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Ergül RB, Butticè S, Yitgin Y, Günver MG, Ozcan F, Nane I, Traxer O, Tefik T. Peak Force of Insertion During Ureteral Access Sheath Placement In An Ex-Vivo Experimental Model With Different Commercially Available Access Sheaths. Urology 2024:S0090-4295(24)00545-4. [PMID: 38964618 DOI: 10.1016/j.urology.2024.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/02/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVES To measure the force necessary to win the resistance during insertion of ureteral access sheaths (UAS) in an experimental homemade model and to compare the peak force of insertion (PFOI) of different commercially available UASs. METHODS Three investigators (2 novice and 1 expert) inserted the UASs into 2 different adapters with diameters of 10 Fr and 8 Fr. The force of insertion was continuously measured with a digital force gauge connected to the UAS during each insertion. Four different brands of UAS with different diameters, totally 11 different UASs were used for the experiment. The PFOI of each UAS was compared among each other and adapter diameters. RESULTS The mean PFOI in adapters 1 and 2 were 1.85 N and 5.32 N, respectively. All of the mean PFOIs were significantly lower in adapter 1 compared to adapter 2, regardless of the novice vs expert surgeons and the UASs. (p<0.001) In adapter 1, the mean PFOI was lowest with the UAS-1 and highest with the UAS-8. In adapter 2, the mean PFOI was lowest with the UAS-3 and highest with the UAS-9. For adapters 1 and 2, no statistical difference was found when comparing an expert and the two novice surgeons. CONCLUSION The PFOI during UAS placement is not solely correlated with UAS thickness and adapter diameters. Other factors such as hydrophilic coating, UAS flexibility, inner dilator properties, UAS smoothness and the actual measured external diameter of UASs should be taken into consideration. The clinical relevance and ureteral injury risk of the UAS PFOI needs to be studied.
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Affiliation(s)
- Rifat Burak Ergül
- Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Salvatore Butticè
- Progress in Endourology, Technology and Research Association. (PETRA); Paolo Borsellino Hospital, Department of Urology, Marsala, Italy
| | - Yasin Yitgin
- Istinye University, Department of Urology, Istanbul, Turkey
| | - Mehmet Güven Günver
- Istanbul University Istanbul Faculty of Medicine, Department of Biostatistics, Istanbul, Turkey
| | - Faruk Ozcan
- Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Ismet Nane
- Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey
| | - Olivier Traxer
- Sorbonne University, GRC n°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon; Sorbonne University, Service d'Urologie, Assistance-Publique Hôpitaux de Paris, Hôpital Tenon; Progressive Endourological Association for Research and Leading Solutions (PEARLS)
| | - Tzevat Tefik
- Istanbul University, Istanbul Faculty of Medicine, Department of Urology, Istanbul, Turkey; Progress in Endourology, Technology and Research Association. (PETRA).
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Tefik T, Ergül RB, Osther P, Giusti G, Preminger GM, Straub M, Rassweiler JJ, Montanari E, Brehmer M, Seitz C, Grasso M, Pearle M, Proietti S, Cloutier J, Gunver MG, Nane I, Ozcan F, Traxer O. The relationship between the force applied and perceived by the surgeon during ureteral access sheath placement: ex-vivo experimental model. World J Urol 2024; 42:329. [PMID: 38753120 PMCID: PMC11098873 DOI: 10.1007/s00345-024-04982-7] [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: 02/25/2024] [Accepted: 04/05/2024] [Indexed: 05/19/2024] Open
Abstract
PURPOSE To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.
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Affiliation(s)
- Tzevat Tefik
- Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey.
- Progress in Endourology, Technology and Research Association (PETRA), Paris, France.
| | - Rifat Burak Ergül
- Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Palle Osther
- Department of Urology, Urological Research Center, Lillebælt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Guido Giusti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Michael Straub
- Department of Urology, Technical University Munich, Munich, Germany
| | | | - Emanuele Montanari
- Department of Urology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marianne Brehmer
- Department of Urology, Stockholm South General Hospital Stockholm, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science, Stockholm South General Hospital Stockholm, Karolinska Institutet, Stockholm, Sweden
| | - Christian Seitz
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Michael Grasso
- Department of Urology, Phelps Hospital/Northwell Health, New York, USA
| | | | - Silvia Proietti
- Department of Urology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Jonathan Cloutier
- Progress in Endourology, Technology and Research Association (PETRA), Paris, France
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec, QC, Canada
| | - MGuven Gunver
- Department of Medical Statistics, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ismet Nane
- Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Faruk Ozcan
- Department of Urology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Olivier Traxer
- Progress in Endourology, Technology and Research Association (PETRA), Paris, France
- GRC N°20, Groupe de Recherche Clinique sur la Lithiase Urinaire, Hôpital Tenon, Sorbonne Université, 75020, Paris, France
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O'Meara S, Cunnane EM, Croghan SM, Cunnane CV, Walsh MT, O'Brien FJ, Davis NF. Mechanical characteristics of the ureter and clinical implications. Nat Rev Urol 2024; 21:197-213. [PMID: 38102385 DOI: 10.1038/s41585-023-00831-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/17/2023]
Abstract
The ureteric wall is a complex multi-layered structure. The ureter shows variation in passive mechanical properties, histological morphology and insertion forces along the anatomical length. Ureter mechanical properties also vary depending on the direction of tensile testing and the anatomical region tested. Compliance is greatest in the proximal ureter and lower in the distal ureter, which contributes to the role of the ureter as a high-resistance sphincter. Similar to other human tissues, the ureteric wall remodels with age, resulting in changes to the mechanical properties. The passive mechanical properties of the ureter vary between species, and variation in tissue storage and testing methods limits comparison across some studies. Knowledge of the morphological and mechanical properties of the ureteric wall can aid in understanding urine transport and safety thresholds in surgical techniques. Indeed, various factors alter the forces required to insert access sheaths or scopes into the ureter, including sheath diameter, safety wires and medications. Future studies on human ureteric tissue both in vivo and ex vivo are required to understand the mechanical properties of the ureter and how forces influence these properties. Testing of instrument insertion forces in humans with a focus on defining safe upper limits and techniques to reduce trauma are also needed. Last, evaluation of dilatation limits in the mid and proximal ureter and clarification of tensile strength anisotropy in human specimens are necessary.
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Affiliation(s)
- Sorcha O'Meara
- Department of Surgery, Royal College of Surgeons of Ireland (RCSI), Dublin, Ireland.
- Department of Urology, Blackrock Clinic, Blackrock, Co., Dublin, Ireland.
| | - Eoghan M Cunnane
- Biomaterials Cluster, Bernal Institute, University of Limerick, Limerick, Ireland
- School of Engineering, University of Limerick, Limerick, Ireland
| | - Stefanie M Croghan
- Department of Surgery, Royal College of Surgeons of Ireland (RCSI), Dublin, Ireland
- Department of Urology, Blackrock Clinic, Blackrock, Co., Dublin, Ireland
| | - Connor V Cunnane
- Biomaterials Cluster, Bernal Institute, University of Limerick, Limerick, Ireland
- School of Engineering, University of Limerick, Limerick, Ireland
| | - Michael T Walsh
- Biomaterials Cluster, Bernal Institute, University of Limerick, Limerick, Ireland
- School of Engineering, University of Limerick, Limerick, Ireland
| | - Fergal J O'Brien
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Trinity Centre for Biomedical Engineering, Trinity College Dublin, Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), RCSI and TCD, Dublin, Ireland
| | - Niall F Davis
- Department of Surgery, Royal College of Surgeons of Ireland (RCSI), Dublin, Ireland
- Department of Urology, Blackrock Clinic, Blackrock, Co., Dublin, Ireland
- Department of Urology and Transplant Surgery, Beaumont Hospital, Dublin, Ireland
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