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Stone Management
digital control boxes that perform the equivalent functions of the stenting is associated with bothersome lower urinary tract symptoms
camera and light source in older systems. The image is decoded, and pain, which can temporarily alter the quality of life of patients.
34
enhanced by a processor and projected onto a monitor. Additionally,
the non-coherent fibre optic fascicles designed to transmit light In addition, there are complications associated with ureteral stenting,
were replaced with a white-light light-emitting diode (LED) including stent migration, urinary tract infection, breakage, encrustation
positioned at the distal end of the ureteroscope. The video and obstruction. Moreover, ureteral stents add some expense to the
endoscope design obviates the need to attach a camera to the overall ureteroscopic procedure, and unless a pull string is attached to
eyepiece of the ureteroscope, resulting in an easier set-up in the distal end of the stent, secondary cystoscopy is required for stent
the operating room and a lighter endoscope to hold for longer removal. There are clear indications for stenting after the completion of
cases. A new generation of digital flexible ureteroscopes seems to ureteroscopy. They include ureteral injury, stricture, solitary kidney, renal
provide superior flexibility and visibility due to the removal of the insufficiency and a large residual stone burden.
conventional optic system, with all its faults. At the same time,
eliminating these fragile components creates the possibility of Another matter of concern is represented by the use of the ureteral
extended durability of the new endoscopes. access sheath. Many centres have documented their routine use
during flexible ureteroscopic procedures,
35
while others occasionally
Gupta reported an initial clinical experience with a prototype applied this technique during rigid ureteroscopy.
36
Conversely, other
ureteroscope with the smallest tip and shaft diameter to date, in a study authors have emphasised the fact that these sheaths are necessary
in which no patient required ureteral dilation.
29
The Ho:YAG laser may be in only a minority of cases.
37
In recent years, the need to reduce the
used on flexible endoscopes, thus allowing calculi fragmentation operation time as well as the convalescence of the patients meant
regardless of their location in the upper urinary tract (see Figure 5). The performing ureteroscopy under local analgesia or sedo-analgesia. The
success rate of Ho:YAG laser lithotripsy was between 91 and 100%, reduced activity duration of the sedo-analgesics allowed their easy
uninfluenced by the chemical composition of the stones. Furthermore, titration as well as the rapid post-operative recovery of the patients.
38
lithotripsy produces small fragments, which do not necessitate The studies performed so far have proved that even the treatment of
additional extraction manoeuvres. The average rates of perforation and renal or ureteral lithiasis may be performed using this type of
post-operative stenosis were 1.1 and 1.2%, respectively. analgesia on the condition that it does not involve complex or time-
consuming procedures.
39
A duration of 60–90 minutes is considered to
Due to the photothermal effect, various chemical reactions related to be the time limit that requires regional or general anaesthesia.
40
calculi composition occurred during lithotripsy. For example, cyanide
production during uric acid stone lithotripsy was demonstrated; Conclusions
however, this was not clinically relevant due to the small quantity of The development of ureteroscopic technology has enriched the
the substance.
30,31
Traditionally, the majority of accessories were made of indications and improved the success rates of the retrograde
stainless steel. Over a decade ago, nitinol instruments (nickel–titanium endoscopic treatment of upper urinary tract lithiasis. Instrument
alloy) were introduced into practice, providing a series of advantages in development has improved efficacy, patient safety and comfort,
comparison with the classic ones. Steel devices present reduced benefiting from the use of nitinol materials and Ho:YAG laser
flexibility, while the nitinol ones have the advantage of ‘mechanical technology. Owing to its minimal morbidity, low rate of
memory’, being able to regain their initial shape after the ‘deformation’ complications and high success rate, retrograde ureteroscopy
procedure ceases; furthermore, their elasticity is superior to that of represents a first-line therapeutic alternative in cases of upper
other materials. These properties provide superiority to the nitinol urinary tract calculi. ■
instruments in manipulating the reno-ureteral calculi.
32
Matters for Debate
Petrisor Geavlete is a Professor in the Department of
Urology at the Saint John Emergency Clinical Hospital in
For many years, the routine placement of ureteral stents was Bucharest and Vice President of the Romanian
considered the standard of care after uncomplicated ureteroscopy for
Association of Urology (RAU). He is also a member of
the European Association of Urology (EAU) Video
stone fragmentation. Recently, however, numerous studies have
Committee, a Board Member of the European Society of
questioned the routine use of stents and demonstrated that in cases Urological Imaging (ESUI) and a member of 11
of uncomplicated ureteroscopy and no in-dwelling stent there is no
international urological societies.
risk of increased complications.
33
It is well-documented that ureteral
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