Background: The Post-Ureteroscopic Lesion Scale (PULS) is a validated, standardised scale that classifies iatrogenic ureteral lesions during ureteroscopy (URS). Objective: To determine risk factors for the various PULS-grades caused by URS. Method: We prospectively investigated the independent influence of various risk factors in correlation with PULS-Grade 1+ and 2+ on 307 patients with ureterorenoscopic stone treatment from 14 German urologic departments. Results: The following are the outcomes of the study: 117 (38.4%) and 188 (61.6%) of the calculi (median stone size 6 mm) were found in the kidney or ureter; 70% and 82.4% underwent preoperative or postoperative ureteral stenting; 44.3 and 7.2% received laser or ballistic lithotripsy; 60% of the patients presented with PULS grade 1+ and 8% with PULS grade of 2+. Only intracorporal lithotripsy revealed a significant independent risk factor for PULS grade 1+ or 2+. Both laser and ballistic therapies raised the probability of PULS grade 1+ by the factors 3.6 (p < 0.001) and 3.9 (p = 0.021), respectively. The ORs in conjunction with PULS grade 2+ were 3.1 (p = 0.038) and 5.8 (p = 0.014) respectively. Neither endpoint exhibited a significant difference regarding the lithotripsic procedure (laser vs. ballistic). Conclusion: Intracorporal lithotripsy is associated with a significant increase in damage to the ureter; further research is needed to determine its long-term effects.

Keywords:
Nephrolithiasis, Urolithiasis, Ureteroscopy, Ureteral damage, Post-ureteroscopic lesion scale
1.
Zheng C, et al: Retrograde intrarenal surgery versus percutaneous nephrolithotomy for treatment of renal stones > 2 cm: a meta-analysis. Urol int 2014; 93: 417–424.
2.
Drake T, Grivas N, Dabestani S, et al: What are the benefits and harms of ureteroscopy compared with shock-wave lithotripsy in the treatment of upper ureteral stones? A systematic review. Eur Urol 2017; 72: 772–786.
3.
D’Addessi A, Bassi P. Ureterorenoscopy: avoiding and managing the complications. Urol int 2011; 87: 251–259.
4.
Schoenthaler M, Wilhelm K, Kuehhas FE, et al: Postureteroscopic lesion scale: a new management modified organ injury scale – evaluation in 435 ureteroscopic patients. J Endourol 2012; 26: 1425–1430.
5.
Schoenthaler M, Buchholz N, Farin E, et al: The post-ureteroscopic lesion scale (PULS): a multicenter video-based evaluation of inter-rater reliability. World J Urol 2014; 32: 1033–1040.
6.
May M, Schönthaler M, Gilfrich C, et al: [Interrater reliability and clinical impact of the post-ureteroscopic lesion scale (PULS) grading system for ureteral lesions after ureteroscopy: results of the German prospective multicenter BUSTER project]. Urologe A 2018; 57: 172–180.
7.
https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00007668& MANDANT=DGU (Accessed December 17, 2017).
8.
Babyak MA: What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med 2004; 66: 411–421.
9.
Vittinghoff E, McCulloch CE: Relaxing the rule of ten events per variable in logistic and Cox regression. Am J Epidemiol 2007; 165: 710–718.
10.
Guzelburc V, Guven S, Boz MY, et al: Intraoperative evaluation of ureteral access sheath-related injuries using post-ureteroscopic lesion scale. J Laparoendosc Adv Surg Tech A 2016; 26: 23–26.
11.
Kaler KS, Valley ZA, Bettir KC, et al: Crowdsourcing evaluation of ureteroscopic videos using the post-Uureteroscopic lesion scale (PULS) to assess ureteral injury. J Endourol 2018; 32: 275–281.
12.
El-Abd AS, Suliman MG, Abo Farha MO, et al: The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: a long-term study at two academic centres. Arab J Urol 2014; 12: 168–172.
13.
Mueller J, Riechert-Mühe N, Schrader AJ, et al. Influence of ureter stenting before ureterorenoscopic treatment of ureteral calculi. Urologe A 2014; 53: 1656–6160.
14.
Chu L, Sternberg KM, Averch TD. Preoperative stenting decreases operative time and reoperative rates of ureteroscopy. J Endourol 2011; 25: 751–754.
15.
Rubenstein RA, Zhao LC, Loeb S, Shore DM, Nadler RB: Prestenting improves ureteroscopic stone-free rates. J Endourol 2007; 21: 1277–1280.
16.
Jessen JP, Breda A, Brehmer M, et al: International collaboration in endourology: multicenter evaluation of prestenting for ureterorenoscopy. J Endourol 2; 30: 268–273.
17.
Fuller TW, Rycyna KJ, Ayyash OM, et al: Defining the rate of primary ureteroscopic failure in unstented patients: a multi-institutional study. J Endourol 2016; 30: 970–974.
18.
Alken P: Intracorporeal lithotripsy. Urolithiasis 2018; 46: 19–29.
19.
Garg S, Mandal AK, Singh SK, et al: Ureteroscopic laser lithotripsy versus ballistic lithotripsy for treatment of ureteric stones: a prospective comparative study. Urol Int 2009; 82: 341–345.
20.
Bapat SS, Pai KV, Purnapatre SS, Yadav PB, Padye AS: Comparison of holmium laser and pneumatic lithotripsy in managing upper-ureteral stones. J Endourol 2007; 21: 1425–1427.
21.
Salvadó JA, Mandujano R, Saez I, et al: Ureteroscopic lithotripsy for distal ureteral calculi: comparative evaluation of three different lithotriptors. J Endourol 2012; 26: 343–346.
22.
Kassem A, Elfayoumy H, Elsaied W, Elgammal M, Bedair A: Laser and pneumatic lithotripsy in the endoscopic management of large ureteric stones: a comparative study. Urol Int 2012; 88: 311–315.
23.
Li L, Pan Y, Weng Z, Bao W, Yu Z, Wang F: A prospective randomized trial comparing pneumatic lithotripsy and holmium laser for management of middle and distal ureteral calculi. J Endourol 2015; 29: 883–887.
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2018
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