1
|
Nakamoto T, Yoshida T, Katayama S, Ohe C, Kawaura T, Horii S, Ikeda J, Kono Y, Murota T, Kitawaki T, Araki M, Kinoshita H. Development and Validation of a Preoperative Nomogram for Endoscopic Management Decision Making in Upper Urinary Tract Urothelial Carcinoma. Ann Surg Oncol 2024; 31:1393-1401. [PMID: 37925655 DOI: 10.1245/s10434-023-14514-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE We aimed to develop and validate a preoperative nomogram that predicts low-grade, non-muscle invasive upper urinary tract urothelial carcinoma (LG-NMI UTUC), thereby aiding in the accurate selection of endoscopic management (EM) candidates. METHODS This was a retrospective study that included 454 patients who underwent radical surgery (Cohort 1 and Cohort 2), and 26 patients who received EM (Cohort 3). Utilizing a multivariate logistic regression model, a nomogram predicting LG-NMI UTUC was developed based on data from Cohort 1. The nomogram's accuracy was compared with conventional European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) models. External validation was performed using Cohort 2 data, and the nomogram's prognostic value was evaluated via disease progression metrics in Cohort 3. RESULTS In Cohort 1, multivariate analyses highlighted the absence of invasive disease on imaging (odds ratio [OR] 7.04; p = 0.011), absence of hydronephrosis (OR 2.06; p = 0.027), papillary architecture (OR 24.9; p < 0.001), and lack of high-grade urine cytology (OR 0.22; p < 0.001) as independent predictive factors for LG-NMI disease. The nomogram outperformed the two conventional models in predictive accuracy (0.869 vs. 0.759-0.821) and exhibited a higher net benefit in decision curve analysis. The model's clinical efficacy was corroborated in Cohort 2. Moreover, the nomogram stratified disease progression-free survival rates in Cohort 3. CONCLUSION Our nomogram ( https://kmur.shinyapps.io/UTUC_URS/ ) accurately predicts LG-NMI UTUC, thereby identifying suitable candidates for EM. Additionally, the model serves as a useful tool for prognostic stratification in patients undergoing EM.
Collapse
Affiliation(s)
- Takahiro Nakamoto
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
- Department of Pathology, Kansai Medical University Hospital, Osaka, Japan
| | - Takashi Yoshida
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan.
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan.
- Faculty of Engineering, Tottori University Graduate School of Engineering, Tottori, Japan.
| | - Satoshi Katayama
- Department of Urology, Dentistry, and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Chisato Ohe
- Department of Pathology, Kansai Medical University Hospital, Osaka, Japan
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan
| | - Takayuki Kawaura
- Department of Mathematics, Kansai Medical University, Osaka, Japan
| | - Satoshi Horii
- Department of Urology, Dentistry, and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Junichi Ikeda
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
| | - Yumiko Kono
- Department of Radiology, Kansai Medical University, Osaka, Japan
| | - Takashi Murota
- Department of Urology and Andrology, General Medical Center, Kansai Medical University, Osaka, Japan
| | - Tomoki Kitawaki
- Department of Mathematics, Kansai Medical University, Osaka, Japan
| | - Motoo Araki
- Department of Urology, Dentistry, and Pharmaceutical Sciences, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Hidefumi Kinoshita
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
| |
Collapse
|
2
|
Meng W, Zhang H, Wang J, Chen B, Jiang Z, Ma L, Guan Y. Retrospective study of single-use digital flexible ureteroscopic lithotripsy versus miniaturized percutaneous nephrolithotomy for 1.5-2.5cm lower pole renal stones. Int Urol Nephrol 2024; 56:55-62. [PMID: 37656387 DOI: 10.1007/s11255-023-03771-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/26/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE Retrospective analysis was performed on the clinical information of patients with 1.5-2.5 cm lower pole renal stones treated by single-use digital flexible ureteroscopic lithotripsy (fURS) and miniaturized percutaneous nephrolithotomy (MPCNL) in affiliated hospital of the Nantong University from January 2020 to December 2022. To compare the safety and efficacy of single-use fURS and MPCNL in the treatment from 1.5cm to 2.5cm lower pole renal stones. METHODS Clinical information of 141 patients were collected and divided into single-use fURS group and MPCNL group according to their treatment methods, including 83 patients in the single-use fURS group and 58 patients in the MPCNL group. Baseline data, data on the clinical characteristics of stones, laboratory examination data, operation time, and postoperative data of the two groups were collected. Statistical analysis was made on the collected data to analyze the differences and causes between the two groups of patients. RESULTS There was no significant difference in the baseline data and preoperative clinical features of 141 patients between the two groups (P > 0.05). In comparison of postoperative serum indexes, the drop values of hemoglobin and creatinine in single-use fURS group were lower than those in MPCNL group, and the difference was statistically significant (P < 0.05). The stone free rate was higher in the MPCNL group than in the single-use fURS group on the first day after surgery. At the 1st month after surgery, the two groups were similar. At 3rd month after surgery, the single-use fURS group was slightly higher than the MPCNL group, with no statistical significance (P > 0.05). The total complication rate in single-use fURS group was slightly lower than that in MPCNL group, but there was no statistical significance (P > 0.05). CONCLUSIONS Single-use fURS has similar safety and efficacy to MPCNL in the treatment of 1.5-2.5cm lower pole renal stones. Single-use fURS may be a new option for the treatment of these stones.
Collapse
Affiliation(s)
- Wei Meng
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, China
| | - Huajun Zhang
- Dalian Medical University, Dalian, 116000, China
| | - Jiahao Wang
- Department of Urology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, 214023, China
| | - Bo Chen
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, China
| | - Zhaosheng Jiang
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, China
| | - Limin Ma
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, China.
| | - Yangbo Guan
- Department of Urology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, China.
| |
Collapse
|
3
|
Juliebø‐Jones P, Ventimiglia E, Somani BK, Æsøy MS, Gjengstø P, Beisland C, Ulvik Ø. Single use flexible ureteroscopes: Current status and future directions. BJUI COMPASS 2023; 4:613-621. [PMID: 37818020 PMCID: PMC10560621 DOI: 10.1002/bco2.265] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/18/2023] [Accepted: 06/04/2023] [Indexed: 10/12/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Patrick Juliebø‐Jones
- Department of UrologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
- EAU YAU Urolithiasis groupArmhemNetherlands
| | - Eugenio Ventimiglia
- EAU YAU Urolithiasis groupArmhemNetherlands
- Department of UrologyIRCCS Ospedale San RaffaeleMilanItaly
| | | | | | - Peder Gjengstø
- Department of UrologyHaukeland University HospitalBergenNorway
| | - Christian Beisland
- Department of UrologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Øyvind Ulvik
- Department of UrologyHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| |
Collapse
|
4
|
Koo K, Wymer KM, Potretzke AM. Reuse and Reprocessing of Endoscopic Instruments: For. Eur Urol Focus 2023; 9:857-858. [PMID: 38040525 DOI: 10.1016/j.euf.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/22/2023] [Indexed: 12/03/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kevin Koo
- Department of Urology, Mayo Clinic, Rochester, MN, USA.
| | - Kevin M Wymer
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
5
|
Shrestha A, Adhikari B, Panthier F, Baidya S, Gauhar V, Traxer O. Flexible ureteroscopy for lower pole calculus: is it still a challenge? World J Urol 2023; 41:3345-3353. [PMID: 37728745 DOI: 10.1007/s00345-023-04606-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023] Open
Abstract
PURPOSE Flexible ureteroscopy (fURS) is steadily gaining popularity in the management of renal calculi, including those located in the lower pole (LP). Due to difficulty in accessing to the LP of kidney in minority of cases with fURS and reports of lower stone-free rate (SFR), it is still considered as a challenge in selected cases. The purpose of the review was to analyze the various aspects of fURS for LP stones. METHODS An extensive review of the recent literature was done including different factors such as anatomy, preoperative stenting, stone size, flexible scopes, types of lasers, laser fibers, suction, relocation, stone-free rates, and complications. RESULTS The significance of various lower pole anatomical measurements remain a subject of debate and requires standardization. Recent improvements in fURS such as single-use digital scopes with better vision and flexibility, high power laser, thulium fiber laser, smaller laser fiber, and accessories have significantly contributed to make flexible ureteroscopy more effective and safer in the management of LP stone. The utilization of thulium fiber lasers in conjunction with various suction devices is being recognized and can significantly improve SFR. CONCLUSIONS With the significant advancement of various aspects of fURS, this treatment modality has shown remarkable efficacy and gaining widespread acceptance in management of LP kidney stones. These developments have made the fURS of LP stones less challenging.
Collapse
Affiliation(s)
- Anil Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal.
- B&B Hospital, Lalitpur, Nepal.
| | | | | | | | | | | |
Collapse
|
6
|
Rutala WA, Weber DJ. Reprocessing semicritical items: An overview and an update on the shift from HLD to sterilization for endoscopes. Am J Infect Control 2023; 51:A96-A106. [PMID: 37890958 DOI: 10.1016/j.ajic.2023.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Semicritical medical devices are defined as items that come into contact with mucous membranes or nonintact skin (e.g., gastrointestinal endoscopes, endocavitary probes). Such medical devices require minimally high-level disinfection. METHODS Analyze the methods used to reprocess semicritical medical devices and identify methods and new technologies to reduce the risk of infection. RESULTS The reprocessing methods for semicritical medical devices is described as well as a shift from high-level disinfection to sterilization for lumened endoscopes. CONCLUSIONS Strict adherence to current guidelines and transition to sterilization for endoscopes is required as more outbreaks have been linked to inadequately disinfected endoscopes and other semicritical items than any other reusable medical devices.
Collapse
Affiliation(s)
- William A Rutala
- Statewide Program for Infection Control and Epidemiology, University of North Carolina Hospitals, Chapel Hill, NC; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, NC.
| | - David J Weber
- Statewide Program for Infection Control and Epidemiology, University of North Carolina Hospitals, Chapel Hill, NC; Division of Infectious Diseases, UNC School of Medicine, Chapel Hill, NC; Department of Infection Prevention, Hospital Epidemiology, University of North Carolina Hospitals, Chapel Hill, NC
| |
Collapse
|
7
|
Docimo S, Sucandy I, Luhrs A, Snow T, Pechman D. TAVAC: choledochoscopy disposable scopes, and the single-stage vs. two-stage approach to choledocholithiasis. Surg Endosc 2023; 37:6611-6618. [PMID: 37464066 DOI: 10.1007/s00464-023-10267-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Previous studies have been published evaluating the benefits and drawbacks of clearing the common bile duct of stones using a single-stage approach (LCBDE + LC) versus a two-stage approach (ERCP followed by LC). These studies have demonstrated that a single-stage approach offers similar outcomes and morbidities as a two-stage approach, with the added benefit of a lower cost and shorter length of stays. However, it is significant we understand why LCBDE is not commonly performed currently and also the lapse in surgical trainee exposure and competence in LCBDE. This paper aims to address the lapse in surgical trainee exposure to LCBDE, evaluate the scopes currently available to perform LCBDE, and review current data evaluating the risks and benefits of single-stage versus two-stage approaches to. METHODS We utilized PubMed to analyze all publications related to the various disposable scopes utilized to perform choledochoscopy. We also discuss the need for disposable scopes and how this new market niche is transforming the choledochoscopy space. RESULTS We analyzed the data related to single-stage and two-stage approach to choledocholithiasis. We noted an overall shorter length of stay and also decreased costs in favor of a single-stage approach. CONCLUSION A single-stage LCBDE is the most cost-effective treatment option for choledocholithiasis in patients with choledocholithiasis undergoing a cholecystectomy. In addition, single-stage approach is associated with shorter length of stay. Knowledge of the available choledochoscopes and tools available to surgeons to perform choledochoscopy is significant. The evidence does support the use of disposable choledochoscope from a cost and cross-contamination perspective. Additionally, efforts should be made to incorporate LCBDE into the teaching paradigm of surgical training programs.
Collapse
Affiliation(s)
| | - Iswanto Sucandy
- Digestive Health Institute at AdventHealth Tampa, Tampa, USA
| | - Andrew Luhrs
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, USA
| | - Tim Snow
- Sentara Martha Jefferson Hospital, Charlottesville, USA
| | - David Pechman
- Zucker School of Medicine at Hofstra, Northwell Health, Hempstead, USA
| |
Collapse
|
8
|
Yoshida T, Ohe C, Nakamoto T, Kinoshita H. Learning from the past and present to change the future: Endoscopic management of upper urinary tract urothelial carcinoma. Int J Urol 2023; 30:634-647. [PMID: 37294007 DOI: 10.1111/iju.15208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/09/2023] [Indexed: 06/10/2023]
Abstract
Current guidelines recommend endoscopic management (EM) for patients with low-risk upper urinary tract urothelial carcinoma, as well as those with an imperative indication. However, regardless of the tumor risk, radical nephroureterectomy is still mainly performed worldwide despite the benefits of EM, such as renal function maintenance, no hemodialysis requirement, and treatment cost reduction. This might be explained by the association of EM with a high risk of local recurrence and progression. Furthermore, the need for rigorous patient selection and close surveillance following EM may be relevant. Nevertheless, recent developments in diagnostic modalities, pathological evaluation, surgical devices and techniques, and intracavitary regimens have been reported, which may contribute to improved risk stratification and treatments with superior oncological outcomes. In this review, considering recent advances in endourology and oncology, we propose novel treatment strategies for optimal EM.
Collapse
Affiliation(s)
- Takashi Yoshida
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan
| | - Chisato Ohe
- Corporate Sponsored Research Programs for Multicellular Interactions in Cancer, Kansai Medical University, Osaka, Japan
- Department of Pathology, Kansai Medical University, Osaka, Japan
| | - Takahiro Nakamoto
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
- Department of Pathology, Kansai Medical University, Osaka, Japan
| | - Hidefumi Kinoshita
- Department of Urology and Andrology, Kansai Medical University, Osaka, Japan
| |
Collapse
|
9
|
Zanaty F, Elshazly M, Kandeel H, Salman B. A single center comparative study of two single use digital flexible ureteroscopy in the management of renal stones less than 2 cm. World J Urol 2023; 41:777-782. [PMID: 36700975 PMCID: PMC10082700 DOI: 10.1007/s00345-023-04290-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
PURPOSE For renal stones < 2 cm, guidelines recommend the use of retrograde intrarenal surgery as a first line treatment option. Many available single use flexible ureteroscopy were found. We aim to compare the effectiveness of two single use flexible ureteroscopy; Pusen Uscope 3011 versus LithoVue in the management of renal stones less than 2 cm. METHODS Our study prospectively included 60 patients equally divided in to two groups: Pusen group and LithoVue group during the period from June 2020 to June 2021. The included patients were above 18 years old. Perioperative details as operative time, fluoroscopy time, hospital stay, and complications were recorded. Stone free rate was assessed. Base purchase cost was also compared. RESULTS There was no statistically significant difference between the two groups regarding age, gender, and body mass index (BMI), stones size, side, number and location. The perioperative evaluation and outcome had no statistically significant differences between the two groups regarding the operative time, hospital stay, access sheath use, and stone free rate or radiation exposure. Among all cases, we had 49 cases (81.6%) with no postoperative complications (21 cases for Pusen group and 28 cases for LithoVue group). The incidence of postoperative complications was significantly higher among Pusen group than LithoVue group (p = 0.02). Initial purchase cost for both FURS had no significant difference (P = 0.86). CONCLUSION RIRS can be performed effectively with Pusen 3011 and LithoVue single use flexible ureteroscopy in patients diagnosed with renal calculi < 2 cm with superior outcomes with LithoVue.
Collapse
Affiliation(s)
- Fouad Zanaty
- Department of Urology, Menoufia University Hospitals, Shibin el Kom, Egypt.
| | - Mohamed Elshazly
- Department of Urology, Menoufia University Hospitals, Shibin el Kom, Egypt
| | - Hossam Kandeel
- Department of Urology, Menoufia University Hospitals, Shibin el Kom, Egypt
| | - Baher Salman
- Department of Urology, Menoufia University Hospitals, Shibin el Kom, Egypt
| |
Collapse
|
10
|
Geavlete B, Mareș C, Popescu RI, Mulțescu R, Ene C, Geavlete P. Unfavorable factors in accessing the pelvicalyceal system during retrograde flexible ureteroscopy (fURS). J Med Life 2023; 16:372-380. [PMID: 37168298 PMCID: PMC10165511 DOI: 10.25122/jml-2023-0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/28/2023] [Indexed: 05/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Bogdan Geavlete
- Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania
| | - Cristian Mareș
- Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania
- Corresponding Author: Cristian Mareș, Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania. E-mail:
| | | | - Răzvan Mulțescu
- Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania
| | - Cosmin Ene
- Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania
| | - Petrișor Geavlete
- Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sf. Ioan, Bucharest, Romania
| |
Collapse
|
11
|
Bragaru M, Multescu R, Georgescu D, Bulai C, Ene C, Popescu R, Geavlete P, Geavlete B. Single-use versus conventional reusable flexible ureteroscopes - an evaluation of the functional parameters. J Med Life 2023; 16:10-15. [PMID: 36873117 PMCID: PMC9979166 DOI: 10.25122/jml-2022-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/27/2022] [Indexed: 03/07/2023] Open
Abstract
The purpose of single-use flexible ureteroscopes (su-fURS) was to overcome the limitations of conventional reusable ureteroscopes in terms of maneuverability and maintenance. We aimed to perform a systematic literature review on available su-fURS performance versus conventional reusable fURS focusing on clinical data. A systematic research using Pubmed was performed evaluating single-use fURS and reusable fURS in urinary tract stone disease, including prospective assessments and case series. This review aimed to provide an overview of single-use and disposable flexible ureteroscopes and to examine and compare their capabilities (deflection, irrigation, optical properties). We included 11 studies, where the single-use fURS were compared to the reusable fURS. The studies with single-use ureteroscopes included data on LithoVue (Boston Scientific), The Uscope UE3022 (Pusen, Zhuhai, China), NeoFlex-Flexible, (Neoscope Inc San Jose, CA), 23 YC-FR-A (Shaogang). For reusable ureteroscopes, data were included on three models, two digital (Karl Storz Flex-XC and Olympus URF-Vo) and one fiber optic (Wolf-Cobra). There were no significant differences in stone-free rate, procedure duration, or functional capabilities between single-use fURS and reusable fURS. The systematic literature review analyzed operative time, functional capabilities, stone-free rates, and postoperative complications of the ureteroscopes, and a special chapter about renal abnormalities to emphasize that they are a good choice having a high proportion of stone-free rates and few risks, particularly in treating difficult-to-access calculi. Single-use fURS demonstrate a comparable efficacy with reusable fURS in resolving renal lithiasis. Further studies on clinical efficacy are needed to determine whether single-use fURS will reliably replace its reusable counterpart.
Collapse
Affiliation(s)
- Marius Bragaru
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Razvan Multescu
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania
| | - Dragos Georgescu
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Cătălin Bulai
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Cosmin Ene
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Razvan Popescu
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Petrişor Geavlete
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Bogdan Geavlete
- Urology Department, Sf. Ioan Emergency Clinical Hospital, Bucharest, Romania.,3 Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| |
Collapse
|
12
|
Gauhar V, Chai CA, Chew BH, Singh A, Castellani D, Tailly T, Emiliani E, Keat WOL, Ragoori D, Lakmichi MA, Teoh JYC, Traxer O, Somani BK. RIRS with disposable or reusable scopes: does it make a difference? Results from the multicenter FLEXOR study. Ther Adv Urol 2023; 15:17562872231158072. [PMID: 36923302 PMCID: PMC10009018 DOI: 10.1177/17562872231158072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/31/2023] [Indexed: 03/16/2023] Open
Abstract
Introduction With several single-use ureteroscopes now available, our aim was to analyze and compare data obtained globally from high-volume centers using both disposable and reusable flexible ureteroscopes and see if indeed in real-world practice either scope has a distinct advantage. Methods Retrospective analysis was performed on the FLEXOR registry, which was created as a TOWER group (Team of Worldwide Endourological Researchers, research wing of the Endourological Society) endeavor. Patients who underwent retrograde intrarenal surgery (RIRS) for renal stones from January 2018 to August 2021 were enrolled from 20 centers globally. A total of 6663 patients whose data were available for analysis were divided into Group 1 (Reusable scopes, 4808 patients) versus Group 2 (Disposable scopes, 1855 patients). Results The age and gender distribution were similar in both groups. The mean stone size was 11.8 mm and 9.6 mm in Groups 2 and 1, respectively (p < 0.001). Group 2 had more patients with >2 cm stones, lower pole stones and of higher Hounsfield unit. Thulium fiber laser (TFL) was used more in Group 2 (p < 0.001). Patients in Group 2 had a slightly higher stone-free rate (SFR) (78.22%) and a lower number of residual fragments (RFs) compared with Group 1 (p < 0.001). The need for further treatments for RF and overall complications was comparable between groups. On multivariate analysis, overall complications were more likely to occur in elderly patients, larger stone size, lower pole stones, and were also more when using disposable scopes with longer operative time. RFs were significantly higher (p < 0.001) for lower pole, larger, harder, multiple stones and in elderly. Conclusion Our real-world practice observations suggest that urologists choose disposable scopes for bigger, lower pole, and harder stones, and it does indeed help in improving the single-stage SFR if used correctly, with the appropriate lasers and lasing techniques in expert hands.
Collapse
Affiliation(s)
- Vineet Gauhar
- Department of Urology, Ng Teng Fong General Hospital, Singapore
| | - Chu Ann Chai
- Urology Unit, Department of Surgery, University of Malaya, Kuala Lumpur, Malaysia
| | - Ben H Chew
- Department of Urology, University of British Columbia, Vancouver, BC, Canada
| | | | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Thomas Tailly
- Department of Urology, University Hospital of Ghent, Ghent, Belgium
| | - Esteban Emiliani
- Urology Department, Fundación Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | - Mohamed Amine Lakmichi
- Department of Urology, University Hospital Mohammed the VIth of Marrakesh, Marrakesh, Morocco
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Olivier Traxer
- Department of Urology, AP-HP, Tenon Hospital, Sorbonne University, Paris, France
| | - Bhaskar Kumar Somani
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| |
Collapse
|
13
|
So WZ, Gauhar V, Chen K, Lu J, Chua WJ, Tiong HY. An in vitro Comparative Assessment of Single-Use Flexible Ureteroscopes Using a Standardized Ureteroscopy Training Model. Urol Int 2022; 106:1279-1286. [PMID: 35709703 PMCID: PMC9811416 DOI: 10.1159/000525246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/22/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Perceived benefits like decreased contamination rates and reduced postoperative incidence of complications after urolithiasis surgery have led to increased adoption of single-use flexible ureteroscopes (su-fURS). Using a validated, standardized simulator model with enhanced "fluoroscopic" capabilities, we performed an in vitro comparative assessment of four commercially available models of su-fURS. Both objective and subjective parameters were assessed in this study. METHODS Two standardized tasks, (1) exploration of the model's kidney collecting system and (2) repositioning of a stone fragment from the upper renal to lower renal pole were assigned to participants, who performed these tasks on all four scopes. Four models of su-fURS (Boston LithoVue, PUSEN PU3033A, REDPINE, INNOVEX EU-ScopeTM) were assessed, with task timings as end-points for objective analysis. Cumulative "fluoroscopic" time was also recorded as a novel feature of our enhanced model. Post-task questionnaires evaluating specific components of the scopes were distributed to document subjective ratings. RESULTS Both subjective and objective performances (except stone repositioning time) across all four su-fURS demonstrated significant differences. However, objective performance (task timings) did not reflect subjective scope ratings by the participants (Rs < 0.6). Upon Kruskal-Wallis H test with post hoc analyses, REDPINE and INNOVEX EU-ScopeTM were the preferred su-fURS as rated by the participants, with overall scope scores of 9.00/10 and 9.57/10. CONCLUSIONS Using a standardized in vitro simulation model with enhanced fluoroscopic capabilities, we demonstrated both objective and subjective differences between models of su-fURS. However, variations in perception of scope features (visibility, image quality, deflection, maneuverability, ease of stone retrieval) did not translate into actual technical performance. Eventually, the optimal choice of su-fURS fundamentally lies in individual surgeon preference, as well as cost-related factors.
Collapse
Affiliation(s)
- Wei Zheng So
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Vineet Gauhar
- Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Kelven Chen
- Department of Urology, National University Hospital, Singapore, Singapore,Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Jirong Lu
- Department of Urology, National University Hospital, Singapore, Singapore,Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Wei Jin Chua
- Department of Urology, National University Hospital, Singapore, Singapore,Department of Surgery, National University of Singapore, Singapore, Singapore
| | - Ho Yee Tiong
- Department of Urology, National University Hospital, Singapore, Singapore,Department of Surgery, National University of Singapore, Singapore, Singapore,*Ho Yee Tiong,
| |
Collapse
|
14
|
Geavlete B, Mareș C, Mulțescu R, Georgescu D, Geavlete P. Hybrid flexible ureteroscopy strategy in the management of renal stones - a narrative review. J Med Life 2022; 15:919-926. [PMID: 36188640 PMCID: PMC9514813 DOI: 10.25122/jml-2022-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
The introduction of single-use flexible ureteroscopes (suFURSs) in daily practice tends to overcome the main limitations of reusable ureteroscopes (reFURSs), in terms of high acquisition costs, maintenance, breakages and repairing costs, reprocessing and sterilization, as retrograde intrarenal surgery (RIRS) is promoted as first-line treatment of renal stones in most cases. A hybrid strategy implies having both instruments in the armamentarium of endourology and choosing the best strategy for cost-efficiency and protecting expensive reusable instruments in selected high-risk for breakage cases such as large stones of the inferior calyx, a steep infundibulopelvic angle or narrow infundibulum, or abnormal anatomy as in horseshoe and ectopic kidney. In terms of safety and efficiency, data present suFURSs as a safe alternative considering operating time, stone-free, and complication rates. An important aspect is highlighted by several authors about reusable instrument disinfection as various pathogens are still detected after proper sterilization. This comprehensive narrative review aims to analyze available data comparing suFURSs and reFURSs, considering economic, technical, and operative aspects of the two types of instruments, as well as the strategy of adopting a hybrid approach to selecting the most appropriate flexible ureteroscope in each case.
Collapse
Affiliation(s)
- Bogdan Geavlete
- Department of Urology, Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sfântul Ioan, Bucharest, Romania
| | - Cristian Mareș
- Department of Urology, Emergency Clinical Hospital Sfântul Ioan, Bucharest, Romania
| | - Răzvan Mulțescu
- Department of Urology, Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sfântul Ioan, Bucharest, Romania
| | - Dragoș Georgescu
- Department of Urology, Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sfântul Ioan, Bucharest, Romania
| | - Petrișor Geavlete
- Department of Urology, Sanador Hospital, Bucharest, Romania
- Department of Urology, Emergency Clinical Hospital Sfântul Ioan, Bucharest, Romania
| |
Collapse
|
15
|
Eismann L, Kretschmer A, Alghamdi A, Eisel M, Sroka R, Stief CG, Strittmatter F. Clinical Evaluation of Single-Use, Fiber-Optic, and Digital Ureterorenoscopes in the Treatment of Kidney Stones. Urol Int 2022; 106:476-481. [DOI: 10.1159/000521505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
<b><i>Introduction:</i></b> Indication of ureteroscopy for the treatment of urolithiasis has expanded immensely over the last decade. Fiber-optic and digital reusable instruments present the standard in clinical practice, but various newly available single-use devices might offer an exciting alternative. To date, the evidence is limited to clinical evaluation and efficacy of single-use ureteroscopes (URS) compared to standard instruments. Therefore, we evaluate a single-use instrument’s clinical characteristics and efficacy in direct comparison with a fiber-optic and digital device. <b><i>Methods:</i></b> A prospective study was conducted for patients undergoing endoscopic therapy for urolithiasis at a tertiary care center. We evaluated the different instruments’ clinical performance in categories of visibility, the stability of visibility, irrigation flow, and surgeon’s satisfaction. Statistical analyses were performed by SPSS using the Chi-Quadrat and Kruskal-Wallis test. A <i>p</i> value of <i>p</i> ≤ 0.05 was defined as statistically significant. <b><i>Results:</i></b> A total number of 77 patients were included and distributed as follows: 35 (46.7%) single-use, 19 (25.3%) digital, and 23 (28%) fiber-optic URS. Patients’ characteristics were homogenous over the three cohorts in sex, stone amount, and localization. The stone-free rate was equal in all three cohorts (<i>p</i> = 0.31). We identify stability of visibility, irrigation flow, and satisfaction were equal in all cohorts (<i>p</i> = 0.73; <i>p</i> = 0.20; <i>p</i> = 0.20). We report a significant difference in visibility, with 100% rated excellent in the digital URS group (<i>p</i> = 0.028). <b><i>Discussion/Conclusions:</i></b> Single-use URS achieve comparable clinical outcomes with equal stone-free rates in direct comparison with fiber-optic and digital reusable instruments. Accordingly, single-use devices present an adequate alternative for endoscopic therapy of urolithiasis.
Collapse
|
16
|
Single-Use Versus Reusable Endoscopes for Percutaneous Biliary Endoscopy with Lithotripsy: Technical Metrics, Clinical Outcomes, and Cost Comparison. J Vasc Interv Radiol 2021; 33:420-426. [PMID: 34958859 DOI: 10.1016/j.jvir.2021.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 12/06/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To compare procedure and fluoroscopy time, technical and clinical success, and costs between single-use and reusable endoscopes in patients undergoing percutaneous biliary endoscopy (PBE) with lithotripsy. MATERIAL AND METHODS In this retrospective study, we included 34 patients (67 procedures) treated with PBE for gallstone removal from October 24, 2014, through February 12, 2020, using reusable (28 procedures) or single-use (39 procedures) endoscopes. We compared 1) procedure time, 2) fluoroscopy time, 3) technical success rate (accessing the biliary system and locating the gallstone), 4) clinical success rate (at least partial gallstone removal), 5) complication rate, and 6) cost of use. Alpha = 0.05. RESULTS Mean (± standard deviation) procedure time was not significantly different between single-use (136 ± 45 minutes) and reusable endoscopes (136 ± 51 minutes) (p = 0.47). Mean fluoroscopy time was significantly shorter for single-use endoscopes (11 ± 8.4 minutes) than for reusable endoscopes (18 ± 12 minutes) (p = 0.01). When comparing single-use vs. reusable endoscopes, rates were not significantly different for technical success (N=37, 95% vs. N=26, 93%) or clinical success (N=35, 90% vs. N=21, 75%) (both, p>0.05). Only 1 complication was noted in the reusable endoscope group (p=0.42). Cost per case was lower for single-use ($1500) than for reusable ($3987) endoscope procedures, primarily due to differences in capital costs and costs due to repair. CONCLUSION Single-use endoscopes offer the potential for less radiation exposure to the patient and lower cost per case, which may reduce financial barriers to offering PBE in interventional radiology practices. Clinical and technical success rates did not differ by endoscope type.
Collapse
|
17
|
Jiang P, Brevik A, Clayman RV. The Life and Death of Percutaneous Stone Removal: "Looking Back-Looking Forward". Urol Clin North Am 2021; 49:119-128. [PMID: 34776046 DOI: 10.1016/j.ucl.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Although percutaneous nephrolithotomy (PCNL) is less morbid than open surgery, it still carries risks of significant complications as well as injury to the renal parenchyma. Flexible ureteroscopic stone removal, although causes no appreciable damage to the renal parenchyma, has limitations, most notably, a lower stone-free rate than PCNL. Advances in our knowledge regarding ureteral physiology combined with technical developments applied to ureteral access sheath deployment and size may well propel retrograde intrarenal surgery to the forefront of kidney stone removal, regardless of stone size or location.
Collapse
Affiliation(s)
- Pengbo Jiang
- Department of Urology, University of California - Irvine, 333 City Boulevard West, Suite 2100, Orange, CA 92868, USA.
| | - Andrew Brevik
- Department of Urology, University of California - Irvine, 333 City Boulevard West, Suite 2100, Orange, CA 92868, USA
| | - Ralph V Clayman
- Department of Urology, University of California - Irvine, 333 City Boulevard West, Suite 2100, Orange, CA 92868, USA
| |
Collapse
|
18
|
Domenech A, Alliende C, Vivaldi B, Pizzi P. Comparison of pre- and post-surgical images of reusable and single use flexible ureteroscopes: a qualitative analysis. Cent European J Urol 2021; 74:459-463. [PMID: 34729238 PMCID: PMC8552943 DOI: 10.5173/ceju.2021.0032.r2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/05/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Given the fragility of reusable ureterorenoscopes, many single use instruments have appeared on the market. Unfortunately, reuse of these scopes occurs in undeveloped countries in order to cut costs. This raises safety concerns for the patient. The aim of this article was to macroscopically evaluate the changes that single use flexible ureterorenoscopes (su-fURS) suffer after a retrograde intrarenal surgery (RIRS), and to compare them to reusable fURS. Material and methods Pre and post-operative images of the instruments used in 23 RIRS were obtained. All the cases had renal calculi of the inferior calix between 10–15 mm, and all of them were treated with Holmium laser. The ureterorenoscopes used were: Storz® Flex X2, Storz® Flex XC, Pusen® 3022, OTU® Wiscope, AnQIng® Innovex and Boston Scientific® LithoVue. Qualitative comparisons of these were made. Results After su-fURS usage, significant damage was observed, especially on the distal tip. Deflection was not compromised. Reusable fURS did not sustain any damage after their use. Conclusions fURS are delicate equipment, especially if they are of single use. The considerable damage sustained by single use scopes could mean that reuse of these instruments is dangerous and should be avoided.
Collapse
Affiliation(s)
- Alfredo Domenech
- Department of Urology, Clínica RedSalud Vitacura, Santiago, Chile.,Department of Urology, Univesidad de los Andes, Santiago, Chile
| | | | - Bruno Vivaldi
- Department of Urology, Clínica RedSalud Vitacura, Santiago, Chile.,Department of Urology, Univesidad de los Andes, Santiago, Chile
| | - Pablo Pizzi
- Department of Urology, Clínica RedSalud Vitacura, Santiago, Chile
| |
Collapse
|
19
|
Meng C, Peng L, Li J, Li Y, Li J, Wu J. Comparison Between Single-Use Flexible Ureteroscope and Reusable Flexible Ureteroscope for Upper Urinary Calculi: A Systematic Review and Meta-Analysis. Front Surg 2021; 8:691170. [PMID: 34722620 PMCID: PMC8548426 DOI: 10.3389/fsurg.2021.691170] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/07/2021] [Indexed: 12/23/2022] Open
Abstract
Objective: This article explores the differences in the effectiveness and safety of the treatment of the upper urinary calculi between single-use flexible ureteroscope (su-fURS) and reusable flexible ureteroscope (ru-fURS). Methods: We systematically searched PubMed, Embase, Cochrane Library, Scopus database, and CNKI databases within a period from the date of database establishment to November 2020. Stata 16 was used for calculation and statistical analyses. Results: A total of 1,020 patients were included in the seven studies. The statistical differences were only found in the Clavien–Dindo grade II postoperative complication [odds ratio (OR) 0.47; 95% CI 0.23–0.98; p = 0.04]. No significant statistical differences were observed in operative time (OT), estimated blood loss (EBL), length of hospital stay (LOS), and stone-free rate (SFR). Conclusion: Our meta-analysis results demonstrate that su-fURS, compared with ru-fURS, has similar effectiveness and better security for treating upper urinary calculi.
Collapse
Affiliation(s)
- Chunyang Meng
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College (University), Nanchong, China
| | - Lei Peng
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College (University), Nanchong, China
| | - Jinze Li
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yunxiang Li
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College (University), Nanchong, China
| | - Jinming Li
- Department of Urology, The Affiliated Hospital of Medical College, North Sichuan Medical College (University), Nanchong, China
| | - Ji Wu
- Department of Urology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College (University), Nanchong, China
| |
Collapse
|
20
|
Mazzucchi E, Marchini GS, Berto FCG, Denstedt J, Danilovic A, Vicentini FC, Torricelli FCM, Battagello CA, Srougi M, Nahas WC. Single-use flexible ureteroscopes: update and perspective in developing countries. A narrative review. Int Braz J Urol 2021; 48:456-467. [PMID: 34786927 PMCID: PMC9060176 DOI: 10.1590/s1677-5538.ibju.2021.0475] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/31/2021] [Indexed: 11/22/2022] Open
Abstract
Flexible ureteroscopy is a well-established method for treatment of urinary stones but flexible ureteroscopes are expensive and fragile devices with a very limited lifetime. Since 2006 with the advent of digital flexible ureteroscopes a great evolution has occurred. The first single-use flexible ureteroscope was launched in 2011 and new models are coming to the market. The aim of this article is to review the characteristics of these devices, compare their results with the reusable devices and evaluate the cost-benefits of adopting single-use flexible ureteroscopes in developing countries.
Collapse
Affiliation(s)
- Eduardo Mazzucchi
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Giovanni Scala Marchini
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | | | - John Denstedt
- Division of Urology, Western University, London, Ontario, Canada
| | - Alexandre Danilovic
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Fabio Carvalho Vicentini
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Fabio Cesar Miranda Torricelli
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Carlos Alfredo Battagello
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - Miguel Srougi
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| | - William Carlos Nahas
- Seção de Endourologia, Divisão de Urologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - FMUSP, São Paulo, SP, Brasil
| |
Collapse
|
21
|
Hendriks N, Henderickx MMEL, Schout BMA, Baard J, van Etten-Jamaludin FS, Beerlage HP, Pelger RCM, Kamphuis GM. How to evaluate a flexible ureterorenoscope? Systematic mapping of existing evaluation methods. BJU Int 2021; 128:408-423. [PMID: 34242475 PMCID: PMC8519042 DOI: 10.1111/bju.15544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/25/2021] [Accepted: 07/02/2021] [Indexed: 01/01/2023]
Abstract
Objectives The objective of this study was to identify, map and review scope‐related and user‐related parameters used to evaluate the quality of flexible ureterorenoscopes. Thereby identifying key items and variability in grading systems. Methods A literature search of four databases (MEDLINE [Ovid], EMBASE [Ovid], Web of Science, Google scholar and the Cochrane Library) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines encompassing articles published up to August 2020. A total of 2386 articles were screened. Results A total of 48 articles were included in this systematic scoping review. All studies had a prospective design. Five key items in the assessment of flexible ureterorenoscopy were distinguished: ‘Manoeuvrability’ (87.5%), ‘Optics’ (64.6%), ‘Irrigation’ (56.3%), ‘Handling’ (39.6%) and ‘Durability’ (35.4%). After regrouping, every key item could be divided into specific subcategories. However, the quality assessment showed a wide variation in denomination, method of measurement, circumstances of measurement, tools used during measurements, number of measurements performed, number of observers, and units of outcomes. Conclusion The research field regarding quality assessment of ureterorenoscopes is heterogeneous. In this systematic scoping review we identified five key parameters: Manoeuvrability, Optics, Irrigation, Handling and Durability, used to grade flexible ureterorenoscopes. However, within these categories we found a wide variety in terms of method of measurements. A standardised, uniform grading tool is required to assess and compare the quality of flexible ureterorenoscopes in the future.
Collapse
Affiliation(s)
- Nora Hendriks
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Urology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - Michaël M E L Henderickx
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Urology, GZA Hospitals, Antwerp, Belgium
| | | | - Joyce Baard
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Faridi S van Etten-Jamaludin
- Research Support, Medical library location AMC, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Harrie P Beerlage
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rob C M Pelger
- Department of Urology, Leids UMC, University of Leiden, Leiden, the Netherlands
| | - Guido M Kamphuis
- Department of Urology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| |
Collapse
|
22
|
Monmousseau F, Ramillon J, Dubnitskiy-Robin S, Faivre d’Arcier B, Le Verger M, Le Fol T, Bruyère F, Rusch E, Brunet-Houdard S, Pradère B. Relevance of Adopting a Hybrid Strategy Mixing Single-Use and Reusable Ureteroscopes for Stones Management: An Economic Study to Support the Best Strategy. J Clin Med 2021; 10:jcm10122593. [PMID: 34208267 PMCID: PMC8230737 DOI: 10.3390/jcm10122593] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Endoscopic procedures such as ureteroscopy (URS) have seen a recent increase in single-use devices. Despite all the advantages provided by disposable ureteroscopes (sURSs), their cost effectiveness remains questionable, leading most teams to use a hybrid strategy combining reusable (rURS) and disposable devices. Our study aimed to create an economic model that estimated the cut-off value of rURS procedures needed to support the profitability of a hybrid strategy (HS) for ureteroscopy. We used a budget impact analysis (BIA) model that estimated the financial impact of an HS compared to 100% sURS use. The model included hospital volume, sterilization costs and the private or public status of the institution. Although the hybrid strategy generally remains the best economic and clinical option, a predictive BIA model is recommended for the decision-making. We found that the minimal optimal proportion of rURS procedures in an HS was mainly impacted by the activity volume and overall number of sterilization procedures. Private and public institutions must consider these variables and models in order to adapt their HS and remain profitable.
Collapse
Affiliation(s)
- Fanny Monmousseau
- Health-Economic Evaluation Unit, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (J.R.); (S.D.-R.); (E.R.); (S.B.-H.)
- EA 7505—Education Ethics Health, Faculty of Medicine, University of Tours, 2 Boulevard Tonnellé, 37044 Tours, France
- Correspondence:
| | - Julien Ramillon
- Health-Economic Evaluation Unit, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (J.R.); (S.D.-R.); (E.R.); (S.B.-H.)
| | - Sophie Dubnitskiy-Robin
- Health-Economic Evaluation Unit, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (J.R.); (S.D.-R.); (E.R.); (S.B.-H.)
- Inserm UMR1246 SPHERE, Universities of Nantes and Tours, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France
| | - Benjamin Faivre d’Arcier
- Department of Urology, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (B.F.d.); (F.B.); (B.P.)
| | - Martine Le Verger
- Pharmacy, CHU de Tours-Trousseau, Avenue de la République, 37170 Chambray-les-Tours, France;
| | - Tanguy Le Fol
- Biomedical Unit, CHU de Tours-Trousseau, Avenue de la République, 37170 Chambray-les-Tours, France;
| | - Franck Bruyère
- Department of Urology, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (B.F.d.); (F.B.); (B.P.)
- PRES Centre Val de Loire, University of Tours, 60 Rue du Plat d’Étain, 37000 Tours, France
| | - Emmanuel Rusch
- Health-Economic Evaluation Unit, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (J.R.); (S.D.-R.); (E.R.); (S.B.-H.)
- EA 7505—Education Ethics Health, Faculty of Medicine, University of Tours, 2 Boulevard Tonnellé, 37044 Tours, France
| | - Solène Brunet-Houdard
- Health-Economic Evaluation Unit, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (J.R.); (S.D.-R.); (E.R.); (S.B.-H.)
- EA 7505—Education Ethics Health, Faculty of Medicine, University of Tours, 2 Boulevard Tonnellé, 37044 Tours, France
| | - Benjamin Pradère
- Department of Urology, CHU de Tours-Bretonneau, 2 Boulevard Tonnellé, 37044 Tours, France; (B.F.d.); (F.B.); (B.P.)
- Comprehensive Cancer Center, Department of Urology, Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| |
Collapse
|
23
|
Bozzini G, Filippi B, Alriyalat S, Calori A, Besana U, Mueller A, Pushkar D, Romero-Otero J, Pastore A, Sighinolfi MC, Micali S, Buizza C, Rocco B. Disposable versus Reusable Ureteroscopes: A Prospective Multicenter Randomized Comparison. Res Rep Urol 2021; 13:63-71. [PMID: 33604311 PMCID: PMC7882796 DOI: 10.2147/rru.s277049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/12/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To compare reusable and disposable flexible ureteroscopes in terms of efficacy and safety for patients undergoing Retrograde Intrarenal Surgery (RIRS). Patients and Methods Patients with a renal stone eligible for RIRS were enrolled in this multicenter, randomized, clinical trial study. Patients were randomized into two groups: group A (90 patients) underwent RIRS with a reusable flexible ureteroscope and group B (90 patients) were treated with a disposable one. Results The patients’ demographics, stone features and pre-operative urine cultures were comparable between the groups. The Stone Free Rates (SFRs) were not significantly different (86.6% and 90.0% for group A and group B, respectively, p=0.11) and the mean cost for each procedure was comparable (2321 € in group A vs 2543 € in group B, p=0.09). However, the days of hospitalization and of antibiotic therapy were higher in group A (p ≤ 0.05). The overall complication rate in group A was 8.8% whilst in group B it was 3.3% (p ≤ 0.05); in particular, group A exhibited a greater number of major complications (Clavien score IIIa-V). The overall postoperative infection rate was 16.6% in group A and 3.3% in group B (p ≤ 0.05). Furthermore, none of the patients in group B developed urosepsis or had a positive blood culture, while 3 patients in group A did (p<0.05). Conclusion The use of disposable ureteroscopes is characterized by significantly lower post-operative complications and infection rates, while having comparable costs and SFRs vis à vis reusable ureteroscopes. Clinical Trial Registration Number: ISRCTN92289221.
Collapse
Affiliation(s)
- Giorgio Bozzini
- Urology Department, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | | | | | - Alberto Calori
- Urology Department, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Umberto Besana
- Urology Department, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Alexander Mueller
- Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Dmitri Pushkar
- Urology Department First Moscow State Medical University, Moscow, Russia
| | | | | | | | | | - Carlo Buizza
- Urology Department, ASST Valle Olona, Busto Arsizio, Varese, Italy
| | - Bernardo Rocco
- Urology Department, Policlinico of Modena, Modena, Italy
| |
Collapse
|
24
|
Patil A, Agrawal S, Singh A, Ganpule A, Sabnis R, Desai M. A Single-Center Prospective Comparative Study of Two Single-Use Flexible Ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China). J Endourol 2021; 35:274-278. [PMID: 32967450 DOI: 10.1089/end.2020.0409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to compare in vivo performance and surgical outcomes with two single-use ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China) with secondary objective being to compare in vivo vision by independent endourologist blinded to ureteroscope manufacturer. Materials and Methods: Fifty patients undergoing retrograde intrarenal surgery with <2 cm renal stones were prospectively allocated: Group 1 (25 patients) for LithoVue and group 2 (25 patients) for Uscope. Pre-, intra-, and postoperative parameters were evaluated. Vision of both ureteroscopes with and without accessory was evaluated by an independent endourologist, blinded to the make of the ureteroscope. Stone clearance was assessed with kidney, ureter, and bladder radiograph (KUB) and ultrasonography KUB at 1 month. Student's t-test for quantitative and chi-square for categorical data was used. Results: Pre- and intraoperative parameters such as need for ureteral dilatation (p > 0.05), ureteral access-sheath size (p = 0.78), accessibility to pelvicaliceal system (p > 0.05), and maneuverability (p > 0.05) were comparable in both groups. Lower-pole access was possible in all cases of LithoVue and slightly difficult in three cases of Uscope (p > 0.5). Intraoperative vision was hazy in four cases of LithoVue and eight cases of Uscope (p = 0.32) during lasing along with three cases of Uscope with accessory (p = 0.24). Blinded endourologist reported more cases of hazy vision with or without accessory or lasing in Uscope arm (p > 0.05). One device had malfunction in LithoVue arm. Complete stone clearance was achieved in all cases at 1 month. Conclusions: We conclude that performance of these two single-use ureteroscopes, LithoVue and Uscope, is comparable in clinical settings with similar clinical outcomes and complications.
Collapse
Affiliation(s)
- Abhijit Patil
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Shashank Agrawal
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Abhishek Singh
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Arvind Ganpule
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Ravindra Sabnis
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Mahesh Desai
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India
| |
Collapse
|
25
|
Inoue T, Okada S, Hamamoto S, Fujisawa M. Retrograde intrarenal surgery: Past, present, and future. Investig Clin Urol 2021; 62:121-135. [PMID: 33660439 PMCID: PMC7940851 DOI: 10.4111/icu.20200526] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 12/18/2022] Open
Abstract
With the recent technological advancements in endourology, retrograde intrarenal surgery has become a more popular procedure for treatment of urolithiasis. Furthermore, since the introduction of new laser systems and advanced flexible ureteroscopy with miniaturized ureteroscopes, the treatment indications for retrograde intrarenal surgery have expanded to include not only larger renal stones of >2 cm but also upper urinary tract urothelial carcinoma, ureteral stricture, and idiopathic renal hematuria. Clinicians must keep up with these trends and make good use of these technologies in the rapidly changing field of endourology. Simultaneously, we must consider the risk of various complications including thermal injury due to laser use, ureteral injury caused by the ureteral access sheath, and radiation exposure during retrograde intrarenal surgery with fluoroscopic guidance. This review focuses on the past, present, and future of retrograde intrarenal surgery and provides many topics and clinical options for urologists to consider.
Collapse
Affiliation(s)
- Takaaki Inoue
- Department of Urology and Stone Center, Hara Genitourinary Hospital, Kobe, Hyogo, Japan.,Department of Urology, Kobe University, Kobe, Hyogo, Japan.
| | - Shinsuke Okada
- Department of Urology, Gyotoku General Hospital, Ichikawa, Chiba, Japan
| | - Shuzo Hamamoto
- Department of Urology, Medical School, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | | |
Collapse
|
26
|
Abstract
PURPOSE OF REVIEW Single-use flexible ureteroscopes (su-fURS) aim at overcoming the main limitations of conventional reusable ureteroscopes in terms of acquisition and maintenance costs, breakages, and reprocessing. However, little data exist to date regarding the superiority of su-fURS at this regard. We aimed to perform a systematic literature review on available su-fURS performance with a focus on clinical data for all articles in the last 10 years. RECENT FINDINGS To date, more than 10 different su-fURS are available on the market, with different characteristics and performance. Some of these devices have top-level features, almost catching up with those observed in reusable flexible ureteroscopes. Clinical evidence is mainly available only for two models, LithoVue and Uscope PU3022, and to date it is not strong enough to support routine adoption and use of su-fURS, with a consequent lack of consensus of specific clinical indications. Cost-effectiveness analyses seem to indicate an economic disadvantage in the routine adoption of su-fURS. Environmental issues related to the use of su-fURS also remain to be inquired and addressed. SUMMARY Since their introduction, su-fURS have gained widespread popularity. Despite their ability at addressing reusable ureteroscope limitations, high-cost and a substantial lack of evidence are still limiting their routine adoption.
Collapse
|
27
|
Critical Assessment of Single-Use Ureteroscopes in an In Vivo Porcine Model. Adv Urol 2020; 2020:3842680. [PMID: 32395126 PMCID: PMC7201811 DOI: 10.1155/2020/3842680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 04/09/2020] [Indexed: 11/18/2022] Open
Abstract
Methods A female pig was placed under general anesthesia and positioned supine, and retrograde access to the renal collecting system was obtained. The LithoVue (Boston Scientific) and Uscope (Pusen Medical) were evaluated by three experienced surgeons, and each surgeon started with a new scope. The following parameters were compared between each ureteroscope: time for navigation to upper and lower pole calyces with and without implements (1.9 F basket, 200 μm laser fiber, and 365 μm laser fiber for upper only) in the working channel and subjective evaluations of maneuverability, irrigant flow through the scope, lever force, ergonomics, and scope optics. Results Navigation to the lower pole calyx was significantly faster with LithoVue compared to Uscope when the working channel was empty (24.3 vs. 49.4 seconds, p < 0.01) and with a 200 μm fiber (63.6 vs. 94.4 seconds, p=0.04), but not with the 1.9 F basket. Navigation to the upper pole calyx was similar for all categories except faster with LithoVue containing the 365 μm fiber (67.1 vs. 99.7 seconds, p=0.02). Subjective assessments of scope maneuverability to upper and lower pole calyces when the scope was empty and with implements favored LithoVue in all categories, as did assessments of irrigant flow, illumination, image quality, and field of view. Both scopes had similar scores of lever force and ergonomics. Conclusions In an in vivo porcine model, the type of single-use ureteroscope employed affected the navigation times and subjective assessments of maneuverability and visualization. In all cases, LithoVue provided either equivalent or superior metrics than Uscope. Further clinical studies are necessary to determine the implications of these findings.
Collapse
|
28
|
Evaluation of flexible ureteroscope with an omni-directional bending tip, using a JOYSTICK unit (URF-Y0016): an ex-vivo study. World J Urol 2020; 39:209-215. [PMID: 32172330 DOI: 10.1007/s00345-020-03151-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/26/2020] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To compare the range of reach of our newly designed omni-directional ureteroscope (URF-Y0016), compared to the commonly used URF-P6, FlexX2s, and LithoVue™ scopes, in the upper, middle, and lower calyces in an ex-vivo pyelocaliceal model. METHODS We fabricated a three-dimensional pyelocaliceal model of the upper, middle, and lower pole calyces using urethane and acrylic resin. The inner surface of the dome of each calyx was engraved with reference lines along eight directions, set at 10° of latitude from the top to the base of the dome, and at angles of 0-90°, to precisely determine the range of reach of each scope. The main feature of the URF-Y0016 scope is the omni-directional bending of the tip of the flexible ureteroscope, with the control of these four directions integrated into a handgun-type control unit with a joystick. The range of reach within each calyx was measured by four expert surgeons. RESULTS The URF-Y0016 scope provided a greater range of reach along all directions in the lower pole calyx compared to URF-P6, FlexX2s, and LithoVue™ scopes (p < 0.001), particularly along the anterior-posterior direction in the lower lobe calyx. However, the URF-Y0016 scope did not influence the improvement of reach range in the upper and middle pole calyx compared to URF-P6, FlexX2s, and LithoVue™ scopes (p = 0.08, p = 0.296). CONCLUSION The novel design of the URF-Y0016 could improve treatment outcomes for calyceal stones in the lower pole in practice.
Collapse
|