PROGRESS IN ENDOSCOPIC. Olivier Traxer.

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1 PROGRESS IN ENDOSCOPIC TREATMENT OF UROLITHIASIS Olivier Traxer Tenon Hospital, Paris, France Université Pierre & Marie CURIE (PARIS VI) Université Pierre & Marie CURIE (PARIS VI)

3 FLEXIBLE URS Since 2001, recent development of new flexible URS and the miniaturisation of instruments t allow today the direct diagnosis and treatment of upper urinary tract diseases Smallest caliber actively deflectable (7.5F) Working channel is 3.6F 2-way active deflect. : degrees Improved fiberoptics and digital technology Basillote JB et al. Urol Clin North Am. 31, 2004

4 F-URS : NEW GENERATION

5 FLEXIBLE URS Flex-X2 DUR-D Access to the entire collecting system : % Busby & Low, 2004 Beiko & Denstedt, 2007 URF-P5 URF-V

6 Improvements in Ureteroscope Design FiberOptic Digital System

7 ELECTROMAGNETIC SPECTRUM NANOMETER RAYON X MICRONDE ONDE RADIO UV VISIBLE INFRA-RED

8 HOLMIUM YAG LASER CALCULASE 10W: Karl Storz Introduction ti of Holmium:YAG laser wich can fragment any type of stone, ablate and cut tissue has expanded the role of FURS Grasso et al, J Clin Laser Med Surg 1998

9 SPECIAL CIRCUMSTANCES DJ INCRUSTATION

10 WIRES MATERIALS DLC & URETERAL ACCESS SHEATH NITINOL BASKET PORT SEAL / MANUAL HAND DEVICE LASER FIBERS

11 NEW NITINOL BASKET N-Compas COOK Medical Coloplast Catch

12 NITINOL RETRIEVING DEVICES

13 NEW NITINOL BASKET N-Trap To prevent stone migration during Rigid URS

14 URETERAL ACCESS SHEATH Facilitate multiple entries/exits Avoid effects of ureteral edema Maintain low intrarenal press. Limit operating time Facilitate irrigation Protect Flexible URS Kourambas, J Urol 2001

15 ADEQUATE FLOW OF IRRIGANT SPECIFIC PORT SEAL & IRRIGATION DEVICES To Preserve & Increase irrigation

16 SET-UP

17 SET-UP

18 LASER AND FIBERS

19 PATIENT POSITION

20 INSPECT EACH CALYX WITH C-ARM CONTROL

21 DIAGNOSTIC (10%) INDICATIONS THERAPEUTIC (90%) - STONES (75%) - Kidney-Ureter Lower Calyx - Cystine - Anatomic abnormal. - Obesity - Coagulopathy - Associat FURS-Perc - Strictures (5%) - Ureter - UPJO - Urothelial Tumors (10%) - Foreign body :stent, - Obstructions - Defect on IVP - Lower Calyx - Unexplained Hematuria - Positive Cytology - Reccurent uroth. tumor Beiko, Urol Clin N Am 2007

22 EAU GUIDELINES 2009 URETERAL STONES EAU Guidelines 2009

23 EAU GUIDELINES 2009 RENAL STONES <= 2 cms EAU Guidelines 2009

24 EAU GUIDELINES 2009 RENAL STONES >= 2 cm EAU Guidelines 2009 ; Grasso 1998

25 F-URS F-URS success rate was defined as stone free (SF) or remaining fragments (RF) less than 3 mm Post operative evaluation: Second look : 1-3 weeks KUB t D 1 d RUS t D 30 KUB at Day 1 and RUS at Day 30 KUB Day 1 and NCCT at Day 30

26 RESULTS (>2 CM) First session SF Rate : 55,6% TRAXER et al, WCE 2009

27 RESULTS (>2 CM) Second session SF Rate: 83.8% TRAXER et al, WCE 2009

28 RESULTS (>2 CM) Third session SF Rate : 93.2% TRAXER et al, WCE 2009

29 RESULTS ( >2 CM) 1st F URS 2nd F URS 3rd F URS 4th F URS 97.90% 89.80% 63% 73.60% 78.90% 52.60% 0.00% 10.50% 2 3 cm > 3 cm

30 LARGE RENAL PELVIC STONE

31 COMPLETE LASER FRAGMENTATION IN ONE SESSION

32 Large Renal stone (multiple) fragmentation with one session

33 TREATMENT OF SOLITARY KIDNEY STONE TOTAL VOLUME : 25 mm (1 session)

34 BILATERALCOMPLEX RENAL STONE BILATERALCOMPLEX RENAL STONE PROCEDURE

35 RESULTS

36 LOWER POLE STONE REPOSITIONING Tipless Nitinol Basket LP Stone < 15 mm Schuster, 2002, Kourambas 2000 EAU Guidelines 2009

37 LOWER POLE STONE REPOSITIONING Kourambas et al (Urol 56, 2000): Stone displaced d w/ nitinol basket or grasper 90% SF for displaced 83% for in situ stones Schuster et al (J Urol 168, 2002): In Situ Displaced N=59 N=19 P-value Overall 71% 94% cm 77% 77% ns >1 cm 29% 100% 0.005

38 LP STONE REPOSITIONING α n Watts n-x Watts Fiber laser in deflected URS : important loss of energy through out the way

39 LOWER POLE STONE STUDY II Group 1 ( 1 cm) (n=67) SWL (n=32) URS (n=35) Stone Free: 1ºoutcome parameter 35 vs 52% (ns) Pearle MS et al. J Urol, 2005

40 Stone-Bearing caliceal diverticulum

41 TECHNIQUE (BLUE)

42 Stone-Bearing caliceal diverticulum

43 Stone-Bearing caliceal diverticulum We successfully treated caliceal diverticulunm stone in lower pole while others calim difficulties of obtaining success rate Glenn M Preminger J endourol 2002; 16: Glenn M. Preminger. J endourol. 2002; 16: Batter S, Dretler S: J Urol 1997; 158

44 Stone-Bearing caliceal diverticulum

45 SPECIAL CIRCUMSTANCES HORSESHOE AND PELVIC KIDNEY Preminger G. J Endourol 2005 Preminger G. J Endourol patients : SFR 85% (1 session)

46 SPECIAL CIRCUMSTANCES COMBINED TREATMENT BODY DEFORMITIES Wignall, Urol Clin N Am Scarpa & Scofone, Eur Urol 2008

47 SPECIAL CIRCUMSTANCES MORBIDLY OBESITY PEDIATRIC Nguyen TA, J Endourol 1998 EAU Guidelines 2009

48 SPECIAL CIRCUMSTANCES INTERNAL / EXTERNAL URINARY INTERNAL / EXTERNAL URINARY DIVERSION

49 SPECIAL CIRCUMSTANCES JJ INCRUSTATION-MIGRATION

50 RESIDUAL FRAGMENTS < 4 mm.. < 2mm.?! Streem J Urol 1995 ; MS Pearle, J. EndoUrol 2009

51 RESIDUELS FRAGMENTS : COAGULUM

52 RANDALL S PLAQUE Percent plaque coverage directly correlates with the number of stones formed even when corrected for the duration of stone disease Kim Journal of Urology 2005

53 RANDALL S PLAQUE Submucosal calcifications erode to papillary surface whereby exposure to urine results in salt deposition an papillary stone formation.

54 RANDALL S PLAQUE Matlaga et al J of Urology Matlaga et al, J. of Urology May 2006

55 ADVANTAGES-DIS OF FLEXIBLE URS Stone removed entirely / outpatient procedure? waiting for fragments to pass Ho-Laser : universally effective /all stones types Radiolucent stones definitively treated with URS Low complication rate (infection, pain, stricture) Bagley, 2008 Special circumstances : Patient Obesity Dash 2002 Scoliosis & body deformities Busby 2004 Bleeding diatheses Watterson 2002 Renal abnormalities (HK) Gupta 2007 Patient preferences DIS: - COST, Time-Consuming, Durability,

56 CONCLUSIONS RIRS: Reliable, Safe & Effective/ kidney stone ttt Technique of RIRS is now well established due to Development of effective F-URS Specific Instrumentat (new grasping devices) Efficient laser Lower Pole Stone is a special indication The challenge in the ensuing years is to refine technique and patient selection for the growing list of endourologic options Multicenter Prospective Randomized Studies are needed

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Clinical Study Predictors of Clinical Outcomes of Flexible Ureterorenoscopy withholmiumlaserforrenalstonegreaterthan2cm

Advances in Urology Volume 2012, Article ID 543537, 6 pages doi:10.1155/2012/543537 Clinical Study Predictors of Clinical Outcomes of Flexible Ureterorenoscopy withholmiumlaserforrenalstonegreaterthan2cm