On the day of surgery, prior to the start of the operative list, patients on the list underwent a world health organisation (WHO) style checklist with the rest of theatre and recovery team, and all high-risk patients were identified with a clear post-operative plan to manage them. Identification of pre-operative antibiotics, venous thromboembolism (VTE) prophylaxis, approximate length of the proposed procedure with any anticipated difficulties were also undertaken. Any anaesthetic or surgical concerns were highlighted to the rest of the team ensuring that all necessary theatre kits and accessories for a given case were available at hand.
A standard protocol-led procedure was carried out for every patient. Under general anaesthetic, patients had an initial cystoscopy and placement of a safety guidewire. A rigid ureteroscopy (4.5F or 6F Wolf or Storz rigid ureteroscope) was then carried out up to the renal pelvis or as far proximally as was safely achievable (or to the ureteric stone), and used to advance the second guidewire into the kidney. For renal stones, if appropriate, a ureteral access sheath (9.5F/11.5F or 12F/14F Cook Flexor sheath, size determined at the time) was introduced over a second guidewire to optimise visualisation, intrarenal pressure and to facilitate extraction of large or multiple renal stones. A flexible ureteroscopy (Storz FlexX2) and laser stone fragmentation was then carried out. All stones were managed by either laser fragmentation, basket extraction or a combination of the two, with all accessible stones fragmented to 1 or 2 mm or dust and larger fragments retrieved actively with a Cook Ngage stone extractor (Cook Medical, USA). In most cases, a 6F ureteral stent was placed post-URS and this was removed via a local anaesthetic flexible cystoscopy 1–3 weeks post-procedure. Unless clinically indicated, patients did not have a routine post-operative urethral catheter insertion and were discharged home the same day.
A standard protocol-led procedure was carried out for every patient. Under general anaesthetic, patients had an initial cystoscopy and placement of a safety guidewire. A rigid ureteroscopy (4.5F or 6F Wolf or Storz rigid ureteroscope) was then carried out up to the renal pelvis or as far proximally as was safely achievable (or to the ureteric stone), and used to advance the second guidewire into the kidney. For renal stones, if appropriate, a ureteral access sheath (9.5F/11.5F or 12F/14F Cook Flexor sheath, size determined at the time) was introduced over a second guidewire to optimise visualisation, intrarenal pressure and to facilitate extraction of large or multiple renal stones. A flexible ureteroscopy (Storz FlexX2) and laser stone fragmentation was then carried out. All stones were managed by either laser fragmentation, basket extraction or a combination of the two, with all accessible stones fragmented to 1 or 2 mm or dust and larger fragments retrieved actively with a Cook Ngage stone extractor (Cook Medical, USA). In most cases, a 6F ureteral stent was placed post-URS and this was removed via a local anaesthetic flexible cystoscopy 1–3 weeks post-procedure. Unless clinically indicated, patients did not have a routine post-operative urethral catheter insertion and were discharged home the same day.
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