Use Of Ureteral Access Sheath Research Articles

Preoperative α1-Blockers Impact on Outcomes of Patients Undergoing Ureteroscopy with Ureteral Access Sheaths: A Systematic Review and Meta-Analysis.

Ureteral access sheath (UAS) use during ureteroscopy has been associated with the risk for ureteral injuries. Preoperative administration of α1-blockers presents as a potential mitigator of such lesions by inducing ureteral relaxation, which may also contribute to improving other surgical outcomes. A comprehensive literature search was conducted across MEDLINE, Embase, and Cochrane databases for studies that compared preoperative α1-blockers administration versus its non-use in adult patients without pre-stenting undergoing ureteroscopy. Binary outcomes were evaluated using risk ratios (RR) and odds ratios (OR) with 95% confidence intervals. Heterogeneity was measured with the Cochran Q test, I2 statistics, and prediction intervals (PI). A DerSimonian and Laird random-effects model was utilized for all outcomes. Eleven studies encompassing 1074 patients undergoing ureteroscopy were included, of whom 522 (48.60%) received α1-blockers before the procedure. Preoperative α1-blockers were associated with a reduction in significant ureteral injuries (RR 0.30; 95% CI 0.17-0.53; I²=6%; PI 0.10-0.88) and an increase in mean successful ureteral access sheath insertion (OR 2.14; 95% CI 1.08-4.23; I²=23%; PI 0.51-8.93). In patients undergoing ureteroscopy lithotripsy, the medications also reduced total complications (RR 0.62; 95% CI 0.46-0.84; I²=0%), and complications graded Clavien-Dindo III or higher (RR 0.16; 95% CI 0.04-0.69; I²=0%). No significant difference between groups was found in the stone-free rate (RR 1.10; 95% CI 0.86-1.40; I²=91%; PI 0.47-2.59). Preoperative α1-blockers were linked to a decrease in significant ureteral injuries with UAS use and fewer complications during ureteroscopy lithotripsy procedures. However, their impact on the successful insertion of a UAS remains uncertain. Consideration of administering preoperative α1-blockers in patients undergoing ureteroscopy with UAS is advisable.

Evaluation of the effect of 9.5/11.5-fr ureteral access sheath use on acute kidney injury with the myo-inositol oxygenase biomarker in patients undergoing retrograde intrarenal surgery: a prospective, randomized, and controlled study

Introduction We aimed to investigate whether a low intrarenal pressure provided by ureteral access sheath (UAS) use had a positive effect on the prevention of acute kidney injury through the evaluation of the myo-inositol oxygenase (MIOX). Material and methods The patients were divided into two groups according to whether a 9.5/11.5-Fr UAS was used during retrograde intrarenal surgery (RIRS): UAS group and non-UAS group. RIRS was performed under gravity irrigation and manual pumping was not used. For the measurement of MIOX, 5 cc blood samples were taken from the patients preoperatively and four hours postoperatively. Results Operation time and hospital stay were significantly longer in the UAS group. The mean preoperative and postoperative MIOX values were 0.77 ± 0.36 ng/ml and 0.74 ± 0.38 ng/ml, respectively, in the UAS group, and 0.74 ± 0.31 ng/ml and 0.83 ± 0.40 ng/ml, respectively, in the non-UAS group. The mean MIOX change was −0.29 ± 0.36 in the UAS group and 0.08 ± 0.44 in the non-UAS group, indicating no significant difference between the groups. Conclusion Even if UAS is not used, significant acute kidney injury is not observed under gravity irrigation and therefore, if we avoid manual pumping, the intrarenal pressure remains low, thus potentially rendering the use of 9,5/11,5-Fr UAS unnecessary.

The Utility and Safety of Ureteral Access Sheath During Retrograde Intrarenal Surgery in Children

ObjectivesTo compare retrograde intrarenal surgery (RIRS) with and without ureteral access sheath (UAS) in different pediatric age groups. MethodsThe data of RIRS for kidney stone in children were obtained from 9 institutions. Demographic characteristics of patients and stones, intraoperative and postoperative results were recorded. While analyzing the data, patients who underwent RIRS without UAS (group 1) (n=195) and RIRS with UAS (group 2) (n=194) were compared. ResultsGroup 1 was found to be young, thin, and short (p<0.001, p=0.021, p<0.001), but there was no gender difference and similar symptoms were present except hematuria, which was predominant in group 2 (10.6% vs 17.3%, p<0.001). Group 1 had smaller stone diameter (9.91 +/- 4.46 vs 11.59 +/- 4.85 mm, p=0.001), shorter operation time (p=0.040), less stenting (35.7% vs 72.7%, p=0.003). Re-intervention rates and stone free rates (SFR) were similar between groups (p=0.5 & p=0.374). However, group 1 had significantly high re-RIRS (p=0.009). SFR had a positive correlation with smaller stone size and TFL usage compared to HFL (p<0.001 & p=0.020), but multivariate analysis revealed only large stone size as a risk factor for residual fragments (p=0.001). ConclusionRIRS can be performed safely in children with and without UAS. In children of smaller size or younger age (<5 years), limited use of UAS was observed. UAS may be of greater utility in stones larger than 1 cm, regardless of the age, and using smaller diameter UAS and ureteroscopes can decrease the complications.

The outcomes of flexible ureteroscopy for renal calculi of 2 cm or more with and without the use of ureteral access sheath: A retrospective study.

The rate of success of retrograde intrarenal surgery (RIRS) for treating urinary tract stones is high, and the procedure is growing in popularity. The routine use of ureteral access sheath (UAS) remains somewhat controversial. The aim of this study was to assess the efficacy and safety of employing UAS during flexible ureteroscopy for treating renal stones ≥ 2 cm. This retrospective study was accomplished from January 2021 to February 2023. From 495 consecutives flexible ureteroscopies, 112 patients had renal stones ≥ 2 cm (60 patients with the use of UAS and 52 patients without). The stone-free status was verified after 8 weeks of operation. The average diameter of the renal stones in non-UAS or UAS treated groups was 22.5 mm and 22.6, respectively. None of the groups differed significantly in terms of stone side, stone size, stone position, or Hounsfield unite but there was significant difference (p < 0.001) among two groups as regard pre-operative stenting (cases with UAS had 23.3% pre-operative stenting). It is not always necessary to use UAS in conjunction with flexible ureteroscopy and laser lithotripsy to treat renal calculi bigger than or equal two cm. Without the assistance of UAS, the surgery may be carried out successfully and safely.

Is It a Good Strategy to Proceed a Retrograde Intrarenal Surgery Session Sheathless After Ureteral Access Sheath Insertion Failure? A RIRSearch Study.

Objectives: To complement our previous findings regarding effect of ureteral access sheath (UAS) use, we checked RIRSearch database for patients who operated without using UAS. The aim of the study was to understand these new data better by comparing outcomes of retrograde intrarenal surgery (RIRS) that continued sheathless after a failed UAS insertion vs those planned and completed sheathless. Materials and Methods: Data of 195 patients who underwent sheathless RIRS for kidney and/or ureteral stones between 2011 and 2021 were retrieved from the database. Patients divided into two groups: cases who were planned and completed sheathless (n = 110, Group 1) and those who proceeded without UAS after insertion failure (n = 85, Group 2). After propensity score matching (PSM), each group consisted of 76 patients. Results: After PSM, stone-free rate for Group 1 (90.8%) was significantly higher than stone-free rate of Group 2 (76.3%) in sheathless RIRS (p = 0.02). Also postoperative complication rate was significantly lower in Group 1 (10.5%) than in Group 2 (27.6%) (p = 0.007). In Group 2, median operating time was longer (60 minutes, interquartile range [IQR]: 40-80) and more unplanned auxilliary procedure (22.4%) was needed than Group 1 (45 minutes, IQR: 40-50 and 3.9%) (both p = 0.001). Stone burden (odds ratio [OR]: 1.002, p = 0.019) and stone density (OR: 1.002, p = 0.003) were associated with high risk of residual stones after RIRS. Higher hydronephrosis grades were associated with increased stone-free rates (OR: 0.588 for residual stone risk, p = 0.024). Cases who completed sheathless by dusting all available stones, as planned preoperatively, were more likely to have stone-free status after RIRS than those who proceeded sheathless after UAS insertion failure (OR: 2.645, p = 0.024). Conclusions: Operation course after UAS insertion failure may be more challenging. In cases who performed without using UAS, surgeons who proceed with procedure sheathless after UAS insertion failure may more frequently run into complications and may fail achieving stone-free status compared with sheathless-planned cases.

Comparison Between Holmium:YAG Laser with MOSES Technology vs Thulium Fiber Laser Lithotripsy in Retrograde Intrarenal Surgery for Kidney Stones in Adults: A Propensity Score-matched Analysis From the FLEXible Ureteroscopy Outcomes Registry.

We evaluated stone-free rate and complications after flexible ureteroscopy for renal stones, comparing thulium fiber laser and holmium:YAG laser with MOSES technology. Data from adults who underwent flexible ureteroscopy in 20 centers worldwide were retrospectively reviewed (January 2018-August 2021). Patients with ureteral stones, concomitant bilateral procedures, and combined procedures were excluded. One-to-one propensity score matching for age, gender, and stone characteristics was performed. Stone-free rate was defined as absence of fragments >2 mm on imaging within 3 months after surgery. Multivariable logistic regression analysis was performed to evaluate independent predictors of being stone-free. Of 2,075 included patients, holmium:YAG laser with MOSES technology was used in 508 patients and thulium fiber laser in 1,567 patients. After matching, 284 patients from each group with comparable baseline characteristics were included. Pure dusting was applied in 6.0% of cases in holmium:YAG laser with MOSES technology compared with 26% in thulium fiber laser. There was a higher rate of basket extraction in holmium:YAG laser with MOSES technology (89% vs 43%, P < .001). Total operation time and lasing time were similar. Nine patients had sepsis in thulium fiber laser vs none in holmium:YAG laser with MOSES technology (P = .007). Higher stone-free rate was achieved in thulium fiber laser (85% vs 56%, P < .001). At multivariable analysis, the use of thulium fiber laser and ureteral access sheath ≥8F had significantly higher odds of being stone-free. Lasing time, multiple stones, stone diameter, and use of disposable scopes showed significantly lower odds of being stone-free. This real-world study favors the use of thulium fiber laser over holmium:YAG laser with MOSES technology in flexible ureteroscopy for renal stones by way of its higher single-stage stone-free rate.

Real-world Practice Stone-free Rates After Ureteroscopy: Variation and Outcomes in a Surgical Collaborative

BackgroundStudies assessing the stone-free rate (SFR) after ureteroscopy are limited to expert centers with varied definitions of stone free. Real-world data including community practices related to surgeon characteristics and outcomes are lacking. ObjectiveTo evaluate the SFR for ureteroscopy and its predictors across diverse surgeons in Michigan. Design, setting, and participantsWe assessed the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry for patients with renal or ureteral stones treated with ureteroscopy between 2016 and 2021 who had postoperative imaging. Outcome measurements and statistical analysisStone free was defined as no fragments on imaging reports within 60 d entered by independent data abstractors. Factors associated with being stone free were examined using logistic regression, including annual surgeon volume. We then assessed variation in surgeon-level SFRs adjusted for risk factors. Results and limitationsWe identified 6487 ureteroscopies from 164 surgeons who treated 2091 (32.2%) renal and 4396 (67.8%) ureteral stones. The overall SFRs were 49.6% (renal) and 72.7% (ureteral). Increasing stone size, lower pole, proximal ureteral location, and multiplicity were associated with not being stone free. Female gender, positive urine culture, use of ureteral access sheath, and postoperative stenting were associated with residual fragments when treating ureteral stones. Adjusted surgeon-level SFRs varied for renal (26.1–72.4%; p < 0.001) and ureteral stones (52.2–90.2%; p < 0.001). Surgeon volume was not a predictor of being stone free for renal stones. Limitations include the lack of imaging in all patients and use of different imaging modalities. ConclusionsThe real-world complete SFR after ureteroscopy is suboptimal with substantial surgeon-level variation. Interventions focused on surgical technique refinement are needed to improve outcomes for patients undergoing ureteroscopy and stone intervention. Patient summaryResults from a diverse group of community practicing and academic center urologists show that for a large number of patients, it is not possible to be completely stone free after ureteroscopy. There is substantial variation in surgeon outcomes. Quality improvement efforts are needed to address this.

PD45-11 DOES THE USE OF A URETERAL ACCESS SHEATH REDUCE INFECTION-RELATED HOSPITALIZATION? REAL-WORLD DATA FROM A SURGICAL COLLABORATIVE

You have accessJournal of UrologyCME1 Apr 2023PD45-11 DOES THE USE OF A URETERAL ACCESS SHEATH REDUCE INFECTION-RELATED HOSPITALIZATION? REAL-WORLD DATA FROM A SURGICAL COLLABORATIVE Russelle. N. Becker, Andrew M. Higgins, Golena Fernandez Moncaleano, Sung Yong Cho, Mohammad Jafri, Jessica Phelps, Jeremy Konheim, Bronson Conrado, Monica S. Van Til, Stephanie Daignault-Newton, Casey A. Dauw, Khurshid R. Ghani, and For The Michigan Urological Surgery IMPROVEMENT Collaborative Russelle. N. BeckerRusselle. N. Becker More articles by this author , Andrew M. HigginsAndrew M. Higgins More articles by this author , Golena Fernandez MoncaleanoGolena Fernandez Moncaleano More articles by this author , Sung Yong ChoSung Yong Cho More articles by this author , Mohammad JafriMohammad Jafri More articles by this author , Jessica PhelpsJessica Phelps More articles by this author , Jeremy KonheimJeremy Konheim More articles by this author , Bronson ConradoBronson Conrado More articles by this author , Monica S. Van TilMonica S. Van Til More articles by this author , Stephanie Daignault-NewtonStephanie Daignault-Newton More articles by this author , Casey A. DauwCasey A. Dauw More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003358.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Elevated intrarenal pressure during ureteroscopy (URS) may result in pyelovenous backflow, which is hypothesized to increase the risk of sepsis. When treating renal stones, the ureteral access sheath (UAS) is considered a pressure mitigation strategy, yet evidence on whether a UAS reduces infectious complications is unclear. Prior studies are limited by small cohorts, heterogenous inclusion criteria, ambiguous endpoints, or lack adequate risk adjustment. We examined UAS use when treating renal stones and its association with infection-related hospitalization in a statewide registry. METHODS: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all patients undergoing single-stage unilateral URS for renal stones, with or without the use of a UAS. We assessed variation in UAS in practices with>10 cases. We evaluated demographic differences between cases with or without UAS. A multivariable logistic regression model was constructed to examine the impact of UAS use and other patient, stone, and surgical factors on 30-day infection-related hospitalization. RESULTS: Among 6,142 patients undergoing URS by 233 urologists across 34 practices, 152 (2.5%) had an infection-related hospitalization within 30 days. Patients with UAS had significantly larger stones, more positive preoperative urine culture, and higher comorbidity. Overall 59% of cases utilized UAS, with significant variation between practices (4.1% to 99.5%, p<0.0001; Figure). Infection-related hospitalization rates were no different for cases with (2.6%) vs. without (2.3%) UAS use (p=0.5). On multivariable analysis, infection-related hospitalizations did not differ by UAS (OR 0.8; 95% CI 0.6 - 1.2; p=0.4), but were associated with higher Charlson Comorbidity Index (CCI 1 vs. 0, OR 1.9; 95% CI 1.2 - 2.9; CCI 2+ vs. 0, OR 2.3; 95% CI 1.4 - 3.6; p<0.001), history of recurrent UTI (OR 2.4; 95% CI 1.4 - 4.0; p<0.01), larger stones (OR per 5mm 1.1; 95% CI 1.0 - 1.3; p=0.04), and positive preoperative urine culture (OR 1.8; 95% CI 1.2 - 2.7; p<0.01). CONCLUSIONS: Utilization of UAS when treating renal stones varies widely across practices within Michigan. UAS did not reduce infection-related hospitalization following URS for renal stones. Source of Funding: Blue Cross Blue Shield of Michigan © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1167 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Russelle. N. Becker More articles by this author Andrew M. Higgins More articles by this author Golena Fernandez Moncaleano More articles by this author Sung Yong Cho More articles by this author Mohammad Jafri More articles by this author Jessica Phelps More articles by this author Jeremy Konheim More articles by this author Bronson Conrado More articles by this author Monica S. Van Til More articles by this author Stephanie Daignault-Newton More articles by this author Casey A. Dauw More articles by this author Khurshid R. Ghani More articles by this author For The Michigan Urological Surgery IMPROVEMENT Collaborative More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-09 SUPERPULSED THULIUM LASER&amp;[TRADE] FIBER VERSUS HIGH-POWER HOLMIUM:YAG LASER IN URETEROSCOPIC LASER LITHOTRIPSY: A CASE-CONTROL STUDY

You have accessJournal of UrologyCME1 Apr 2023MP35-09 SUPERPULSED THULIUM LASER&[TRADE] FIBER VERSUS HIGH-POWER HOLMIUM:YAG LASER IN URETEROSCOPIC LASER LITHOTRIPSY: A CASE-CONTROL STUDY Willian Ito, Nicholas Choi, George Letner, Dillon Prokop, Nicholas Genz, Bristol Whiles, Crystal Valadon, Md Islam, Mihaela Sardiu, Donald Neff, David Duchene, and Wilson Molina Willian ItoWillian Ito More articles by this author , Nicholas ChoiNicholas Choi More articles by this author , George LetnerGeorge Letner More articles by this author , Dillon ProkopDillon Prokop More articles by this author , Nicholas GenzNicholas Genz More articles by this author , Bristol WhilesBristol Whiles More articles by this author , Crystal ValadonCrystal Valadon More articles by this author , Md IslamMd Islam More articles by this author , Mihaela SardiuMihaela Sardiu More articles by this author , Donald NeffDonald Neff More articles by this author , David DucheneDavid Duchene More articles by this author , and Wilson MolinaWilson Molina More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Currently, a limited number of studies have compared high-power laser platforms for ureteroscopic lithotripsy (URS-L). We aimed to examine the outcomes of the SuperPulsed Thulium Fiber™ (SPTF) vs. the high-power holmium:YAG (HoYAG) laser for URS-L. METHODS: We conducted a retrospective chart review from 01/2019-12/2021 of patients undergoing elective URS-L for nephrolithiasis with HoYAG (Lumenis Pulse P120H™, 120W, Boston Sci®) or SPTF (Soltive™, 60W, Olympus®) laser modalities, regardless of stone size, location, or scope type. Exclusion criteria included patients with any urinary diversion, patients who did not undergo follow-up imaging or complete a 12-week post-procedural visit. Stone free status (SFS) was defined as the absence of stone fragments ≥2 mm on follow up imaging (ultrasound or CT scan). RESULTS: Of the initial 508 patients, 336 met inclusion criteria. Table 1 displays basic characteristics, with no significant difference between HoYAG and SPTF groups. Dusting technique was utilized more often in the SPTF group (18.5% vs. 6.2%, p=.039). Overall, SFS for HoYAG and SPTF were 85.9% vs. 85.3% (OR 1.07, CI 95% 0.56–2.06, p=0.82), respectively. In the stone location subgroup analysis, SFS results were comparable (Table 2). In our model, only BMI (OR 0.94, p=.002) and stone size (OR 0.94, p<.001) were correlated with SFS. When controlling for patients’ BMI, stone size, density, location, and use of ureteral access sheath, we found an adjusted OR 1.01 (CI 95% 0.46–2.23), with no statistical difference between laser modalities (p=0.96). CONCLUSIONS: Overall, there is no significant difference in SFS between HoYAG and SPTF groups, along with similar ablation efficiency and complication rates. Although ablation speed was significantly higher in the SPTF, total operative time was comparable. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e472 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Willian Ito More articles by this author Nicholas Choi More articles by this author George Letner More articles by this author Dillon Prokop More articles by this author Nicholas Genz More articles by this author Bristol Whiles More articles by this author Crystal Valadon More articles by this author Md Islam More articles by this author Mihaela Sardiu More articles by this author Donald Neff More articles by this author David Duchene More articles by this author Wilson Molina More articles by this author Expand All Advertisement PDF downloadLoading ...

V02-05 FIRST-IN-HUMAN EXPERIENCE WITH THE LITHOVUE TM ELITE SINGLE USE URETEROSCOPE: IMPACT OF UAS ON INTRARENAL PRESSURE

You have accessJournal of UrologyCME1 Apr 2023V02-05 FIRST-IN-HUMAN EXPERIENCE WITH THE LITHOVUETM ELITE SINGLE USE URETEROSCOPE: IMPACT OF UAS ON INTRARENAL PRESSURE Ben H. Chew, Abdulghafour Halawani, Kyochul Koo, Victor K. F. Wong, and Naeem Bhojani Ben H. ChewBen H. Chew More articles by this author , Abdulghafour HalawaniAbdulghafour Halawani More articles by this author , Kyochul KooKyochul Koo More articles by this author , Victor K. F. WongVictor K. F. Wong More articles by this author , and Naeem BhojaniNaeem Bhojani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003232.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We described the 1st in human use of the novel pressure sensing digital flexible ureteral scope, LithoVue Elite (Boston Scientific). By measuring intrarenal pressure in renal time, we were able to determine if the pressure may become elevated and contribute to potential postoperative complications. METHODS: The LithoVue Elite Ureteroscope was used clinically and the first in human cases have occurred in Canada. A pressure bag set at 150 mmHg was used for pressurized irrigation. A ureteral access sheath was used at the discretion of the surgeon. Pressure readings were delivered 4 times a second. Readings of the intrarenal pressure are displayed on the video interface where the endoscopic image is viewed in real time (Figure 1). RESULTS: Two cases are discussed here. One case shows that the intrarenal pressure with a ureteral access sheath ranges between 25-30 mmHg. In the exact same patient on the other kidney, no ureteral access sheath was used and the pressure is seen to be approximately 100 mmHg. Another case shows a patient under spinal anesthesia. When the pressure goes >115 mmHg, the patient describes pain and insertion of a UAS lowers the pressure to 15 mmHg and her pain subsides. CONCLUSIONS: The LithoVue Elite ureteroscope was able to monitor intrarenal pressure in real time. Ureteral access sheath use in these 2 cases showed a decrease in intrarenal pressure and where the patient was awake under spinal anesthetic, a UAS decreased her pain from high intrarenal pressure. The use of a new ureteroscope that can monitor intrarenal pressure in real time will help further investigation of the effects of intrarenal pressure during and after ureteroscopy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e169 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ben H. Chew More articles by this author Abdulghafour Halawani More articles by this author Kyochul Koo More articles by this author Victor K. F. Wong More articles by this author Naeem Bhojani More articles by this author Expand All Advertisement PDF downloadLoading ...

PD28-07 FIRST-IN-HUMAN EXPERIENCE USING THE LITHOVUE ELITE SINGLE USE URETEROSCOPE TO MEASURE INTRARENAL PRESSURE: THE CANADIAN EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023PD28-07 FIRST-IN-HUMAN EXPERIENCE USING THE LITHOVUE ELITE SINGLE USE URETEROSCOPE TO MEASURE INTRARENAL PRESSURE: THE CANADIAN EXPERIENCE Ben H. Chew, Kyochul Koo, Abdulghafour Halawani, Jeddah, Saudi Arabia, Victor K. F. Wong, and Naeem Bhojani Ben H. ChewBen H. Chew More articles by this author , Kyochul KooKyochul Koo More articles by this author , Abdulghafour HalawaniAbdulghafour Halawani More articles by this author , Jeddah Jeddah More articles by this author , Saudi ArabiaSaudi Arabia More articles by this author , Victor K. F. WongVictor K. F. Wong More articles by this author , and Naeem BhojaniNaeem Bhojani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003313.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Intrarenal pressure (IRP) is thought to play a role in complications following ureteroscopy. This area is poorly studied because of the difficulty in routinely measuring IRP. We report on our first-in-human experience using the LithoVue EliteTM ureteroscope (Boston Scientific). METHODS: A single-arm retrospective observational analysis was performed in 46 consecutive patients undergoing ureteroscopic lithotripsy using the LithoVue Elite™ system with pressure sensing capability between April-October, 2022 at 2 centres. A pressure bag set at 150mmHg or hand irrigation with a 60cc syringe was used for irrigation and a ureteral access sheath (UAS) was placed at the physician’s discretion. Median and maximum IRPs, and relative cumulative time exceeding 20, 40, 60, 80, 100, 120, 140, 160, and 200 mmHg per total procedure time were analyzed. The two-sample Mann-Whitney U-test was used with a statistical significance set at p<0.005. RESULTS: Median patient age and body mass index (BMI) were 62.5 (IQR 47.8–72.0) years and 29.4 (23.3–32.8) kg/m2 (Table 1). During the median total procedure time of 31.9 (IQR 17.4–44.9) minutes, median and maximum IRPs were 30.0 (IQR 21.0–51.5) and 177.0 mmHg (IQR 129.0–266.0), respectively. IRP remained below 60 mmHg 91.3% of the procedure times (Figure 1). Patients with Asian ethnicity and hypertension had higher pressures and a longer relative cumulative time≥20 mmHg compared to others, while patients with tight ureters and without UAS use exhibited longer cumulative times≥60 mmHg . The smaller 10/12 Fr UAS did not lower pressures as much as the 11/13 Fr and 12/14 Fr UAS (p<0.001). Age, pre-stenting, preoperative α-blockade, and BMI did not show any statistically significant associations with IRP. CONCLUSIONS: IRP can now be routinely measured during ureteroscopy. Patients had a median IRP of 30 mmHg and a maximum of 177 mmHg. The use of a smaller UAS (<12/14 Fr), Asian ethnicity, hypertension and tight ureters were found to have higher IRPs in our study. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e821 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ben H. Chew More articles by this author Kyochul Koo More articles by this author Abdulghafour Halawani More articles by this author Jeddah More articles by this author Saudi Arabia More articles by this author Victor K. F. Wong More articles by this author Naeem Bhojani More articles by this author Expand All Advertisement PDF downloadLoading ...

Assessment of factors influencing operating time during retrograde intrarenal surgery for renal stone in tertiary care hospital of Nepal

Retrograde intrarenal surgery (RIRS) is an effective and safe method for the management of intrarenal stone showing high stone-free rates. Its main advantage is decrease in operative morbidity for the patient, as well as a faster recovery. The current study aimed to study the factors influencing operating time during retrograde intrarenal surgery for renal stone in tertiary care hospital. It is an observational descriptive cross sectional study using purposive sampling method which was conducted among 188 patients who underwent retrograde intrarenal surgery (RIRS) for management of nephrolithiasis in Department of Urology of B&amp;B hospital, Lalitpur, Nepal. The baseline information of the factors affecting operating time were obtained like age, gender, site of renal stone, prestented or not, body mass index (BMI), ureteral access sheath (UAS) use, stone volume and stone density. The mean operating time was high in renal stone with calcium ammonium urate composition. On linear regression analysis, operative times significantly increased with greater stone volumes and also pre-stenting and ureteral access sheath use did significantly difference on operative time. It revealed stone volume to be the most significant predictor of operative time. Thus, the present study provides valuable information regarding the factors influencing operating time during retrograde intrarenal surgery for renal stone.

Understanding the Role of Ureteral Access Sheath in Preventing Post-Operative Infectious Complications in Stone Patients Treated with Ureteroscopy and Ho:YAG Laser Lithotripsy: Results from a Tertiary Care Referral Center.

The use of ureteral access sheaths (UAS) limits the irrigation-induced increase in intrarenal pressure during ureteroscopy (URS). We investigated the relationship between UAS and rates of postoperative infectious complications in stone patients treated with URS. Data from 369 stone patients treated with URS from September 2016 to December 2021 at a single institution were analyzed. UAS (10/12 Fr) placement was attempted in case of intrarenal surgery. The chi-square test was used to assess the relationship between the use of UAS and fever, sepsis, and septic shock. Univariable and multivariable logistic regression analyses tested the association of patients' characteristics and operative data and the rate of postoperative infectious complications. Full data collection of 451 URS procedures was available. Overall, UAS was used in 220 (48.8%) procedures. As for postoperative infectious sequalae, we recorded fever (n = 52; 11.5%), sepsis (n = 10; 2.2%), and septic shock (n = 6; 1.3%). Of those, UAS was not used in 29 (55.8%), 7 (70%), and 5 (83.3%) cases, respectively (all p > 0.05). At multivariable logistic regression analysis, performing URS without UAS was not associated with the risk of having fever and sepsis, but it increased the risk of septic shock (OR = 14.6; 95% CI = 1.08-197.1). Moreover, age-adjusted CCI score (for fever-OR = 1.23; 95% CI = 1.07-1.42, sepsis-OR = 1.47; 95% CI = 1.09-1.99, and septic shock-OR = 1.61; 95% CI = 1.08-2.42, respectively), history of fever secondary to stones (for fever-OR = 2.23; 95% CI = 1.02-4.90) and preoperative positive urine culture (for sepsis-OR = 4.87; 95% CI = 1.12-21.25) did emerge as further associated risk factors. The use of UAS emerged to prevent the onset of septic shock in patients treated with URS, with no clear benefit in terms of fever and sepsis. Further studies may help clarify whether the reduction in fluid reabsorption load mediated by UAS is protective against life-threatening conditions in case of infectious complications. The patients' baseline characteristics remain the main predictors of infectious sequelae in a clinical setting.

Location of ureteral access sheath in the ureter. Does it affect the fluid flow in different calyces?

The aim of this study was to evaluate outflow variation in different locations of the pyelocaliceal system with the use of different ureteral access sheath (UAS) sizes and different UAS positioning. The experimental setup included an anaesthetised porcine model, a 7.5-Fr ureteroscope with a 200-μm laser fibre inserted in the working channel, a hand-held pumping irrigating system, and UAS of different sizes, namely: 9.5/11.5 Fr, 12/14 Fr, and 14/16 Fr. Each UAS was placed just below the ureteropelvic junction (UPJ) or in the mid-ureter. The ureteroscope was placed in the renal pelvis, upper and lower calyces, and outflow measurements were obtained with 3-second interval pumping for one minute in every experimental setup. The UAS positioning in the mid-ureter was associated with significantly higher outflow rates in the lower calyx (p = 0.041). While the UAS was below the UPJ, we observed a trend of lower outflow rate in the lower calyx, which was completely inverted when the UAS was in the mid-ureter. Increasing the UAS size from 9.5/11.5 Fr to 12/14 Fr led to a significant increase in outflow in the renal pelvis and upper calyx (p = 0.007), but not in the lower calyx. A further increase to 14/16 Fr did not produce increased flow. Different locations of the pyelocaliceal system have different fluid mechanics during fURS. In the renal pelvis and upper calyx increasing the diameter of the UAS improved the outflow, whereas in the lower calyx the position of the UAS seems to be the most relevant factor. These variables should be considered when performing fURS, especially with high-power laser lithotripsy.

Safety of the ureteral access sheath in unstented ureters

Introduction and objective: With advances in technology in recent years, the indications for flexible ureterorenoscopy (fURS) for the treatment of upper urinary tract stones have expanded. To facilitate retrograde access to the kidney, extraction of fragments and reduction of intrarenal pressure during surgery, the ureteral access sheath (UAS) was introduced. The aim of the present study was to investigate the incidence of postoperative stricture after the use of UAS in unstented patients and the effectiveness and safety of different sizes of UAS. Material and methods: A retrospective study was performed, including 240 fURS procedures with the use of UAS, performed between January 2019 and April 2022. We excluded cases in which a previous intervention was performed, patients with a JJ stent, nephrostomy or impacted stones, patients who underwent radiation treatment, or had urinary tract malignancies. The postoperative stricture was considered the presence of hydronephrosis on ultrasound examination or on CT scan in the first and third months. A comparative analysis of the effectiveness and safety of using the 11/13 Fr UAS and the 12/14 Fr UAS was performed. Results: The cohort included 167 patients with a postoperative follow-up of 3 months. In 143 patients (85.7%) UAS 11/13 Fr was used, in 24 patients (14.3%) UAS 12/14 Fr. No postoperative stricture was found in any of the patients. There was no significant difference in efficacy after one procedure using UAS 11/13 versus UAS 12/14 (93.0% vs. 91.7%, p=0.684), despite the larger stone volume in UAS 12/14 (123.4±93.5 mm2 vs. 95.5±41.5, p=0.009). Mean operative time was significantly longer in UAS 11/13 (38.7±11.2 min vs 50.2±16.2 min; p=0.049). Larger UAS size was not associated with more complications compared to a smaller size, comparative safety analysis found no significant differences in the incidence of intra- and postoperative complications (0% vs. 0.7%, p=0.821 and 8.4% vs. 7.2% p=.705, respectively). Conclusions: The results of this study suggest that UAS use has no impact on the efficacy of fURS and is not associated with an increased rate of intra- and postoperative complications.

Impact of ureteral access sheath use on outcomes of flexible ureteroscopy for renal stones

Introduction and objective: Improvements in endoscopic technologies have led to an expansion of flexible ureteroscopy indications in the treatment of renal and ureteral stones. Ureteral access sheath (UAS) was introduced in the clinical practice to facilitate endoscopic access into the upper urinary tract, reduce intrarenal pressure during the procedure and allow the extraction of fragments. The objective of this study is to analyze the impact of UAS on the efficacy and safety of flexible ureteroscopy (fURS) for the treatment of renal stones. Material and methods: a prospectively collected database including 251 consecutive patients treated with fURS between January 2018 and November 2022 was analyzed. Patients were divided into two groups: group 1 – without UAS, 21 patients (8.3%) and group 2 – with UAS, 231 patients (91.7%). UAS was used at the surgeon’s discretion and 3 patients (1.2%) underwent a sheathless procedure due to failure of UAS insertion. Data on patients’ preoperative characteristics and fURS efficacy and safety were compared. Results: There were no statistically significant differences in patients’ preoperative characteristics except for stone size and surface, which were significantly larger in group 2 (9.6±4.1 vs 13.8±5.2 mm; р&lt;0.001 and 68.6±74.2 vs 128.3±109.3 mm2, p=0.002, respectively). Operating time was significantly longer in group 2 (33.6±12.9 vs 42.0±12.9 min, p=0.005). Stone-free rate after a single procedure and at 3rd postoperative month was similar between groups (95.2% vs 87%, p=0.486 and 95.2% vs 88.7%, p=0.709, respectively). The intra- and postoperative complication rates were higher for group 1 (4.8% vs 0.8%, р=0.011 and 14.3% vs 12.1%, p=0.062, respectively). Multivariate regression model identified stone surface (р&lt;0.001), number of stones (p=0.005) and calcium oxalate monohydrate stone composition (р=0.005), but not UAS use (p=0.580), as independent predictors for stone-free rate following fURS. Conclusions: The results of this study suggest that UAS use has no impact on the efficacy of fURS and is not associated with an increased rate of intra- and postoperative complications.

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.

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.

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.

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 ...