While cystolitholapaxy for bladder stones is commonly performed using a transurethral approach, large or complex stone burdens in patients with complex lower urinary tract anatomy may make this inefficient or infeasible. Percutaneous cystolitholapaxy is a safe, effective, minimally invasive alternative for diverse indications, including patients with benign prostatic hyperplasia, urethral stricture disease, closed bladder neck, continent catheterized channel, or other urinary diversion. In this article, we review the indications for and advantages of percutaneous cystolitholapaxy and describe our step-by-step technique for this procedure, including representative imaging and favored equipment. We also discuss preoperative and postoperative considerations, management of potential complications, strategies to optimize clinical outcomes and patient safety, and comparisons with transurethral approaches. Finally, we report outcomes from our institutional series of percutaneous cystolitholapaxy cases to highlight the safety and efficacy of the procedure.

You have accessJournal of UrologyStone Disease: Surgical Therapy (Including ESWL) IV (PD47)1 May 2024PD47-06 IMPACT OF INTEGRATED, REAL-TIME DIGITAL MEASUREMENT ON SURGEON DECISION MAKING IN URETEROSCOPIC STONE SURGERY Alexander Krueger, Drew M. Smith, Andrew T. Parzych, Robert Qi, Aaron M. Potretzke, Dan Stoianovici, David Holmes, Mark Lifson, and Kevin Koo Alexander KruegerAlexander Krueger , Drew M. SmithDrew M. Smith , Andrew T. ParzychAndrew T. Parzych , Robert QiRobert Qi , Aaron M. PotretzkeAaron M. Potretzke , Dan StoianoviciDan Stoianovici , David HolmesDavid Holmes , Mark LifsonMark Lifson , and Kevin KooKevin Koo View All Author Informationhttps://doi.org/10.1097/01.JU.0001008652.62443.0a.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Accurate estimation of stone fragment size during ureteroscopic lithotripsy facilitates decisions to extract fragments or leave them behind for spontaneous passage. A novel software capable of accurately measuring these fragments in real-time during ureteroscopy has been developed, but the impact on surgeons' decision-making is not known. The aim of this study is to assess the clinical use of this software and its impact on intraoperative decision-making. METHODS: Adult patients undergoing elective flexible ureteroscopy and laser lithotripsy for renal stones were prospectively enrolled. Surgeons could request digital measurement of stones or fragments at any time during the procedure. All measurements were reported to the surgeon in real-time. Surgeons were surveyed after each case about the reasons for taking measurements and how the measurements impacted their intraoperative decisions. 30-day clinical complications were recorded. RESULTS: Among a total of 51 patients undergoing ureteroscopy, surgeons took an average of 2.1 (range 1-6) intraoperative measurements per case. The software was deployed successfully in all cases. Surgeons reported that the primary purpose of taking intraoperative measurements was to determine whether post-lithotripsy fragments were extractable (26, 51.0%) or sufficiently small to leave behind (5, 9.8%). However, surgeons also took measurements prior to lithotripsy to confirm extractability (23, 45.1%), or to assess overall stone size (4, 9%). Following stone measurements, surgeons changed intraoperative plans in 17 (33%) cases and instead continued lithotripsy (8, 15.7%), extracted fragments (7,13%), or left fragments behind for passage (2, 3.9%) (Figure 1). Surgeons rated the ability to take intraoperative measurements as "very helpful" (66%) or "somewhat helpful" (34%). In no cases (0%) were measurements "not helpful." The time burden of taking affected procedural efficiency in only 4% of cases. There was 1 sepsis complication among the cases (2%). CONCLUSIONS: The ability to take real-time stone measurements during flexible ureteroscopy changed surgeons' intraoperative decisions in 33% of cases. This may improve procedural efficiency and reduce fragment extraction failures and ureteral injury. Download PPT Source of Funding: Endourological Society © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e982 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Alexander Krueger More articles by this author Drew M. Smith More articles by this author Andrew T. Parzych More articles by this author Robert Qi More articles by this author Aaron M. Potretzke More articles by this author Dan Stoianovici More articles by this author David Holmes More articles by this author Mark Lifson More articles by this author Kevin Koo More articles by this author Expand All Advertisement PDF downloadLoading ...

INTRODUCTION:The Karl Storz FLEX-XC1 is a novel single-use flexible ureteroscope that uses the same videographics platform as its reusable digital counterpart. We evaluated the technical performance of the FLEX-XC1 in its initial clinical use. METHODS:We reviewed a series of consecutive ureteroscopy procedures performed by 2 endourologists using the FLEX-XC1 for indications for which we typically use a single-use device: total stone burden > 15 mm or > 10 mm in the lower pole, anticipated case duration > 60 minutes, bilateral procedure, or upper tract urothelial cancer procedures. We assessed device tip deflection, intraoperative mechanical failure, and clinical outcomes for each case. Surgeons rated visual clarity, image quality, and maneuverability on a 1 to 5 Likert scale. RESULTS:Of 29 procedures using FLEX-XC1, 27 (93%) were successfully completed. Preoperative upward deflection was < 270° in 6 (21%) cases, and downward deflection was < 270° in 9 (31%) cases. Three types of intraoperative malfunctions occurred: rotational twisting of deflectable tip (4 cases, 13%), device not advancing through distal ureter (1 case, 3%), and working channel not accommodating a 365-μm laser (1 case, 3%). Visual clarity, image quality, and maneuverability were rated as 5 "very good" or 4 "good" in 100%, 100%, and 97% of cases, respectively. No device-specific or general 30-day complications were observed. CONCLUSIONS:The FLEX-XC1 showed comparable image quality and maneuverability to reusable digital devices. We observed incomplete deflection in up to 31% of cases and mechanical failure in 2 cases. The FLEX-XC1 may be advantageous in prolonged cases where maintaining visual clarity is paramount.

Introduction Single-use flexible ureteroscopes are an increasingly popular alternative to reusable ureteroscopes. In this study, we performed a benchtop examination of the physical and optical properties of the new Dornier Axis™ (Webling, Germany) single-use ureteroscope. Methods Ten new, never-used Dornier Axis™ ureteroscopes were assessed for optical performance, maximal tip deflection and irrigation flow rate with empty working channel and with insertion of a 200μm and 365μm laser fibers, and a 1.9Fr nitinol basket. All ureteroscopes were then fully deflected 100 times in each direction, and maximal deflection angles were re-measured with and without instruments in the working channel. All measurements were performed in duplicate. In-vitro optical testing for resolution, image distortion, and depth of field was performed and compared versus the LithoVue™ (Boston Scientific, Marlborough, MA) single-use ureteroscope. Statistical analyses using paired Wilcoxon rank-sum tests and Kruskal-Wallis multiple-group comparison tests were performed in R. Results Median maximal deflection angles exceeded 300 degrees (°) in both directions before and after 100 full deflection cycles for all groups except the 365μm laser fiber group. After 100 deflection cycles, there was no change in the majority of working instruments, except decrease in upward flexion with an empty channel and 200μm Moses™ laser fiber, and downward flexion with 200μm Flexiva™ laser fiber (all <10°). After excluding the 365μm fiber, there was no difference in multi-group comparison for upward and downward flexion pre- and post-cycling. Median flow rate through an empty channel was 48.0 ml/min and decreased significantly with all used instruments (p<0.001). Compared to the LithoVue™, the Axis™ demonstrated superior resolution at all tested distances and less distortion. Conclusions The new Dornier Axis™ single-use ureteroscope demonstrates excellent tip deflection which remains unchanged following 100 manual flexions in each direction. The Axis™ also demonstrates superior optical performance compared to the LithoVue™ in benchtop testing.

Introduction: Manipulation of Holmium:Yttrium-Aluminum-Garnet laser parameters such as pulse energy (PE), frequency, and duration can impact laser lithotripsy ablation efficiency. In 2017, Lumenis introduced Moses (TM) Technology, which uses pulse modulation to enhance the delivery of energy from fiber to stone as well as to minimize stone retropulsion. Since the introduction of Moses Technology, other companies have brought additional pulse modulation concepts to market. The purpose of this in vitro study is to compare the pulse characteristics and stone ablation efficiency of Lumenis Moses Technology with Quanta's Vapor Tunnel (TM). Materials and Methods: Submerged BegoStone phantoms were systematically ablated using either the Lumenis Moses Pulse 120H or the Quanta Litho 100 clinical laser system. Two PEs (0.4 and 1 J), three fiber-stone standoff distances (SDs) (0.5, 1, 2 mm), and all available pulse duration and modulation modes for each laser were tested in combination. Fiber speed was adjusted to scan across the stone surface at either 1 or 10 pulses/mm to form single pulse craters or an ablation trough, respectively. Volumes of single craters and 1 mm trough segments were imaged and quantified using optical coherence tomography. Results: Ablation volumes decreased with decreasing PE and increasing SD. Statistically significant variability was seen between pulse types (PT) at every tested parameter set. Among pulse modulation modes, Moses Distance (MD) was superior at 0.5 mm in all testing and at 2 mm in trough testing. Vapor Tunnel (VT) was superior in 2 mm single crater testing. All modulated pulses performed similarly at 1 mm. Conclusions: In this benchtop model of laser lithotripsy, stone ablation was significantly impacted by PT. MD demonstrated superior or noninferior stone ablation at most tested parameters. VT maintained its efficacy the best as SD increased. Future work should focus on the mechanistic differences of these modes relative to other traditional laser pulse modes.

Introduction: Manipulation of Holmium:YAG (Ho:YAG) laser parameters such as pulse energy, frequency, and duration can impact laser lithotripsy ablation efficiency. In 2017, Lumenis introduced Moses™ Technology which uses pulse modulation to enhance the delivery of energy from fiber to stone as well as to minimize stone retropulsion. Since the introduction of Moses™ Technology, other companies have brought additional pulse modulation concepts to market. The purpose of this in vitro study is to compare the pulse characteristics and stone ablation efficiency of Lumenis' Moses™ Technology with Quanta's Vapor Tunnel™. Methods: Submerged BegoStone phantoms were systematically ablated using either the Lumenis MOSES™ Pulse 120H or the Quanta Litho 100 clinical laser system. Two pulse energies (0.4J and 1J), three fiber-stone standoff distances (0.5, 1, 2mm), and all available pulse duration and modulation modes for each laser were tested in combination. Fiber speed was adjusted to scan across the stone surface at either 1 pulse/mm or 10 pulses/mm to form single pulse craters or an ablation trough, respectively. Volumes of single craters and 1 mm trough segments were imaged and quantified using optical coherence tomography (OCT). Results: Ablation volumes decreased with decreasing pulse energy and increasing standoff distance. Statistically significant variability was seen between pulse types at every tested parameter set. Among pulse modulation modes, Moses Distance was superior at 0.5mm in all testing and at 2mm in trough testing. Vapor Tunnel was superior in 2mm single crater testing. All modulated pulses performed similarly at 1mm. Conclusions: In this benchtop model of laser lithotripsy, stone ablation was significantly impacted by pulse type. Moses Distance demonstrated superior or non-inferior stone ablation at most tested parameters. Vapor Tunnel maintained its efficacy the best as standoff distance increased. Future work should focus on the mechanistic differences of these modes relative to other traditional laser pulse modes.

Purpose: Although cavitation during laser lithotripsy (LL) contributes to the Moses effect, the impact of cavitation on stone damage is less clear. Using different laser settings, we investigate the role of cavitation bubbles in energy delivery and stone damage. Materials and Methods: The role of cavitation in laser energy delivery was characterized by using photodetector measurements synced with high-speed imaging for laser pulses of varying durations. BegoStone samples were treated with the laser fiber oriented perpendicularly in contact with the stone in water or in air to assess the impact of cavitation on crater formation. Crater volume and geometry were quantified by using optical coherence tomography. Further, the role of cavitation in stone damage was elucidated by treatment in water with the fiber oriented parallel to the stone surface and by photoelastic imaging. Results: Longer pulse durations resulted in higher energy delivery but smaller craters. Stones treated in water resulted in greater volume, wider yet shallower craters compared with those treated in air. Stones treated with the parallel fiber showed crater formation after 15 pulses, confirmed by high-speed imaging of the bubble collapse with the resultant stress field captured by photoelastic imaging. Conclusions: Despite improved energy delivery, the longer pulse mode produced smaller crater volume, suggesting additional processes secondary to photothermal ablation are involved in stone damage. Our critical observations of the difference in stone damage treated in water vs in air, combined with the crater formation by parallel fiber, suggest that cavitation is a contributor to stone damage during LL.

However when using a SPTFL: shorter operative time and lithotripsy time; no stone retropulsion was observed. Stone retropulsion was recorded a Ho:YAG laser (Grade 1 in 5 cases, Grade 2 in 3 cases, Grade 3 in 3 cases).

You have accessJournal of UrologyStone Disease: Surgical Therapy VII (MP69)1 Apr 2020MP69-03 THE EFFECTS OF LASER PULSE DURATION ON ENERGY DELIVERY AND STONE DAMAGE DURING LASER LITHOTRIPSY Derek Ho*, Dominick Scialabba, Russell Terry, Robert Qi, Glenn Preminger, Michael Lipkin, and Pei Zhong Derek Ho*Derek Ho* More articles by this author , Dominick ScialabbaDominick Scialabba More articles by this author , Russell TerryRussell Terry More articles by this author , Robert QiRobert Qi More articles by this author , Glenn PremingerGlenn Preminger More articles by this author , Michael LipkinMichael Lipkin More articles by this author , and Pei ZhongPei Zhong More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000949.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although modern laser lithotripsy (LL) systems offer pulse duration (PD) modulation during treatment, its effect on both the underlying mechanisms of stone damage and treatment efficiency are unclear. We investigate the effects of varying laser PD on the energy delivery to the stone and surrounding fluid and its resultant effects on bubble geometry and stone crater formation. METHODS: Three pulse modes of varying PD (Fragmenting ≈ 75 µs, Standard ≈ 150 µs, Advanced ≈ 200 µs) from a clinical LL system (H Solvo 35-watt laser, Dornier MedTech) were used to treat fixed Begostone samples. A 400 µm laser fiber was placed in contact with the stone surface and delivered varying number of pulses (1 – 100) for each pulse mode (n = 5). Crater volume (CV) was quantified using optical coherence tomography (OQ Labscope, Lumedica) following LL. The effects of PD on cavitation during treatment and power delivery to the stone were quantified with high-speed imaging and photodetector measurements, respectively. RESULTS: We observed a rapid increase in CV over the first 5-10 pulses in all three pulse modes before a plateau after 20-30 pulses, accompanied by a characteristic transition in bubble geometry from a small, flat bubble to a large hemispherical bubble. Longer PDs resulted in higher energy delivery efficiency, but lower mean CV (0.737 mm3, 0.602 mm3, and 0.535 mm3 for fragmentation, standard, and advanced mode after 100 pulses, respectively; p < 0.05). High-speed imaging synced with photodetector measurements correlated higher energy delivery with the expansion of the vapor bubble. CONCLUSIONS: As CV enlarged, more laser energy was absorbed by the intermediate fluid, leading to a large bubble formation with a concomitant reduction in stone damage at increasing pulse numbers. This important observation demonstrates that fiber-stone distance is a critical parameter in treatment efficiency regardless of PD. Significantly, this is the first experimental validation of improved energy delivery to the stone with longer PDs with more pulse energy delivered following the formation of a vapor bubble. However, the reduced CV for longer PD suggests that other factors, such as cavitation erosion and stress, may play a significant role in stone damage. Source of Funding: This projected is supported by the NIH (P20 DK123970). DH is supported by the NIH (K12 DK100024). © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1044-e1044 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Derek Ho* More articles by this author Dominick Scialabba More articles by this author Russell Terry More articles by this author Robert Qi More articles by this author Glenn Preminger More articles by this author Michael Lipkin More articles by this author Pei Zhong More articles by this author Expand All Advertisement PDF downloadLoading ...

Purpose: Nonrepresentative biopsy sampling of prostate cancers with a biopsy Gleason score of 8 can adversely influence decisions regarding androgen deprivation in men receiving primary radiation therapy. The frequency of and factors associated with downgrading Gleason 8 biopsies at prostatectomy are not well known. Materials and Methods: We used records from NCDB (National Cancer Database), a hospital based registry in the United States, of 72,556 men with prostate cancer diagnosed from 2010 to 2013, including 5,474 with Gleason 8 biopsies and no other high progression risk criteria according to NCCN (National Comprehensive Cancer Network (R)) Guidelines (R). The prevalence of Gleason 8 downgrading was calculated. Generalized estimating equation multivariable regression models were used to estimate the prevalence ratios and 95% CIs of downgrading by demographic and clinical factors, and evaluate the association of Gleason 8 downgrading with cT (clinical T) to pathological T category up staging. Results: Of 5,474 Gleason 8 biopsies in men lacking other high progression risk criteria 3,263 (60%) were downgraded, changing the progression risk category from high to intermediate. A higher prevalence of Gleason 8 downgrading was significantly and independently associated with decreasing age, African American race, lower cT category, lower prostate specific antigen quartile and certain combinations of primary and secondary Gleason grades (3 thorn 5 greater than 4 thorn 4 greater than 5 thorn 3). Gleason 8 downgrading in cases of cT less than 3 was independently and significantly associated with a lower prevalence of up staging (prevalence ratio = 0.65, 95% CI 0.61-0.69). Conclusions: Downgrading Gleason 8 biopsies is common. Patient evaluation based on Gleason 8 biopsies often results in overestimating progression risk and disease extent, which may lead to overtreatment.

Current risk-stratification guidelines for prostate cancer depend heavily on prostate-specific antigen (PSA) and the Gleason scoring of biopsy cores, both which have limitations in discerning the aggressiveness of prostate cancer in certain clinical cases. Recent advances in molecular genetics have yielded biopsy-based genomic assays and biomarker tests that can provide additional information in situations where risk stratification based on more commonly used methods remain unclear. Such genomic assays are supported by an increasing body of literature, leading to select coverage by insurance reimbursement, although contemporary major guidelines have not made conclusive recommendations. Such trends suggest that biopsy-based molecular biomarkers likely will have an increasing role in the management of prostate cancer in the future.

It is controversial whether African American men(AAM) with low-risk prostate cancer (PC) should be placed on active surveillance (AS). Recent literature indicates AAM diagnosed with low-risk disease have increased pathologic upgrading and disease progression. We evaluated the surgical pathology of AAM and Caucasians who underwent prostatectomy to assess the suitability of AAM for AS. We retrospectively reviewed 1,034 consecutive men who underwent open prostatectomy between 2004 and 2015; 345 Caucasians and 58 AAM met the American Urological Association criteria for low-risk PC. We excluded from analysis two men whose prostatectomies were aborted. Chi-square test, Fisher’s exact test, and Wilcoxon rank sum test were used for statistical analysis. AAM with low-risk PC have a lower rate of surgical upgrading and similar rates of adverse pathology compared with Caucasians. 29.8% of AAM (17/57) diagnosed with low-risk disease but 44.5% of Caucasians (153/344) had disease upgrading at prostatectomy ( p < .04), although AAM overall were less likely to be clinically diagnosed with low-risk cancer (33.1 vs. 41.7%, p < .05). AAM with low-risk pathology were younger (median 55 vs. 59 years, p < .001) and had smaller prostates (32 vs. 35 g, p < .04). AAM with preoperative low-risk disease have lower rates of surgical upgrading and similar adverse pathology compared with Caucasians. There may be a Will-Rogers effect as AAM with aggressive disease appear more likely to be stratified into intermediate- and high-risk groups, leaving those AAM diagnosed with low-risk disease fully eligible for AS. Our results support that AS for AAM should remain a viable option.

INTRODUCTION AND OBJECTIVES: Prostate cancer (PCa) diagnostics would greatly benefit from more accurate, non-invasive techniques for the detection of clinically significant disease, leading to a reduction of over-diagnosis and over-treatment. Multiparametric MRI (mpMRI) is being used increasingly and has proven to be a valuable addition to the PCa diagnostic pathway. A novel biomarker-based risk score (SelectMDx) assessing urinary HOXC6 and DLX1 mRNA expression levels combined with traditional clinical risk factors, was recently developed to predict high-grade PCa (Gleason score >/1⁄47) upon prostate biopsy and to reduce the number of unnecessary biopsies. The aim of this study was to investigate the correlation between the risk score and mpMRI outcomes. METHODS: The patients in this retrospective observational cohort were previously included in the validation study of the SelectMDx risk score, in which urine was collected after digital rectal examination (DRE) from men undergoing prostate biopsies based on an elevated serum PSA level (>/1⁄43.0 ng/ml) and/or suspicious DRE. A subset of patients underwent an mpMRI after prostate biopsies were performed (n1⁄4174). The indications for performing MRI were based on persistent clinical suspicion of PCa after negative prostate biopsies or staging after PCa was found upon biopsy. RESULTS: 102 of 174 patients (59%) had PCa detected upon prostate biopsy, of which 54 (53%) had high-grade disease and a significantly higher SelectMDx risk score (p<0.001). The median SelectMDx risk score was also significantly higher in patients who had a suspicious lesion on MRI (p<0.001). For 81 mpMRI’s the PIRADS classification was reported and there was a positive correlation observed between the risk score and the PIRADS classification (Figure 1). A Kruskal-Wallis test indicated a statistically significant difference in SelectMDx risk scores between the different PIRADS groups (p<0.001). CONCLUSIONS: The novel urinary biomarker-based risk score is a promising tool in PCa detection. This study showed promising results regarding the correlation between the SelectMDx risk score with MRI outcomes. This risk score could potentially guide clinicians in selecting patients at risk for significant PCa for mpMRI.