Antiretropulsive devices (ARDs) have been described since the early 2000s and offer a logical prophylactic solution to the often annoying problem of proximal migration of stone during semirigid ureteroscopy (srURS). As stated in the article, ARDs have been shown in previous reports to provide benefits of improving stone-free rates and providing potential time and cost savings. However, major cost savings may be limited to when a retropulsed stone necessitates a separate secondary procedure (Ursiny, J Urol 2013). This study is the first to address utilization of ARD on a worldwide stage. Using the Endourology Society CROES office database (URS Global Study), nearly 10,000 ureteroscopic cases were evaluated including ∼1400 wherein an ARD was utilized. As expected, the ARD improved stone migration, stone-free rates, and shorter length of stay (presumably by preventing secondary procedures) while being associated with higher rates of complication (bleeding, fever, and urinary tract infection). This is particularly important as many practice settings may not have facile access to flexible ureteroscope (because of cost or operating room setup; e.g., surgery center). Although it is beneficial to see where ARD is utilized (geographic location and patient and stone characteristics) and that it seems to be beneficial when utilized (1.6% treatment effect benefit), it would have been great if this study was able to pinpoint where ARDs are most useful; impacted stones, larger stones, stones that are in the proximal ureter? However, the design of this observational study may not have allowed for this type of controlled comparison. This is where further research should be directed, as it would help determine when it would be most cost and time efficient to open up another disposable during URS.
In our clinical practice (academic practice at tertiary care hospital), ARDs are rarely utilized. Perhaps this is because of inertia of our clinical practice/training or the ease with which a flexible ureteroscope can be accessed to retrieve a stone should it migrate into the renal pelvis. However, I am certain that if I were performing an srURS in a setting where a flexible ureteroscope is not easily available, I am more likely to utilize an ARD.
