Slawomir G. Kata

Flexible Ureteroscopy and Laser Lithotripsy for Stones >2 cm: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE Urinary stones >2 cm are traditionally managed with percutaneous nephrolithotomy (PCNL). Recently, flexible ureteroscopy and laser lithotripsy) (FURSL) has been used to manage them with comparable results. In a comparative study of renal stones between 2 and 3 cm, FURSL was reported to need less second-stage procedures and be just as effective as PCNL. Our purpose was to review the literature for renal stones >2 cm managed by ureteroscopy and holmium lasertripsy. MATERIALS AND METHODS A systematic review and quantitative meta-analysis was performed using studies identified by a literature search from 1990s (the first reported large renal stones treated ureteroscopically) to August 2011. All English language articles reporting on a minimum of 10 patients treated with FURSL for renal stones >2 cm were included. Two reviewers independently extracted the data from each study. The data of studies with comparable results were included into a meta-analysis. RESULTS In nine studies, 445 patients (460 renal units) were reportedly treated with FURSL. The mean operative time was 82.5 minutes (28-215 min). The mean stone-free rate was 93.7% (77%-96.7%), with an average of 1.6 procedures per patient. The mean stone size was 2.5 cm. An overall complication rate was 10.1%. Major complications developed in 21 (5.3%) patients and minor complications developed in 19 (4.8%) patients. A subgroup analysis shows that FURSL has a 95.7% stone-free rate with stones 2-3 cm and 84.6% in those >3 cm (P=0.01), with a minor complication rate of 14.3% and 15.4%, respectively, and a major complication rate of 0% and 11.5%, respectively. CONCLUSION In experienced hands, FURSL can successfully treat patients with stones >2 cm with a high stone-free rate and a low complication rate. Although the studies are from high-volume experienced centers and may not be sufficient to alter everyday routine practice, this review has shown that the efficacy of FURSL allows an alternative to PCNL.

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.

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.

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.

Mitomycin C instillation following ureterorenoscopic laser ablation of upper urinary tract carcinoma.

Introduction: Instillation of Mitomycin C (MMC) should prevent implantation of cancer cells released during endoscopic treatment and prevent recurrences as seen in carcinoma of the bladder. Aim: To develop and evaluate a protocol for a single dose MMC instillation following Holmium: YAG laser ablation of upper urinary tract transitional cell carcinoma (UUT-TCC). Setting and Design: A single institute prospective study. Materials and Methods: MMC instillations protocol was designed and offered to patients between August 2005 and April 2011. Following tumor ablation, MMC was instilled into upper urinary tract (UUT) over 40 minutes. All the patients were regularly followed up. Results: Twenty UUT units (19 patients) were managed for UUT-TCCs using our MMC protocol. Two UUT units had G1pTa tumors, 14 had G2pTa, 2 had G3pTa, and 2 had G3pT1. At a mean follow-up of 24 months (range 1-72 months), 13/20 (65%) of the UUT units remained cancer-free, 3 (15%) UUT units developed stricture and were treated with endoscopic dilatation, only 1 (5%) of these developed long-term complications. None of the patients developed postoperative renal impairment or systemic side-effects. Conclusions: Using a set standard protocol, MMC can safely be instilled into the UUT after TCC ablation with minimal complications or side effects, good preservation of renal function, and with a low recurrences rate comparable to the literature.

Decreasing the Cost of Flexible Ureterorenoscopic Procedures

OBJECTIVE To treat calculus disease, perform diagnostic procedures, for endoscopic management of upper tract tumours and in selected cases for laser guided endopyelotomy there is an increase in the use of Flexible Ureterorenoscopy (FURS). METHODS We wanted to prospectively audit the cost of flexible ureterorenoscopic procedures undertaken in our department between March 2009 and March 2010. RESULTS Based on our business model, the cost of diagnostic FURS is £131 (equivalent to €157 or

Diagnosis of upper urinary tract tumours: is photodynamic diagnosis assisted ureterorenoscopy required as an addition to modern imaging and ureterorenoscopy?

196.50), FURS and lasertripsy for stones is between £296 and £429 (€355-€515 or

Oral 5‐aminolevulinic acid in simultaneous photodynamic diagnosis of upper and lower urinary tract transitional cell carcinoma – a prospective audit

444-

Photodynamic diagnostic ureterorenoscopy: A valuable tool in the detection of upper urinary tract tumour

644), and that for endoscopic management of upper tract transitional cell carcinomas is between £148 and £225 (€178-€270 or

Accuracy of photodynamic diagnosis in the detection and follow-up of patients with upper urinary tract lesions: Initial 3-year experience

222-