Determining the Safety Threshold for the Passage of a Ureteral Access Sheath in Clinical Practice Using a Purpose-Built Force Sensor

No AccessJournal of UrologyAdult Urology1 Aug 2021Determining the Safety Threshold for the Passage of a Ureteral Access Sheath in Clinical Practice Using a Purpose-Built Force SensorThis article is commented on by the following:Editorial CommentEditorial Comment Shlomi Tapiero, Kamaljot S. Kaler, Pengbo Jiang, Sherry Lu, Courtney Cottone, Roshan M. Patel, Zhamshid Okhunov, Michael J. Klopfer, Jaime Landman, and Ralph V. Clayman Shlomi TapieroShlomi Tapiero Department of Urology, University of California, Irvine , Kamaljot S. KalerKamaljot S. Kaler Department of Surgery, Section of Urology, University of Calgary, Alberta, Canada , Pengbo JiangPengbo Jiang Department of Urology, University of California, Irvine , Sherry LuSherry Lu Department of Urology, University of California, Irvine , Courtney CottoneCourtney Cottone Department of Urology, University of California, Irvine , Roshan M. PatelRoshan M. Patel Department of Urology, University of California, Irvine , Zhamshid OkhunovZhamshid Okhunov Department of Urology, University of California, Irvine , Michael J. KlopferMichael J. Klopfer California Institute for Telecommunications and Information Technology, University of California, Irvine , Jaime LandmanJaime Landman Department of Urology, University of California, Irvine , and Ralph V. ClaymanRalph V. Clayman *Correspondence: Department of Urology, University of California, 333 City Blvd. West, Suite 2100, Irvine, California 92868 telephone: 714-456-6567; E-mail Address: [email protected] Department of Urology, University of California, Irvine View All Author Informationhttps://doi.org/10.1097/JU.0000000000001719AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract Purpose: Ureteral injury is a frequent complication of ureteral access sheath deployment. We sought to define the safe threshold of force for the passage of a ureteral access sheath using a novel ureteral access sheath force sensor. Materials and Methods: Ureteral access sheath-force sensor measurements were recorded in 210 renal units. A 16Fr ureteral access sheath was deployed initially based on a prior porcine study. If 6 N was reached, the surgeon was advised to downsize the 16Fr ureteral access sheath. In each case, a post-ureteroscopic lesion scale was recorded. Regression models were used to estimate the impact of adjusted variables on post-ureteroscopic lesion scale grade, 16Fr ureteral access sheath deployment, and peak force. Results: A 16Fr ureteral access sheath was deployed in 127 (61%) renal units with a mean peak force of 5.7 N. Two high-grade ureteral injuries occurred; in both cases >6 N of force was recorded. Post-ureteroscopic lesion scale grade correlated directly with peak insertion force (p <0.01). Bacteriuria within 60 days of the procedure (OR 2.009, p=0.034), combination of preoperative stent plus oral tamsulosin (OR 2.998, p=0.045), and prior ipsilateral stone surgery (OR 2.13, p=0.01) were independent predictors of successful 16Fr ureteral access sheath deployment. Among patients with neither prior ipsilateral stone surgery nor preoperative stent, preoperative tamsulosin facilitated passage of a 16Fr ureteral access sheath (OR 2.750, p=0.034). Conclusions: Ureteral access sheath associated ureteral injury can be averted by limiting the insertion force to ≤6 N. Prior stone surgery, preoperative indwelling ureteral stent plus oral tamsulosin, and recently treated bacteriuria favored passage of a 16Fr ureteral access sheath. In the naïve, unstented patient, preoperative tamsulosin favored deployment of a 16Fr ureteral access sheath. References 1. : Surgical management of stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 2016; 196: 1161. Link, Google Scholar 2. : Recent development for pyeloureteroscopy: guide tube method for its introduction into the ureter. J Urol 1974; 112: 176. Link, Google Scholar 3. : Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Urology 2003; 61: 713. Google Scholar 4. : Ureteral access sheath provides protection against elevated renal pressures during routine flexible ureteroscopic stone manipulation. J Endourol 2004; 18: 33. Google Scholar 5. : Systemic inflammatory response syndrome after flexible ureteroscopic lithotripsy: a study of risk factors. J Endourol 2015; 29: 25. Google Scholar 6. : Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: the Clinical Research Office of the Endourological Society Ureteroscopy Global Study. World J Urol 2015; 33: 2137. Google Scholar 7. : Does a ureteral access sheath facilitate ureteroscopy?J Urol 2001; 165: 789. Link, Google Scholar 8. : Techniques to maximize flexible ureteroscope longevity. Urology 2002; 60: 784. Google Scholar 9. : Improved durability of flex-Xc digital flexible ureteroscope: how long can you expect it to last?Urology 2014; 84: 32. Google Scholar 10. : Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol 2013; 189: 580. Link, Google Scholar 11. Ureteral wall injury with ureteral access sheaths: a randomized prospective trial. J Endourol. 2020; 34: 932. Google Scholar 12. : Ureteral access sheath deployment: how much force is too much? Initial studies with a novel ureteral access sheath force sensor in the porcine ureter. J Endourol 2019; 33: 712. Google Scholar 13. : Postureteroscopic lesion scale: a new management modified organ injury scale-evaluation in 435 ureteroscopic patients. J Endourol 2012; 26: 1425. Google Scholar 14. : The argument against the routine use of ureteral access sheaths. Urol Clin N Am 2004; 31: 83. Google Scholar 15. : Laser Doppler flowmetric determination of ureteral blood flow after ureteral access sheath placement. J Endourol 2002; 16: 583. Google Scholar 16. : Which ureteral access sheath is compatible with your flexible ureteroscope?J Endourol 2014; 28: 286. Google Scholar 17. : Assessment of stricture formation with the ureteral access sheath. Urology 2003; 61: 518. Google Scholar 18. : Incidence and predictors for ipsilateral hydronephrosis following ureteroscopic lithotripsy. Urology 2015; 86: 465. Google Scholar 19. : Ureteral stricture formation after removal of impacted calculi. J Urol 1998; 159: 723. Link, Google Scholar 20. : Endoscopic features of impacted ureteral stones. J Urol 2004; 171: 89. Link, Google Scholar 21. : A prospective study analyzing the association between high-grade ureteral access sheath injuries and the formation of ureteral strictures. Urology 2019; 128: 38. Google Scholar 22. : The impact of preoperative α-adrenergic antagonists on ureteral access sheath insertion force and the upper limit of force required to avoid ureteral mucosal injury: a randomized controlled study. J Urol 2018; 199: 1622. Link, Google Scholar 23. : Anatomic, functional, and pathologic changes from internal ureteral stent placement. Urology 1992; 40: 385. Google Scholar 24. : Impact of a double-pigtail stent on ureteral peristalsis in the porcine model: initial studies using a novel implantable magnetic sensor. J Endourol 2005; 19: 170. Google Scholar 25. : Predicting an effective ureteral access sheath insertion: a bicenter prospective study. J Endourol 2014; 28: 1414. Google Scholar 26. : Irrigant flow and intrarenal pressure during flexible ureteroscopy: the effect of different access sheaths, working channel instruments, and hydrostatic pressure. J Endourol 2010; 24: 1915. Google Scholar 27. : Can we provide low intrarenal pressures with good Irrigation flow by decreasing the size of ureteral access sheaths?J Endourol 2016; 30: 49. Google Scholar 28. : Increasing the size of ureteral access sheath during retrograde intrarenal surgery improves surgical efficiency without increasing complications. World J Urol 2018; 36: 971. Google Scholar 29. : Practice patterns of ureteral access sheath during ureteroscopy for nephrolithiasis: a survey among endourologists worldwide. BMC Urol 2019; 19: 58. Google Scholar 30. : Medical impulsive therapy (MIT): the impact of 1 week of preoperative tamsulosin on deployment of 16-French ureteral access sheaths without preoperative ureteral stent placement. World J Urol 2018; 36: 2065. Google Scholar © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of UrologyMay 7, 2021, 12:00:00 AMEditorial CommentJournal of UrologyMay 7, 2021, 12:00:00 AMEditorial Comment Volume 206Issue 2August 2021Page: 364-372 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.Keywordsurolithiasisureterureteroscopykidney calculiMetricsAuthor Information Shlomi Tapiero Department of Urology, University of California, Irvine More articles by this author Kamaljot S. Kaler Department of Surgery, Section of Urology, University of Calgary, Alberta, Canada More articles by this author Pengbo Jiang Department of Urology, University of California, Irvine More articles by this author Sherry Lu Department of Urology, University of California, Irvine More articles by this author Courtney Cottone Department of Urology, University of California, Irvine More articles by this author Roshan M. Patel Department of Urology, University of California, Irvine More articles by this author Zhamshid Okhunov Department of Urology, University of California, Irvine More articles by this author Michael J. Klopfer California Institute for Telecommunications and Information Technology, University of California, Irvine More articles by this author Jaime Landman Department of Urology, University of California, Irvine More articles by this author Ralph V. Clayman Department of Urology, University of California, Irvine *Correspondence: Department of Urology, University of California, 333 City Blvd. West, Suite 2100, Irvine, California 92868 telephone: 714-456-6567; E-mail Address: [email protected] More articles by this author Expand All Advertisement Loading ...