included for analysis. Mean age was 9.54 +/- 4.76 years. The number of patients in groups A, B and C were 67 (21.3%), 83 (26.4%) and 164 (52.2%) respectively. The mean stone size was 10.7 +/- 4.62 mm. While pre-stenting was performed in 155 (49.4%) of patients, ureteral access sheaths (UAS) was used in 54.5% of patients, and majority (71%) utilizing holmium laser for stone fragmentation. The SFR was 75.5% with 77(24.5%) having residual fragments. All post-surgical complications were minor Clavein Dindo (CD) classification and included ureteric injury (n=5), pelvicalyceal injury (n=5, all in group A), fever (n=20), hematuria (n=11) and sepsis (n=2). CONCLUSIONS: RIRS is acceptable as a firstline intervention in the paediatric population with reasonable efficacy and low morbidity; Complications are slightly higher in Group A and this should be taken into account while counselling patients. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e288 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ee Jean Lim More articles by this author Olivier Traxer More articles by this author Yesica Quiroz Madarriaga More articles by this author Daniele Castellani More articles by this author Khi Yung Fong More articles by this author Vinson Wai Shun Chan More articles by this author Anna Bujons Tur More articles by this author Amelia Pietropaolo More articles by this author Deepak Ragoori More articles by this author Anil Shrestha More articles by this author Chandra Mohan Vaddi More articles by this author Tanuj Paul Bhatia More articles by this author Mriganka Mani More articles by this author Patrick Juliebø-Jones More articles by this author Stephen Griffin More articles by this author Esther García Rojo More articles by this author Mariela Corrales More articles by this author Cagri Akin Sekerci More articles by this author Yiloren Tanidir More articles by this author Jeremy Yuen-Chun Teoh More articles by this author Vineet Gauhar More articles by this author Bhaskar Kumar Somani More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP036 - 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.

MP036 - 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.

V08 - Treatment of large paediatric stone with Flexible Ureteroscopy and Laser Lithotripsy (FURSL) and Ureteral Access Sheath (UAS)

V08 - Treatment of large paediatric stone with Flexible Ureteroscopy and Laser Lithotripsy (FURSL) and Ureteral Access Sheath (UAS)

MP44-15 EARLY EXPERIENCE WITH VACUUM ASSISTED URETERAL ACCESS SHEATHS

You have accessJournal of UrologyCME1 May 2022MP44-15 EARLY EXPERIENCE WITH VACUUM ASSISTED URETERAL ACCESS SHEATHS Daniel Wong, and Alana Desai Daniel WongDaniel Wong More articles by this author , and Alana DesaiAlana Desai More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002610.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vacuum assisted ureteral access sheaths (V-UAS) have been eagerly adopted with the hopes of improved surgical outcomes. Reports from outside the US have found increased stone free rates, decreased operative times, and decreased infectious complications with V-UAS. However there have been no data published from the US. Herein, we report our findings 1 year after implementation of Clearpetra V-UAS at our institution. METHODS: From May 2020 to September 2021, all unilateral ureteroscopy cases by a single surgeon using a V-UAS (Clearpetra) were retrospectively reviewed. These were compared to matched cases using an institutional database of stone cases from 2016 to May 2020, when Clearpetra became available. Cases were matched based on regular ureteral access sheath use, surgeon, stone burden, preexisting ureteral stent, preoperative UTI, and neurogenic bladder. Outcomes of interest were stone free rate as determined by follow up ultrasound or CT scan within 3 months of procedure and postop infection defined by T >38°C, WBC >12K or <4K, HR >90, or UTI within 30 days of procedure. RESULTS: There were 27 unique V-UAS cases identified. Randomly matched cases were compared for operative time, stone free rate, infectious complications, and 30-day unplanned encounters. There were no differences in any outcomes of interest (Figure 1). CONCLUSIONS: V-UAS performed on par with standard ureteral access sheaths. There was no increase in complication rate or unplanned encounters, indicating V-UAS is a safe treatment option. V-UAS offered no benefit in terms of operative time, stone free rate, or infectious complications in this initial cohort. It remains to be seen whether there is an optimal stone characteristic for V-UAS or whether V-UAS requires an initial learning curve for improvement. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e758 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Wong More articles by this author Alana Desai More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP44-04 REAL-WORLD PRACTICE STONE-FREE RATES AFTER URETEROSCOPY FROM A SURGICAL COLLABORATIVE: MUCH TO IMPROVE

You have accessJournal of UrologyCME1 May 2022MP44-04 REAL-WORLD PRACTICE STONE-FREE RATES AFTER URETEROSCOPY FROM A SURGICAL COLLABORATIVE: MUCH TO IMPROVE Hyung Joon Kim, Stephanie Daignault-Newton, John M. DiBianco, S. Mohammad Jafri, Brian Seifman, Eduardo Kleer, Casey A. Dauw, and Khurshid R. Ghani Hyung Joon KimHyung Joon Kim More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , John M. DiBiancoJohn M. DiBianco More articles by this author , S. Mohammad JafriS. Mohammad Jafri More articles by this author , Brian SeifmanBrian Seifman More articles by this author , Eduardo KleerEduardo Kleer More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , and Khurshid R. GhaniKhurshid R. Ghani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002610.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The stone-free rate (SFR) is an important outcome measure of quality after ureteroscopy for urinary stones. Recent studies show SFRs may not be as high as previously reported. However, these studies are from expert centers, and data from real-world community practice is lacking. We examined the SFR and its predictors following ureteroscopy among diverse practices in the state of Michigan. METHODS: We used the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stone (ROCKS) registry to identify ureteroscopy cases for renal and ureteral stone location, respectively, treated between 2016 and 2021, that had postoperative imaging. Stone-free was defined as no fragment detected on imaging within 60 days. Practice and surgeon-level SFR variation was assessed. Surgeon volume was categorized according to quartiles of annual volume. Factors associated with SFR were examined using logistic regression. RESULTS: 6,487 ureteroscopies were performed across 29 practices and 164 surgeons, to treat 2,091 (32.2%) renal and 4396 (67.8%) ureteral stones. The SFR was 49.6% and 72.7% for renal and ureteral stone location, respectively. For renal stones, larger stone size, lower pole location, and multiplicity were significantly associated with residual fragments (Table 1). For ureteral stones, female gender, larger stone size, proximal location, multiplicity, positive urine culture, use of ureteral access sheath, and post-ureteroscopy stenting were predictors for low SFR (Table 1). No significant differences in SFRs were identified regarding pre-stenting and surgeon volume. Surgeon variation in the SFR for renal and ureteral stones, when adjusted for risk factors, was 29.0-68.7% (p <0.0001) and 51.4-86.4% (p <0.0001), respectively (Figure 1). CONCLUSIONS: There is substantial surgeon-level variation in the SFR after ureteroscopy in Michigan. Our findings demonstrate the need for quality efforts to improve these outcomes. Source of Funding: Blue Cross Blue Shield of Michigan © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e752 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hyung Joon Kim More articles by this author Stephanie Daignault-Newton More articles by this author John M. DiBianco More articles by this author S. Mohammad Jafri More articles by this author Brian Seifman More articles by this author Eduardo Kleer More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author Expand All Advertisement PDF DownloadLoading ...

PD55-03 PATIENT-REPORTED OUTCOMES FOLLOWING HOME URETERAL STENT REMOVAL AFTER URETEROSCOPY

You have accessJournal of UrologyCME1 May 2022PD55-03 PATIENT-REPORTED OUTCOMES FOLLOWING HOME URETERAL STENT REMOVAL AFTER URETEROSCOPY John Graves, John Bell, Amul Bhalodi, Will Cranford, Adam Dugan, and Jason Bylund John GravesJohn Graves More articles by this author , John BellJohn Bell More articles by this author , Amul BhalodiAmul Bhalodi More articles by this author , Will CranfordWill Cranford More articles by this author , Adam DuganAdam Dugan More articles by this author , and Jason BylundJason Bylund More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002635.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urologists often place temporary indwelling ureteral stents after ureteroscopy, but little is known about ideal stent dwell time and we lack rigorously-gathered data about tolerance. We are seeking to study the effect of stent duration on patient-reported outcomes by having patients remove their stent at three vs. seven days postoperatively, and then conducting a phone survey to assess outcomes. METHODS: Patients undergoing uncomplicated ureteroscopy for stone disease are screened for eligibility. Exclusion criteria include bilateral ureteroscopy, solitary kidney, need for additional procedure, or pregnancy. Patients are randomized to remove the stent at home either three or seven days after surgery. A few days after scheduled removal, an independent clinical research associate calls to collect data regarding stent tolerance, removal, and unscheduled calls or ER visits. RESULTS: To date, 80 patients have been randomized to either three (n=44, 55.7%) or seven (n=35, 44.3%) days. Seventy-two (90%) have been successfully contacted. Nearly 80% reported removal on the planned day. A prior ureteral stent was present in 31 patients (44.2%) and a ureteral access sheath was used in 33 cases (47.1%). Thirteen patients (18.6%) reported no problem with their stent, while 55 (64.3%) reported mild or moderate bother and 12 (17.2%) described either severe bother or absolute misery. Only four patients (5.8%) required narcotics for greater than two days after removal. While most patients (n=56, 80%) experienced 30 minutes or less of severe pain (impaired function) after removal, 11 (15.7%) reported this pain for greater than six hours. More patients (n=27, 38.5%) experienced mild/moderate pain ("bothersome but not limiting") for greater than six hours. Significantly more patients without a prior stent reported at least a moderate bother compared to those with one (61.5% vs 25.8%, p=0.006) and more patients without sheath use visited the ER than those with (33% vs 11.1%, p=0.04). Insufficient patients have been accrued thus far to address the question of 3 vs 7 day stent duration. CONCLUSIONS: Most patients adhere to planned stent removal date, tolerate the stent well, do not call a provider or visit the emergency department, and do not experience severe pain following stent removal. The most common issue after stent removal is self-limited pain. Patients with a prior stent report less discomfort, and when an access sheath is used, patients are less likely to present to the ED. These numbers can help counsel patients regarding home ureteral stent removal and guide future efforts to optimize stent use. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e948 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Graves More articles by this author John Bell More articles by this author Amul Bhalodi More articles by this author Will Cranford More articles by this author Adam Dugan More articles by this author Jason Bylund More articles by this author Expand All Advertisement PDF DownloadLoading ...