Brief Summary

A 60-year-old woman with left UPJ stone (10x10x10mm) and a small stone in the LKLP (3x3x3mm). She felt flank pain and underwent ESWL x1 at a local clinic.

DTPA renal scan showed functional deterioration in the left kidney (Rt: Lt = 58/42). GFR was 45.8/32.4.

The table setting was like this picture.

Devices and instruments

Flexible ureteroscopy: Flex-Xc (Storz), URF-V2 (Olympus), Lithovue (Boston Scientific).

Ureteral access sheath: Navigator (Boston Scientific), UroPass (Olympus), ReTrace (Coloplast for only display)

Guidewire: Terumo Guidewire (stiff type), Superstiff (Boston Scientific)

Catheter: Dual lumen catheter (Boston Scientific), Ureteral catheter (Cook)

Laser: Versa Pulse 100W (Lumenis)

Stone basket: 1.9Fr Zerotip (Boston Scientific), 1.5Fr NGage (Cook), Dormia (Coloplast for only display)

Irrigation: HiLine (Coloplast)

DJ stent: Percuflex (Boston Scientific)

DJ remover: Isiris (Coloplast for only display)

Procedures

Removal of the pre-stented DJ stent (Unfortunately Isiris not used at this time)

Cystoscopy insertion

Terumo guidewire insertion into left ureter

Ureteral access sheath insertion

Flex-Xc URS insertion connected to HiLine irrigation system

Energy setting for fragmentation (0.8J + 5Hz -> 1.0J + 5Hz -> 1.3J + 5 Hz)

Stone: gray and black surface with active stone formation

Manual irrigation with HiLine with two fingers (exhuastive action when the surgery is prolonged)

Fragmented stones migrated into the upper calyx, Stone basketing

Stone basketing for lower pole stone

Topics

# Mechanism of action of Isiris: integrated forcep into a disposable flexible cystoscopic system with a portable monitor system

# Trendelenbug position is necessary?

Pros for box-corner pop-dusting technique, Cons for uncomfortable position

# Laser fiber sheath unpealed > pealed off

Easy detection with blue color

Laser fiber protection

To lessen scope damage due to small fiber particles

Cutting with a pair of simple Mayor scissors is better than the typical cutter

# Surgeon's position

Standing for easy control of devices such as C-arm, pedals and devices

Sitting for comfortable surgery

# Manual irrigation is better than automated irrigation system?

- HiLine had a little bit stiff pump system, but it was very effective to guarantee low intrarenal pressure and fragmentation of stones.

- No suction or irrigation. It can induce infection or bleeding

# Ureteral access sheath: ReTrace, a new-generation sheath with a single terumo guidewire (stiff type)

# Ureter injury inspection during scope removal

Different options

# Irrigation system: manual irrigation system is really better than automated one?

# Access sheath: safety guidewire is still necessary?

# No suction is necessary? Suction can really induce bleeding or infection? Is it really clinically important? Please consider integrated system of access sheath of injection and suction (ClearPetra-TM by wellead)