Ureteroscopy has undergone many advances in recent decades. As a result, it is able to treat an increasing range of patient groups including special populations such as pregnancy, anomalous kidneys and extremes of age. Such advances include Holmium laser, high-power systems and pulse modulation. Thulium fibre laser is a more recent introduction to clinical practice. Ureteroscopes have also been improved alongside vision and optics. This article provides an up-to-date guide to these topics as well as disposable scopes, pressure control and developments in operating planning and patient aftercare. These advances allow for a custom strategy to be applied to the individual patient in what we describe using a new term: Tailored endourological stone treatment (TEST). Level of evidence: 5
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Introduction: Urolift is an established intervention for symptoms of bladder outflow obstruction caused by benign prostate enlargement. Reported advantages include its minimally invasive profile, short learning curve and feasibility as a day case procedure. Our aim was to use a national registry as a means to evaluate the nature of complications and device failures that have been documented to occur. Methods: Retrospective review was performed of the US Manufacturer and User Facility Device Experience (MAUDE) database, a prospective register, which contains voluntarily submitted adverse events associated with surgical devices. Information collected include event timing, underlying cause, procedural completion, complications and mortality status. Results: Between 2016 and 2023, 103 device failures, 5 intra-operative complications and 165 post-operative complications (early: 151, late: 14) were registered. The commonest device problem (56%, n = 58) was failure of the implant to deploy with subsequent requirement for complete replacement. There were 50 cases of documented urosepsis. 62 patients with post operative haematuria were registered including 12 that underwent emergency embolisation. Other complications included stroke ( n = 5), pulmonary embolism ( n = 3) and necrotising fasciitis ( n = 1). Twelve ITU admissions were registered. In the reports, 22 cases were filed that recorded a hospital stay of 7 days or more. Eleven deaths were captured in the database over the study period. Conclusion: While urolift is recognised as less invasive intervention compared to alternatives such as transurethral resection of the prostate, serious adverse events have been reported to occur including death. Our findings can provide learning points for surgeons and allow for improved patient counselling and treatment planning accordingly.
METHODS: Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry, we identified all single-stage cases of URS laser lithotripsy performed for renal stones between 2016-2022. Data was collected by independent abstractors at each practice using standardized definitions. Stone-free rate (SFR) was defined as zero fragments on imaging reports (ultrasound, x-ray, CT scan) within 60 days. We assessed practice and urologist-level utilization of dusting vs. fragmentation/basketing. We compared characteristics of patients. Using multivariable regression we assessed the association of each technique with 30-day postoperative emergency department (ED) visits accounting for patient, stone, and surgical characteristics.RESULTS: Among 4,772 ureteroscopy procedures for renal stones performed by 230 surgeons across 34 practices, 2,838 (59%) were performed with a dusting technique. Significant variation in use of dusting was observed across practices (3-99%, p<0.001) and urologists (0-100%, p<0.001) (Figure 1). Utilization was greatest in larger practices. Dusting was used more frequently for larger stones (median [IQR]: 9mm [7-13] vs 8mm [6-11], p<0.001) and stones in multiple locations (30% vs. 20%, p<0.001). Ureteral access sheaths (55% vs 72%, p<0.001) and post-operative stents (79% vs 86%, p<0.001) were used less frequently with dusting. Post-operative imaging was performed in 48% of patients; SFR was lower with dusting (41% vs 57%, p<0.001). Dusting was associated with higher ED visits on multivariable analysis (OR 1.4, p[0.006).CONCLUSIONS: Six of ten patients with renal stones undergoing URS are treated with a dusting technique in Michigan. Our data suggests dusting is more frequently used in larger practices which could be related to access of high-power lasers. Real-world practice indicates dusting is associated with more post-operative ED visits.
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