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      Controversies in ureteroscopy: Wire, basket, and sheath

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          Abstract

          In the last one to two decades, flexible ureteroscopy has rapidly expanded its role in the treatment of urologic stone disease. With the frequent and expanded use of flexible ureteroscopy, other ancillary instruments were developed in order to ease and facilitate this technique, such as ureteral access sheaths (UAS) and a variety of wires and baskets. These developments, along with improved surgeon ureteroscopic competence, have often brought into question the need to implement the “traditional technique” of flexible ureteroscopy. In this review, we discuss a brief history of flexible ureteroscopy, its expanded indications, and the controversy surrounding the use of UAS, wires, and baskets.

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          Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation.

          B Auge, Glenn Preminger, Sumal V. Raj … (2004)
          New-generation flexible ureteroscopes allow the management of proximal ureteral and intrarenal pathology with high success rates, including complete removal of ureteral and renal calculi. One problem is that the irrigation pressures generated within the collecting system can be significantly elevated, as evidenced by pyelovenous and pyelolymphatic backflow seen during retrograde pyelography. We sought to determine if the ureteral access sheath (UAS) can offer protection from high intrarenal pressures attained during routine ureteroscopic stone surgery. Five patients (average age 72.6 years) evaluated in the emergency department for obstructing calculi underwent percutaneous nephrostomy (PCN) tube placement to decompress their collecting systems. The indications for PCN tube placement were obstructive renal failure (N=1), urosepsis (N=2), and obstruction with uncontrolled pain and elevated white blood cell counts (N=2). Flexible ureteroscopy was subsequently performed with and without the aid of the UAS while pressures were measured via the nephrostomy tube connected to a pressure transducer. Pressures were recorded at baseline and in the distal, mid, and proximal ureter and renal pelvis, first without the UAS, and then with the UAS in place. The average baseline pressure within the collecting system was 13.6 mm Hg. The mean intrarenal pressure with the ureteroscope in the distal ureter without the UAS was 60 mm Hg and with the UAS was 15 mm Hg. With the ureteroscope in the midureter, the pressures were 65.6 and 17.5 mm Hg, respectively; with the ureteroscope in the proximal ureter 79.2 and 24 mm Hg, and with the ureteroscope in the renal pelvis 94.4 and 40.6 mm Hg, respectively. All differences at each location were statistically significant (P<0.008). Compared with baseline, all pressures measured without the UAS were significantly greater, but only pressures recorded in the proximal ureter and renal pelvis after UAS insertion were significantly higher (P<0.03). The irrigation pressures transmitted to the renal pelvis and subsequently to the parenchyma are significantly greater during routine URS without the use of the UAS. The access sheath is potentially protective against pyelovenous and pyelolymphatic backflow, with clinical implications for the ureteroscopic management of upper-tract transitional cell carcinoma, struvite stones, or calculi associated with urinary tract infection.
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            Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience.

            Ravi Munver, V Bird, Jayant Uberoi … (2010)
            Percutaneous nephrostolithotomy (PCNL) is the current standard of care for management of large renal stones (>2 cm). Recent studies have evaluated flexible ureterorenoscopy (URS)/holmium laser lithotripsy as an alternative treatment for patients with contraindications to or preference against PCNL. Stones in an intermediate size range (2-3 cm) may be most amenable to URS/laser lithotripsy as definitive treatment in a single stage. We report a multi-institutional series of URS/laser lithotripsy for renal stone burdens that measure 2 to 3 cm. Patients who underwent URS/holmium laser lithotripsy for renal stones that measured 2 to 3 cm were identified retrospectively at three tertiary care centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients with renal stone burdens of 2 to 3 cm who were treated by URS/laser lithotripsy and had at least one postoperative visit and imaging study were included. Stone clearance was evaluated using 0-2 mm and <4 mm residual stone burden on postoperative imaging. One hundred and twenty patients underwent URS/holmium laser lithotripsy for renal stones of 2 to 3 cm. Mean stone burden was 2.4 cm, and mean body mass index was 29.3 kg/m². Indications for URS/laser lithotripsy vs PCNL included patient preference (57), technical or anatomic factors (24), patient comorbidities (17), failed shockwave lithotripsy (9), patient body habitus (3), solitary kidney (3), chronic renal insufficiency (3), and strict anticoagulation (2). Thirty-one (26%) patients had stent placement preprocedure, and 94 (78%) patients underwent outpatient surgery. A ureteral access sheath was used in 67%. One hundred and one (84%) patients underwent single-stage procedures. There was one intraoperative complication (ureteral perforation), and there were eight minor postoperative complications (6.7%). The reoperation rate through the mean 18-month follow-up was 3/120 or 2.5%. Seventy-six (63%) patients had residual stone burden of 0 to 2 mm, and 100 (83%) patients had residual burden of <4 mm. We demonstrate that single-stage URS/holmium laser lithotripsy is effective for management of renal stones that measure 2 to 3 cm through intermediate follow-up. Staged procedures can be used selectively for technical reasons or disease factors. Although PCNL achieves superior stone clearance overall, URS/laser lithotripsy is a viable treatment option for selected patients.
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              Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr.

              J S Afane, E O Olweny, E Bercowsky … (2000)
              Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting. We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability. The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit. Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Urol
                Journal ID (iso-abbrev): Indian J Urol
                Journal ID (publisher-id): IJU
                Title: Indian Journal of Urology : IJU : Journal of the Urological Society of India
                Publisher: Medknow Publications & Media Pvt Ltd (India )
                ISSN (Print): 0970-1591
                ISSN (Electronic): 1998-3824
                Publication date (Print): Jul-Sep 2013
                Volume: 29
                Issue: 3
                Pages: 244-248
                Affiliations
                [1]Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
                Author notes
                For correspondence: Dr. Manoj Monga, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Q10-1, Cleveland, OH 44195, USA. E-mail: mongam@ 123456ccf.org
                Article
                Publisher ID: IJU-29-244
                DOI: 10.4103/0970-1591.117287
                PMC ID: 3783706
                PubMed ID: 24082447
                SO-VID: a7d59a85-afc7-49e8-9770-2a275ffd8b3a
                Copyright © Copyright: © Indian Journal of Urology
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Categories
                Subject: Symposium

                ScienceOpen disciplines: Urology
                Keywords: basket,calculus,controversy in urology,flexible ureteroscopy,safety wire,ureter,ureteral access sheath
                Data availability:
                ScienceOpen disciplines: Urology
                Keywords: basket, calculus, controversy in urology, flexible ureteroscopy, safety wire, ureter, ureteral access sheath

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