Jonathan Cloutier

Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks

BACKGROUNDnThanks to advancements in the endoscopic armamentarium, flexible ureteroscopy (fURS) has become a viable and attractive option for the treatment of renal stones because of its high stone-free rates (SFRs) and low morbidity.nnnOBJECTIVEnTo describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety.nnnDESIGN, SETTING, AND PARTICIPANTSnA retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed.nnnSURGICAL PROCEDUREnUreteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnClinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed.nnnRESULTS AND LIMITATIONSnThe mean overall stone size was 16.5 ± 7.9mm. Ureteral access sheath placement was possible in 287 patients (90.8%). At 1-mo follow-up, the overall primary SFR was 79.1%; the secondary and tertiary SFRs were 89.5% and 91.5%, respectively. The mean operative time was 72.6 ± 27.5min. The mean number of procedures was 1.27. Complications were reported in 92 patients (29.1%) overall, with Clavien grade 1 in 55 patients (17.4%), grade 2 in 30 patients (9.5%), grade 3 in 6 patients (1.9%), grade 4 in 1 patient (0.3%), and grade 5 in none. The main limitation of the study was the retrospective nature.nnnCONCLUSIONSnThe fURS procedure is safe and effective for the treatment of renal stones. A staged procedure is necessary to achieve stone-free status with large calculi.nnnPATIENT SUMMARYnFlexible ureteroscopy is an effective treatment with low complication rates for the majority of renal stones. Both the modern highly technological armamentarium and surgical know-how should be available.

Early repeated ureteroscopy within 6–8 weeks after a primary endoscopic treatment in patients with upper tract urothelial cell carcinoma: preliminary findings

AbstractObjectivesnTo evaluate the cancer detection rate (CDR) of an early repeated flexible ureteroscopy (2nd-look-URS) and its impact on the conservative management of patients affected with upper urinary tract urothelial carcinoma (UTUC).Materials and methodsnClinical and surgical data from 41 patients with UTUC who underwent 2nd-look-URS within 60xa0days of their first URS with concomitant laser tumour photoablation at a single tertiary care referral centre from 2009 to 2013 were retrospectively analyzed. Radical nephroureterectomy was offered during follow-up in case of massive tumour recurrence (defined as a tumour not completely removable only with a conservative approach). Descriptive statistics tested the impact of 2nd-look-URS outcomes on subsequent endoscopic evaluation. Kaplan–Meier curves assessed massive tumour recurrence-free survival (mRFS) rates according to the presence of a tumour at 2nd-look-URS. Cox regression analyses identified predictors of mRFS.ResultsnCDR at 2nd-look-URS was 51.2xa0%. CDRs at third URS were 81.3 and 41.2xa0% in patients with a positive and a negative 2nd-look-URS, respectively (pxa0=xa00.02). At a mean (median) follow-up of 34.6 (27.6) months, mRFS rates were 88 and 48xa0% in patients with negative and positive 2nd-look-URS, respectively (log rankxa0=xa00.015). Tumour grade at first URS and 2nd-look-URS outcomes achieved predictor status for mRFS (HR 6.1, 95xa0% CI 1.42–26.27 and HR 5.39, 95xa0% CI 1.18–24.66, respectively, all pxa0≤xa00.03).Conclusions2nd-look-URS-related CDR in conservatively treated UTUC patients was 51.2xa0%. 2nd-look-URS outcomes affected the findings of both subsequent endoscopic evaluation and mRFS. Further studies are needed to confirm the benefits of this approach in terms of patient outcomes.

Confocal Laser Endomicroscopy in the Management of Endoscopically Treated Upper Urinary Tract Transitional Cell Carcinoma: Preliminary Data

PURPOSEnTo describe our initial experience with confocal laser endomicroscopy (CLE) for the evaluation and treatment of patients with upper urinary tract transitional cell carcinoma (UUT-TCC).nnnMATERIALS AND METHODSnPreliminary data were analyzed from 11 patients with suspicion of UUT-TCC scheduled for flexible ureteroscopy (f-URS) and consensual holmium-YAG laser tumor ablation. CLE was performed before endoscopic biopsy and laser photoablation of the suspected lesion using a 3F-diameter flexible probe UroFlex™ B (Cellvizio® system; Mauna Kea Technologies, Paris, France), which allows to obtain microscopic resolution imaging (3.5u2009μm), with a field of view of 325u2009μm and a depth of tissue imaging of 40 to 70u2009μm. Video sequences were analyzed offline and thereafter compared with histopathologic findings.nnnRESULTSnCLE technique was feasible and showed good quality imaging in all patients. Overall, the Cellvizio system provided reliable images of healthy urothelium when the probe was pointed toward normal tissue, showing umbrella cells on the surface and vessels in the lamina propria. Moreover, CLE displayed the characteristic features of high-density cellular aggregates and fibrovascular stalks in four patients with pathologically confirmed low-grade UUT-TCC. In the patient with pathologically confirmed high-grade UUT-TCC, more distorted microarchitecture and tortuous vessels were clearly recognized with CLE.nnnCONCLUSIONSnThese preliminary data showed the feasibility of CLE technique when applied to the diagnosis of UUT-TCC. Further clinical studies are required to confirm CLE accuracy in distinguishing healthy urothelial tissue from malignant lesions, thus helping clinicians in targeting ureteroscopic biopsy and improving the conservative management of UUT-TCC patients.

The glue-clot technique: a new technique description for small calyceal stone fragments removal

AbstractnDuring the last 20xa0years, the technology advancement of small flexible ureterorenoscopes has dramatically changed the management of renal calculi. Retrograde intrarenal surgery (RIRS) has currently a high impact on active stone treatment, and it is increasingly used worldwide. Nevertheless, kidney stone fragmentation and direct removal of fragments require many passages of the ureteroscope, is often time-consuming, and may be very difficult through anatomical and technical factors. We describe a simple, feasible and efficient technique for small stone fragments retrieval, which are often difficult to remove during RIRS.

Do We Really Need to Wear Proper Eye Protection When Using Holmium:YAG Laser During Endourologic Procedures? Results from an Ex Vivo Animal Model on Pig Eyes.

PURPOSEnWe sought to evaluate the effect of holmium:yttrium-aluminum-garnet (Ho:YAG) laser exposure on ex vivo pig eyes and to test the protective action of different glasses in preventing eye lesions in case of accident.nnnMATERIALS AND METHODSnWe pointed the tip of a Ho:YAG laser fiber from different distances (0, 3, 5, 8, 10, and 20 cm, respectively) toward the center of the pupil of the pig eye. The Ho:YAG laser was activated for 1 or 5 seconds at three different settings (0.5 J-20 Hz, 1 J-10 Hz, and 2 J-10 Hz, respectively). The experiment was repeated using laser safety glasses and eyeglasses. A total of 78 pig eyes were used. The effects of the Ho:YAG laser on pig eyes were assessed by histopathology. Comparable laser emission experiments were performed on thermal paper at different distances using different pulse energies.nnnRESULTSnHo:YAG laser-induced corneal lesions were observed in unprotected eyes, ranging from superficial burning lesions to full-thickness necrotic areas, and were directly related to pulse energy and time of exposure and inversely related to the distance from the eye. When the laser was placed 5 cm or more, no corneal damage was observed regardless of the laser setting and the time of exposure. Similar distance/energy level relationships were observed on thermal paper. No damage was observed to the lens or the retina in any of the Ho-YAG laser-treated eyes or in any of the eyes protected by laser safety and eyeglasses.nnnCONCLUSIONSnHo:YAG lasers can cause damage when set to high energy, but only to the cornea, from close distances (0-5 cm) and in the absence of eye protection. Eyeglasses are equally effective in preventing laser damage as laser safety glasses.

Comprehensive flexible ureteroscopy (FURS) simulator for training in endourology: The K-box model.

Over the last two decades there has been an increase in the incidence of kidney stone disease with a simultaneous rise in the use of ureteroscopy for its management [1]. Flexible ureteroscopy training is variable and still largely dependent on high fidelity models and virtual reality (VR) simulation, both of which are expensive and not readily available in many parts of the world. There is also a lack of good quality bench trainers. In a recent survey of endourologists worldwide, flexible ureteroscopy was considered as a first line treatment for stones <2 cm [2]. With this in mind, we have developed a new portable bench-training box model for training in flexible ureteroscopy and endourology. This is a low-cost reusable model for flexible ureteroscopy training allowing the user to manipulate the scope, place a guidewire and access sheath, use a basket to catch/relocate the stone and finally to use a Holmium YAG laser to fragment the stone. n nK-box nThe K-box (K – Box®, Porges-Coloplast, France) is a new generation portable bench-training model for flexible ureteroscopy. It is made of polyurethane and consists of 4 independent boxes with each of these boxes representing a different training model with three separate entry and exit points (Figures 1, u200b,2).2). It also comes with a ‘tool tray’, which can be used within the boxes for various training exercises. To use the K-box and perform the exercises, the trainees need to have an endoscope, camera system and screen, light source and disposables such as guidewires, access sheaths, baskets and stents. Trainees can familiarize themselves with different flexible ureterscope movements such as pronation/supination, forward/backward movement, scope deflection and grasping/releasing of objects/stones mimicking the movements in the renal pelvicalyceal system. In addition to this, it allows step-by-step guidewire and access sheath placement along with stone fragmentation (Figures 3, u200b,4).4). Although the exercises are done with the box closed while the trainee is watching the screen, when a trainee is unsure or lost in the training model they have the option of opening the flap which enables them to see their position (almost being a surrogate for a radiological image/fluoroscopy). The newly designed flexible ureteroscopy training model allows the surgeon to make the specific movements required when performing flexible ureteroscopy in humans. n n n nFigure 1 n nK-box and its components (1.1 – portable K-box, 1.2 – box open (left) and closed (right), 1.3 – tool tray, 1.4 – K-box with water to use with laser for stone fragmentation). n n n n n nFigure 2 n nK-box with all four boxes with embossed markings (opened view) showing various configurations for manipulation of the objects within it. n n n n n nFigure 3 n nStep by step technique (3.1 – placement of guidewire, 3.2 – placement of access sheath, 3.3 – placement and manipulation of flexible ureteroscope). n n n n n nFigure 4 n nManipulation in the pelvicalyceal system (4.1 – stone basketing with a flexible ureteroscope via the access sheath, 4.2 – movement of object from A to B). n n n nThese boxes can either be used separately or in combination in any random order. A silicone aerosol spray can be used to make the inside surfaces of K-box smoother to minimize friction. To enable laser use, the K-box can be used with water allowing fragmentation of stones.

A guidewire introducer as a ureteral foreign body: A case report

A 63-year-old male, previously treated for a ureteral tumour by a right-sided segmental ureterectomy and end-to-end anastomosis of ureteral segments, was referred to our clinic for endoscopic follow-up. During his follow-up, he was diagnosed with partial right-sided ureteral stricture which eventually progressed to complete obstruction. During the ureteroscopy, as the stenotic segment did not allow passage of an hydrophilic guidewire, an antegrade-retrograde approach was decided. On the antegrade endoscopic view, a near-complete stenosis was diagnosed and a nephrostomy catheter (12 Fr) was placed. A second intervention was planned and from the nephrostomy tract, the ureteroscope was placed into the right pyelocaliceal system. The diagnostic ureteroscopy revealed a foreign object proximal to the stenotic area. Right-sided segmental ureterectomy of the stenotic segment with ureteroneocystostomy and removal of the foreign object was performed. This is the only case in literature to reveal a guidewire introducer as a ureteral foreign body. This case also highlights the importance of the fragility of the ureter, the importance of the equipment, of always being watchful during a surgery, and the importance of checking the integrity of the equipment at the end of each procedure.

Which Patients with Upper Tract Urothelial Carcinoma Can be Safely Treated with Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution

Purpose We tested the effects of tumor size, distribution and grade on progression‐free survival in patients with upper tract urothelial carcinoma treated with flexible ureteroscopy with Ho:YAG laser photoablation. Materials and Methods Included in analysis were data on 92 consecutive patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation from 2003 to 2015 at a single tertiary care referral center. Stringent followup was offered according to EAU (European Association of Urology) guidelines. Progression during followup was defined by tumor upgrading, distant metastases and/or a relapsing tumor that could not be completely removed with a conservative approach. Kaplan‐Meier curves were used to assess the rate of disease progression according to tumor size (1 or less cm vs greater than 1 cm), tumor distribution (unifocal vs multifocal) and tumor grade (low vs high). Cox regression analysis was done to test the impact of clinical and pathological characteristics on the rate of progression‐free survival. Results At a median followup of 52 months (IQR 27.8–76.4) the progression‐free survival rate was 68% vs 72% in patients with a tumor size of 1 or less vs greater than 1 cm (p = 0.9), 72% vs 69% in patients with unifocal vs multifocal lesions (p = 0.6) and 75% vs 52% in patients with a low vs a high grade tumor (p = 0.03). On multivariable Cox regression analysis tumor grade at first treatment was the only independent predictor of disease progression (HR 5.16, 95% CI 1.19–22.26, p = 0.03). Conclusions High tumor grade independently decreased progression‐free survival in patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation. Tumor size greater than 1 cm and multifocality did not increase the risk of disease progression in patients treated conservatively with Ho:YAG laser photoablation.

Which Patients with Upper Tract Urothelial Carcinoma Can Be Safely Treated with Conservative Treatment by Flexible Ureteroscopy with Holmium:YAG Laser Photoablation? Long-Term Results from a High Volume Institution

Purpose We tested the effects of tumor size, distribution and grade on progression‐free survival in patients with upper tract urothelial carcinoma treated with flexible ureteroscopy with Ho:YAG laser photoablation. Materials and Methods Included in analysis were data on 92 consecutive patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation from 2003 to 2015 at a single tertiary care referral center. Stringent followup was offered according to EAU (European Association of Urology) guidelines. Progression during followup was defined by tumor upgrading, distant metastases and/or a relapsing tumor that could not be completely removed with a conservative approach. Kaplan‐Meier curves were used to assess the rate of disease progression according to tumor size (1 or less cm vs greater than 1 cm), tumor distribution (unifocal vs multifocal) and tumor grade (low vs high). Cox regression analysis was done to test the impact of clinical and pathological characteristics on the rate of progression‐free survival. Results At a median followup of 52 months (IQR 27.8–76.4) the progression‐free survival rate was 68% vs 72% in patients with a tumor size of 1 or less vs greater than 1 cm (p = 0.9), 72% vs 69% in patients with unifocal vs multifocal lesions (p = 0.6) and 75% vs 52% in patients with a low vs a high grade tumor (p = 0.03). On multivariable Cox regression analysis tumor grade at first treatment was the only independent predictor of disease progression (HR 5.16, 95% CI 1.19–22.26, p = 0.03). Conclusions High tumor grade independently decreased progression‐free survival in patients with upper tract urothelial carcinoma treated with Ho:YAG laser photoablation. Tumor size greater than 1 cm and multifocality did not increase the risk of disease progression in patients treated conservatively with Ho:YAG laser photoablation.

Tips for Flexible Ureteroscopy

The first flexible ureteroscope was introduced in 1983 and since then, the use of flexible ureterorenoscopy (F-URS) has never ceased to grow, and its indications have continued to expand. This chapter presents some particularities, tips and tricks of F-URS that could accommodate urologists throughout general and particular circumstances. Urologists who have an interest in flexible ureteroscopy should be armed of patience, and be always on the lookout for the next step and the technical possibilities to assist him in troublesome situations. There are plenty of equipments and tricks in flexible ureteroscopy, and the surgeon needs to know the existence of them and accomplish his own experience and familiarity.