LithoVue™: A new single-use digital flexible ureteroscope

Single-use flexible ureteroscopes: practice patterns, attitudes, and preferences for next-generation concepts

Background

Single use flexible ureteroscopes (su-fURS) have emerged as an alternative to reusable flexible ureteroscopes (r-fURS) for the management of upper urinary tract calculi. However, little is known about urologist usage and attitudes about this technology. Through a worldwide survey of endourologists, we assessed practice patterns and preferences for su-fURS.

Methods

An online questionnaire was sent to Endourology Society members in January 2021. The survey explored current su-fURS practice patterns, reasons for/against adoption, and preferences for next generation models including developments in imaging, intra-renal pressure, heat generation, and suction. Responses were collected through QualtricsXM over a 1-month period from surgeons in North America, Latin America, Europe, Asia, Africa, and Oceania. The study was conducted according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

Results

208 (13.9%) members responded to the survey. Most respondents (53.8%) performed >100 ureteroscopies per year. 77.9% of all respondents used su-fURS for less than half of all procedures while only 2.4% used su-fURS for every procedure. 26.0% had never used a su-fURS. Overall, usage was not influenced by a surgeon's geographic region, practice environment, or years of experience. Top reasons for not adopting su-fURS were cost (59.1%) and environmental impact (12.5%). The most desired improvements in design were smaller outer shaft size (19.4%), improved optics and vision (15.9%), and wireless connectivity (13.6%). For next generation concepts, the functions most commonly described as essential or important by respondents was the ability to suction fragments (94.3%) while the function most commonly noted as not important or unnecessary was incorporation of a temperature sensor (40.4%).

Conclusions

su-fURS are not commonly used, even among urologists who perform a high number of fURS. The primary concern for adoption is cost and environmental impact. Suction capability was considered the most important future development.

The role of planetary health in urologic oncology

INTRODUCTION

Climate change and global warming are an omnipresent topic in our daily lives. Planetary health and oncology represent two critical domains within the broader spectrum of healthcare, each addressing distinct yet interconnected aspects of human well-being. We are encouraged to do our part in saving our planet. This should include the decisions we make in our professional life, especially in uro-oncology, as the healthcare sector significantly contributes to environmental pollution.

AREAS COVERED

There are many aspects that can be addressed in the healthcare sector in general, as there are structural problems in terms of energy consumption, water waste, therapeutic techniques, transportation and drug manufacturing, as well as in uro-oncology specific areas. For example, the use of different surgical techniques, forms of anesthesia and the use of disposable or reusable instruments, each has a different impact on our environment. The literature search was carried out using PubMed, a medical database.

EXPERT OPINION

We are used to making decisions based on the best outcome for patients without considering the impact that each decision can have on the environment. In the present article, we outline options and choices for a more climate-friendly approach in urologic oncology.

Comparing outcomes of single-use vs reusable ureteroscopes: a systematic review and meta analysis

Flexible ureterolithotripsy is a frequent urological procedure, usually used to remove stones from the kidney and upper ureter. Reusable uretero-scopes were the standard tool for that procedure, but recent concerns related to sterility and maintenance and repair costs created the opportunity to develop new technologies. In 2016, the first single-use digital flexible ureteroscope was introduced. Since then, other single-use ureteroscopes were developed, and studies compared them with the reusable ureteroscopes with conflicting results. The purpose of this study is to describe the literature that compares the performance of single-use and reusable flexible ureteroscopes in retrograde intrarenal surgery for urinary stones. A Systematic Review was performed in October 2022 in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). A search in MEDLINE, EMBASE, Web of Science, Google Scholar and LILACS retrieved 10,039 articles. After screening, 12 articles were selected for the Meta-Analysis. No differences were found in stone-free rate (OR 1.31, CI 95% [0.88, 1.97]), operative time (MD 0.12, CI 95% [-5.52, 5.76]), incidence of post-operative fever (OR 0.64, CI 95% [0.22, 1.89]), or incidence of post-operative urinary tract infection (OR 0.63 CI 95% [0.30, 1.32]). No differences were observed in the studied variables. Hence, the device choice should rely on the availability, cost analysis and surgeons' preference.

Can the introduction of single-use flexible ureteroscopes increase the longevity of reusable flexible ureteroscopes at a high volume centre?

OBJECTIVES

To assess whether the introduction of single use flexibles ureteroscopes (su-fURS) at our high-volume centre had an advantageous impact on the turn-over and breakage rates of reusable fURS (re-fURS).

METHODS

We analysed re-fURS number of usages and breakages at our centre between February 2015 and December 2018. We recorded the number of usages for analysed scope between the first usage until a breakage requiring reconditioning. Usage count was restarted following each reconditioning episode. Since su-fURS (Lithovue, Boston Scientific, USA) were introduced at our center in September 2016, we had the chance to compare different re-fURS life cycles according to both su-fURS availability and usage intensity (i.e., number of su-fURS used during each re-fURS life cycle). We then explored the relationship between su-fURS usage intensity and reusable scope survival (i.e., number of utilizations before any breakage requiring reconditioning) using locally weighted scatterplot smoothing (LOWESS) approach.

RESULTS

Five different re-fURSs were employed at our centre, for a total of 1820 usages and 40 breakages requiring reconditioning. The overall mean (SD) number of usages before breaking was 40 (22). After su-fURS introduction, mean (SD) re-fURS number of usages increased from 35 (22) to 49 (20), (+ 40%, p = 0.02). The relationship between su-fURS usage intensity and reusable scopes survival showed a linear survival increase after 10 or more su-fURS scopes were used per life cycle.

CONCLUSIONS

The life cycle of re-fURS increased by 40% after the introduction of su-fURS. Ten or more used su-fURS per life cycle were associated with increased re-fURS survival.

Critical Assessment of Single-Use Ureteroscopes in an In Vivo Porcine Model

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.

Endoscopic treatment of lower pole stones: is a disposable ureteroscope preferable? Results of a prospective case-control study

Introduction

The best option for lower pole stone management is still under debate. With the recent incorporation of disposable ureteroscopes, discussion on this topic has been renewed. The aim of the present study was to compare the results obtained with flexible disposable ureteroscopes with those obtained using reusable ureteroscopes in the treatment of inferior calyx stones.

Material and methods

A case-control study was carried out using data registered prospectively in a database at our center. The clinical results obtained in two groups of patients were analyzed. In the first group of patients, a reusable flexible fiber-optic ureteroscope (Cobra^®, Richard Wolf) was used, and in the second group, a disposable flexible ureteroscope was used (Uscope 3022^®, Pusen Medical). The variables analyzed included: operative time, fluoroscopy time, need for postprocedure ureteral catheter, stone-free rate (fragments <1 millimeter) and complications. The results were evaluated using a Student's t test, a Mann-Whitney test and a Fisher's test.

Results

There were 31 cases with disposable ureteroscopes and 30 cases with a reusable ureteroscope. Both groups were comparable in their demographic and clinical variables. The characteristics regarding length, width and angle of the infundibulum (measured by retrograde ureteropyelography) were also comparable. There were no differences in the clinical findings with respect to the stone-free rate, need for a ureteral catheter, complications or hospital stay. Significant differences were found in the average surgery time (56.1 vs. 77 minutes; P = 0.01) and in the fluoroscopy time (66.1 vs. 83.4 seconds; P = 0.02), both favoring the use of single use ureteroscopes.

Conclusions

In this study, disposable flexible ureteroscopes have been validated as an option that is in the least equivalent to reusable ureteroscopes based on clinical results. The shorter surgical and fluoroscopy durations are possible advantages considering the high costs associated with time spent in the operating room and the need to reduce ionizing radiation.

Characteristics of current digital single-use flexible ureteroscopes versus their reusable counterparts: an in-vitro comparative analysis

Background

Single-use flexible ureterorenoscopes (fURSs) have been recently introduced aiming to offer solutions to the sterilization, fragility and cost issues of the reusable fURSs. In order to be a viable alternative, the single-use scopes must prove similar capabilities when compared to their reusable counterparts. The goal of our in-vitro study was to compare the current reusable and single-use digital fURSs regarding their deflection, irrigation and vision characteristics.

Methods

We compared in-vitro 4 single-use fURSs-LithoVue™ (Boston Scientific, Marlborough, Massachusetts, USA), Uscope™ (Zhuhai Pusen Medical Technology Co. Ltd., Zhuhai, Guangdong Province, China), NeoFlex™ (NeoScope Inc, San Jose, California, USA) and ShaoGang™ (YouCare Technology Co. Ltd., Wuhan, China) versus 4 reusable fURSs-FLEX-X^c (Karl Storz SE & Co KG, Tuttlingen, Germany), URF-V2 (Olympus, Shinjuku, Tokyo, Japan), COBRA vision and BOA vision (Richard Wolf GmbH, Knittlingen, Germany). Deflection and irrigation abilities were evaluated with different instruments inserted through the working channel: laser fibres (200/273/365 µm), retrieval baskets (1.5/1.9/2.2 Fr), guide wires [polytetrafluoroethylene (PTFE) 0.038 inch, nitinol 0.035 inch] and a biopsy forceps. A scoring system was designed to compare the deflection impairment. Saline at different heights (40/80 cm) was used for irrigation. The flow was measured with the tip of the fURS initially straight and then fully deflected. The vision characteristics were evaluated (field of view, depth of field, image resolution, distortion and colour representation) using specific target models.

Results

Overall, the single-use fURSs had superior in-vitro deflection abilities than the reusable fURSs, in most settings. The highest score was achieved by NeoFlex™ and the lowest by ShaoGang™. PTFE guide wire had most impact on deflection for all fURSs. The 200 µm laser fibre had the lowest impact on deflection for the single-use fURSs. The 1.5 Fr basket caused the least deflection impairment on reusable fURSs. At the end of the tests, deflection loss was noted in most of the single-use fURSs, while none of the reusable fURSs presented deflection impairment. ShaoGang™ had the highest irrigation flow. Increasing the size of the instruments occupying the working channel led to decrease of irrigation flow in all fURSs. The impact of maximal deflection on irrigation flow was very low for all fURSs. When instruments were occupying the working channel, the single-use fURSs had slightly better in-vitro irrigation flow than the reusable fURSs. The field of view was comparable for all fURSs, with LithoVue™ showing a slight advantage. Depth of field and colour reproducibility were almost similar for all fURSs. ShaoGang™ and Uscope™ had the lowest resolution. FLEX X^c had the highest image distortion while LithoVue™ had the lowest. Partial field of view impairment was not for Uscope™ and ShaoGang™.

Conclusions

In-vitro, there are differences in technical characteristics of fURSs. It appears that single-use fURSs deflect better than their reusable counterparts. Irrespective of deflection, the irrigation flow of the single-use fURSs was slightly superior to the flow of the reusable fURSs. Overall, reusable fURSs had better vision characteristics than single-use fURSs. Further in-vivo studies might be necessary to confirm these findings.

First clinical evaluation of the new single-use flexible and semirigid Pusen ureteroscopes

Introduction

The purpose of the present study was to clinically evaluate two new single-use Pusen ureteroscopes, one semirigid with a flexible tip (srURS) and one flexible (fURS).

Materials and methods

During ten consecutive procedures (five srURS and five fURS), we subjectively evaluated on a scale from 0 (poor) to 10 (excellent), the scope's deflection, image quality, and maneuverability prior to, during and after the surgery. Patient demographics, complications with the devices, and troubleshooting were recorded.

Results

There were a total of ten patients, five of which were female while the other five were male. Mean age was 58.9 years. Seven patients had a single kidney stone with mean size of 9.6 mm (1.6-20 mm). Half of the patients were pre-stented. For the fURS, the preoperative image quality rating was 8.4 (8-10), compared with 6.8 (4-9) during surgery. The preoperative deflection rating was 9.6+ 0.9 (8-10), while during surgery this decreased to 8.0 (6-10) and to 6.0 (4-8) when using a laser fiber. The srURS had a preoperative image quality rating of 9.2 (8-10), which decreased to 7.6 (6-9) while using the scope. The deflection rating decreased from 9.4 (7-10) preoperatively to 7.0 (1-10) postoperatively, and a similar reduction was observed in the maneuverability rating, from 9.6 (8-10) to 7.4 (1-10). Ureteroscopy was considered as a standard in four of the fURS and three of the srURS procedures. The mean overall satisfaction rating was 6.

Conclusions

The two new single-use ureteroscopes, one flexible and one semirigid, were considered to have allowed standard ureteroscopy in four and three out of the five procedures for each scope, respectively. The image quality, deflection, and maneuverability ratings decreased during the procedure for both scopes.

Retrograde intrarenal surgery using the single - use flexible ureteroscope Uscope 3022 (Pusen™): evaluation of clinical results

Introduction

Reusable endoscopes have some limitations regarding their continued use. To sort out these problems, several disposable devices have appeared on the market. Our objective is to show our clinical results with a new digital flexible single-use ureteroscope.

Materials and methods

This study presents a prospective series of patients who underwent endoscopic surgery as treatment for renal stones using the digital disposable endoscope Uscope 3022™. Demographic, procedure and stone information were registered including surgery time, stone-free rate, need of ureteral catheterization and complications, among others. The behavior of the ureteroscope in terms of image quality and problems associated with flexibility and the working channel were also registered.

Results

A total of 71 procedures were included in the analysis. The mean age was 49.9 years old, with 70.4% of male patients. Mean stone size was 11.4 mm (4 to 40 mm). The most frequent stone location was in the lower calyces (28.2%). The stone burden was high (>2 cm) in 8.4% of patients. The mean surgical time was 56.6 minutes (15–180 min). In 94.4% of the cases, a laser was used with dusting parameters. The global stone-free rate (SFR) was 95.2%, but in the subgroups analysis SFR were significantly superior in stones less than 10 mm (97.9%) versus stones between 10 and 20 mm (94.5%) and greater than 20 mm (78.3%) (p <0.01). The postoperative placement of double-J stents was required in 66.2% of patients. Two minor complications were recorded and they were related to the ureteral access sheath used. There were no problems regarding the performance of the ureteroscope.

Conclusions

The clinical data observed in this series does not differ from the results traditionally obtained with other reusable devices. To our knowledge, this series is the first worldwide report evaluating the clinical behavior and results in humans of the Uscope 3022.

Single-use flexible ureteropyeloscopy: a systematic review

PURPOSE

Data assessing the effectiveness of single-use flexible ureteropyeloscopy (FURS) are limited. This study evaluates and compares single-use FURS with conventional reusable FURS.

METHODS

A systematic search using electronic databases (Pubmed and Embase) was performed for studies evaluating single-use FURS in the setting of urinary tract stone disease. Outcome measures included a comparative evaluation of their mechanical, optical and clinical outcomes.

RESULTS

Eleven studies on 466 patients met inclusion criteria. In vitro comparative data were available on three single-use flexible ureteropyeloscopes (LithoVue™, Polyscope™ and SemiFlex™) and clinical data were available on two (LithoVue™ and Polyscope™). The overall stone-free rate and complication rate associated with single-use FURS was 87 ± 15% and 9.3 ± 9%, respectively. There were no significant differences in procedure duration, stone size, stone clearance and complication rates when single-use FURS and reusable FURS were compared (duration: 73 ± 27 versus 74 ± 13 min, p = 0.99; stone size: 1.36 ± 0.2 versus 1.34 ± 0.18 cm, p = 0.93; stone-free rate: 77.8 ± 18 versus 68.5 ± 33%, p = 0.76; complication rate 15.3 ± 10.6 versus 15 ± 1.6%, p = 0.3).

CONCLUSIONS

Single-use FURS demonstrates comparable efficacy with reusable FURS in treating renal calculi. Further studies on clinical efficacy and cost are needed to determine whether single-use FURS will reliably replace its reusable counterpart.

Ureteroscopy for stone disease: expanding roles in the modern era

INTRODUCTION

The prevalence of urolithiasis is increasing worldwide and is causing significant morbidity and cost to the healthcare systems. While ureteroscopy (URS) has been established as a treatment option, our review highlights the expanding role of URS for the management of more complex stones and patients in the modern era.

MATERIAL AND METHODS

Ureteroscopy has shown to have good outcomes with stone free rates (SFR) comparable to other treatment modalities. Relevant publications have been identified. Their findings were critically appraised and used to formulate clinically oriented conclusions.

RESULTS

The use of URS has increased and now includes URS management for large stones, bilateral stone disease, obesity, pregnancy, pediatrics, solitary kidney, horseshoe kidney and patients with a bleeding diathesis.

CONCLUSIONS

With advances in URS technique and technology, its role has expanded to offer treatment in difficult clinical scenarios with good outcomes.

A Prospective Case-Control Study Comparing LithoVue, a Single-Use, Flexible Disposable Ureteroscope, with Flexible, Reusable Fiber-Optic Ureteroscopes

OBJECTIVE

LithoVue™ is a novel, single-use, digital flexible ureteroscope that was released to the US market in January 2016. There are scant data regarding its performance in humans. Procedural outcomes comparing LithoVue with reusable ureteroscopes are presented in patients undergoing ureteroscopy for upper urinary tract pathology.

PATIENTS AND METHODS

Clinical outcomes between two groups of patients undergoing flexible ureteroscopy for upper urinary tract pathology were analyzed. The first group underwent surgery utilizing LithoVue, and the second group used reusable fiber-optic flexible ureteroscopes. Differences in procedural outcomes, operative times, and time spent in hospital were analyzed using two-tailed t-tests and chi-squared and Fisher's exact tests.

RESULTS

One hundred fifteen cases utilizing LithoVue and 65 cases utilizing reusable ureteroscopes were included in this study. Demographics, surgical indications, stone size, location, total stone burden, composition, procedural outcomes, and complications were comparable between groups. For all cases, LithoVue procedures lasted 54.1 ± 25.7 minutes compared with 64.5 ± 37.0 minutes for reusable scope procedures (p < 0.05) and for stone removal cases, 57.3 ± 25.1 vs 70.3 ± 36.9 minutes, respectively (p < 0.05). Scope failure occurred in 4.4% of LithoVue cases and 7.7% of reusable cases (p = 0.27).

CONCLUSIONS

LithoVue represents a feasible alternative to reusable ureteroscopes with a low rate of scope failure comparable with reusable ureteroscopes. Its use shortens procedure duration, a finding that warrants further investigation.