First prospective clinical assessment of the ILY® robotic flexible ureteroscopy platform.

PURPOSE: To present the initial prospective clinical assessment of the ILY® robotic ureteroscopy manipulator platform, focusing on its safety and effectiveness. METHODS AND MATERIALS: Data gathered from 31 kidney units which underwent elective robotic flexible ureteroscopy (FURS) for renal stone management utilizing the ILY® robotic system. Patient demographics, stone characteristics, surgical durations, perioperative and post-operative complications, and follow-up parameters were collected. Our primary outcome was evaluating the efficacy and safety of the ILY® robotic ureteroscopy for treating kidney stones. Therefore, we analyzed complication rates, surgical durations, and the stone-free rate during follow-up. RESULTS: Our cohort consisted of 29 patients, presenting with 45 stones with a median volume of 736.22 mm3. The median operation time was 85 min, accompanied by 3 min for robot draping, 3.5 min for robot docking, 48 min of console operation, and lasing time of 36.75 min. Post operative stay for all patients was 1 day, while complications were observed in 9.68% of cases. Notably, all complications were classified as CVD (Clavien-Dindo) class 1 due to pain requiring emergency department visit. The stone-free rate achieved was 93.55%, and none of the patient required reoperation for the treated stone. CONCLUSION: In the first prospective clinical experience of the ILY® robotic FURS, we demonstrated its efficacy and safety. To further investigate its clinical practical value, additional investigations are warranted, including direct comparative analyses with manual flexible ureteroscopy techniques.

In Pursuit of the Optimal Dusting Settings with the Thulium Fiber Laser: An In Vitro Assessment.

Objective: Low energy and high frequency settings are used in stone dusting for holmium lasers. Such settings may not be optimal for thulium fiber laser (TFL). With the seemingly endless combination of settings, we aim to provide guidance to the practicing urologists and assess the efficiency of the TFL platform in an automated in vitro "dusting model." Materials/Methods: Three experimental setups were designed to investigate stone dusting produced by an IPG Photonics TLR-50 W TFL system using 200 µm fiber and soft BegoStone phantoms. The most popular 10 and 20 W dusting settings among endourologist familiar with TFL were evaluated. We directly compared short pulse (SP) vs long pulse (LP) mode using various combinations of pulse energy (Ep) and pulse frequency (F). Thereafter, we tested the 10 and 20 W settings and compared them among each other to elucidate the most efficient settings at each power. Treatments were performed under the same total laser energy delivered to the stone at four different standoff distances (SDs) with a clinically relevant scanning speed of either 1 or 2 mm/sec. Ablation volumes were quantified by optical coherence tomography to assess stone dusting efficiency. Fragment size after ablation at different pulse energies was evaluated by sieving and evaluating under a microscope after treatment. Results: Overall, SP provided greater ablation volume when compared with LP. Our dusting efficiency model demonstrated that the maximum stone ablation was achieved at the combination of high energy/low frequency settings (p < 0.005) and at a SD of 0.2 mm. At all tested pulse energies, no stone phantoms were broken into fragments >1 mm. Conclusions: During stone dusting with TFL, SP offers superior ablation to LP settings. Optimal dusting at clinically relevant scanning speeds of 1 and 2 mm/sec occurs at high energy/low frequency settings. Thulium lithotripsy with high Ep does not result in increased fragment size.

Ureteroscopy with thulium fiber laser lithotripsy results in shorter operating times and large cost savings.

PURPOSE: Prolonged ureteroscopy (URS) is associated with complications including ureteral perforation, stricture, and urosepsis. As laser lithotripsy is one of the most common urologic procedures, small cost savings per case can have a large financial impact. This retrospective study was designed to determine if Thulium fiber laser (TFL) lithotripsy decreases operative time and costs compared to standard Holmium:YAG (Ho:YAG) lithotripsy without pulse modulation. METHODS: A retrospective review of URS with laser lithotripsy was conducted for 152 cases performed from August 2020 to January 2021. Variables including cumulative stone size, location, chemical composition, prior ureteral stenting, and ureteral access sheath use were recorded for each case. A cost benefit analysis was performed to show projected cost savings due to potentially decreased operative times. RESULTS: Compared to Ho:YAG, use of TFL resulted in an average decrease of 12.9 min per case (p = .021, 95% CI [2.03-23.85]). In subgroup analysis of cases with cumulative stone diameter less than 15 mm, the difference was 14.0 min (p = .007, CI [3.95-23.95]). For cases less than 10 mm, the mean difference was 17.3 min in favor of TFL (p = .002, 95% CI [6.89-27.62]). This ~ 13 min reduction in operative time resulted in saving $440/case in direct operating room costs giving our institution a range of $294,000 to $381,900 savings per year. CONCLUSIONS: TFL has a significantly shorter operative time and decreased cost when compared to the standard Ho:YAG for equivalent kidney stone and patient characteristics. Longer term follow up is needed to see if recurrence rates are affected.

Socioeconomic Disparities in the Acute Management of Stone Disease in the United States.

INTRODUCTION: Patients admitted to the hospital with an acute, noninfected episode of urolithiasis are candidates for medical expulsive therapy, ureteral stent placement, or upfront ureteroscopy (URS). We sought to assess socioeconomic factors influencing treatment decisions in managing urolithiasis and to determine differences in outcomes based on treatment modality. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database, and State Emergency Department Database for California from 2007 to 2011 and for Florida from 2009 to 2014 were utilized. Patients who were admitted to the hospital with a primary diagnosis of kidney or ureteral stone were identified. The initial treatment modality utilized was assessed and factors that influenced that decision were analyzed. Multivariate logistic regression model was fit to determine factors independently associated with upfront URS. Lastly, outcomes of noninfected patients who underwent stent alone vs URS were compared. RESULTS: We identified 146,199 patients who had an inpatient admission with urolithiasis. Overall, 45% of patients had no intervention at the time of their evaluation. Of the 55% of patients who underwent surgical intervention, 42% underwent stent alone, 44% underwent upfront URS, 1% had a PCN tube placement, 8% underwent extracorporeal shockwave lithotripsy, while 5% underwent PCNL. On multivariate logistic regression model, minorities, younger patients, publicly uninsured patients, more comorbid patients, those admitted on the weekends, and those admitted to an academic institution had significantly lower odds of undergoing upfront URS. Secondary analysis demonstrated clinical and economic advantages of upfront URS vs stent alone in eligible patients. CONCLUSION: Upfront URS is an overlooked procedure that has clinical and cost-saving implications. Unfortunately, minorities, publicly insured patients, and those admitted on the weekend are less likely to undergo upfront URS, a disparity that should be addressed by urologist.

The Moses holmium system - time is money.

INTRODUCTION: The Moses technology of the holmium laser has been shown to decrease retropulsion in the ureter and procedural time in kidney stones during laser lithotripsy. Theoretically, these improvements could lead to cost savings for the patient. MATERIALS AND METHODS: All patients with total laser energy data recorded who underwent ureteroscopy with laser lithotripsy by a single surgeon at a tertiary care center were included. Total lasing time was calculated from the total laser energy. Sub-analyses were done on stone size and stone composition. The procedure time using Moses technology was projected to be approximately 35% less than procedure time without the Moses technology based on prior in vitro studies. The projected cost savings was then utilized to predict cost-effectiveness of the Moses technology. RESULTS: Forty patients underwent ureteroscopy with laser lithotripsy. Mean stones size was 10.2 mm and mean lasing time was 3.02 minutes. Linear regression showed a positive association between stone size and laser time, p = 0.01. There was no significant correlation between stone composition or stone Hounsfield units and lasing time. On cost analyses, for stones of all sizes the Moses system has a price differential of an increase in $292.36 when compared to the standard Holmium TracTip system. Specifically for stones larger than 10 mm, the price differential is an increase in $253.16 for the Moses technology. CONCLUSION: The decrease in lasing time achieved by the Moses system does not translate into sufficient cost savings to off-set the higher cost of the laser fiber and software.

Retrospective Cost Analysis of a Single-Center Reusable Flexible Ureterorenoscopy Program: A Comparative Cost Simulation of Disposable fURS as an Alternative.

OBJECTIVE: The increasing number of flexible ureterorenoscopy (fURS) procedures, the fragility of devices, and their growing maintenance and repair costs represent a substantial burden for urologic departments. Disposable single-use fURS devices offer many advantages over reusable fURS. Among them, the LithoVue™ model shows the best clinical utility. In our study, we assessed the economic aspects of reusable fURS application compared with the potential costs and benefits of single-use fURS (LithoVue™). Indications for single-use fURS were proposed based on potential risk factors of reusable fURS damage. MATERIALS AND METHODS: This single-center retrospective analysis compared the actual cost of reusable fURS procedures with the potential costs of LithoVue™ based on the price offered by the manufacturer. Consecutive case analysis of damaged fURS was performed to determine potential risk factors associated with fURS damage. RESULTS: The study group consisted of 423 reusable fURS procedures conducted between January 2013 and December 2016. During this period, 102 (24.11%) diagnostic fURS and 321 (75.89%) fURS for kidney stone therapy were performed. In 32 of 423 (7.57%) fURS cases, devices were postoperatively deemed defective, 9 of which were used for diagnostic procedures (9/102; 8.82%), 7 for stone removal (7/148; 4.73%), and 16 for stone removal and laser (Ho:YAG) application (16/173; 9.25%). The average cost per reusable fURS procedure was found to be €503.26. CONCLUSIONS: Disposable fURS is a more expensive option for high-volume centers. Based on our case analysis, laser disintegration treatment of multiple, large stones in the lower kidney pole of recurrent stone formers, as well as a steep infundibulopelvic angle (IPA ≤50°), seems to be the main risk factor for fURS damage. For these cases, disposable fURS may be a cost-effective alternative; however, a prospective comparison of economic outcomes between disposable and reusable fURS, together with confirmation of the proposed damage risk factors, is needed.

Cost-Free Laser Caging in the Operating Room.

We have assembled a three-step process for securing and presetting the functional length of the laser fiber to be used for ureteroscopic lithotripsy. For this process, three components are required: a sterile piece of adhesive, an empty guidewire casing with a pre-attached Luer-Lok™ fitting, and a SureSeal® adapter. The only additional piece of equipment for this arrangement not routinely used during ureteroscopy is the sterile adhesive strip.

Update on lasers in urology 2014: current assessment on holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripter settings and laser fibers.

PURPOSE: The purpose of the study was to review the existing literature on holmium:yttrium-aluminum-garnet laser lithotripsy regarding lithotripter settings and laser fibers. METHODS: An online search of current and past peer-reviewed literature on holmium laser lithotripsy was performed on several databases, including PubMed, SciElo, and Google Scholar. Relevant studies and original articles about lithotripter settings and laser fibers were examined, and the most important information is summarized and presented here. RESULTS: We examine how the choice of lithotripter settings and laser fibers influences the performance of holmium laser lithotripsy. Traditional laser lithotripter settings are analyzed, including pulse energy, pulse frequency, and power levels, as well as newly developed long-pulse modes. The impact of these settings on ablation volume, fragment size, and retropulsion is also examined. Advantages of small- and large-diameter laser fibers are discussed, and controversies are highlighted. Additionally, the influence of the laser fiber is examined, specifically the fiber tip preparation and the lithotripter settings' influence on tip degradation. CONCLUSIONS: Many technical factors influence the performance of holmium laser lithotripsy. Knowing and understanding these controllable parameters allows the urologist to perform a laser lithotripsy procedure safely, efficiently, and with few complications.

Pneumatic versus laser ureteroscopic lithotripsy: a comparison of initial outcomes and cost.

PURPOSE: To audit the cost of laser versus pneumatic semirigid ureteroscopic lithotripsy and to analyze their relative initial outcomes and cost. METHODS: Hundred and eighty-seven patients who underwent semirigid ureteroscopic lithotripsy were analyzed retrospectively in terms of age and sex of the patients; location and size of the stones; the type of probe and ancillary equipment such as guide wire, basket catheter, JJ stent requirements; irrigation amount; operation time; the cost of the anesthesia and further treatments such as a JJ stent removal operation and shock wave lithotripsy requirements and their costs. Two groups were formed based on this type of lithotripters, pneumatic and laser lithotripsy. RESULTS: Operation times (min.) in terms of the stone size, for stones <100 and >100 mm(2) were 20.75 ± 10.78 and 25.82 ± 14.23, respectively (p = 0.007). Operation times for the pneumatic and laser groups were 33.05 ± 11.36 and 15.25 ± 6.14, respectively (p < 0.05).The stone-free rates for pneumatic and laser groups were 89.6 % (n = 69) and 98.2 % (n = 108), respectively (p = 0.01). The mean cost of the operations for each of the study groups was 261.5 ± 66.13 and 311.7 ± 51.97 US$, respectively (p = 0.001). The mean cost in terms of the stone size, for stones <100 and >100 mm(2), was 272.86 ± 53.05 and 323.71 ± 66.88 US$, respectively (p = 0.01). CONCLUSIONS: It seems that usage of laser lithotripsy (LL) in patients with ureteral stones is more effective than pneumatic lithotripsy (PL) in terms of operation time and SF rate. On the other hand, the mean cost of LL seems to be more expensive than PL. Urologists should think these parameters before the choice of these two treatment modalities. The higher the effectiveness, the greater the cost.

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

INTRODUCTION: It was the aim of this study to compare the efficiency and safety between shock wave lithotripsy (SWL) and ureteroscopic holmium laser lithotripsy (URL) methods for ureteral calculi while also determining which option is more cost-effective. PATIENTS AND METHODS: During January 2008 to September 2009, a prospective randomized study was conducted to compare both modalities for the management of solitary radiopaque ureteral stones. Patient and stone characteristics, treatment outcome and charges were documented. Both options were compared using univariate statistical tests to identify the efficiency quotient and cost-effectiveness for ureteral calculi according to the stone location. RESULTS: A total of 257 patients were in the SWL group, while 269 were in the URL group. The efficiency quotients for SWL and URL were 0.81 and 0.88, respectively. The initial stone-free rate of URL for lower ureteral calculi was higher (p = 0.002), while the complication rate of SWL for upper ureteral calculi was lower (p = 0.027). The SWL group required lower hospitalization charges (USD 440 vs. 1,221; p < 0.001), lower total charges (USD 454 vs. 1,284; p < 0.001) and a shorter period of hospitalization (5.4 vs. 6.6 days; p < 0.001) compared with the URL group for all ureteral locations. For mid and lower ureteral calculi, the postoperative office visits of the URL group were fewer (1.03 vs. 1.1 times; p = 0.001). CONCLUSIONS: Primary in situ SWL for upper and middle ureteral calculi showed lower complication rates compared to URL and was more cost-effective in Eastern China. However, primary URL was a better option for treating lower ureteral stones with a higher stone-free rate but was more expensive.

Outcomes of flexible ureteroscopic lithotripsy with holmium laser for upper urinary tract calculi.

OBJECTIVE: To assess the perioperative and financial outcomes of flexible ureteroscopic lithotripsy with holmium laser for upper tract calculi in 44 patients. MATERIALS AND METHODS: Between February 2004 and September 2006, 44 patients treated for upper tract stone with flexible ureteroscopic lithotripsy were evaluated. Renal stones were associated with collecting system obstruction in 15 (34%) patients, failed extracorporeal shock-wave lithotripsy (SWL) occurred in 14 (32%) patients, unilateral multiple stones in 18 (41%) patients, and multiple bilateral stones in 3 (7%). In 29 (66%) patients, the stone was located in the inferior calyx. Perioperative and financial outcomes were also evaluated. RESULTS: 50 procedures were performed in 44 patients. The mean stone burden on preoperative CT scan was 11.5 +/- 5.8 mm. The mean operative time was 61.3 +/- 29.4 min. The stone free rate was 93.1% after one procedure and 97.7% after a second procedure, with overall complication rate of 8%. Therapeutic success occurred in 92% and 93% of patients with lower pole stones and SWL failure, respectively. Treatment failure of a single session was associated with presence of a stone size larger than 15 mm (p = 0.007), but not associated with inferior calyx location (p = 0.09). Surgical disposables were responsible for 78% of overall costs. CONCLUSION: Flexible ureteroscopy using holmium laser is a safe and effective option for the treatment of upper urinary tract calculi. In addition, it can be considered an attractive option as salvage therapy after SWL failure or kidney calculi associated with ureteral stones. Stone size larger than 15 mm is associated with single session treatment failure.

Outcomes of flexible ureteroscopic lithotripsy with holmium laser for upper urinary tract calculi

OBJECTIVE: To assess the perioperative and financial outcomes of flexible ureteroscopic lithotripsy with holmium laser for upper tract calculi in 44 patients. MATERIALS AND METHODS: Between February 2004 and September 2006, 44 patients treated for upper tract stone with flexible ureteroscopic lithotripsy were evaluated. Renal stones were associated with collecting system obstruction in 15 (34 percent) patients, failed extracorporeal shock-wave lithotripsy (SWL) occurred in 14 (32 percent) patients, unilateral multiple stones in 18 (41 percent) patients, and multiple bilateral stones in 3 (7 percent). In 29 (66 percent) patients, the stone was located in the inferior calyx. Perioperative and financial outcomes were also evaluated. RESULTS: 50 procedures were performed in 44 patients. The mean stone burden on preoperative CT scan was 11.5 ± 5.8 mm. The mean operative time was 61.3 ± 29.4 min. The stone free rate was 93.1 percent after one procedure and 97.7 percent after a second procedure, with overall complication rate of 8 percent. Therapeutic success occurred in 92 percent and 93 percent of patients with lower pole stones and SWL failure, respectively. Treatment failure of a single session was associated with presence of a stone size larger than 15 mm (p = 0.007), but not associated with inferior calyx location (p = 0.09). Surgical disposables were responsible for 78 percent of overall costs. CONCLUSION: Flexible ureteroscopy using holmium laser is a safe and effective option for the treatment of upper urinary tract calculi. In addition, it can be considered an attractive option as salvage therapy after SWL failure or kidney calculi associated with ureteral stones. Stone size larger than 15 mm is associated with single session treatment failure.

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.

Assessment of basic endoscopic performance using a virtual reality simulator.

BACKGROUND: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. STUDY DESIGN: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). RESULTS: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p < 0.001), and evaluator assessment (p < 0.001). Comparing the posttest results of the control and trained arms, we found significantly better posttest scores in the trained group for the following parameters: ability to perform the task (p = 0.035), overall performance (p = 0.004), and total evaluator score (p < or = 0.001). CONCLUSIONS: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.

Fluoroscopically guided laser lithotripsy versus extracorporeal shock wave lithotripsy for retained bile duct stones: a prospective randomised study.

BACKGROUND AND AIMS: To compare extracorporeal shock wave lithotripsy (ESWL) and laser induced shock wave lithotripsy (LISL) of retained bile duct stones to stone free rate, number of therapeutic sessions, and costs. PATIENTS: Thirty four patients were randomly assigned to either ESWL or LISL therapy. The main reasons for failure of standard endoscopy were due to stone impaction (n = 12), biliary stricture (n = 8), or large stone diameter (n = 14). METHODS: An extracorporeal piezoelectic lithotripter with ultrasonic guidance and a rhodamine 6G laser with an integrated stone tissue detection system were used. LISL was performed exclusively under radiological control. RESULTS: Using the initial methods complete stone fragmentation was achieved in nine of 17 patients (52.4%) of the ESWL group and in 14 of 17 patients (82.4%) in the LISL group, or combined with additional fragmentation techniques 31 of the 34 patients (91.2%) were stone free at the end of treatment. In comparison LISL tended to be more efficient in clearing the bile ducts (p = 0.07, NS). Significantly less fragmentation sessions (1.29 v 2.82; p = 0.0001) and less additional endoscopic sessions (0.65 v 1.6; p = 0.002) were necessary in the LISL group. There were no major complications in either procedure. CONCLUSIONS: Compared with ESWL, fluoroscopically guided LISL achieves stone disintegration more rapidly and with significantly less treatment sessions, which leads to a significant reduction in cost.