Repair Rate and Associated Costs of Reusable Flexible Ureteroscopes: A Systematic Review and Meta-analysis

Single-use flexible ureteroscopes: practice patterns, attitudes, and preferences for next-generation concepts

Background

Single use flexible ureteroscopes (su-fURS) have emerged as an alternative to reusable flexible ureteroscopes (r-fURS) for the management of upper urinary tract calculi. However, little is known about urologist usage and attitudes about this technology. Through a worldwide survey of endourologists, we assessed practice patterns and preferences for su-fURS.

Methods

An online questionnaire was sent to Endourology Society members in January 2021. The survey explored current su-fURS practice patterns, reasons for/against adoption, and preferences for next generation models including developments in imaging, intra-renal pressure, heat generation, and suction. Responses were collected through QualtricsXM over a 1-month period from surgeons in North America, Latin America, Europe, Asia, Africa, and Oceania. The study was conducted according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

Results

208 (13.9%) members responded to the survey. Most respondents (53.8%) performed >100 ureteroscopies per year. 77.9% of all respondents used su-fURS for less than half of all procedures while only 2.4% used su-fURS for every procedure. 26.0% had never used a su-fURS. Overall, usage was not influenced by a surgeon's geographic region, practice environment, or years of experience. Top reasons for not adopting su-fURS were cost (59.1%) and environmental impact (12.5%). The most desired improvements in design were smaller outer shaft size (19.4%), improved optics and vision (15.9%), and wireless connectivity (13.6%). For next generation concepts, the functions most commonly described as essential or important by respondents was the ability to suction fragments (94.3%) while the function most commonly noted as not important or unnecessary was incorporation of a temperature sensor (40.4%).

Conclusions

su-fURS are not commonly used, even among urologists who perform a high number of fURS. The primary concern for adoption is cost and environmental impact. Suction capability was considered the most important future development.

Single use flexible ureteroscopes: a review of current technologies and cost effectiveness analysis

PURPOSE OF REVIEW

Flexible ureteroscopy (fURS) has evolved into both diagnostic and therapeutic modalities. Our review discusses the cost-effectiveness of single use flexible ureteroscopes (su-fURS) and the use of these instruments in routine urological practice.

RECENT FINDINGS

There are studies which support the use of su-fURS with an argument of both cost and clinical utility over reusable flexible ureteroscopes (ru-fURS). However, the cost may vary across countries, hence is difficult to compare the results based on the current literature. Perhaps therefore there is a role for hybrid strategy incorporating ru- and su-fURS, where su-fURS are employed in complex endourological cases with a high risk of scope damage or fracture to preserve ru-fURS, with the ability to maintain clinical activity in such an event.

SUMMARY

While there seems to be some cost advantages with su-fURS with reduced sterilization and maintenance costs, the data supporting it is sparse and limited. This choice of scope would depend on the durability of ru-fURS, procedural volumes, limited availability of sterilization units in some centers and potential risk of infectious complications. It is time that cost-benefit analysis is conducted with defined outcomes for a given healthcare set-up to help with the decision making on the type of scope that best serves their needs.

Perspectives on technology: to use or to reuse, that is the endoscopic question-a systematic review of single-use endoscopes

OBJECTIVE

To compare clinical outcomes of single-use endoscopes with those of reusable endoscopes to better define their role within urology.

METHODS

A systematic search of electronic databases was performed. All studies comparing the clinical outcomes of participants undergoing urological procedures with single-use endoscopes to those of participants treated with reusable endoscopes were included. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

RESULTS

Twenty-one studies in 3943 participants were identified. Six different single-use flexible ureteroscopes and two different single-use flexible cystoscopes were assessed. There were no differences in mean postoperative infection rates (4.0% vs 4.4%; P = 0.87) or overall complication rates (11.5% vs 11.9%; P = 0.88) between single-use and reusable endoscopes. For patients undergoing flexible ureteroscopy there were no differences in operating time (mean difference -0.05 min; P = 0.96), length of hospital stay (LOS; mean difference 0.06 days; P = 0.18) or stone-free rate (SFR; 74% vs 74.3%; P = 0.54) between the single-use and reusable flexible ureteroscope groups.

CONCLUSION

This study is the largest to compare the clinical outcomes of single-use endoscopes to those of reusable endoscopes within urology, and demonstrated no difference in LOS, complication rate or SFR, with a shorter operating time associated with single-use flexible cystoscope use. It also highlights that the cost efficiency and environmental impact of single-use endoscopes is largely dependent on the caseload and reprocessing facilities available within a given institution. Urologists can therefore feel confident that whether they choose to 'use' or to 'reuse' based on the financial and environmental implications, they can do so without negatively impacting patient outcomes.

Single use flexible ureteroscopes: Current status and future directions

Introduction

Single use ureteroscopes are a technological innovation that have become available in the past decade and gained increased popularity. To this end, there are now an increasing number of both benchside and clinical studies reporting outcomes associated with their use. Our aim was to deliver a narrative review in order to provide an overview of this new technology.

Methods

A narrative review was performed to gain overview of the history of the technology's development, equipment specifications and to highlight potential advantages and disadvantages.

Results

Findings from preclinical studies highlight potenial advantages in terms of the design of single use ureteroscopes such as the lower weight and more recent modifications such as pressure control. However, concerns regarding plastic waste and environmental impact still remain unanswered. Clinical studies reveal them to have a non inferior status for outcomes such as stone free rate. However, the volume of evidence, especially in terms of randomised trials remains limited. From a cost perspective, study conclusions are still conflicting and centres are recommended to perform their own micro cost analyses.

Conclusions

Most clinical outcomes for single use ureteroscopes currently match those achieved by reusable ureteroscopes but the data pool is still limited. Areas of continued debate include their environmental impact and cost efficiency.

Reuse and Reprocessing of Endoscopic Instruments: For

Reusable endoscopes appear to be most environmentally sustainable when the carbon footprint of routine device maintenance is optimized. Single-use endoscopes may offer cost-savings in clinical settings that accelerate device damage, such as prolonged procedure time or complex patient anatomy. For many urology practices, a hybrid approach that integrates single-use and reusable devices may be most economically sensible and environmentally sound.

Clinical Evaluation of Miniature Flexible Scope for Diagnosis of Ureteroscope Working Channel Defects

Introduction: To evaluate flexible ureteroscope working channels with a 1.06 mm digital borescope (Clarus Medical, Minneapolis, MN) and identify factors contributing to ureteroscope damage over time. Materials and Methods: We performed a single institutional prospective study of patients undergoing stone surgery using a nondisposable flexible ureteroscope. A 1.06 mm borescope was used to evaluate ureteroscopes before and after surgery. Borescope videos were reviewed by two independent researchers to quantify average pre- and postprocedural damage. Results: Twenty-five procedures were performed with pre- and postprocedural borescope assessment between August 2021 and February 2022. All patients received preoperative CT imaging depicting a mean axial stone size of 14.1 ± 8.4 mm and density of 923.4 ± 458.1 HU. Mean operative time was 63.8 ± 34.0 minutes. The average number an instrument passes through the working channel was 2.1 ± 1.6. Laser was used in 11 cases with mean laser time of 18.8 ± 19.7 minutes and mean total energy of 5.8 ± 4.2 KJ. On preoperative assessment, all ureteroscopes had some form of defect (24% shave, 32% pinhole, 96% dents and scratches, and 28% discolorations). During postoperative assessment, 23/25 (92%) ureteroscopes showed additional damage with an average of 3.7 ± 2.8 imperfections acquired after one use. Significant differences were seen in acquired shavings (p = 0.028) and scratches or dents (p = 0.018). Of the 355 imperfections seen on postoperative evaluation, 0.4% were shave, 3% were pinhole, 85.8% were dents and scratches, and 10.8% were discolorations. Conclusion: The Clarus borescope observed defects after the majority of flexible ureteroscopy procedures for nephrolithiasis. Although such disruptions may not immediately render ureteroscopes nonfunctional, they are more common than previously described and could increase maintenance costs. Further studies are needed to investigate the burden of unit damage per procedure to raise operator awareness and reduce preventable ureteroscope imperfections.

Single-Use Ureteroscopy and Environmental Footprint: Review of Current Evidence

PURPOSE OF REVIEW

Ureteroscopy is a well-established treatment modality for kidney and ureteric calculi in addition to playing a key role in upper tract cancer diagnostics. Traditional reusable flexible ureteroscopes are technologically advanced and expensive pieces of equipment that require repeat sterilisation and periodical repair. These issues have led to the development of single-use flexible ureteroscopes that are disposed of after each case. Whilst this may be advantageous in many respects, the environmental impact of such technology is yet to be fully determined. The aim of this review is to therefore identify and summarise the available literature concerning the environmental footprint of single-use ureteroscopy.

RECENT FINDINGS

To identify the latest research on this topic, a systematic search of world literature was conducted using the Medline, Embase, and PsycINFO databases. PRISMA guidelines were followed and articles were assessed by all authors and relevant study results were included in a narrative format. Only one relevant article was identified and included. This study found that a single-use flexible ureteroscope (LithoVue^TM by Boston Scientific) generated an equivalent amount of carbon dioxide per case to a contemporary reusable flexible ureteroscope. Literature concerning the environmental footprint of single-use ureteroscopy is worryingly lacking. No conclusions can be definitively drawn from a single study and further research is imperative given the global climate crisis and the significant contribution that healthcare services have to the environmental problem.

Breakage Costs in Flexible Ureteroscopy: Digital vs. Fiberoptic Modalities

OBJECTIVE

To compare the maintenance costs of digital flexible ureteroscopes (DFU) versus fiberoptic flexible ureteroscopes (FFU) to understand the long-term financial impact associated with breakage in a flexible ureteroscopy (f-URS) program.

METHODS

Data for breakage of FFU and DFU at an academic institution from 2019 to 2021 were obtained from our vendor (Karl Storz) and analyzed by month. Correlation test was used to evaluate significant differences in number of procedures, number of breakage events, breakage rates, and repair cost per month. Cumulative analyses were utilized to examine the number of procedures before failure (time to failure - TTF) and repair costs per procedure (RCpP).

RESULTS

We performed a total of 2,154 f-URS, including 1,355 with FFU and 799 with DFU (P<.001). Although we found a higher number of breakage events in FFU (n=124) than DFU (n=73) (P<.001), the overall breakage rate was similar, 9.9% vs. 8.8%, respectively (P=0.86). On cumulative analysis, both modalities reached the same TTF plateau (11 cases) after 18 months. After 400 cases, the RCpP for DFU was 1.25 times higher than for FFU (P=0.04).

CONCLUSION

Overall, we found no difference in overall scope breakage rates between DFU and FFU. Although there was no difference in TTF over time, at the beginning DFU displayed considerable higher durability, leading to lower RCpP. Furthermore, DFU's endurance leveled off to FFU over time, resulting in higher RCpP after 400 cases. This finding may be explained by the presence of renewed scopes after repair.

Advances in Ureteroscopy: New technologies and current innovations in the era of Tailored Endourological Stone Treatment (TEST)

Ureteroscopy has undergone many advances in recent decades. As a result, it is able to treat an increasing range of patient groups including special populations such as pregnancy, anomalous kidneys and extremes of age. Such advances include Holmium laser, high-power systems and pulse modulation. Thulium fibre laser is a more recent introduction to clinical practice. Ureteroscopes have also been improved alongside vision and optics. This article provides an up-to-date guide to these topics as well as disposable scopes, pressure control and developments in operating planning and patient aftercare. These advances allow for a custom strategy to be applied to the individual patient in what we describe using a new term: Tailored endourological stone treatment (TEST).

Level of evidence: 5