Retrograde Intrarenal Surgery for Lithiasis Using Suctioning Devices: A Shift in Paradigm?

New suction endoscopes, ureteral access sheaths (UAS) and catheters aim to improve the efficacy of flexible ureteroscopy and optimize its safety. Suction UAS with non-flexible tips have shown promising results, especially in maintaining low intrarenal pressure, but also in removing small debris and reducing the "snow globe" effect. In addition, suctioning UAS with a flexible tip offers the advantage of being able to be navigated through the pyelocaliceal system to where the laser lithotripsy is performed. It can also remove small stone fragments when the flexible ureteroscope is retracted, using the Venturi effect. Direct in-scope suction (DISS) involves aspirating dust and small stone debris through the working channel of a flexible ureteroscope, thus regulating intrarenal pressure and improving visibility. Steerable aspiration catheters are other devices designed to increase stone clearance of the pyelocaliceal system. They are inserted under fluoroscopic guidance into every calyx after retraction of the flexible ureteroscope, alternating irrigation and aspiration to remove dust and small gravels. Combining flexible-tip suction UAS and the DISS technique may offer some advantages worth evaluating. The advantage of using these instruments to achieve a low intrarenal pressure was demonstrated. The true practical impact on the long-term stone-free status is a matter requiring further studies.

NO Residual Stones after Flexible Ureteroscopy for Renal Stones - Update 2021. A Narrative Brief Review.

Urolithiasis is a major health problem which is on the rise worldwide. New procedures and technological tools have arisen, providing the urologist with a vast arsenal of options for stone disease management. The goal of this narrative review is to summarize the most recent advancements and demonstrate their efficacy in reducing complications and increasing surgical efficacy. The latest modern advances in increasing stone rate after flexible ureteroscopy were included. The ureteral access sheet concept represents one of the most important parts in this procedure and new performances achieved in this field like suction and pressure control were evaluated. Another important aspect in flexible ureteroscopy is related to laser fibres. The latest achievements in Holmium and Thulium fibres were analysed and compared using both dusting and fragmenting techniques. After analysing these aspects, the conclusion was that suction improved visualization by removing "stone storm" and bleeding during the procedure and Thulium laser had the potential to become the new "gold standard" in the pursuit of obtaining a higher stone free rate.

Applicability of Magnetic Sensors in Interlocking Systems.

Rail interlocking systems follow the progress of technology and train speeds. Nowadays, new systems are designed based on microcontrollers and reliable software, requiring many hours of testing to ensure their proper functionality and bug-free coding. However, in many countries, there are still older relay solutions implemented that are not envisaged to be upgraded in the near future partially due to costs but mainly due to the fact they function very well, being based on a highly reliable element: the relay. However, specialized maintenance personnel are becoming more difficult to find, so automation systems that check the proper relay functionality are a key element to ensure a longer lifetime of existing systems. In this article, the authors present a monitoring solution based on magnetic sensors that proved capable of provide reliable information about the relays, hence revealing the first step in a relay automated control system.

Bilateral same-session flexible ureteroscopy for renal stones: a feasible method.

A staged ureteroscopic procedure is generally preferred to treat bilateral renal stones. In this study, we evaluated the feasibility of bilateral same-session flexible ureteroscopy (BS-fURS) in renal stones. A total of 81 patients underwent bilateral BS-fURS between March 2014 and March 2021 for bilateral renal stones. The mean stone burden per patient was 17±4 (range 7-27 mm). The average stone density was 1240 HU (970 to 1510). We used 4 types of ureteroscopes: Olympus URF-V2 (34 cases), Storz Flex X2 (30 cases), single-use PUSEN PU 3022 (12 cases), and single-use PUSEN - PU 3033A (5 cases). We specifically set our Holmium laser for dusting, pop-corning, and fragmenting. We found 31 calcium oxalate monohydrate cases, 11 calcium oxalate dehydrate cases, 17 uric acid cases, and 22 magnesium ammonium phosphate cases. The mean operating time was 77 min. (range 52 to 85) for both renal units. The SFRs were evaluated between 1 and 3 months with computed tomography (fragments >3 mm were defined as residual). Double J stenting (6Fr.) was applied bilaterally in 8 cases (9.87%) and unilateral in 34 cases (41.97%). The overall SFRs after 1 and 2 procedures were 81.48% (66/81 cases) and 92.59% (75/81 cases), respectively. Postoperative complications after an overall 96 procedures were Clavien I-II (18.75%) and Clavien III (3.12%). Urinary tract infections were observed in 13 cases (16.04%) without any case of urosepsis. Our experience suggested some BS-fURS advantages as a single anesthetic session and potentially reduced cost associated with treatment. BS-fURS seem feasible, especially for medium-sized bilateral renal stones in high-volume centers.

Analysis of the Possibility to Detect Road Vehicles via Bluetooth Technology.

As road traffic networks become more congested and information systems are implemented to manage traffic flows, real-time data gathering becomes increasingly important. Classic detectors are placed in one point of the network and are able to provide information only from that area. As useful as this is, it lacks the big picture of the routes the vehicles usually travel. There are applications developed to help individuals make their way into the road network, but these are no solutions that deal with the cause of traffic; rather, they counteract the effects. It becomes obvious that a proper management system, with knowledge of all the relevant aspects will better serve all travelers. The detection solution proposed in this paper is based on Bluetooth detectors. This system is able to match detected devices in the road network, filter the results, and generate a vehicle count that is proved to follow RADAR detection results.

Romanian National premiere with the new Thulium SuperPulsed Laser in the endourological treatment of urolithiasis.

In this paper, we aimed to verify the efficiency and functionality of the new Soltive Thulium Fiber Laser (TFL) in the treatment of urinary stones. The Soltive Laser System was used in 17 urolithiasis cases: 10 renal, 5 ureteral, and 2 bladder stone patients. The average stone size was 13.1 mm (ranging between 11-29 mm) for the kidney, 8 mm (ranging between 6-12 mm) for the ureter, and 31 mm (ranging between 27-34 mm) for the bladder. Only single calculi patients were included in the study. We used 100 and 150 µm core-diameters fibers (CDF). Three settings were applied: 0.15 J/100 Hz for "fine dusting", 0.5 J/30 Hz for "dusting" and 1 J/15 Hz for the fragmentation mode. The mean operative time was 34 minutes for renal, 21 minutes for ureteral, and 39 minutes for bladder stones. The visibility was optimal in all cases. The stone-free rate at 1 month after treatment was 95% for renal calculi and 100% for ureteral and bladder stones. Very fine dust made of stone fragments smaller than 1 mm in size that passed spontaneously through the access sheath was observed, especially subsequent to the "fine dusting" mode. The complication rate was very low: 1 patient was classified as Clavien grade 1 and 1 patient as Clavien grade 2, and this was the case for renal stones only. No urinary tract infections were observed. The new Soltive TFL appears to be a remarkably promising tool in the therapeutic approach of urolithiasis. Lithotripsy was achieved up to the level of extremely small stone fragments with improved efficiency while also optimizing the operative time.

Initial Experience with the New Super Thin Single-use Pusen Flexible Ureteroscope 7.5 Fr in Renal Stones Endoscopic Treatment.

Introduction: Single-use flexible ureteroscopes (SU-fURS) seems to overcome the main limitations of conventional reusable ureteroscopes in terms of acquisition and maintenance costs and breakages. Our aim was to analyz the efficiency and safety of the thinnest single use flexible scope from Pusen: Uscope Pusen, PU 3033A (Tip = 7.5 Fr.). Material and Methods: We analyzed data from 24 patients with pyelocaliceal stones from January to March 2021. The mean age of the patients was 49 years (range 27 to 71 years). There were unique stones, 7 pyelic, 10 in inferior calyx, 4 in the middle calyx and 3 in superior calyx. The average stone size (larger diameter) was 18 mm (12-26 mm). We used Uscope Pusen 7.5 Fr. (PU 3033A) and Dornier Medilas H Solvo laser. In all cases we applied no touch technique (NTT). We did't used CArm for progression control of the ureteroscope. We evaluated the patients for stone-free rate (SFR), mean operation time and complication rate. Results: The average operative time was 72 +- 21 minutes, range 66-131 min. For all 24 patients we didn't use wires or ureteral access sheath (NTT). Concerning the laser settings for dusting we used low energy: 0.5J, high frequency: 50 Hz, for pop-corning we used high energy: 1 J, medium frequency: 10-50 Hz, and for fragmenting high energy: 1 J, low frequency: 10 Hz. The stone-free status (residual fragments under 3 mm.) after one month was 91,7%. In 2 patients we need the second session with completely dusting of the residual stones. The visibility was optimal and we didn't describe any mucosal lesions of the ureter when we retired the scope. The intrarenal maneuverability was very good. Clavien I and II occurred in 6 patients. Conclusions: This new SU-fURS (7.5 Fr.) seems to be very effective and safe offering us an easy NTT. No ureteral damage and one day surgery are the main real minimally invasive characteristics of this ureteroscope.

Single-Use vs Reusable Ureteroscopes in Horseshoe Kidney Stones.

Introduction: Horseshoe kidney (HSK) is one of the most frequent renal malformations which appears to present an increased risk of stone formation caused by abnormal urine drainage. This study aims to compare the results of single-use flexible ureteroscopy (SUfURS) vs reusable devices (RfURS) with holmium laser in treating stones in HSK cases. Material and method: Between February 2017 and June 2021, 29 patients diagnosed with renal stone disease and horseshoe kidney were retrospectively analyzed. Subjects were divided into two groups: Group 1 (14 patients) undergoing SUfURS and Group 2 (15 patients) operated with RfURS devices. We analyzed the mean stone burden, operation time, stone free rate and complications. The surgical equipment was represented by the SUfURS PU3022 (Zhuhai Pusen Medical Technology) and RfURS URF-V2 (Olympus). Results: The two groups had a similar mean stone burden: 22 ± 6 mm (range 15-31 mm) for Group 1 and 24 ± 7 mm (range 16-30 mm) for Group 2. The average operative time was better for Group 1 (86 ± 17 min) vs Group 2 (89 ± 20 min). The stone-free status was similar for both groups after the first session (57.14% for Group 1 vs 53.33% for Group 2) and slightly in favor of Group 1 as compared to Group 2 (85.71% vs 73.33%, respectively) after the second session. The overall complication rate (Grades I, II and III) was almost similar in both groups, with a slightly prevalence for Group 1 (no major complications Grade IV and V). Conclusion:Flexible ureteroscopy represents an effective alternative treatment technique for large stones in kidney abnormalities. single-use flexible ureteroscopy can be successfully used to treat patients with genetically renal malformations and its results may be slightly better than those provided by using RfURS devices.

Use of Energy Efficient Sensor Networks to Enhance Dynamic Data Gathering Systems: A Comparative Study between Bluetooth and ZigBee.

As road traffic conditions worsen due to the constantly increasing number of cars, traffic management systems are struggling to provide a suitable environment, by gathering all the relevant information from the road network. However, in most cases these are obtained via traffic detectors placed near road junctions, thus providing no information on the conditions in between. A large-scale sensor network using detectors on the majority of vehicles would certainly be capable of providing useful data, but has two major impediments: the equipment installed on the vehicles should be cheap enough (assuming the willingness of private car owners to be a part of the network) and be capable of transferring the required amount of data in due time, as the vehicle passes by the road side unit that acts as interface with the traffic management system. These restrictions reduce the number of technologies that can be used. In this article a series of comprehensive tests have been performed to evaluate the Bluetooth and ZigBee protocols for this purpose from many points of view: handshake time, static and dynamic data transfer (in laboratory conditions and in real traffic conditions). An assessment of the environmental conditions (during tests and probable to be encountered in real conditions) was also provided.

NBI-assisted digital flexible ureteroscopy in transitional renal cell carcinoma - an evidence-based assessment "through the looking glass" of the pathological analysis.

INTRODUCTION: Digital flexible ureteroscopy (FURS) increasingly became a routine diagnostic procedure in upper urinary tract transitional cell carcinoma (UUT-TCC). Identifying elements that may suggest the malignant nature of a lesion and obtaining biopsy specimens sufficient for a reliable pathological analysis remain difficult challenges. Narrow-band imaging (NBI) technology appears to provide a more accurate observation of the upper tract urothelium. PATIENTS, MATERIALS AND METHODS: During this prospective analysis, white light (WL) and NBI-assisted digital FURS were performed in 87 consecutive patients admitted for primary suspicion of UUT-TCC. The endoscopic technique comprised digital WL FURS, followed by the NBI assessment of the renal collecting system' mucosa. All suspicious areas of the pyelocaliceal urothelium were biopsied using the grasping forceps, separately for WL and NBI findings. RESULTS: A total of 113 UUT-TCC tumors (104 pTa and nine carcinoma in situ - CIS) were confirmed by pathology in 62 patients. The patients' detection rate was significantly improved in NBI mode when compared to standard FURS (98.4% versus 91.9%, respectively), due to cases either exclusively diagnosed with UUT-TCC (8.1%) or presenting additional urothelial tumors (12.9%). Overall, 13 pTa and two CIS lesions were solely observed in NBI, which was on the other hand characterized by a significantly increased proportion of unnecessary biopsies (NBI versus WL rate of false-positive results - 17.5% versus 10.1%, respectively). CONCLUSIONS: As additional tool for the standard WL evaluation of the pyelocaliceal system' urothelium, NBI-guided biopsies were emphasized as providing a significant diagnostic improvement during digital FURS.

Robotic Flexible Ureteroscopy Versus Classic Flexible Ureteroscopy in Renal Stones: the Initial Romanian Experience.

INTRODUCTION: Roboflex Avicenna represents a new device for flexible ureteroscopy, able to provide an efficient lithotripsy for renal calculi, Bucharest being the fourth place in the world where such a device is already in use. MATERIAL AND METHODS: The study was prospective and included a number of 132 patients equally randomized which underwent standard flexible ureteroscopy and robotic flexible ureteroscopy for renal calculi between July and February 2016. All the procedures were performed with aStorz XC flexible ureteroscope in association with Avicenna Roboflex. Stone fragmentation was performed using a Dornier Medilas 20H, Holmium Laser of 20 watt power and 2.1 µm wavelength. RESULTS: The mean age was 48 years (range 26-77 years) and the mean stone size was 2.1 cm (range 1.1-3.6 cm) for the first group (FURS), while for the second one (robotic FURS) the mean age was 51 years (range 25-74 years) and the mean stone size was 2.4 cm (range 1.0-3.7 cm). The fragmentation time of the stones was better for robotic FURS (37 min versus 39 min). After 3 months, the stone free rate was 89.4% versus 92.4%, that representing a performance of the robotic technique over the classical one. In some cases were noticed residual fragments smaller than 3 mm, in 13.6% of patients who underwent FURS, respectively in 12.1% of robotic FURS™ cases. CONCLUSIONS: The robotic treatment of kidney stones represents a comparative alternative to flexible ureteroscopy, with overall similar outcomes.