Failures and complications of transurethral ureteroscopy in 297 cases: conventional rigid instruments vs. small caliber semirigid ureteroscopes

Peri-Ureteral Abscess Formation Following Ureteroscopic Laser Lithotripsy: A Case Report

We report the case of a patient with a previous history of obstructive renal calculus disease who initially presented with a symptomatic calculus in her right mid-ureter, requiring ureteroscopy with laser lithotripsy and ureteral stent placement. Shortly after the removal of the stent, the patient was found to have a peri-ureteral abscess, necessitating percutaneous drainage by interventional radiology, and placement of an additional ureteral stent. Adverse reactions to these procedures are rare and, to our knowledge, this is the only documented case of peri-ureteral abscess as a complication of ureteroscopic laser lithotripsy or of ureteral stenting. In addition to developing a peri-ureteral abscess, this patient also experienced deep vein thrombosis (DVT) and subsegmental pulmonary embolism (PE), which also have not been found to be a common complication of laser lithotripsy or ureteral stent placement in any of the studies that we reviewed for this article. The complications that were previously rare are unfortunately on the rise, possibly in the setting of both increased access to invasive therapies as well as the increased rates of diabetes and obesity. Survivability hinges on prompt recognition and treatment of these complications. In the event that a peri-ureteral abscess is discovered, prompt treatment with broad-spectrum antibiotics is recommended in addition to interventional radiology and urology consultation. Antibiotics should cover conventional intra-abdominal and urologic abscess regimens.

Predicting ureteral status below the ureteral calculi in patients undergoing ureteroscopic lithotomy

BACKGROUND

During ureteroscopy, severe ureter straightness or contortion may occur before the stone is passed.

PURPOSE

To identify clinical factors associated with distal ureteral status below the ureteral calculi in patients before surgery.

MATERIAL AND METHODS

From October 2016 to March 2017, 101 patients with ureteral calculi who underwent ureteroscopic lithotripsy were reviewed. Patients who lacked clinical data and underwent preoperative indwelling ureteral stent placement were excluded. Univariate and multivariate analyses were performed to determine the clinical factors associated with intraoperative findings.

RESULTS

A total of 101 patients were enrolled in the study (mean age  =  54 years; mean stone size  =  7.9 ± 4.5 mm). Overall, 25 of the 101 patients (24.7%) were diagnosed with poor distal ureteral status defined as intraoperative ureterostenosis or contortion resulting in a ureteroscope being unable to pass during the initial attempt. Univariate analysis showed significant differences in renal parenchyma thickness, ureteral wall thickening on imaging, and stone location (all, P < 0.05) with and without poor distal ureteral status. On multivariable analysis, renal parenchyma thickness (adjusted odds ratio [aOR] 0.288; 95% confidence interval [CI] 0.099-0.838; P = 0.022) and ureteral wall thickening on imaging (aOR 6.114; 95% CI 2.015-18.548; P = 0.001) independently predicted poor distal ureteral status. However, only renal parenchyma thickness was associated with severe ureter straightness or tortuosity that resulted in conversion.

CONCLUSION

In conclusion, renal parenchyma thickness and ureteral wall thickening on imaging were associated with poor distal ureteral status. Therefore, patients with these predictive factors should undergo more intensive preparation before surgery.

Should ureteroscopy be performed for patients after ureteral reconstruction with autologous onlay flap/graft?

Background

To analyze the safety and clinical significance of performing ureteroscopy after ureteral reconstruction with autologous onlay/graft. To describe the ureteroscopic appearances of the appendiceal onlay flap and lingual mucosa graft.

Methods

Beginning in August 2018, we conducted a prospective cohort study of autologous onlay/graft techniques to repair ureteral strictures. The perioperative data of 42 patients who had undergone surgery more than 6 months prior were collected prospectively. During the postoperative follow-up, ureteroscopy was performed in 27 patients (64.3%) after surgery (group A), and ureteroscopy was not performed in the other 15 patients (35.7%) (group B). We carried out a comparative study of these two groups of patients. Analyses were conducted mainly on complications related to ureteroscopy and the success rate of ureteral reconstruction surgery.

Results

There were no significant differences in patient demographic data or the length of ureteral reconstruction between the two groups (P>0.05). For the ureteroscopy group, the median time from repair surgery to ureteroscopy was 3 (range, 2-7) months, there was no poor healing of the anastomosis, and the ureteral lumen of all patients was unobstructed. Some expected observations can be found in the ureteral lumen, such as mucosa edema, stones, follicles and granulation tissue. Among the 27 patients, one patient (3.7%) developed bleeding intraoperatively and 7 patients (25.9%) were found to have low-grade (Clavien-Dindo I and II) postoperative complications, including 5 cases of fever and 2 cases of bleeding. The mean follow-up times of patients in group A and group B were 16.7±6.4 and 19.0±10.1 months, respectively. The objective success (imaging showed hydronephrosis ease) rate of the two groups was 100%. The subjective success (symptom relief) rates of group A and group B were 96.3% and 100%, respectively.

Conclusions

Patients after autologous onlay flap/graft ureteroplasty do not need to undergo routine ureteroscopy unless there is aggravation of hydronephrosis or other indications for ureteroscopy, such as 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.

Ureteric stenting vs not stenting following uncomplicated ureteroscopic lithotripsy: A prospective randomised trial

Objective

To compare three groups of patients who underwent uncomplicated ureteroscopic lithotripsy (URSL) and to evaluate whether stenting could be eliminated after the procedure, as there is no consensus about whether a ureteric stent should be placed after uncomplicated ureteroscopy for stone retrieval.

Patients and methods

In this randomised clinical trial (NCT04145063) 105 patients underwent uncomplicated URSL for ureteric stones. They were prospectively randomised into three groups: Group 1 (34 patients) with a double pigtail ureteric stent, Group 2 (35 patients) with a double pigtail ureteric stent with extraction string, and Group 3 (36 patients) with no ureteric stent placed after the procedure. The outcomes measured were: postoperative visual analogue scale (VAS) score for flank pain and dysuria score, urgency, frequency, suprapubic pain, haematuria, analgesia requirement, operative time, re-hospitalisation, and return to normal physical activity.

Results

The mean (SD) operative time was significantly longer in groups 1 and 2 compared to Group 3, at 22.2 (9.1), 20.2 (6) and 15.1 (7.1) min, respectively (P < 0.001). The results of the VAS for flank pain and dysuria scores, urgency, frequency, haematuria, and suprapubic pain showed a significant difference at all time-points of follow-up, being significantly higher in groups 1 and 2 compared to Group 3 (all P < 0.001). Further analysis showed that measured outcomes, and analgesia need for groups 1 and 2 were similar, at all time-points except at week 1 and 1 month where Group 2 patients’ had less symptoms (P < 0.001).

Conclusion

Double pigtail ureteric stent placement appears to be unnecessary in procedures considered ‘uncomplicated’ by operating urologists during surgery. The advantages of the double pigtail ureteric stent with extraction string over the double pigtail ureteric stent only include earlier and easier removal with earlier relief of symptoms, and less analgesia requirements.

Abbreviations

KUB: plain abdominal radiograph of the kidneys, ureters and bladder; URSL: ureteroscopic lithotripsy; VAS: visual analogue scale

Prevention strategies for ureteral stricture following ureteroscopic lithotripsy

Ureteral stricture formation after ureteroscopic lithotripsy is a late complication that can lead to hydronephrosis and a subsequent risk of renal deterioration. The specific incidence is unknown, and the mechanism of stricture formation has not been completely explained. In this review, we summarize the current evidence regarding the incidence of this condition and discuss its pathogenesis. We then list preventive strategies to reduce the morbidity of ureteral strictures.

Benefits and risks of ureteral access sheaths for retrograde renal access

PURPOSE OF REVIEW

Ureteral access sheath (UAS) became increasingly popular worldwide. However, the safety of its routine use remains controversial. The aim of the current revision is to provide a systematic review on the benefits and disadvantages of the UAS.

RECENT FINDINGS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Two reviewers independently searched the literature, finally identifying 20 articles valuable for this review. The use of UAS demonstrated several advantages to facilitate retrograde intrarenal access, lower intrarenal pressure, protect the ureter, protect the scope, and expedite stone extraction. Despite this, there is also some evidence that UAS use may be associated with acute ureteral injury and long-term complications, apparently related to maneuvers for UAS insertion and mucosal or deeper layers of injury and ischemia. Furthermore, there are still pending questions on the possible increase in stone-free rates, and decrease in operative time and costs.

SUMMARY

Although the use of UAS is associated with some risk and limiting factors, it appears from this systematic review that its use is common and safe for the retrograde intrarenal access. Therefore, UAS is highly recommended for the treatment of upper tract disease by means of retrograde intrarenal surgery.

The effect of ureteroscope size in the treatment of ureteral stone: 15-year experience of an endoscopist

OBJECTIVE

We aimed to investigate the ureter stone treatment results performed by using different- caliber semirigid ureteroscopes (URS).

MATERIAL AND METHODS

Adult patients who were treated for ureteral stones by a single endoscopist between January 2000 and March 2015 were analyzed. The patients were divided into 3 groups in accordance with the caliber of the ureteroscope used: 10/10.5 F Storz (Karl Storz, Tuttlingen, Germany) (January 2002-January 2005) URS was used in group 1, 8.9/9.8 F Storz (February 2005-December 2011) URS was used in group 2, and 6/7.5 FWolf (Richard Wolf, Knittlingen, Germany) (January 2012-March 2015) URS was used in group 3. Patients' age and gender, size and site of stones, stone-free rates (SFR), intra- and perioperative complication rates, and durations of surgery were compared among the groups. Intraoperative complications were classified according to modified Satava, and perioperative complications were classified according to modified Clavien classification systems.

RESULTS

A total of 2461 patients treated for ureteral stones were analyzed. There were 583 patients in group 1 (10/10.5 F Storz), 1302 patients in group 2 (8.9/9.8 F Storz), and 576 patients in group 3 (6/7.5 F Wolf). SFR were 83.7%, 87.4%, and 92.2% in groups 1, 2, and 3, respectively (p=0.01). Duration of surgery was 30.34±10.36 min in group 1, 31.61±10.10 min in group 2, and 42.40±7.35 min in group 3 (p=0.01). The overall complication rates classified according to modified Satava classification were 10.8%, 7.6%, and 6.9% (p=0.01) while grade 3 modified Satava complication rates were 1.9%, 1.5%and 0.5% in groups 1, 2, and 3, respectively (p=0.01).

CONCLUSION

In this study, we found that more frequent use of a small- caliber URS resulted in a longer duration of surgery and an increased rate for JJ stent insertion, however it facilitated a safer and more successful ureteroscopy procedure.

Prospective randomized comparison between fluoroscopy-guided ureteroscopy versus ureteroscopy with real-time ultrasonography for the management of ureteral stones

CONTEXT AND AIMS

Ureteroscopy is the definitive management for ureteric stone. Conventional ureteroscopy uses fluoroscopy guidance which has radiation exposure to patients as well as hospital staff. Ultrasound is a good radiation-free alternative for using in the urological procedure. With this background, we executed a prospective randomized trial comparing fluoroscopy-guided ureteroscopy versus ultrasound-guided ureteroscopy.

SUBJECTS AND METHODS

Patients were randomized into two groups (41 into fluoroscopy and 41 into ultrasound group after exclusion) in a single center from July 2014 to March 2015. Semi-rigid ureteroscopy was used in all cases. Ultrasound was used to place guide wire and postprocedure stents placement in ultrasound group. Patient's characteristics; intra- and post-operative parameters were compared between the two groups.

STATISTICAL ANALYSIS USED

SPSS version 16.0 (Chicago, IL, USA) was used for statistical analysis. The results were presented as percentages and means (± standard deviation). The categorical/dichotomous variables were analyzed using Chi-squared test. Continuous variables were analyzed using unpaired t-test.

RESULTS

A total of 102 adult patients were randomized in this trial and eighty patients undergo the final analysis. Mean stone burden was 41.75 ± 13.44 (17.94-79.20 mm²). Mean operative time was 43.90 ± 12.99 (25-82 min) in fluoroscopy group versus 45.61 ± 11.62 (28-78 min) in ultrasound group. The initial success rate was 93.75% (92.30% in fluoroscopy vs. 95.12% in ultrasound group). Overall complications noted in 8.75% and most of the complications were minor in nature.

CONCLUSIONS

Ultrasound-guided ureteroscopy is safe and effectively for ureteric stone. Fluoroscopy can be avoided during ureteroscopy for uncomplicated stone. No radiation ureteroscopy is feasible with good success and minimal complication. Larger sample size with multicentric trial needed for its greater applicability.

Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

INTRODUCTION

Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes.

METHODS

A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used.

RESULTS

During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients.

CONCLUSION

Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.

Reporting ureteroscopy complications using the modified clavien classification system

Objective:

Perioperative complications are one of the surrogate indicators of surgical outcomes. However, reporting these complications need a precise grading system. Our aim is to report and grade the complications of semirigid ureteroscopy in ureteral stone management according to the modified Clavien classification system.

Materials and Methods:

This is a prospective study conducted From January 2012 to June 2013. All patients with ureteral stones who were indicated for semirigid URS were evaluated. All procedures were performed by the same surgeon. The data recorded including patient demographics, clinical indication, stone size and location, operative time and complications were classified according to the modified Clavien classification system. The patients were followed for 8 weeks postoperatively.

Results:

148 patients included, Stone distribution was: 89 (60.1%) lower ureteral, 26 (17.6%) mid ureteral, and 33 (22.3%) upper ureteral. the mean stone size was 8.6 mm. Urgent URS done in 23% of patient. The overall stone free rate was 88.5%, the individual stone free rate for the upper, middle and lower ureter were 87.9%, 84.6%, and 89.9%, respectively. The mean operative time was 31.9 min (20-50 min.). Complications occurred in 26.35% of patients. Grade I complications occurred in 32 patients (26.1%), grade II in 9 (6.1%), grade IIIa in 7 (4.7%), grade IIIb in 8 (5.4%), grade IVa in two patient (1.35%), and grade IVb in one patient (0.7%). No grade V complication was encountered.

Conclusion:

Ureteroscopy becomes the vanguard interventional therapy for ureteral stones with well-established efficacy and safety. It is of paramount importance to adopt a precise structured classification system for reporting surgical complications, that should be flexible and comprehensive in order to accommodate the various and rapidly expanding surgical fields.

Determinants of holmium:yttrium-aluminum-garnet laser time and energy during ureteroscopic laser lithotripsy

OBJECTIVE

To evaluate the association of preoperative noncontrast computed tomography stone characteristics, laser settings, and stone composition with cumulative holmium:yttrium-aluminum-garnet (Ho:YAG) laser time/energy.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent semirigid/flexible ureteroscopy and Ho:YAG laser lithotripsy (200 or 365 μm laser fiber; 0.8-1.0 J energy; and 8-10 Hz rate) at 2 tertiary care centers (April 2010-May 2012). Studied parameters were as follows: patient's characteristics; stone characteristics (location, burden, hardness, and composition); total laser time and energy; and surgical outcomes.

RESULTS

One hundred patients met our inclusion criteria. Mean stone size was 1.01 ± 0.42 cm and volume 0.33 ± 0.04 cm(3). Mean stone radiodensity was 990 ± 296 HU, and Hounsfield units density 13.8 ± 6.0 HU/mm. All patients were considered stone free. Stone size and volume had a significant positive correlation with laser energy (R = 0.516, P <.001; R = 0.621, P <.001) and laser time (R = 0.477, P <.001; R = 0.567, P <.001). When controlling for stone size, only the correlation between HU and laser time was significant (R = 0.262, P = .011). In the multivariate analysis, with exception of stone composition (P = .103), all parameters significantly increased laser energy (R(2) = 0.524). Multivariate analysis revealed a positive significant association of laser time with stone volume (P <.001) and Hounsfield units density (P <.001; R(2) = 0.512). In multivariate analysis for laser energy, only calcium phosphate stones required less energy to fragment compared with uric acid stones. No significant differences were found in the multivariate laser time model.

CONCLUSION

Ho:YAG laser cumulative energy and total time are significantly affected by stone dimensions, hardness location, fiber size, and power. Kidney location, laser fiber size, and laser power have more influence on the final laser energy than on the total laser time. Calcium phosphate stones require less laser energy to fragment.

Differences in ureteroscopic stone treatment and outcomes for distal, mid-, proximal, or multiple ureteral locations: the Clinical Research Office of the Endourological Society ureteroscopy global study

BACKGROUND

Ureteroscopy has traditionally been the preferred approach for treatment of distal and midureteral stones, with shock wave lithotripsy used for proximal ureteral stones.

OBJECTIVE

To describe the differences in the treatment and outcomes of ureteroscopic stones in different locations.

DESIGN, SETTING, AND PARTICIPANTS

Prospective data were collected by the Clinical Research Office of the Endourological Society on consecutive patients treated with ureteroscopy at centres around the world over a 1-yr period.

INTERVENTION

Ureteroscopy was performed according to study protocol and local clinical practice guidelines.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Stone location, treatment details, postoperative outcomes, and complications were recorded. Pearson's chi-square analysis and analysis of variance were used to compare outcomes among the different stone locations.

RESULTS AND LIMITATIONS

Between January 2010 and October 2012, 9681 patients received ureteroscopy treatment for stones located in the proximal ureter (n=2656), midureter (n=1980), distal ureter (n=4479), or multiple locations (n=440); location in 126 patients was not specified. Semirigid ureteroscopy was predominantly used for all stone locations. Laser and pneumatic lithotripsy were used in the majority of cases. Stone-free rates were 94.2% for distal ureter locations, 89.4% for midureter locations, 84.5% for proximal ureter locations, and 76.6% for multiple locations. For the proximal ureter, failure and retreatment rates were significantly higher for semirigid ureteroscopy than for flexible ureteroscopy. A low incidence of intraoperative complications was reported (3.8-7.7%). Postoperative complications occurred in 2.5-4.6% of patients and varied according to location, with the highest incidence reported for multiple stone locations. Limitations include short-term follow-up and a nonuniform treatment approach.

CONCLUSIONS

Ureteroscopy for ureteral stones resulted in good stone-free rates with low morbidity.

PATIENT SUMMARY

This study shows that patients who have ureteral stones can be treated successfully with ureteroscopy with a low rate of complications for the patient.

Controversies in ureteroscopy: Wire, basket, and sheath

In the last one to two decades, flexible ureteroscopy has rapidly expanded its role in the treatment of urologic stone disease. With the frequent and expanded use of flexible ureteroscopy, other ancillary instruments were developed in order to ease and facilitate this technique, such as ureteral access sheaths (UAS) and a variety of wires and baskets. These developments, along with improved surgeon ureteroscopic competence, have often brought into question the need to implement the “traditional technique” of flexible ureteroscopy. In this review, we discuss a brief history of flexible ureteroscopy, its expanded indications, and the controversy surrounding the use of UAS, wires, and baskets.

Does stone entrapment with ″Uro-Net″ improve Ho:YAG laser lithotripsy efficiency in percutaneous nephrolithotomy and cystolithopaxy?: an in vitro study

PURPOSE

to test the effect of stone entrapment on laser lithotripsy efficiency.

MATERIALS AND METHODS

Spherical stone phantoms were created using the BegoStone® plaster. Lithotripsy of one stone (1.0 g) per test jar was performed with Ho:YAG laser (365 µm fiber; 1 minute/trial). Four laser settings were tested: I-0.8 J,8 Hz; II-0.2J,50 Hz; III-0.5 J,50 Hz; IV-1.5 J,40 Hz. Uro-Net (US Endoscopy) deployment was used in 3/9 trials. Post-treatment, stone fragments were strained though a 1mm sieve; after a 7-day drying period fragments and unfragmented stone were weighed. Uro-Net nylon mesh and wire frame resistance were tested (laser fired for 30s). All nets used were evaluated for functionality and strength (compared to 10 new nets). Student's T test was used to compare the studied parameters; significance was set at p < 0.05.

RESULTS

Laser settings I and II caused less damage to the net overall; the mesh and wire frame had worst injuries with setting IV; setting III had an intermediate outcome; 42% of nets were rendered unusable and excluded from strength analysis. There was no difference in mean strength between used functional nets and non-used devices (8.05 vs. 7.45 lbs, respectively; p = 0.14). Setting IV was the most efficient for lithotripsy (1.9 ± 0.6 mg/s; p < 0.001) with or without net stabilization; setting III was superior to I and II only if a net was not used.

CONCLUSIONS

Laser lithotripsy is not optimized by stone entrapment with a net retrieval device which may be damaged by high energy laser settings.

Comparison of a 4.5 F semi-rigid ureteroscope with a 7.5 F rigid ureteroscope in the treatment of ureteral stones in preschool-age children

The aim of this study was to compare the success and complication rates of a 4.5 F ureteroscope with a 7.5 F ureteroscope in the treatment of urolithiasis in preschool-age children. We retrospectively reviewed 69 ureteroscopy (URS) procedures in a pediatric population (40 boys, 29 girls). We divided the patients into two groups according to the type of ureteroscope used: group 1 (n = 42, Storz 7.5 F) and group 2 (n = 27, Wolf 4.5 F). We statistically compared all the procedures performed in both groups regarding patient age, complication rates, whether the procedure was therapeutic, and whether we used a guidewire. Additionally, in cases with ureteral stones, we also compared the stone clearance rate and the necessity of X-ray imaging between the two groups. The mean patient age was 56.04 months in group 1 and 47.48 months in group 2 (p = 0.057). The stone-free rate was 78.6 % in group 1 and 92.6 % in group 2 (p > 0.05). However, when we compared the stone-free rates for patients younger than 3 years, the rate was 66.7 % in group 1 and 93.8 % in group 2 (p < 0.05). The difference was not statistically significant for patients between the ages of 4 and 7 years. The success and failure rates revealed better outcomes for treatment of ureteral stones with a 4.5 F ureteroscope. We recommend the use of the mini-ureteroscope, especially in infants and preschool-age children.

Ureterorenoscopy: avoiding and managing the complications

Retrograde exploration of the ureter and kidneys is currently a widely used and well-established procedure to deal with problems of a diagnostic and therapeutic nature with reduced invasiveness. The process of miniaturizing the instruments combined with the steady improvement in video quality has continuously amplified its potential applications, maintaining the procedure safe and rapid. During an operation, however, unexpected events may condition a change to the programme or determine the onset of even more serious complications. Our aim is to analyze such events and complications and recommend potential solutions to prevent and/or deal with such happenings.

Is a safety wire necessary during routine flexible ureteroscopy?

BACKGROUND AND PURPOSE

The use of flexible ureteroscopy (URS) for nephrolithiasis has been rapidly expanding. Initially, safety guidewires were maintained alongside the ureteroscope during stone manipulation to prevent loss of access and allow stent insertion in the event of perforation. We intend to determine the safety of flexible URS without a separate safety guidewire in a large series of patients.

METHODS

A retrospective chart review was performed on all cases of flexible URS with laser lithotripsy performed by a single surgeon from August 2003 to May 2008. Preoperative patient characteristics, radiographic stone sizes, operative findings, and postoperative outcomes were recorded. Patients with renal or ureteropelvic junction (UPJ) stones were isolated for a qualitative data analysis.

RESULTS

Flexible URS was performed on 305 kidneys in 246 consecutive patients, of which 59 cases were bilateral. Cases were subdivided into complicated and uncomplicated. Two hundred seventy cases were uncomplicated and performed without a safety guidewire. No intraoperative complications resulted from the lack of a safety guidewire, including no cases of lost access, ureteral perforation/avulsion, or need for percutaneous nephrostomy tube. Thirty-five cases were complicated, necessitating a safety guidewire. Of these, 16 had concomitant obstructing ureteral stones, 5 had encrusted ureteral stents, and 14 had difficult access because of large stone burden or aberrant anatomy.

CONCLUSIONS

This study demonstrates that, in a large series of patients, a safety guidewire was not necessary for routine cases of flexible URS with laser lithotripsy on renal or UPJ stones. Particular cases with complicated anatomy, difficult access, concomitant ureteral stones, simultaneous stone basketing, or bulky stone burden still necessitate use of a safety guidewire because of increased risk of adverse outcomes.

Comparison of ureteroscopic procedures with rigid and semirigid ureteroscopes in pediatric population: does the caliber of instrument matter?

OBJECTIVES

To compare the results of two different ureteroscopes in pediatric ureteroscopy (URS) procedures.

PATIENTS AND METHODS

Sixty-five consecutive URS procedures in pediatric population (39 males, 26 females) were retrospectively evaluated. The subjects were divided in two groups according to the type of ureteroscope used: Group 1 (n = 32, Wolf 8F) and group 2 (n = 33, ACMI 6.9F). All the procedures performed in both groups were statistically compared regarding patient age, gender, lateralization, complication rates, whether the procedure was diagnostic or therapeutic, and whether a guide-wire was used. Additionally, in cases with ureteral stones, stone clearance rate and the necessity of a stone extractor were also compared between the groups. All data were statistically analyzed using chi-square and t tests, where appropriate. A p value less than 0.05 was considered as significant.

RESULTS

Mean age of the groups were comparable (9.44 +/- 4.3 and 8.67 +/- 3.9, p = 0.456). There was no statistically meaningful difference between the groups regarding patients' gender, lateralization rates, whether the procedure was diagnostic or therapeutic, the need for a guide-wire use, and complication rates (p > 0.05). In cases with ureteral stones, both groups exhibited statistically comparable results in stone clearance rates and the use of a stone extractor (p > 0.05).

CONCLUSIONS

Data on this comparison demonstrated that both ureteroscopy devices in pediatric population can be used safely in URS procedures. Neither the diameter nor the rigidity is significantly affecting the outcomes and success rates <or=8F caliber.

Experience with impacted upper ureteral stones; should we abandon using semirigid ureteroscopes and pneumatic lithoclast?

Introduction

The AUA/EAU Ureteral Stones Guideline Panel reported that the stone free rate for the proximal ureteral stones is around 81% when treated by either SWL or ureteroscopy (URS).

Complication rates, most notably ureteral perforation and long-term complications of URS such as stricture formation rates, have been reduced to < 5%. Moreover, impacted ureteral calculi are more difficult to fragment with SWL because of the lack of natural expansion space for stones, this result in a situation that is better managed by ureteroscopy. The aim of this study is to assess the efficacy, safety, and complications of impacted upper ureteral stone disintegration using semirigid ureteroscopes and pneumatic lithotripsy.

Methods

We retrospectively analyzed the records of 267 consecutive patients with impacted upper ureteral stones (9–20 mm) who were treated by semirigid ureteroscopes and pneumatic disintegration. The efficacy of treatment was estimated using the stone-free rate and all treatment related complications were analyzed.

Results

Except for 24 cases where the stone migrated to the kidney, the stone was successfully treated ureteroscopically, with a low rate of minimal complications such as mild hematuria (18.4%), short term low grade fever (13.5%). Only 3 patients (1.1%) had high grade fever and none had post operative stricture.

Conclusion

The use of semirigid URS and pneumatic lithotripsy in impacted upper ureteral stones in experienced hands has very satisfactory results with minimal complications. When Holmium laser and flexible URS are not available, semirigid URS and pneumatic lithotripsy is a good alternative that shouldn't, yet, be abandoned.

Semirigid ureteroscopy for ureteral stones: a multivariate analysis of unfavorable results

PURPOSE

We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi.

MATERIALS AND METHODS

We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results.

RESULTS

The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively).

CONCLUSIONS

Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

Ureteral Catheterization in Uncomplicated Ureterolithotripsy: A Randomized, Controlled Trial

OBJECTIVE

To evaluate short-term ureteral catheterization in patients undergoing ureteroscopic lithotripsy for ureteral calculi.

METHODS

Patients (n = 140) with ureteral calculi who were candidates for ureterolithotripsy were enrolled. Stone size was 5-10mm. The operation was performed with an 8-9.8F semirigid ureteroscope without active dilatation and stones were fragmented with a 1F pneumatic lithotrite. Uncomplicated cases (109 patients) were randomized to catheterized (C) and noncatheterized (NC) groups. In the 54 C group patients, a polyurethane catheter (5F) was passed through the ureter after lithotripsy with the end attached to a Foley placed in urethra, which was removed after 24h. Postoperatively, all patients were evaluated for flank and suprapubic pain, renal colic, irritative urinary symptoms, peritonism, frequency of analgesic usage, urinary tract infection, duration of hospitalization, postdischarge visits (due to renal colic/pain), readmission, and residual stone rates.

RESULTS

On the first postoperative day, the percentage of patients experiencing flank pain and renal colic was significantly higher in the NC group (76% and 45%) compared with the C group (20% and 2%); 67% of NC patients required analgesic administration during hospital stay versus 20% of C patients (p<0.001). Suprapubic pain and urethral irritation were reported by 13% and 37% of C patients, respectively, and 5% and 4% of NC patients. However, peritonism was developed more often in NC patients (27% vs. 13%). Hospital stay was 1 d for all patients. Three days postoperatively, 40% of NC patients complained of at least one episode of flank pain compared with 7% of C patients (p<0.001). Incidence of urinary tract infections was 4% in NC and 7% in C group patients. Postdischarge visits were necessary in 20% of NC patients and 5% of C patients. No patient in either group required readmission. No complaints were reported nor residual stones discovered on 2-wk follow-up radiographs in either group.

CONCLUSIONS

Short-term ureteral catheterization in uncomplicated ureteroscopy and lithotripsy has a role in reducing early postoperative morbidities. It may also decrease pain and colic after discharge.

Complications of 2735 retrograde semirigid ureteroscopy procedures: a single-center experience

BACKGROUND AND PURPOSE

Ureteroscopy is nowadays one of the techniques most widely used for upper urinary- tract pathology. Our goal is to describe its complications in a large series of patients.

PATIENTS AND METHODS

Between June 1994 and February 2005, 2436 patients aged 5 to 87 years underwent retrograde ureteroscopy (2735 procedures) under video and fluoroscopic assistance. We used semirigid ureteroscopes (8/9.8F Wolf, 6.5F Olympus, 8F and 10F Storz) for 384 diagnostic and 2351 therapeutic procedures. Upper urinary-tract lithiasis (2041 cases), ureteropelvic junction stenosis (95 cases), benign ureteral stenosis (29 cases), tumoral extrinsic ureteral stenosis (84 cases), iatrogenic trauma (35 cases), superficial ureteral tumors (16 cases), superficial pelvic tumors (7 cases), and ascending displaced stents (44 cases) were the indications. The mean follow-up period was 56 months (range 4-112 months).

RESULTS

The rate of intraoperative incidents was 5.9% (162 cases). Intraoperative incidents consisted of the impossibility of accessing calculi (3.7%), trapped stone extractors (0.7%), equipment damage (0.7%), and double- J stent malpositioning (0.76%). In addition, migration of calculi or stone fragments during lithotripsy was apparent in 116 cases (4.24%). The general rate of intraoperative complications was 3.6% (98 cases). We also saw mucosal injury (abrasion [1.5%] or false passage [1%]), ureteral perforation (0.65%), extraureteral stone migration (0.18%), bleeding (0.1%), and ureteral avulsions (0.11%). Early complications were described in 10.64%: fever or sepsis (1.13%), persistent hematuria (2.04%), renal colic (2.23%), migrated double-J stent (0.66%), and transitory vesicoureteral reflux (4.58%, especially in cases with indwelling double-J stents). We also found late complications such as ureteral stenosis (3 cases) and persistent vesicoureteral reflux (2 cases). Most (87%) of the complications followed ureteroscopic therapy for stones. Three fourths (76%) of the complications occurred in the first 5 years of the series.

CONCLUSIONS

According to our experience, mastery of ureteroscopic technique allows the urologist to proceed endourologically with minimum morbidity. Despite the new smaller semirigid instruments, this minimally invasive maneuver may sometimes be aggressive, and adequate training is imperative.

Results with 7.5F versus 10F rigid ureteroscopes in treatment of ureteral calculi

OBJECTIVES

To compare the success and complication rates in the treatment of ureteral stones with a 7.5F versus a 10F ureteroscope.

METHODS

A total of 100 patients who were scheduled for ureteroscopy to treat ureteral calculi between December 2000 and December 2002 were randomly assigned to procedures with a 7.5F (group 1; n = 50) or 10F (group 2; n = 50) ureteroscope. The group results were compared.

RESULTS

Group 1 had 36 distal, 9 middle, and 5 proximal ureteral stones. Group 2 had 37 distal, 6 middle, and 7 proximal ureteral stones. No statistically significant differences were noted between the two groups with respect to the mean stone size or operation time (P = 0.175 and P = 0.636, respectively). Pneumatic lithotripsy was used in 62% and 50% of the procedures in group 1 and 2, respectively, and stones or fragments were retrieved with basket catheters in 92% and 76% of the group procedures, respectively. The difference between the group rates for successful basket catheter extraction was statistically significant (P = 0.029). Of the patients in group 1 and 2, 84% and 80%, respectively, were stone free after a single procedure (P = 0.603). The corresponding failure rates in the two groups were 6% and 12% (P = 0.295), and the corresponding early and late complication rates in the two groups were 6% and 4% (P = 0.646). None of the patients in group 1 developed late complications. One individual (2%) in group 2 developed ureteral stenosis during long-term follow-up (P = 0.315).

CONCLUSIONS

The success and failure rates revealed better outcomes for treatment of ureteral calculi with a 7.5F ureteroscope, but the differences were not statistically significant. The complication rates were similar between the two groups. Basket catheters were used more frequently with the 7.5F scope, and the rates of in situ lithotripsy and postoperative ureteral stent placement were also greater in patients treated with this instrument.

Complications of ureteroscopy

Ureteroscopy has undergone a dramatic evolution over the last two decades. Although ureteroscopic injury is the most common cause of ureteral trauma because of the large number of ureteroscopic procedures performed, improvements in instrumentation and technique have resulted in a reduced incidence of serious complications. Despite significant technologic advances, however, surgical misadventures still occur, some of which have lasting consequences. Careful attention to instrument selection and surgical technique are critical to reduce untoward events related to ureteroscopy. As such, adverse sequelae associated with ureteroscopy should be related to the underlying pathology itself rather than to the treatment.

Ureteral Ultrasonic Lithotripsy Revisited: A Neglected Tool?

BACKGROUND AND PURPOSE

Ultrasonic lithotripsy was one of the first modalities used for treating renal and ureteral stones. However, in recent years, it has been largely replaced by newer techniques such as laser lithotripsy with rigid as well as flexible ureteroscopes. The aim of this study was to review the results and our current indications for ureteroscopic ultrasonic lithotripsy (UUL).

PATIENTS AND METHODS

Between October 2000 and May 2002, 340 ureteroscopies were performed for the treatment of ureteral stones in the Rabin Medical Center. Of this series, 9 patients (2.6%) underwent UUL using a semirigid 8F ureteroscope (Wolf) and an Olympus ultrasonic lithotripter (LUS-1) with a 4.5F hollow probe. Four patients had Steinstrasse following shockwave lithotripsy, four had large (1-2-mm) ureteral stones, and one had an impacted calcified ureteral double-J stent. Stones >5 mm were initially fragmented by the holmium laser (550-microm fiber). A double-J stent was placed in all patients. The mean follow-up time was 20 months.

RESULTS

The mean operative time was 84 minutes. No intraoperative complications occurred. The mean hospital stay was 3.9 days. Eight patients became stone free after the first procedure, and the other underwent secondary ureteroscopy, which rendered him stone free.

CONCLUSIONS

Patients in whom UUL is performed are relatively complex stone patients. The use of ultrasonic lithotripsy following, or in combination with, laser or ballistic devices utilizes the unique properties of UUL, which combines stone fragmentation and efficient removal of small fragments. The technique was particularly useful in patients with Steinstrasse or a large stone burden. Thus, UUL has a limited but significant role in the treatment of ureteral stones.

Transurethral ureterorenolithotripsy using new automated irrigation/suction system controlling pressure and flow compared with standard irrigation: a randomized pilot study

PURPOSE

To compare in a random fashion an automated irrigation/suction pump system with the standard pressurized technique during transurethral ureterorenolithotripsy.

PATIENTS AND METHODS

Between July 2001 and December 2001, 47 patients were prospectively included. Prior to randomization, rigid instruments were allocated to 25 patients (group R) and flexible instruments to 22 patients (group F) according to stone location. The groups R and F were then randomized separately, and the pressurized technique was employed in groups R1 and F1, while the automated system was employed in groups R2 and F2. Operative time, amount of liquid consumed, and stone-free rate at the end of the procedure were analyzed.

RESULTS

For the entire series, ureteroscopy time using the automated system (mean 42 +/- 17[SD] minutes; range 15-90 minutes) was 35% less than with the pressurized technique (mean 65 +/- 25 minutes; range 20-135 minutes) (P = 0.04 Wilcoxon score). The stone-free rate was significantly higher in groups R2 + F2 (92%) than in groups R1 + F1 (69%) (P = 0.048).

CONCLUSION

With the ENDO FMS UROLOGY system, there was a significant reduction in the mean ureteroscopy time: 32% less with the rigid instrument and 53% less with the flexible instrument. This seems to be attributable to a wider working space and highly improved visibility. The integrated suction at constant flow allows efficient evacuation of stone fragments while limiting cavity pressure. These results, obtained on 47 patients, should be confirmed by larger randomized studies.

Assessment of stricture formation with the ureteral access sheath

OBJECTIVES

To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether the device might cause significant ureteral trauma.

METHODS

Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureterotomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and 70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days (range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients.

RESULTS

The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The access sheath did not appear to be a contributing factor.

CONCLUSIONS

The results of our series indicate that the ureteral access sheath is safe and beneficial for routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered. We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac vessels.

Routine radiologic surveillance for obstruction is not required in asymptomatic patients after ureteroscopy

OBJECTIVE

A retrospective medical record review was performed with the goal of determining the need for radiologic evaluation after ureteroscopy.

PATIENTS AND METHODS

Of 183 patients undergoing ureteroscopic procedures at our institution between 1989 and 1993, 131 underwent postoperative radiologic studies capable of diagnosing ureteral obstruction. Of these patients, 110 (84%) were asymptomatic after the procedure, and radiologic procedures capable of displaying obstruction were performed at a median of 60 days (mean 73 days; standard deviation 189 days) after ureteroscopy.

RESULTS

None of these asymptomatic patients displayed obstruction at the time of the routine follow-up radiologic procedure. Of those 21 patients (16%) who experienced flank pain subsequent to ureteroscopy, 13 were found to have ureteral obstruction secondary to ureteral calculus. One patient (1/131 or 0.8%) was found to have a ureteral stricture, which occurred after a full-thickness ureteral injury. All cases of postoperative obstruction were heralded by a concomitant display of flank pain.

CONCLUSION

Routine postoperative radiologic studies are not necessary in surveillance for obstruction in the asymptomatic postureteroscopy patient, as obstruction should become evident by virtue of flank pain. The exception to this practice may be in patients experiencing a ureteral perforation intraoperatively, who may be at greater risk of stricture.

A new generation of semirigid fiberoptic ureteroscopes

BACKGROUND

Further advances in endoscope technology have allowed the development of a new generation of tightly packed fiberoptics encased within a rigid ureteroscope. The tips of these semirigid ureteroscopes measure between 5.0F and 11.9F, and their working channels measure between 1.8F and 5.5F, which allows passage of routine endoscopc instruments. Additionally, several manufacturers have recently produced straight-channel fiberoptic semirigid endoscopes with an offset lens which allow usage of rigid lithotripsy devices. New fiber-packing techniques provide numerous pixels within the image bundle. These ureteroscopes have varied distal lens systems, but all have excellent vision in the field of view.

METHODS

Over the past 28 months, we have performed transurethral ureteroscopy in 187 patients, having utilized semirigid ureteroscopes in 158 patients for diagnostic procedures (8.7 %), stone manipulation (78.7 %), removal of migrated stents (4.4%), and surgery of stricture, tumor, or foreign bodies (8.2%). In more than 50% of our cases, ureteral dilation was not necessary, and the semirigid ureteroscope was passed to the area of interest without difficulty.

RESULTS

We accessed the site of pathology in 96.2% of patients. Overall, complications occurred in 6.9% of patients. However, of these problems, 93.6% were small ureteral perforations (only three of which were caused by the semirigid ureteroscope itself), and all cases but one were managed successfully by a ureteral stent. No postoperative strictures were noted.

CONCLUSION

This new generation of semirigid fiberoptic ureteroscopes represents another significant advance in the endourologic management of ureteral disease.

Pneumatic lithotripsy applied through deflected working channel of miniureteroscope: results in 143 patients

Although extracorporeal shockwave lithotripsy (SWL) is a successful treatment for ureteral calculi, introduction of miniureteroscopes has advanced endoscopic management. We combined the use of a semirigid ureteroscope with a pneumatic lithotripter (Swiss Lithoclast) for the treatment of ureteral calculi. From January 1992 to August 1994, 143 patients (87 male, 56 female; mean age 48.7 years; age range 22-74 years) with urolithiasis underwent endoscopic lithotripsy with the Swiss Lithoclast under general anesthesia. The 0.8 = mm probe was inserted through the deflected working channel (3.4F) of the Micro-6L ureteroscope (tip diameter 6.9F). The calculi were in the distal (N = 96; 67.1%), mid (N = 34; 23.8%), and proximal part (N = 13; 9.1%) of the ureter. The mean stone size was 6.8 mm (range 5-26 mm). Of the 137 patients whose stones we could access adequately, 70 (51.1%) were stone free immediately after the procedure, and another 31 (22.6%) had residual fragments <3 mm that passed spontaneously. The remaining 36 patients underwent another 50 procedures; 30 SWL sessions in 26 patients (19%), 17 further endoscopic lithotripsies in 14 (10.2%), and open surgery in 3. Application of the Swiss Lithoclast through semirigid miniureteroscopes is highly effective for endoscopic lithotripsy, regardless of stone composition. Deflection of the probe up to 30 degrees did not impair the disintegration rate. Because of the high migration rate of mid and proximal ureteral stones, the Swiss Lithoclast is not recommended in these cases as a primary procedure. Low capital cost and simple and safe handling are the device's major advantages over laser lithotripsy.

Ureteroscopic lithotripsy using mini-endoscope and Swiss lithoclast: experience in 147 cases

To evaluate the efficacy of a semirigid mini-endoscope and the Swiss Lithoclast compared with a conventional rigid endoscope and ultrasound, the results of transurethral ureteroscopic lithotripsy in 147 patients over a period of 30 months were analyzed according to the type of ureteroscope (rigid v semirigid) and energy (ultrasound v Lithoclast) used. In the initial 25 cases (Group I), a conventional rigid ureteroscope and ultrasound were used. The latter 122 patients (Group II) were subjected to ureteroscopic lithotripsy using a miniscope and the Lithoclast. The results were superior in Group II with respect to the overall success rate (p = 1.6 x 10[-2]), first-attempt success rate (p = 2.9 x 10[-4]), and the need for ureteral dilation (P = 1.0 x 10[-6]) compared with Group I. There were no major complications. Overall, minor complications (hematuria and urinary tract infection) were observed in 25% of the cases. Further, the results of ureteroscopic lithotripsy in Group II were comparable to those of SWL in situ for upper ureteral calculi and better than for those located in the iliac and lower ureter as reported previously. Our results demonstrate that the Swiss Lithoclast provides effective fragmentation of even hard and smooth stones without increasing the complication rate. This lithotripter is reliable, safe, and simple to operate. In addition, the cost of maintenance is almost nil.