The evolution and progress of ureteroscopy

Unfavorable factors in accessing the pelvicalyceal system during retrograde flexible ureteroscopy (fURS)

Flexible ureteroscopy (fURS) is a well-established procedure for treating multiple upper-urinary tract pathologies, particularly renoureteral lithiasis. Endoscopes have undergone significant advancements, including miniaturization, improved optics, and increased maneuverability. In addition, advancements in accessory instruments, such as the performance of laser fibers, guidewires, and extraction probes, have played a significant role in improving the overall performance of flexible ureteroscopy procedures. However, despite these advancements, unique circumstances can make achieving optimum results during flexible ureteroscopy challenging. These include congenital renal anomalies (horseshoe kidneys, ectopic kidneys, rotation anomalies), as well as the unique intrarenal anatomy (infundibulopelvic angle, infundibular length) or the specifications of the endoscope in terms of maneuverability (active and passive deflection). This review explored challenging scenarios during flexible ureteroscopy procedures in the pyelocaliceal system.

Outcomes of flexible uretrorenoscopy for solitary renal stones up to 15 mm, hits and misses: A single-surgeon experience

Abstract:

Introduction: In this study, we retrospectively evaluated the outcomes of flexible uretrorenoscopy (fURS) for removal of solitary renal stones sized up to 15 mm.

Material and Methods:

We evaluated the data of 115 patients who underwent fURS at our unit between Jan 2018 and Dec 2019. All fURS were performed by a single surgeon using Flex-2 flexiscope. Ureteral Access sheath (UAS) of size 9/11 fr was used in all patients. Stones were fragmented using 20 watts laser. Few fragments were retrieved using Nitinol zero tip basket for assessment of the passability of remaining dust and sent for stone analysis. Data pertaining to demographic characteristics, stone size, stone site, operative time, intra and post operative complications were retrieved from the records.

Results:

Of the 115 patients who underwent fURS, 71 (61.7%) were male and 44 (38.2%) were female. Average age of patients was 32.9±8.9 years; the average body mass index was 22.9±3.9 kg/m2. Average size of the stone was 11.0±1.5 × 10.2±1.3 mm. The stone free rates at the end of 3 weeks and 3 months were 97% and 99%, respectively.

Conclusion:

fURS is an effective minimally-invasive procedure for removal of single stones up to 15 mm in size. We observed minimal morbidity rates and acceptable stone free rates in our series.

Outcomes of loco-regional anaesthesia in ureteroscopy for stone disease: a systematic review

PURPOSE OF REVIEW

Routine ureteroscopy (URS) for stone disease is performed under a general anaesthesia. However, controversy exists on the role of loco-regional anaesthesia and the outcomes associated with it. Here we review the challenges, outcomes and complications of loco-regional anaesthesia for URS. A Cochrane style review was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines to evaluate the outcomes of loco-reginal anaesthesia for URS in stone disease, including all English language articles from January 1980 and December 2019.

RECENT FINDINGS

Twenty-one studies (1843 procedures) with a mean age of 46 years and a male : female ratio of 1.2 : 1 underwent URS under loco-regional anaesthesia. The mean stone size was 9 mm (range:4-21 mm) and except five papers, all other papers included stones in the ureter of which the majority were in the distal ureter. The conversion to general anaesthesia was needed in 2.7% patients (range 1-21%) across studies, with a stone free rate of 48-100%. The complication rate varied from 1.4 to 36%. Although the intraoperative complications included ureteric injury (n = 21) or perforation (n = 4), the postoperative complications included fever (n = 37), urinary tract infection (n = 20), haematuria (n = 4), urosepsis (n = 4) and others (n = 7).

SUMMARY

The present systematic review shows that local anaesthetic URS is a potential alternative to general anaesthetic URS in carefully selected patients. Randomised controlled trials with subgroup analysis are required to further assess whether loco-regional anaesthesia URS is noninferior to general anaesthesia URS and might help determine if the former approach should become more widespread.

Device profile of the LithoVue single-use digital flexible ureteroscope in the removal of kidney stones: overview of safety and efficacy

Introduction: Flexible ureteroscopy is a commonly performed urologic procedure for visualization and treatment of the upper urinary tracts. Traditionally, ureteroscopy has been performed with reusable scopes, which have large initial purchasing costs. LithoVue was the first widely adopted single-use flexible ureteroscope clinically available in 2016 and has caused reevaluation of this paradigm. Areas covered: This review is an objective assessment of the LithoVue single-use ureteroscope based on available studies at the time of publication. The authors searched major databases for papers that included the term 'LithoVue' and included relevant papers. The state of the market, technical specifications, results from clinical studies and cost analyses, and competitors are discussed. Expert opinion: The LithoVue single-use flexible ureteroscope has comparable clinical performance to existing reusable ureteroscopes based on available data. Direct clinical comparisons to competing single-use ureteroscopes, many of which are relatively new, are limited. In numerous pre-clinical studies LithoVue performed favorably compared to available competitors. Cost analyses suggest that benefit of single-use ureteroscopes is institution-specific, and will likely be favorable at a low volume of cases and with high local costs for repairs of reusable scopes.

Flexible ureteroscopy: technique, tips and tricks

During the last decades, the surgical management of kidney stones benefited of many technological advances and one of them is the development of flexible ureteroscopy (fURS). This tool, ancillary equipment such as graspers and baskets, and lithotripsy technique with Holmium:YAG laser underwent many improvements leading to a widening of its indications with diagnostic and therapeutic management of upper urinary tract pathologies such as urolithiasis and urothelial tumors. The objective of this review is to describe the surgical technique for fURS as well as tips and tricks for the treatment of renal stones.

Semi-rigid ureteroscopy: indications, tips, and tricks

Advances in ureteroscopic technology, alongside broadening treatment options have fuelled the rapid expansion of endourology. Semi-rigid ureteroscopy is a well-known procedure used globally for varying urological conditions, with high success rates. This article aims to provide ‘tips and tricks’ for the semi-rigid ureteroscopy procedure, and the management of commonly encountered pathology such as renal stones, ureteric strictures, and urothelial tumours.

Evaluation of a Novel Single-Use Flexible Ureteroscope

Introduction: A novel single-use flexible ureteroscope promises the optical characteristics and maneuverability of a reusable fourth-generation flexible ureteroscope. In this study, the LithoVue Single-Use Digital flexible ureteroscope was directly compared with contemporary reusable flexible ureteroscopes, with regard to optics, deflection, and irrigation flow. Methods: Three flexible ureteroscopes such as the LithoVue (Single Use; Boston Scientific), Flex-Xc (Karl Storz, Germany), and Cobra (Richard Wolf, Germany) were assessed in vitro for image resolution, distortion, color representation, grayscale imaging, field of view, and depth of field. Ureteroscope deflection was tested with an empty channel followed by placement of a 200 μm laser fiber and a 1.9F wire basket, a 2.0F nanoelectric pulse lithotripsy (NPL) probe, and a 2.4F NPL probe. Ureteroscope irrigation flow was measured using normal saline at 100 cm, with an empty channel followed by a 200 μm laser fiber, a 1.9F wire basket and a 2.0F NPL probe. Results: The LithoVue showed the largest field of view, with excellent resolution, image distortion, and depth of field. No substantial difference was demonstrated in color reproducibility or in the discernment of grayscales between ureteroscopes. The LithoVue maintained full deflection ability with all instruments in the working channel, although the Flex-Xc and Cobra ureteroscopes showed loss of deflection ranging from 2° to 27°, depending on the instrument placed. With an empty channel, the LithoVue showed an absolute flow rate similar to the Flex-Xc ureteroscope (p = 0.003). It maintained better flow with instruments in the channel than the Flex-Xc ureteroscope. The Cobra ureteroscope has a separate 3.3F instrument channel, keeping flow rates the same with instrument insertion. Conclusion: The LithoVue Single-Use Digital ureteroscope has comparable optical capabilities, deflection, and flow, making it a viable alternative to standard reusable fourth-generation flexible digital and fiberoptic ureteroscopes.

Minimally invasive surgical treatment for kidney stone disease

Minimally invasive interventions for stone disease in the United States are mainly founded on 3 surgical procedures: extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy. With the advancement of technology, treatment has shifted toward less invasive strategies and away from open or laparoscopic surgery. The treatment chosen for a patient with stones is based on the stone and patient characteristics. Each of the minimally invasive techniques uses an imaging source, either fluoroscopy or ultrasound, to localize the stone and an energy source to fragment the stone. Extracorporeal shock wave lithotripsy uses a shock wave energy source generated outside the body to fragment the stone. In contrast, with ureteroscopy, laser energy is placed directly on the stone using a ureteroscope that visualizes the stone. Percutaneous nephrolithotomy requires dilation of a tract through the back into the renal pelvis so that instruments can be inserted directly onto the stone to fragment or pulverize it. The success of the surgical intervention relies on performing the least invasive technique with the highest success of stone removal.

[Initial experience of first 225 flexible ureteroscopy with laser lithotripsy in a primary care hospital]

INTRODUCTION

During the last decade, the advent of flexible ureteroscopy with laser lithotripsy has revolutionized the management of upper urinary tract stones. Our center is a primary care hospital that is equipped with this technology since January 2011. This study reported our initial experience of first 225 cases.

MATERIEL AND METHODS

This study is a descriptive, retrospective and monocentric analysis. The first 225 cases, operated consecutively by 3 surgeons during 26 months, were analyzed. We have used 2 flexible ureteroscopes (1 digital, 1 optical). Laser source was an Holmium laser (Stonelight) at a power of 5 watts.

RESULTS

The mean age was 53 years (± 10.2) and the mean stones size was 11 mm (2.3). In 49% of cases, ureteroscopy was chosen for the first, without prior treatment. In 59% of cases, ureteroscopy was used after failure of other treatment (ESWL in 70% of cases). The mean operative time was 72 minutes (± 16.6) and the mean length of stay was 2.6 days (± 0.8). The first session of ureteroscopy was a success in 93% of cases without residual fragments after 1 month. The frequency of postoperative complications was estimated at 8% (Clavien I and II).

CONCLUSION

Flexible ureteroscopy with laser lithotripsy was a safe and effective technique, allowing the treatment of all upper urinary tract stones, especially on failure of other treatment. Its place in the first intention is widespread in our exercise, especially among obese patients, patients on anticoagulant therapy or with stone of the lower pole.

Prospective Randomized Trial Comparing 2 Flexible Digital Ureteroscopes: ACMI/Olympus Invisio DUR-D and Olympus URF-V

OBJECTIVE

To compare 2 digital flexible ureteroscopes in a randomized, prospective, clinical trial; the complementary metal oxide semiconductor-based Gyrus ACMI/Olympus Invisio DUR-D and the charged coupled device-based Olympus URF-V.

METHODS

Patients scheduled for ureteroscopy were prospectively enrolled and randomized between the DUR-D and URF-V. Patient demographics, laser and total procedure time, laser energy, lower pole time, and difficulties encountered were recorded. The visibility and maneuverability were rated on a scale of 0-10.

RESULTS

A total of 101 patients (58 women) with a mean age of 49.5 years (20-80 years) were enrolled. Laser lithotripsy (mean stone size, 11.8 mm) was performed in 88 patients, 10 underwent stone basketing, and 3 had diagnostic ureteroscopy. For the DUR-D and URF-V, the mean total operative time (26.5 vs 25 minutes), laser time (12.5 vs 13 minutes), lower pole time (9 vs 11 minutes), and basket time (14.5 vs 13 minutes) were comparable. In 3 of 45 (6.6%) and 6 of 56 (10.7%) cases, the stone could not be reached with the DUR-D and URF-V, respectively. A fiberoptic scope (URF-P5) reached the stone in all cases. On a scale of 0-10, the mean visibility was 6.86 and 8.73 (P <.01) and the maneuverability was 7.18 and 8.17 (P <.01) for DUR-D and URF-V, respectively. There were 8 repairs, 4 for each scope. The DUR-D averaged 11.25 cases per repair and the URF-V averaged 14.

CONCLUSION

The URF-V offered better visibility and maneuverability compared with the DUR-D. Both had similar failure rates compared with the previous study with fiberoptic scopes.

Flexible ureterorenoscopy: Tips and tricks

With advancement in technology, improvement in endoscope and ancillary equipment, more complex procedures can be performed using flexible ureterorenoscopy. In this review article we provide a summary of flexible ureterorenoscopic procedures with “tips and tricks” for success for each type of procedure. It looks at the disposables used with flexible ureterorenoscopic procedures, set up and patient positioning for gaining access, insertion and handling of scope and the use of urethral access sheath. We also provide techniques for various flexible ureterorenoscopic procedures including management of renal stones, calyceal diverticula and upper tract urothelial tumours.

A new world revealed: early experience with digital ureteroscopy

PURPOSE

The latest digital ureteroscope, the DUR-D (Gyrus ACMI Inc., Southborough, Massachusetts) offers image quality that greatly exceeds current analog image capabilities. The purpose of this report was to document the applicability of this device in studying the earliest stages of stone formation.

MATERIALS AND METHODS

Symptomatic patients with nephrolithiasis (less than 1 cm in diameter) were prospectively enrolled and their renal papilla digitally mapped prior to stone removal. Recovered stones were photographed and analyzed using micro-computerized tomography. If the procedure could not be completed with the DUR-D, a conventional ureteroscope was used. Minors, pregnant patients and those with systemic disorders were excluded.

RESULTS

Eight patients (10 renal units), 2 cystine and 6 calcium oxalate stone formers, were studied with a mean age of 50.1 years. Excellent images were collected for all papilla except in 2 cases; a proximal ureteral stricture and acute angulation of the lower pole collecting system, respectively. There were no mechanical device failures. Of the 10 renal units 7 had stents postoperatively and there were no patient complications.

CONCLUSIONS

The ease of use and high quality images of digital ureterorenoscopy will allow the documentation of the earliest stages of calcium oxalate stone formation and, thereby, advance our understanding of the pathogenesis of calcium oxalate stone formation.

Present Practice and Treatment Strategies in Endourological Stone Management

OBJECTIVES

The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trends between urologists with regard to the application of endourological stone management to identify trends and differences in treatment strategies among urologists.

METHODS

A total of 695 certified urologists and urological residents answered the ESUT Endourological Stone Management Questionnaire. There were 136 (28.7%) chief urologists, 240 (50.6%) staff urologists and 98 (20.7%) residents. The respondents were classified according to both the geographical origin (in four groups: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE) and Outside Europe (OE)), and department size (number of urological beds per department: small < or = 25, medium 26-50 beds, large > 50 beds) in order to identify any differences in the replies.

RESULTS

On average, 40.1 newly diagnosed patients and 73.6 revisits with urolithiasis are seen a month per department. According to the replies, there are no significant differences in total numbers of treatments in ESWL and/or endourological stone managements amongst the geographically based groups. Monthly, on average 68.5 ESWL treatments and 23.0 URS are performed per department. A significant majority of surveyed urologists performs URS with a rigid or semi-rigid instrument (79%) instead of a flexible instrument (21%, p = 0.003). URS is more frequently performed outside Europe (p = 0.02) with a more frequent use of dormia catheters (p < 0.001). On average, 20.9 double g-stents are placed monthly in each department, most commonly before or after endourological procedures (p < 0.001). Percutaneous procedures are performed by 69.6% of the respondents with a mean of 16.8 PNL procedures a month. PNL for stone management is mainly performed in Eastern Europe and non-European countries (p = 0.017). Nephrostomy tubes are used by 77.7% of the responding urologists. Monthly, 13.1 nephrostomy tubes are placed, mostly during PNL or after endourological procedures (40.7%).

CONCLUSION

The data obtained from the 695 urologists and residents provides information on the performed procedures and the use of material. In general, respondents from different geographical locations perform similar procedures and use identical material; however URS and PNL are performed more frequently outside of Europe, whereas laser lithotripsy is frequently used in Northern European counties.