Current status of ureteroscopic treatment for urolithiasis

One- versus two-surgeon active stone retrieval procedures for flexible ureteroscopy: An off-site simulator comparative study

OBJECTIVES

To evaluate the efficacy of the one-surgeon basketing technique compared to the conventional two-surgeon method for flexible ureteroscopy.

METHODS

Seven urologists (three trained and four less-trained surgeons) extracted three renal stones using each technique with an off-site simulator. We analyzed the task completion time, the number of times the basket forceps were opened and closed, and unexpected events during stone-catching, for both techniques.

RESULTS

There was no significant difference in the total task completion time between the one-surgeon (102.0 [interquartile range 63.5-164.0] s) and two-surgeon (99.5 [interquartile range 75.0-145.3] s) techniques. However, the time it took the trained surgeons to extract all stones was significantly shorter with the one-surgeon than with the two-surgeon technique (19.0 [interquartile range 18.0-20.0] s vs 34.0 [interquartile range 25.0-40.0] s; P = 0.049). Among the less-trained surgeons, the opposite effect was observed, but this difference was not statistically significant (96.5 [interquartile range 61.0-134.5] s vs 64.0 [interquartile range 51.5-77.0] s; P = 0.489). The number of times the forceps were opened and closed during stone-catching was significantly lower with the one-surgeon technique than with the two-surgeon technique (5.0 [interquartile range 4.0-5.0] times vs 9.0 [interquartile range 6.0-14.5] times; P = 0.018).

CONCLUSIONS

The one-surgeon technique can offer comparable efficacy to the two-surgeon technique. If surgeons are sufficiently trained, a one-surgeon basketing technique for performing flexible ureteroscopy might become a new technical modality for extracting renal stones.

Retrograde ureteroscopy in the management of distal ureteric stones: A retrospective analysis of outcome and complications

Background

Urinary stones affect 8%-15% of the world population. In Nigeria, contemporary reports have shown that the incidence of urinary stones is rising. The distal ureter has been described as the most common location of ureteric stones. This study seeks to review our experience in the ureteroscopic management of distal ureteric stones with a view to appraising the stone clearance rate and the complications seen in our patients.

Patients and Methods

This descriptive study reviewed the record of 21 patients, who had semirigid ureteroscopy and pneumatic lithotripsy for distal ureteric stone between October 2015 and September 2018. All patients had computed tomography urography preoperatively to locate the stone. Data on patients' demographics, indication for the surgery, location and size of stone, preoperative double-J (DJ) placement, postoperative DJ stent placement, intraoperative and postoperative complications, and status of stone clearance were retrieved and subjected to statistical analysis.

Results

The mean age of the patients was 37.95 ± 11.09 (range, 21-67) years. The mean stone size was 8.06 ± 2.87 mm with a range of 4.8 mm-15.0 mm. Out of the 21 patients, 20 (95.2%) had the procedure for recurrent ureteric colic and 1 (48%) was for hematuria. Four (19.0%) patients had DJ stent preoperatively, whereas 17 (81.0%) patients did not have. Fourteen (66.7%) patients had intraoperative ureteric dilatation. Postoperative DJ stent was placed in 17 (81.0%) patients, whereas 4 (19.0%) patients did not have. Three (14.3%) patients had mucosal flap, 6 (14.3%) had mucosal abrasion, 2 (9.5%) had bleeding, 1 (4.8%) patient had transient hematuria postoperatively, and 2 (9.5%) patients had urinary tract infection. Nineteen (90.5%) patients had complete clearance in a single surgery. Two (9.5%) patients had symptomatic residual fragments that required repeat ureteroscopy.

Conclusion

Our study has shown that ureteroscopy is a useful and safe technique in the removal of stones in distal ureter.

Robotic stone surgery - Current state and future prospects: A systematic review

Objective

To provide a comprehensive review of robot-assisted surgery in urolithiasis and to consider the future prospects of robotic approaches in stone surgery.

Materials and methods

We performed a systematic PubMed© literature search using predefined Medical Subject Headings search terms to identify PubMed-listed clinical research studies on robotic stone surgery. All authors screened the results for eligibility and two independent reviewers performed the data extraction.

Results

The most common approach in robotic stone surgery is a robot-assisted pyelolithotomy using the da Vinci™ system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Several studies show this technique to be comparable to classic laparoscopic and open surgical interventions. One study that focused on ureteric stones showed a similar result. In recent years, promising data on robotic intrarenal surgery have been reported (Roboflex Avicenna™; Elmed Medical Systems, Ankara, Turkey). Initial studies have shown its feasibility and high stone-free rates and prove that this novel endoscopic approach is safe for the patient and comfortable for the surgeon.

Conclusions

The benefits of robotic devices in stone surgery in existing endourological, laparoscopic, and open treatment strategies still need elucidation. Although recent data are promising, more prospective randomised controlled studies are necessary to clarify the impact of this technique on patient safety and stone-free rates.

Results of day-case ureterorenoscopy (DC-URS) for stone disease: prospective outcomes over 4.5 years

PURPOSE

To investigate the prospective outcomes of day-case ureterorenoscopy (DC-URS) for stone disease. With the rising prevalence of stone disease in the face of finite resources, there is increasing pressure to undertake procedures as a day case avoiding in-patient stay. There are a limited number of studies reporting on the feasibility of ureteroscopy as a day-case procedure. This study aimed to investigate the prospective outcomes and predictors precluding to DC-URS for stone disease in patients treated in our university teaching hospital.

MATERIALS AND METHODS

Between March 2012 and July 2016, consecutive cases of adult stone ureteroscopy performed or supervised by a single surgeon were recorded in a prospective database. Patients underwent pre-operative counselling in a specialist stone clinic and were admitted to a dedicated 'Surgical day unit' on the day of surgery. A standardised anaesthetic protocol was adhered to in all cases. Data on patient demographics, stone parameters, pre-operative assessment, operative details, length of stay, stone-free rate and complication rates were collected and analysed.

RESULTS

A total of 544 consecutive adult ureteroscopy for stone disease were conducted over the study period with a day-case rate of 77.7%. Thirty-nine percent of failed day-case ureteroscopy were due to late completion of ureteroscopy and due to associated social circumstances of patients. The mean stone size, operating time duration and post-operative stent insertion rates for DC-URS patients were 14 mm, 46 min and 96.5%, respectively. Post-operatively, the mean stone-free rate (SFR), unplanned re-admissions and complications for DC-URS patients were 95, 4 and 4%, respectively. A higher failure of DC-URS was related to patient's age (p = 0.003), positive pre-operative urine culture (p < 0.001), elevated pre-operative serum creatinine (p < 0.001) and higher mean operating time (p < 0.02).

CONCLUSION

Based on our results, a day-case ureteroscopy rate of nearly 78% can be achieved. With its acceptable complication rate, and low re-admission rates, DC-URS is a safe and feasible option in a majority of patients with stone disease.

The value of three-dimensional helical computed tomography for the retrograde flexible ureteronephroscopy in the treatment of lower pole calyx stones

Objective

The aim of our study was to determine if there is any advantage of three-dimensional helical computed tomography (3D-HCT) over intravenous urogram (IVU) for the retrograde flexible ureteronephroscopy in the treatment of lower pole calyx stones.

Methods

From June 2012 to January 2014, a total of 52 cases of lower pole renal stones underwent retrograde intrarenal surgery (RIRS) in our center. All patients underwent a preoperative IVU and three-dimensional helical computed tomography urography (3D-CTU) program to define the collecting system anatomy, manly concerning the following lower pole features; infundibu-lopelvic angle (IPA), infundibular length (IL), and infundibular width (IW). The examinations were performed in the same center of reference with a standardized method and with 3D-HCT Siemens Somaton Plus equipment. The measurements were performed by the same researcher, using a ruler and a square.

Results

Based on clinical threshold difference of the anatomic factors on an IVU image to compare the difference between an IVU image and a 3D-CT image of 52 patients, the IPA was <30° when measured on intravenous pyelography (IVP) for 21 patients. We found that with the IPA of <30° measured with IVP only 19% (4/21) were correctly classified in the same size category using 3D-HCT, whereas 81% (17/21) were upgraded to 40–50° on 3D-CT. This difference was significant between IVP and 3D-HCT.

Conclusions

3D-HCT has advantages over IVU when analyzing the morphometric and the morphological features of kidney lower pole spatial anatomy for the retrograde flexible ureteronephroscopy in the treatment of lower pole calyx stones.

Subcapsular renal hematoma after ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy

Subcapsular renal hematoma (SRH) after ureteroscopic lithotripsy (URSL) using holmium:yttrium-aluminum-garnet (Ho:YAG) laser to treat ureteric stones is a rare complication. We aimed to review our unit's experience of post-URSL subcapsular renal hematoma. From 2006 to 2012, 2059 URSLs using F9.5 rigid ureteroscope were performed in our unit. Patients with post-URSL symptomatic renal hematoma were reviewed. Perioperative information on patients' renal function, stone characteristics, and degree of renal hydronephrosis were reviewed. Operative data, postoperative information such as clinical manifestation, changes in blood parameters, CT findings, and subsequent treatment were documented. Of the 2059 patients treated with URSL and Ho:YAG laser, three patients were diagnosed as subcapsular renal hematoma after surgery; the age is 57, 61, and 63 years old, respectively. Preoperative imaging examination showed that two patients and one patient had obstructing middle and proximal ureteral stones ranging in size from 0.8 to 1.6 cm, and three patients had thin renal cortices. The double-J ureteral stents were inserted in all cases regularly. All three subcapsular renal hematoma patients had the loin pain of the operation side and fever, and one patient had significant hemoglobin drop (from 111 to 61 g/L) who need to transfusion. Two patients presented within 24 h of URSL, and one patient presented on day 10. One patient was treated conservatively for 3 weeks and recovered with bed rest, antibiotics, hemostasis, and analgesia with no intervention or drain. The other two patients underwent ultrasonography-guided drainage of the hematoma. Two-month follow-up CT scans or ultrasonography confirmed the resolution of the hematoma in all three cases. Renal subcapsular hematoma after URSL is a rare and one of serious complications. Subcapsular renal hematoma should be considered when patients have the symptoms of significant loin pain after URSL for obstructing ureteral stones with thin renal cortices. The treatment of post-URSL renal subcapsular hematomas needs to be customized for each patient.

Holmium laser lithotripsy with semi-rigid ureteroscopy: a first-choice treatment for impacted ureteral stones in children?

Background

We aimed to assess the effectiveness of semi-rigid ureteroscopy and holmium laser lithotripsy in the treatment of impacted ureteral stones in children.

Material/Methods

We evaluated a total of 32 children under the age of 18 years treated with ureteroscopic holmium laser lithotripsy for impacted ureteral stones between January 2005 and July 2013. Their stone-free state was defined as the absence of any residual stone on radiologic evaluation performed 4 weeks postoperatively. Complications were evaluated according to the modified Clavien classification.

Result

The mean patient age was 9.5±5.1 years (range 1–18 years). Seven (21.8%) of the stones were located in the proximal ureter, 9 (28.2%) were in the mid-ureter, and 16 (50%) were in the distal ureter. The mean stone size was calculated as being 10.46±3.8 mm² (range 5–20). The stone-free rate was 93.75% (30/32 patients) following primary URS. Additional treatment was required for only 2 (6.25%) of the patients. After the procedure, a D-J stent was placed in all the patients. The total complication rate was 15.6% (5 patients). The 10 total complications in these 5 patients were 5 (15.6%) Grade I, 1 (3.1%) Grade II, 2 (6.25%) Grade IIIa, and 2 (6.25%) Grade IIIb. The mean follow-up period was 16.5 months (range 3–55).

Conclusions

For the treatment of impacted ureteral stones in children, holmium laser lithotripsy with semi-rigid ureteroscopy, with its low retreatment requirement and acceptable complication rates, is an effective and reliable method in experienced and skilled hands as a first-choice treatment approach.

Management of Clinically Insignificant Residual Fragments following Shock Wave Lithotripsy

Clinically insignificant residual fragments (CIRFs) are small fragments (less than 5 mm) that are present in upper urinary tract at the time of regular post-SWL followup. The term is controversial because they may remain silent and asymptomatic or become a risk factor for stone growth and recurrence, leading to symptomatic events, and need further urologic treatment. Although a stone-free state is the desired outcome of surgical treatment of urolithiasis, the authors believe that the presence of noninfected, nonobstructive, asymptomatic residual fragments can be managed metabolically in order to prevent stone growth and recurrence. Further urologic intervention is warranted if clinical indications for stone removal are present.

Intracorporeal laser lithotripsy

Objectives

To review the current literature on intracorporeal laser lithotripsy.

Methods

We searched PubMed for relevant reports up to January 2012, using the keywords ‘laser’, ‘lithotripsy’ and ‘intracorporeal’.

Results

We studied 125 relevant reports of studies with various levels of evidence. Efficient lithotripsy depends on the laser variables (wavelength, pulse duration and pulse energy) and the physical properties of the stones (optical, mechanical and chemical). The most efficient laser for stones in all locations and of all mineral compositions is the holmium yttrium–aluminium–garnet laser (Ho:YAG). The frequency-doubled double-pulse Nd:YAG laser functions through the generation of a plasma bubble. New laser systems, such as the erbium:YAG and the thulium laser, are under evaluation. Laser protection systems have also been developed for the novel digital flexible ureteroscopes. Although complications are rare, a high relevant clinical suspicion is necessary.

Conclusions

Laser lithotripsy technology is continuously developing, while the Ho:YAG laser remains the reference standard for intracorporeal lithotripsy.

Modern management of stone disease in patients with a solitary kidney

Analysing the data available in the literature, contemporary methods of treatment of nephrolithiasis are limited to the methods of minimally invasive percutaneous nephrolithotomy (PCNL) and ureterorenoscopic lithotripsy (URSL), not excluding their use in the presence of developmental abnormalities and kidney impairment only. Minimally invasive methods have become standard procedures. A complement to ineffective URSL and PCNL treatment is extracorporeal shock wave lithotripsy. This is confirmed by 30 years of observation in the only treatment of kidney calculi by Alken launched in 1981 and continued by Jones et al. Before the era of endoscopic procedures (PCNL and URSL) effectively removed the only deposits in the kidney in open operations. Minimally invasive treatments are recommended for patients with localized deposits in the pelvicalyceal system or solitary kidney ureter. They are recognized as safe and effective treatment in a solitary kidney in particular in patients who have already been operated on.

Cost-effectiveness analysis of ureteroscopic laser lithotripsy and shock wave lithotripsy in the management of ureteral calculi in eastern China

INTRODUCTION

It was the aim of this study to compare the efficiency and safety between shock wave lithotripsy (SWL) and ureteroscopic holmium laser lithotripsy (URL) methods for ureteral calculi while also determining which option is more cost-effective.

PATIENTS AND METHODS

During January 2008 to September 2009, a prospective randomized study was conducted to compare both modalities for the management of solitary radiopaque ureteral stones. Patient and stone characteristics, treatment outcome and charges were documented. Both options were compared using univariate statistical tests to identify the efficiency quotient and cost-effectiveness for ureteral calculi according to the stone location.

RESULTS

A total of 257 patients were in the SWL group, while 269 were in the URL group. The efficiency quotients for SWL and URL were 0.81 and 0.88, respectively. The initial stone-free rate of URL for lower ureteral calculi was higher (p = 0.002), while the complication rate of SWL for upper ureteral calculi was lower (p = 0.027). The SWL group required lower hospitalization charges (USD 440 vs. 1,221; p < 0.001), lower total charges (USD 454 vs. 1,284; p < 0.001) and a shorter period of hospitalization (5.4 vs. 6.6 days; p < 0.001) compared with the URL group for all ureteral locations. For mid and lower ureteral calculi, the postoperative office visits of the URL group were fewer (1.03 vs. 1.1 times; p = 0.001).

CONCLUSIONS

Primary in situ SWL for upper and middle ureteral calculi showed lower complication rates compared to URL and was more cost-effective in Eastern China. However, primary URL was a better option for treating lower ureteral stones with a higher stone-free rate but was more expensive.

[Narrow band imaging: description of the technique and initial experience with upper urinary tract carcinomas]

PURPOSE

Endoscopic treatment of upper urinary tract carcinomas (UUTC) is becoming more and more prevalent compared to non-conservative surgery. Our goal was to determine if NBI technology could improve tumour detection.

MATERIAL

Twenty-seven patients with known or suspected UUTC were prospectively enrolled and treated using the Olympus URF-V flexible ureteroscope. We report 13 new cases (48%) and 14 known cases as follow up (52%). White light and NBI were subsequently performed to examine the upper urinary tract. Visual aspect of the lesions could be compared using both types of light. Biopsies were taken for all apparent lesions prior to vaporization by Holmium laser.

RESULTS

Forty-three lesions were detected in 21 patients. Five lesions (14.2%) in four patients were detected through NBI light only among the 35 lesions containing UUTC. Two out of four of these patients were new cases and would not have been diagnosed with white light alone. Three UUTC-treated (8.5%) had extended margins in NBI. Thirteen biopsies (26%) were not valid. Altogether, the tumour detection rate improved by 22.7% in seven patients (25.9%) by using the NBI method.

CONCLUSION

Upper urinary tract endoscopy with NBI light is a new technology that improves visualization of UUCT and enables diagnosis of lesions non visible in white light. This procedure cannot yet be recommended for daily practice and further validation of the technique is required.

Ureteroscopy of Ureteral Stones: Our Experience

Introduction and Objectives

ureteroscopy is now a widely used procedure in urology. Technological advances in endourology are used to manage the majority of ureteral stones (1). In this study we evaluated retrospectively our cases of ureteral lithiasis treated by ureteroscopy.