MATERIALS AND METHODS
This study was approved by the local institutional ethical board (ANEAH-E-1762). All patients provided informed consent. Between September 2016 and March 2019, 154 consecutive RIRS procedures with adjunctive use of an UAS for kidney stone were prospectively included the study. All patients evaluated by anamnesis, medical history, physical examination, microscopic urinalysis, urine culture, complete blood cell count, serum biochemistry analysis, computerized tomography with/without contrast material. Patients with positive urine cultures were treated preoperatively with the appropriate antibiotics. Patients with previous stone history and urinary surgery, urinary system abnormalities (horseshoe, ectopic and malrotated kidneys, duplicated collecting systems and calyceal diverticulum stones), any degree of ureteral dilatation and the initial sheath was not placed successfully were excluded from the study. All the patients were not pre-stented.
A 9.5/11.5-F UAS (Cook™, Cook Medical, Dublin, Ireland) (35cm or 45cm length for females or males, respectively) was used during procedures. All procedures were performed under general anesthesia. Diagnostic ureterorenoscopy (URS) was performed by using 9.5-F semi-rigid ureteroscope (Karl Storz™, Karl Storz, Tuttlingen, Germany) routinely before RIRS to detect ureteral stone or stricture, to place a hydrophilic guide-wire and for the optical dilatation. A 9.5/11.5-F ureteral access sheath was placed over the guide-wire and a 7.5-F flexible ureteroscope (Karl Storz Flex-X2™, Karl Storz, Tuttlingen, Germany) was passed through the sheath. Kidney stones were fragmented with a 30W Holmium:YAG laser generator (SphinxX™, Lisa, Katlenburg-Lindau, Germany). Extraction of residual fragments was not performed as a routine procedure. At the end of the operation, we entered to the ureter under guidance of guide wire with 9.5-F semi-rigid ureteroscope and whole ureter was inspected. JJ stent was inserted based on surgeon decision and removed approximately 14–28 days postoperatively.
Intra-operative ureteral lesion grade classified using the classification methodology previously described by Traxer and Thomas[7] with categorization of five grades, ranging from 0-4, defined by the characteristics in Table 1. Modified Clavien-Dindo Classification [10] was used to report postoperative complications.
At postoperatively first month, ≤3 mm residual stones were accepted as stone free. All patients were evaluated by computed tomographic urography in the first year after treatment. A stricture is defined as a fixed narrowing ureteral wall with proximal dilatation. [11]