Publications by authors named "Carlos A Batagello"

15 Publications

  • Page 1 of 1

Tranexamic acid in patients with complex stones undergoing percutaneous nephrolithotomy: a randomized, double-blinded, placebo-controlled trial.

BJU Int 2021 Feb 25. Epub 2021 Feb 25.

Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Objectives: To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones who have undergone percutaneous nephrolithotomy (PCNL).

Material And Methods: In a randomized, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomized (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236.

Results: The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%, relative risk: 0.21, 95% confidence interval (CI): 0.03-0.76; P = 0.033, number-needed-to-treat: 12). Patients randomized to the tranexamic acid group showed higher immediate and three-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [95% CI]: 2.37 [1.15-4.87], P = 0.019, and 46.2% vs 28.1%, odds ratio [95% CI]: 2.20 [1.20-4.02], P = 0.011, respectively). Faster hemoglobin recovery was demonstrated by patients in the tranexamic group (mean, 21.3 days, P = 0.001). No statistical differences were found in operative time and complications between groups.

Conclusions: Tranexamic acid administration is safe and reduces the need for blood transfusion by five times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contributes to better stone clearance rate and faster hemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.
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http://dx.doi.org/10.1111/bju.15378DOI Listing
February 2021

Bilateral simultaneous percutaneous nephrolithotomy versus staged approach: a critical analysis of complications and renal function.

Rev Assoc Med Bras (1992) 2020 Dec;66(12):1696-1701

Divisão de Urologia, Departamento de Cirurgia, Faculdade Medicina da Universidade de São Paulo, São Paulo, SP, Brasil.

Introduction: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function.

Methods: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay.

Results: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012).

Conclusion: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.
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http://dx.doi.org/10.1590/1806-9282.66.12.1696DOI Listing
December 2020

Understanding urologic scientific publication patterns and general public interests on stone disease: lessons learned from big data platforms.

World J Urol 2020 Oct 27. Epub 2020 Oct 27.

Section of Endourology, Division of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar 255, Cerqueira César, 05403-900, Sao Paulo, Brazil.

Purpose: To analyse patterns of stone disease online information-seeking behaviours in the United States and to correlate with urological literature publication aspects.

Methods: To compare Relative Search Volume (RSV) among different twelve preselected urologic keywords we chose "United States" as country and "01/01/2009-31/12/2018" as time range on Google Trends (GT). We defined "ureteroscopy" as a reference and compared RSV against it for each term. RSV was adjusted and normalized in a scale 0-100. Trend presence was evaluated by Mann-Kendall Test and magnitude by Sen's Slope Estimator (SS). Weather influence on RSV was also investigated by comparison of the ten hottest versus ten coldest states. Pearson correlation analysis was performed between number of Pubmed publications and RSV for each term over time.

Results: We found an upward tendency (p < 0.01) for most terms. Higher temporal trends were seen for "kidney stone" (SS = 0.36), "kidney pain" (SS = 0.39) and "tamsulosin" (SS = 0.21). Technical treatment terms had little search volumes and no increasing trend. States with hotter weather showed higher mean RSV for "kidney stone" than colder ones. There was little correlation between GT and Pubmed for most terms, with the exception of "kidney stone" (R = 0.89; p < 0.01), "URS" (R = 0.81; p < 0.01), and "laser lithotripsy" (R = 0.74; p = 0.01).

Conclusion: There was a significant increase in online search for medical information related to stone disease. Citizens tend to look for generic terms related to symptoms or the disease itself. States with hotter weather show higher RSV than colder states. There is a discrepancy between public and medical community medical terms.
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http://dx.doi.org/10.1007/s00345-020-03477-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7590553PMC
October 2020

Percutaneous nephrolithotomy in patients with spinal cord injury: should all these patients be automatically assigned a Guy's stone score of 4?

World J Urol 2020 Sep 15. Epub 2020 Sep 15.

Division of Urology, University of Sao Paulo Medical School, Av. Vereador Jose Diniz, 3300, conj. 208, Sao Paulo, SP, 04604-006, Brazil.

Purpose: To assess the complication and stone-free rates of PCNL in patients with spinal cord injury (SCI) and to evaluate whether this population should be assigned a Guy's stone score (GSS) of 4.

Methods: A case-control study was conducted, and electronic charts were reviewed to search for patients with SCI, bladder dysfunction, and kidney stones who had undergone PCNL. Control cases were randomly selected from among patients with complete staghorn calculus (GSS = 4).

Results: One hundred and seventeen patients were included. Patients with SCI had a significant shorter operative time (119 vs. 141 min; p = 0.018). There were no significant differences between the groups in terms of the patients' position, number of renal tracts, bleeding or transfusion rate; however, there was a significantly higher complication rate (23.1% vs. 7.8%; p = 0.009) and a longer hospital stay (5.8 vs. 3.1 days; p = 0.002) among patients with SCI. With regards to the stone-free rate in patients with different grades of GSS patients with SCI who had a GSS of 1 had a stone-free rate of 85.7%, while those with a GSS of 2, 3, or 4 had 50%, 50%, and 31.5%, respectively (p = 0.024). Only patients with a GSS of 4 in the SCI group had outcomes that were similar to those of control patients (31.5% vs. 31.6%).

Conclusion: Patients with SCI should not be automatically assigned GSS 4. Stone-free rate is related to stone burden in these patients, although they do show a higher complication rate and a longer hospital stay than non-neurological patients.
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http://dx.doi.org/10.1007/s00345-020-03443-1DOI Listing
September 2020

The impact of COVID-19 in medical practice. A review focused on Urology.

Int Braz J Urol 2021 Mar-Apr;47(2):251-262

Setor de Endourologia, Divisão de Urologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.99.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857770PMC
December 2020

Renal Stone Features Are More Important Than Renal Anatomy to Predict Shock Wave Lithotripsy Outcomes: Results from a Prospective Study with CT Follow-Up.

J Endourol 2020 01 21;34(1):63-67. Epub 2019 Nov 21.

Division of Urology, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

Lower pole kidney stones have been associated with poor shock wave lithotripsy (SWL) outcomes because of its location. However, the real impact of collecting system anatomy on stone clearance after SWL is uncertain. There is a lack of prospective well-controlled studies to determine whether lower pole kidney stones have inferior outcomes than nonlower pole kidney stones when treated with SWL. We prospectively evaluated patients with a single kidney stone of 5-15 mm undergoing SWL from June 12 through January 19. All patients were subjected to computed tomography before and 3 months after the procedure. Demographic data (age, gender, and body mass index), stone features (stone size, stone area, stone density, and stone-skin distance-SSD), and collecting system anatomy (infundibular length and width, and infundibulopelvic angle) were recorded. Outcomes (fragmentation and stone clearance rates) were compared between lower pole and nonlower pole cases. Then, a multivariate analysis including all variables was performed to determinate which parameters significantly impact on SWL outcomes. One hundred and twenty patients were included in the study. Mean stone size was 8.3 mm and mean stone density was 805 Hounsfield units. Overall stone fragmentation, success, and stone-free rates were 84.1%, 64.1%, and 34.1%, respectively. There were no significant differences in stone fragmentation (76.0% 71.4%;  = 0.624), success rate (57.6% 53.3%;  = 0.435), and stone-free rate (40.2% 35.7%;  = 0.422) in the lower nonlower pole groups, respectively. On multivariate analysis, only stone density ( < 0.001) and SSD ( = 0.006) significantly influenced fragmentation. Stone size ( = 0.029), stone density ( = 0.002), and SSD ( = 0.049) significantly influenced kidney stone clearance. Stone size, stone density, and SSD impact on SWL outcomes. Lower pole kidney stones have similar fragmentation and stone clearance compared with nonlower pole kidney stones.
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http://dx.doi.org/10.1089/end.2019.0545DOI Listing
January 2020

A comprehensive literature-based equation to compare cost-effectiveness of a flexible ureteroscopy program with single-use versus reusable devices.

Int Braz J Urol 2019 Jul-Aug;45(4):658-670

Seção de Endourologia da Divisão de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, SP, Brasil.

Purpose: To critically review all literature concerning the cost-effectiveness of flexible ureteroscopy comparing single-use with reusable scopes.

Materials And Methods: A systematic online literature review was performed in PubMed, Embase and Google Scholar databases. All factors potentially affecting surgical costs or clinical outcomes were considered. Prospective assessments, case control and case series studies were included.

Results: 741 studies were found. Of those, 18 were duplicated and 77 were not related to urology procedures. Of the remaining 646 studies, 59 were considered of relevance and selected for further analysis. Stone free and complication rates were similar between single-use and reusable scopes. Operative time was in average 20% shorter with digital scopes, single-use or not. Reusable digital scopes seem to last longer than optic ones, though scope longevity is very variable worldwide. New scopes usually last four times more than refurbished ones and single-use ureterorenoscopes have good resilience throughout long cases. Longer scope longevity is achieved with Cidex and if a dedicated nurse takes care of the sterilization process. The main surgical factors that negatively impact device longevity are lower pole pathologies, large stone burden and non-use of a ureteral access sheath. We have built a comprehensive fi nancial costeffective decision model to fl exible ureteroscope acquisition.

Conclusions: The cost-effectiveness of a fl exible ureteroscopy program is dependent of several aspects. We have developed a equation to allow a literature-based and adaptable decision model to every interested stakeholder. Disposable devices are already a reality and will progressively become the standard as manufacturing price falls.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837614PMC
September 2019

Endoscopic guided PCNL in the prone split-leg position versus supine PCNL: a comparative analysis stratified by Guy's stone score.

Can J Urol 2019 02;26(1):9664-9674

Section of Endourology, Division of Urology, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.

Introduction: The optimal patient positioning for percutaneous nephrolithotomy (PCNL) based on the complexity of stone burden is not yet defined. Thus, we aimed to evaluate the intraoperative parameters, effectiveness and complications of patients undergoing PCNL between the endoscopic-guided prone split-leg PCNL (ePSL) and the supine PCNL by stratifying patients according to Guy's stone score (GSS).

Materials And Methods: A retrospective chart review was conducted of patients undergoing PCNL at two high-volume tertiary referral centers. At one center, patients underwent PCNL using the ePSL technique, while at the second center, patients underwent PCNL in supine. Patient demographics and stone characteristics, operative details, complications and effectiveness were compared between groups. The impact of obesity was also investigated.

Results: Of 830 subjects, a total of 449 (54%) underwent PCNL in ePSL and 381 (46%) in supine. The ePSL group had a greater mean age and body mass index. No statistical differences were found in gender, serum chemistry and Charlson comorbidity index. After stratifying patients by GSS, the differences in baseline stone burden between PSL and supine lost significance and both groups could be compared. Complications were not statistically different between both groups. Univariate analysis demonstrated that multiple tracts and lower pole access were more prevalent in supine. In addition, for GSS1-3, ePSL was correlated with reduced operative time, radiation exposure, length of hospital stay and need for secondary procedure. Multivariate analysis correlated ePSL with lower radiation exposure and need for secondary procedures (p = 0.01). In comparison to the whole trial population, the same tendencies were appreciated for obese cohort.

Conclusions: This is the first report focusing on the performance differences between ePSL and supine PCNL stratified by GSS. Both techniques are safe, with a low rate of complications. For GSS1-3, ePSL reduces radiation exposure and requires less need for both multiple access and secondary procedure.
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February 2019

Response to Lange re: Calcium Oxalate Urolithiasis: A Case of Missing Microbes?

J Endourol 2018 11;32(11):1007

1 Department of Urology, Cleveland Clinic , Cleveland, Ohio.

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http://dx.doi.org/10.1089/end.2018.29049.cabDOI Listing
November 2018

Calcium Oxalate Urolithiasis: A Case of Missing Microbes?

J Endourol 2018 11 20;32(11):995-1005. Epub 2018 Oct 20.

1 Department of Urology, Cleveland Clinic , Cleveland, Ohio.

Introduction: Urinary stone disease (USD) has known associations with the gut microbiota. Approximately 80% of kidney stones contain oxalate as a primary constituent and diverse oxalate-degrading bacteria exist within the human gut, which may protect against USD. Although bacteriotherapy represents a promising strategy to eliminate oxalate and reduce the risk of USD, oxalate-degrading probiotics have had limited success. To identify limitations of oxalate-degrading probiotics and refine development of bacteriotherapies to prevent USD, we review the literature associated with the gut microbiota and USD.

Materials And Methods: A literature search was performed to identify publications that examine the role of oxalate-degrading bacteria or the whole gut microbiota in oxalate metabolism and the pathophysiology of USD. We conducted a meta-analysis of studies that examined the association of the whole gut microbiota with USD. In addition, we evaluated the gut microbiota of healthy individuals and those with comorbidities related to USD using publically available data from the American Gut Project (AGP).

Results: Studies on Oxalobacter formigenes reveal that colonization by this species is not a good predictor of USD risk or urinary oxalate excretion. The species of oxalate-degrading bacteria used in probiotics and duration of administration do not impact efficacy or persistence. Studies focused on the whole gut microbiota reveal broad shifts in the gut microbiota associated with USD and a diverse microbial network is associated with oxalate metabolism. AGP data analysis demonstrated a strong overlap in microbial genera depleted in diseased individuals among USD and comorbidities.

Conclusions: The associations between the gut microbiota and USD extend beyond individual functional microbial species. Common shifts in the gut microbiota may facilitate the onset of USD and/or comorbidities. The successful development of bacteriotherapies to inhibit USD will need to incorporate strategies that target a broad diversity of bacteria rather than focus on a few specialist species.
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http://dx.doi.org/10.1089/end.2018.0294DOI Listing
November 2018

Recurrent Penile Fracture-Case Report and Alternative Surgical Approach.

Sex Med 2018 Sep 3;6(3):263-266. Epub 2018 May 3.

Sexual Medicine Group, Division of Urology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.

Introduction: Penile refracture is an exceedingly rare event, with very few published studies. To the best of our knowledge, this is the first documented case in the literature of penile fracture with 3 same-site recurrences.

Aims: To describe the case of a 25-year-old Caucasian man with recurrent penile fracture ultimately treated with resuture and patch reinforcement.

Methods: Patient history (clinical and surgical) and literature review.

Results: After the 3rd same-site recurrence, patch reinforcement over the sutured area was performed. The patient had an uneventful recovery and no recurrences to date.

Conclusion: There is no evidence indicating the superiority of non-absorbable sutures. Bovine pericardium reinforcement over the sutured area was used to minimize the chance of another recurrence. More studies are necessary to investigate its safety and efficacy in this scenario. Nascimento B, Guglielmetti GB, Miranda EP, et al. Recurrent Penile Fracture-Case Report and Alternative Surgical Approach. Sex Med 2018;6:263-266.
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http://dx.doi.org/10.1016/j.esxm.2018.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6085271PMC
September 2018

The Impact of Thiazides and Potassium Citrate on Bone Mineral Density Evaluated by CT Scan in Stone Formers.

J Endourol 2018 06 24;32(6):559-564. Epub 2018 Apr 24.

1 Glickman Urological and Kidney Institute , Cleveland Clinic, Cleveland, OH, USA.

Introduction: Thiazides and citrate prevent kidney stones and improve bone mineral density (BMD). The objective of this study was to opportunistically utilize the noncontrast CT (NCCT) scan used for stone detection to identify those with low BMD and follow the impact of potassium citrate and thiazides on longitudinal BMD measurements.

Materials And Methods: A retrospective analysis was performed on 299 kidney stone patients treated with thiazides and/or potassium citrate for a minimum of 1 year. For each patient, BMD was estimated at L1 with CT attenuation measured in HU. A level of 160 HU was chosen to distinguish normal from low BMD. Pairwise t-test was used to compare the continuous outcomes before and after treatment for the whole cohort and the low BMD subgroup. Linear regression was performed to find if any association exists between the duration of follow-up and the changes in HU. A matched pair t-test was performed to compare among the medications used and the impact of their doses on the HU outcomes.

Results: Patients with low BMD (HU <160) comprised (n = 186, 62.2%) the cohort. A total of 16.1% normalized after 1 year of treatment and 68% had an increase in HU. The mean change in HU was 8.6 (p = 0.0001). Linear regression demonstrated no association between the duration of treatment and the HU changes (p = 0.64). Hydrochlorothiazide (HCTZ) 50 mg was more effective at improving BMD (HU +19.7, p = 0.04) compared with 25 mg (+2.9) or 12.5 mg (HU +6.4). Majority of the low BMD subgroup were either postmenopausal women (n = 88) or men with age older than 60 (n = 74) and both showed a significant increase in HU (3.125, 10.731), p-value (0.0453, 0.0007), respectively.

Conclusion: Stone health and bone health are synergistic. The impact of thiazides and citrates on BMD can be monitored opportunistically with the NCCT scan.
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http://dx.doi.org/10.1089/end.2017.0940DOI Listing
June 2018

Current trends of percutaneous nephrolithotomy in a developing country.

Int Braz J Urol 2018 Mar-Apr;44(2):304-313

Divisão de Urologia, Grupo de Endourologia Hospital das Clínicas Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil.

Introduction: To present the current practice patterns on percutaneous nephrolithotomy (PCNL) in a developing country.

Materials And Methods: A survey was offered to Brazilian urologists during the II International Endourology Symposium held in Sao Paulo, in 2015. The first seven questions were related to demographic data while the 20 remaining were directed to urologists who performed PCNL.

Results: From 250 participants, 100 replied to the survey, 81% performed PCNL and 60.4% of performers had been in practice for less than 15 years. Eighty-one percent were trained in the prone position and 64% in supine. PCNL was learned during the residency in 66.7% and 2.5% had fellowship training. Prone position was the preferred decubitus for simple or complex calculi, though for obese patients there was no difference. Younger surgeons prefer supine while older surgeons prefer prone. The access was obtained by the surgeon in all cases, 96.3% use fluoroscopy and 3.7% prefer ultrasonography. Forty-seven percent use ultrasonic lithotripters and 4.1% laser. For kidney drainage, 71.6% place a nephrostomy tube. Double J stent is left in 77%. The postoperative image method was CT for 50%. Colonic injury was reported by 25%, predominantly in the senior group without statistically difference between positions.

Conclusions: From a selected group of urologists, we observe that Brazilian urologists usually gain their own access for PCNL guided by fluoroscopy. They predominantly prefer the prone position, use fascial dilators, ultrasonic lithotripters and place a nephrostomy tube when exiting the kidney. Fellowship programs, ultrasonography, flexible nephoscopy and tubeless procedures could be encouraged.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2017.0292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050544PMC
May 2018

In Vitro Evaluation of Single-Use Digital Flexible Ureteroscopes: A Practical Comparison for a Patient-Centered Approach.

J Endourol 2018 03 5;32(3):184-191. Epub 2018 Jan 5.

1 Section of Endourology, Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School , Sao Paulo, Brazil .

Objective: To compare the manufacturing and in vitro performance characteristics of two single-use flexible ureteroscopes with a permanent optical flexible ureteroscope.

Materials And Methods: Two single-use flexible ureteroscopes, LithoVue (Boston Scientific) and Pusen (1rs. generation; Zhuhai Pusen Medical Technology Company Limited, China), were tested and compared with a permanent Flex-X ureteroscope (Karl Storz, Germany) in terms of technical characteristics, optics, deflection mechanism, and additional parameters which could potentially affect surgical technique.

Results: Pusen was the lightest ureteroscope while the LithoVue had the longest working length. LithoVue had a higher resolution power than the other two ureteroscopes at all distances tested (p < 0.001). Pusen showed higher resolution than Flex-X (p < 0.01). Field of view was wider for LithoVue (87°), followed by Flex-X (85°) and Pusen (75°). Color representation was superior for Flex-X than LithoVue and then Pusen. LithoVue outperformed Pusen and Flex-X for all settings with instruments in terms of deflection loss (p < 0.01). Pusen had the highest irrigation flow (52 mL/min) with an empty working channel (p < 0.01). LithoVue and Pusen showed similar flow rates with a 200 μm (21 mL/min) and 365 μm laser fiber (7 mL/min) and 1.3F basket (18 mL/min), being superior to Flex-X (p < 0.01). With the 1.9F basket, LithoVue had superior flow rate (7 mL/min) than Pusen (3.5 mL/min) and Flex-X (4 mL/min; p = 0.01).

Conclusion: LithoVue outperformed the other ureteroscopes in terms of optical resolution, field of view, deflection capacity, and irrigation flow with larger instruments. Pusen is the lighter scope and showed better results in terms of irrigation when no instruments are in place. Flex-X was superior in terms of color representation.
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http://dx.doi.org/10.1089/end.2017.0785DOI Listing
March 2018