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Introduction: The advent of single-use disposable flexible ureteroscopes allows for rapid prototyping of novel endoscopes. In this regard, we sought to develop a female-specific ureteroscope, with ...

Introduction: Elevated intrarenal pressure (IRP) during flexible ureterorenoscopy (FURS) is a predictor of postoperative complications. The aim of this study is to evaluate IRP during FURS in a por...

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to c...

Objectives: To assess the effect of irrigation settings and the size of ureteral access sheath (UAS) on the maximal intra-pelvic pressure (IPPmax) during ureteroscopy (URS) in pigs. Materials and Methods: In supine position, three anesthetized female pigs underwent cystoscopy to insert a 6F ureteral catheter in each ureter. Pigs were then turned to prone position to establish a percutaneous access, insert a 10F nephrostomy tube in the kidney, and connect it to a urodynamic device. An 8F semi-rigid ureteroscope or the Flex-X2 Flexible Ureteroscope was used with two irrigation settings: gravity flow and manual pumping using a commercial pump. URS was performed without UAS and with the UAS 9.5/11, 12/14, 14/16 at the ureteropelvic junction and the IPPmax was recorded. Results: Under gravity irrigation, the recorded IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 0 and 30 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 23, 6, 2, and 1 cmH2O, respectively. Under manual pumping, the IPPmax during semi-rigid URS in the distal ureter and the renal pelvis was 84 and 105 cmH2O, respectively. Further, the IPPmax during flexible URS in the renal pelvis without UAS, with UAS 9.5/11.5, with UAS 12/14, and with UAS 14/16 was 45, 46, 18, and 1 cmH2O, respectively. Conclusion: Manual pumping can significantly increase the IPPmax to unsafe levels during URS. The UAS can significantly decrease the IPPmax, even under manual pumping. The larger the UAS, the lower the IPPmax. The use of UAS can render URS safer by acting as a safeguard against the consequences of increased IPP, even under forced irrigation.

A ball-tip holmium laser fiber (TracTip; Boston Scientific) has been developed to theoretically reduce damaging friction forces generated within a ureteroscope working channel. We compared the insertional forces and damage with a ureteroscope inner lining when inserting standard flat-tip and ball-tip laser fibers.A standard ureteroscope channel liner was placed in a 3D-printed plastic mold. Molds were created at four angles of deflection (30°, 45°, 90°, and 180°) with a 1 cm radius of curvature. New 200 μm ball-tip (TracTip; Boston Scientific) and 200 μm flat-tip (Flexiva; Boston Scientific) laser fibers were advanced through the liner using a stage controller. A strain gauge was used to measure force required for insertion. Each fiber was passed 600 times at each angle of deflection. The ureteroscope liner was changed every 150 passes. Leak testing was performed every 50 passes or when the insertional force increased significantly to assess damage to the liner.At all deflection angles, the average insertional force was significantly lower with the ball-tip laser fibers compared with flat-tip laser fibers (p 0.001). All trials with the ball-tip lasers were completed at each angle without any leaks. Two of four trials using flat-tip fibers at 45° deflection caused liner leaks (at 91 and 114 passes). At 90° deflection, all flat-tip trials caused liner leaks on first pass. The 180° trials could not physically be completed with the flat-tip laser fiber. Within the flat- and ball-tip groups, an increasing amount of force was needed to pass the fiber as the degree of deflection increased (p 0.001).The ball-tip holmium laser fiber can be safely passed through a deflected ureteroscope without causing liner perforation. The standard flat-tip fiber requires greater insertion force at all angles and can cause the ureteroscope liner to leak if it is deflected 45° or more.

Reusable ureteroscope durability and need for repair are significant sources of expense and inefficiency for patients and urologists. Utilization of LithoVue™, a disposable flexible digital ureteroscope, may address some of these concerns. To identify its economic impact on clinical care, we performed a micro-cost comparison between flexible reusable fiberoptic ureteroscopes (URF-P6™) and LithoVue.For this prospective, single-center micro-costing study, all consecutive ureteroscopies performed during 1 week each in July and August 2016 utilized either URF-P6 or LithoVue ureteroscopes respectively. Workflow data were collected, including intraoperative events, postoperative reprocessing cycle timing, consumables usage, and ureteroscope cost data.Intraoperative data analysis showed mean total operating room time for URF-P6 and LithoVue cases were 93.4 ± 32.3 and 73.6 ± 17.4 minutes, respectively (p = 0.093). Mean cost of operating room usage per case was calculated at $1618.72 ± 441.39 for URF-P6 and $1348.64 ± 237.40 for LithoVue based on institutional cost rates exclusive of disposables. Postoperative data analysis revealed costs of $107.27 for labor and consumables during reprocessing for URF-P6 cases. The costs of ureteroscope repair and capital acquisition for each URF-P6 case were $957.71 and $116.02, respectively. The total ureteroscope cost per case for URF-P6 and LithoVue were $2799.72 and $2852.29, respectively.Micro-cost analysis revealed that the cost of LithoVue acquisition is higher per case compared to reusable fiberoptic ureteroscopes, but savings are realized in labor, consumables, and repair. When accounting for these factors, the total cost per case utilizing these two ureteroscopes were comparable.

Single-use ureteroscopes have been gaining popularity in recent years. We compare the optics, deflection, and irrigation flow of two novel single-use flexible ureteroscopes-the YC-FR-A and the NeoFlex-with contemporary reusable and single-use flexible ureteroscopes.Five flexible ureteroscopes, YC-FR-A (YouCare Tech, China), NeoFlex (Neoscope, Inc., USA), LithoVue (Boston Scientific, USA), Flex-Xc (Karl Storz, Germany), and Cobra (Richard Wolf, Germany), were assessed in vitro for image resolution, distortion, field of view, depth of field, color representation, and grayscale imaging. Ureteroscope deflection and irrigation were also compared.The YC-FR-A showed a resolution of 5.04 lines/mm and 4.3% image distortion. NeoFlex showed a resolution of 17.9 lines/mm and 14.0% image distortion. No substantial difference was demonstrated regarding the other optic characteristics between the two. Across all tested ureteroscopes, single-use or reusable, the digital scopes performed best with regard to optics. The YC-FR-A had the greatest deflection at baseline, but lacks two-way deflection. The NeoFlex had comparable deflection at baseline to reusable devices. Both ureteroscopes had substantial loss of deflection with instruments in the working channel. The YC-FR-A had the greatest irrigation rate. The NeoFlex has comparable irrigation to contemporary ureteroscopes.The YouCare single-use fiberoptic flexible ureteroscope and NeoFlex single-use digital flexible ureteroscope perform comparably to current reusable ureteroscopes, possibly making each a viable alternative in the future. Newer YouCare single-use flexible ureteroscopes with a digital platform and two-way deflection may be more competitive, while the NeoFlex devices are undergoing rapid improvement as well. Further testing is necessary to validate the clinical performance and utility of these ureteroscopes, given the wide variety of single-use devices under development.

To evaluate and compare FlexorFlexorVue and a reusable fiber optic flexible ureteroscope were each tested in an artificial kidney model. The experimental setup included the visualization of colored pearls and the extraction of calculi with two different extraction devices (NCircleNearly all calices (99%) were correctly identified using the reusable scope, indicating full kidney access, whereas 74% of the calices were visualized using FlexorVue, of which 81% were correctly identified. Access to the lower poles of the kidney model was significantly less likely with the disposable device, and time to completion was significantly longer (755 s vs 153 s, p 0.001). The stone clearance success rate with the disposable device was 23% using the NGage and 13% using the NCircle basket. Overall NASA-TLX scores were significantly higher using FlexorVue. The conventional reusable device also demonstrated superior maneuverability, handling, and image quality.FlexorVue offers a semidisposable deflecting endoscopic system allowing basic ureteroscopic and cystoscopic procedures. For its use as an addition or replacement for current reusable scopes, it requires substantial technical improvements.

To improve the safety and efficacy of ureteroscopic lithotripsy for the treatment of ureteral stone, we made a simple modification to the standard ureteral access sheath (mUAS) and developed a novel technique to overcome the deficiencies of the current procedure.We added an oblique suction-evacuation port with pressure regulating mechanism to the UAS to allow active egress of irrigation fluid and stone fragments. A pressure vent was placed on the egress port. Continuous negative pressure aspiration was connected to the egress port, whereas the continuous irrigation was delivered through the endoscope with a pressure pump. Stone fragmentation was performed using a holmium-YAG laser through a semirigid ureteroscope. Tiny stone fragments were evacuated in the space between the sheath and the scope. When larger fragments came into the sheath that were too large to exit between the scope and the sheath, the scope was withdrawn to just proximal to the bifurcation of the oblique port. This opened up an unimpeded egress channel for the larger fragments. We attempted this procedure in 104 consecutive patients.Seventy-four patients had effective insertion of mUAS. Seven patients failed semirigid ureteroscopy despite effective placement of mUAS. Patient with effective semirigid ureteroscopic lithotripsy had 100% immediate stone clearance and no observed stone retropulsion. Patients who failed semirigid ureteroscopy were converted to flexible ureteroscopy. Five patients had completed stone clearance. The overall immediate stone-free rate was 97.3% and 100% at 1-month follow-up. Complications included two fevers and one minor ureteral false passage.Our modification of UAS has reduced stone retropulsion, improved stone clearance, improved visual field, and probably reduced the intraluminal pressure.

To investigate the effectivity of 4.5F ultrathin ureteroscope (UT-URS) without any need for active or passive dilation in the treatment of adult patient population in whom ureteral orifices cannot be engaged using conventional URS.Among a total of 512 adult patients who had undergone URS between April 2012 and November 2015 in our department for diagnostic or therapeutic purposes, 43 (8.4%) patients required ureteral dilation because we could not engage ureteral orifice. In adult patients in whom we could not engage ureteral orifice with 7.5F and 8F semirigid URS, we tried to complete the operation using 4.5F UT-URS without resorting to dilation. Age and gender of the patients, indication for operation, stone size, location, operative times, laterality of stone(s), stone-free rates, length of hospital stay, and complications were recorded.Mean age of the patients was 34.5 ± 11.2 (21-66) years. The patients had undergone operations for ureteral stone (n = 39), unexplained hydronephrosis (n = 2), and ureteral stenosis (n = 2). Mean stone size was 8.2 ± 2.3 (4-18) mm. Mean operative time was 64.2 ± 13.5 minutes. In 37 of 39 patients, a complete stone-free rate (94.8%) was achieved. Mean length of hospital stay was 8.9 ± 5.8 hours.It has been demonstrated that in an adult patient population in whom ureteral orifices cannot be engaged using conventional URS, ureteral access could be achieved with 4.5F UT-URS without any need for dilation. At the same time, use of 4.5F UT-URS resulted in an acceptable treatment success and lower complication rates in most of these patients without the need for a second session.

Purpose: To evaluate LithoVue, the new single-use digital flexible ureteroscope, in a human cadaveric model and compare it with a nondisposable fiber optic and digital flexible ureteroscopes. Materials and Methods: LithoVue, a conventional fiber optic, and digital flexible ureteroscopes were each tested in four renal units of recently deceased female cadavers by three surgeons. The following parameters were analyzed: accessibility to the kidney and navigation of the entire collecting system with and without ureteral access sheath (UAS), lower pole access measuring the deflection of the ureteroscope with the working channel empty, and with inside two different baskets and laser fibers. A subjective evaluation of maneuverability and visibility was assessed by each surgeon at the end of every procedure. Results: Kidney access into the Renal unit 1 was not possible without UAS for all ureteroscopes because of noncompliant ureter at the level of sacroiliac joint. The reusable digital ureteroscope was unable to reach one calix of the lower pole and one calix of the upper pole (Renal units 2 and 3) without UAS placement. Lower pole access with baskets and laser fibers was possible for each ureteroscope after UAS placement. No statistically significant differences were detected in angle deflection between ureteroscopes. The digital ureteroscope was preferred for visibility in all procedures: LithoVue for maneuverability in six procedures, fiber optic in five procedures, and the digital ureteroscope in one procedure. Conclusions: LithoVue seems to be comparable with conventional ureteroscopes in terms of visibility and manipulation into the collecting system in fresh human cadavers. Further studies in humans are needed to determine the clinical value of this new instrument.

The improvements in flexible ureteroscopes provide efficient access to the upper urinary tract and advancements in laser technology strengthens the endourologists' armamentarium. The endourologists must be aware of the advantages and the potential complications of these powerful technological equipments. Our aim is to demonstrate temperature evolution during laser use inside an artificial kidney model.We created a bench model using K-Box(®) immersed into a saline-filled heating tank, which was used to obtain the needed temperature inside the cavity to provide different real-time situations. An endotracheal thermometer was placed inside. We used Olympus URF-P6 ureteroscope and Rocamed Holmium:yttrium-aluminium-garnet laser with two different fibers; 200 and 272 μm, at five different settings. Irrigation at room (24.5°C) and body (36.5°C) temperatures was used. We measured temperatures at 15th, 30th, and 45th seconds and 1st, 2nd, and 5th minutes of laser use with and without irrigation. We stopped measurements when temperature reached the upper limit of the endotracheal thermometer.When irrigation was closed, with 272-μm laser fiber, we reached the temperature limit more rapidly with saline tank at 36.5°C than the tank at 24.5°C. When irrigation was closed, with both fibers and regardless of tank temperature and laser settings, the system surpassed the maximum temperature limit. With 272-μm laser fiber, the limit was reached as early as the 30th second. When the irrigation was open, we did not reach the maximum temperature limit regardless of tank temperature and laser setting. When two laser fibers were compared, the temperature increase was more pronounced with 272-μm fiber, but the difference was not statistically significant.Laser use during flexible ureteroscopy may cause increased intrarenal temperatures. Rapid increases should be kept in mind when irrigation is closed. The irrigation seems to limit the temperature increase when used with any laser setting.

Introduction: Standard technique in renal pelvis tumor resection involves fluoroscopy-guided access, tract dilatation, tumor resection, and nephrostomy tube placement. A ureteroscope-guide...

To evaluate the ignition and burn risk associated with contemporary fiberoptic and distal sensor endoscopic technologies.We used new and used SCB Xenon 300 light sources to illuminate a 4.8 mm fiberoptic cable, 10 mm laparoscope, 5 mm laparoscope, rigid cystoscope, semirigid ureteroscope, flexible cystoscope, flexible fiberoptic ureteroscope, distal sensor cystoscope, and a distal sensor ureteroscope (Karl Storz, Inc., Tuttlingen, Germany). We measured peak temperatures at the distal end of each device. We then evaluated each device on a flat and folded surgical drape to establish ignition risk. Finally, we evaluated the effects of all devices on human cadaver skin covered by surgical drape.Peak temperatures recorded for each device ranged from 26.9°C (flexible fiberoptic ureteroscope) to 194.5°C (fiberoptic cable). Drape ignition was noted when the fiberoptic cable was placed against a fold of drape. Contact with the fiberoptic cable, 10 mm laparoscope, 5 mm laparoscope, and distal sensor cystoscope resulted in cadaver skin damage. Cadaver skin damage occurred despite little or no visible change to the surgical drape. Rigid and flexible fiberoptic cystoscopes and flexible fiberoptic ureteroscopes had no effect on surgical drapes or cadaver skin.Fiberoptic light cables and some endoscopic devices have the potential to cause thermal injury and drape ignition. Thermal injury may occur without visible damage to drapes. Surgeons should remain vigilant regarding the risks associated with these devices and take necessary safety precautions to prevent patient injury.

Background: Since the development of the first flexible ureteroscope, in 1964, technological advances in image quality, flexibility, and deflection have led to the development of the first single-use digital flexible ureteroscope, LithoVue™ (Boston Scientific, Marlborough, MA). With respect to reusable fiber-optic and now digital ureteroscopes, there is an initial capital cost of several thousand dollars (USD) as well as, controversy regarding durability, the cost of repairs and the burdensome reprocessing steps of ureteroscopy. The single-use LithoVue eliminates the need for costly repairs, the occurrence of unpredictable performance, and procedural delays. Renal stones located in the lower pole of the kidney can be extremely challenging as extreme deflections of greater than 160° are difficult to maintain and are often further compromised when using stone treatment tools, such as laser fibers and baskets. This case describes an initial use of the LithoVue digital disposable ureteroscope in the effective treatment of lower pole calculi using a 365 μm holmium laser fiber. Case Report: A 35-year-old female, with a medical history significant for chronic bacteriuria, and recurrent symptomatic culture proven urinary tract infections, underwent localization studies. Retrograde ureteropyelography demonstrated two calcifications adjoining, measuring a total of 1.4 cm, overlying the left renal shadow. Urine aspirated yielded clinically significant, >100,000, Escherichia coli and Streptococcus anginosus bacteriuria, which was felt to be originating from the left lower calix. This case used the newly FDA-approved LithoVue flexible disposable ureteroscope. The two stones were seen using the ureteroscope passed through an ureteral access sheath in the lower pole calix. A 365 μm holmium laser fiber was inserted into the ureteroscope and advanced toward the stones. There was no loss of deflection as the ureteroscope performed reproducibly. The laser was used for more than 4000 pulses at 15 W, producing mucoid debris and fragments. A 1.9F nitinol basket was, then, used to extract the fragments, and the patient was rendered stone free. Treatment success was confirmed by plain abdominal film obtained 1 week after stent removal. Conclusion: The LithoVue system single-use digital flexible ureteroscope provides an economical advantage over both reusable digital and fiber-optic ureteroscopes. The LithoVue system uses the enhanced image resolution of the digital complementary metal oxide semiconductor imager, similar to other reusable digital ureteroscopes, while maintaining the small ureteroscope size of a flexible fiber-optic ureteroscope, allowing for consistent and effective lower pole access. Deflection characteristics are maintained even when thicker laser fibers are passed through the working channel.

Background: Endourology is a widely used means by which to manage urolithiasis. Patient anatomy can oftentimes limit what can be accomplished with current technology. Case Presentation: This is a case of a patient with renal and ureteral stones within a transplant kidney. Her anatomy would not allow for a standard retrograde ureteroscopic approach. We describe a method by which to overcome this difficult scenario by using a rigid cystoscope as a platform by which a ureteroscope was passed to allow for stone removal. Conclusion: For this difficult case, we effectively used our instruments to achieve our goal of retrograde ureteroscopy in a transplant kidney with an unfavorably angulated ureter.

Various endoscopic instruments used in treating renal stones have been used in managing bladder calculi. Our aim is to evaluate the use of transurethral ureteroscopic pneumatic cystolithotripsy for the management of large bladder calculi.In a retrospective study conducted between May 2005 and July 2011, 53 patients with solitary bladder stones were subjected to our technique, transurethral ureteroscopic pneumatic cystolithotripsy. The mean patient age was 54.3 years. The mean stone size was 4.8 cm. Diagnostic cystoscopy was performed first. A semirigid ureteroscope with a pneumatic probe was introduced through the cystoscope sheath, and pneumatic lithotripsy was performed. The cystoscope sheath works as a draining channel, allowing bladder evacuation. The bladder collapses over the stone and, subsequently, prevents stone migration, which shortens the lithotripsy's duration. Stone immobilization allows the transmission of full pneumatic power to the stone. The stone fragments were removed through periodic bladder irrigation using an Ellick evacuation-irrigation system, and a 16F Foley catheter was placed at the end of the procedure.Our technique was effective in all cases, including stone-free bladders. No surgical complications were detected. The mean operative time was 83 ± 21.0 minutes, which is comparable to that of standard management. The mean duration of lithotripsy and evacuation was 29.7 ± 18.4 minutes. In the postoperative period, patients were followed up for 18 months, with no urethral stricture being reported in any case.The transurethral ureteroscopic pneumatic cystolithotripsy procedure is a safe technique for the management of large bladder calculi. It allows the bladder to collapse over the stone, leading to stone immobilization and, subsequently, decreasing lithotripsy duration. Our procedure is associated with a minimal chance of postoperative urethral injury because all stone fragments are evacuated through the cystoscope sheath, without contact with the urethral urothelium.

Examination of the pyelocaliceal system using a flexible ureteroscope necessitates accurate orientation of the tip of the instrument. This study assessed the use of a novel real-time ureteroscopic navigation system in a pyelocaliceal phantom.The navigation system used a magnetic tracking device to determine the position of the ureteroscope in a pyelocaliceal phantom and displayed the position of the endoscope on a three-dimensional image that could be rotated. Twenty-eight urologists were divided into group A and group B (seven novice surgeons and seven experienced surgeons in each group). All participants were asked to examine the phantom and identify the positions of three designated calices, without the navigation system (Task 1) and with the navigation system (Task 2). In group A, participants performed Task 1 followed by Task 2. In group B, participants performed Task 2 followed by Task 1. The accuracy rate (AR) of identifying the calices, migration length (ML) of the tip of the ureteroscope, and time (T) taken to complete the task were recorded. The results were compared between Task 1 and Task 2, and between novice and experienced surgeons.The AR for Task 2 was 100% in both group A and group B. The AR was significantly lower in Task 1 than in Task 2 for both novice and experienced surgeons in both groups (group A: novice P=0.016, experienced P=0.034; group B: novice P=0.015, experienced P=0.015; Wilcoxon test). In Group A, T was significantly longer in Task 1 than in Task 2 for experienced surgeons. There were no significant differences in ML or T between novice and experienced surgeons.Our novel ureteroscopic navigation system improved the accuracy of ureteroscopic maneuvers. Further development of this system for use in clinical ureteroscopic procedures is planned.

Endoscopic treatment of renal calculi relies on surgeon assessment of residual stone fragment size for either basket removal or for the passage of fragments postoperatively. We therefore sought to determine the accuracy of endoscopic assessment of renal calculi size.Between January and May 2013, five board-certified endourologists participated in an ex vivo artificial endoscopic simulation. A total of 10 stones (pebbles) were measured (mm) by nonparticipating urologist (N.D.P.) with electronic calibers and placed into separate labeled opaque test tubes to prevent visualization of the stones through the side of the tube. Endourologists were blinded to the actual size of the stones. A flexible digital ureteroscope with a 200-μm core sized laser fiber in the working channel as a size reference was placed through the ureteroscope into the test tube to estimate the stone size (mm). Accuracy was determined by obtaining the correlation coefficient (r) and constructing an Altman-Bland plot.Endourologists tended to overestimate actual stone size by a margin of 0.05 mm. The Pearson correlation coefficient was r=0.924, with a p-value0.01. The estimation of small stones (4 mm) had a greater accuracy than large stones (≥4 mm), r=0.911 vs r=0.666. Altman-bland plot analysis suggests that surgeons are able to accurately estimate stone size within a range of -1.8 to +1.9 mm.This ex vivo simulation study demonstrates that endoscopic assessment is reliable when assessing stone size. On average, there was a slight tendency to overestimate stone size by 0.05 mm. Most endourologists could visually estimate stone size within 2 mm of the actual size. These findings could be generalized to state that endourologists are accurately able to intraoperatively assess residual stone fragment size to guide decision making.

Background and PurposeRecent advances in distal sensor technologies have made distal sensor ureteroscopes both commercially and technically feasible. We evaluated performance characteristics and optics of a new generation distal sensor Flex-XC (XC) and a standard flexible fiberoptic ureteroscope Flex-X2 (X2), both from Karl Storz, Tuttlingen, Germany.Materials and MethodsThe ureteroscopes were compared for active deflection, irrigation flow, and optical characteristics. Each ureteroscope was evaluated with an empty working channel and with various accessories. Optical characteristics (resolution, grayscale imaging, and color representation) were measured using United States Air Force test targets. We digitally recorded a renal porcine ureteroscopy and laser ablation of a stone with the X2 and with the XC. Edited footage of the recorded procedure was shown to different expert surgeons (n=8) on a high-definition monitor for evaluation by questionnaire for image quality and performance.ResultsThe XC had a higher resolution than the X2 at 20 and 10 mm 3.17 lines/mm vs 1.41 lines/mm, 10.1 vs 3.56, respectively (P=0.003, P=0.002). Color representation was better in the XC. There was no difference in contrast quality between the two ureteroscopes. For each individual ureteroscope, the upward deflection was greater than the downward deflection both with and without accessories. When compared with the X2, the XC manifested superior deflection and flow (P

It is generally advised to keep a safety guidewire (SGW) in the ureter alongside the ureteroscope during endoscopy of the upper urinary tract, but little is known of how the SGW influences the forces exerted on the ureteroscope in the ureter. The purpose of this study was to investigate whether the presence of an SGW during ureteroscopy (URS) in a normal clinical setting will influence the pushing and pulling forces exerted on a semirigid ureteroscope.In a 1-year period (2010-2011), 40 patients admitted to Haukeland University Hospital for endoscopic treatment of renal pelvic stone disease were included in a clinical randomized crossover trial measuring the forces needed to move a semirigid ureteroscope during URS. A digital force meter was connected to the ureteroscope to perform the force measurements. The pushing and pulling forces were measured at four locations during URS with and without an SGW. The patients were randomized to whether the first series of force measurements should be with or without SGW. Paired-samples t tests were used comparing the forces in the two series.Significantly higher forces were found both when inserting and retracting the semirigid endoscope when an SGW was used compared with times when an SGW was omitted. The mean percentage increase in the forces with an SGW in place varied between 51.8% and 112.5% across locations and directions. A limitation is that the study has been performed with a semirigid ureteroscope only.An SGW substantially increased the resistance against moving a semirigid ureteroscope up and down the ureter. The SGW may thus be an obstacle to the ureteroscopic procedure and may even increase the risk of harming the ureter in some patients.

Ascertaining the optimal depth of dilator progression is a crucial factor during tract dilation in percutaneous nephrolithotomy. Dilation is generally guided under fluoroscopy, ultrasonography, or combination of both techniques, and it is still difficult to prevent overdilation causing perforation and vascular injury or underdilation causing difficulty in establishment of access. Thus, improvements in dilation technique bears clinical significance. Our aim was to evaluate the feasibility in an animal model of using the "visual dilator system" for optimal percutaneous tract dilation under real-time visual guidance.The visual dilator system consisted of a transparent hollow dilator made of polyvinyl chloride and a rigid ureteroscope inserted within its lumen. The ureteroscope was connected to a standard endoscopic camera system. The dilator system backloaded with an access sheath was passed over a guidewire to dilate the tract and position the access sheath under visual guidance. Saline was used as irrigation to maintain clarity during dilation. The dilation technique was implemented to establish percutaneous access tract in six PCNL simulator models made from fresh porcine kidney placed inside an eviscerated chicken carcass and four female swine (eight kidneys) to experimentally evaluate its feasibility and efficacy.All tracts were successfully established with dilation through the intervening tissue layers, approach into the target calix, as well as access sheath placement being visually monitored through the dilator wall to confirm accuracy. All procedures were free of dilation-related complications such as collecting system perforation, excessive bleeding (in-vivo model), or loss of access. The limited number of animal models and lack of randomized comparative study with other dilator modalities were major drawbacks of the study.The study demonstrates feasibility of percutaneous access tract dilation using a Visual dilator system. This technique can provide visual confirmation of accuracy in dilation to improve safety and efficacy of the procedure.

For the narrow ureter that will not accommodate a ureteroscope, it is common practice to place a ureteral stent, to allow subsequent ureteroscopy in the passively dilated ureter. Surprisingly, there are limited data on the effectiveness or safety of these maneuvers.We retrospectively analyzed patients managed with ureteral stent placement followed by another attempt at ureteroscopy after an initial attempt of flexible ureteroscopy failed because the ureteroscope would not pass up an otherwise normal ureter.Of 41 patients with follow-up who underwent ureteral stenting for this reason, the ureteroscope passed with ease poststenting in 29 (71%) and there was continued resistance in 12. Of these 12 patients, the ureteroscopy was continued despite resistance in 9, while another stent was placed in the remaining 3. Of these three patients, the third attempt at ureteroscopy was successful in two, and further attempts at ureteroscopy were not made after the third attempt failed in one. With a mean overall follow-up of 32 months, two patients (5%) developed ureteral strictures. Both were among nine patients in whom repeat ureteroscopy was performed despite resistance, with a rate of obstruction of 22% in this subgroup. Overall, ureteral stenting allowed successful ureteroscopy in 98% of patients.Ureteral stenting with subsequent ureteroscopy is a successful and safe method of addressing a narrow ureter that initially does not allow passage of a flexible ureteroscope, as long as persistent subsequent attempts to insert the ureteroscope are made only if it passes easily.

Controversy exists in the literature regarding flexible ureterorenoscopy (F-URS) durability, with a variable expected number of uses from a new F-URS. In this study, a tertiary center experience with the use of two consecutive F-URS is reported and suggestions as to how to improve durability further are made.All F-URS performed in the same tertiary care center between July 2009 and February 2011, with two new instruments Flex-X, were reviewed retrospectively. All renal pathology were included. Ureteral cases were excluded. A 9.5F semirigid ureteroscope was always used at the start for a ureteral optical predilation and to explore the upper urinary tract for possible lithotripsy/laser ablation/biopsy. The F-URS was introduced sequentially to explore the remaining calices. Data pertaining to the procedure were collected. The method of sterilization was complete immersion with Cidex®.The instruments were substituted after 113 and 102 procedures, respectively. The first F-URS was used for a total operative time of 79 hours and 10 minutes while the second one was used for 71 hours and 25 minutes (mean 75 hours and 15 min). Procedure duration was 15 to 175 minutes (mean 58 min). The flexible instruments were used for a mean of 42 minutes per procedure (range 13-153 min). The indications for F-URS were therapeutic in 75.4% and diagnostic in 22.8% of the cases. For lower pole calculi, the stone was relocated in 65.2% and managed with the nonflexed flexible instrument 90% of the time. The most common causes of damage of F-URS were: Deflection mechanism impairment, inner sheath damage, and fiberoptic bundle breaks.Increased durability of F-URS was from a variety of factors, a key element of which was the method of sterilization, while routine use of the semirigid instrument initially further contributed significantly to increase the number of F-URS procedures, saving overall costs.

The development of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. We compared the use of semirigid and flexible ureteroscopy for the management of shockwave lithotripsy-refractory, isolated renal pelvic calculi by evaluating stone-free rates, operating room times, and associated complications.Ureteroscopic stone treatment was attempted in 47 patients with isolated renal pelvic stones between November 2008 and December 2010. The procedures were performed under general anesthesia. Semirigid ureteroscopy was routinely performed in all patients. If the stones were accessible in the renal pelvis with the semirigid ureteroscope (S-URS), they were then treated with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser through S-URS under direct vision. If the stones were not accessible, flexible ureteroscopy was then performed. Preoperative, operative, and postoperative data were retrospectively analyzed.In 25 of 47 patients, renal pelvic stones were accessible with S-URS, and the stones were fragmented with the Ho:YAG laser using S-URS. In the remaining 22 patients, the stones were accessed with the flexible ureteroscope (F-URS), and the fragmentation of stones was performed with the Ho:YAG laser using the F-URS. There were no significant differences in age, body mass index, grade of hydronephrosis, mean stone size, and stone laterality among the two groups. The mean operative times were 71.90 ± 17.90 minutes in the S-URS group and 93.41 ± 18.56 minutes in the F-URS group (P=0.001). The stone-free rates at postoperative day 1 and at the 1 month follow-up were 72% and 76% in the S-URS group and 81.8% and 86.4% in the F-URS group, respectively (P=0.861 and P=0.368). We found no significant differences among groups with regard to stone-free rates, complication rates, and hospital lengths of stay.Although it is well known that flexible ureteroscopy permits a detailed caliceal examination and therapeutic interventions, semirigid ureteroscopy is also often another sufficient means of reaching the renal pelvis in selected patients.

To evaluate forces exerted on a stone with different ureteroscopic irrigation systems.A 3 mm steel simulated stone was welded to a 3F stone basket and inserted into the working channel of a 4.5F Wolf semirigid ureteroscope. The basket shaft was attached to a 50 g load cell. The urterescope was placed in a ureteral model (14F silicon tubing). Simulated blood (McCormick™ Red Dye, 1 dye drop/15 mL H(2)O) was dripped adjacent to the stone at 12 drops/min. Endoirrigation devices were attached to the ureterscope and irrigation was applied at a rate sufficient to maintain visualization of the stone. Force on the stone was measured with the following endoirrigation systems: Boston Scientific™ Single-Action-Pump System (SAP) hand-pump and NuVista Medical™ Flo-Assist(®) foot-pump.No significant difference (p=0.19) in the number of pumps required to maintain a clear endoscopic field was found between the SAP (0.20±0.075/second) and Flo-Assist device (0.25±0.056/second). The pump duration of the Flo-Assist was found to be less (1.12±0.40 seconds) than the SAP (1.35±0.31 seconds), but not significantly different (p=0.24). The average maximum impulse was significantly lower (p=0.0002) for the SAP (8.34×10(-5) Ns) than the Flo-Assist (1.96×10(-3) Ns). Total maximum impulse (2.02×10(-5) Ns) for the SAP and total average impulse (5.51×10(-6) Ns) were found to be lower than the Flo-Assist device. The Flo-Assist had a total maximum impulse of 4.49×10(-4) Ns and total average impulse of 8.85×10(-6) Ns, however, these differences were not statistically significant.The hand-pump (SAP) and foot-pump (Flo-Assist) irrigation devices tested require comparable amounts of pumps for similar durations of time to maintain endoscopic visualization. Overall, the SAP device exerts less average maximum force on the stone than the Flo-Assist device.

Because of increased clinical relevance of retrograde intrarenal surgery (RIRS), a variety of stone retrieval baskets have been introduced into endourology. Differences in shape and material may have consequences in performance and efficacy of RIRS. The aim of the study was to evaluate the in vitro performance of multiple commercially available nitinol retrieval baskets.Ten manufacturers of baskets for RIRS were invited to participate in this evaluation. The evaluation included measurement of the basket's internal resistance toward deflection, the influence on the deflection angle of a flexible ureteroscope (URF-P5, Olympus), and basket function in maximum deflection of the scope. All measurements were performed five times.Nine manufacturers, providing a total of 15 baskets, decided to participate in this evaluation. Maximum deflection of the ureteroscope (275 degrees) was achieved in 12 baskets and reduced in 3. In maximum deflection, complete opening of the basket was possible in 13 samples. In one case, partial opening of the basket was possible; one basket failed. The measurement of the basket's internal resistance showed wide variations (5.97 to 38 mm deflection/g), consecutively leading to increased inner radius of the fully deflected scope in 10 of 15 tested samples.The tested baskets showed wide variations in their resistance toward bending. Influence on overall deflection capacity seems minor, however. On the other hand, higher resistance leads to increased inner radius of the fully deflected renoscope, which may alter functionality. Knowledge about the basket's key feature and differences in basket performance may be crucial to choose the best tool for the patient.

Recent advances in endoscope design have placed the charged coupled device chip on the tip of the endoscope. The image is instantly digitalized and converted into an electrical signal for transmission. Digital technology was first introduced into flexible cystoscopes/nephroscopes and subsequently into rigid and flexible ureteroscopes. Herein, we assess the image characteristics and advantages of a new generation of digital flexible ureteroscopes.The Olympus URF-V flexible digital ureteroscope and the Olympus URF-P3 fiberoptic ureteroscope were assessed in vitro for image resolution, distortion, color representation, grayscale imaging, field of view, and depth of field.The digital ureteroscope had a higher resolution at 3, 5, 10, and 20 mm (25.2 lines/mm vs. 8.0, 14.1 vs. 5.0, 6.3 vs. 2.8, and 3.2 vs. 1.3), respectively. Distortion with the digital flexible ureteroscope was lower, though not statistically significant. Color representation was better with the digital ureteroscope, whereas contrast evaluation was comparable between both scopes. The digital flexlible ureteroscope produced a 5.3 times larger image size compared with the standard fiberoptic flexible uretersocpe with a narrower field of view. The depth of field was limited by light and not the optic or the camera for both ureteroscopes.The development of digital flexible ureteroscopes represents a significant technological advance in urology. These devices offer significantly improved resolution and color reproduction as compared with traditional fiberoptic flexible ureteroscopes. Future clinical trials are warranted to ultimately determine the advantages of these innovative endoscopes.

It has been postulated that laser insertion sheaths prevent mechanical damage to the inside of working channels of flexible ureteroscopes. The presented study, for the first time, aims at confirming this hypothesis and visualized the damage of the endoscopic working channel by video-endoluminal observation after a series of laser fiber passages with or without the protection of a laser fiber insertion sheath.Four nonassembled working channels of two different manufacturers (Olympus™, Wolf™) were tested in a deflection model (50° and 180°). Flexifib™ laser fibers (LISA laser products) with an optical core diameter of 273 μm were inserted through 0.9% NaCl irrigated working channels in cycles of 10 insertions either with or without protection of the Flexgard™ insertion sheath. After 30 insertions, the examination cycle was reduced to 5 insertions each cycle until breakage. Test cycles were followed by endoluminal video examination of the working channel with the 2.4F flexible fiber scope by Polydiagnost™. Damage to the working channel was classified as streaks with superficial stress marks of the surface, scratches with embossed margins, or perforations.No scratching or perforation occurred in the insertion sheath group in up to 150 insertions in all working channels and both deflection grades. In the group without insertion sheaths, scratches were visible after 40 to 50 insertions with 50° deflection and 30 insertions with 180° deflection. Perforations of the working channels were seen after 95 insertions with 50° and 60 insertions with 180° deflection.Severe damage to working channels depends on the degree of deflection and may occur after 30 insertions only. Relevant damage to the working channel may be avoided by using a laser fiber insertion sheath.

Purpose: To characterize the mechanical and optical properties of the PolyScope ® endoscope system and to examine the clinical outcome in patients who were undergoing ureteronephroscopy. Materials and Methods: Mechanical assessment involved measurement of the deflection angle and irrigation flow rate. Optical resolution and distortion, field and angle of view, and light transmission and output formed the optical assessment. Clinical assessment was made in a series of consecutive ureteronephroscopy procedures. The optical cord was disconnected after each procedure, and the image fiber was assessed for damage. Results: The mean value for the angle of maximum active tip deflection with an empty working channel was 265 degrees (261-275 degrees). Deflection was impaired most with insertion of the 3.0F basket (10% decrease) and least with an indwelling 220μm laser fiber (2% decrease). Irrigation flow rate was 57mL/min with an empty working channel. Flow was reduced by 50% and 68%, with the insertion of a 200μm or 365μm laser probe, respectively, and by 92.5% with a 3.2F basket. No damage to the image fiber occurred. The PolyScope optics system could identify a target of about 0.125mm at a distance of 2 to 4mm, based on 3 line-pairs/mm needed for clear identification. Lithotripsy of renal calculi was performed for 40 stone burdens in 32 patients; the resulting stone-free rate was 87.5%. Conclusion: The novel semidisposable ureteroscope system PolyScope was simple to use, effective, and reliable in this preliminary clinical evaluation. It overcomes the inherent fragility of comparable devices, which renders the need for maintenance unnecessary.

Purpose: To evaluate the indications for, and the effects of, the management of renal caliceal calculi with deflectable tip rigid ureteroscopy. Patients and Methods: We designed a new deflectable tip rigid ureteroscope, and 175 patients with renal caliceal calculi received deflectable tip rigid ureteroscopic lithotripsy with a holmium laser. Results: From December 2003 to December 2007, the procedure was successfully performed in all patients with a mean operative time of 28 minutes (range 19–45 min). The mean size of renal caliceal stones was 1.3 cm (range 0.8–2.4 cm). Seventeen patients had concurrent proximal ureteral calculi. The mean lithotripsy time was 11 minutes (range 5–22 min), and the mean discharge time was 3 days after operation. The overall stone-free rate at the 1-month follow-up was 83%. Conclusion: Ureteroscopic lithotripsy with the novel deflectable tip rigid ureteroscope is a safe procedure and combines the advantages of rigid and flexible ureteroscopy, especially for renal cal...

Retrieval of a proximally migrated ureteral stent is a technically challenging endoscopic procedure. We describe the use of a paired wire helical stone retrieval basket through a flexible ureteroscope to remove proximally migrated ureteral stents.Five ureteral stents were lost in the proximal (1) and distal (4) ureter after lithotripsy or stent exchange. Once the location of the distal aspect of the ureteral stent was identified by either fluoroscopy or ureteroscopy, a safety guidewire was placed alongside the migrated stent. A flexible ureteroscope was brought to the distal end of the stent under direct visualization. Through the working port of the ureteroscope, the paired wire helical basket was deployed to grasp or coaxially cannulate the lumen of the migrated stent. Once inside the stent, the basket was then opened. The outward resistance of the deployed basket is sufficient to provide enough lateral force to reposition the stent into the bladder.All stents were successfully retrieved without complication. No patient had visual evidence of ureteral injury, and all patients were discharged on the same day as their procedure.While proximal migration of a ureteral stent is usually caused by technical error, the ideal technique to reposition the stent should require the least time, trauma to the ureter, and expense to the patient. We describe a simple technique to retrieve migrated stents anywhere along the urinary tract.

Background and Purpose: Urologic resectoscope loops often are manipulated to reposition the angle. The effects of these maneuvers on the efficiency and functionality of the loop have never been tested. Our goal was to evaluate the changes in tensile strength, conductivity, and dispersion of cautery effect resulting from such manipulation. Materials and Methods: Resectoscope loops manufactured by Karl Storz, Olympus, Boston Scientific, and ACMI were tested for tensile strength and unevenness of cautery effect before and after one manipulation from an angel of 15° posterior to 15° anterior deviation. Results: Prior to manipulation, the loops demonstrated a tensile strength of approximately 40 lb to failure. After one manipulation, the tensile strength was reduced by 90.1% (P < 0.001), with 46.7% of the loops failing to meet minimum industry standards. Manipulation of the loops increased the resistance to current flow within the wire. Microscopic evaluation showed longitudinal fracture lines at the manipulated sites. Conclusion: Physician-manipulated resectoscope loop angles have a dramatic effect on the strength of the loop as well as the dispersion of energy. A bend of 30° results in 46.7% of the loops failing to meet minimum tensile-strength standards and alters the effectiveness and dispersion of electrical current. Infrared photography confirms the defect to be generated at the point of manipulation, thereby reducing the anticipated capabilities at a constant setting of the loop energizer. Ultimately, the quality of surgical resection suffers from even one manipulation of a resectoscope loop.

We studied the physical damage to the working channel of flexible ureteroscopes caused by insertion of various accessories. A procedure was developed to avoid channel damage.An experimental model representing a flexible ureteroscope was prepared, and damage to its working channel was evaluated by inserting instruments through it. Deflection angles of the channel were changed from 0 degrees to 120 degrees, and each device was inserted and removed 100 times for each selected angle of the channel. Any induced pinholes were identified by an air-leak test. Also, the inside of the channel was inspected with an extremely fine fiberscope.Insertions of 3F biopsy forceps or a 2.4F Nitinol stone-retrieval device caused only slight damage to the model channel, even when the deflection angle was 120 degrees. However, the tips of 200- or 250-microm holmium laser fibers shaved the inner surface of the channel at 60 degrees of deflection, and at 120 degrees, the laser fiber either penetrated the channel or could not be advanced because of resistance by the channel wall. When the laser fiber was inserted within a protective tube, the channel was never damaged, even when the deflection angle was 120 degrees.When devices are inserted into the working channel of a flexible ureteroscope, damage to the wall depends on the kind of device and deflection angle. Harm could be avoided by inserting the devices, especially laser probes, within a protective tube.

Introduction of an instrument into the working channel of ureteroscopes adversely affects flow and deflection. We evaluated the alterations in ureteroscope channel flow and deflection caused by available Nitinol(R) baskets.We compared the effects of 11 Nitinol baskets on irrigation flow and deflection of three flexible ureteroscopes (Olympus P3, ACMI DUR8, and ACMI DUR8 Elite). ANOVA was used to compare the loss of flow and deflection for each basket, with P values adjusted for multiple comparisons by the Tukey method.Ureteroscope flow and deflection were progressively adversely affected by all baskets as their diameter increased. The average baseline irrigant flow (46.6 mL/min) was decreased significantly: by 78.5% (to 9.9 mL/min), with the smaller baskets (Microvasive 1.9F and Cook 2.2F) and by 99.1% (to 0.4 mL/min) with the larger baskets (ACMI 3.0F and Microvasive 3.0F). Similarly, the mean baseline upward deflection (162 degrees) decreased by 2 degrees (1.2%) for the Cook 2.4F N-Compass and by 20 degrees (12.3%) for the ACMI 3.0F. Loss of downward deflection from baseline (170 degrees) ranged from 6 degrees (3.5%) for the Microvasive 1.9F to 17 degrees (10%) for the Microvasive 2.6F grasping forceps. The least deterioration in flow and deflection occurred with the two smallest baskets (Microvasive 1.9F and Cook 2.2F).Ureteroscope irrigation flow and deflection deteriorate progressively with larger-caliber Nitinol baskets. The Microvasive 1.9F and Cook 2.2F baskets resulted in the least deterioration of irrigation and deflection metrics. However, basket size is not the only factor responsible for changes in flow and ureteroscope deflection.

The Peditrol is a novel hands-free irrigation device that delivers a bolus of irrigant through the ureteroscope when the foot pedal is deployed. The purpose of this study was to compare the flow and pressures created by the Peditrol with those of commonly used methods of irrigation.Flows through a flexible 6.9F Olympus ureteroscope (F-URS) and a 7.5F semirigid ACMI ureteroscope (S-URS) were measured in duplicate with the working channel empty and with a 2.2F Nitinol basket or a laser fiber in the working port. Irrigant flow was pressurized by gravity drainage at 100 cm H(2)O (GI), pressurized irrigant bag at 300 cm H(2)O (PI), handheld 60-cc syringe (HS), and the Peditrol. A 20-gauge angiocatheter was placed through the parenchyma into the renal pelvis of an ex-vivo cadaveric porcine kidney and attached to a pressure transducer. Pressures were measured in triplicate using the same irrigation techniques.With a basket or 200-microm laser fiber in the working port of the F-URS, Peditrol mean flows were superior to those of PI (3.3 and 6.3 times, respectively; P0.001) but similar to those of HS (0.7 to 1.1 times). All irrigation types resulted in intrarenal pressures greater than gravity irrigation (P0.05). The Peditrol demonstrated intrapelvic pressures40 cm H(2)O when used with a 12/14F ureteral access sheath (AS). Without an AS, the intrapelvic pressure reached 92 cm H(2)O, similar to the pressures reached with the S-URS under various irrigation conditions (84-287 cm H(2)O) and comparable to the HS method through the F-URS (97 cm H(2)O).The Peditrol irrigation device generates superior flow through an F-URS compared with GI or PI, particularly with an instrument in the working port. Intrarenal pressures when used with an F-URS and AS are low. When an AS is not used, the intrarenal pressure is similar to or lower than pressures obtained using an S-URS with different irrigation modalities.

The role of ureteronephroscopy in the diagnosis and treatment of upper-tract disease has expanded dramatically in recent years with technological advances. In a study involving 14 urologists, we measured the practical performance and durability of the most common commercially available flexible ureteroscopes.Six commercially available flexible ureteroscopes (Circon-ACMI DUR 8, ACMI DUR 8-Elite, Storz 11274AA, Wolf 7325.172-7.5Fr, Wolf 7330.072-9.0 Fr, Olympus URF-P3) were used consecutively 102 times over a 7-month period. Comparative data, including preoperative and postoperative maximal deflection angles and luminosity, were accumulated, as well as a survey of insertion methods, irrigation methods, instruments used in the working channel, visibility, maneuverability, and overall satisfaction. Maintenance records were analyzed to evaluate the need or reason for repair.Overall satisfaction, visibility, luminosity, and maneuverability were similar for all instruments. The ACMI DUR-8 Elite scored slightly higher than the others, but the difference was not statistically significant. Ureteroscopes were used an average of 10 to 34 times between breakages. The ACMI DUR-8 and DUR-8 Elite instruments had a higher durability score than the others, but with significantly more uses. Channel perforation by a laser fiber was the predominant cause of ureteroscope breakage.All ureteroscopes performed similarly by objective and subjective criteria. The largest and newest instruments were significantly more durable than the smaller ones, even in the hands of numerous endoscopists. This finding has significant implications for the cost-effectiveness of the various ureteroscopes.

Ultrasonic lithotripsy was one of the first modalities used for treating renal and ureteral stones. However, in recent years, it has been largely replaced by newer techniques such as laser lithotripsy with rigid as well as flexible ureteroscopes. The aim of this study was to review the results and our current indications for ureteroscopic ultrasonic lithotripsy (UUL).Between October 2000 and May 2002, 340 ureteroscopies were performed for the treatment of ureteral stones in the Rabin Medical Center. Of this series, 9 patients (2.6%) underwent UUL using a semirigid 8F ureteroscope (Wolf) and an Olympus ultrasonic lithotripter (LUS-1) with a 4.5F hollow probe. Four patients had Steinstrasse following shockwave lithotripsy, four had large (1-2-mm) ureteral stones, and one had an impacted calcified ureteral double-J stent. Stones5 mm were initially fragmented by the holmium laser (550-microm fiber). A double-J stent was placed in all patients. The mean follow-up time was 20 months.The mean operative time was 84 minutes. No intraoperative complications occurred. The mean hospital stay was 3.9 days. Eight patients became stone free after the first procedure, and the other underwent secondary ureteroscopy, which rendered him stone free.Patients in whom UUL is performed are relatively complex stone patients. The use of ultrasonic lithotripsy following, or in combination with, laser or ballistic devices utilizes the unique properties of UUL, which combines stone fragmentation and efficient removal of small fragments. The technique was particularly useful in patients with Steinstrasse or a large stone burden. Thus, UUL has a limited but significant role in the treatment of ureteral stones.

One of the barriers to a more widespread dissemination of flexible ureteroscopy are the costs associated with the ureteroscope itself. The initial purchase price of the ureteroscope can be high, and the lifespan of the scope can be distressingly short. An important challenge inherent in the use of reusable flexible ureteroscopes is the oftentimes-involved process of cleaning the scope from a previous case and readying it for the next case. These processes are complex, and involve multiple personnel throughout many positions within the hospital (nurses, technologists, technicians, etc). A complete accounting of the costs associated with flexible ureteroscopy must, necessarily take all of these steps into consideration. The authors have performed a very nice study that takes the first step towards such an accounting. As the economic pressures associated with medical care become ever more intense, a better understanding of the true costs of surgical procedures is most welcome. For flexible ureteroscopy, a pr...

We report our initial experience with a prototype ureteroscope having the smallest tip diameter and shaft with an offset eyepiece for the treatment of ureteral stones.A series of 21 male and 4 female patients between the ages of 1.5 and 57 years underwent treatment with the new ureteroscope for stones in the lower (24) and middle (1) ureter. All four of the children were boys. All patients were operated on by a single urologist. Patient sex, age, side, location and size of stone, type of anesthesia, requirement for a guidewire, use of stent, requirement for ureteral dilatation, operative time, type of intracorporeal lithotripsy used if any, type of stone-grasping device used, success rate, length of hospital stay, and complications were recorded.None of the patients required ureteral dilatation, and a guidewire was used in only three patients. Eight patients were operated on with instillation of 2% lidocaine gel alone, while another five patients required intravenous pentazocine and midazolam. Eight patients were operated on with monitored anesthesia care under propofol and one under ketamine. Three patients required general anesthesia. A double-J stent was not required in 15 patients. The success rate was 100%, and complications were minor.The new ureteroscope can treat the majority of lower-ureteral stones of up to 1.2 cm even in male patients under lidocaine gel with or without intravenous sedation or monitored anesthesia care. These patients can be treated as day-care cases. None of the patients required ureteral dilatation, and stent is now being omitted in most patients. All children were treated in one session.

Whereas ureteroscopic lithotripsy is more efficacious than SWL in treating lower-ureteral stones, the same has not been universally said of its ability to treat proximal ureteral stones. Because failed proximal lithotripsy is often attributable to the complications associated with stone migration into the renal pelvis and calices, an instrument that can prevent this migration is a potentially important tool in the ureteroscopic armamentarium. This study sought to assess the role of just such an instrument, the Stone Cone, in proximal-ureteral lithotripsy.We treated 19 consecutive patients having proximal-ureteral stones using semirigid ureteroscopy, a Stone Cone Nitinol urologic retrieval coil, and holmium:YAG laser lithotripsy with a 200- or 365-microm fiber. In all patients, both the Stone Cone and the laser fiber were utilized under direct visual guidance through the working channel(s) of the ureteroscope.All 19 patients were rendered stone free after Ho:YAG laser lithotripsy in conjunction with a Stone Cone. No stone fragments were noted to migrate into the renal pelvis, and the Stone Cone did not break or become entrapped in any of the 19 cases.The Stone Cone is a powerful new tool for proximal-ureteral lithotripsy and will likely revolutionize the treatment of proximal-ureteral stones. The savings in morbidity, time, and money associated with not having to chase stone fragments using flexible ureteroscopy are considerable.

Prior to the development of the technique of laser prostatectomy, contemporary modifications to resectoscope design for transurethral prostatectomy had been scant. With the introduction of laser prostatectomy and the characterization of the "mini-TURP" technique, a new demand for improved continuous-flow cystoscopes and resectoscopes has developed. The ideal cystoscope design for laser prostatectomy would require the following: (1) continuous irrigant flow for optimum cooling of the laser element; (2) a large inflow port so that flow is not impaired by the presence of the fiber in the working channel; (3) a large outflow port to maximize irrigant flow; and (4) a fiber stabilizer to enable easy manipulation of the fiber in the center of the viewing field. The ideal resectoscope design for laser prostatectomy would require the following: (1) continuous flow of irrigant for cooling of the laser fiber; (2) stabilization of the laser fiber in the center of the field of view; (3) the ability to interchange electrocautery loops with laser fibers without changing the sheath; and (4) the ability to apply laser energy to tissue with the same Iglesias action used in transurethral resection of the prostate (TURP). This review analyzes the features of the new continuous-flow cystoscopes and resectoscopes manufactured specifically for use in laser prostatectomy. All manufacturers were requested to submit their most up-to-date literature and photographs of the specific instruments they manufacture. The technical specifications, advantages, and disadvantages of each instrument are discussed.

Introduction: This video presents our novel endoscopic technique for management of complete ureteral avulsion from uretero-vesical junction (UVJ). Materials and Methods: A retrospective study of prospective data on 1934 ureteroscopic stone manipulation procedures performed at our Urology Department in Saudi German Hospital–Jeddah from January 2001 to January 2011 was conducted. The ureterorenoscope used was an 8F, Storz, semirigid ureterorenoscope. During this period, three cases of complete ureteral avulsion from UVJ were recorded. All these three cases were managed successfully by our novel endoscopic technique that we present in this video. Surgical Procedure: Postavulsion event, the ureteroscope is withdrawn outside the patient keeping the guidewire (GW) in place. A Double-J (DJ) stent is then applied along the GW up to the kidney. The ureteroscope is then reinserted into the bladder, and guided by the DJ through the avulsion site into the retro peritoneum up to the lower end of the avulsed u...

Purpose: To recommend a novel endoscope, Aihua (AH)-1 stone removal system (SRS), and introduce the structure and function to treat bladder stones. Materials: SRS is composed by illuminant and imaging component, continuous-flow component, a jaw to grab and extract stone, lithotripsy tube, handle, and sheath. The entire device is usually attached to a video camera to provide vision for the surgeon. During surgical procedure, first 26F SRS was inserted into bladder to search stone. Then, stone was grabbed and fixed using jaw, and lithotripsy was performed with holmium laser or pneumatic lithotripter through lithotripsy tube. Fragments could be extracted using jaw through sheath synchronously. If there were more residual small fragments, Ellik evacuator could be connected with sheath to wash out them. Finally, resectoscope was inserted in urethra to perform transurethral resection of the prostate (TURP). Between January 2008 and July 2010, 37 cases of bladder stone with benign prostatic hyperplasia ...

Background: Flexible ureteroscopy is used for diagnosing and treating upper urinary tract diseases. Despite technological advances in making flexible ureteroscopes smaller, they suffer from a grainy image. Therefore, new technology with better resolution is needed. New Technology: The new Invisio DUR-D digital flexible ureteroscope from Gyrus ACMI was tested. The tip houses dual LED-driven light carriers, which obviates the need for an external light source, thus eliminating the risk of drape fires and patient burns. A 1-mm digital camera at the tip eliminates the need for fragile low-resolution fiberoptics and provides superior resolution. Since there are no external cameras or light cables, the DUR-D is much lighter (505 g compared with 1012 g). Laser detection system deactivates the laser to prevent accidental misfiring of the laser within the ureteroscope. Conclusions: The latest generation of digital ureteroscopes provides superior resolution and safety. Long term use is needed to test its durability.

Most patients are stented after ureteroscopy for stone extraction. This practice necessitates a second procedure to remove the stent, with its inherent morbidity. The aim of our study was to determine whether routine stenting of the ureter is really necessary after ureteroscopy.This prospective study evaluated 26 men and 18 women admitted for elective distal ureteral stone fragmentation. The stones ranged in size from 6 mm to 1 cm. Of the series, 16 patients (10 men) had been stented prior to ureteroscopy. A 9F semirigid ureteroscope was used in 31 cases, and a 7.5F semirigid ureteroscope was used in the other 11 cases; there was no need for ureteral orifice dilatation with either ureteroscope. Ballistic intracorporeal lithotripsy was performed in all cases with the Swiss Lithoclast; all stone fragments were retrieved with a 3F helical basket. The patients were followed up as inpatients for 24 hours and reviewed in the clinic 1 week later with a request to report if they felt significant discomfort or loin pain or became feverish.Only one patient (male) had to be readmitted with loin pain. Two others (both women) complained when they attended for follow-up of having had dull lower abdominal pain and some frequency.The low incidence of complications in this preliminary study suggests that routine stenting is not necessary after ureteroscopy. The chief exception to this statement is patients who had a difficult and prolonged stone fragmentation.

The Finlayson ureteral access system was used to facilitate passage of the 11.5F rigid ureteroscope in 31 patients (32 procedures). Patients ranged in age from 19 to 87 years. The indications were ...

Flexible nephroscopes and ureteroscopes make it possible to see calculi in remote calices, but it is often impossible to remove these with existing technology. Flat-wire baskets impede deflection and can traumatize the papilla. This study compares the performance of a new 3.2F tipless nickel-titanium (Nitinol) basket with that of an existing 3.0F flat-wire basket. Specifications were compared using a 15F nephroscope and a 7.5F flexible ureteroscope in a pig kidney model. A calculus was placed in a calix, and the author and two residents were timed while using both baskets to retrieve the stone. To open fully, the flat-wire basket needed to protrude 1.2 cm further than the tipless basket. The tipless basket did not restrict deflection of the nephroscope, whereas the flat-wire basket limited flexion by 24 degrees and extension by 28 degrees. The tipless basket did not restrict extension of the 7.5F ureteroscope but limited flexion by 10 degrees. The flat-wire basket limited flexion by 79 degrees and extension by 72 degrees. Using the pig kidney model, the three operators took a mean of 5.3, 11.8, and 6.4 seconds to catch the stone with the tipless basket. Using the flat-wire basket, the mean times were 15.3, 34.5, and 28.9 seconds (combined data: 8.2 seconds for the tipless basket and 27.8 seconds with the flat-wire basket; P = 0.0001). Only the flat-wire basket was seen to traumatize the papilla. The Nitinol tipless basket has significant advantages over the flat-wire basket.

Seventy-three patients with ureteral calculi ranging in size from 5 x 5 to 10 x 30 mm and two patients with Steinstrasse underwent lithotripsy with a pulsed tunable dye laser (504-nm wavelength; l-µsec bursts). The laser fiber was passed through a ureteral catheter or a new laser basket via a ureteroscope. In 70 cases, the patients were partially or entirely freed of stones. There were three equipment failures necessitating another form of lithotripsy, and two stones (one of brushite and one of cystine) that did not respond to laser energy and required ultrasonic lithotripsy. The laser is particularly useful in patients with impacted ureteral stones that cannot be bypassed and requires a smaller ureteroscope than does ultrasonic lithotripsy. It is now my preferred type of ureteroscopic lithotripsy unless the stone is thought to be of calcium oxalate monohydrate.