Is It the Load That Breaks You or the Way You Carry It: How Demanding Is Endourology?

Objective: Surgical outcomes are dependent on multiple factors. Besides patient-related or procedure-related factors, several surgeon-related factors contribute to surgical outcomes. The Surgery Task Load Index (SURG-TLX) questionnaire helps to assess the impact of several stressors on the perceived demands of surgeons during surgery. In this study, we evaluate the applicability of the SURG-TLX questionnaire for endourologic procedures and set a first point of reference. Materials and Methods: Between March and August 2022, 15 urologists and urology residents at a tertiary referral center for endourology completed the SURG-TLX questionnaire after endourologic procedures. After data acquisition, all participants were asked to evaluate the applicability of the questionnaire for endourologic procedures. Results: A total of 130 procedures were included between March and August 2022. Situational stress had the lowest median score (3.0/20; interquartile range [IQR] 2.0-7.0) and task complexity the highest (5.0/20; IQR 3.0-8.0). After weighing, the dimensions showed different proportions when compared with the nonweighted scores. Distractions received the highest score (15.0/100; IQR 7.5-32.8), temporal demands (6.0/100; IQR 3.0-12.5), and situational stress the lowest (6.0/100; IQR 2.0-21.0). This was caused by the higher weight that was attributed to distractions (3.4/5), as opposed to task complexity (2.6/5). In the questionnaire regarding applicability of the SURG-TLX, the overall satisfaction (6.0/10; IQR 5.0-7.0) and clarity (6.5/10; IQR 5.0-7.5) were moderate. The user-friendliness and applicability of the questionnaire were rated high (7.0/10; IQR 5.5-8.0 and 7.0/10; IQR 6.0-8.0, respectively) and task load (3.0/10; IQR 2.0-5.0) and time load (2.0/10; IQR 2.0-3.5) low. Conclusion: The SURG-TLX questionnaire is appropriate to assess the different dimensions of workload during endourologic procedures. Furthermore, the perceived workload during endourologic procedures is relatively low.

The Diagnostic Yield and Concordance of Ureterorenoscopic Biopsies for Grading of Upper Tract Urothelial Carcinoma: A Dutch Nationwide Analysis.

Objectives: To evaluate the diagnostic yield and concordance of upper tract urothelial carcinoma (UTUC) grading between ureterorenoscopic biopsies and surgical resections. Materials and Methods: The nationwide Dutch Pathology Registry (nationwide network and registry of histo- and cytopathology in the Netherlands [PALGA]) was searched for UTUC-positive renal units (RUs) with histopathology excerpts from ureterorenoscopic biopsies and surgical resections, matched for laterality and localization of the tumor, from 2011 until 2018. The positive predictive value (concordance) of the biopsy grade with regard to the final grade according to the World Health Organization (WHO) 2004 classification was calculated. Results: A total of 1002 UTUC-positive rental units were included, of which 776 UTUC-positive RUs were graded according to the WHO 2004 classification in the ureterorenoscopic biopsy, the localization-matched surgical resection, or in both. The diagnostic yield of biopsies for a classifying diagnosis was 89% with a sensitivity for UTUC of 84%. In case of UTUC, the diagnostic yield for biopsy-based grading and staging was 97% and 72%, respectively. The concordance of high-grade biopsies with regard to the final histopathology was 97% and 62% for low-grade biopsies. Upgrading to final high grade occurred in 33% of the low-grade biopsies. Downgrading to final low grade occurred in 2% of high-grade biopsies. Conclusions: This is the first study to portray the limitations of ureterorenoscopic biopsies for UTUC in a nationwide cohort. The diagnostic yield of ureterorenoscopic biopsies for a classifying diagnosis is suboptimal, but the diagnostic yield for grading according to the WHO 2004 classification is high. Yet, a worrisome amount of ureterorenoscopic biopsies are upgraded with regard to the surgical resection. Consequently, one-third of patients, who qualify for kidney-sparing treatment according to one of the criteria recommended for risk stratification, might be stratified incorrectly. These findings stress the importance of a timely and stringent ureterorenoscopic follow-up after kidney-sparing surgery and highlight the need for improvements in the diagnostic approach to optimize the risk stratification.

Upper Tract Urothelial Carcinoma Grade Prediction Based on the Ureteroscopic Appearance: Caution Should be Taken.

OBJECTIVES: To investigate the diagnostic accuracy, inter-rater and intrarater agreement of grade predictions based on the visual appearance of papillary upper tract urothelial carcinoma (UTUC) during digital ureteroscopy. METHODS: Nine urologists predicted the histopathologic grade of 64 papillary UTUC (low-grade vs high-grade) by assessing the visual appearance of the tumors in videos from digital ureteroscopy. The diagnostic accuracy was estimated by comparing the grade predictions with the histopathology from colocalized biopsies. Inter-rater agreement was assessed by pairwise inter-rater percentage agreement and Fleiss Kappa analysis. The videos were rated in a random order again 30 days after the first assessment to evaluate the intrarater percentage agreement. RESULTS: Low-grade tumors were predicted correctly in 37%-85% of the cases with a median concordance of 59% for questionnaire 1 and 66% for questionnaire 2. High-grade tumors were predicted correctly in 26%-91% of the cases with a median concordance of 52% and 61% for each questionnaire. The median pairwise inter-rater percentage agreement was 66% for both questionnaires with a Fleiss Kappa of 0.29 and 0.38, respectively. The median intrarater percentage agreement was 81%. CONCLUSION: The histopathologic grade of UTUC is essential to the risk-stratification for treatment selection. Predictions of the histopathologic grade based on the visual appearance of papillary UTUC with digital ureteroscopy are often incorrect in comparison with biopsy results and yield low inter-rater agreement. Urologists must be aware of these limitations in the assessment of the tumor grade during digital ureteroscopy to warrant good clinical practice.

Pre-Use Ureteroscope Contamination after High Level Disinfection: Reprocessing Effectiveness and the Relation with Cumulative Ureteroscope Use.

PURPOSE: We assessed the frequency of preoperative and persistent microbial contamination of flexible ureteroscopes after reprocessing and the relation of contamination to cumulative ureteroscope use. MATERIALS AND METHODS: We evaluated the effectiveness of high level disinfection with peracetic acid as well as data on ureteroscope use for 20 new flexible ureteroscopes from December 2015 to December 2017 at a single center. In the operating room pre-use and postuse microbial samples of the ureteroscope shaft and working channel were collected to evaluate microbial contamination after reprocessing. Positive cultures were defined as 30 cfu/ml or greater of skin flora, or 10 cfu/ml or greater of uropathogenic microorganisms. A generalized estimating equation model was used to analyze whether cumulative ureteroscope use was associated with positive pre-use cultures. RESULTS: Microbial samples were collected during 389 procedures. Pre-use ureteroscope cultures were positive in 47 of 389 procedures (12.1%), of which uropathogens were found in 9 of 389 (2.3%) and skin flora in 38 of 389 (9.8%). Urinary tract infection symptoms did not develop in any of the patients who underwent surgery with a uropathogen contaminated ureteroscope. In 1 case the pre-use culture contained the same bacteria type as the prior postuse culture. Cumulative ureteroscope use was not associated with a higher probability of positive cultures. CONCLUSIONS: Microbial contamination of reprocessed ureteroscopes was found in an eighth of all procedures. Notably uropathogenic microorganisms were discovered in a small proportion of all procedures. Persistent ureteroscope contamination with uropathogens was only rarely encountered. Cumulative ureteroscope use was not associated with a higher probability of microbial contamination.

Durability of Flexible Ureteroscopes: A Prospective Evaluation of Longevity, the Factors that Affect it, and Damage Mechanisms.

BACKGROUND: Flexible ureteroscopy is an established treatment modality for evaluating and treating abnormalities in the upper urinary tract. Reusable ureteroscope (USC) durability is a significant concern. OBJECTIVE: To evaluate the durability of the latest generation of digital and fiber optic reusable flexible USCs and the factors affecting it. DESIGN, SETTING, PARTICIPANTS: Six new flexible USCs from Olympus and Karl Storz were included. The primary endpoint for each USC was its first repair. Data on patient and treatment characteristics, accessory device use, ureteroscopy time, image quality, USC handling, disinfection cycles, type of damage, and deflection loss were collected prospectively. INTERVENTION: Ureteroscopy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: USC durability was measured as the total number of uses and ureteroscopy time before repair. USC handling and image quality were scored. After every procedure, maximal ventral and dorsal USC deflection were documented on digital images. RESULTS AND LIMITATIONS: A total of 198 procedures were performed. The median number of procedures was 27 (IQR 16-48; 14h) for the six USCs overall, 27 (IQR 20-56; 14h) for the digital USCs, and 24 (range 10-37; 14h) for the fiber optic USCs. Image quality remained high throughout the study for all six USCs. USC handling and the range of deflection remained good under incremental use. Damage to the distal part of the shaft and shaft coating was the most frequent reason for repair, and was related to intraoperative manual forcing. A limitation of this study is its single-center design. CONCLUSIONS: The durability of the latest reusable flexible USCs in the current study was limited to 27 uses (14h). Damage to the flexible shaft was the most important limitation to the durability of the USCs evaluated. Prevention of intraoperative manual forcing of flexible USCs maximizes their overall durability. PATIENT SUMMARY: Current flexible ureteroscopes proved to be durable. Shaft vulnerability was the most important limiting factor affecting durability.

Surgical teaching in urology: patient safety and educational value of 'LIVE' and 'SEMI-LIVE' surgical demonstrations.

PURPOSE: To evaluate the opinion of urologists and their audience regarding patient safety and educational value of live surgical demonstrations (LSD) and semi-live surgical demonstrations (semi-LSD). METHODS: Following the '2017 Challenges in Endourology' meeting, a survey addressing patient safety and the educational value of LSD and semi-LSD was disseminated online to all participants. Survey outcomes of LSD and semi-LSD were compared. RESULTS: All 279 respondents attended both LSD and semi-LSD. Overall, 53% of said respondents stated that patient safety was always the highest priority for LSD, while 74% noted the same for semi-LSD. The complication risk in LSD was perceived equal by 57% of the respondents when compared to cases of similar difficulty in routine practice, while 38% perceived it as a greater risk. For semi-LSD, the complication risk was perceived equal by 84%, while 5% perceived it to be a greater risk in comparison to general practice. On a scale from 0 (no value) to 10 (highly valuable), the average educational value of LSD and semi-LSD was rated 8.4 and 8.3, respectively. A substantial percentage of the surgeons who perform LSD express concerns that live surgery is not the optimal setting to ensure patient safety. CONCLUSIONS: LSD remains a popular tool for surgical education among urologists and their audience. However, patient safety remains a concern and is perceived less of a concern for semi-LSD. The educational value of LSD and semi-LSD was scored equally high. Therefore, we should consider to advocate the use of semi-LSD more often.

Ureteroscopic Urinary Stone Treatment Among Patients With Renal Anomalies: Patient Characteristics and Treatment Outcomes.

OBJECTIVE: To evaluate patients' characteristics, surgical procedure data, and outcomes of ureterorenoscopy (URS) stone treatment in patients with a horseshoe kidney (HSK), ectopic kidney (EK), and malrotated kidney (MK). MATERIALS AND METHODS: This study is a subanalysis of the Clinical Research Office of the Endourological Society URS Global Study, which was a prospective multicenter observational study, collecting data on URS stone treatment from consecutive patients over a 1-year period. A total of 114 centers in 32 countries participated. This analysis acuminated on URS stone treatment in the specified renal anomalies: HSK, EK, and MK. For each group, patient characteristics, operation data, and treatment outcomes were evaluated. RESULTS: Of the 11,885 patients included in the Clinical Research Office of the Endourological Society URS study, 43 patients had HSK, 27 EK, and 16 MK. The stone-free rate (SFR) in the HSK group was 77% for renal stones and 85% for ureteral stones. In the HSK group, the intraoperative complication rate was 11.6% and the postoperative complication rate was 7%, including 1 Clavien grade IIIa and 1 IIIb complication. In the EK group, the SFR was 20% for renal stones and 94% for ureteral stones, with an intraoperative complication rate of 14.8% and a postoperative complication rate of 7.4%. One Clavien IVa complication was reported. In the MK group, the SFR was 71% for renal stones and 88% for ureteral stones, with an intraoperative complication rate of 6.3%. No postoperative complications occurred in this group. CONCLUSION: URS is an effective and safe treatment modality to remove ureteral and renal stones in patients with HSK and MK. The effectiveness of URS for renal stones in EK was low.

Outcomes of Ureterorenoscopic Stone Treatment in 301 Patients with a Solitary Kidney.

Objectives: To determine the stone-free rates and intra- and postoperative complication rates and grades of ureterorenoscopic stone treatment in patients with a solitary kidney. Methods: This study is a subanalysis of the Clinical Research Office of the Endourological Society (CROES) ureterorenoscopy (URS) study, which is a prospective international multicenter observational study. Over a 1-year period, consecutive patients treated with ureterorenoscopy for urinary stones were included. Patients entered in this analysis were those with a solitary functioning kidney. Descriptive data on patient characteristics, stone-free rates, complication rates, and grades were evaluated for three separate groups: patients treated with ureteroscopy for ureteral stones, for renal stones, and a combination of renal and ureteral stones. Results: A total of 301 patients were treated for stones in a solitary kidney; 219 were treated for ureteral stones. In this group, the stone-free rate was 88.6%, with an intraoperative complication rate of 7.4% and postoperative complication rate of 4.1%. Totally, 57 patients were treated for renal stones. In this group, the stone-free rate was 56.4%, with an intraoperative complication rate of 7.0% and postoperative complication rate of 10.5%. There were 25 patients who were treated for renal stones in combination with ureter stones. In this group, the stone-free rate was 60.0%, with an intraoperative complication rate of 12.0% and postoperative complication rate of 10.5%. Within the three groups, 72% of the postoperative complications were classified as Clavien I and II. Conclusions: Ureteroscopy is an effective and safe treatment modality for the removal of ureteral and renal stones in patients with a solitary kidney. Stone location as well as total stone burden seems to be important factors influencing the ability to render patients stone free. Moreover, single session ureteroscopic stone removal was less effective for the treatment of larger renal stones or renal stones in combination with ureteral stones.

Outcome from 5-year live surgical demonstrations in urinary stone treatment: are outcomes compromised?

PURPOSE: To compare intra- and post-operative outcomes of endourological live surgical demonstrations (LSDs) and routine surgical practice (RSP) for urinary stones. METHODS: Consecutive ureterorenoscopic (URS) and percutaneous (PNL) urinary stone procedures over a 5-year period were reviewed. Procedures were divided into LSDs and RSP. Differences between the groups were separately analysed for URS and PNL. Primary outcomes included intra- and post-operative complication rates and grades. Secondary outcomes were operation time, length of hospital stay, stone-free rate, and retreatment rate. Pearson's Chi-square analysis, Mann-Whitney U test, and logistic and linear regression were used to compare outcomes between LSDs and RSP. RESULTS: During the study period, we performed 666 URSs and 182 PNLs, and 151 of these procedures were LSDs. Among URSs, the overall intra-operative complication rate was 3.2% for LSDs and 2.5% for RSP (p = 0.72) and the overall post-operative complication rate was 13.7% for LSDs and 8.8% for RSP (p = 0.13). Among PNLs, the overall intra-operative complication rate was 8.9% for LSDs and 5.6% for RSP (p = 0.52) and the overall post-operative complication rate was 28.6% for LSDs and 34.9% for RSP (p = 0.40). For both URSs and PNLs, no statistically significant differences in complication grade scores were observed between LSDs and RSP. Operation time was significantly longer for LSD-URS group, but there was no difference between the PNL groups. There were no significant differences in length of hospital stay and stone-free rate. The retreatment rate was higher in the LSD-URS group compared with RSP-URS group but similar between the PNL groups. Multiple logistic regression analyses, adjusting for confounders, revealed no association between LSD and more or less favourable outcomes as compared to RSP. CONCLUSION: Live surgical demonstrations do not seem to compromise patients' safety and outcomes when performed by specialised endourologists.

Characteristics and outcomes of ureteroscopic treatment in 2650 patients with impacted ureteral stones.

PURPOSE: To describe stone-free rates and complications of ureteroscopic treatment for impacted compared with non-impacted ureteral stones and evaluate predictive variables for impaction. METHODS: The Clinical Research Office of the Endourological Society prospectively collected 1 consecutive year of data from 114 centers worldwide. Patients eligible for inclusion were patients treated with ureteroscopy for ureteral stones. Patient characteristics, treatment details, and outcomes were compared with regard to stone impaction. Logistic regression analyses were conducted to explore predictive variables for ureteral stone impaction and to analyse the effect of impaction on outcomes. RESULTS: Of the 8543 treated patients, 2650 (31%) had impacted and 5893 (69%) non-impacted stones. The stone-free rate was 87.1% for impacted stones, which is lower compared with 92.7% for non-impacted stones (p < 0.001). Intra-operative complication rates were higher for impacted stones (7.9 versus 3.0%, p < 0.001). Significantly higher ureteral perforation- and avulsion rates were reported in the impacted stone group compared with the non-impacted stone group. No association between stone impaction and post-operative complications could be shown. Female gender, ASA-score >1, prior stone treatment, positive pre-operative urine culture, and larger stones showed to be predictive variables for stone impaction. CONCLUSIONS: Ureteroscopic treatment for impacted stones is associated with lower stone-free rates and higher intra-operative complication rates compared with treatment for non-impacted stones. The predictive variables for the presence of stone impaction may contribute to the identification of stone impaction during the diagnostic process. Moreover, identification of stone impaction may aid the selection of the optimal treatment modality.