Ureteral Catheter Research Articles

Quantification of outflow resistance for ureteral drainage devices used during ureteroscopy.

Since renal pelvis pressure is directly related to irrigation flowrate and outflow resistance, knowledge of outflow resistance associated with commonly used drainage devices could help guide the selection of the type and size of ureteral access sheath or catheter for individual ureteroscopic cases. This study aims to quantitatively measure outflow resistance for different drainage devices utilized during ureteroscopy. With measured irrigation flowrate and renal pelvis pressure, outflow resistance was calculated using a hydrodynamic formula. After placement of a drainage device into a silicone kidney-ureter model, a disposable ureteroscope with a 9.5-Fr outer diameter was inserted with its tip positioned at the renal pelvis. Irrigation was delivered through the ureteroscope from varying heights above the renal pelvis. Renal pelvis pressure was measured directly from the port of the kidney model using a pressure sensor (Opsens, Canada). Outflow resistance was determined by plotting flowrate versus renal pelvis pressure. All trials were performed in triplicate for each drainage device inserted. Flowrate was linearly dependent on renal pelvis pressure for all drainage devices tested. Outflow resistance values were 0.2, 1.1, 1.4, 3.9, and 6.5 cmH2O/[ml/min] for UAS 13/15 Fr, UAS 11/13 Fr, UAC 6 Fr, UAC 4.8 Fr, and UAC 4.0 Fr, respectively, across the range of commonly used irrigation flowrates. In this study, outflow resistance of different ureteral drainage devices was quantitatively measured. This knowledge can be useful when selecting which type and size of drainage device to insert to maintain safe renal pelvis pressure during ureteroscopy.

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women

PurposeTo evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women. Materials and MethodsEighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined. ResultsA total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19–85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001). ConclusionsImaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.

Rendezvous Technique: Step by Step

Introduction: The treatment of complete ureteral stenosis varies depending on the severity and location of injury but can include ureteral stent placement and surgical repair. Long-term percutaneous nephrostomy (PN) drainage is another treatment option, but it leads to deterioration of the patient's quality of life. Therefore, as an alternative to surgery similar to ureteroureterostomy, the combined antegrade and retrograde approach, the so-called rendezvous technique, is required. Materials and Methods: A 52-year-old man with a history of prior flexible ureterorenoscopy for a 12 mm ureteral stone in the ureteropelvic junction presented with insidious onset complete ureteral stenosis. A nephrostomy tube was placed, and the patient was referred to our center. An anterograde and retrograde pyelography confirmed a diagnosis of ureteropelvic stenosis thought to be secondary to prior endoscopic procedure. A combined antegrade–retrograde rendezvous dilatation of stenosis was planned. A fiber-optic and digital ureteroscope were used through the left ureter and the nephrostomy tract, respectively, and allowed a careful visual examination of the ureteral lesion. The complete stenosis did not allow the passage of a 0.035″ Terumo guidewire. Transillumination and fluoroscopy were used to direct the retrograde lasering of the tissue to create the new ureteral path with thulium fiber laser technology. Laser settings were 1 J for pulsed energy and 5 Hz for pulsed frequency with short pulse. Results: After reaching the pelvis through the retrograde access, a Double-J ureteral catheter (8F) was placed to reduce the risk of restenosis and a nephrostomy tube. Laser time was 4 minutes and 38 seconds and total energy emitted was 1.39 KJ. The nephrostomy tube was removed after 48 hours. The procedure was well tolerated and after 3 days the patient was discharged with the Double-J. A retrograde pyelography was performed 1 month later showing contrast passage. Conclusions: Combined antegrade–retrograde rendezvous dilatation offers a safe and viable alternative to high-risk surgery in patients with complete ureteropelvic stenosis. A.S. and M.C. have nothing to disclose. O.T. is a consultant for Boston Scientific, Coloplast, EMS, IPG, Quanta and Rocamed, but has no specific conflicts relevant to this study. Runtime of video: 4 mins 46 secs Consent: Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

A robust localization approach for Percutaneous Nephrolithotomy (PCNL): A single-center retrospective study.

Percutaneous Nephrolithotomy (PCNL) represents the gold standard treatment method for cases with large kidney stones. As a critical step in performing PCNL, the procedure of establishing a safe and accurate nephrostomy tract will dramatically impact the treatment quality of patients with large-sized kidney stones. This work attempts to describe a new and improved process of establishing an accurate nephrostomy tract and clinically evaluate the effectiveness and safeness of this proposed methodology. This work represents a retrospective single-center study carried out between August 2013 and November 2019. The collected samples consist of 937 patients who were operated on using PCNL coupled with our proposed procedure. Briefly, a preoperative B-ultrasonography was firstly performed to decide the puncture point in a simulated surgical position where was marked with ureteral catheter segments (2-3 cm). A computed tomography (CT) scan was followed to correct the anchor points in the simulated surgical position. After this, an accurate puncture operation was performed under the real-time guidance of intraoperative B ultrasound. Examining this study, 851 subjects with renal stones and 86 subjects with ureteropelvic junction stones were included for the PCNL operation project. All samples were grouped with Guy's grading system: grade I, II, III, and IV patients there were 0.00%, 42.69%, 51.01%, and 6.30%, respectively. Among these patients, the average age was 48.49 ± 10.80 years old, with a male to female ratio of around 1.73:1. This study showed that our developed method warrants an accurate and safe PCNL operation that involves the process of establishing the nephrostomy tract. Other advantageous attributes of this new PCNL process include negligible radiation exposure, lesser complications, and low failure rates. More importantly, this new localization approach is particularly attractive for hospitals that are new to the field of adopting PCNL considering its safeness, effectiveness, and learnability.

The Current State of Knowledge Regarding the Use of Double J Catheters in Treating Obstructive Urolithiasis

"Urinary lithiasis is a common pathology in the modern era. Its significance lies in the possible complications that may arise as well as in its potential for recurrence. The treatment and prevention of recurrences of urinary lithiasis often require the intervention of several specialists: urologists, nephrologists, endocrinologists, nutritionists, biochemists, etc. In the last 20 years, the treatment strategy for urinary lithiasis has changed, with minimally invasive methods replacing laparoscopic or open surgery. These are effective and have rare complications. Whichever treatment method is chosen, it may be necessary to temporarily divert the upper urinary tract by inserting double J catheters for preventive, curative, or palliative purposes. Ureteral catheters have had to be improved over time to avoid two major incidents: their migration and colonization. Various materials were used, varying the shape, size, length, guide as well as approaches. The urinary infection-urolithiasis association is frequent, without always being able to specify the cause-effect relationship. The rate of urinary colonization appears to be influenced by the presence of stent colonization as well as the time since the implant. The association of chronic diseases or emergency insertion is associated with an increased risk of urinary colonization. Complications induced by the time of the double J catheter being implanted are rare, and minor and disappear with its removal. In the case of failure to insert a double J ureteral catheter, the alternative would be to perform an ultrasound-guided percutaneous nephrostomy. Double J ureteral catheter insertion is an effective minimally invasive option in the treatment of obstructive urolithiasis. "

Simple Identification of Diverting Ureters With Ileal Conduit Using Fluorescent Ureteral Catheter During Laparoscopic Rectal Cancer Surgery.

Kondo, Akihiro M.D., Ph.D.1; Kumamoto, Kensuke M.D., Ph.D.1; Asano, Eisuke M.D., Ph.D.1; Tsunemori, Hiroyuki M.D., Ph.D.2; Sugimoto, Mikio M.D., Ph.D.2; Okano, Keiichi M.D., Ph.D.1 Author Information

Determination of optimal stent length: a survey of urologic surgeons.

Ureteral double-J stent length is an important factor affecting stent-related symptoms. Multiple techniques exist to determine ideal stent length for a given patient, however, little is known about what techniques urologists rely on. Our objective was to identify how urologists determine optimal stent length. An online survey was e-mailed in 2019 to all members of the Endourology Society. The survey sought to assess what methods are commonly used to determine choice of stent length, along with frequency of stent placement post ureteroscopy, duration of stenting, availability of different stent lengths and the use of stent tether. 301 urologists (15.1%) responded to our survey. Following ureteroscopy, 84.5% of respondents would stent at least 50% of the time. Following uncomplicated ureteroscopy, most respondents (52.0%) would leave a stent for 2-7 days. Patient height was most commonly ranked first as the method of choice in determining stent length (47.0%), followed by estimation based on experience only (20.6%) and intra-operative direct measurement of ureteric length (19.1%). Most respondents utilized multiple methods in determination of optimal stent length. Most respondents (66.5%) were interested in a simple intra-operative technique utilizing a special ureteral catheter that would help choose the most appropriate stent length. Post-ureteroscopy stent insertion is common and patient height is the most common method of choice used in determining optimal stent length. Most respondents were interested in using a simple, novel ureteral catheter device that would allow them to more accurately select optimal stent length.

Retrograde ureteral catheterization under local anesthesia for emergency drainage in patients with infection and hydronephrosis secondary to ureteral calculi: Experience from a tertiary care hospital.

The aim is to evaluate the safety and efficacy of retrograde ureteral catheterization under local anesthesia in patients with urinary tract infections complicated by hydronephrosis caused by ureteral stone obstruction. From October 2020 to September 2021, a retrospective analysis of patients' medical records was performed. Records of past history, physical examination, laboratory tests, and imaging investigations were reviewed. Retrograde ureteric stent (RUS) was performed under local anesthesia using cystoscopes and guided by portable fluoroscopy. Real-time fluoroscopy was used to verify the double-J stent position and confirm a smooth process. The postoperative recovery and length of admission were also recorded. A total of 14 patients with ureteral stone obstruction with infective hydronephrosis received 15 total emergency RUS procedures (one bilateral). Intraoperative findings, operation times, and infection signs were recorded and analyzed. All patients met systemic infection criteria, with a mean body temperature of 38.7°C ± 1.7°C. Leukocytosis was noted in 8 (57.1%) patients. Elevated C-reactive protein (8.5 ± 6.3 mg/L) and procalcitonin (24.1 ± 22.0 ng/mL) were found in 13 (92.9%) and 9 (64.3%) patients, respectively. Mean stone size was 8.5 ± 6.3 mm, mostly localized to the upper ureter (upper: 12; middle: 0; lower: 3). Mean operation time was 14.1 ± 4.3 min. After emergency drainage, all patients improved and were discharged after infection was controlled. The average length of admission was 6.2 ± 2.2 days. RUS under local anesthesia is safe and effective for treating infective hydronephrosis due to ureteral stone obstruction. A randomized controlled trial with a large sample remains necessary to validate these findings.

Effectiveness of Fluorescent Ureteral Catheter in Identifying Ureter During Sigmoidectomy

59歳の男性で，左下腹部痛と発熱を認めたため当院を受診した．下腹部に限局した圧痛と筋性防御を認めたが，反跳痛は認めなかった．白血球数16,200/μl，CRP 5.29mg/dlを認め，腹部CT検査ではS状結腸の壁肥厚を認め，周囲に遊離ガス像を認めた．S状結腸穿孔，限局性腹膜炎と診断し，手術を勧めたが患者の同意が得られず絶食と抗生剤による治療を行った．全身状態は改善したのちに精査を行いS状結腸癌と診断した．腹部CT検査で腫瘍は左骨盤壁への近接が予測され，麻酔導入後に蛍光尿管ステントを留置した．腹腔鏡下に手術を行い，術中所見で腫瘍は尿管に近接していたが，近赤外光で尿管を視認し，尿管への浸潤は認めなかった．しかし精管への癒着浸潤が疑われ，腹腔鏡下S状結腸切除術，精管合併切除術を行った．術前に尿管損傷を危惧する際において蛍光尿管ステントは術中に尿管の位置を把握するために有用であると考えられた．

Симультанная билатеральная ретроградная интраренальная хирургия c использованием тулиевого волоконного лазера.

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

EGS P32V Laparoscopic transcystic Antegrade Biliary Stenting

Abstract Background Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis including pancreatitis. Symptomatic gall stones patients have up to 20% risk of having common bile duct (CBD) stones too. Although, guidelines have been laid down for management of suspected CBD stones, in practice there is a lot of variability and lack of standardisation. The waiting list for Magnetic resonance cholangiopancreatography (MRCP) is long, resulting in delayed treatment and increased length of hospital stay. Similarly, pre-operative endoscopic retrograde cholangiopancreatography (ERCP) can also increase the length of hospital stay due to long waiting lists, limited availability and overall risk of complications as high as 30%. Hence, the role of on-table cholangiogram (OTC) while performing laparoscopic cholecystectomy has been explored. The guidelines state that OTC should be performed in fit for surgery patients, without pre-operative investigations for diagnosing CBD stones. We have been practising early cholecystectomy with on-table cholangiogram (during the index admission), with selective insertion of antegrade biliary stent in patients with choledocholithiasis. We facilitate ERCP with stent removal and clearance of CBD stones after 4 weeks post-operatively. We aim to present our technique of laparoscopic antegrade biliary stent insertion. Methods We follow the standard four-port technique for Laparoscopic cholecystectomy. Following dissection of Calot's triangle and visualisation of ‘critical view of safety’, an on-table cholangiogram is performed using a standard technique. If CBD stones are visualised, a transcystic antegrade stenting is done by Seldinger technique (without clearing the CBD of stones). The cholangiogram catheter is removed and flex-tip ureteric catheter is inserted transcystically. Through the ureteric catheter a flex-tip guidewire is inserted into CBD till its tip is visualised in the duodenum, under C-arm guidance. The ureteral catheter is then withdrawn carefully with guidewire placed satisfactorily. A double pig tail end biliary stent is rail-roaded over the guidewire, using a pushing catheter fashioned appropriately. As soon as the tip of the stent is visualised beyond the ampulla (in the X-ray), the guidewire and pushing catheter are withdrawn. The curling up of both ends of the stent is visualised and confirmed through C-arm guidance. Thereafter the procedure of cholecystectomy, as standard, is completed. Results The results of this procedure were analysed from 2014 to 2017, and subsequently published in 2018. Conclusions This technique does not involve skills required for CBD exploration. Hence, can be performed by general surgeons with expertise in minimal access surgeries, as it does not involve a steep learning curve. This technique is safe, reliable and cost-effective. It also decreases delays in biliary decompression, in-hospital stay and ensures timely treatment.

Optimization of the outcome of percutaneous nephrolithotomy regarding urinary leakage, what should we do?

To evaluate the factors affecting urinary leakage post percutaneous nephrolithotomy. To define those at high risk in whom a double J stent for 4 weeks or external ureteral catheter fixation for at least 3 days is indicated at the end of procedure. A total of 140 patients who underwent single-stage Percutaneous Nephrolithotomy (PCNL) with single or multiple accesses were included between February 2014 and March 2019. A detailed history, laboratory and radiological investigations were performed on all patients. All patients were classified according to postoperative urinary leakage into three groups. We defined leakage as a leakage from percutaneous puncture site. Group 1 (90 patients), No leakage was defined as leakage < 12 hours. In group 2 (32 patients), short-term leakage was defined as leakage 12-48 hours, and in Group 3 (18 patients), prolonged urinary leakage > 48 hours. Patients with short-term and prolonged urinary leakage had a significantly shorter access tract. Most patients (93.8%) with short-term leakage had an access tract of 71-90 mm, while > 50% of patients (55.6) with prolonged leakage had an access tract of 51-70 mm (p <0.001). Multivariate ordinal regression revealed that Operative time, length of the access tract and parenchymal thicknesses significantly predict short-term and prolonged leakage. For predicting the prolonged urinary leakage, the length of access tract and parenchymalthickness showed significant areas under the curve (AUC); 78% (95% CI: 69 – 85, p = 0.002) and 94% (95% CI: 87 – 97, p <0.001), respectively. Operative time, length of the access tract and parenchymal thickness significantly predict short-term and prolonged leakage.

An overview of diverticular pathophysiology and its treatment

Diverticula are protrusions that resemble sacs in the colon's wall. Acute or chronic problems are experienced by 4% of diverticula patients. Diverticulosis development has been linked in large part to the western way of life. Colonic diverticular disease has become more common. Obesity, smoking, and inadequate fibre consumption are risk factors for the illness. Most of the time, surgery is not necessary to treat this; however, if the bleeding is significant, angiography and endovascular intervention may be helpful. Ureteral catheters should be considered when a patient has undergone radiation therapy, resurgery, or preoperative imaging reveals an abnormal anatomy. Oral antibiotics can help prevent surgical site infections after an elective colon resection, according to studies. Using nonabsorbable oral antibiotics like erythromycin, neomycin, and metronidazole reduces surgical site infections overall.

Initial Experience With Extraperitoneal Laparoscopic Radical Cystectomy With Pelvic Organ-Preserving and Orthotopic Neobladder Techniques for Bladder Cancer in Female Patients

To present the extraperitoneal laparoscopic radical cystectomy (ELRC) technique, and initial outcomes of organ-preserving and orthotopic neobladder (ONB) techniques for bladder cancer in selected females. Data including patient characteristics, operative time, blood loss, transfusion rate, length of hospital stay, and pathologic outcomes, as well as 30- and 90-day complications were collected between April 2018 and May 2021 from females who underwent ONB after ELRC.. Regular follow-up focused on patients' oncological and functional outcomes, and postoperative sexual function status was assessed using the Female Sexual Function Index (FSFI). Eleven females with a mean age of 53 years who underwent ELRC with pelvic organ-preservation and ONB were analyzed retrospectively. All procedures were completed successfully. The mean operative time was 264.82 ± 33.81 min, and the average intraoperative blood loss was 128 ± 18.19 mL. All patients had negative pathological margins and no lymph node metastases. The average hospital stay was 10.72 days. The single J ureteral stent and catheter were usually removed 3 - 4 weeks after the procedure. The FIFS assessment of postoperative sexual function showed that the patients were relatively satisfied. ELRC with pelvic organ preservation and ONB technology was a safe and feasible surgical strategy for the selected female patients. Preserving organs and vascular nerve bundles seemed to be safe in oncological and produced encouraging functional results. Further rigorous prospective studies with more patients and long-term follow-up data are needed to assess the oncologic and functional results.

Tubeless Ureterorenoscopy-Our Experience Using a 120 W Laser and Dusting Technique: Postoperative Pain, Complications, and Readmissions.

Introduction and Objective: Both double J-stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In select situations, a tubeless approach is possible and safe. In tubeless cases, we use a sheathless dusting technique with the Lumenis® MOSES Pulse™120 H Holmium: YAG laser. We evaluated these three drainage subgroups and compared postoperative pain, complications, and readmissions. Methods: A retrospective database of 269 consecutive patients who underwent primary ureterorenoscopy for the treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post-operative drainage as Tubeless, UC, and DJS. The decision on whether to perform post-operative drainage was by surgeon preference. Demographic and clinical parameters such as stone location, number, and burden, hydronephrosis grade, and postoperative complications (fever, acute renal failure, and the obstruction of the upper urinary tract by Stone Street) were assessed. Pain was assessed using a 0−10 Visual Analog Scale score (VAS) and the use of analgesics by dose/case in each group. Results: There were 70 (26%) tubeless, 136 (50%) UC, and 63 (24%) DJS cases. Patients drained with DJSs had a significantly higher stone burden, more severe obstruction, and prolonged operative time. Tubeless and UC-drained patients had the same stone characteristics with maximal diameters of 8.4 (6.1−12) mm and 8 (5.2−11.5) mm in comparison to the stented group, with 12 (8.6−16.6) mm, p < 0.01. The operation time was the longest in the stented group at 49 min (IQR 33−60) in comparison to the UC and tubeless groups at 32 min (23−45) and 28 min (20−40), respectively (p < 0.001). Auxiliary procedures were more prevalent in the stented group, but the overall stone-free rate was not significantly different, p = 0.285. Postoperative ER visits, readmissions, and complications were the highest in the UC-drained group, at 20% in the UC vs. 6% in the tubeless and 10% in the stented groups. Post-operative pain levels and analgesic use were significantly lower in the tubeless group with a significant reduction in opiate usage. Conclusions: A tubeless approach is safe in selected cases with fewer post-operative complications. While DJS should be considered in complex cases, UC may be omitted in straightforward cases since it does not appear to reduce immediate postoperative complications. Those fitted for tubeless procedures had improved postoperative outcomes, facilitating outpatient approach to upper urinary tract stone treatment and patient satisfaction.

Дорожная карта перкутанного доступа в почку под ультразвуковым контролем

The key point of successful PCNL is getting access to the renal collecting system. Ureteral catheterization and injection of contrast material provide an important advantage of visualizing and dilating the collecting system. However, catheterization increases the operation time, exposure to anesthesia, and requires additional reusable and disposable medical supplies. The purpose of the study was to develop a surgical algorithm for accessing the renal collecting system for mini-PCNL without catheterization.We analyzed the treatment results of 82 patients with a single kidney stone, who underwent mini-PCNL without prior catheterization of the ureter. The percutaneous access was obtained according to the roadmap we had developed. The puncture was performed under X-ray control and US guidance. For a calyx stone, the puncture was performed "to the stone". For a pelvis stone, the targeted calyx was accessed using the following algorithm where each next step was performed if the puncture had been impossible at the previous one: 1. 30 min before the operation: infusion load of normal saline, 1000 ml. 2. Intraoperatively: intravenous furosemide, 60 mg. 3. Puncture "to the pelvic stone", injecting contrast material into the collecting system and correcting the access puncture through the required calyx.In all 82 cases, puncture access was performed without ureteral catheterization. In 20 patients with calyceal stones, puncture onto a stone was successfully performed in 100% of the cases. Of 62 patients with pelvic stones, preliminary infusion was enough to allow a successful puncture in 49 (79%), access after intravenous administration of furosemide was obtained in 13 (21%), and a primary puncture onto a pelvic stone had to be done in 6 (10%) patients.Our proposed algorithm for accessing the PCS of the kidney was successfully used in 100% of the cases. It makes possible to avoid routine ureteral catheterization and thus reduce the overall operation time and the risk of complications, as well as save medical supplies. Clearly, such results require that the surgeon should have significant experience with puncture interventions under ultrasound control.

Ureterolysis for Deep Infiltrating Endometriosis Using Indocyanine Green on the Robotic Platform

<h3>Study Objective</h3> To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green under near-infrared fluorescence on the robotic platform. <h3>Design</h3> Stepwise demonstration using narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> A 43-year-old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for two aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. <h3>Interventions</h3> In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous indocyanine green has previously been described to assist with resection of endometriosis.^1-3 Alternatively, we describe a technique that allows for easier identification of ureters using indocyanine green (ICG) injection retrogradely in ureteral stents while visualized under near-infrared fluorescence (NIRF).^4-5 1. Perform cystoscopy and place bilateral open-ended 5-French ureteral catheters. Inject indocyanine green retrogradely in each ureteral catheter, and place caps to seal the catheters to maximize ICG retention. 2. Once robotic-assisted laparoscopic surgery is started, use NIRF to identify the ureter. The ureter will emit green fluorescence, whereas the surrounding tissue will not. 3. Once the ureter is identified, NIRF is intermittently used to safely follow the course of the ureter and perform ureterolysis, while excising endometriosis. <h3>Measurements and Main Results</h3> The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3-week postoperative visit, pelvic pain had completely resolved. <h3>Conclusion</h3> This case demonstrates the use of intra-ureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

Clinical Comparison between Three Single-Use Flexible Ureteroscope Models: A Real-World Experience

Introduction: Studies comparing different single-use flexible ureteroscope (su-fURS) models are lacking. The objective was to compare three types of su-fURS: the Uscope 3022 (PUSEN), LithoVue (Boston Scientific), and EU-scope (Innovex). Methods: This was a retrospective study comparing the clinical outcomes from patients undergoing flexible ureteroscopy with one of the three su-fURS for upper urinary tract stone treatment between September 2019 and 2021. Analysis included total surgery and fluoroscopy time, post-procedure ureteral catheter, stone-free rate (SFR), and complications. Results: There were 104 cases with the Uscope 3022, 141 with LithoVue, and 80 with EU-scope. Groups were comparable in terms of stone size, location and density, and prior double-J stent presence. Multivariate analysis showed no difference in terms of SFR: 79% (Uscope 3022), 77.5% (LithoVue), and 81% (EU-scope); p = 0.38. Significant differences were found for total surgery and fluoroscopy time, as well as ureteral access sheath use (p < 0.001), favoring the EU-scope group. Discussion/Conclusion: The three devices evaluated are highly effective in treatment of kidney stones. Reasons for difference in total surgery and fluoroscopy time and access sheath use are not clear. However, this could be explained by technical aspects of these devices, such as external diameter, optical resolution, and field of view.

Laparoscopic Abdominal Cerclage after Prior Radical Trachelectomy

<h3>Study Objective</h3> To present a case and surgical video of laparoscopic abdominal cerclage placement after prior radical trachelectomy and demonstrate techniques in overcoming challenging dissections and an alternative surgical technique in placement of cerclage. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> In the operating room with a patient in dorsal lithotomy position with both arms tucked. A 10mm port was placed at the umbilicus and 3 additional 5mm ports were placed in the right and left lower quadrant and suprapubic region. A uterine manipulator, flexible laparoscopic, and bipolar sealing device were used. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> A 34yo P2 with prior surgical history of exploratory laparotomy, radical trachelectomy, sentinel lymph node mapping, pelvic lymphadenectomy for stage 1B1 cervical squamous cell cancer. She had been disease free for two years and she had erosion of her vaginal cerclage that had been placed at the time of her original surgery. She had two prior cesarean deliveries prior to her cervical cancer diagnosis and desired future fertility. She underwent a laparoscopic abdominal cerclage with cystoscopy and ureteral catheter placement. <h3>Measurements and Main Results</h3> Laparoscopic placement of abdominal cerclage was successful. Surgical techniques in navigating difficult dissections are reviewed in the video. In the absence of a cervicouterine junction, placement a 5mm Mersilene tape cerclage at the neo-cervical region was successful. There were no intra or post-operative complications. Patient had a good surgical recovery. <h3>Conclusion</h3> This video demonstrates challenges in placement of an abdominal cerclage following a radical trachelectomy due to distortion of anatomy and dense post-surgical adhesions. The video demonstrates that laparoscopic placement at the neo-cervical junction can be accomplished successfully and safely.

Efficacy and safety of retrograde ureteroscopy for the treatment of impacted proximal ureteral stones larger than 10 mm

Introduction and objective: Optimal management of large impacted proximal ureteral stones remains controversial. Retrograde ureteroscopy in these cases may be challenging due to the presence of mucosal edema and inflammation, tortuousity and unusual angulations of the ureter. The objective of this study is to evaluate the efficacy and safety of retrograde ureteroscopy (URS) for the treatment of impacted proximal ureteral stones larger than 10 mm. Material and methods: A prospectively collected database of 143 patients, who underwent retrograde ureteroscopy for impacted proximal ureteral stones ≥ 10 mm between January 2016 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates, complications and auxiliary procedures was analyzed. Results: Patients’ mean age was 54.2±13.4 years, and male-to-female ratio – 67.8%/32.2%. Mean stone length was 14.2±5.4 mm and mean stone width – 9.6±2.9 mm. 26 (18.2%) patients were on preoperative anticoagulation therapy, which could not be discontinued. 26 patients (18.2%) had preoperative drainage with ureteral stent JJ, and 7 (4.9%) – with percutaneous nephrostomy. Stone-free rate after single procedure was 88.8%. Mean operative time was 44.2±15.4 min. There were no cases of failed endoscopic access to the stone. Flexible ureteroscopy was performed in 34 (23.8%) cases. Postoperative drainage was ureteral stent JJ in 71 (49.7%) patients and ureteral catheter for 24 h – in 33 (23.1%). Most common postoperative complications were fever in 5 (3.5%) and postoperative renal colic – in 5 (3.5%) patients. 8 patients (5.6%) underwent SWL for treatment of residual fragments and 2 (1.4%) – retrograde intrarenal surgery. Conclusions: The results from this study demonstrate that retrograde ureteroscopy is an effective and safe treatment modality for impacted proximal ureteral stones ≥ 10 mm. Its high stone-free rate and low complication rate make retrograde URS a suitable first-line treatment for anticoagulated patients with impacted proximal ureteral stones, who are at increased risk of complications from the antegrade approach