José A. Salvadó

Ureteroscopic lithotripsy for distal ureteral calculi: comparative evaluation of three different lithotriptors.

INTRODUCTION AND OBJECTIVES We report the results of a randomized controlled trial comparing three different lithotriptors using semirigid ureteroscopy (URS) for distal ureteral stones. METHODS Between September 2009 and November 2010 69 patients undergoing ureteroscopy were randomized to three groups: LithoClast classic (Group 1), Holmium Laser (Group 2), and StoneBreaker™ (Group 3). A 7.5F semirigid ureteroscope was used in all procedures. The primary outcome was differences in fragmentation time. Secondary outcomes were stone-free rates, intraoperative complications, stone-up migration, hospital stay, analgesic requirement, and need for auxiliary procedures. Patients were followed up at 15 days, 30 days, and 3 months. The stone-free status was defined with noncontrast computed tomography performed at first control. Univariate and multivariate analysis were performed to determine clinical and surgical factors that have direct impact on the success of ureteroscopy. Chi-square test and Analysis of Covariance (ANCOVA) tests were used for statistical comparisons. RESULTS There were no differences between sociodemographic variables. Average stone size was 7.17±2.04 mm in Group 1; 7.89±2.73 mm in Group 2; and 7.79±2.97 mm in Group 3 (p=0.79). Fragmentation time were similar between lithotriptors; 27.12±4.07 minutes in Lithoclast group; 21.78±2.81 minutes in Laser group, and 27.14±4.71 minutes in StoneBreaker group (p=0.74). Stone-free rates were 96%±11.18% (group 1), 96.9%±8% (group 2), and 96.9%±8.4% (group 3) (p=0.1). No difference was observed in stone-up migration, postoperative Double-J stent placement, or auxiliary procedures. Stone size and the placement of a second working wire were associated with shorter fragmentation time (p<0.01). CONCLUSIONS The three lithotripsy devices evaluated behaved similarly in terms of the ability to fragment stones, and were equally effective for distal ureteral stones. Adequate fragmentation and fragment removal are mainly dependant on stone size and surgical technique (use of auxiliary wire).

PD35-11 NEW DIGITAL SINGLE-USE FLEXIBLE URETEROSCOPE (PUSEN TM): FIRST CLINICAL EXPERIENCE

INTRODUCTION AND OBJECTIVES: We report the clinical results of flexible ureteroscopy using the new digital single-use flexible ureteroscope from PUSEN (New South Wales, Australia). This device has an outer diameter of 9 Fr, with a working channel of 3,6 Fr. The deflection system has both options of standart and reverse modes with maximum deflection of 270 in both directions. METHODS: Between August and October 2016 we performed flexibleureteroscopy (FUR)using thenewdevice.Theprimaryoutcomewas stone free rates, secondary outcomeswere total time of the procedure, total time of fluoroscopy and perioperative complications. The tertiary outcome was the behavior of the instrument during and at the end of the procedure RESULTS: A total of eleven FUR were performed. The present study included eight male patients and three female patients, with an average age of 39 years (range 23-65 years). All the patient were treated using a 12 Fr access sheath and holmium laser lithotripsy(260 mm fiber). The average stone size was 6 mm (range 4-10 mm), and stones were located as follow: 3 in proximal ureter, 6 in renal pelvis and 2 in lower calix. Total time taken to complete the surgery was 45 minutes (range 25-85 min). The number of stones treated per patient varied between 1 and 4. Mean fluoroscopy time was 50 seconds. We achieved 100% stone free rate in eight cases and 80% in the remaining three. One patient present an ureteral wall injury, with mucosal erosion at time of ureteral access sheath placement. A double J stent was placed in all patients. The device behaves properly during and at the end of the procedure, there was no loss in image quality or deflection capacity, being able to safely finish all the cases carried out. CONCLUSIONS: With respect to outcomes evaluated in this study with the PUSEN digital single use flexible ureteroscope seems to be similar in comparison to reusable flexible ureteroscope. The clinical results achieved in the present study suggest that this device could be considered a valid method to treat endoscopically renal and proximal ureteral stones reducing maintenance costs.

MP75-07 INTRAVESICAL INSTILLATION OF LEVOBUPIVACAINE AS AN ADJUNCT TO REDUCE THE URETERAL STENT ASSOCIATED DISCOMFORT: A DOUBLE BLIND RANDOMIZED CONTROLLED TRIAL.

INTRODUCTION AND OBJECTIVES: The insertion of double J ureteral catheters is a common practice in modern urology. Unfortunately, different symptoms may occur with indwelling stents, such as dysuria, hematuria, flank and suprapubic pain. The objective of the present study was to evaluate the safety and efficacy of levobupivacaine as an intravesical instillation in the control of pain and urinary symptoms generated by the ureteral stent. METHODS: 77 patients with double J catheter (Percuflex 26/6 TM, Boston Scientific) after endoscopic treatment of an ureteral stone were randomized into 2 groups. Both groups received standard therapy for catheter discomfort management (paracetamol, ketorolac and tamsulosine). At the end of the procedure group 1 received instillation of 30 cc of saline and group 2 received a dose of 150 mg (30 cc) of intravesical levobupivacaine. Surgeon and patient were blinded for type of instillation received. Symptomatology was evaluate at 4 and 24 hours after the procedure and at the moment of catheter removal. The USSQ survey, in its Spanish-validated version, was used for this purpose. Plasma levels of levobupivacaine were measured at 5, 10, 15 and 20 minutes after instillation in both groups. RESULTS: Both groups were comparable in terms of age, location and size of stone treated , duration of procedure, stone free rate and days of catheter permanence. Statistical analysis showed significant reduction in group 2 regarding the intensity of pain at 4 hours postoperatively (p 1⁄4 0.02). In addition, during the catheter carrying period, those patients in whom the levobupivacaine solution was applied had less alteration in work activities (p 1⁄4 0.03), and less discomfort in the sexual sphere (p 1⁄4 0.01) Plasma levels of levobupivacaine in the 40 patients exposed to the drug were undetectable (<0.1 mg / dL). There were no side effects attributable to intravesical levobupivacaine. CONCLUSIONS: To our knowledge this is the first clinical trial using levobupivacaine in bladder instillation, which demonstrate better pain control in the immediate postoperative period. There is a significant effect on daily life parameters that could allow better tolerance to the catheter during the time it should remain installed. Also, the use of this substance does not imply a higher cost and its safe, without side effects.

Subcapsular Renal-Infected Hematoma After Retrograde Intrarenal Surgery: A Rare but Serious Complication

Abstract We report a case of a 53-year-old woman affected by a left kidney stone and persistent positive urinary culture treated by retrograde intrarenal surgery. During postoperative day 1, she developed a sudden back pain associated with a decrease in hemoglobin. CT scan showed a subcapsular hematoma giving the impression of partial compression of kidney and upper urinary tract. For that reason, in the first instance, a Double-J ureteral stent was installed. Unfortunately, an open surgical drainage was necessary because a secondary infection of the hematoma was evident during the following days.