Combined antegrade and retrograde endoscopic approach for the management of urinary diversion-associated pathology

Combined antegrade-retrograde cystourethroscopic rendezvous procedure for the management of a severe urethral stricture during kidney transplantation: A case report

INTRODUCTION

External bladder drainage with an indwelling transurethral catheter is standard during kidney transplant. Difficult Foley catheter placement is a frequent problem and one of the most common reasons for intraoperative urology consults. Suprapubic catheters are usually placed if retrograde urologic instrumentation options fail to cross the urethral obstruction. We report an alternative option with an antegrade-retrograde endoscopic approach.

PRESENTATION OF CASE

This case illustrates a urethral rendezvous procedure applied successfully to traverse an occult mid-urethral stricture for Foley catheter placement during kidney transplantation in a 69-year-old diabetic man with end-stage renal disease and anuria.

DISCUSSION

The combined antegrade-retrograde rendezvous techniques have largely been described in the treatment of complex ureteric strictures more so than urethral strictures. This technique has not been described in the setting of a complex urethral stricture encountered during kidney transplantation. After utilization of the urinary tract rendezvous technique during kidney transplantation, our patient experienced an uneventful post-operative course with excellent renal allograft function.

CONCLUSION

The combined antegrade-retrograde urinary tract rendezvous technique is a feasible and safe technique that can help manage occult severe urethral strictures found at the time of kidney transplantation instead of suprapubic catheter placement when retrograde urologic instrumentation options fail to cross the obstruction.

ACR Appropriateness Criteria® Radiologic Management of Urinary Tract Obstruction

Acute obstructive uropathy is a medical emergency, which often is accompanied by acute renal failure or sepsis. Treatment options to resolve the acute obstructive process include conservative medical management, retrograde ureteral stenting, or placement of percutaneous nephrostomy or nephroureteral catheters. It is important to understand the various treatment options in differing clinical scenarios in order to guide appropriate consultation. Prompt attention to the underlying obstructive process is often imperative to avoid further deterioration of the patient's clinical status. A summary of the data and most up-to-date clinical trials regarding treatment options for urinary tract obstruction is outlined in this publication. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Combined antegrade and retrograde access to difficult ureters: revisiting the rendezvous technique

INTRODUCTION

Complex ureteric strictures present a significant challenge to the endourologist and uro-radiologist. Multiple separate interventions to try to cross the stricture are often attempted. We describe our experience managing a heterogenous patient group using the 'rendezvous' procedure.

METHODS AND MATERIALS

16 patients and 18 ureters (one bilateral procedure, and two separate procedures in one patient) underwent rendezvous procedures. Seven patients had coexisting ureteric calculi treated. Each case was followed up for between 3 months and 5 years.

RESULTS

In 16/18 ureters there was technical success at time of surgery; successfully crossing the stricture, allowing ureteroscopic access to the ureter, dilating and/or stenting the ureter. 2/18 were unsuccessful; one secondary to advanced malignancy resulting in a uretero-vaginal fistula and the second a failure to remove a retained, displaced ureteric stent. Of the 18 ureteric procedures; 7/18 were stent free at 3 months, improving to 8/18 stent free at 6 months. 4/18 remained nephrostomy dependent (failure of drainage despite stent or failure to stent) at 3 months, increasing to 6/18 being nephrostomy dependent at 6 months. 1/16 remained dialysis dependent with a nephrostomy tube. For those procedures involving ureteric calculi, 6/7 were stone free and 1/5 had a persistent stone fragment requiring further intervention.

CONCLUSIONS

A combined approach may decrease the number of separate interventions required, with the aim of removing the need for a long-term nephrostomy, as well as providing opportunity to treat ureteric calculi in the context of stricture disease. Our experience has been that where the rendezvous has been required to treat strictures caused by malignant extrinsic compression, stenting has not been successful; this information is key to informed consent in a group of patients who may have a limited life expectancy.

Retrograde Endourological Management of Upper Urinary Tract Abnormalities in Patients with Ileal Conduit Urinary Diversion: A Dual-Center Experience

INTRODUCTION

Patients with ileal conduit urinary diversions are at an increased risk of long-term upper urinary tract (UUT) complications, including anastomotic strictures, infections, and urolithiasis. The reconstructed urinary system poses challenges for endoscopic manipulation. We present and describe our dual-center experience in performing retrograde ureteroscopy to treat or diagnose UUT abnormalities in patients with ileal conduit incontinent diversion.

PATIENT AND METHODS

We performed a retrospective analysis of medical records for all patients with previous urinary diversion who underwent retrograde ureteroscopic procedures via the ileal loop in our institutions over a 9 year period (between June 2007 and August 2016).

RESULTS

Fifty-four procedures were performed in 36 patients. Mean age was 61 (28-90) years. Average time from diversion to ureteroscopic procedure was 13.0 (0.08-53) years. Stone disease was the most common indication for intervention in 35.2% (19/54) of cases, with a stone-free rate of 78.9% (15/19). Other indications included surveillance of transitional-cell carcinoma in 22.2% (12/54), diagnostic flexible ureteroscopy (fURS) in 20.4% (11/54), stricture management in 11.1% (6/54), removal of encrusted stent/nephrostomy in 7.4% (4/54), urine leak after diversion in 1.9% (1/54), and miscellaneous in 1.9% (1/54). Successful retrograde access was possible in 74% (40/54) of cases. A long and tortuous ileal segment, too difficult to negotiate, was the most common cause of failure to access the UUT. In 13 out of 54 (24.1%) cases, retrograde fURS was combined with simultaneous percutaneous antegrade access. Six patients (11.1%) developed postprocedural pyrexia requiring additional antibiotic therapy, and one (1.9%) patient required embolization of the renal artery for ongoing bleeding. Median length of stay was 1 day (0-55), with 13 (24%) being performed as day-case procedures.

CONCLUSIONS

Retrograde ureteroscopy in patients with ileal conduits can be technically challenging due to distorted anatomy. This procedure can be safely performed in experienced hands with standard endourological equipment. An antegrade approach can be carried out simultaneously, which may be required in a small number of patients.

Experience with 45 Consecutive Patients with Neobladders Undergoing Retrograde Ureteroscopy for Upper Tract Abnormalities

Introduction

In this study we reviewed the feasibility, technique, complications and outcomes of retrograde ureteroscopy in patients with orthotopic neobladders.

Methods

We retrospectively reviewed our retrograde ureteroscopic experience in patients with orthotopic ileal neobladder diversions. Data were collected and analyzed regarding patient characteristics, indications, technique, success and complications of the procedure.

Results

Between 1995 and 2013, 45 patients with neobladders underwent 77 retrograde ureteroscopy sessions on 97 renal units for filling defects (47 cases), urothelial thickening (9), calculi (4), positive cytology (27) and/or positive fluorescence in situ hybridization (15) on followup. The ureter and renal pelvis were successfully instrumented in 78 of 97 units (80.4%), with 85.3% success in Hautmann-type neobladders (75 renal units attempted), 50% in Studer-type neobladders (8 renal units attempted) and 71.4% in unascertained-type neobladders (14 renal units attempted). Causes of failure involved the inability to locate the ureteral orifice (8 cases), to cannulate the orifice (6 cases) or to advance the ureteroscope due to tortuosity (5 cases). Among the successful attempts with appropriately documented findings 35.9% of cases with filling defects (39) were confirmed malignant and 61.5% were confirmed benign by ureteroscopy. All cases with a positive cytology (23) and 85.7% of cases with positive fluorescence in situ hybridization (14) were confirmed malignant by retrograde ureteroscopy, and 2 of the 4 cases of calculi were successfully managed retrogradely.

Conclusions

Retrograde ureteroscopic evaluation of upper tract abnormalities is feasible and practical in patients with orthotopic neobladders. Identification and cannulation of the ureteral orifice are challenging, particularly in tortuous situations, but difficulties can be overcome with fluoroscopic techniques. Retrograde ureteroscopy avoids the morbidity of percutaneous access with minimal complications.

Progressive ureteral dilations and retrograde placement of single-j stent guided by flexible cystoscope for management of ureteroenteral anastomotic stricture in patients after radical cystectomy and bricker urinary diversion

PURPOSE

To evaluate the safety and efficacy of retrograde placement of single-J stent guided by a flexible cystoscope for management of ureteroenteral anastomotic stricture in patients after radical cystectomy and Bricker urinary diversion.

PATIENTS AND METHODS

Between January 2008 and June 2012, 11 patients with ureteroenteral anastomotic stricture after open radical cystectomy and Bricker urinary diversion were enrolled in this study. All patients were treated with retrograde placement of single-J stent guided by a flexible cystoscope. A 7F single-J stent was placed for 6 weeks.

RESULTS

Of the 11 patients, seven strictures occurred on the left side, two on the right side, and two on both sides. The retrograde procedure was successfully performed in 10 cases, and the remaining 1 was successful on the right side but failed on the left side. Upper urinary tract infection was well controlled in all three patients with fever. After a follow-up of 12 to 66 months, eight patients had long-term symptom relief, one patient had open surgery to remove the stricture and re-implant the ureter, and one patient died because of tumor recurrence. The only failed case was that of a left side percutaneous nephrostomy, but the patient was lost to follow-up.

CONCLUSIONS

Retrograde placement of a single-J ureteral stent guided by a flexible cystoscope is safe and effective for ureteroenteral anastomotic stricture in patients with Bricker urinary diversion, and it brings fewer complications. The procedure is minimally invasive and could avoid immediate surgery for most patients.

Surgical management of urolithiasis in patients after urinary diversion

OBJECTIVE

To present our experience in surgical management of urolithiasis in patients after urinary diversion.

PATIENTS AND METHODS

Twenty patients with urolithiasis after urinary diversion received intervention. Percutaneous nephrolithotomy, percutaneous based antegrade ureteroscopy with semi-rigid or flexible ureteroscope, transurethral reservoir lithotripsy, percutaneous pouch lithotripsy and open operation were performed in 8, 3, 2, 6, and 1 patients, respectively. The operative finding and complications were retrospectively collected and analyzed.

RESULTS

The mean stone size was 4.5 ± 3.1 (range 1.5-11.2) cm. The mean operation time was 82.0 ± 11.5 (range 55-120) min. Eighteen patients were rendered stone free with a clearance of 90%. Complications occurred in 3 patients (15%). Two patients (10%) had postoperative fever greater than 38.5 °C, and one patient (5%) suffered urine extravasations from percutaneous tract.

CONCLUSIONS

The percutaneous based procedures, including percutaneous nephrolithotomy, antegrade ureteroscopy with semi-rigid ureteroscope or flexible ureteroscope from percutaneous tract, and percutaneous pouch lithotripsy, provides a direct and safe access to the target stones in patients after urinary diversion, and with high stone free rate and minor complications. The surgical management of urolithiasis in patients after urinary diversion requires comprehensive evaluation and individualized consideration depending upon the urinary diversion type, stone location, stone burden, available resource and surgeon experience.

Retrograde ureteroscopy via a continent urinary diversion: surgical techniques and common pitfalls

PURPOSE

We assessed our experience performing retrograde ureteroscopy (URS) in patients with a continent urinary diversion.

METHODS

A retrospective review was performed of patients with a continent urinary diversion necessitating URS for diagnostic or therapeutic purposes from 2002 to 2013.

RESULTS

We identified 11 male and 1 female patients with a continent urinary diversion with a mean age of 62.5 years (27-77) who underwent 13 procedures on 17 renal units. Indication for URS was diagnostic in 10 (77%), stone disease in 2 (15%), and stricture in 1 (8%). URS was attempted a median of 6.2 years (1.3-14.5) after diversion creation. Retrograde URS was attempted in 17 renal units with 10 (59%) accessed successfully. One procedure was staged with antegrade wire access obtained before retrograde URS. Inability to identify the afferent limb or ureteral orifice one (20%), tortuosity of afferent limb two (40%), angulation one (20%), and length of the afferent limb one (20%) were causes for unsuccessful retrograde URS. Of the successfully attempted retrograde URS, 75% occurred within the past 5 years. There were no complications in the successful retrograde URS group. Ureteral stents or nephrostomy tubes were left in place postprocedure in six (50%) patients.

CONCLUSION

While technically challenging, retrograde URS can be performed successfully in patients with an orthotopic neobladder once the learning curve for the procedure is overcome.

Antegrade percutaneous flexible endoscopic approach for the management of urinary diversion-associated complications

PURPOSE

We present our experience in the minimally invasive management of postoperative complications associated with urinary diversions using an ureteral access sheath (UAS) in an antegrade approach.

PATIENTS AND METHODS

From 2005 to 2011, 21 antegrade flexible ureteroscopies (F-URS) were performed in 17 patients with a urinary diversion. Urinary diversions in this population consisted of ileal conduits, orthotopic neobladders, catheterizable pouches, and an ureterosigmoidostomy in 9, 5, 2, and 1 patients, respectively. The most important reason for treatment was recurrent upper urinary tract infection. The indication for intervention was stone disease in 15 procedures and strictures in 6 cases. In two patients, "staged-therapy" was performed. Using UAS in an antegrade approach was the main concept.

RESULTS

A nephrostomy tube was already in place in 14 (66.6%) procedures, which was the access route used. Successful puncture was performed in all other patients. Eighty percent of patients were rendered stone free after the first antegrade session. Moreover, all strictures were successfully managed by dilation. In two sequential procedures in a patient, there was an inability to perform stone treatment because of abnormal position of the ureter (kinked), which did not allow the ureterorenoscope to pass. All other procedures were uneventful. Postoperative complications were reported in four procedures. There was significant urinary tract infection in two patients as well as an obstructed nephrostomy tube in two patients.

CONCLUSION

An antegrade endoscopic procedure using UAS in patients who present with stones or ureterointestinal stricture as late complications of urinary diversion is a feasible, well-tolerated technique, especially when using smaller access sheaths.

Management of stones in abnormal situations

Stones in abnormal situations present a management conundrum to the urologist. Many of these situations are relatively rare and literature is scanty on the appropriate management. We review the current literature on the management of stones in the setting of pregnancy, calyceal diverticulum, urinary diversions, pelvic kidneys, transplant kidneys, autosomal dominant polycystic kidney disease, horseshoe kidneys, and other renal anomalies. The aims of treatment are complete stone-free status. The modality of treatment should be individualized to the size and location of stone and type of abnormal situation confronted.

Percutaneous nephrolithotripsy in patients with urinary diversions: a case-control comparison of perioperative outcomes

PURPOSE

To compare the operative techniques and perioperative outcomes of patients with urinary intestinal diversions undergoing percutaneous nephrolithotripsy (PCNL), to a control cohort of patients without diversions.

PATIENTS AND METHODS

The medical records of all patients who were treated with PCNL from 1990 to 2009 were retrospectively reviewed. Each urinary diversion patient's first PCNL was age-matched with four controls who were undergoing PCNL. The perioperative outcomes were compared between the diversion and control cohorts.

RESULTS

Twenty-five patients with a urinary diversion who had undergone 33 PCNLs were identified. The mean age was 49.3 (8-85) years for the diversion group and 48.9 (4-84) for the control group. Urinary tract infection (64% vs 15% patients, P<0.0001), neurologic disease (64% vs 2%, P<0.0001), previous procedure for the same calculus (24% vs 4%, P=0.0004), urinary tract abnormalities (56% vs 14%, P<0.0001), solitary kidney (20% vs 3%, P=0.0081), and struvite stones (80% vs 12.5%, P=0.0006) were more commonly observed in the diversion group. Percutaneous access gained by a radiologist (40% vs 0%, P<0.0001), second-look nephroscopy (36% vs 16%, P=0.0466), and an increase in the frequency of fever or sepsis (8% vs 0%, P=0.0387) were identified more frequently in the diversion group.

CONCLUSIONS

Patients with upper tract calculi and urinary diversions are challenging to the endourologist because of anatomic factors that can make percutaneous access more difficult; ultrasonography-guided access can be helpful in this setting. Patients with urinary diversions can be treated as safely and effectively by PCNL as nondiverted patients.

Treatment of upper urinary lithiasis in patients who have undergone urinary diversion

Patients undergoing urinary diversion are at high risk for developing stone disease due to the metabolic and structural features intrinsic to the creation of a urinary reservoir. The utilization of shockwave lithotripsy as well as antegrade and retrograde endoscopic techniques in appropriately selected patients affords a relatively safe and effective means of stone removal. This review focuses on the etiology of stone formation in patients with urinary diversion and examines the most relevant and current reports on expulsive techniques and their associated outcomes for patients within this population who develop upper urinary tract calculi.

Percutaneous treatment of large upper tract stones after urinary diversion

OBJECTIVES

To present our experience in percutaneous management of large upper tract stones after urinary diversion.

METHODS

From October 1984 to March 2005, 20 percutaneous nephrolithotomy and 4 antegrade ureteroscopy procedures were performed in 17 men and 7 women, with a mean age of 53.5 years. The urinary diversions were an ileal W neobladder, hemi-Kock pouch, ileal conduit, and rectal bladder in 10, 7, 4, and 3 patients, respectively. The median interval between diversion and stone management was 1.5 years. Success was defined as a stone-free, nonobstructed renal unit at 3 months after the intervention. Follow-up was performed every 6 months with intravenous urography or noncontrast computed tomography for diagnosis of stone recurrence and evaluation of renal morphology.

RESULTS

Renal punctures were guided with ultrasonography in 18 patients (75%) and fluoroscopy in 6 patients. One intraoperative complication (4.16%) and two postoperative complications (8.3%) occurred. All patients with ureteral stones became stone free after one procedure. Auxiliary procedures were needed in 5 patients after percutaneous nephrolithotomy; 2 patients required a second session and 3 needed extracorporeal shock wave lithotripsy. The overall success rate was 87.5% (21 patients). One patient with treatment failure underwent open surgery, and two with small residual fragments were followed up. Long-term follow-up data were available for 15 patients. The stone recurrence rate was 33.3% (5 patients) after a median follow-up of 40 months (range 14 to 132). Recurrent stones were treated with extracorporeal shock wave lithotripsy.

CONCLUSIONS

The results of our study have demonstrated that percutaneous treatment of large upper tract stones after urinary diversion offers a high success rate with minimal morbidity. However, regular follow-up after treatment is recommended.

The surgical management of stones in patients with urinary diversions

PURPOSE OF REVIEW

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population.

RECENT FINDINGS

Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible.

SUMMARY

Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

Retrograde ureteroscopy in patients with orthotopic ileal neobladder urinary diversion

PURPOSE

We assess the feasibility, technique, complications and clinical outcomes of retrograde ureteroscopy in patients with orthotopic ileal neobladder.

MATERIALS AND METHODS

We retrospectively reviewed our ureteroscopy experience to identify procedures performed in patients who had previously undergone cystectomy with orthotopic ileal neobladder urinary diversion. These procedures were reviewed and data collected regarding patient characteristics, indication for endoscopic evaluation, surgical technique, findings, complications and followup.

RESULTS

Eight patients with neobladder diversion were taken for 9 sessions in the cystoscopy suite for attempted retrograde ureteroscopy on 13 renal units. The indication for ureteroscopy was an upper tract filling defect, positive cytology or calculi. The ureter and renal pelvis were successfully accessed and visualized in 10 of 13 renal units. The cause of failure in the 3 unsuccessful procedures was inability to access the ureteral orifice. Mean operative time +/- SD was 78 +/- 34 minutes. Urothelial abnormalities were identified in 4 patients, extrinsic compression in 2 and stones in 3. In 1 patient postoperative hematuria developed, which spontaneously resolved. Fluoroscopy was essential to identify the afferent limb of the reservoir, and a directional guide wire was helpful in engaging the ureteral orifice.

CONCLUSIONS

Ureteroscopic evaluation and treatment of upper tract abnormalities are feasible and practical in most patients with orthotopic neobladder urinary diversion. Identification of the ureteral orifice is challenging but can be accomplished with a combination of endoscopic and fluoroscopic techniques. This procedure avoids the morbidity of percutaneous access, and complications are minimal.

Stones in urinary diversions: update on medical and surgical issues

PURPOSE OF REVIEW

Patients who undergo urinary tract diversion are at an increased risk of urolithiasis for various reasons. The purpose of this article is to provide an up-to-date summary of the progress that has been made in the pathogenesis, diagnosis and treatment of stones in patients with urinary diversions. Finally, we will provide recommendations for follow-up in patients with urinary diversions who develop urinary tract calculi.

RECENT FINDINGS

In contemporary studies, the incidence of urolithiasis in patients with urinary diversion appears to be decreasing. Computed tomography scanning has been shown to be superior to ultrasound in the diagnosis of calculi in such patients. Endourological procedures have become the mainstay of therapy for stones in patients with urinary diversions. Since the introduction of extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy and ureteroscopy, the need for open surgery has decreased, even in this anatomically unique and surgically challenging patient population.

SUMMARY

Urolithiasis is an established long-term complication of urinary diversion. In recent years, significant advances have been made in the pathogenesis, diagnosis and treatment of such stones. As a result of potential stone-related complications, we recommend lifelong surveillance for all patients with urinary stones and diversions, with medical therapy when indicated, in order to minimize these complications.

Ureteral stents and their use in endourology

Ureteral stents have assisted urologists in the performance of surgery of the urinary tract for many years. They can have both diagnostic and therapeutic value, but are used most frequently as adjuncts to endoscopic or minimally invasive procedures. This review provides an update of the current uses for ureteral stents, technology of biomaterials, complications associated with indwelling ureteral stents and the future of stents in urology.

Low-power holmium laser for the management of urinary tract calculi, structures, and tumors

BACKGROUND AND PURPOSE

Introduction of the holmium laser has provided an indispensable tool for the management of urinary tract stones, strictures, and superficial urothelial tumors. While full-power holmium lasers are required for laser resection of the prostate, lower-power devices can be utilized for all cases of stone fragmentation and stricture incision and most cases of superficial urothelial tumors. Herein, we report our initial experience in utilizing a low-power holmium laser in our endourologic practice.

PATIENTS AND METHODS

Over a 6-month period, we have utilized both low-power (25 W) and full-power (80 W) holmium lasers to fragment urinary tract stones, incise ureteral or urethral strictures, and ablate superficial urothelial tumors. A series of 80 consecutive patients were assessed prospectively. Laser fibers with a diameter of 200 microm and 365 microm were employed with power settings of 6.4 to 10 W. Laser fiber size and power settings were similar for the low- and full-power devices.

RESULTS

Overall, 95% of the stones were completely fragmented, with a stone-free rate at 3 months of 92%. All strictures were incised, with a 91% patency rate at 3 months. Complete tumor ablation was attained in 70%, with a tumor-free rate of 60% at 3 months. Results were equivalent for the low- and full-power lasers. The 200-microm laser fiber allowed adequate access throughout the upper urinary tract during flexible ureteroscopy and flexible nephroscopy. The 365-microm laser fiber was employed via rigid and semirigid endoscopes.

CONCLUSIONS

A low-power holmium laser supplies adequate fragmentation and incision power for virtually all endourologic cases. It also provides ablative power in most situations. The only current urologic application that cannot be performed with the low-power device is laser prostatic resection, which requires 60 to 80 W of power. The reduced-power holmium laser should be considered as a low-cost alternative for the management of urinary tract stones, strictures, and urothelial tumors, especially in centers where laser prostatic resection is not performed.