D. Duane Baldwin, MD, is an endourology/laparoscopic urology fellow and instructor of surgery, Vanderbilt University Medical Center, Nashville, TN.

D. Duane Baldwin, MD

Renal and ureteral stones are among the most commonly encountered conditions in urology. As patients increasingly become obese and morbidly obese, the incidence of nephrolithiasis will only increase. Endourology is a technologically intensive subspecialty with near continual advancement of the tools available to treat stones. In order to stay on the cutting edge of management for stones, urologists must rapidly understand and incorporate advancements in technology and technique into clinical practice. Here, these high-volume stone surgeons demonstrate novel approaches to classification, visualization, and treatment of stones. Commentary on each video is provided by 

 assistant professor of urology at the University of Michigan, Ann Arbor, and by 'Y'tube Section Editor 

 assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

 present a summary of their techniques designed to reduce radiation exposure during uncomplicated ureteroscopy. The video will show how a detailed review of preoperative imaging; use of tactile feedback and external visual cues; use of pulsed fluoroscopy if imaging should be required; use of direct vision for renal mapping; and fluoroless stent placement can all be combined in accordance with the principles of ALARA (As Low As Reasonably Achievable) to reduce radiation exposure to the patient, surgeon, and staff.

In a very nice video, Dr. Baldwin demonstrates the technique of fluoroless ureteroscopy. While some urologists may have undertaken such a method when performing ureteroscopy on pregnant patients, fluoroless ureteroscopy as a standard method is likely to raise eyebrows. I have to credit the video for providing thought-provoking content that questions the current paradigm for ureteroscopic surgery. I for one, would love to see the day when I can ditch my heavy lead apron! As the video suggests, patients with accurate pre-operative imaging, single stones, and existing indwelling ureteral stents are the most ideal candidates. However, until we are able to assess patient outcome data-both from a safety and stone clearance perspective-it remains a controversial primary technique.

While not a standard technique, fluoroless ureteroscopy is a very novel approach to safely obtaining ureteral access. Employing it in selected patient populations, as the authors suggest, definitely makes sense. Many of the described techniques, such as using a paper marker on the ureteroscope to guide choice of stent length and marking the desired length of stent, can help facilitate optimal stent placement. Perhaps most importantly, this video brilliantly illustrates how careful review of preoperative imaging can facilitate a smooth and safe endoscopic case.

Stone dusting during ureteroscopy is an emerging technique that utilizes high-watt holmium lasers to ablate stones into sub-millimeter fragments. In this video,

describes some tips and tricks for high-frequency dusting when treating renal stones, including the new technique of pop-dusting.

Stone dusting is a novel technique that can greatly facilitate the speed and, potentially, the stone-free rate, after ureteroscopy. By obviating or minimizing the need to basket multiple small fragments of stones from a complex system, dusting allows rapid disintegration of a relatively large stone burden. Here, the authors give novel techniques to position stone fragments in locations that facilitate dusting, and they also provide their preferred energy and frequency settings for various techniques.

Papillary grading system for patients with urolithiasis
	 

Technologic improvements have allowed an unprecedented ability to see within the kidney during endoscopic stone treatment. There is increasing recognition that the renal papillae of stone-forming patients frequently have unique appearances. Appreciation of these papillary changes has potential to provide meaningful clinical information, but a standardized description of papillary appearance is necessary prior to exploring possible associations with clinical outcomes, according to 

While it is recognized that the appearance of the papilla in stone-forming patients may be variable, the significance of these changes is not well understood. Are patients with certain endoscopic appearances more likely to benefit from metabolic management, or more at risk for stone recurrence? Dr. Borofsky and his colleagues have created a very elegant instructional video that establishes a new papillary grading system for patients with nephrolithiasis. The system classifies papillary appearances based on the degree of plugging, pitting, loss of contour, and amount of Randall’s plaque. This endoscopic grading system may prove to be a useful clinical and research tool, and requires further validation and study.

Here, the authors describe a novel technique to classify renal papilla appearance during endoscopy. Widespread application of this system could allow sub-stratification of stone formers into different prognostic categories and help predict treatment outcomes as well as recurrence rates.

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Articles

In these videos, high-volume stone surgeons demonstrate novel approaches to classification, visualization, and treatment of stones.

D. Duane Baldwin, MD

Articles

Ureteroscopy: Surgeons show techniques, tips in videos