A study comparing dusting to basketing for renal stones ≤ 2 cm during flexible ureteroscopy

ABSTRACT Objectives To compare the dusting efficiency and safety with basketing for treating renal stones ≤ 2 cm during flexible ureteroscopy (fURS). Materials and methods This study included 218 patients with renal stones ≤ 2 cm treated with fURS. Among them, 106 patients underwent dusting, and 112 patients underwent fragmentation with basket extraction. All patients were followed up for 3 months postoperatively. The operating time, lasing time, stone-free rate (SFR) and complication rate were compared. Results The mean stone size in the dusting group was 1.3 cm, whereas 1.4 cm in the basketing group. The mean operative time was significantly lower in the dusting group than in the basketing group (43.1±11.7 minutes VS 60.5±13.4 minutes, P <0.05), but the lasing time was significantly longer for the dusting group than for the basketing group (17.7±3.9 minutes VS 14.1±3.6 minutes, P <0.05). SFR was significantly higher in the basketing group immediately after the operation and follow-up after 1 month (76.8% vs 55.7%, P= 0.001 and 88.4% vs 78.3%, P = 0.045). However, the SFR was similar for both groups (88.8% in the dusting group vs. 90.2% in the basketing group) after 3 months postoperatively. There was no statistical difference in the complication rates between the two groups. Conclusions Dusting has advantages in shortening the operation time and reducing the operation cost, but the lasing time was longer compared with the basketing. Although there is no difference in long-term effect, basketing is superior to dusting in terms of short-term SFR. Moreover, dusting should be avoided in some special cases and basketing a better choice. Both techniques are effective for the treatment of renal stones ≤ 2 cm and choice depends on patient demographic and stone characteristics.

Nefrolitotomía Endoscópica ex vivo del injerto renal de donante vivo con instrumento flexible

Introduction: The finding of an asymptomatic stone in the study of a living kidney donor does not necessarily contraindicate donation, however, there is no consensus on the management of these cases. The use of a graft with lithiasis may represent a risk of recurrence in the remaining kidney in the donor and eventual obstructive complications in the transplanted kidney. The objective of this work is to present the usefulness of ureteroscopy (URS) to resolve lithiasis ex vivo before transplantation. Material and Methods: Donors with a small, asymptomatic kidney stone and with an analysis of lithogenic factors without relevant findings were considered to continue in the donation process. The kidney unit with stone was selected for nephrectomy. Results: Four donor kidneys underwent flexible URS after nephrectomy under hypothermic preservation conditions during bench preparation. The average time of the procedure was 35 minutes and the stone was extracted in all cases without incident. The transplant was carried out in the usual way and the evolution of the recipients was without complications and with excellent renal function. During follow-up, no recurrence of lithiasis was observed in donors or recipients. Conclusions: In this experience, the URS of the donor kidney was a feasible procedure and was not associated with adverse consequences for the graft. The main advantage of this procedure is to avoid the potential risk to the recipient of an obstructive graft complication.

Comparison of safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by flexible ure-teroscopy / 北京大学学报(医学版)

OBJECTIVE@#To compare the safety and effectiveness of active migration technique and in situ lithotripsy technique in the treatment of 1-2 cm upper ureteral calculi by retrograde flexible ureteroscopy.@*METHODS@#A total of 90 patients with 1-2 cm upper ureteral calculi treated in the urology department of Beijing Friendship Hospital from August 2018 to August 2020 were selected as the subjects. The patients were divided into two groups using random number table: 45 patients in group A were treated with in situ lithotripsy and 45 patients in group B were treated with active migration technique. The active migration technique was to reposition the stones in the renal calyces convenient for lithotripsy with the help of body position change, water flow scouring, laser impact or basket displacement, and then conduct laser lithotripsy and stone extraction. The data of the patients before and after operation were collected and statistically analyzed.@*RESULTS@#The age of the patients in group A was (51.6±14.1) years, including 34 males and 11 females. The stone diameter was (1.48±0.24) cm, and the stone density was (897.8±175.9) Hu. The stones were located on the left in 26 cases and on the right in 19 cases. There were 8 cases with no hydronephrosis, 20 cases with grade Ⅰ hydronephrosis, 11 cases with grade Ⅱ hydronephrosis, and 6 cases with grade Ⅲ hydronephrosis. The age of the patients in group B was (51.8±13.7) years, including 30 males and 15 females. The stone diameter was (1.52±0.22) cm, and the stone density was (964.6±214.2) Hu. The stones were located on the left in 22 cases and on the right in 23 cases. There were 10 cases with no hydronephrosis, 23 cases with grade Ⅰ hydronephrosis, 8 cases with grade Ⅱ hydronephrosis, and 4 cases with grade Ⅲ hydronephrosis. There was no significant diffe-rence in general parameters and stone indexes between the two groups. The operation time of group A was (67.1±16.9) min and the lithotripsy time was (38.0±13.2) min. The operation time of group B was (72.2±14.8) min and the lithotripsy time was (40.6±12.6) min. There was no significant difference between the two groups. Four weeks after operation, the stone-free rate in group A was 86.7%, and in group B was 97.8%. There was no significant difference between the two groups. In terms of complications, 25 cases of hematuria, 16 cases of pain, 10 cases of bladder spasm and 4 cases of mild fever occurred in group A. There were 22 cases of hematuria, 13 cases of pain, 12 cases of bladder spasm and 2 cases of mild fever in group B. There was no significant difference between the two groups.@*CONCLUSION@#Active migration technique is safe and effective in the treatment of 1-2 cm upper ureteral calculi.

Does displacement of lower pole stones during retrograde intrarenal surgery improves stone-free status?: a systematic review and meta-analysis

Purpose: Kidney stones are one of the most common urological diseases worldwide. The size and location of the stone are the most important factors in determining the most suitable treatment options. The aim of this review was to evaluate the displacement of lower pole stones. Methods: Three studies assessing the efficacy of translocating kidney stones from the lower pole of the kidney to other locations during retrograde intrarenal surgery published in the last 20 years were included. A systematic search was conducted in the PubMed, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), and Web of Science databases using the following search terms: "Lower pole," "Lithotripsy." Meta-analysis was performed using Review Manager version 5.4. Results: Stone-free rates were improved through displacement (odds ratio - OR = -0.15; 95% confidence interval-95%CI -0.24--0.05; p = 0.002; I2 = 21%), but at the cost of increased surgical duration (mean difference = -12.50; 95%CI -24.06--0.95; p = 0.03; I2 = 94%). Although this represents a potentially negative outcome, the improvement in clearance rates justifies the additional investment of time and effort. Conclusions: Displacement of lower pole kidney stones for subsequent lithotripsy brings significant benefits in terms of stone-free rate, with no difference in laser energy usage. However, it results in increased surgical time. Despite these factors, the benefits to patients undergoing the procedure are substantial.

Diameter of ureteral access sheath and ureteral stenosis development: a systematic review

Purpose: Ureteral access sheaths (UAS) are widely used in ureteroscopy. UAS are believed to pose a significant risk for ureteral stenosis due to ureteral mucosal compression, but little evidence supports this claim. Our systematic review aimed to investigate the relationship between different UAS diameters and stenosis risk. Methods: A systematic search was conducted in PubMed, Embase, Web of Science, Scopus, and Cochrane, from its inception to May 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane guidelines were followed. χ2 test was performed to compare the prevalence within the groups. Results: Six nonrandomized trials and one randomized, with a total of 962 patients, were included. The overall incidence of ureteral stenosis of 0.9%. UAS sizes were: 9.5/11.5Fr, 10/12Fr, 11/13Fr, 12/14Fr, and 14/16Fr. Within each subgroup, the incidence of ureteral stenosis was: 0.4, 8, 0, 1, and 1% (p = 0.099). No trend for stenosis was observed among larger UAS. Conclusions: In this systematic review, no relationship between UAS diameter and incidence of ureteral stenosis was observed. Nonetheless, additional randomized controlled trials are required to support this finding.

Use of artificial intelligence for sepsis risk prediction after flexible ureteroscopy: a systematic review / Uso da inteligência artificial na predição do risco de sepse pós-ureteroscopia flexível: uma revisão sistemática

ABSTRACT Introduction: flexible ureteroscopy is a minimally invasive surgical technique used for the treatment of renal lithiasis. Postoperative urosepsis is a rare but potentially fatal complication. Traditional models used to predict the risk of this condition have limited accuracy, while models based on artificial intelligence are more promising. The objective of this study is to carry out a systematic review regarding the use of artificial intelligence to detect the risk of sepsis in patients with renal lithiasis undergoing flexible ureteroscopy. Methods: the literature review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The keyword search was performed in MEDLINE, Embase, Web of Science and Scopus and resulted in a total of 2,496 articles, of which 2 met the inclusion criteria. Results: both studies used artificial intelligence models to predict the risk of sepsis after flexible uteroscopy. The first had a sample of 114 patients and was based on clinical and laboratory parameters. The second had an initial sample of 132 patients and was based on preoperative computed tomography images. Both obtained good measurements of Area Under the Curve (AUC), sensitivity and specificity, demonstrating good performance. Conclusion: artificial intelligence provides multiple effective strategies for sepsis risk stratification in patients undergoing urological procedures for renal lithiasis, although further studies are needed.

RESUMO Introdução: a ureteroscopia flexível é uma técnica cirúrgica minimamente invasiva utilizada para o tratamento de litíase renal. A urosepse pós-operatória é uma complicação rara, mas potencialmente fatal. Os modelos tradicionais utilizados para prever o risco dessa condição apresentam precisão limitada, enquanto modelos baseados em inteligência artificial são mais promissores. O objetivo desse estudo é realizar uma revisão sistemática a respeito do uso de inteligência artificial para detecção do risco de sepse em pacientes com litíase renal submetidos à ureteroscopia flexível. Métodos: a revisão de literatura está de acordo com o Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A busca com palavras-chave foi realizada no MEDLINE, Embase, Web of Science e Scopus e resultou no total de 2.496 artigos, dos quais 2 se enquadraram nos critérios de inclusão. Resultados: os dois estudos utilizaram modelos de inteligência artificial para predizer o risco de sepse após utereroscopia flexível. O primeiro teve uma amostra de 114 pacientes e foi baseado em parâmetros clínicos e laboratoriais. O segundo teve uma amostra inicial de 132 pacientes e foi baseado em imagens de tomografia computadorizada no pré-operatório. Ambos obtiveram boas medidas de Area Under the Curve (AUC), sensibilidade e especificidade, demonstrando boa performance. Conclusão: a inteligência artificial fornece múltiplas estratégias eficazes para estratificação do risco de sepse em pacientes submetidos a procedimentos urológicos para litíase renal, ainda que mais estudos sejam necessários.

Application of controllable negative pressure suction sheath in flexible ureteroscopic lithotripsy in the treatment of renal calculi / 现代泌尿外科杂志

【Objective】 To compare the clinical application value of controllable negative pressure suction outer sheath and ordinary flexible endoscope outer sheath in flexible ureteroscopic lithotripsy with holmium laser in the treatment of renal calculi less than or equal to 2 cm in diameter. 【Methods】 A total of 85 patients with renal calculi were selected and randomly divided into negative pressure group (n=45) and ordinary group (n=40). The operation time, complications, infection indexes 2 h after operation, adverse reactions, treatment efficacy and stone-clearance rate were compared between the two groups. 【Results】 The sheath was successfully implanted and holmium laser lithotripsy was performed in both groups. The negative pressure group had significantly shorter operation time than the ordinary group [(43.3±4.9) min vs. (66.2±5.8) min, P0.05). The increase of infection indexes (procalcitonin and leukocyte) 2 h after operation were significantly lower in the negative pressure group than in the ordinary group (P<0.05). The efficacy in the negative pressure group was 91.11% (41/45) and the stone-clearance rate was 95.56% (43/45), which were significantly better than those in the ordinary group (72.50% (29/40) and 80% (32/40), respectively. The total incidence of adverse reactions such as renal colic, gross hematuria and ureteral stone street was higher in the ordinary group than in the negative pressure group (P<0.05). 【Conclusions】 Controllable negative pressure suction sheath in flexible ureteroscopic lithotripsy is more effective, as the circulation perfusion keeps the operation field clear, reduces the operation time and improves the stone-clearance rate, while the negative pressure suction lowers the pelvis pressure to prevent infectious urine from entering the blood.

Application of minimally invasive percutaneous nephroscopic plasma electrode decortication in the treatment of renal cysts / 现代泌尿外科杂志

Laparoscopic decortication is the standardized surgical treatment for simple renal cysts. With the continuous maturation of minimally invasive techniques, percutaneous nephroscopic decortication and decompression is gradually implemented, which has advantages of minimal invasiveness, fast recovery and good prognosis. Ureteroscopic plasma electrode is a modified procedure, which can achieve more exact intraoperative hemostasis and efficient cutting efficiency than traditional surgery. This article reviews the current treatments of simple renal cysts, and introduces our experience of using minimally invasive percutaneous nephroscopic plasma electrode decortication, its surgical procedures and technical points.

Application of anterograde flexible ureteroscope combined with retrograde ureteroscope in the treatment of lower ureteral calculi with ureteral atresia in lateral lithotomy / 现代泌尿外科杂志

【Objective】 To investigate the safety and efficacy of flexible ureteroscope (FU) combined with retrograde ureteroscope (URS) in the treatment of lower ureteral calculi with ureteral atresia. 【Methods】 Clinical data of 7 patients treated during Jan.2018 and Jun.2021 were retrospectively analyzed. 【Results】 Ureteral calculi and ureteral atresia were successfully treated, without serious complications. Six to eight weeks after operation, CT examination showed that hydronephrosis was relieved to varying degrees and the ureteral stents were in good position, without residual stones. Six months after operation, there was no significant exacerbation of hydronephrosis and the renal function remained stable. 【Conclusion】 Anterograde FU combined with retrograde URS has high stone-clearance rate, small trauma and high safety in the treatment of ureteral stricture and ureteral calculi.

Advantages and disadvantages of ureteroscope in the diagnosis and treatment of upper tract urothelial carcinoma / 现代泌尿外科杂志

Ureteroscopy plays an important role in the diagnosis and treatment of upper tract urothelial carcinoma (UTUC). Conventional ureteroscopy (URS) can not only identify the location, appearance and size of a tumor, but also assess tumor grade by biopsy. The continued development of electronic flexible ureteroscopy and assistive technologies has led to further advances in the diagnosis of UTUC. Ureteroscopic laser ablation can be used to treat low grade malignancy, renal insufficiency, or isolated kidney. However, the use of URS may have potential risks such as delay of radical treatment, increased surgical difficulty, intraoperative or postoperative complications and intravesical recurrence. This article reviews the advantages and disadvantages of ureteroscopy in the diagnosis and treatment of UTUC.

Effects of preoperative ureteroscopy on intravesical recurrence after radical nephroureterectomy of upper tract urothelial carcinoma / 现代泌尿外科杂志

【Objective】 To investigate the effects of preoperative ureteroscopy (URS) on the intravesical recurrence (IVR) in patients with upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). 【Methods】 The clinical data of 241 UTUC patients treated during May 2012 and Jan.2020 in the Second Hospital of Laozhou University were retrospectively analyzed. The patients were divided into URS before RNU group (URS group) and non-URS before RNU group (non-URS group). The cumulative IVR rate, progression-free survival (PFS) and overall survival (OS) after RNU were compared, and the survival curve was drawn. Cox proportional hazards models were used to assess risk factors affecting IVR. 【Results】 Of the 241 patients, 64 (26.6%) were included in the URS group and 177 (73.4%) in the non-URS group. In the URS group, 49 underwent biopsy and 15 did not. All patients were followed up for a median of 44 (3 to 122) months, with a median time to recurrence of 12 (3 to 56) months. IVR occurred in 18 patients (28.1%) in the URS group and 25 (14.1%) in the non-URS group. Kaplan-Meier survival analysis showed that the cumulative IVR rate was higher in the URS group than in the non-URS group (all P<0.05), regardless of whether patients had a history of bladder cancer (BC) or not, while PFS was lower in the URS group than in the non-URS group (P=0.007). Cox multivariate regression analysis showed that URS (P=0.031) and complicated renal pelvis tumor and ureteral tumor (P=0.004) were independent risk factors for IVR. 【Conclusion】 Preoperative URS increases the incidence of IVR in patients with UTUC, and routine preoperative use of URS is not recommended.

Efficacy and safety of 3-dimensional laparoscopic pyeloplasty and ultrasound-guided flexible ureteroscopy lithotripsy in the treatment of ureteropelvic junction obstruction and renal calculi / 现代泌尿外科杂志

【Objective】 To evaluate the efficacy and safety of 3-dimensional laparoscopic pyeloplasty and ultrasound-guided flexible ureteroscopy lithotripsy (3DLP-UGFURL) in the treatment of ureteropelvic junction obstruction (UPJO) and renal calculi. 【Methods】 The clinical data of 29 patients of UPJO complicated with renal calculi treated with 3DLP-UGFURL during Dec.2017 and Jul.2022 were retrospectively analyzed. There were 23 males and 6 females with average age of (35.3±13.6) years. The lesions were on the left side in 20 cases, on the right side in 9 cases, and all were unilateral. One case was complicated with horseshoe kidney. The body mass index (BMI) was 23.6±3.9. Multiple calculi of renal pelvis or calyces occurred in 16 cases, and the rest were single calculi. The maximum diameter of calculi was (1.2±0.6)cm. There were 2 cases of mild hydronephrosis, 19 cases of moderate hydronephrosis and 8 cases of severe hydronephrosis. 【Results】 All operations were successful. The operation time of 3DLP was (84.2±15.4)min. Operation time of UGFURL was (42.8±15.7)min. Estimated blood loss was (36.9±13.6)mL. Indwelling time of drainage tube was (3.6±1.6)d. Indwelling time of urinary catheter and postoperative hospital stay was (6.8±1.2)d. One month after operation, the stone removal rate was 97.4%. The retention time of ureteral stent was 2.7 months. During the follow-up of (24.5±10.0)months, there were 45 Clavien Dindo grade 1 complications. 【Conclusion】 3DLP-UGFURL is safe and effective in the treatment of UPJO complicated with renal calculi, but it still needs long-term follow-up data.

Clinical efficacy of flexible ureteroscopic lithotripsy under local anesthesia and risk factors of perioperative pain / 现代泌尿外科杂志

【Objective】 To explore the efficacy of flexible ureteroscopic lithotripsy (FURL) under local anesthesia (LA) in the treatment of upper urinary tract calculi, and to analyze the risk factors of pain. 【Methods】 Clinical data of 255 patients treated during Apr.2022 and Sep.2022 were reviewed, including visual analogue score (VAS) of pain during ureteroscopy, sheath placement, holmium laser lithotripsy, 1 hour and 8 hours after operation. VAS ≥5 was defined as significant pain. Clinical and follow-up data of the significant pain group and non-significant pain group were analyzed with logistic regression to analyze the risk factors of pain in FURL under LA. 【Results】 Altogether 198 patients (77.6%) successfully completed the operation, and the stone-free rate (SFR) was 89.9% (178/198). The VAS of ureteroscopy was the highest (4.49±1.08), and 73 patients (28.6%) experienced significant pain. Univariate analysis showed that significant pain was associated with gender, previous surgical history, age, body mass index (BMI), education level, and ASA classification (P<0.05). Multivariate analysis showed that male (OR=2.896, 95%CI:1.413-5.933, P=0.040) and BMI≥28 (OR=7.776, 95%CI:2.268-26.657, P=0.001) were independent risk factors of significant pain, while age ≥65 years (OR=0.237, 95%CI:0.083-0.672, P=0.007) and previous surgical history (OR=0.156, 95%CI:0.032-0.754, P=0.021) were the protective factors. 【Conclusion】 It is feasible and effective to treat upper urinary tract calculi with FURL under LA. The presence of significant pain is associated with factors such as gender, age, BMI and previous surgical history.

Comparison of the efficacy and safety of ShuoTong ureteroscopy and flexible ureteroscopy in the treatment of upper ureteral calculi with CT numberical value greater than 1000 HU / 中华泌尿外科杂志

Objective:To compare the clinical efficacy and safety of Shuo Tong ureteroscopy(ST-URS) and flexible ureteroscope(FURS)combined with holmium laser lithotripsy in the treatment of upper ureteral calculi with CT numerical value ≥ 1000 HU.Methods:A retrospective analysis of the clinical data of patients of upper ureteral calculi with CT numberical value≥1000 HU in the First Affiliated Hospital of Xiamen University was made from January 2018 to November 2020.There were 61 cases treated with ShuoTong ureteroscopy holmium laser lithotripsy (ST-URS group), including 45 males and 16 females, with 40 on the left and 21 on the right, age of(48.3±12.7) years, body mass index of(24.7±2.7)kg/m 2, the diameter of stone of(1.50±0.45)cm, and the CT numberical value of(1 288.8±179.0)(1 017-1 738)HU. There were 87 cases were treated with flexible ureteroscopy holmium laser lithotripsy (FURS group), including 58 males and 29 females, with 56 on the left and 31 on the right, age of(48.5±13.0) years, body mass index of(24.1±3.8)kg/m 2, the stone diameter of(1.45±0.40)cm, and the CT numberical value of(1 311.3±188.9)(1 009-1 817)HU. There were no significant differences in gender, age, body mass index, the location of stone, the diameter of stone and the CT numberical value of stone( P>0.05)between the two groups. For ST-URS group, a rigid ureteral channel sheath and standard mirror(F7.5/11.5)were placed under direct vision, exiting the standard mirror, leaving the channel sheath, inserting a lithotripsy mirror(F4.5/6.5)and a holmium laser[Power: 8-30 W(0.4-1.0 J/20-30 Hz)], and withdrawing the stone fragments after crushing the stone by "nibbling method" . For FURS group, a hard ureteroscope(F8/9.8)was used to explore the lesion side of the ureter, inserting a guide wire and placing a soft ureteral sheath, then inserting a flexible ureteroscope(F8)for holmium laser lithotripsy, and useing a stone basket to remove larger stone fragments. Ureteral stent was routinely indwelled after the operation. On the day 1 and 1 month after the operation, imaging examinations were performed to evaluate the stone-free rate. No residual stones or the diameter of stone was ≤0.4 cm and no urinary tract infection or any symptoms were defined as stone free. The operation time, blood loss, success rate of stage Ⅰ ureteral access sheath placement, incidence of postoperative complications, stone-free rate(SFR) at 1 day after operation, SFR at 1 month after operation, postoperative hospital stay and hospitalization costs were compared between the two groups. According to the size of calculi, the 2 groups were divided into 2 subgroups(≥1.5 cm and <1.5 cm)in order to make further analysis. The operation time, stone-free rate(SFR) at day 1 after operation and SFR at 1 month after operation were compared between the two groups. Results:The operation time of the ST-URS group was shorter than the FURS group(40.10 min vs. 49.43 min, P=0.020), and the incidence of postoperative complications was lower than the FURS group[3.28%(2/61)vs. 13.79%(12/87), P=0.031]. The SFR at day 1 after operation was significantly higher than the FURS group[60.7%(37/61)vs. 25.3%(22/87), P<0.01], and the hospitalization cost was lower than that of the FURS group(27 686 yuan vs. 32 281 yuan, P<0.010). There were no significant differences in the blood loss[(4.92±9.51)ml vs.(3.95±6.04)ml, P=0.452], success rate of stageⅠureteral access sheath placement[ 96.7%(59/61)vs. 96.6%(84/87), P=1.000], SFR at 1 month after operation[81.97%(50/61) vs. 75.86%(66/87), P=0.375] and postoperative hospital stay[(2.5±1.4)d vs.(2.4±0.8)d, P=0.543] between the two groups. When the size of calculi was ≥1.5cm, the operation time of the ST-URS group was shorter than the FURS group (43.67 min vs 55.00 min), the SFR at 1 day after operation was higher than the FURS group[40.00%(12/30)vs. 9.38%(3/32)], and the above differences are all statistically significant ( P<0.05). Conclusions:Compared with the FURS, for the treatment of upper ureteral calculi with CT numerical value ≥1000 HU, the ST-URS has shorter in operative time, lower in hospitalization cost and incidence of postoperative complications and higher SFR at day 1 after operation. The ST-URS is a safe and effective surgical technique, which is superior in the treatment of larger(≥1.5 cm) stones.

Efficacy and safety of balloon dilation technique during ureteroscopic lithotripsy with "difficult ureter" / 中华泌尿外科杂志

Objective:To summarize the preliminary clinical experience of utilizing ureteral balloon dilation catheter in the treatment of "difficult ureter" during ureteroscopic lithotripsy, and to discuss the efficacy and safety of the technique.Methods:Clinical data of 28 patients (30 sides) with upper urinary tract calculi admitted to Beijing Tsinghua Changgung Hospital Affiliated to Tsinghua University from April 2021 to July 2022 were retrospectively analyzed. There were 23 males (82.1%) and 5 females (17.9%), with age of (51.5±13.6) years. Among the 30 sides, 20 (66.7%) on the left and 10(33.3%) were on the right. Calculi were either located in the renal pelvis or calyxes in 7 sides (23.3%), upper ureter in 17 sides (56.7%), and lower ureter in 6 sides (20.0%). The maximum diameter of the stones was (9.4±4.2)mm, and 23 sides (76.7%) were combined with hydronephrosis before surgery. When "difficult ureter" was encountered during the procedure, that is, it was difficult to insert ureteroscope or ureteral access sheath (UAS) due to small ureteral lumen, balloon catheter was used for dilation in the first stage, in which the balloon diameter was 4 mm on 22 sides and 5mm on 8 sides. The instrument was retrogradely inserted through the working channel of F8 semi-rigid ureteroscope, and the small site of the ureteral lumen was dilated under direct endoscopic view. After a single dilation, the balloon catheter was withdrawn, and the effect of dilation was evaluated by semi-rigid ureteroscopy to determine whether to proceed with the following procedures. The intraoperative data were recorded, including surgical method, stage of "difficult ureter" occurred, site of the small part of the ureter, related data of utilizing ureteral dilatation balloon catheter, grade of ureteral injury after dilatation (according to the 0-4 grading classification of endoscopic ureteral injuries), total operation time, balloon catheter-related adverse events, stone-free rate, and time of removing ureteral stents.Results:Among the 30 sides, 29 (96.7%) had difficulty in the stage of ureteroscope insertion, and 1(3.3%) had difficulty in the stage of UAS insertion. A total of 37 small sites of ureter were involved, including 18 in the intramural segment, 10 in the lower part, 2 in the middle part, and 7 in the upper part. Each site was dilated once with a median time of 3 (0.5, 5.0) minutes and a median maximum balloon pressure of 1 215.9(1 215.9, 1 443.9)kPa[12.0(12.0, 14.3)atm]. There were 28 sites of grade Ⅰ injury, 8 sites of grade Ⅱinjury, and 1 site of grade Ⅲinjury. The total duration of unilateral procedure was (73.4±30.3) min. Ureteroscope or UAS insertion was successful in 28 sides(93.3%) after balloon dilation, and failed in 2 sides(6.7%), both of which were in the stage of inserting ureteroscope and ureteral stent was indwelled for the second-stage procedures. On the first day after surgery, the hemoglobin level was (134.1±12.9)g/L, which was significantly different from the preoperative parameters ( P<0.01), and serum creatinine level was (86.7±23.2)μmol/L, which showed no significant difference from the preoperative one ( P=0.263). The primary stone-free rate was 92.9% (26/28), and the total postoperative complication rate was 13.3% (4/30), including 3 of grade Ⅰ (lateral lower abdominal pain requiring additional analgesic drugs) and 1 of grade Ⅱ (postoperative hematuria requiring intravenous hemostatic drugs). Follow-up was conducted for 3 months. All of the 28 successful sides had their ureteral stents removed before the last follow-up, and the time of removal was (36.9±11.5) days. No hydronephrosis was found in the ipsilateral kidney by ultrasound 3 months after operation. Conclusions:Balloon dilation technique showed good efficacy and safety in the treatment of "difficult ureter" during ureteroscopic lithotripsy.

Transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts: A retrospective study

ABSTRACT Background: We aimed to investigate the clinical efficacy and safety of transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts. Materials and Methods: Between October 2017 and April 2021, the clinical data of 65 patients with parapelvic renal cysts were evaluated retrospectively. Thirty-one patients with parapelvic cysts (Group 1) underwent a transurethral flexible ureteroscopic incision and drainage with a holmium laser, whereas the other 34 patients (Group 2) underwent retroperitoneal laparoscopic unroofing. The patients' clinical features were documented. The surgery time, intraoperative blood loss, hospitalization time, complications and cyst size were recorded and statistically assessed one year following the procedure. Results: All of the patients were successfully treated with flexible ureteroscopic incision and drainage or retroperitoneal laparoscopic unroofing. In terms of clinical parameters, such as age, gender, BMI, location, cyst size, and Bosniak classification of renal cysts, no statistically significant difference was detected between Groups 1 and 2. Compared to the control group (Group 2), Group 1 demonstrated a shorter surgery duration, less intraoperative blood loss, and a shorter hospital stay (p < 0.001). However, no significant differences in complications and cyst size were observed between the two groups one year after the surgery (p > 0.05). Conclusions: Transurethral flexible ureteroscopic incision and drainage with holmium laser in the treatment of parapelvic renal cysts has obvious advantages over traditional surgery, and is worthy of advancement and application, but its long-term effect needs further follow-up studies.

Comparison of the outcomes of flexible ureteroscopy and mini-percutaneous nephrolithotomy for the treatment of kidney stones: a matched-pair analysis

SUMMARY OBJECTIVE: Mini-percutaneous nephrolithotomy is a recent advancement in the field of kidney stone treatment; however, its role has not been completely established. We aimed to compare the outcomes of initial Mini-percutaneous nephrolithotomy and flexible ureteroscopy. METHODS: A retrospective review of consecutive mini-percutaneous procedures was performed. Inclusion criteria were as follows: all percutaneous nephrolithotomy procedures performed with an access sheath up to 24Fr, kidney stone burdens up to 1550 mm3; and the presence of postoperative computed tomography (for control). The data collected for Mini-percutaneous nephrolithotomy procedures were paired 1:2 with patients treated with flexible ureteroscopy for stones between 100 and 1550 mm3, and with postoperative computed tomography for control. A 14Fr Mini-percutaneous nephrolithotomy set was used. The stone-free rate was defined as the absence of fragments on the control computed tomography, whereas success was limited to 2-mm residual fragments. Statistical analysis was performed using SPSS version 19. RESULTS: A total of 63 patients met the inclusion criteria (42 with flexible ureteroscopy and 21 with mini-percutaneous nephrolithotomy). Demographic data were comparable. The stone-free rate and success were similar between the groups (76.2 vs. 66.7%, p=0.42 and 90.5 vs. 85.7%, p=0.57). The complication rate was also similar (26.1 vs. 9.6%, p=0.188), but Mini-percutaneous nephrolithotomy had longer hospitalization and fluoroscopy time (p=0.001 in both). CONCLUSIONS: Our initial study of Mini-percutaneous nephrolithotomy showed that it is a promising procedure, with outcomes similar to flexible ureteroscopy, but with higher inpatient numbers and fluoroscopy times. A larger study population size and better equipment may improve the outcomes of mini-percutaneous nephrolithotomy.

Complementary Ureterorenoscopy after extracorporeal Shock Wave Lithotripsy in proximal ureteral stones: success and complications

SUMMARY OBJECTIVE: The aim of this study was to demonstrate the effect of extracorporeal shock wave lithotripsy application on the success and complications of ureteroscopic lithotripsy in proximal ureter stones. METHODS: The data of 87 patients who did not respond to shock wave lithotripsy and underwent ureteroscopic lithotripsy were retrospectively analyzed and classified as group I, and 99 patients who received ureteroscopic lithotripsy as primary treatment were classified as group II. Demographic features, response to treatment, and preoperative and postoperative complications were compared between the two groups. RESULTS: There was no difference between the two groups in terms of gender, operation times, stone sizes, and ureteroscope diameters. (p>0.05). Infective complications such as postoperative fever, pyelonephritis, and urosepsis were similar in both groups (p=0.142, p=0.291, and p=0.948). Stone migration was observed in 10 (11.5%) and 6 (6.1%) patients in groups I and II, respectively (p=0.291). Impacted stone was seen in 47 (54%) patients in group I and in 15 (15.2%) patients in group II (p<0.0001). Mucosal laceration occurred in 11 (12.6%) and 3 (3%) patients in groups I and II, respectively (p=0.028). Ureteral perforation was detected in 3 (3.4%) patients in group I and 1 (1%) patient in group II, whereas ureteral avulsion was not observed in either group (p=0.524). CONCLUSIONS: It was concluded that the application of shock wave lithotripsy before ureteroscopic lithotripsy in proximal ureter stones did not affect the success. Although the results are similar in terms of postoperative infection, shock wave lithotripsy application has been found to increase the risk of stone impaction into the mucosa and ureteral laceration.

Lower pole anatomy of horseshoe kidney and complete ureteral duplication: Anatomic and radiologic study applied to endourology

ABSTRACT Purpose: To analyze the 3-dimensional intrarenal anatomy of horseshoe kidneys (HK) and kidney with complete ureteral duplication (CUD), in polyester resin endocasts of the collecting system and in patients submitted to 3D computerized tomography scan (CT-scan). Materials and Methods: We analyzed seven 3-dimensional polyester resin endocasts of the kidney collecting system obtained from 6 fresh adult cadavers (4 with unilateral CUD and 2 with horseshoe kidney) and CT-scan reconstruction images of kidneys from 24 patients: 6 patients with HK, 8 with CUD and 10 patients without renal anomalies that were used as controls. We analyzed the spatial distribution of the calices, the infundibula diameters, the angle between the lower infundibulum and the renal pelvis (LIP) and the angle between the lower infundibulum and the inferior minor calyces (LIICA). Measurements of the width and length of the inferior infundibulum and the infundibula of the minor calyces, as well as the angles (LIP and LIICA) were made with the aid of the LibreOffice 6.3 software. The data were analyzed with the IBM® SPSS® Statistics. Results: There was no statistical difference in the inferior pole measurements between the groups with anomalies and the control group, both in polyester resin endocasts and CT-scan reconstruction images for LIP. When we compared the LIP in the CT-scan between HK versus CUD (p= 0.003), and HK versus the control group (p= 0.035), we observed statistical difference. Conclusions: The knowledge of spatial anatomy of lower pole is of utmost importance during endourologic procedures in patients with kidney anomalies. In the present study we observed that horseshoe kidneys had more restrictive anatomic factors in lower pole than the complete ureteral duplication.

PNEUMATIC URETEROSCOPIC LITHOTRIPSY VERSUS LAPAROSCOPIC URETEROLITHOTOMY FOR LARGE UPPER URETERAL STONES- AN INITIAL EXPERIENCE.

Objective: The treatment of choice for large upper ureteral stones is controversial. In the developing nations, semi rigid ureteroscopy is the preferred treatment modality for ureteric stones even in upper ureter. However, Laparoscopic ureterolithotomy has started gaining acceptance for the treatment of large proximal ureteral stones. This study was done to compare solely the outcomes of semi-rigid pneumatic ureterolithotripsy (URSL) and transperitoneal laparoscopic ureterolithotomy (LU) for large upper ureteric stones. Methods: In all, 30 patients who met the inclusion criteria were randomised into 2 groups: URSLand LU. The groups were compared for stone clearance rate, operative time, complication rates.Results: LU had significantly higher stone clearance rate both at discharge (p=0.014) and at 3 weeks post operatively (p = 0.033) than URSL. On the other hand, URSLhad significantly shorter mean operating time (p<0.0001), length of hospital stay (p=0.0013) and required less auxiliary procedures than LU group. No major complications were observed and the complication rate was not statistically significant among the groups (p=0.41).Conclusion: Laparoscopic ureterolithotomy was associated with higher stone clearance rate but with longer hospital stay and operative time than URSL, however the complications were similar. Consequently, the procedure of choice for large proximal ureteric calculi should be based on the expertise of the surgeon, patient's choice and the availability of equipments