Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p = 0.984) and basketing time (12 vs 19 minutes; p = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm3/min, p = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p = 0.375) and postoperative complications (single: 7% vs dual: 11%, p = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.

Multidisciplinary Approach and Outcomes of Pretreatment Small (cT1a) Renal Mass Biopsy: Single-Center Experience.

Purpose: We evaluated our experience of a multidisciplinary approach to renal mass biopsy (RMB) for small renal masses (SRMs) employing in-office ultrasound (US)-guided biopsy by urology (24%), CT, or US biopsy by interventional radiology (IR) (79%), and endoscopic ultrasound (EUS)-guided biopsy by gastroenterology (GI) (4%). Materials and Methods: A single-institution retrospective review of patients who underwent RMB for SRM from May 2013 to August 2019 was conducted. Data regarding patient demographics, tumor characteristics, biopsy technique, histopathology, and management were collected. Diagnostic rates, concordance with final pathology, complications, and outcomes were analyzed. Results: Of the 192 biopsies reviewed, 63% biopsies were malignant, 20% were benign, and 17% were nondiagnostic. Based on biopsy results, 71 patients (37%) elected active surveillance. Thirty-eight (20%) patients underwent cryoablation, 56 (29%) underwent partial nephrectomy, 14 (7%) underwent radical nephrectomy, and the remaining patients were treated elsewhere. The rate of surgery for benign pathology after pretreatment RMB was 3%. The concordance rate between biopsy and final pathology was 99% for malignancy, 96% for specific pathology subtype, and 85% for renal cell carcinoma grade. Median time from diagnosis to definitive treatment was 97 days (urology: 76, IR: 110 and GI: 54, p = 0.002). Three (1.6%) Clavien I complications were reported. Conclusion: Our multidisciplinary approach to RMB for clinical stage T1a demonstrated favorable safety and diagnostic rates, which effectively directed management strategies and minimized surgery for benign disease. Urologist-performed office biopsies significantly shortened the time from diagnosis to definitive treatment. Our experience with GI EUS biopsy has demonstrated feasibility and safety for tumors that were otherwise not accessible percutaneously.

Emergency versus elective ureteroscopy for the management of ureteral stones.

OBJECTIVE: To assess the safety and efficacy of emergency ureteroscopy (URS) compared with elective URS. METHODS: We conducted a retrospective analysis of patients who underwent URS for isolated ureteral stones in a single center from October 2001 to February 2014. Our patient cohort was divided into two groups: an emergency URS group (Group A), which consisted of patients who underwent URS within the first 24 h of admission, and an elective or planned URS group (Group B). The URS success rate was defined as being the incidence of successful stone fragmentation and whether there was resolution of renal obstruction. RESULTS: A total of 2957 patients' medical records were available for analysis. Of these, 704 (21%) comprised of emergency cases and the remaining 2253 (79%) were elective cases. Patients in Group A were younger, had a smaller BMIs, and had smaller stone sizes (p < 0.001). The URS success rate was found to be 97% in Group A and 96% in Group B (p = 0.35). Intraoperative or postoperative complication rates were not found to vary significantly between the groups (8% vs 7%, respectively, p = 0.50). The incidence of ureteral stenting was nearly twice as high if URS was performed during night hours (85% vs 45%, p < 0.001). However, ureteral stenting was more prevalent in Group B compared to Group A patients (57% vs 25%, p < 0.001), possibly as a result of the number of pre-stented patients (73%). CONCLUSIONS: Emergency URS is an effective and safe option for patients with renal colic. Younger patients without pre-existing obesity and with stone sizes up to 8 mm located in the distal ureter might be a better match for emergency URS.

Caveat Emptor: The Heat Is "ON"-An In Vivo Evaluation of the Thulium Fiber Laser and Temperature Changes in the Porcine Kidney During Dusting and Fragmentation Modes.

Introduction: We sought to examine the intrarenal fluid and tissue temperature alterations during dusting and fragmentation with the thulium fiber laser (TFL) in an in vivo porcine kidney. Materials and Methods: In two female Yorkshire pigs, temperature was continuously measured within the upper, interpolar, and lower calices along with the renal pelvis using multipoint thermal sensor probes; another temperature probe was situated at the tip of the ureteroscope. Four experimental protocols were performed for each animal: dual lumen ureteroscope with both warmed (37°C) irrigation and room temperature (20°C-22°C) irrigation and single lumen ureteroscope with warmed and room temperature irrigation. Of note, in each pig, one kidney underwent ureteroscopy (URS) with a 14F ureteral access sheath (UAS) in place, whereas the other kidney had no UAS placed. A 200-µm TFL fiber was fired at three laser settings: (1) dusting at 0.5 J, 80 Hz (40 W) with continuous activation until 5 minutes expired or a temperature of 44°C was reached, (2) low-power fragmentation 1 J, 10 Hz, (10 W), and (3) high-power fragmentation at 1.5 J, 20 Hz (30 W). In all cases, the pulse width was 1 ms. For fragmentation, the laser was activated for 10 seconds with a 2-second intermission for a 1-minute period (five cycles). Results: In the absence of a UAS, in all but one circumstance, temperatures reached or exceeded 44°C at all laser settings with the use of either warm or room temperature irrigation fluid, regardless of the type of ureteroscope used. Of concern, temperatures recorded at the tip of the URS were 4°C to 22°C less than the temperatures recorded in the renal calices. In contrast, with a 14F UAS in place, six distinct groups had temperatures that did not exceed 44°C, specifically at low- and high-power fragmentation settings with room temperature irrigation for both sets of ureteroscopes and at dusting and low-power fragmentation settings with warm temperature irrigation solely for the single lumen ureteroscope. Temperatures recorded at the tip of the ureteroscope with the deployment of a UAS yielded temperature differences ranging from 17°C less to 19°C more than the renal calices. Conclusions: TFL is a novel laser technology for lithotripsy. In the absence of a UAS, high-power TFL fragmentation settings in particular may create temperatures within the collecting system that could result in urothelial tissue injury. Of note, peak temperatures recorded at the tip of the ureteroscope may misrepresent the actual intrarenal temperature during TFL laser lithotripsy.

Nontransecting Anastomotic Urethroplasty Via Ventral Approach Without Full Mobilization of the Corpus Spongiosum Dorsal Semicircumference.

OBJECTIVE: To present a novel surgical approach to performing bulbar urethroplasty and to assess its initial outcomes and safety. MATERIALS AND METHODS: From January 2016 to March 2019, anastomotic urethroplasty without full mobilization and dissection of corpus spongiosum dorsal semicircumference was performed in 8 males with bulbar strictures by a single surgeon. Patients were given uroflowmetry, urethrography, and International Index of Erectile Function (IIEF) questionnaires at their 3- and 12- month follow-up visits postoperatively. RESULTS: Mean stricture length was 2.3 cm (±0.59 cm) and mean surgery time was 131 minutes. No early or late postoperative complications were observed. Median maximum flow rate (Qmax) assessed 3 months after surgery was 22.35 mL/sec (±6.4 mL/sec). There were no significant changes in median IIEF score postoperatively (preoperative IIEF = 18.4 vs postoperative IIEF = 19.6; P >.05). During patients' 1-year observation period, no signs of constriction in the anastomosis were revealed with urethrography. One of the limitations of this technique is a necessity of more precise corpus spongiosum preparation to ensure perioperative hemostasis and good visualization. This outcome may, however, require additional time and increased blood loss during a surgeon's learning curve of the procedure. CONCLUSION: The initial experience of this minimally invasive urethroplasty technique showed high efficiency and no early stricture recurrences. However, the clinical significance of additional preservation of innervation and blood supply, the potential to further optimize this technique's functional outcomes, and applicability of this technique in patients with spongiofibrosis requires further investigation. Our results make it possible to consider this technique as a possible alternative to classic anastomotic urethroplasty.