Decreasing cost of flexible ureterorenoscopy: single-use laser fiber cost analysis.

OBJECTIVE: To demonstrate a cost benefit while using disposable laser fibers as compared with reusable laser fibers. Flexible ureteroscopy (FURS) is a central component of endourology. It is vital that for service provision and training purposes, costs are kept down while delivering this service. Laser fibers are known to damage scopes causing high repair and/or replacement costs. MATERIALS AND METHODS: Data for consecutive FURS procedures during 2 periods in a single center were compared. First, with the use of reusable fibers and second, with single-use fibers. Cost of laser fibers and repairs was recorded. The study excludes the cost of the initial purchase of the ureterorenoscopes or the holmium laser equipment and costs associated with staffing and hospital stay. RESULTS: The total number of FURS carried out in period 1 and period 2 was 260 and 265, respectively. A total of 13 reusable (185 procedures) and 168 disposable laser fibers were used in these 2 periods, respectively. There was a reduction in laser damaged ureteroscopes from 9 to 3 in the second period. This resulted in a £ 16,800 reduction in repair cost. This more than offsets the increased costs of single-use fibers. CONCLUSION: On the basis of our data, it is more cost-effective to use a disposable laser fiber, as it prevents scope damage, which can happen because of microfractures with repeated laser use. Moreover, this will also save time and/or resource required with sterilization.

Oral 5-aminolevulinic acid induced Photodynamic Diagnostic Ureterorenoscopy--does the blood pressure require monitoring?

BACKGROUND: Photodynamic Diagnosis has been proven to improve detection of superficial bladder cancer and improve visualisation of resection margins. The use of 5-aminolevulinic acid as the photosensitising agent has been associated with side effects, specifically hypotension. We aimed to evaluate the effect of oral 5-ALA on the blood pressure in a group of patient who underwent Photodynamic Diagnostic Ureterorenoscopy. METHODS: We carried out an observational study on all patients who underwent PDD-Ureterorenoscopy with oral 5-ALA between July 2009 and September 2011. Pre-administration, hourly post-administration and hourly post-operative blood pressures were noted. Mean arterial blood pressure and the threshold for cerebral ischaemia were calculated as well. RESULTS: The study includes thirty-eight procedures which involved twenty-four patients with a mean age of 74 (SD±16.95). Hypotension was defined as <80% of the systolic or diastolic baseline blood pressure. Twenty patients were hypotensive pre-operatively after the ingestion of 5-ALA while 21 patients were hypotensive post-operatively. Three patients crossed their MAP threshold pre-operatively and were symptomatic. Fast infusion of intravenous fluids improved their symptoms. CONCLUSION: Hypotension is a common occurrence after the ingestion of 5-ALA. Patients undergoing PDD Ureterorenoscopy should have their blood pressure monitored closely after the ingestion of 5-ALA.

Irrigant flow and intrarenal pressure during flexible ureteroscopy: the effect of different access sheaths, working channel instruments, and hydrostatic pressure.

PURPOSE: Our aim was to determine the optimal size of access sheath for ureteroscopy and stone lasertripsy to achieve good irrigant flow while maintaining the lowest possible intrarenal pressure. MATERIALS AND METHODS: We used an in vitro anatomic model into which a pressure transducer was incorporated. Cook Peel-Away 10F, Flexor 12F, 14F, 16F single lumen, and a new 14F Flexor dual-lumen sheath were tested. Irrigant flow and intrarenal pressure were measured with an empty ureteroscope working channel and with a 1.4F or 2.4F basket within the working channel with a hydrostatic pressure of 1 m and 2 m, respectively. For the dual-lumen sheath, the irrigation was either connected to the scope or the second channel of the access sheath. Two other configurations were tested: 4F ureteral catheter placed alongside a 10F sheath (configuration 1) or a 5F ureteral catheter within a 16F access sheath (configuration 2). RESULTS: With an empty working channel, irrigant flow increased with sheath diameter. The presence of a 1.4F or 2.4F basket, however, reduced flow up to 65% and 90%, respectively. Increasing the hydrostatic column to 2 m height improved the irrigant flow but with a predisposition to a higher intrarenal pressure. Using configurations 1 and 2, the flow rates improved by 250% and 700%, respectively, with a 2.4F basket in the working channel, and could also be used with a 2 m hydrostatic column without raising the intrarenal pressure. CONCLUSIONS: Increased access sheath diameter does not improve flow when the working channel of a flexible ureteroscope is occupied. Our proposed configuration of a ureteral access catheter placed inside or alongside the access sheath provides by far the highest flow rates without a rise in the intrarenal pressure.

Photodynamic diagnosis (PDD) for upper urinary tract transitional cell carcinoma (UT-TCC): evolution of a new technique.

INTRODUCTION: Transitional cell carcinoma of renal pelvis and ureter account was traditionally treated with nephroureterectomy. With the advent of rigid and flexible ureteroscopes endoscopic access to the ureter and renal pelvis for diagnosis and treatment has become a reality. We did fluorescence ureteroscopy using oral 5-ALA to diagnose upper tract urothelial tumours for four patients. Here we describe this technique and assess its feasibility to diagnose ureteric and renal pelvicalyceal tumours. MATERIALS AND METHODS: A prospective pilot study was performed to assess the feasibility of PDD using oral 5-amino levulinic acid (ALA) for upper urinary tract tumours. RESULTS: Four patients underwent PDD guided flexible ureteroscopy of the upper urinary tract. Obvious exophytic tumour seen on white light was also seen as red fluorescence on blue light. All areas with red fluorescence were biopsied (including additional areas not seen on white light) and were confirmed to be transitional cell carcinoma. CONCLUSION: Photodynamic diagnosis using oral 5-ALA and subsequent treatment of upper tract urothelial tumours is safe and feasible with additional advantages of detecting lesions not visualised on conventional white light endoscopy.