Preoperative α1-Blockers Impact on Outcomes of Patients Undergoing Ureteroscopy with Ureteral Access Sheaths: A Systematic Review and Meta-Analysis.

Introduction: The use of a ureteral access sheath (UAS) during ureteroscopy (URS) has been associated with the risk for ureteral injuries. Preoperative administration of α1-blockers presents a potential mitigator of such lesions by inducing ureteral relaxation, which may also contribute to improving other surgical outcomes. Methods: A comprehensive literature search was conducted across MEDLINE, Embase, and Cochrane databases for studies comparing preoperative α1-blockers administration vs its non-use in adult patients without pre-stenting undergoing URS. Binary outcomes were evaluated using risk ratios (RRs) and odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was measured with the Cochran's Q test, I2 statistics, and prediction intervals (PIs). A DerSimonian and Laird random-effects model was utilized for all outcomes. Results: Eleven studies encompassing 1074 patients undergoing URS were included, of whom 522 (48.60%) received α1-blockers before the procedure. Preoperative α1-blockers were associated with a reduction in significant ureteral injuries (RR 0.30; 95% CI 0.17-0.53; I2 = 6%; PI 0.10-0.88) and an increase in mean successful UAS insertion (OR 2.14; 95% CI 1.08-4.23; I2 = 23%; PI 0.51-8.93). In patients undergoing exclusively ureteroscopy lithotripsy (URSL), the medications also reduced total complications (RR 0.62; 95% CI 0.46-0.84; I2 = 0%) and complications graded Clavien-Dindo III or higher (RR 0.16; 95% CI 0.04-0.69; I2 = 0%), but no significant difference between groups was found in the stone-free rate (RR 1.10; 95% CI 0.86-1.40; I2 = 91%; PI 0.47-2.59). Conclusion: Preoperative α1-blockers were linked to a decrease in significant ureteral injuries with UAS use and fewer complications during URSL procedures. However, their impact on the successful insertion of a UAS remains uncertain. Consideration of administering preoperative α1-blockers in non-stented adult patients undergoing URS with UAS is advisable.

Two-shift operation mode can improve the efficiency and comfort of flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm.

PURPOSE: To compare two-shift operation mode and single player mode different impact on surgical results and operator comfort in flexible ureteroscopic holmium laser lithotripsy for renal calculi larger than 1.5cm. MATERIALS AND METHODS: From december 2017 to december 2018, 92 patients with renal calculi admitted to Qilu Hospital and were treated through fl exible ureteroscopy. They were randomized in two-shift group (n=50) and single player group (n=42). The operative time, blood loss, hospitalization stay after operation, residual fragments (≥4mm) rate, fragmentation speed, postoperative complications and operator's fatigue score were compared. RESULTS: There was no significant difference between two groups regarding age, gender, illness side, stone size, blood loss, operative time, postoperative hospitalization stay, complications, etc (p >0.05). The fragmentation speed was 44.5±20.0mm3/min in two-shift group compared with 34.2±17.3mm3/min in single player group (p=0.037). Residual fragments (≥4mm) rate after fi rst surgery was 18% in two-shift group, while the residual fragments (≥4mm) rate was 40.5% after first surgery in single player group (p=0.017). The total fatigue score of two-shift group was 8.4 compared to 29.9 in single player group (p <0.001). CONCLUSION: In flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm, two-shift operation mode can raise the fragmentation speed and stone clearance rate, as well as signifi cantly lower operator's fatigue level and improve operator's comfort.

Two-shift operation mode can improve the efficiency and comfort of flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1. 5cm

ABSTRACT Purpose: To compare two-shift operation mode and single player mode different impact on surgical results and operator comfort in flexible ureteroscopic holmium laser lithotripsy for renal calculi larger than 1.5cm. Materials and Methods: From december 2017 to december 2018, 92 patients with renal calculi admitted to Qilu Hospital and were treated through flexible ureteroscopy. They were randomized in two-shift group (n=50) and single player group (n=42). The operative time, blood loss, hospitalization stay after operation, residual fragments (≥4mm) rate, fragmentation speed, postoperative complications and operator's fatigue score were compared. Results: There was no significant difference between two groups regarding age, gender, illness side, stone size, blood loss, operative time, postoperative hospitalization stay, complications, etc (p >0.05). The fragmentation speed was 44.5±20.0mm3/min in two-shift group compared with 34.2±17.3mm3/min in single player group (p=0.037). Residual fragments (≥4mm) rate after first surgery was 18% in two-shift group, while the residual fragments (≥4mm) rate was 40.5% after first surgery in single player group (p=0.017). The total fatigue score of two-shift group was 8.4 compared to 29.9 in single player group (p <0.001). Conclusion: In flexible ureteroscopic holmium laser lithotripsy for the treatment of renal calculi larger than 1.5cm, two-shift operation mode can raise the fragmentation speed and stone clearance rate, as well as significantly lower operator's fatigue level and improve operator's comfort.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

PURPOSE: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. MATERIALS AND METHODS: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. RESULTS: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition. CONCLUSIONS: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices

ABSTRACT Purpose to critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes. Materials and Methods A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included. Results 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive financial cost-effective decision model to flexible ureteroscope acquisition. Conclusions The cost-effectiveness of a flexible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.

Ureterolitotripsia para a remoção de cálculos ureterais / Ureterolithotripsy for removal of ureteral stones

CONTEXTO: Ureterolitotripsia, ULT, é o tratamento de escolha para o cálculo ureteral e vem sendo realizada há mais de 20 anos no Brasil em serviços privados e em alguns hospitais-escola. Entretanto, ainda não está incorporada ao SUS. TECNOLOGIA: Ureterolitotripsia. PERGUNTAS: A ULT é segura, efetiva e custo-efetiva em comparação ao procedimento disponível em primeira linha, a litotripsia extracorpórea por ondas de choque, LECO, para a remoção de cálculos ureterais? EVIDÊNCIAS CIENTÍFICAS: Pela revisão sistemática da literatura foi possível selecionar e reanalisar os estudos de 03 metanálises recentes, relevantes e com baixo risco de vieses. Nestas, concluiuse que a ULT está relacionada a um efeito 10% maior quando se avalia a liberação dos cálculos, com taxa de complicações similar à litotripsia extracorpórea por ondas de choque, LECO. Na literatura internacional a ULT é considerada o procedimento de primeira escolha para o tratamento de cálculos ureterais proximais e distais por estar relacionada a alta eficiência e baixa morbidade quando comparada aos demais procedimentos para a remoção de cálculos ureterais. AVALIAÇÃO ECONÔMICA: A avaliação econômica em nosso meio mostra que a ULT é menos custoefetiva que a litotripsia extracorpórea por ondas de choque, LECO. As comparações internacionais mostram relações de custo-efetividade mais favoráveis ao procedimento por ULT em relação aos demais para a remoção de cálculos ureterais incluindo a LECO. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: A partir da movimentação das autorizações de internação hospitalar, AIH, atribuíveis à litíase ureteral proximal grave, estima-se que entre 10.000 e 15.000 pacientes poderiam ser beneficiados pela incorporação da ULT (de 9% até 13,6% dos 110.000 pacientes tratados com LECO ambulatoriamente). Considerando-se o custo adicional de R$ 3.475,39 encontrado em hospital de São Paulo (microcusteio), a verba orçamentária local investida variou entre R$ 34.753.900,00 e R$ 52.130.850,00. Considerando uma média global (do valor na Tabela do SUS ponderado pela proporção de cirurgias) de ressarcimento de R$ 754,17, os 10.000 a 15.000 procedimentos de ULT, que já estão sendo realizados, teriam um impacto orçamentário adicional de R$ 568.644,42 até R$ 4.339.495,99. As principais limitaçõesincluem a heterogeneidade nos estudos, o estudo local foi retrospectivo, houve avaliação parcial das taxas e custos dos eventos adversos e complicações da LECO, os custos pagos no pregão público do Estado de São Paulo são menores que nas outras fontes de dados (por exemplo, materiais e medicamentos no Banco de Preços em Saúde (BPS) do Ministério da Saúde). CONCLUSÃO: A evidência atualmente disponível sobre eficácia e segurança da ULT para tratamento de cálculos ureterais proximais está baseada em dezenas de estudos randomizados e prospectivos, com nível de evidência 1B e grau forte de recomendação. Os resultados apresentados pelos estudos meta-analíticos mostram resolutividade da ULT 10% maior que o método de LECO (sucesso de mais pacientes livres de cálculos ureterais dentre os tratados) e taxa de complicações similares às da litotripsia extracorpórea por ondas de choque, LECO. O modelo para estimar a relação de custo-efetividade com base nos dados empíricos observados em nosso meio mostrou custo adicional da ULT, embora as publicações internacionais recentes, em que se revisaram as relações de custo-efetividade, apontem para um favorecimento da ULT como mais eficiente em comparação com a LECO. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Os membros do Plenário presentes em sua 72ª reunião ordinária, no dia 08 de novembro de 2018, indicaram que o tema seja submetido à Consulta Pública com recomendação preliminar favorável à incorporação no SUS da ureterolitotripsia condicionada à não ocorrência de custos incrementais em relação aos procedimentos comparados. Considerou-se que a técnica tem maior resolutividade e possui taxa de complicações similares ao procedimento disponível no SUS. CONSULTA PÚBLICA: A consulta pública n° 01 de 2019 foi realizada entre os dias 12/01/2019 e 31/01/2019. Foram recebidas 78 contribuições sendo 21 pelo formulário para contribuições técnico-científicas e 57 pelo formulário para contribuições sobre experiência ou opinião. No conjunto das contribuições, 92,3% do total foram enviadas por profissionais de saúde. Em 90% das contribuições enviadas afirma-se concordância total com a recomendação preliminar. Entre as discordâncias parciais alegou-se que a ressalva de equiparação de valores entre os procedimentos utilizados em litíase do trato urinário pode prejudicar a disponibilização dessa tecnologia no SUS e que seria necessário formalizar um algoritmo para otimizar o uso dos recursos mais complexos para os estratos de maior complexidade do tratamento dessa doença. Entre os documentos técnicos recebidos, 2 artigos e 1 citação foram encaminhados, todos 3 já incluídos nas revisões sistemáticas e Diretrizes utilizadas para estruturar e descrever as evidências científicas que embasaram o presente relatório técnico da CONITEC. Entendeu-se que as contribuições submetidas não trouxeram argumentação suficiente para modificar a recomendação preliminar. RECOMENDAÇÃO FINAL: Após a apresentação no dia 07 de fevereiro de 2019 do consolidado das 78 contribuições recebidas na consulta pública n° 1 de 2019, os membros da CONITEC presentes na 74ª reunião ordinária deliberaram, por unanimidade, que fosse ratificada a recomendação inicial favorável à incorporação da ureterolitotripsia transureteroscópica para litíase do trato urinário, condicionada à não ocorrência de custos incrementais aos procedimentos comparados. Nesta data, assinou-se o registro de deliberação nº. 422/2019 pela incorporação da tecnologia. DECISÃO: Incorporar a ureterolitotripsia transureteroscópica para litíase do trato urinário, no âmbito do Sistema Único de Saúde - SUS. Dada pela Portaria nº 15, publicada no Diário Ofical da União nº 54, seção 1, página 66, em 22 de março de 2019.

Micro-ureteroscopy for treatment of pelvic ureteral stone in pediatric patient.

INTRODUCTION: During the last years there has been an effort in miniaturizing the endoscopic devices. The video presents an alternative for the management of distal ureteral stone, using a ureteral access of 4.85 Fr and 27 cm of length, previously described as micro-ureteroscopy. MATERIAL AND METHODS: This procedure was performed through a 3-part all-seeing needle, consisting of micro-optics 0.9 mm in diameter with a 120-degree angle of view, an irrigation channel and an integrated light. CLINICAL CASE: Seven year-old boy, with history of preterm birth (29 weeks) was referred to our consultation complaining of left back pain and an elevation of serum creatinine. The renal ultrasound revealed a left ureterohydronephrosis, caused by a 10 mm stone located 13 mm from the ureterovesical junction. The patient underwent a micro-ureteroscopy with laser lithotripsy. The stone was fragmented with an average energy of 0.5 J with 12 Hz of frequency. The total energy spent was 12514 J. At the end of the procedure, a double J stent was placed. The procedure lasted 45 minutes and was uneventful. The patient was discharged 24h after the procedure without complaints and remained stone free. CONCLUSION: Micro-ureteroscopy is a safe and effective technique in distal ureteral lithiasis treatment in children. The small dimensions of the equipment increase the safety of the procedure making this a good option for the treatment of ureteral stones in children.

Does ureteral access sheat usage lead to permanent damage in the ureter? A placebo controlled trial in a rabbit model.

PURPOSE: To evaluate the clinical stenosis or precursor histological changes that ureteral access sheaths commonly used in ureteroscopic surgeries may cause in the long term in ureter. METHODS: In this study, the animals were divided into 9 groups and according to their groups, ureters of the rabbits were endoscopically fitted with 2F and 3F ureter catheters. The catheters were left in place and withdrawn after a specified period of time. All the ureters were excised and evaluated macroscopically, microscopically and histologically. Ureter diameters were measured and FGF-2 (+) labeled fibroblasts were counted in connective tissue as stenosis precursors. RESULTS: Macroscopically or microscopically, no stenosis was found in any group. The ureter diameter of the group that were catheterized for the longest time with the catheter that had the widest diameter was significantly lower than the group with the shorter duration and the catheter with the narrower diameter and the control group. When the groups were compared in terms of their FGF values, there was a significant difference in FGF-2 counts at all three ureter levels (p <0.05). CONCLUSION: The use of ureteral access sheath may lead to histological changes, as its diameter and duration increase.

Ureteral access sheaths: a comprehensive comparison of physical and mechanical properties

ABSTRACT Introduction: Ureteral access sheaths (UAS) facilitate flexible ureteroscopy in the treat- ment of urolithiasis. The physical properties of UAS vary by manufacturer and model. We compared three new UAS: Glideway (GW, Terumo, 11/13Fr, 12/14Fr), Pathway (PW, Terumo 12/14F) and Navigator HD (NHD, Boston Scientific, 11/13Fr, 12/14Fr) in the domains of safety characteristics, positioning characteristics, lubricity and radio- opacity. Materials and Methods: In vitro testing of the three UAS included safety testing-tip perforation force, sheath edge deformation and dilator extraction forces. Positioning characteristics tested included tip bending, stiffness (resistance to coaxial buckling forces), kinking (resistance to perpendicular forces), and insertion forces. Lubricity was assessed by measured frictional forces of the outer sheath. Finally, radio-opacity was tested utilizing fluoroscopic imaging of the three 12F sheaths and inner dilators. Results: The PW (0.245 lb) and GW (0.286 lb) required less force for tip perforation compared to the NHD (0.628 lb). The NHD sheath edge deformation was mild compared to more severe deformation for the PW and GW. The PW (1.008 lb) required greater force than the GW (0.136 lb) and NHD (0.043 lb) for inner dilator removal. The GW (3.69 lbs) and NHD (4.17 lb) had similar inner dilator tip stiffness when bent, while the PW had the weakest inner dilator tip, 1.91 lbs. The PW (0.271 lb) was most susceptible to buckling and kinking (1.626 lb). The most lubricious UAS was the NHD (0.055 lbs for 12F). The NHD (0.277 lbs) required the least insertional force through a biological model and possessed the greatest radio-opacity. Conclusions: Comparison of different commercially available UAS in various sizes reveals that there are mechanical differences in sheaths that may play a role clinically. The Terumo sheaths' (GW and PW) were outperformed by the Boston Scientific NHD in simulating safety, ease of use and radio-opacity.

Does ureteral access sheat usage lead to permanent damage in the ureter? A placebo controlled trial in a rabbit model

Abstract Purpose: To evaluate the clinical stenosis or precursor histological changes that ureteral access sheaths commonly used in ureteroscopic surgeries may cause in the long term in ureter. Methods: In this study, the animals were divided into 9 groups and according to their groups, ureters of the rabbits were endoscopically fitted with 2F and 3F ureter catheters. The catheters were left in place and withdrawn after a specified period of time. All the ureters were excised and evaluated macroscopically, microscopically and histologically. Ureter diameters were measured and FGF-2 (+) labeled fibroblasts were counted in connective tissue as stenosis precursors. Results: Macroscopically or microscopically, no stenosis was found in any group. The ureter diameter of the group that were catheterized for the longest time with the catheter that had the widest diameter was significantly lower than the group with the shorter duration and the catheter with the narrower diameter and the control group. When the groups were compared in terms of their FGF values, there was a significant difference in FGF-2 counts at all three ureter levels (p <0.05). Conclusion: The use of ureteral access sheath may lead to histological changes, as its diameter and duration increase.

Ureteral access sheaths: a comprehensive comparison of physical and mechanical properties.

INTRODUCTION: Ureteral access sheaths (UAS) facilitate flexible ureteroscopy in the treatment of urolithiasis. The physical properties of UAS vary by manufacturer and model. We compared three new UAS: Glideway (GW, Terumo, 11/13Fr, 12/14Fr), Pathway (PW, Terumo 12/14F) and Navigator HD (NHD, Boston Scientific, 11/13Fr, 12/14Fr) in the domains of safety characteristics, positioning characteristics, lubricity and radioopacity. MATERIALS AND METHODS: In vitro testing of the three UAS included safety testing-tip perforation force, sheath edge deformation and dilator extraction forces. Positioning characteristics tested included tip bending, stiffness (resistance to coaxial buckling forces), kinking (resistance to perpendicular forces), and insertion forces. Lubricity was assessed by measured frictional forces of the outer sheath. Finally, radio-opacity was tested utilizing fluoroscopic imaging of the three 12F sheaths and inner dilators. RESULTS: The PW (0.245 lb) and GW (0.286 lb) required less force for tip perforation compared to the NHD (0.628 lb). The NHD sheath edge deformation was mild compared to more severe deformation for the PW and GW. The PW (1.008 lb) required greater force than the GW (0.136 lb) and NHD (0.043 lb) for inner dilator removal. The GW (3.69 lbs) and NHD (4.17 lb) had similar inner dilator tip stiffness when bent, while the PW had the weakest inner dilator tip, 1.91 lbs. The PW (0.271 lb) was most susceptible to buckling and kinking (1.626 lb). The most lubricious UAS was the NHD (0.055 lbs for 12F). The NHD (0.277 lbs) required the least insertional force through a biological model and possessed the greatest radio-opacity. CONCLUSIONS: Comparison of different commercially available UAS in various sizes reveals that there are mechanical differences in sheaths that may play a role clinically. The Terumo sheaths' (GW and PW) were outperformed by the Boston Scientific NHD in simulating safety, ease of use and radio-opacity.

In Vitro Evaluation of Single-Use Digital Flexible Ureteroscopes: A Practical Comparison for a Patient-Centered Approach.

OBJECTIVE: To compare the manufacturing and in vitro performance characteristics of two single-use flexible ureteroscopes with a permanent optical flexible ureteroscope. MATERIALS AND METHODS: Two single-use flexible ureteroscopes, LithoVue (Boston Scientific) and Pusen (1rs. generation; Zhuhai Pusen Medical Technology Company Limited, China), were tested and compared with a permanent Flex-X2 ureteroscope (Karl Storz, Germany) in terms of technical characteristics, optics, deflection mechanism, and additional parameters which could potentially affect surgical technique. RESULTS: Pusen was the lightest ureteroscope while the LithoVue had the longest working length. LithoVue had a higher resolution power than the other two ureteroscopes at all distances tested (p < 0.001). Pusen showed higher resolution than Flex-X2 (p < 0.01). Field of view was wider for LithoVue (87°), followed by Flex-X2 (85°) and Pusen (75°). Color representation was superior for Flex-X2 than LithoVue and then Pusen. LithoVue outperformed Pusen and Flex-X2 for all settings with instruments in terms of deflection loss (p < 0.01). Pusen had the highest irrigation flow (52 mL/min) with an empty working channel (p < 0.01). LithoVue and Pusen showed similar flow rates with a 200 µm (21 mL/min) and 365 µm laser fiber (7 mL/min) and 1.3F basket (18 mL/min), being superior to Flex-X2 (p < 0.01). With the 1.9F basket, LithoVue had superior flow rate (7 mL/min) than Pusen (3.5 mL/min) and Flex-X2 (4 mL/min; p = 0.01). CONCLUSION: LithoVue outperformed the other ureteroscopes in terms of optical resolution, field of view, deflection capacity, and irrigation flow with larger instruments. Pusen is the lighter scope and showed better results in terms of irrigation when no instruments are in place. Flex-X2 was superior in terms of color representation.

Is a safety guidewire needed for retrograde ureteroscopy?

INTRODUCTION: It is generally advised to have a safety guidewire (SGW) present during ureteroscopy (URS) to manage possible complications. However, it increases the strenght needed to insert and retract the endoscope during the procedure, and, currently, there is a lack of solid data supporting the need for SGW in all procedures. We reviewed the literature about SGW utilization during URS. METHOD: A review of the literature was conducted through April 2017 using PubMed, Ovid, and The Cochrane Library databases to identify relevant studies. The primary outcome was to report stone-free rates, feasibility, contraindications to and complications of performing intrarenal retrograde flexible and semi-rigid URS without the use of a SGW. RESULTS: Six studies were identified and selected for this review, and overall they included 1,886 patients where either semi-rigid or flexible URS was performed without the use of a SGW for the treatment of urinary calculi disease. Only one study reported stone-free rates with or without SGW at 77.1 and 85.9%, respectively (p=0.001). None of the studies showed increased rates of complications in the absence of SGW and one of them showed more post-endoscopic ureteral stenosis whenever SGW was routinely used. All studies recommended utilization of SGW in complicated cases, such as ureteral stones associated with significant edema, ureteral stricture, abnormal anatomy or difficult visualization. CONCLUSION: Our review showed a lack of relevant data supporting the use of SGW during retrograde URS. A well-designed prospective randomized trial is in order.

Is a safety guidewire needed for retrograde ureteroscopy? / Fio guia de segurança é necessário na ureteroscopia?

Summary Introduction: It is generally advised to have a safety guidewire (SGW) present during ureteroscopy (URS) to manage possible complications. However, it increases the strenght needed to insert and retract the endoscope during the procedure, and, currently, there is a lack of solid data supporting the need for SGW in all procedures. We reviewed the literature about SGW utilization during URS. Method: A review of the literature was conducted through April 2017 using PubMed, Ovid, and The Cochrane Library databases to identify relevant studies. The primary outcome was to report stone-free rates, feasibility, contraindications to and complications of performing intrarenal retrograde flexible and semi-rigid URS without the use of a SGW. Results: Six studies were identified and selected for this review, and overall they included 1,886 patients where either semi-rigid or flexible URS was performed without the use of a SGW for the treatment of urinary calculi disease. Only one study reported stone-free rates with or without SGW at 77.1 and 85.9%, respectively (p=0.001). None of the studies showed increased rates of complications in the absence of SGW and one of them showed more post-endoscopic ureteral stenosis whenever SGW was routinely used. All studies recommended utilization of SGW in complicated cases, such as ureteral stones associated with significant edema, ureteral stricture, abnormal anatomy or difficult visualization. Conclusion: Our review showed a lack of relevant data supporting the use of SGW during retrograde URS. A well-designed prospective randomized trial is in order.

Resumo Introdução: O uso de fio guia de segurança (FGS) costuma ser recomendado para a realização de ureteroscopia para prevenir e solucionar complicações durante o procedimento. Seu uso, porém, aumenta a força necessária para manipular o aparelho endoscópico dentro da luz ureteral e, atualmente, existe uma carência de dados consistentes que indiquem o uso do FGS em todos os procedimentos. Método: Uma revisão da literatura foi realizada em abril de 2017 utilizando as ferramentas PubMed, Ovid e The Cochrane Library para identificar estudos relevantes. O desfecho primário da análise foi reportar taxas de resolução dos cálculos, viabilidade, contraindicações e complicações relacionadas ao não uso do FGS. Resultados: Seis estudos foram incluídos na análise, totalizando 1.886 pacientes, nos quais foi realizada ureteroscopia semirrígida ou flexível sem o uso do FGS no tratamento de cálculos renais ou ureterais. Somente um estudo relatou taxa livre de cálculos com ou sem FGS, sendo 77,1 e 85,9%, respectivamente (p=0.001). Todos os estudos mostraram não haver aumento da taxa de complicação na ausência do FGS e um deles relatou aumento de estenose ureteral pós-endoscopia no grupo que utilizou o FGS. Todos os estudos recomendam o uso do FGS em casos complicados, como cálculos ureterais associados a edema de mucosa, estenose ureteral, anomalias anatômicas ou dificuldade de visualização do cálculo. Conclusão: Nossa revisão mostrou que faltam dados relevantes para justificar o uso do FGS durante a ureteroscopia.

Evaluation of the Spies TM modalities image quality

Introduction The Spies™ system (Karl-Storz®) was introduced into digital ureteroscopy to improve endoscopic vision. To date, there is no data to either indicate which of the Spies modalities is better for improving diagnosis and treatment procedures, nor to compare the modalities in terms of image quality. The aim of this study was to evaluate and compare the image quality of five Spies™ modalities (SM) to the standard white light in an in-vitro model. Materials and Methods Two standardized grids and 3 stones of different composition were recorded in white light and the 5SM (Clara, Chroma, Clara+Chroma), Spectra A and B) using 4 standardized aqueous scenarios. Twelve templates were done in order to simultaneously compare the same objective in the different modalities. Six urologists, five medical students, five urology residents, and five persons not involved with urology evaluated each video on a scale of 1 (very bad) to 5 (very good). Results Comparing white light to SM, subjects scored better the quality of Clara and Clara+Chroma than white light (p=0.0139 and p<0.05) and scored worse Spectra A and B (p=0.0005 and p=0.0023)). When comparing Clara to the other SM, it was ranked equivalent to Clara+Chroma (p=0.67) and obtained a higher rank than Chroma, Spectra A and B (p<0.05, p=0.0001 and p=0.0001). In the multivariate analysis mean scores were higher among urologists. Conclusion In all analyzed scenarios, the subjects ranked Clara and Clara+Chroma as the modalities with better image quality compared to white light.

Evaluation of the Spies TM modalities image quality.

INTRODUCTION: The Spies™ system (Karl-Storz®) was introduced into digital ureteroscopy to improve endoscopic vision. To date, there is no data to either indicate which of the Spies modalities is better for improving diagnosis and treatment procedures, nor to compare the modalities in terms of image quality. The aim of this study was to evaluate and compare the image quality of five Spies™ modalities (SM) to the standard white light in an in-vitro model. MATERIALS AND METHODS: Two standardized grids and 3 stones of different composition were recorded in white light and the 5SM (Clara, Chroma, Clara+Chroma), Spectra A and B) using 4 standardized aqueous scenarios. Twelve templates were done in order to simultaneously compare the same objective in the different modalities. Six urologists, five medical students, five urology residents, and five persons not involved with urology evaluated each video on a scale of 1 (very bad) to 5 (very good). RESULTS: Comparing white light to SM, subjects scored better the quality of Clara and Clara+Chroma than white light (p=0.0139 and p<0.05) and scored worse Spectra A and B (p=0.0005 and p=0.0023). When comparing Clara to the other SM, it was ranked equivalent to Clara+Chroma (p=0.67) and obtained a higher rank than Chroma, Spectra A and B (p<0.05, p=0.0001 and p=0.0001). In the multivariate analysis mean scores were higher among urologists. CONCLUSION: In all analyzed scenarios, the subjects ranked Clara and Clara+Chroma as the modalities with better image quality compared to white light.

Retrospective comparative study of rigid and flexible ureteroscopy for treatment of proximal ureteral stones

ABSTRACT Background: We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS). Subjects and methods: Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications. Results: The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusıon: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.

Retrospective comparative study of rigid and flexible ureteroscopy for treatment of proximal ureteral stones.

BACKGROUND: We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS). SUBJECTS AND METHODS: Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications. RESULTS: The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusion: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone.

PURPOSE: The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group. MATERIALS AND METHODS: From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system. RESULTS: Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively. CONCLUSIONS: RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.