Endoluminal Isoproterenol Irrigation Decreases Renal Pelvic Pressure During Flexible Ureterorenoscopy: A Clinical Randomized, Controlled Study

doi:10.1016/j.eururo.2008.03.092

European Urology

Volume 54, Issue 6, December 2008, Pages 1404-1413

https://doi.org/10.1016/j.eururo.2008.03.092 Get rights and content

Abstract

Objectives

Irrigation during ureterorenoscopic procedures causes increased pelvic pressure (PP), which may lead to intrarenal backflow with potential harmful consequences. This study aims to investigate PP response to intraluminal administration of isoproterenol (β-agonist; ISO) during flexible ureterorenoscopy.

Methods

Twelve patients admitted for retrograde intrarenal stone surgery (RIRS) were included. Patients were randomized to (1) irrigation with saline (n = 6) or (2) irrigation with ISO 0.1 μg/mL (n = 6). Irrigation rate was standardized to 8 mL/min. A ureteral catheter was retrogradely placed in the renal pelvis for PP measurements. PP, heart rate (HR), and mean arterial pressure (MAP) were also measured.

Results

Baseline PP was 12.1 ± 4 mm Hg in the saline group and 10.3 ± 4 mm Hg in the ISO group (p = 0.44).

In the saline group, PP increased to a mean 33 ± 12 mm Hg during ureterorenoscopy. In the ISO group, PP was a mean 19 ± 3 mm Hg (p = 0.029).

During endoscopy, PP peaks as high as 328 mm Hg were noted during saline irrigation. The number of pressure peaks above 50 mm Hg was minimized dramatically during ISO irrigation (p = 0.035). No systemic side effects to ISO irrigation were observed.

Conclusion

For the first time, a randomized, controlled human study demonstrates that pharmacologic modulation of the ureter is possible during upper urinary tract endoscopy. The ability to relax ureteral tone during endoscopy may have clinical advantages.

Introduction

Although the usefulness of rigid and flexible ureteroscopy (URS) in therapeutic and diagnostic indications is well known, less emphasis has been placed on the risks associated with these procedures. Occasionally, URS can be challenging in a spastic ureter, and acute dilatation of the ureter or short-term stenting may be necessary prior to instrumentation. Complications of URS include perforation, bleeding, stricture, infection, and sepsis [1], [2], [3]. Irrigation during ureteroscopic procedures increases renal pelvic pressure (PP), potentially causing intrarenal, pyelo-venous, and pyelo-lymphatic backflow as well as rupture of the collecting system. Schwalb et al showed that high-pressure irrigation during URS in pigs caused irreversible, deleterious effects in the kidney parenchyma, and it is proposed that infectious complications may result from renal extravasation [4]. The possibility of modulating upper urinary tract dynamics during endoscopy, therefore, may be of potential benefit.

In a previous randomized, controlled study in pigs, we showed that irrigation with isoproterenol (ISO) can effectively reduce renal PP during ureterorenoscopy without side effects [5]. In a human phase 2 study on potential side effects, we showed that ISO could safely be used for endoluminal administration [6]. The present study is the first clinical, randomized, controlled study that evaluates the potential for endoluminal drug administration during human ureterorenoscopy. The primary object of the study was to investigate the effect of the β-agonist ISO on PP during flexible ureterorenoscopy in patients undergoing retrograde intrarenal stone surgery (RIRS).

Section snippets

Patient selection

Patients were recruited from the Department of Urology, Fredericia and Kolding Hospitals. Twelve patients admitted for RIRS because of stones in the renal calyces or pelvis were included. Hypertensive patients and patients using α- or β-adrenergic agents or blockers or calcium antagonists were excluded. The use of non-steroidal anti-inflammatory drugs (NSAIDs) was abandoned 48 h prior to the RIRS procedure. None of the patients had JJ-stents or ureteral stones on admission for RIRS. All patients

Results

Stone size ranged from 3–9 mm, with a mean of 5.7 ± 2.9 mm. The mean PPs in both groups are presented in Table 1. The baseline PPs are measurement averages obtained prior to ureteroscopic instrumentation. Mean PPs (± SD) for each patient in the saline group and in the ISO group are shown in Fig. 1, Fig. 2, respectively.

There was no statistically significant difference in mean baseline PP between the saline group (12.1 ± 4 mm Hg) and the ISO group (10.3 ± 4 mm Hg) (p = 0.44). Mean PPs were similar in period

Discussion

Our results confirmed that endoluminal ISO 0.1 μg/mL is capable of reducing PP during flexible ureterorenoscopy. This study was a logical next step from our previous studies [5], [6]. Following the observations by Danuser and Jakobsen, who showed ISO's relaxing effect on pig ureters [7], [8], we previously proved in a randomized swine study that ISO 0.1 μg/mL significantly reduced PP during flexible ureterorenoscopy [5]. In the study on pigs, ISO irrigation was maintained for 60 min, and the

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Irrigation with isoproterenol diminishes pelvic pressure increases without side effects during ureterorenoscopy. A randomized controlled study in a porcine model

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Understanding intrarenal backflow: Intrarenal pressure during ureteroscopy and beyond
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How to measure intra-renal pressure during flexible URS: historical background, technological innovations and future perspectives
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La presión intrarrenal (PIR) alta es un factor de riesgo de complicaciones infecciosas relacionadas con la ureterorrenoscopia (URS). Aunque diversos métodos han sido descritos para reducir la PIR, todavía no es posible evaluar los valores de PIR en tiempo real durante la URS. El objetivo de este estudio es llevar a cabo una revisión sistemática de la bibliografía relativa a los métodos endoscópicos para la medición de la PIR durante la URS.
Se llevó a cabo una búsqueda y revisión sistemática en Medline, PubMed y Scopus, de acuerdo con la declaración Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA), y se redactó una síntesis narrativa de los resultados del estudio.
La investigación abarcó un total de 19 artículos. En ellos se presentaban cuatro métodos no invasivos (es decir, endoscópicos) para medir la PIR: catéter ureteral, cable sensor, sistema de irrigación con sensor de presión integrado, y una novedosa vaina de acceso ureteral que integra succión, irrigación y medición de la PIR.
El presente documento proporciona una visión global de los sistemas de medición clínica de la PIR durante la URS existentes. Aún no se ha desarrollado un sistema óptimo, pero pronto los urólogos podrán medir la PIR en su práctica diaria. Las implicaciones de esta información durante la cirugía aún se desconocen. Los sistemas capaces de integrar irrigación y succión con monitoreo de PIR y temperatura parecen ser los mejores.
High intrarenal pressure (IRP) is a potential risk factor for infectious complications related to URS. Methods to lower IRP have been described. However, it is still not possible to assess live IRP values during URS. The objective of this study was to perform a systematic review of the literature regarding endoscopic methods to measure IRP during URS.
A systematic search and review of Medline, PubMed and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta Analysis (PRISMA) checklist and a narrative synthesis of the study results was performed.
A total of 19 articles were included in the review. Four non invasive (i.e. endoscopic) methods to measure IRP were reported: ureteral catheter, sensor wire, pressure sensor proximal to an irrigation system and a novel ureteral access sheath that integrates suction, irrigation, and IRP measurement.
We provide here a comprehensive overview of the reported clinical measuring systems of IRP during URS. The ideal system has not been developed yet, but urologists will be able to measure IRP during their daily practice soon. The implications of having this type of data during surgery remains unknown. Systems that could integrate irrigation, suction, IRP and temperature seems to be ideal.
Comparison of irrigation flows between different irrigation methods for flexible ureteroscopy: An in vitro study
2022, Progres en Urologie
Citation Excerpt :
Data are presented in Table 1. Recently, attention has focused on intrarenal pressure and its levels reached during endourological procedures such as f-URS [11–24]. Some factors have been identified to impact it during f-URS such as irrigation pressure, occupation of the working channel, and use of a UAS [12–14,17,18,20–22,24].
To compare the irrigation flows between different irrigation methods for f-URS.
We compared the automatic irrigation system Endoflow II to gravity-based irrigation, and gravity-based irrigation with pressure cuff. Irrigation pressures were set at 40 and 100 cmH₂O. A LithoVue f-URS with a 3.6 Fr working channel was used for the experiments. The f-URS was placed in straight alignment without active deflection on the operating table. For each irrigation pressure level, we evaluated the influence of the occupation of the working channel of the f-URS with an empty working channel, a 272 μm laser fiber, a 1.9 Fr nitinol basket. The outflow from f-URS was measured by the volume of irrigation fluid collected using a graduated glass at 1 min, 2 min, 3 min and 5 min.
Irrigations flows remained constant over the time for the Endoflow II and the gravity-based irrigation methods regardless of the irrigation pressure and setting. For the pressure cuff method, the irrigation flow remained constant only when the working channel was occupied either by the nitinol basket or the laser fiber. Irrigation flow with the Endoflow II were constantly higher than gravity-based irrigation methods. Irrigation flow significantly increased with increased irrigation pressure. In the presence of any instruments at any irrigation pressure, the flow decreased as the size of the instrument in the working channel increased.
Automatic irrigation system Endoflow II provided higher irrigation flows than gravity-based irrigation methods. The irrigation flow decreased as the size of the instrument in the working channel increased. Further studies conducted in vivo are needed to investigate if the differences found between irrigation methods result in higher intrarenal pressure during procedures.
4.
Comparer les débits d’irrigation entre différentes méthodes d’irrigation couramment utilisées en urétéroscopie souple (URS-S).
L’URS-S LithoVue avec un CO de 3,6 Fr a été utilisé pour l’ensemble des expériences. L’URSS était maintenu rectiligne pour chacune des expériences. Pour chacune des méthodes d’irrigation étudiées (système d’irrigation automatique EndoflowII, irrigation par gravité et irrigation par gravité avec brassard à pression), les pressions d’irrigation utilisées étaient de 40 et 100 cmH₂O. Pour chaque niveau de pression d’irrigation, nous avons évalué l’influence de l’occupation du CO de l’URS-S: CO libre, CO occupé par une fibre laser de 272 μm, CO occupé par un panier en nitinol de 1,9 Fr. Le débit d’irrigation sortant de l’URS-S était mesuré par le volume de liquide d’irrigation collecté dans une éprouvette graduée à 1 min, 2 min, 3 min et 5 min.
Les débits d’irrigation étaient constants au cours du temps pour l’Endoflow II et la méthode d’irrigation par gravité, quelles que soient la pression l’irrigation et l’occupation du CO. Pour la méthode d’irrigation avec brassard de pression, le débit d’irrigation ne restait constant que lorsque le CO était occupé par le panier ou la fibre laser. Le débit d’irrigation augmentait avec l’augmentation de la pression d’irrigation pour l’ensemble des méthodes d’irrigation, quelle que soit l’occupation du CO. Le débit d’irrigation avec l’Endoflow II était constamment plus élevé que les deux autres méthodes d’irrigation. Pour l’ensemble des méthodes d’irrigation et quel que soit le niveau de pression d’irrigation, le débit d’irrigation diminuait lors de l’occupation du CO, et ce, d’autant plus que la taille de l’instrument occupant le CO augmentait.
Les débits d’irrigations avec le système d’irrigation automatique Endoflow II étaient constamment plus élevés que les méthodes d’irrigation par gravité. D’autres études, menées in vivo, sont nécessaires pour déterminer si ces différences trouvées entre les méthodes d’irrigation entraînent une augmentation de la pression pyélique pendant une URS-S.
4.
A new training model using the self-healing properties of supramolecular hydrogels for endoscopic combined intrarenal surgery
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Intrarenal pressures during flexible ureteroscopy: an insight into safer endourology
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Temperature Measurements During Flexible Ureteroscopic Laser Lithotripsy: A Prospective Clinical Trial
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Endo-urologyEndoluminal Isoproterenol Irrigation Decreases Renal Pelvic Pressure During Flexible Ureterorenoscopy: A Clinical Randomized, Controlled Study

Abstract

Objectives

Methods

Results

Conclusion

Introduction

Section snippets

Patient selection

Results

Discussion

J Urol

J Urol

J Urol

J Urol

Eur Urol

Urology

J Urol

J Urol

Complications of 2735 retrograde semirigid ureteroscopy procedures: a single-center experience

J Endourol

Comparison of outcomes of ureteroscopy for ureteral calculi located above and below the pelvic brim

Urology

Irrigation with isoproterenol diminishes pelvic pressure increases without side effects during ureterorenoscopy. A randomized controlled study in a porcine model

Scand J Urol Nephrol

Endo-urology
Endoluminal Isoproterenol Irrigation Decreases Renal Pelvic Pressure During Flexible Ureterorenoscopy: A Clinical Randomized, Controlled Study