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Current Status of Flexible Ureteroscopy in Urology

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Current Status of Flexible Ureteroscopy in Urology Review Article Korean J Urol 2015;56:680-688. http://dx.doi.org/10.4111/kju.2015.56.10.680 pISSN 2005-6737 • eISSN 2005-6745 Current status of flexible ureteroscopy in urology Sung Yong Cho Department of Urology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea Retrograde intrarenal surgery (RIRS) is being performed for the surgical management of upper urinary tract pathology. With the development of surgical instruments with improved deflection mechanisms, visuality, and durability, the role of RIRS has expanded to the treatment of urinary calculi located in the upper urinary tract, which compensates for the shortcomings of shock wave litho- tripsy and percutaneous nephrolithotomy. RIRS can be considered a conservative treatment of upper urinary tract urothelial cancer (UTUC) or for postoperative surveillance after radical treatment of UTUC under an intensive surveillance program. RIRS has a steep learning curve and various surgical techniques can be used. The choice of instruments during RIRS should be based on increased surgical efficiency, decreased complications, and improved cost-benefit ratio. Keywords: Laser lithotripsy; Surgical equipment; Transitional cell carcinoma; Urolithiasis This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. INTRODUCTION or working channels. Flexible ureteroscopes were not widely utilized until the introduction of the new flexible 1. The expanding role of retrograde intrarenal ureteroscope and the holmium:yttrium aluminium garnet surgery in upper urinary tract pathology (YAG) laser system in the 1990s [4-8]. Flexible ureteroscopes Retrograde intrarenal surgery (RIRS) refers to the basically consist of the optical system of the fiberoptic surgical management of upper urinary tract pathologies image and light bundles, a deflection mechanism, and a with a retrograde ureteroscopic approach. With the working channel [9]. However, recently developed digital development of new surgical instruments, the deflection flexible ureteroscopes are expected to provide improved mechanism, visuality, and durability of RIRS have improved. image quality and durability because they do not require Recently, the role of RIRS has expanded to the treatment a separate light cable or camera head [10,11]. Narrow- of urinary calculi and urothelial malignancies in the upper band imaging digital flexible ureteroscopes are expected to urinary tract. increase the detection rate of upper urinary tract urothelial malignancy [12]. Deflecting mechanisms have been greatly 2. History and recent developments of flexible developed as well. Deflection angles have recently been ureteroscopic devices extended to 275 degrees, which enables ureteroscopic tips to The first flexible ureteroscopic procedures were access the entire renal collecting system, including the lower introduced in the 1960s [1-3]. However, these flexible minor calices. Almost all flexible ureteroscopes currently ureteroscopes had no integrated deflecting systems available have working channels of at least 3.6 Fr in size, Received: 27 July, 2015 • Accepted: 21 August, 2015 Corresponding Author: Sung Yong Cho Department of Urology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea TEL: +82-2-870-2394, FAX: +82-2-870-3863, E-mail: [email protected] ⓒ The Korean Urological Association, 2015 www.kjurology.org 680 [15]. Unfavorable factors[15]. for of success SWL includeSWL- SWL for treating renal stones. Previous investigations investigations Previous SWL forstones. renal treating (<5 mm) [19-23]. Furthermore, SWL often requires multiple[19-23]. (<5 mm) and reported on the risk(SFRs) and[15-18] ofstone sizes surgeons should consider RIRS or PCNL to treat renal and and renal treat to PCNL or RIRS consider should surgeons patient stones with mm, pain or stones>15 hematuria, surgical outcomes. Fr smallerworking haveof triedchannel diameters to 3.3 demonstrated inversecorrelations stone-freebetween rates the best guarantee to of equipment the disadvantages many investigators haveshown ofthe disadvantages methods in patients with multiple stones. In these cases, cases, In these stones. multiple with in patients methods and RIRS are the available treatment options for options are active treatment and the available RIRS advancesin the technicalof aspects flexible ureteroscopes, growth, stones in patients at high risk of stone formation, >20 mm [14]. >20 RIRSmm [14]. cannot be recommended as the first observation notis theshockoption ofwave Rather, choice. obstruction caused byinfections,stones, symptomatic With [13]. Fr 9.9 to increased was ofsheaths outer the better acquire to channel of single a limitation the overcome concerning profession oramount of travelIn these[14]. preference, cases, comorbidity, and patients’ social situation which permits adequate irrigation and insertion ofstone widelySurgeons should used. know theadvantages and upper ureter stones. ureteral obstruction with the need foradditional procedures instruments have become the requisites of RIRS. flexibleDual-channel with retrieval devices. ureteroscopes resistant stones, steep resistantinfundibular-pelvic stones, a angles, long laser lithotripsy systems, ureteral access sheaths, guidewires, treatments and longer treatment periods than other surgical surgical other than periods treatment longer and treatments and alower mm), narrow pole calyx infundibulum(>10 treatment of However, renal stones mm <20 in[14]. size oftreatment renal [14]. calculi nephrolithotomy lithotripsypercutaneous (PCNL), (SWL), currently are that flexibleureteroscopes various the lists for urolithiasis showed a broad spectrum of indicators for the active of indicators removal of spectrum kidneysuch stones, asstone a broad showed for urolithiasis highly flexibleand flexiblestone baskets, forceps, these visual fields the However, and diameter surgical outcomes. Korean J Urol 2015;56:680-688. JUrol Korean op andsurgical stones ofrenal removal 1. Active COPY OFFLEXIBLEURETEROS CURRENT ROLE tions PCNL should be the first treatment choice for stones Until now, SWL remained the first forchoice SWL remained the Untilnow, Recently, Recently, theEuropean Association of Urology guidelines Table1 - - Expanding role ofRIRSinuppertract pathology Expanding role Table 1. Characteristics of the widely used flexible ureteroscopes Gyrus ACMI Olympus Karl Storz Richard Wolf Striker Characteristic Flex-Xc Flexvision DUR-8 DUR-8 Elite DUR-D (digital) URF-P5,6 URF-V2 Flex-X2 Viper Cobra (digital) U500 Tip and shaft diameter (Fr) 6.75/10.1 8.7/10.1 8.7/9.3 4.9/7.95 (P6) 8.4/8.5 7.5 8.5 6/8.8 6/9.9 6.9/* Working length (mm) 650 640 650 670 670 670 700 680 680 * Channel size (Fr) 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.3 (dual) 3.6 www.kjurology. Deflection angle (°) 170/180 170/180, secondary defection 250 180/275 (P5), 275 (P6) 275 270 270 270 270 275 View angle (°) 80 80 90 80 88 90 85 * *No information shown in the brochure. org 681 Cho treatment option for stones >20 mm. PCNL has generally 2) Stone multiplicity been considered to be a safe surgical method with overall Concomitant renal and ureter stones or bilateral renal low postoperative complication rates and the highest SFR stones can be efficiently and safely removed by RIRS in a compared with other surgical methods [24,25]. Although single session [31,32]. This combined approach is expected to serious complications such as perioperative massive bleeding, reduce the need for future procedures and seems to be more urine leakage, bowel injury, hemothorax, and fistula are cost-ef f ective. rare [26], increasing attention has been paid to the need for other minimally invasive surgical options to compensate for 3) Lower pole stones the shortcomings of PCNL. Unfavorable factors for SWL include a steep infundibular- pelvic angle, a long lower pole calyx, or a narrow infundibulum 2. RIRS for renal and upper tract calculi in patients with a lower pole stone [14,19-22]. PCNL is the first Recently, technological advances in flexible ureteroscopy, treatment option for lower pole stones along with a surgical coupled with the development of novel endoscopic baskets procedure [33-35]. However, RIRS has shown comparable and flexible lithotrites, have allowed the role of RIRS to surgical efficacy and safety as well in these investigations. expand to the treatment of renal and upper tract calculi. Definite indications for RIRS have not yet been established. 4) Bleeding disorders However, the possible indications for RIRS for renal stones Because RIRS does not require a percutaneous procedure are as follows: and has little probability of vessel injury during the surgical • Midsized renal stones not appropriate for SWL or procedure, RIRS seems to be superior to PCNL or SWL for PCNL patients who take anticoagulant therapy. Until now, the • Failed SWL or SWL-resistant stones ureteroscopic procedure including RIRS has shown its safety • Radiolucent stones in patients with bleeding disorders with an acceptable level • Anatomical abnormalities, e.g., steep infundibular-pelvic of increase in complications [36-38]. angle, long lower pole calyx, or narrow infundibulum The presence of a bleeding disorder is one of the • Concomitant renal and ureter stones contraindications
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