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Objective: To evaluate long-term surgical and functional outcomes of cystinuric patients exclusively treated with Ureteroscopy (URS)., Methods: Data from patients treated for cystine stones at a single academic center were retrospectively analyzed. The management protocol consisted of (i) treating symptomatic or > 7 mm stones, (ii) multi-staged URS for voluminous stones, (iii) referring patients to a dedicated nephrological clinic. The eGFR was calculated according to the MDRD formula. CKD category was assessed according to the NKF classification. Relevant CKD was defined as CKD category ≥ 3a. Descriptive statistics were used to analyze the cohort data., Results: Data from 46 cystinuric patients treated with 332 URS were available. Median age at diagnosis and at first URS in our center were 18 and 32 years, respectively. Median follow-up was 101 months. Median number of URS and recurrences per patient were 6 and 2, respectively. The median interval between the first and the last available creatinine level was 64 months. Median first and last eGFR were 72 and 74 mL/min, respectively. Overall, 83% of patients had stable or improved renal function within the study period. Ureteral stricture occurred in 3 (6.5%) patients., Conclusions: Cystinuria requires intensive endoscopic management. Most patients treated with URS have stable or improved renal function within a long-term follow-up. CKD is a not neglectable event that potentially occurs at an early stage of life. Current findings should be considered for the surgical management of cystinuric patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To compare the irrigation flows between different irrigation methods for f-URS., Methods: We compared the automatic irrigation system Endoflow II to gravity-based irrigation, and gravity-based irrigation with pressure cuff. Irrigation pressures were set at 40 and 100cmH 2 O. A LithoVue f-URS with a 3.6Fr working channel was used for the experiments. The f-URS was placed in straight alignment without active deflection on the operating table. For each irrigation pressure level, we evaluated the influence of the occupation of the working channel of the f-URS with an empty working channel, a 272μm laser fiber, a 1.9Fr nitinol basket. The outflow from f-URS was measured by the volume of irrigation fluid collected using a graduated glass at 1min, 2min, 3min and 5min., Results: Irrigations flows remained constant over the time for the Endoflow II and the gravity-based irrigation methods regardless of the irrigation pressure and setting. For the pressure cuff method, the irrigation flow remained constant only when the working channel was occupied either by the nitinol basket or the laser fiber. Irrigation flow with the Endoflow II were constantly higher than gravity-based irrigation methods. Irrigation flow significantly increased with increased irrigation pressure. In the presence of any instruments at any irrigation pressure, the flow decreased as the size of the instrument in the working channel increased., Conclusions: Automatic irrigation system Endoflow II provided higher irrigation flows than gravity-based irrigation methods. The irrigation flow decreased as the size of the instrument in the working channel increased. Further studies conducted in vivo are needed to investigate if the differences found between irrigation methods result in higher intrarenal pressure during procedures., Level of Proof: 4., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: Kidney Stone Calculator (KSC) is a free, three-dimensional (3D) planning software for flexible ureteroscopy(fURS) with Holmium:YAG(Ho:YAG) endocorporeal lithotripsy (EL). KSC provides the stone volume (SV) and expected duration of lithotripsy (ExDL) estimations based on non-enhanced-CT scan (NECT) DICOM series. We aimed to provide a preclinical and clinical evaluation of KSC., Patients and Methods: A preclinical evaluation measured the SV by three operators (resident, endourology expert and research engineer) among 17 NECT cases. Between January and March 2020, a multicentric, prospective, observational double-blind clinical evaluation was conducted in patients presenting with renal stones treated with Ho:YAG-EL during fURS and preoperative NECT. Demographic and surgical data were collected. The primary endpoint was a significant median difference between ExDL and EffectiveDL (EfDL). Second, efficiency (J/mm 3 ) and efficacy (mm 3 /min) ratios were calculated., Results: The preclinical evaluation showed no significant difference in the SV measurements among operators (p > 0.05). Pearson and Kendall coefficients of 0.99 and 0.98, respectively, were found. Twenty-six patients were included in the clinical evaluation, with a median age of 55 years. In 66% of cases, there was a single stone located in the lower pole, with a density > 1000 Hounsfield Unit observed in 42% and 85% of cases. A 14% [Q1-Q3 (5.4-24.8); p = 0.36] median difference between ExDL and EfDL was noted, which was greater in the case of lower pole stones with no possible relocation (p = 0.008). Median values of 17.6 J/mm 3 and 0.4 (0.32-0.56) mm 3 /s EL were also noted., Conclusions: Kidney Stone Calculator is a reproducible and accurate software that allows for an estimation of the stone burden and provides an ExDL for URSf. Defining the influencing factors of EL will improve its ExDL., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To compare intrapelvic pressure (IPP) levels achieved during f-URS, mini-PCNL, standard PCNL, and endoscopic combined intrarenal surgery in a kidney model., Methods: A silicone model simulating the complete urinary tract was used for all the experiments. We compared: a 9.5Fr f-URS, a 12Fr mini-nephroscope and a 26Fr nephroscope. The irrigation pressure was set at 40 and 193 cmH 2 O. We compared: f-URS-S ± ureteral access sheath (UAS, 10/12Fr, 11/13Fr, 12/14Fr) ± 273 μm laser fiber, Mini-PCNL with different sizes of operating sheath (15/16Fr, 16.5/17.5Fr, 21/22Fr) ± 365 μm laser fiber, Standard PCNL with an operating sheath of 30Fr ± Lithotripter LithoClast Master 11.4Fr., Results: f-URS: IPP values ranged between 1.4 and 46.2 cmH 2 O. Factors reducing IPP were an irrigation pressure at 40 cmH 2 O, an occupied working channel, and the use of a UAS except with the 10/12Fr at 193 cmH 2 O. Mini-PCNL: IPP values ranged between 2.4 and 39.7 cmH 2 O. Factors reducing IPP were irrigation pressure at 40 cmH 2 O, a large operating sheath (> 15/16Fr). The occupation of the working channel did not affect the IPP at 40 cmH 2 O, while it decreased at 193 cmH 2 O. Standard PCNL: IPP values ranged between 1.4 and 7.3 cmH 2 O. Occupancy of the working channel did not affect IPP at 40 cmH 2 O, while it increased at 193 cmH 2 O., Conclusion: We recorded for the first time IPP values according to different endourological techniques and configurations. IPP never exceed 50 cmH 2 O irrespectively of the assessed technique/setup. The factors reducing IPP were a low irrigation pressure (40 cmH 2 O), the use of a UAS or a working sheath appropriate to the diameter of the endoscope, as well as the occupation of the working channel in the case of f-URS., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: A recently introduced device (LithoVue Empower™ or LE, Boston Scientifics, USA) allows the surgeon to directly control the stone-retrieving basket without the need of an assistant during flexible ureteroscopy. We aimed to evaluate the stone-retrieval performance of this device., Methods: We used a bench-training model for flexible ureteroscopy, the Key-box (K-Box®, Porgès-Coloplast, France), to compare the LE configured with a 1.9F stone-retrieval tipless basket (ZeroTip™, Boston Scientific, USA) and a traditional assistant-maneuvered 1.9F stone-retrieval tipless basket. Seven experienced endo-urologists and seven residents-in-training retrieved a fake stone from three different renal cavities of the K-Box with increasing access complexity first with the traditional basket and then with the LE device. We recorded retrieval time and all the operators filled in the NASA Task Load Index (TLI) for the self-evaluation of their performance. We then compared the use of LE in terms of retrieval time, failure rates, and NASA-TLI scores., Results: Stone retrieval times and failure rates were similar according to the retrieval technique, although residents had non-statistically significant shorter times with the LE. NASA-TLI scores revealed lower frustration (p = 0.03) when LE was used by experienced urologists as compared to the traditional basketing. When stratifying the analyses according to surgical experience, fully trained urologists performed faster stone retrieval and showed lower effort scores than residents-in-training (p < 0.05)., Conclusions: The individually controlled retrieval system is an effective device assisting stone retrieval and does not necessitate specific training among experienced endo-urologists. Young residents might benefit from LE during their learning curve.

Objectives: To estimate the total energy needed to ablate 1mm 3 of stone volume (Joules/mm 3 ) during flexible ureteroscopic lithotripsy using a low-power Ho:YAG laser device, as a proxy of lithotripsy efficacy., Patients and Methods: We selected 30 patients submitted to flexible ureteroscopy for renal stones whose volume was bigger than 500 mm 3 . A 35 W Ho:YAG laser (Dornier Medilas H Solvo 35, Germany) was used for every procedure with a 272 µm laser fiber. We recorded laser parameters, the total energy delivered by the laser fiber, the time from the first laser pulse until the last one (lithotripsy time), and the active laser time as provided by the machine. We then estimated J/mm 3 values and determinants, along with ablation speed (mm 3 /s), and laser activity (ratio between laser active time and lithotripsy time)., Results: Median (IQR) stone volume and stone density were respectively 1599 (630-3502) mm 3 and 1040 (753-1275) Hounsfield units (HU). In terms of laser parameters, median (IQR) energy and frequency were 0.6 (0.4-0.8) J and 15 (15-18) Hz. Median (IQR) total delivered energy and lithotripsy time were 37,050 (13,375-57,680) J and 68 (36-88) min, respectively. Median (IQR) J/mm 3 and ablation speed were, respectively, 19 (14-24) J/mm 3 and 0.7 (0.4-0.9) mm 3 /s. The laser was active during 84% (70-95%) of the total lithotripsy time. HU density > 1000 was associated with reduced efficacy., Conclusions: It is possible to perform laser lithotripsy using a low-power laser device with a virtually continuous laser activity. The estimation of the pre-operative parameters as well as the J/mm 3 values are fundamental for a proper pre-operatory planning.

Purpose: To evaluate the feasibility of measuring the intrapelvic pressure (IPP) during f-URS with a wire including a pressure sensor and to assess IPP profiles during the procedure., Methods: Patients undergoing f-URS for stone disease were recruited. A wire with pressure sensor was placed in the renal cavities to measure IPP. For these cases, either no ureteral access sheath (UAS) or 10/12 or 12/14-Fr UASs were used according to surgeon discretion. Irrigation was ensured by a combination of a continuous pressure generator set at 80 cmH 2 O and a hand-assisted irrigation system providing on-demand forced irrigation to provide proper visibility. Pressures were monitored in real time and recorded for analysis., Results: Four patients undergoing five f-URS were included. IPP monitoring was successful in all patients. Mean baseline IPP was 6 cmH 2 O. During f-URS with only the endoscope in the renal cavities and irrigation pressure set at 80 cmH 2 O without any forced irrigation, the mean IPP was 63 cmH 2 O. Mean IPP during laser lithotripsy with the use of on-demand forced irrigation was 115.3 cmH 2 O. The maximum pressure peaks recorded during this therapeutic period using forced irrigation ranged from 289.3 to 436.9 cmH 2 O., Conclusion: High IPP levels may be achieved during f-URS with on-demand irrigation systems. The impact of these high pressures on the risk of complications and long-term consequences still need to be evaluated adequately. But, in this preliminary pilot study, IPP could be reliably and conveniently monitored and recorded using a wire with a digital pressure sensor.

The factors that can reduce intrarenal pressure during flexible ureteroscopy and percutaneous nephrolithotomy have been identified as low irrigation pressure, use of a ureteral access sheath or operating sheath appropriate fothe diameter of the endoscope, and occupation of the working channel in the case of flexible ureteroscopy., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

There is currently insufficient in vivo evidence that high-power Ho:YAG lasers improve retrograde intrarenal surgery or the ablation efficacy. While prospective trials are awaited, a low-cost, silent, low-power Ho:YAG laser that requires only a standard electrical outlet is more than sufficient for retrograde intrarenal surgery., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: We compared the hydrocoated silicone stent (Coloplast Imajin® hydro) to Percuflex™ Plus stent (Boston Scientific) in terms of patient comfort and quality of life after flexible ureteroscopy for stone disease over a 5-week prospective followup., Materials and Methods: This is a multicenter, single-blind, prospective, randomized trial of 141 patients treated with flexible ureteroscopy for renal stones. Primary outcome was Ureteral Stent Symptom Questionnaire (USSQ) Body Pain Index recorded before Double-J® stent removal at day (D) 20. Secondary endpoints were USSQ scores at intermediate dates (D2, D7, D20) and 2 weeks after stent withdrawal (D35), occurrence of adverse events and stent encrustation., Results: The trial was completed by 113 (80.1%) patients. Mean (SD) USSQ body pain scores were 25% lower at D20 for the silicone stent at 18.7 (11.4) vs 25.1 (14.2) (p=0.015). No difference in terms of adverse events and safety profile was observed. USSQ urinary symptoms scores at D2, D7 and D20 were lower in the silicone stent group at 26.4 (7.7) vs 31.8 (8.1) at D20 (p <0.001). The use of USSQ self-questionnaires was associated with a limited number of missing or incomplete answers., Conclusions: The primary results of this large sample prospective randomized controlled study comparing the silicone Imajin hydro stents to the Percuflex Plus stent show that silicone stents are associated with significantly less patient discomfort. We would recommend their use in patients who require stenting for stone disease.

Introduction: The aim of this paper was to give a complete overview of all published complications associated with ureteroscopy and their according management and prevention in current urological practice., Materials and Methods: This review was registered in PROSPERO with registration number CRD42018116273. A bibliographic search of the Medline, Scopus, Embase and Web of Science databases was performed by two authors (V.D.C. and E.X.K.). According to the Population, Intervention, Comparator, Outcome (PICO) study design approach and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards, a consensus between these authors was found relating to the thematic structure of this review., Results: Ureteral stent discomfort, ureteral wall injury and stone migration are the most frequently reported complications. The worst complications include urosepsis, multi-organ failure and death. Incidence rates on these and other complications varied extensively between the reviewed reports., Conclusion: Ureteroscopy seems to be associated with more complications than currently reported. The present overview may help urologists to prevent, recognize and solve complications of ureteroscopy. It may also stimulate colleagues to perform prospective studies using standardized systems for classifying complications. These are warranted to compare results among different studies, to conduct meta-analyses, to inform health care workers and to counsel patients correctly about possible risks of ureteroscopy.

Objective: To evaluate whether the position of the working channel affects the effectiveness of flexible ureteroscopy., Materials and Methods: We compared the ureteroscopes Flex-X2S and Flex-XC (working channel at the 9 and 3 o'clock positions, respectively) in eight cavities of a K-Box model, simulating the distribution of the right and left intrarenal calyces. In the first and second settings, each cavity contained a 1-cm stone, lying on the bottom and fixed on the anterior sheet covering the box, respectively. In the third setting, the posterior and lateral surface of each cavity was draped with graph paper. Once the flexible ureteroscope entered each cavity, we measured and compared (i) the proportion of stone surface targeted by the laser (STL) and (ii) the proportion of graph paper burned by the laser (PBL) obtained with the two instruments., Results: Higher STLs and PBLs were obtained with the 3 o'clock position than the 9 o'clock position in the right posterior and left anterior cavities (mean ± sd STL 87% ± 15% vs 46% ± 38% and 78% ± 35% vs 43% ± 24%, respectively; P < 0.05), and on the right posterior surfaces of the middle-lower/lower cavities (PBL 72% vs 31% and 77% vs 35%, respectively; P < 0.01) and on the left lateral surface of the lower cavities (PBL 45% vs 25%; P = 0048), respectively. Conversely, the 9 o'clock position provided higher STLs and PBLs than the 3 o'clock position in the left posterior and right anterior cavities (mean ± sd STL 84% ± 20% vs 65% ± 28% and 79% ± 30% vs 44% ± 35%, respectively; P ≤ 0.02), and on the left posterior and right lateral surfaces of the lower cavities (PBL 59% vs 34% and 50% vs 21%, respectively; P ≤ 0.04)., Conclusions: The position of the working channel of the flexible ureteroscope should be considered when planning flexible ureteroscopy, especially when dealing with the lower pole., (© 2019 The Authors BJU International © 2019 BJU International Published by John Wiley & Sons Ltd.)

Purpose: To identify the causes of prolonged length of hospital stay (LOHS) of patients treated with flexible ureteroscopy (fURS). The secondary endpoint was to identify the predictors of complications., Methods: A retrospective single-center cohort study was conducted between January 2011 and December 2015. All consecutive patients treated with a planned fURS, regardless of the indication, AND stayed hospitalized for at least one additional day compared to the traditional postoperative LOHS of our center (=1 day) were included. A multivariate analysis was performed to investigate predictive factors of prolonged LOHS., Results: Two hundred and seventy-two patients were included in the final analysis. The median duration of LOHS was two days [2-18]. Forty-seven percent of patients were discharged beyond day 1 and had no complication. Among them, 56% stayed for simple surveillance decided by the surgeon without any specific treatment introduced and 52% stayed for continuation of intravenous preoperative antibiotics. Of the remaining 144 patients who had a complication, 85.4% (123/144) had a minor complication (Clavien 1 or 2). In multivariate analysis, predictive factors of prolonged LOHS (discharge after day 1) were neurological comorbidities (paraplegia, spina bifida, multiple sclerosis) with an odds ratio of 4.39 [1.7; 11.4]., Conclusions: The causes of prolonged LOHS were mainly related to comorbidities. A number of patients stayed hospitalized without complications. The identification of predictive factors of complications and prolonged LOHS may allow better selection of patients eligible for outpatient surgery and select those for whom inpatient surgery is still recommended., Level of Evidence: 3., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: To present attributes of currently available flexible ureteroscopes to define the best flexible ureteroscope for upper tract urothelial carcinoma (UTUC) treatment., Materials and Methods: Scopus and Medline databases were searched for articles relating to performance of flexible ureteroscopes. A consensus for final inclusion of articles judged to be relevant for UTUC treatment was reached between the authors. Instrument characteristics were extracted from manufacturers' product brochures., Results: Smaller cross-sectional size of instruments is associated with increased probability for successful primary access to the upper urinary tract. The smallest flexible ureteroscopes are fiberoptic scopes. Smaller ureteroscopes also allow comparatively increased irrigation flow at constant intrarenal pressure. Digital flexible ureteroscopes achieve superior image quality compared to their fiberoptic counterparts, at the price of lower end-deflection ability. Image enhancement technologies such as narrow-band imaging (NBI), photodynamic diagnosis (PDD) and Image 1-S (formerly SPIES) are based on subjective image interpretation by the operator. NBI and PDD significantly increase tumor detection rate. The highest subjective image quality score of the Image 1-S technology is reached by the "Clara + Chroma" mode. Single-use ureteroscopes offer potential advantages over reusable scopes, including sterility, absence of contamination, immediate availability and exemption of previous instrument wear., Conclusions: Miniaturization, digital image caption and image enhancement technologies seem to be the major determinants defining the best flexible ureteroscope for UTUC treatment. The impact of further factors, such as distal tip design, torque, working channel position, risk of contamination, as well as upcoming technological innovations should be evaluated in randomized controlled trials.

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To assess the intermediate- and long-term effect of high-grade ureteral injuries from ureteral access sheaths., Methods: Patients undergoing ureteroscopy for upper tract calculi were prospectively enrolled at 2 sites from 2010 to 2015. A 12/14 French sheath was used and the ureter was inspected with a flexible ureteroscope during withdrawal of the sheath and recorded. The videos were then evaluated by 2 blinded endourologists, and any injuries were graded per the Traxer ureteral injury scale. Only high-grade injuries were included. The primary endpoint was defined as ongoing hydronephrosis without an obstructing stone on follow-up imaging indicating a ureteral stricture. Logistic regression analysis was used to assess the relationship between hydronephrosis, ureteral injury, and other patient variables., Results: Fifty-six patients were identified with high-grade ureteral injuries. Sixteen patients (28.6%) were female. Median age was 56.4 years (range 14-85). Median follow-up was 35.8 months (range 0-88). Three patients (5.5%) had hydronephrosis on follow-up imaging, only 1 of whom developed a de novo ureteral stricture. On univariate analysis, hydronephrosis was associated with a shorter stent duration (P = .11) and older age (P = .17)., Conclusion: Endoscopically identified high-grade ureteral lesions following ureteral access sheath placement do not lead to clinically significant sequelae on intermediate term follow-up, with a stricture rate comparable to those without visible injuries of 1.8%., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The aim of the present paper was to review the literature on all available ureteral access sheaths (UASs) with their indications, limitations, risks, advantages and disadvantages in current modern endourological practice. Two authors searched Medline, Scopus, Embase and Web of Science databases to identify studies on UASs published in English. No time period restriction was applied. All original articles reporting outcomes or innovations were included. Additional articles identified through references lists were also included. Case reports, editorials, letters, review articles and meeting abstracts were excluded. A total of 754 abstracts were screened, 176 original articles were assessed for eligibility and 83 articles were included in the review. Based on a low level of evidence, UASs increase irrigation flow during flexible ureteroscopy and decrease intrapelvic pressure and probably infectious complications. Data were controversial and sparse on the impact of UASs on multiple reinsertions and withdrawals of a ureteroscope, stone-free rates, ureteroscope protection or damage, postoperative pain, risk of ureteral strictures, and also on its cost-effectiveness. Studies on the benefit of UASs in paediatrics and in patients with a coagulopathy were inconclusive. In the absence of good randomized data, the true impact of UASs on surgery outcome remains unclear. The present review may contribute to the evidence-based decision-making process at the individual patient level regarding whether or not a UAS should be used., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Introduction: Since 2012 Elmed has been working on a robot specifically designed for flexible ureteroscopy. After the first version of Avicenna Roboflex, a second version was developed in 2015, with significant changes especially in the irrigation system. We consider mandatory for the endourologist that works with the Avicenna Roboflex be aware of the functioning of the irrigation system., Materials and Methods: We connected a container to the pump's irrigation system and measured the quantity of saline per second delivered by each speed setting, with/without the flush in five different modalities: pump on its own, pump with ureteroscope, with two laser fibers, with 1.9 Fr basket, and with a Terumo guidewire., Results: The highest mean flow-rates were observed in the 200- micrometer laser fiber, after the pump on its own. Median flowrates for all speed settings were significantly higher for the pump on its own than for the URS in both flushed and nonflushed modes (p = 0.045, p = 0.039 respectively). There was no statistically significant difference in median flow-rates between the guide wire and basket in all of the speed settings (p = 0.932 and p = 0.977). For both laser fibers there was no statistically significant difference between the median flow rate on both nonflush and flush modes. (p = 0.590 & p = 0.590). There was a linear correlation between the speed setting and the increase measured with the flush-option for pump only measurements (r = 0.602, p = 0.038). There was no statistically significant difference between laser fibers and the pump on its own on the increase of flow rate with flush mode. (p = 0.443 for the 272- micrometer fiber and p = 0.219 for the 200-micrometer fiber)., Conclusion: The irrigation system of the new Avicenna Roboflex is optimized compared to the previous version. However other more complex studies concerning the live flow/pressure relationship are needed before firm conclusions can be made.

During the last decades, the surgical management of kidney stones benefited of many technological advances and one of them is the development of flexible ureteroscopy (fURS). This tool, ancillary equipment such as graspers and baskets, and lithotripsy technique with Holmium:YAG laser underwent many improvements leading to a widening of its indications with diagnostic and therapeutic management of upper urinary tract pathologies such as urolithiasis and urothelial tumors. The objective of this review is to describe the surgical technique for fURS as well as tips and tricks for the treatment of renal stones.

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., (Copyright © 2018 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Holmium:YAG laser is the most used laser for urolithiasis. Generally, we use metallic scissors to cut the fiber tip to restore its effectiveness. Many cleaving methods have been described to avoid fiber damage and to restore its greatest power to the fiber. There is a lack of information regarding which cleaving method should be used and its effect on the fiber. In order to compare these effects, we studied different cleavage methods in terms of power output and its effects on the fiber., Methods: New single-use 272-μm fibers were used with a holmium:YAG laser lithotripter. Five kinds of fiber tips were compared: a new intact fiber, cleaved with ceramic scissors, cleaved with metallic scissors, first cleaved then stripped and first stripped then cleaved. The fibers were used against synthetic stones (BegoStone ® ) similar to calcium oxalate monohydrate, with fragmentation (SP, 5 Hz, 1.5 J) and dusting (LP, 15 Hz, 0.5 J) settings. We measured power output at 0, 1, 5, 10 and 15 min., Results: For fragmentation parameters, there was a statistical difference between the 5 groups at 0 and 1 min of laser use (p < 0.05) and none for time period over 1 min (p = 0.077-0.658). For dusting parameters, there was a statistical difference between the 5 groups at 0 min of laser use (p < 0.05) and none for time period over 0 min (p = 0.064-1)., Conclusion: Cleaving the fiber tip may restore its effectiveness to the fiber, but only for a limited time, although it may preserve the scopes from damage.

Background and Purpose: Modern flexible ureteroscopes (fURSs) have good deflection, but despite this, approaching an acute angled calix can still be difficult. The goals of our in vitro study were to assess the ability of the available modern fURSs to effectively access the sharp angled calices and to compare the end-tip deflection of the various fiber-optic and digital fURSs., Materials and Methods: Using a bench-training model for FURS (K-Box, Porgès-Coloplast), we tried to access an acute angled calix with nine different fURSs (BOA vision, COBRA vision, R.Wolf; FLEX X 2 , FLEX Xc, K.Storz; LithoVue, Boston Scientific; URF-P5, URF-P6, URF-V, URF-V2, Olympus). Passing the fURSs through a ureteral access sheath (ReTrace, Porgès-Coloplast), the maximum end-tip deflection for every fURS was measured with the tip extended out from the sheath at 1, 2, 3, and 4 cm. Two ranking methods were designed for scoring the fURSs, one based on total ranking points and the other on total degrees of deflection., Results: While all fiber-optic fURSs (except URF-P6) were able to access the sharp angled calix, none of the digital fURSs (except FLEX Xc) reached the difficult angled calix. Similarly, all fiber-optic fURSs had better end-tip deflection compared with the digital fURSs, except FLEX Xc, which was as deflectable as the fiber-optic fURSs. The fURSs showed an end-tip deflection (median difference of almost 21°) in favor of fiber-optic fURSs. Based on the scoring, the highest ranked fURS (best deflection) was FLEX X2 and the lowest ranked fURS (worst deflection) was URF-V2., Conclusions: Digital fURSs were less effective in accessing the sharp angled calix and they had lesser end-tip deflection compared with the fiber-optic counterparts. When approaching a difficult lower pole calix, it might be better to use a fiber-optic fURS.

Introduction: We evaluated a new digital single-use flexible ureteroscope, LithoVue™ with respect to deflection, image quality and maneuverability., Methods: A prospective cohort study was conducted in eight tertiary reference centers in Europe in December 2015 and January 2016. All consecutive patients included underwent flexible ureteroscopy and were 18 years or older. Deflection and image quality pre- and post-use and maneuverability were rated with a Likert scale., Results: A total of 40 procedures were performed (five per institution). The indication for FURS was treatment of renal stones in 92.5 % of the cases. Before LithoVue™ usage, the median measured upward and downward deflections were both 270°. Image quality was rated as "very good" in 65 % of cases and "good" in 30 %. Maneuverability was "very good" in 77.5 % and "good" in 17.5 %. At the final evaluation, median upward and downward deflections were both 270°. Image quality was still "very good" in 65 % of cases and "good" in 30 % with no significant difference compared with preoperative data (p = 1). Maneuverability was "very good" in 72.5 % and "good" in 17.5 %, with no significant difference compared with preoperative data (p = 0.92). Two LithoVue™ broke during surgery (5 %): one occurring in extreme deflection with acute infundibulopelvic angle and spontaneous loss of vision for the second one., Conclusion: The LithoVue™ displayed good image quality, active deflection and maneuverability. Further evaluation of surgical outcomes and cost analysis will help to present the best utility of this single-use FURS in current practice.

Purpose: We sought to test the content validity of a new training model for flexible ureteroscopy: the Key-Box., Material and Methods: Sixteen medical students were randomized to undergo a 10-day training consisting of performing 10 different exercises aimed at learning specific movements with the flexible ureteroscope, and how to catch and release stones with a nitinol basket using the Key-Box (n = 8 students in the training group, n = 8 students in the nontraining control group). Subsequently, an expert endourologist (O.T.) blindly assessed skills acquired by the whole cohort of students through two exercises on ureteroscope manipulation and one exercise on stone capture selected among those used for the training. A performance scale (1-5) assessing different steps of the procedure was used to evaluate each student. Time to complete the exercises was measured. Mann-Whitney Rank Sum test was used for comparisons between the two groups., Results: Mean scores obtained by trained students were significantly higher compared with those obtained by nontrained students (all p < 0.001). All trained students were able to complete the two exercises on ureteroscope manipulation within 3 minutes, whereas two students (25%) were not able to finish the exercise on stone capture. Conversely, four (50%) and six (75%) nontrained students were not able to finish one out of the two exercises on ureteroscope manipulation and the exercise on stone capture, respectively. The mean time to complete the three exercises was 76.3, 69.9, and 107 and 172.5, 137.9, and 168 seconds in the trained and nontrained groups, respectively (all p < 0.001)., Conclusions: The K-Box ® seems to be a valid easy-to-use training model for initiating novel endoscopists to flexible ureteroscopy.

Objective: To report the first performance of simultaneous bilateral percutaneous nephrolithotomy and flexible ureteroscopy carried out in tandem by 2 different surgeons in a patient with bilateral medium-sized renal calculi, describing step-by-step details of the surgical technique., Materials and Methods: A 46-year-old man, affected with hyperparathyroidism, was diagnosed with asymptomatic bilateral medium-sized renal stones. An abdominal noncontrast computed tomography scan revealed a left single kidney stone with a maximum diameter of 16 mm and 2 right renal stones located in the pelvis and in the lower calyx, of 21 and 19 mm in maximum diameter, respectively. A bilateral simultaneous percutaneous nephrolithotomy on the right side and flexible ureteroscopy on the left side were therefore carried out., Results: The total operative time was 80 minutes. No intra- or postoperative complications were experienced. On postoperative day 1, the creatinine serum level was stable (0.7 mg/dL); he was discharged home 48 hours later. Ureteral stents were removed 7 days after the procedure. At 2 weeks follow-up, an abdominal noncontrast computed tomography scan showed a stone-free status and no changes in renal function were detected., Conclusion: A simultaneous bilateral endoscopic manipulation is feasible and safe and it can be offered in the presence of medium-sized bilateral renal stones in high-volume centers by experienced surgeons., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Thanks 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., Objective: To describe our surgical technique for fURS, step-by-step, for the treatment of renal stones and to assess its effectiveness and safety., Design, Setting, and Participants: A retrospective analysis of 316 consecutive patients who underwent fURS for renal stones at our institution between March 2014 and September 2015 was performed., Surgical Procedure: Ureteroscopy and laser lithotripsy using a standardized technique with last-generation flexible ureteroscopes., Outcome Measurements and Statistical Analysis: Clinical data were collected in a dedicated database. Intraoperative and postoperative outcomes were assessed. A descriptive statistical analysis was performed., Results and Limitations: The 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., Conclusions: The 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., Patient Summary: Flexible 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., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: To evaluate LithoVue, the new single-use digital flexible ureteroscope, in a human cadaveric model and compare it with a nondisposable fiber optic and digital flexible ureteroscopes., Materials and Methods: LithoVue, a conventional fiber optic, and digital flexible ureteroscopes were each tested in four renal units of recently deceased female cadavers by three surgeons. The following parameters were analyzed: accessibility to the kidney and navigation of the entire collecting system with and without ureteral access sheath (UAS), lower pole access measuring the deflection of the ureteroscope with the working channel empty, and with inside two different baskets and laser fibers. A subjective evaluation of maneuverability and visibility was assessed by each surgeon at the end of every procedure., Results: Kidney access into the Renal unit 1 was not possible without UAS for all ureteroscopes because of noncompliant ureter at the level of sacroiliac joint. The reusable digital ureteroscope was unable to reach one calix of the lower pole and one calix of the upper pole (Renal units 2 and 3) without UAS placement. Lower pole access with baskets and laser fibers was possible for each ureteroscope after UAS placement. No statistically significant differences were detected in angle deflection between ureteroscopes. The digital ureteroscope was preferred for visibility in all procedures: LithoVue for maneuverability in six procedures, fiber optic in five procedures, and the digital ureteroscope in one procedure., Conclusions: LithoVue seems to be comparable with conventional ureteroscopes in terms of visibility and manipulation into the collecting system in fresh human cadavers. Further studies in humans are needed to determine the clinical value of this new instrument.

Background and Purpose: Flexible ureterorenoscopy (F-URS) plays a major role in the management of kidney stones. Ureteral access sheaths (UAS) are important tools for F-URS. In this study, we aimed to evaluate the difference in intrarenal pressures between different flexible ureteroscopes while using the same UAS and to calculate the irrigation flow variance., Materials and Methods: Eight different flexible ureteroscopes were tested with five different UAS on an artificial kidney model to measure intrarenal pressures and irrigation flow. Irrigation at 60 cmH2O pressure was performed; the pressure and the irrigation flow amount were recorded with different states of the operator channel: Free, with the laser fiber (272 μm), and with the nitinol basket (1.9F) inside., Results: The highest pressure recorded was 46.68 cmH2O with Wolf Boa and 9.5/11.5F Cook Medical UAS. All the ureteroscopes that fit inside the 10/12F Coloplast ReTrace provided pressures below 40 cmH2O. The inner diameter of the 10/12F Rocamed Bi-Flex is actually 11F, so intrarenal pressures were lower and irrigation flow was higher. With the 11/13F Boston Scientific Navigator HD and 12/14F Coloplast ReTrace, the pressures were very low. The irrigation flow measurements were in concordance with pressure measurements., Conclusion: The ureteroscope sizes diminished with advancements in technology. Small-sized ureteroscopes can provide low intrarenal pressures with good irrigation flow when used with convenient small-sized access sheaths. The compatibility between the ureteroscopes and UASs should be anticipated by all endourologists and considered during F-URS. The advantages of 10/12 UASs in terms of intrarenal pressure and irrigational flow should make these access sheaths an interesting first-line choice.

Objective: To assess the evolution of the annual number of surgical procedures and the surgical management for urolithiasis., Methods: A retrospective monocentric study was conducted between 1985 and 2014 in a French academic institution. The study population was divided into four groups: extracorporeal shock wave lithotripsy (SWL), flexible and rigid ureteroscopy (URS), percutaneous nephrolithotomy (PCNL) and open surgery. The annual number of surgical procedures as well as the distribution of each technique was determinated by using the operating records., Results: In all, 23,162 procedures were performed during this period. The annual number of procedures rose from 410 in 1985 to 1071 in 2014, representing a rise of 161%. SWL represented 85.6% (351/410) of all surgeries in 1985 then 21.3% in 2014 (228/1071). In contrast, URS accounted for 4.4% (18/410) of all surgeries in 1985 and rose to 76% (814/1071) in 2014. The number of URS has reached the SWL in 2007 and then became the main surgical treatment. The number of PCNL remained stable during the study period but its proportion decreased due to the increased activity, representing 7.1% (29/410) in 1985 and 2.6% (28/1071) in 2014. Open surgery is rarely practiced and represents currently 0.1%., Conclusion: The number of surgical procedures for urolithiasis has more than doubled in 30years. SWL represented the main treatment until 2007 and its number decreased whereas ureteroscopy represents now the most common stone treatment in our institution, PCNL remaining stable., Level of Evidence: 5., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To compare the efficacy and the safety of flexible ureterorenoscopy (f-URS) in the treatment of kidney stones according to the body mass index (BMI), which seems to be less influenced by weight compared with shock wave lithotripsy and percutaneous nephrolithotomy., Methods: We conducted a retrospective monocentric study in patients with a known BMI who underwent an f-URS for kidney stones between 2006 and 2008. Success rates in the obese patients (OP) group (BMI ≥30 kg/m(2)) were compared with success rates in the normal weight patients (NWP) control group (BMI <25 kg/m(2)). Patients with a BMI ≥40 kg/m(2) were defined as morbidly obese patients (MOP), a subgroup of the OP group. The success was defined as a stone-free status (no or ≤2 mm residual stone) at the time of control, 3 months after the procedure assessed by kidneys-ureters-bladder radiography coupled with ultrasound (only in NWP with radiopaque stones), or computed tomography-scan., Results: A total of 327 procedures were performed, including 97 f-URS in 87 OP (including 14 procedures in 13 MOP) and 230 procedures for 188 NWP. The overall success rate was 67.4% and 68% in the NWP and OP, respectively; P = .91 (71.4% in the MOP subgroup). Success rates decreased with an increasing stone size without any differences between the groups. Regardless of location and stone size (<10, 10-20, >20 mm), there was no statistical difference in the success rate. Postoperative morbidity was similar in both groups and occurred in 2.44% of cases., Conclusion: f-URS for kidney stones resulted in similar outcomes in NWP and OP, and even MOP, regardless of stone size and location and with equivalent morbidity., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: The use of a ureteral access sheath (UAS) during flexible retrograde intrarenal surgery (RIRS) has become increasingly popular. Our aim was to evaluate the accessibility of a new UAS device, allowing the transformation of the working guidewire into a safety guidewire., Methods: A prospective, multicenter study was conducted between January and February 2010 in six European tertiary reference centers. Patients needing flexible RIRS were eligible to participate in the study. In all cases, insertion of the Re-Trace™ (12/14Fr, Coloplast, Denmark) was attempted at the beginning of the procedure. Insertion success was defined as placement of the UAS in the lumbar ureter with successful disengagement of the working guidewire, which turned into a safety guidewire. Influence of gender and pre-stenting status was analyzed by univariate analysis., Results: 137 UASs were used in 75 male and 62 female patients. 25.5% of ureters were pre-stented: men were 2.17 more often pre-stented than women. The overall Re-Trace™ insertion rate was 82.5%. Success rate was not significantly different between men and women (77.3 vs. 88.7%, respectively, p = 0.11). Pre-stenting status did not significantly influence the success rate (p = 0.31). When analyzing the combined influence of pre-stenting status and gender, the worst success rates seemed to be obtained in men without pre-stenting, but no significant differences were found between groups., Conclusions: Re-Trace™ UAS showed good overall insertion rates. This evaluation validated the new concept of guidewire disengagement: A single wire automatically switches from working to safety role.

Objective: We aim to evaluate the outcome of flexible ureterorenoscopy (F-URS) with holmium laser in treating renal diverticular stone as a minimal invasive option., Patients and Methods: We reviewed retrospectively the records of 45 patients who underwent F-URS using holmium laser from 2004 to 2011 for symptomatic renal diverticular stone. The presenting symptoms were renal colic, urinary tract infection or hematuria. The F-URS used after the Shock Wave Lithotripsy (SWL) failure in 30 (66.7 %) patients. The repeated treatment by F-URS was carried out twice for four patients; in three patients, it was correlated to the size of the stone and it was because of failure to identify the diverticulum in one patient. The follow up visit range were between 4 to 6 weeks with plain radiograph (KUB) and renal ultrasound or non-contrast CT scan (NCCT)., Results: Of our data, there were 45 patients, 22 women and 23 men (mean age of 46.3 years, range 18-72). We found 28 patients (62.2 %) who had stone free (SF), 10 patients (22.2 %) with clinically insignificant residual fragments (less than 3mm in size) and residual fragments (RF) in seven patients (15.6 %). Success rate was considered as stone free or insignificant residual fragment, which was obtained in 38 patients (84.4 %). The symptom-free was in 42 patients (93.3 %)., Conclusion: In our experience, F-URS using holmium laser was very effective minimally-invasive technique that could be the best option for the treatment of renal diverticular stone especially for those who resist the treatment with the SWL. It showed an excellent stone clearance rate, minimal morbidity rate and brief hospital stay., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Les avancées technologiques en endo-urologie font désormais de l'urétéroscopie souple (URSS) une technique de choix pour traiter les calculs urinaires mais aussi un casse-tête lorsqu'il s'agit de choisir son équipement. La mise en place d'un guide de sécurité au sein des cavités rénales (nitinol, 0,035″, « stiff ») par cystoscopie rigide est non obligatoire mais constitue un critère de sécurité. Il en est de même concernant les gaines d'accès urétéral, celles avec aspiration étant en cours d'évaluation. Si leur utilisation réduit la pression et la température au sein des cavités rénales facilitant la vision, leur insertion peut occasionner des lésions urétérales. Les systèmes d'irrigation utilisant la gravité avec pompe manuelle sont à privilégier pour minimiser le risque de barotraumatisme. Le choix de l'urétéroscope est complexe : diamètre, capacité de déflexion, position du canal opérateur et qualité de vision sont à considérer. Aussi, il est difficilement envisageable de n'utiliser qu'un modèle endoscope pour l'intégralité des URSS. Les lasers Holmium:Yttrium-Aluminium-Grenat (Ho:YAG) et Thulium Fibré (TFL) sont aujourd'hui recommandés pour le traitement des calculs urinaires en URSS, avec un avantage potentiel du TFL pour la pulvérisation fine. Les paniers sont nombreux et divers, leur taille et forme devant également être considérées avant acquisition. En fin d'intervention, un drainage urétéral n'est pas systématique, mais les sondes JJ en silicone ont montré des risques d'incrustation et de gêne fonctionnelle plus faibles que les sondes faites de polyuréthane. Flexible ureteroscopy is now widely used as the preferred option to surgically treat a urinary stone, due to several technological advancements. Thus, choosing the adequate equipment is challenging, but respects safety concepts. Indeed, placing the safety wire (nitinol, 0,035″, "stiff") under rigid cystoscopy is not mandatory but improve safety. Regarding ureteral access sheath (UAS), considerations are similar: UAS facilitates vision, pressure and temperature control but can also be responsible of ureteral injuries at insertion. Suction devices are now under evaluation and could not be discussed. To limit the barotrauma risk, irrigation devices with manual pumps should be used (40 cmH 2 0). Choosing a flexible ureteroscope (fURS) is challenging; a special attention has to be given to size, deflexion, working channel position and vision. Thus, using a single fURS is hardly imaginable. Both Holmium:Yttrium-Aluminium-Garnet (Ho:YAG) and Thulium Fiber (TFL) lasers are recommended to treat urinary stones during fURS, with a potential advantage of TFL on thin pulverization. A wide variety of baskets exists and size and shape have to be considered before acquisition. Finally, if ureteral stenting is not mandatory in uncomplicated cases, silicone stents present a lower risk of encrustation and stent-related symptoms compared to polyurethane ones. [ABSTRACT FROM AUTHOR]

Trois risques d'exposition oculaire lors des chirurgies endoscopiques urologiques existent : les projections de liquides biologiques et d'irrigation, le rayonnement laser et les rayons X. Afin de prévenir ces risques et leurs conséquences, le port de lunettes de protection est recommandé. Cette revue a pour objectif de détailler chacun de ces risques et donner les éléments nécessaires pour une protection adaptée. Three risks of ocular exposure during endoscopic urological surgeries exist: splashes of body fluids and irrigation solution, laser and X-ray radiations. In order to prevent these risks and their consequences, the wear of protective glasses is recommended. The purpose of this review was to detail these three risks and provide recommendations for appropriate eye protection. [ABSTRACT FROM AUTHOR]