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Flexible ureteroscopy: technique, tips and tricks

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Abstract

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.

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References

  1. Marshall VF (1964) Fiber optics in urology. J Urol 91:110–114

    Article  CAS  PubMed  Google Scholar 

  2. Takayasu H, Aso Y, Takagi T, Go T (1971) Clinical application of fiber-optic pyeloureteroscope. Urol Int 26(2):97–104

    Article  CAS  PubMed  Google Scholar 

  3. Takayasu H, Aso Y (1974) Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol 112(2):176–178

    Article  CAS  PubMed  Google Scholar 

  4. Johnston WK 3rd, Low RK, Das S (2004) The evolution and progress of ureteroscopy. Urol Clin N Am 31(1):5–13

    Article  Google Scholar 

  5. Basillote JB, Lee DI, Eichel L, Clayman RV (2004) Ureteroscopes: flexible, rigid, and semirigid. Urol Clin N Am 31(1):21–32

    Article  Google Scholar 

  6. Proietti S, Dragos L, Molina W, Doizi S, Giusti G, Traxer O (2016) Comparison of new single-use digital flexible ureteroscope versus nondisposable fiber optic and digital ureteroscope in a cadaveric model. J Endourol 30(6):655–659

    Article  PubMed  PubMed Central  Google Scholar 

  7. Doizi S, Kamphuis G, Giusti G, Andreassen KH, Knoll T, Osther PJ, Scoffone C, Pérez-Fentes D, Proietti S, Wiseman O, de la Rosette J, Traxer O (2017) First clinical evaluation of a new single-use flexible ureteroscope (LithoVue™): a European prospective multicentric feasibility study. World J Urol 35(5):809–818

    Article  PubMed  Google Scholar 

  8. Türk C, Neisius A, Petřík A, Seitz C, Skolarikos A, Tepeler A, Thomas K (2017) EAU Guidelines on Urolithiasis. https://uroweb.org/guideline/urolithiasis. Accessed Oct 2017

  9. Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, Pace KT, Pais VM Jr, Pearle MS, Preminger GM, Razvi H, Shah O, Matlaga BR (2016) Surgical management of stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 196(4):1153–1160

    Article  PubMed  Google Scholar 

  10. Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP, Pace KT, Pais VM Jr, Pearle MS, Preminger GM, Razvi H, Shah O, Matlaga BR (2016) Surgical management of stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 196(4):1161–1169

    Article  PubMed  Google Scholar 

  11. Park HK, Paick SH, Oh SJ, Kim HH (2004) Ureteroscopic lithotripsy under local anesthesia: analysis of the effectiveness and patient tolerability. Eur Urol 45(5):670–673

    Article  PubMed  Google Scholar 

  12. Cybulski PA, Joo H, Honey RJ (2004) Ureteroscopy: anesthetic considerations. Urol Clin N Am 31(1):43–7, viii

    Article  Google Scholar 

  13. Emiliani E, Talso M, Baghdadi M, Ghanem S, Golmard J, Pinheiro H, Gkentzis A, Butticè S, Traxer O (2016) The use of apnea during ureteroscopy. Urology 97:266–268

    Article  PubMed  Google Scholar 

  14. Johnson GB, Portela D, Grasso M (2006) Advanced ureteroscopy: wireless and sheathless. J Endourol 20(8):552–555

    Article  PubMed  Google Scholar 

  15. Dickstein RJ, Kreshover JE, Babayan RK, Wang DS (2010) Is a safety wire necessary during routine flexible ureteroscopy? J Endourol 24(10):1589–1592

    Article  PubMed  Google Scholar 

  16. Patel SR, McLaren ID, Nakada SY (2012) The ureteroscope as a safety wire for ureteronephroscopy. J Endourol 26(4):351–354

    Article  PubMed  Google Scholar 

  17. Ulvik Ø, Rennesund K, Gjengstø P, Wentzel-Larsen T, Ulvik NM (2013) Ureteroscopy with and without safety guide wire: should the safety wire still be mandatory? J Endourol 27(10):1197–1202

    Article  PubMed  Google Scholar 

  18. Dutta R, Vyas A, Landman J, Clayman RV (2016) Death of the safety guidewire. J Endourol 30(9):941–944

    Article  PubMed  Google Scholar 

  19. Giusti G, Proietti S, Villa L, Cloutier J, Rosso M, Gadda GM, Doizi S, Suardi N, Montorsi F, Gaboardi F, Traxer O (2016) Current standard technique for modern flexible ureteroscopy: tips and tricks. Eur Urol 70(1):188–194

    Article  PubMed  Google Scholar 

  20. Newman RC, Hunter PT, Hawkins IF, Finlayson B (1987) The ureteral access system: a review of the immediate results in 43 cases. J Urol 137(3):380–383

    Article  CAS  PubMed  Google Scholar 

  21. Rehman J, Monga M, Landman J, Lee DI, Felfela T, Conradie MC, Srinivas R, Sundaram CP, Clayman RV (2003) Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Urology 61(4):713–718

    Article  PubMed  Google Scholar 

  22. Auge BK, Pietrow PK, Lallas CD, Raj GV, Santa-Cruz RW, Preminger GM (2004) Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol 18(1):33–36

    Article  PubMed  Google Scholar 

  23. Kaplan AG, Lipkin ME, Scales CD Jr, Preminger GM (2016) Use of ureteral access sheaths in ureteroscopy. Nat Rev Urol 13(3):135–140

    Article  PubMed  Google Scholar 

  24. Al-Qahtani SM, Letendre J, Thomas A, Natalin R, Saussez T, Traxer O (2014) Which ureteral access sheath is compatible with your flexible ureteroscope? J Endourol 28(3):286–290

    Article  PubMed  Google Scholar 

  25. Emre Sener T, Cloutier J, Villa L, Marson F, Butticè S, Doizi S, Traxer O (2016) Can we provide low intrarenal pressures with good irrigation flow by decreasing the size of ureteral access sheaths? J Endourol 30(1):49–55

    Article  Google Scholar 

  26. Doizi S, Knoll T, Scoffone CM, Breda A, Brehmer M, Liatsikos E, Cornu JN, Traxer O (2014) First clinical evaluation of a new innovative ureteral access sheath (Re-Trace™): a European study. World J Urol 32(1):143–147

    Article  PubMed  Google Scholar 

  27. Breda A, Emiliani E, Millán F, Scoffone CM, Knoll T, Osther PJ, Liatsikos E (2016) The new concept of ureteral access sheath with guidewire disengagement: one wire does it all. World J Urol 34(4):603–606

    Article  PubMed  Google Scholar 

  28. Gupta PK (2007) Is the holmium:YAG laser the best intracorporeal lithotripter for the ureter? A 3-year retrospective study. J Endourol 21(3):305–309

    Article  PubMed  Google Scholar 

  29. Rassweiler J, Rassweiler MC, Klein J (2016) New technology in ureteroscopy and percutaneous nephrolithotomy. Curr Opin Urol 26(1):95–106

    Article  PubMed  Google Scholar 

  30. Zhong P, Tong HL, Cocks FH, Pearle MS, Preminger GM (1998) Transient cavitation and acoustic emission produced by different laser lithotripters. J Endourol 12(4):371–378

    Article  CAS  PubMed  Google Scholar 

  31. Rassweiler JJ, Klein J (2016) Re: update on lasers in urology. Current assessment on holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripter settings and laser fibers. Eur Urol 70(3):538–539

    Article  PubMed  Google Scholar 

  32. Villa L, Cloutier J, Compérat E, Kronemberg P, Charlotte F, Berthe L, Rouchausse Y, Salonia A, Montorsi F, Traxer O (2016) 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. J Endourol 30(3):332–337

    Article  PubMed  Google Scholar 

  33. Kronenberg P, Traxer O (2015) Are we all doing it wrong? Influence of stripping and cleaving methods of laser fibers on laser lithotripsy performance. J Urol 193(3):1030–1035

    Article  PubMed  Google Scholar 

  34. Haddad M, Emiliani E, Rouchausse Y, Coste F, Berthe L, Doizi S, Butticè S, Somani B, Traxer O (2017) Impact of laser fiber tip cleavage on power output for ureteroscopy and stone treatment. World J Urol 35(11):1765–1770

    Article  CAS  PubMed  Google Scholar 

  35. Talso M, Emiliani E, Haddad M, Berthe L, Baghdadi M, Montanari E, Traxer O (2016) Laser fiber and flexible ureterorenoscopy: the safety distance concept. J Endourol 30(12):1269–1274

    Article  PubMed  Google Scholar 

  36. Kronenberg P, Traxer O (2015) Update on lasers in urology 2014: current assessment on holmium:yttrium-aluminum-garnet (Ho:YAG) laser lithotripter settings and laser fibers. World J Urol 33(4):463–469

    Article  PubMed  Google Scholar 

  37. Kronenberg P, Traxer O (2014) In vitro fragmentation efficiency of holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy—a comprehensive study encompassing different frequencies, pulse energies, total power levels and laser fibre diameters. BJU Int 114(2):261–267

    Article  PubMed  Google Scholar 

  38. Wezel F, Häcker A, Gross AJ, Michel MS, Bach T (2010) Effect of pulse energy, frequency and length on holmium:yttrium-aluminum-garnet laser fragmentation efficiency in non-floating artificial urinary calculi. J Endourol 24(7):1135–1140

    Article  PubMed  Google Scholar 

  39. Spore SS, Teichman JM, Corbin NS, Champion PC, Williamson EA, Glickman RD (1999) Holmium:YAG lithotripsy: optimal power settings. J Endourol 13(8):559–566

    Article  CAS  PubMed  Google Scholar 

  40. Corbin NS, Teichman JM, Nguyen T, Glickman RD, Rihbany L, Pearle MS, Bishoff JT (2000) Laser lithotripsy and cyanide. J Endourol 14(2):169–173

    Article  CAS  PubMed  Google Scholar 

  41. Sea J, Jonat LM, Chew BH, Qiu J, Wang B, Hoopman J, Milner T, Teichman JM (2012) Optimal power settings for holmium:YAG lithotripsy. J Urol 187(3):914–919

    Article  PubMed  Google Scholar 

  42. Hecht SL, Wolf JS Jr (2013) Techniques for holmium laser lithotripsy of intrarenal calculi. Urology 81(2):442–445

    Article  PubMed  Google Scholar 

  43. Chawla SN, Chang MF, Chang A, Lenoir J, Bagley DH (2008) Effectiveness of high-frequency holmium:YAG laser stone fragmentation: the “popcorn effect”. J Endourol 22(4):645–650

    Article  PubMed  Google Scholar 

  44. Emiliani E, Talso M, Cho SY, Baghdadi M, Mahmoud S, Pinheiro H, Traxer O (2017) Optimal settings for the noncontact holmium:YAG stone fragmentation popcorn technique. J Urol 198(3):702–706

    Article  PubMed  Google Scholar 

  45. Bach T, Geavlete B, Herrmann TR, Gross AJ (2008) Working tools in flexible ureterorenoscopy—influence on flow and deflection: what does matter? J Endourol 22(8):1639–1643

    Article  CAS  PubMed  Google Scholar 

  46. Pasqui F, Dubosq F, Tchala K, Tligui M, Gattegno B, Thibault P, Traxer O (2004) Impact on active scope deflection and irrigation flow of all endoscopic working tools during flexible ureteroscopy. Eur Urol 45(1):58–64

    Article  PubMed  Google Scholar 

  47. Preminger GM, Tiselius HG, Assimos DG, Alken P, Buck AC, Gallucci M, Knoll T, Lingeman JE, Nakada SY, Pearle MS, Sarica K, Türk C, Wolf JS Jr, American Urological Association Education and Research, Inc, European Association of Urology (2007) 2007 Guideline for the management of ureteral calculi. Eur Urol 52(6):1610–1631

    Article  PubMed  Google Scholar 

  48. Proietti S, Dragos L, Somani BK, Butticè S, Talso M, Emiliani E, Baghdadi M, Giusti G, Traxer O (2017) In vitro comparison of maximum pressure developed by irrigation systems in a kidney model. J Endourol 5

  49. Dragos LB, Somani BK, Sener ET, Buttice S, Proietti S, Ploumidis A, Iacoboaie CT, Doizi S, Traxer O (2017) Which flexible ureteroscopes (digital vs. fiber-optic) can easily reach the difficult lower pole calices and have better end-tip deflection: in vitro study on K-box. A PETRA evaluation. J Endourol 31(7):630–637

    Article  PubMed  Google Scholar 

  50. Auge BK, Dahm P, Wu NZ, Preminger GM (2001) Ureteroscopic management of lower-pole renal calculi: technique of calculus displacement. J Endourol 15(8):835–838

    Article  CAS  PubMed  Google Scholar 

  51. Seto C, Ishiura Y, Egawa M, Komatsu K, Namiki M (2006) Durability of working channel in flexible ureteroscopes when inserting ureteroscopic devices. J Endourol 20(3):223–226

    Article  PubMed  Google Scholar 

  52. Baghdadi M, Emiliani E, Talso M, Servián P, Barreiro A, Orosa A, Proietti S, Traxer O (2017) Comparison of laser fiber passage in ureteroscopic maximum deflection and their influence on deflection and irrigation: do we really need the ball tip concept? World J Urol 35(2):313–318

    Article  PubMed  Google Scholar 

  53. Shin RH, Lautz JM, Cabrera FJ, Shami CJ, Goldsmith ZG, Kuntz NJ, Kaplan AG, Neisius A, Simmons WN, Preminger GM, Lipkin ME (2016) Evaluation of novel ball-tip holmium laser fiber: impact on ureteroscope performance and fragmentation efficiency. J Endourol 30(2):189–194

    Article  PubMed  Google Scholar 

  54. Kronenberg P, Traxer O (2016) Lithotripsy performance of specially designed laser fiber tips. J Urol 195(5):1606–1612

    Article  PubMed  Google Scholar 

  55. Haddad M, Emiliani E, Rouchausse Y, Coste F, Doizi S, Berthe L, Butticè S, Somani B, Traxer O (2017) Impact of the curve diameter and laser settings on laser fiber fracture. J Endourol 31(9):918–921

    Article  PubMed  Google Scholar 

  56. Sejiny M, Al-Qahtani S, Elhaous A, Molimard B, Traxer O (2010) Efficacy of flexible ureterorenoscopy with holmium laser in the management of stone-bearing caliceal diverticula. J Endourol 24(6):961–967

    Article  PubMed  Google Scholar 

  57. Traxer O, Thomas A (2013) Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 189(2):580–584

    Article  PubMed  Google Scholar 

  58. Auge BK, Preminger GM (2002) Ureteral stents and their use in endourology. Curr Opin Urol 12(3):217–222

    Article  PubMed  Google Scholar 

  59. Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW (1997) Ureteroscopy: current practice and long-term complications. J Urol 157(1):28–32

    Article  CAS  PubMed  Google Scholar 

  60. Netto Júnior NR, Claro Jde A, Esteves SC, Andrade EF (1997) Ureteroscopic stone removal in the distal ureter. Why change? J Urol 157(6):2081–2083

    Article  PubMed  Google Scholar 

  61. Knudsen BE, Beiko DT, Denstedt JD (2004) Stenting after ureteroscopy: pros and cons. Urol Clin N Am 31(1):173–180

    Article  Google Scholar 

  62. Rapoport D, Perks AE, Teichman JM (2007) Ureteral access sheath use and stenting in ureteroscopy: effect on unplanned emergency room visits and cost. J Endourol 21(9):993–997

    Article  PubMed  Google Scholar 

  63. Nabi G, Cook J, N’Dow J, McClinton S (2007) Outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis. BMJ 334(7593):572

    Article  PubMed  PubMed Central  Google Scholar 

  64. Song T, Liao B, Zheng S, Wei Q (2012) Meta-analysis of postoperatively stenting or not in patients underwent ureteroscopic lithotripsy. Urol Res 40(1):67–77

    Article  PubMed  Google Scholar 

  65. Haleblian G, Kijvikai K, de la Rosette J, Preminger G (2008) Ureteral stenting and urinary stone management: a systematic review. J Urol 179(2):424–430

    Article  PubMed  Google Scholar 

  66. Tang L, Gao X, Xu B, Hou J, Zhang Z, Xu C, Wang L, Sun Y (2011) Placement of ureteral stent after uncomplicated ureteroscopy: do we really need it? Urology 78(6):1248–1256

    Article  PubMed  Google Scholar 

  67. Netto NR Jr, Ikonomidis J, Zillo C (2001) Routine ureteral stenting after ureteroscopy for ureteral lithiasis: is it really necessary? J Urol 166(4):1252–1254

    Article  PubMed  Google Scholar 

  68. Keeley FX Jr, Timoney AG (2007) Routine stenting after ureteroscopy: think again. Eur Urol 52(3):642–644

    Article  PubMed  Google Scholar 

  69. Gerber GS, Stockton BR (2006) Use of stents after ureteroscopic stone removal. J Endourol 20(6):383–385

    Article  PubMed  Google Scholar 

  70. de la Rosette J, Denstedt J, Geavlete P, Keeley F, Matsuda T, Pearle M, Preminger G, Traxer O, CROES URS Study Group (2014) The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients. J Endourol 28(2):131–139

    Article  PubMed  Google Scholar 

  71. Auge BK, Sarvis JA, L’esperance JO, Preminger GM (2007) Practice patterns of ureteral stenting after routine ureteroscopic stone surgery: a survey of practicing urologists. J Endourol 21(11):1287–1291

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, Tenon Hospital, Assistance-Publique Hôpitaux de Paris, 4 rue de la Chine, 75020, Paris, France

    Steeve Doizi & Olivier Traxer

  2. Pierre et Marie Curie University, Paris, France

    Steeve Doizi & Olivier Traxer

  3. Groupe de Recherche Clinique sur la Lithiase Urinaire, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France

    Steeve Doizi & Olivier Traxer

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  1. Steeve Doizi
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  2. Olivier Traxer
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Correspondence to Olivier Traxer.

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Steeve Doizi: None. Olivier Traxer: Boston Scientific, Coloplast, EMS, Olympus, Rocamed.

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Doizi, S., Traxer, O. Flexible ureteroscopy: technique, tips and tricks. Urolithiasis 46, 47–58 (2018). https://doi.org/10.1007/s00240-017-1030-x

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