2.3. General setting and surgical apparatus for URS

URS was performed under general or lumbar anesthesia in the lithotomy position. All PDD-DLA procedures were performed by a single endourologist (T.Y). The general setup is shown in Figure 1. A D-Light C system (Karl Storz, Tuttlingen, Germany) and a protoporphyrin IX excitation eyepiece filter permitting blue-violet light (SBI Pharmaceuticals, Tokyo, Japan) were used for PDD. URF-P6 or P7 (Olympus, Tokyo, Japan) and Ultrathin 6-Fr (Richard Wolf, Knittlingen, Germany) ureteroscopes were used. A UROMAT E.A.S.I. SCB device (Karl Storz) was used to adjust irrigation pressure levels to obtain an adequate irrigation flow according to the surgical procedure. Tumor extraction was performed with an N-Circle nitinol tipless stone extractor (Cook Medical, Bloomington, IN, USA). Piranha forceps (Boston Scientific, Marlborough, MA, USA) were used to perform ureteroscopic biopsy. A Revolix120 Tm:YAG laser system (LISA Laser Products, Katlenburg-Lindau, Germany) and Lumenis Pulse 120H Ho:YAG laser system (Lumenis, Yokneam Illit, Israel) were used for ablation. The laser settings were as follows: 5 W (left pedal) and 15 W (right pedal) for Tm:YAG; and 0.4 J/15 Hz in the long-pulse mode (left pedal) and 1 J/10 Hz in the short-pulse mode (right pedal) for Ho:YAG. For both laser systems, 272-μm laser fibers were used; the outer cover was peeled off to expose the tip of the quartz part (5 mm) to indicate the penetration depth (Fig. 1). For patients with proximal ureteral or renal pelvic tumors, a ureteral access sheath (10/12-, 11/13-, or 12/14-Fr) was routinely placed.

Patient positioning and surgical devices. PDD = photodynamic diagnosis.