Use Of Ureteral Access Sheath Research Articles

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 ...

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 ...

LBA02-08 RISK FACTORS FOR INCREASED STENT-ASSOCIATED SYMPTOMS FOLLOWING URETEROSCOPY FOR URINARY STONES: RESULTS FROM THE URINARY STONE DISEASE RESEARCH NETWORK (USDRN) STENTS STUDY

You have accessJournal of UrologyCME1 May 2022LBA02-08 RISK FACTORS FOR INCREASED STENT-ASSOCIATED SYMPTOMS FOLLOWING URETEROSCOPY FOR URINARY STONES: RESULTS FROM THE URINARY STONE DISEASE RESEARCH NETWORK (USDRN) STENTS STUDY Jonathan Harper, Hongqiu Yang, Naim Maalouf, Jodi Antonelli, Alana Desai, Henry Lai, Peter Reese, Gregory Tasian, Hunter Wessells, Hussein Al-Khalidi, Ziya Kirkali, and Charles Scales Jonathan HarperJonathan Harper More articles by this author , Hongqiu YangHongqiu Yang More articles by this author , Naim MaaloufNaim Maalouf More articles by this author , Jodi AntonelliJodi Antonelli More articles by this author , Alana DesaiAlana Desai More articles by this author , Henry LaiHenry Lai More articles by this author , Peter ReesePeter Reese More articles by this author , Gregory TasianGregory Tasian More articles by this author , Hunter WessellsHunter Wessells More articles by this author , Hussein Al-KhalidiHussein Al-Khalidi More articles by this author , Ziya KirkaliZiya Kirkali More articles by this author , and Charles ScalesCharles Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002670.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The USDRN STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) sought to identify risk factors for increased post-ureteroscopic pain, urinary symptoms, and their interference with daily activities in a prospective multicenter observational cohort study. METHODS: Patients aged ≥12 years undergoing unilateral ureteroscopy with ureteral stent placement for stone treatment were enrolled at 4 U.S. clinical centers. Participants reported symptoms at baseline, on post-operative days (POD) 1, 3, 5, at stent removal, and day 30 post-stent removal using the Brief Pain Inventory short form and PROMIS measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index (LURN SI-10). Multivariable analyses using mixed-effects linear regression models were implemented. RESULTS: 424 participants (396 adults) were enrolled. Median age (years) was 54 in adults and 15 in adolescents; 46.9% were female. Dominant stone location was ureteral in 56% and renal in 44% of participants. Mean ureteroscopy time was 57(SD ±30) min. There was a marked increase in pain and urinary symptoms from baseline to POD 1, with a gradual fall on days 3 to 5, returning below baseline 30 days after stent removal. As pain intensity decreased over time, interference remained elevated. On multivariable regression (Table), older age was associated with less postoperative pain intensity (p=0.004). Having chronic pain conditions (p<0.001), prior severe ureteral stent pain (p=0.021), and depression at baseline (p<0.001) were each associated with higher pain intensity. Neither stone location, ureteral access sheath use, nor stent size were associated with average pain intensity, pain interference, or urinary symptoms. CONCLUSIONS: In this well-characterized, multicenter prospective cohort, interference persisted even as pain intensity decreased over time. Patient factors such as depression, rather than surgical factors, impacted symptom severity. These findings provide a foundation for patient counseling and highlight potential targets for future efforts to mitigate the burden of stent-associated symptoms. Source of Funding: NIH/NIDDK © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1044 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jonathan Harper More articles by this author Hongqiu Yang More articles by this author Naim Maalouf More articles by this author Jodi Antonelli More articles by this author Alana Desai More articles by this author Henry Lai More articles by this author Peter Reese More articles by this author Gregory Tasian More articles by this author Hunter Wessells More articles by this author Hussein Al-Khalidi More articles by this author Ziya Kirkali More articles by this author Charles Scales More articles by this author Expand All Advertisement PDF DownloadLoading ...

What is the impact of pulse modulation technology, laser settings and intraoperative irrigation conditions on the irrigation fluid temperature during flexible ureteroscopy? An in vivo experiment using artificial stones.

To investigate the effect of different combinations of laser power settings and irrigation conditions using the pulse modulation technology of Quanta™ on irrigation fluid temperature (IFT) during FURS (flexible ureteroscopy) on an in-vivo porcine model with artificial stones. A female pig was used. Following the insertion of artificial stones (Begostone™, BEGO USA, Lincoln, RI), a K-type thermocouple was fixed to the created percutaneous access tract. Real-time recordings of IFT during FURS were performed without UAS (ureteral access sheath), with 10/12 UAS, 12/14 UAS and 14/16 UAS. Stone fragmentation was achieved using Quanta Litho Cyber Ho 150W™ (Samarate, Italy). The IFT was recorded for 30s, during laser activation, with power settings of 20, 40, 60, 75 and 100W under both manual pump and gravity irrigation. The IFT rise above 54°C was recorded above a power of 40W when gravity irrigation was used. The use of UAS prolonged the time for IFT to reach high values, although high power settings increase IFT within seconds from the laser activation. Under pump irrigation, only the 100W power setting without the use of UAS resulted in dangerous IFT after approximately 10s. The high-power Ho:YAG laser can cause a damaging thermal effect to the kidney exceeding the threshold of 54°C, under gravity irrigation. Lower power settings (up to 40W) can be used with safety. According to our experiment, when using high power settings, the use of UAS and manual pump irrigation, is the safest combination regarding renal thermal damage.

Contribution of Ureteral Access Sheath Use to the Efficacy of Semirigid Ureterorenoscopy in Upper Ureteral Stones Smaller than 2 cm: Experiences of a Single Center

Objective: The aim of our paper is to answer the question that during the ureteroscopy procedure if ureteral access sheath could facilitate operation, could decrease complication rates,operation time,requirement of additional surgery. Method: The patients were randomly divided into two groups. Group 1 contained 44 patients for whom a UAS was not used and Group 2 consisted of 70 patients for whom a UAS was used during the URS procedure. The operation was continued using the semirigid ureteroscope within the UAS. Results: There were no statistically significant differences between the two groups in terms of the mean age, BMI, ASA score, mean stone density, previous unsuccessful interventions, history of stone disease, mean grade of hydronephrosis in renal pelvis and mean stone size. the mean operation time was 41 minutes for Group 1 and 30 minutes for Group 2, with a statistically significant difference (p < 0.001), consistent with the literature. Similarly, the difference in the mean fluoroscopy time was statistically significant, being determined as six minutes for Group 1 and three minutes for Group 2 (p < 0.001). Conclusions: Use of UAS was statistically significantly superior in terms of many parameters, such as increased stone-free rate, shorter operation time, and reduced requirement of additional surgery. Furthermore, the complication rates did not significantly differ between the UAS and non-UAS groups. We also consider that the advantages of a higher stone-free rate and reduced requirement of secondary interventions make the cost of UAS acceptable.

Routine Use of Ureteral Access Sheaths for Ureteroscopy: Yay or Nay?

n/a.

Perirenal Extravasation After Retrograde Intrarenal Surgery for Renal Stones: A Prospective Study.

BackgroundThe incidence and consequences of the perirenal extravasation of the irrigation fluid during retrograde intrarenal surgery (RIRS) are not fully elucidated. The objective of this study was to assess the incidence, risk factors, and complications of perirenal extravasation of irrigation fluid during RIRS.MethodsThis prospective observational study was conducted in the Department of Urology, Bir Hospital, Kathmandu, Nepal, from January 2020 to March 2021. Patients undergoing RIRS for renal stones less than 2 cm in diameter were included in the study. Irrigation during the procedure was performed using isotonic normal saline under gravity at 50 cm from the symphysis pubis of patients with intermittent manual compression if required. Lithotripsy was performed with 120-Watt Ho:YAG laser using 200-micron laser fiber. Retrograde pyelogram was performed after the completion of lithotripsy to document the presence or absence of extravasation on fluoroscopic images. A double-J stent was placed at the end in all patients. Patients were observed for systemic inflammatory response syndrome (SIRS) features. Postoperative abdominal ultrasonography was performed on the first postoperative day to assess the perirenal collection together with complete blood count. The visual analogue scale (VAS) was used to assess pain in postoperative period. The preoperative patient’s and stone characteristics, hydronephrosis, intraoperative characteristics, and postoperative findings were analyzed.ResultsA total of 71 patients who underwent RIRS during the study period were analyzed. The mean (SD) stone size was 13.19 (3.12) mm. Intraoperative perirenal extravasation of contrast was noted in eight (11.26%) patients; however, no patient had ipsilateral perirenal collection on ultrasonography obtained on the first postoperative day. No significant differences were observed among patients with or without perirenal extravasation in terms of mean stone size, laser settings, operative duration, and lasing duration. Use of ureteral access sheath (UAS) was associated with lower incidence of extravasation; however, it was not significant. SIRS was documented in eight patients overall, with none of the patients with extravasation having features of SIRS. Patients with extravasation experienced more postoperative flank pain (p<0.05).ConclusionPerirenal extravasation was common during RIRS and was associated with higher postoperative pain scores. Stone size, use of UAS, laser settings, operative duration, and lasing duration were not associated with an increased risk of extravasation. Extravasation was not associated with increased postoperative complications.

Role of low- versus high-power laser in the treatment of lower pole stones: prospective non-randomized outcomes from a university teaching hospital.

Introduction:Ureteroscopy and laser stone fragmentation [flexible ureteroscopy and laser lithotripsy (FURSL)] has risen over the last two decades. Laser technology has also evolved over the time, shifting from low- to high-power lasers with the addition of MOSES technology that allows for ‘dusting and pop-dusting’ of stones. The aim of the study was to look at the outcomes of FURSL in lower pole stones (LPS) using low- and high-power lasers.Patient and Methods:In this study, we compared the outcomes of low-power holmium laser (group A, 20 W) and high-power holmium laser (group B, including both 60 W MOSES integrated system and 100 W lasers) for all patients with LPS treated with laser lithotripsy. Data were collected for patient demographics, stone location, size, pre- and postoperative stent, length of stay, complications and stone free rate (SFR).Results:A total of 284 patients who underwent FURSL procedure for LPS were analysed (168 group A, 116 group B). Outcomes showed that compared with group A, group B had a higher SFR (91.6% versus 96.5%, p = 0.13) and shorter operative time (52 versus 38 min, p < 0.001). The median length of stay was <24 h in all groups (day-case procedures). The complication rate was comparable between the two groups but with more infectious complications (n = 7) noted in group A compared with group B (n = 3) (p = 0.53).Conclusion:Compared with low-power laser, the use of high-power laser for LPS significantly reduced the use of ureteral access sheath (UAS), postoperative stent and procedural time. Although non-statistically significant, the SFR was higher in the high-power group even for relatively larger stone sizes, which was also reflected in a reduction of sepsis-related complication rates with these lasers.

Does ureteral access sheath have an impact on ureteral injury?

Objective:To present a well-organized review about ureteral access sheath impact on ureteral injury.Materials and Methods:Systemic search on literature was done. Total of 3766 studies observed by two urologists and results were unified. A Prisma diagram was used for eliminating irrelevant studies and at the end of elimination process 28 studies were found eligible for this review.Results:Not only clinical studies but also comparative experimental animal studies show that there is no significant data to claim that ureteral access sheath insertion causes more ureteral injury. Pre-stented patients were found to be at lower risk for ureteral injury. Risk of progression to ureteral injury seems to be low even if ureteral injury occurs with insertion of ureteral access sheath.Conclusion:Summary of studies’ results indicate that use of ureteral access sheath doesn’t increase ureteral injury. This review may help understanding safety profile of ureteral access sheath on evidence-based level. There is not enough data to make a statement that ureteral access sheath prevents ureteral injury.

The use of ureteral access sheath during mini-percutaneous nephrolithotomy with high-power holmium YAG laser.

To present our preliminary results and describe a technical modification of mini-PCNL (12Fr) with the insertion of a ureteral access sheath (UAS) to facilitate the procedure. A prospective study for the time period of January 2020 to January 2021 was conducted including patients with renal stones sized ≤ 25mm in whom prone mini-PCNL (tract size 12Fr) together with the retrograde insertion of UAS was performed. All patients had been prestented at least 1week prior to the planned surgery. A single-step tract dilation to 12Fr diameter was performed through a nonpapillary medial puncture. The lithotripsy was achieved using high-power holmium yttrium aluminum garnet laser (Ho:YAG) with the 60W power setting (40Hz and 1.5J). The follow-up investigations were planned at 1-month after the surgery. In total, 32 patients with the median age and stone size of 56.5 (IQR = 53-62) years and 20.8 (IQR = 19.3-22.7) mm were included. The median operative and cumulative fluoroscopy time were 34.0 (IQR = 29.9-37.5) and 1.9 (1.8-2.1) min, respectively. The stone-free rate (SFR) at 1-month follow-up was 93.8% (30/32). Only one patient developed a fever and required prolonged antibiotic administration. None of the patients experienced clinically significant bleeding. Our preliminary results showed that the use of UASs during mini-PCNL procedures is feasible and provides directed evacuation of the stone fragments reaching 93.8% SFR at a 1-month follow-up. Future well-designed studies are necessary to prove our findings.

Multi-aspect analysis of ureteral access sheath usage in retrograde intrarenal surgery: A RIRSearch group study

ObjectiveTo evaluate the effect of ureteral access sheath (UAS) use and calibration change on stone-free rate and complications of retrograde intrarenal surgery (RIRS). MethodsData from 568 patients undergoing RIRS for kidney or upper ureteral stones were retrospectively included. Firstly, patients were compared after 1:1 propensity score matching, according to UAS usage during RIRS (UAS used [+] 87 and UAS non-used [−] 87 patients). Then all UAS+ patients (n=481) were subdivided according to UAS calibration: 9.5–11.5 Fr, 10–12 Fr, 11–13 Fr, and 13–15 Fr. Primary outcomes of the study were the success and complications of RIRS. ResultsStone-free rate of UAS+ patients (86.2%) was significantly higher than UAS− patients (70.1%) after propensity score matching (p=0.01). Stone-free rate increased with higher caliber UAS (9.5–11.5 Fr: 66.7%; 10–12 Fr: 87.0%; 11–13 Fr: 90.6%; 13–15 Fr: 100%; p<0.001). Postoperative complications of UAS+ patients (11.5%) were significantly lower than UAS− patients (27.6%) (p=0.01). Complications (8.7%) with 9.5–11.5 Fr UAS was lower than thicker UAS (17.2%) but was not statistically significant (p=0.09). UAS usage was an independent factor predicting stone-free status or peri- and post-operative complications (odds ratio [OR] 3.654, 95% confidence interval [CI] 1.314–10.162; OR 4.443, 95% CI 1.350–14.552; OR 4.107, 95% CI 1.366–12.344, respectively). ConclusionUse of UAS in RIRS may increase stone-free rates, which also increase with higher caliber UAS. UAS usage may reduce complications; however, complications seemingly increase with higher UAS calibration.