The Accordion Antiretropulsive Device Improves Stone-Free Rates During Ureteroscopic Laser Lithotripsy

Reverse Trendelenburg Positioning Minimizes Stone Retropulsion During Ureteroscopic Laser Lithotripsy: A Prospective Randomized Study

Purpose: Retropulsion of stone fragments during ureteroscopic laser lithotripsy (URSLL) remains a challenge for urologists and is associated with increased operative time and reduced stone-free rate (SFR). In this study, we compared the rate of retropulsion of ureteral stones during URSLL between the standard dorsal lithotomy (SDL) position and dorsal lithotomy position with reverse Trendelenburg (RT). Materials and Methods: Patients with ureteral stones requiring surgical intervention between May 2019 and January 2022 were randomized to undergo URSLL in either SDL or RT positions. The primary outcome of this study was stone retropulsion. Secondary outcomes included retropulsion to the kidney, SFR, operative time, 30-day emergency department visits and complications, and the need for conversion from semirigid to flexible ureteroscope. Differences between groups were evaluated using the chi-square test, Fisher exact test, Kruskal-Wallis test, or t-test. Results: A total of 114 patients were included in the study, with 57 patients in each group. There were no differences between groups in terms of baseline demographics or stone characteristics. Retropulsion was significantly less frequent in the RT group (68.4% vs 10.5%, p < 0.01). Similarly, the RT group was favored for lower risk of retropulsion into the kidney (40.4% vs 5.3%, p < 0.01), operative time (43.5 vs 33.0 minutes, p = 0.02), and need for ureteroscope conversion (16.7% vs 2.2%, p = 0.04). There was no difference in the SFR (100% vs 95%, p = 0.49). Conclusions: RT positioning during URSLL for ureteral stones significantly decreases the rate of stone retropulsion, operative time, and the need for conversion from semirigid to flexible ureteroscope.

Cost-effectiveness of anti-retropulsive devices varies according to the locations of proximal ureteral stones: a retrospective cohort study

Background

Anti-retropulsive devices are often used to prevent stone migration in the treatment of proximal ureteral calculi. They are helpful. However, in the meantime, they also add extra expenses. This study was carried out to investigate the best criteria for treating proximal ureteral stones with anti-retropulsive devices.

Methods

Data from all patients who underwent ureteroscopic holmium: YAG laser lithotripsy for solitary upper ureteral stones in 2018 were collected. Patients who encountered stone retropulsion during the process of inserting the ureteroscope were excluded. Patients were divided into either group URS or group URS + ARD depending on whether the anti-retropulsive device was used. Then, the stone-free rate, expenses and other criteria were compared between groups according to stone location. Stone-free was defined as no stones present.

Results

For stones located ≤ 30 mm from the ureteropelvic junction (UPJ), the stone-free rates for the URS group were 80% and 80% at one day and one month after the operation, respectively. Those for the URS + ARD group were 71.4% and 78.6% at one day and one month, respectively. For stones located 31–90 mm from the UPJ, the stone-free rates were 84.7% and 84.7% for the URS group and 89.6% and 95.5% for the URS + ARD group at one day and one month, respectively. A statistically significant difference occurred at one month. For stones located > 90 mm from the UPJ, the two groups were both stone free. In the URS + ARD group, expenses were higher. In addition, the mean diameter of residual stones derived from stones located at 31–90 mm from the UPJ was statistically smaller, and 4 of 7 residual stones passed spontaneously within one month, which was obviously more than that in other locations and the URS group. Other outcomes, including operation time and postoperative stay, showed no significant difference between the groups.

Conclusion

Anti-retropulsive devices are indeed helpful, but they might be cost-effective for stones located solely in the middle part of the upper ureter, not for those too close to or far from the ureteropelvic junction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00995-9.

Dual usage of a stone basket: Stone capture and retropulsion prevention

INTRODUCTION

Stone migration during ureteroscopy (URS) for proximal ureteric calculi is a constant challenge. Several retropulsion prevention devices have been developed to optimize URS outcomes. Our technique involves capturing the stone within a four-wire Nitinol stone basket and then performing laser lithotripsy to dust the stone while it is engaged in the basket. The dusted fragments wash out with the irrigation fluid and once small enough, the remaining stone is removed intact.

METHODS

A retrospective chart review was performed of all proximal semi-rigid URS procedures for a solitary calculus (2000-2016). We compared our new technique introduced in 2010 to URS control procedures that did not use retropulsion prevention techniques or devices.

RESULTS

One hundred and forty patients underwent URS for proximal ureteric calculi. Mean stone diameter was 9.3±3.4 mm, with similar impaction rate between both groups (44.1% vs. 43.1% control; p=n/s). The mean surgical procedure time was 53.3±17.9 minutes for the new technique and 65.2±29.2 minutes for the control group (p=0.005). Compared to the new technique, the control group had a higher rate of retropulsion (33.3% vs. 14.7%; p=0.01) and required flexible URS more often to exclude or remove residual fragments (24.1% vs. 59.1%; p=0.001). Using the new technique, stone-free rates were higher (79.1% vs. 69.4%; p=n/s) and there was a lower likelihood of leaving residual fragments both <3 mm and ≥3 mm (p=0.001).

CONCLUSIONS

Our novel technique results in shorter operative times, lower retropulsion rates, and decreases postoperative residual stone fragments.

Preclinical Testing of a Combination Stone Basket and Ureteral Balloon to Extract Ureteral Stones

We have developed the Peralta Stone Extraction System to increase the safety of ureteral stone extraction. The device combines a nitinol stone basket and low-pressure balloon into a single device. After visualization, the stone is captured in the tipless nitinol basket and enveloped by a low-pressure balloon. We tested the performance of device prototypes in a porcine model using stone mimics with diameters ranging from 4.2 to 6.2 mm. Stones extracted with the device required less force when compared with stones in a standard ureteral stone basket. The force reduction was most pronounced for stones greater than 4.2 mm in diameter, and when traversing a ureteral stenosis model. In conclusion, a combination stone basket and balloon device may provide a new and safer way to extract ureteral stones.

Devices to help combat stone retropulsion during ureteroscopic lithotripsy in 2016

Proximal migration of stones during ureteroscopic lithotripsy is a common problem that faces many urologists and reduces stone-free rates, which translates into higher costs and longer operative times. In a bid to increase stone-free rates, there are several anti-retropulsion devices on the market, to help urologists during ureteroscopic lithotripsy. We previously reviewed these anti-retropulsion devices and wish to update what is currently available on the market.

Impact of using thiocolchicoside during endoscopic ureteral calculi removal: A preliminary study

OBJECTIVE

To evaluate the effects of thiocolchicoside during endoscopic treatment of ureteral calculus.

MATERIAL AND METHODS

Between May 2014 and December 2014, 498 consecutive patients were enrolled. Exclusion criteria were operations under general anaesthesia, chancing laser lithotripter settings, and urinary tract infection. All patients were divided into three groups: Group 1 consisted of patients who were not administered thiocolchicoside, group 2 consisted of patients who were administered 5 mg thiocolchicoside, and group 3 consisted of patients who were administered 10 mg thiocolchicoside. Demographic, perioperative, and postoperative data were recorded. Complications were noted according to Clavien-Dindo classifications. A p value of p ≤ 0.05 was considered statistically significant.

RESULTS

A total of 427 patients (319 male and 108 female) with full data were investigated. Mean age was 43.3 ± 13.3 years. There were 157 patients in group 1, 141 patients in group 2, and 129 patients in group 3. Stone migration and operation time were significantly lower in groups 2 and 3 than in group 1 (respectively; p < 0.001, p = 0.03). However, usage of jj stents was significantly lower in group 3 than in the other groups (p < 0.001).

CONCLUSION

Stone migration can be decreased by using locally administered thiocolchicoside in irrigation solution during endoscopic treatment of ureteral calculus. Additional doses may decrease usage of jj stents and operation time.

Antiretropulsion devices

PURPOSE OF REVIEW

Stone migration during the treatment of ureteral stones can prove frustrating and increases both healthcare cost and patient morbidity. Antiretropulsion devices have been engineered to prevent stone migration.

RECENT FINDINGS

Improvements in antiretropulsion devices allow for efficient prevention of stone migration during ureteroscopic lithotripsy with minimal adverse effects or complications. Multiple devices are now available each with advantages and disadvantages. New devices are currently engineered to prevent stone migration and maintain ureteral access. Antiretropulsion devices appear to be cost-effective to prevent stone migration during intracorporeal lithotripsy.

SUMMARY

Antiretropulsion devices have been safely and effectively used during ureteroscopic procedures. These tools increase stone-free rates, decrease morbidity and new studies have demonstrated their cost-effectiveness.

Pushing the boundaries of ureteroscopy: current status and future perspectives

Substantial advances in ureteroscopy have resulted in the incorporation of this procedure into routine urological practice in many centres worldwide. Subsequently, an abundance of clinical data and technological progression have enabled the development of novel solutions that have increased the efficacy of ureteroscopy, and reduced associated morbidity and costs. In addition the indications for this retrograde approach have been expanded, and pyelocalyceal diverticulum, infundibular stenosis, urolithiasis in pregnant women or in patients with urinary diversions, as well as upper urinary tract tumours can now be managed using this methodology. New endoscopes are continuously developed, with different manufacturers choosing various technical solutions to further increase the efficacy and safety-and sometimes decrease costs-of ureteroscopy, including miniaturization, inclusion of digital optical systems and dual working channels, and the introduction of disposable apparatus. The holmium laser, currently the most-versatile energy source available, enables tissue incision, tumour ablation, and intracorporeal lithotripsy. Modern ancillary instruments are diverse, flexible, and durable, and novel devices used in daily clinical practice can minimize ascendant migration of stone fragments and, therefore, decrease the failure rate of the retrograde ureteroscopic approach. However, the peak of ureteroscopy evolution seems to remain distant, with further improvement of endoscopes and ancillary instruments, and robot-assisted ureteroscopy representing only some of the areas in which future developments are possible.

The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients

PURPOSE

To assess the current indications for ureteroscopy (URS) treatment, outcome in terms of stone-free rate, and intra- and postoperative complications using the modified Clavien grading system.

PATIENTS AND METHODS

The Clinical Research Office of the Endourological Society collected prospective data as part of the URS Global Study for consecutive patients treated with URS at centers around the world for 1 year. URS was performed according to study protocol and local clinical practice guidelines. The stone size and location were recorded and postoperative outcome and complications, graded according to the modified Clavien grading system, reported.

RESULTS

Between January 2010 and October 2012, 11,885 patients received URS at 114 centers in 32 countries; 1852 had only renal stones, 8676 had only ureteral stones, and 1145 patients had both types of stone. Fragmentation was performed principally using a laser device (49.0%) or a pneumatic device (30.3%); no device was used in 17.9% of the patients. A high stone-free rate (85.6%) was achieved. The large majority of patients did not receive any further treatment for renal or ureter stones (89.4%). The postoperative complication rate was low (3.5%). The most frequent complication was fever (1.8%); a blood transfusion was required in 0.2% of patients. The majority of complications were Clavien grade I or II (2.8% of patients).

CONCLUSION

URS is an established minimal invasive treatment for urinary stones with a high success rate and low morbidity. Recent advances have expanded the indication for urinary stones, which now ranges from treatment of smaller sized distal ureter stones by semirigid URS to larger sized renal pelvis stones treated by flexible URS.