International Journal of Urology (2019)
14091
Original Article
Single use versus reusable digital flexible ureteroscopes: A
prospective comparative study
Jonathan Kam,1,2,3 Yuigi Yuminaga,1 Kieran Beattie,1 Koi Yi Ling,1 Mohan Arianayagam,1,4
Bertram Canagasingham,1 Richard Ferguson,1 Celalettin Varol,1,4 Mohamed Khadra,1,3 Matthew Winter1
and Raymond Ko1,3,4
1
Nepean Urology Research Group, Sydney, 2Faculty of Medicine, The University of Newcastle, Newcastle, 3Sydney Medical School,
The University of Sydney, and 4Macquarie University, Sydney, New South Wales, Australia
Abbreviations & Acronyms
$A = Australian dollars
CI = confidence interval
ECIRS = endoscopic
combined intrarenal surgery
fURS = flexible
ureteroscopes
NS = non significant
NSW = New South Wales
PCNL = percutaneous
nephrolithotomy
Correspondence: Jonathan
Kam B.Med., B.Sci. (Med)
(Hons), M.D., Department of
Urology, Gosford Hospital,
Holden Street, Gosford, NSW
2250, Australia. Email:
jonathan.s.kam@gmail.com
Received 15 January 2019;
accepted 16 July 2019.
© 2019 The Japanese Urological Association
doi: 10.1111/iju.
Objectives: To compare the performance and surgical outcomes of two different
single-use digital flexible ureteroscopes with a reusable video flexible ureteroscope.
Methods: Patients undergoing retrograde flexible ureteroscopy at Nepean Hospital,
Sydney, Australia, were included in this study. Three different flexible ureteroscopes
were used in this study: (i) single-use digital LithoVue (Boston Scientific, Marlborough,
MA, USA); (ii) single-use digital PU3022A (Pusen, Zhuhai, China); and (iii) reusable digital
URF-V2 (Olympus, Tokyo, Japan). Visibility and maneuverability was rated on a 5-point
Likert scale by the operating surgeon. Operative outcomes and complications were
collected and analyzed.
Results: A total of 150 patients were included in the present study. Of these, 141
patients had ureteroscopy for stone treatment, four for endoscopic combined intrarenal
surgery and five for diagnostic/tumor treatment. There were 55 patients in the LithoVue
group, 31 in the PU3022A group and 64 patients in the Olympus URF-V2 group. The
URF-V2 group had higher visibility scores than both the single-use scopes and higher
maneuverability scores when compared with the PU3022A. The LithoVue had higher
visibility and maneuverability scores when compared with the PU3022A. There were no
differences in operative time, rates of relook flexible ureteroscopes, scope failure or
complication rates observed.
Conclusions: Single-use digital flexible ureteroscopes have visibility and
maneuverability profiles approaching that of a reusable digital flexible ureteroscope.
Single-use flexible ureteroscopes achieve similar clinical outcomes to the more expensive
reusable versions.
Key words: endoscopes, kidney calculi, laser lithotripsy, renoscopy, ureteroscopy.
Introduction
First described in 1987, single-use digital fURS have only recently gained increasing use.1
Decreasing costs and improved performance have resulted in a higher uptake of the single-
use fURS in some major tertiary referral stone centers.2,3 Concerns over the sterilizing process
for reusable fURS and their link to the transmission of infection between patients, and an
increasing consciousness about the environmental impact of fURS4 have also elevated the
profile of single-use fURS.5 Several studies have shown that single-use fURS are becoming
more economically viable, especially in lower-volume centers and for cases with a higher risk
of damage to reusable fURS.6–8 Several studies have shown that reusable fURS suffer damage
requiring repair after 10–25 cases.9,10 Once a ureteroscope has been repaired, it is more likely
to be damaged again, requiring further repair.9 The fragility of reusable fURS can result in
significant repair costs over time, which has also driven the increased uptake of single-use
fURS in some centers.
There are many single-use digital fURS already on the market, including LithoVue (Boston
Scientific, Marlborough, MA, USA), PU3022A (Pusen, Zhuhai, China), Polyscope (Lumenis,
Yokneam, Israel, Polydiagnost, Hallbergmoos, Germany), Semi-Flex Scope (Maxiflex, Los
Angeles, CA, USA), FlexoVue (Cook Medical, Bloomington, IN, USA) and Yc-FR-A
1
J KAM ET AL.
(YouCare Tech, Wuhan, China).11 In vitro testing has shown
that single-use scopes have equivalent optics, deflection abil-
ity and working channel flow rates to more expensive reusa-
ble scopes.12–17
In vivo testing has been limited. A European multicenter
evaluation of the single-use LithoVue in 40 procedures found
that operators rated the image quality as “good” or “very
good” in 95% of cases. Maneuverability was also rated simi-
larly in 90% of these cases.2 A case–control study comparing
LithoVue with the reusable fiber-optic URF-P6 (Olympus,
Tokyo, Japan), found comparable procedural outcomes and
complication rates.3 That study also found that the overall,
mean procedure time was 10 min shorter in cases using the
LithoVue.3 A recent systematic review found no difference in
operative time, stone clearance or complications between dis-
posable and reusable fURS.18
There are currently no in vivo studies comparing the per-
formance of the different types of single-use fURS. To date,
just two studies have compared single-use scopes with mod-
ern reusable video fURS. One study of 34 patients compared
the LithoVue with the fiber-optic URF-P5/P6 (Olympus) and
the digital Flex Xc (Storz, Tuttlingen, Germany), and showed
that the LithoVue scored lower on most user comfort and
maneuverability scores.19 Another study of 136 patients
showed similar operative outcomes and complications
between the Flex Xc/X2S and LithoVue.20
The present study aimed to compare the operative perfor-
mance of two single-use digital fURS with a reusable video
fURS. We hypothesized that single-use fURS would have a
similar performance to reusable fURS with a lower scope
failure rate.
Methods
A prospective, single-center, cross-sectional study was carried
out by the Nepean Urology Research Group at Nepean
Hospital, Sydney, NSW, Australia, from January 2016 to
November 2017. Nepean Hospital is a high-volume, tertiary
referral center for complex stone disease situated in Sydney,
Australia. The inclusion criteria were: (i) patients undergoing
retrograde fURS for the management of renal calculi, tumors
and ureteric strictures or ECIRS; (ii) aged >18 years; and (iii)
able to consent in English. Institutional review board
approval for this project was authorized (project-LNR/16/
NEPEAN/36) by the NSW Health Nepean and Blue Moun-
tains Local Health District Research Committee. All proce-
dures performed in studies involving human participants were
in accordance with the ethical standards of the institutional
and/or national research committee, and with the 1964 Hel-
sinki declaration and its later amendments or comparable eth-
ical standards. Informed written consent was obtained from
all participants in this study. All patients had a preoperative
urine culture with preoperative antibiotics if required. Intraop-
erative antibiotics were given according to the Australian
Therapeutic Guidelines for all patients. The procedure was
performed by one of five urological residents or urologists.
Patients underwent retrograde fURS using one of the three
digital fURS. The first group (Disposable 1) underwent sur-
gery using the single-use LithoVue (Boston Scientific) and
2 © 2019 The Japanese Urological Association
the second group (Disposable 2) used the single-use
PU3022A (Pusen). The third group (Reusable) utilized the
reuseable digital URF-V2 (Olympus). It is not feasible to
blind surgeons to the fURS used given the nature of this
study. Selection of the fURS was based on the availability of
each type of fURS and individual operator preference on the
day of surgery.
Preoperative data on all patients were collected in a
prospectively maintained database. The number, location and
size of calculi were evaluated by computed tomography scan-
ning. Total stone burden was defined as the sum of the lar-
gest diameter of each calculi present. At the end of each
case, the surgeon was asked to rate on a 5-point Likert scale
(1, bad; 2, poor; 3, fair; 4, good; 5, very good) the visibility
and maneuverability of the fURS for each case. This subjec-
tive 5-point Likert scale was based on the original in vivo
assessment of the LithoVue ureteroscope by Doizi et al.2
Scope failure was defined as the fURS’s condition being
unsuitable to complete the procedure and a different fURS
being required to complete the case. Readmission and com-
plications within 30 days were classified according to the
Clavien–Dindo system.21,22 Subanalysis for patients undergo-
ing fURS (without concurrent PCNL) for renal calculi were
carried out to reduce heterogeneity in the sample population.
A theoretical cost analysis comparing the costs of repair of
reusable fURS with the costs of the disposable fURS was
carried out. All costings are reported in $A ($A1 is approxi-
mately $US0.75). As our institution has a no-fault institution-
wide contract for all endoscopes, it was not possible to calcu-
late the exact cost incurred for each reusable fURS repair. A
cost of $26 000 for each reusable fURS purchase and
$10 000 per major repair was selected for our theoretical
analysis, which is in line with the costs reported in other
fURS cost analysis articles.20
Data were analyzed using IBM SPSS Statistics for Win-
dows, version 24.0 (IBM Corporation, Armonk, NY, USA).
Normality tests were carried out on continuous variables.
Comparisons between multiple groups were carried out with
analysis of variance tests followed by post-hoc Tukey hon-
estly significant difference tests. Non-parametric Kruskal–
Wallis tests followed by Mann–Whitney U-tests were carried
out on variables that were not normally distributed. Categori-
cal variables were analyzed using Fisher’s exact test.
Results
A total of 150 patients were included in the present study. Of
these, 55 patients underwent retrograde fURS using Dispos-
able 1, 31 patients with Disposable 2 and 64 patients with
the Reusable fURS. There were no differences in the patient
demographics, stone number, location or stone burden
between the three groups (Table 1). A total of 141 patients
had flexible ureteroscopy for stone treatment, four for ECIRS
and five for diagnostic/tumor treatment.
Visibility and maneuverability
A representative image from all three ureteroscopes is shown
in Figure 1. There was a significant difference in the
 Comparison of flexible ureteroscopes

Table 1 Patient, stone and operative characteristics

Mean (95% CI) Disposable 1 (n = 55) Disposable 2 (n = 31) Reusable (n = 64) P-value

Age (years) 53.5 (46.2–60.7) 54.1 (46.0–62.2) 53.3 (47.6–59.0) NS

Female 14 (26%) 10 (32%) 25 (39%) NS
Surgery indication
Retrograde stone treatment 51 (93%) 27 (87%) 59 (92%) NS
PCNL (ECIRS) for stone treatment 4 (7%) 1 (3%) 1 (2%)
Diagnostic/tumor treatment 0% 3 (10%) 4 (6%)
Affected side
Left 30 (55%) 20 (64%) 34 (53%) NS
Right 25 (45%) 11 (36%) 30 (47%)
Renal abnormalities Pelvic kidney (1) 0 Pelvic kidney (1) NS
Characteristics for patients undergoing retrograde stone surgery (n = 137)
Pre-stented 40 (72%) 20 (63%) 45 (71%) NS
Ureteric access sheath used 54 (98%) 31 (100%) 64 (100%) NS
Previous flexible ureteroscopy 4 (7%) 3 (10%) 3 (5%) NS
No. stones 2.3 (1.6–2.9) 1.8 (1.5–2.2) 2.0 (1.7–2.4) NS
Total stone burden, mm (mean) 14.7 (11.2–18.1) 12.8 (9.7–15.9) 13.3 (11.0–15.6) NS
Lower pole stone treated 26 (47%) 14 (44%) 26 (41%) NS

(a) (b) (c)

Fig. 1 Comparative images from (a) LithoVue and (b) Pusen PU3022A in the same patient. Images were recorded from the LithoVue and Pusen monitor, respec-
tively. Note that both images have a bright central image with shadowing of the peripheral image. (c) A comparative image from a separate patient recorded from
the Olympus Endoscopy Tower Monitor from the Olympus URF-V2 is shown for comparison.

visibility scores (H[2] = 25.480, P < 0.001) and maneuver-
ability scores (H[2] = 25.974, P < 0.001) between the three
digital fURS groups. For visibility scores (out of a maximum
of 5 points) the Reusable fURS (4.8, 95% CI 4.7–5.0) out-
performed both the Disposable 1 (4.2, 95% CI 4.0–4.5,
U = 1286, P = 0.002) and the Disposable 2 (3.9, 95% CI
3.44–4.4, U = 421, P < 0.001; Figs 2,3). The Disposable 1
had a higher visibility score than the Disposable 2 (U = 545,
P = 0.009). The Disposable 2 (4.1, 95% CI 3.9–4.3) had a
lower maneuverability score than the Disposable 1 (4.7, 95%
CI 4.5–5.0, U = 545.5, P = 0.009) and the Reusable (4.9,
95% CI 4.8–5.0, U = 480.5, P < 0.001; Figs 2,3).
Scope failure and complications
A total of 14 fURS (9%) failed during the operations, with
no difference in the failure rate between the three groups.
There was no difference in the complication rate between the
three groups (Table 2). All three groups had one case where
a difficult to reach stone was successfully reached when
changing to a different type of scope (i.e. from disposable to
reusable and vice versa). The most common scope failure
was no image shown when the scope was plugged in (three
cases) and damage to the deflection mechanisms of the fURS
(three cases).
Subanalysis for retrograde stone surgery
A subanalysis was carried out for the 137 patients undergoing
fURS for retrograde stone surgery to decrease heterogeneity
in the patient population. The differences in maneuverability
and visibility scores between the fURS groups were similar
to the analysis of the entire patient sample. There was a sig-
nificant difference in the visibility scores (H[2] = 24.939,
P < 0.001) and maneuverability scores (H[2] = 29.889,
P < 0.001) between the three digital fURS groups. The Reu-
sable (4.8, 95% CI 4.6–4.9) outperformed both the Dispos-
able 1 (4.5, 95% CI 4.3–4.6, U = 1157, P = 0.012) and the

© 2019 The Japanese Urological Association 3

J KAM ET AL.

Visibility score 6.25 per 100 cases. At an estimated $10 000 per major
repair, this results in an estimated repair cost of $625 per
*
case. At our institution, this is approaching the cost of the
**
Disposable 2, which is approximately 50–75% of the cost of
5 ** the Disposable 1.
When capital procurement costs for the purchase of reu-
sable fURS and endoscope video display towers are consid-
4
ered, the cost per case for reusable fURS is likely to be
similar to disposable fURS, although this depends on the
3 volume of cases. For example, most centers would have at
(/5)

least four reusable fURS on the shelves. At a purchase cost

2 of ~$26 000, this results in a cost of (capital costs of four
fURS $104 000 + repair cost of $625 per case) $166 500
per 100 cases or $1665 per case for the first 100 cases,
1
with this cost decreasing with more cases being performed.
Figure 4 shows how the cost per case decreases over time
0 with more cases being performed. Thus, for high-volume
LithoVue PU3022A URF-V2 centers, disposable fURS are more economical over a per-
iod of 4 years if they are priced <$800, while for low-vol-
Fig. 2 Comparison of visibility scores between the three flexible uretero- ume institutions, they would need to be priced <$1200 to
scope groups. *P < 0.05, **P < 0.01.
be economical.

Maneuverability
Discussion
*
The present study is the first in vivo comparison of two sin-
5 * gle-use video fURS with a reusable video fURS. The results
of our study show that single-use video fURS are approach-
4 ing the performance of reusable video fURS. This study
showed there was a difference in image quality and maneu-
verability between single-use and reusable digital fURS.
3 There was also a small difference between the Disposable 1
(/5)

and Disposable 2 in terms of visibility and maneuverability.

2 The present study showed that each scope had similar surgi-
1
0 ity and image quality.2,19 Although the present study showed
LithoVue PU3022A URF-V2
Fig. 3 Comparison of maneuverability scores between the three flexible
ureteroscope groups. *P < 0.01.
Disposable 2 (3.9, 95% CI 3.5–4.2, U = 320, P < 0.001) in
visibility score ratings. The Disposable 1 had a higher visibil-
ity score than the Disposable 2 (U = 408, P = 0.003). The
Disposable 2 (4.2, 95% CI 4.0–4.3) had a lower maneuver-
ability score than the Disposable 1 (4.7, 95% CI 4.5–4.8,
U = 349, P < 0.001) and the Reusable (4.8, 95% CI 4.7–4.9,
U = 294, P < 0.001). There were no differences between the
three groups in respect to surgical operating time, time in the
operating theater, radiation dose or rate of relook fURS
required after the procedure (Table 3). There was also no dif-
ference in these areas between the five operating procedural-
ists (Table S1).
Cost analysis
During the study period, four reusable fURS required major
repair from damage during fURS, resulting in a repair rate of
cal outcomes of scope failure, rates of relook fURS, operating
time and complications.
Similar to previous studies by Doizi et al. and Bell et al.,
both single-use scopes rated highly in terms of maneuverabil-
a difference in image quality and maneuverability between
single-use and reusable scopes, as well as between the two
single-use scopes, this difference was <1 point on the 5-point
rating scale we used in this study. Whether this translates to
a clinically significant difference is debatable, given that the
different scopes had comparable surgical outcomes in our
study. Interestingly, we did not find that single-use scopes
significantly decreased operating time, like that found in the
study by Usawachintachit et al.3 Conversely, single-use fURS
use was associated with a mean operating time >10 min
greater than that of the reusable fURS group, although this
finding was not statistically significant because of a wide
range of operating times. This finding might be related to the
lower image quality scores associated with single-use fURS.
Cost is also an important aspect of single-use fURS. A
recent Australian study estimated a repair cost per case of
$695. When the purchase cost was added to this, a cost of
approximately $50 000 per 28 cases was calculated, resulting
in a purchase cost of approximately $1500 per disposable
fURS to be more economical than reusable fURS.19 A USA
study of 655 fURS also showed similar costings.20 Our

4 © 2019 The Japanese Urological Association

 Comparison of flexible ureteroscopes

Table 2 Intraoperative and postoperative complications

Disposable 1 (n = 55) Disposable 2 (n = 31) Reusable (n = 64) P-value

Loss of deflection post 1 (2%) 0% 2 (3%) NS
procedure
Scope failure 3 (5%) 6 (10%) 5 (8%) NS
• Deflection handle broke • 270 µm laser fiber would not fit • Laser broke in channel and
compromising the deflection down working channel (1) lasered through scope (1)
mechanism (1) • No image when scope plugged into • No image when scope plugged
• Scope shaft broke (1) tower (2) into tower (1)
• Unable to navigate extremes of • Unable to reach lower pole • Tension wire snapped
pelvic kidney. Stone eventually calculus- changed to Reusable (1) compromising deflection
basketed with Reusable (1) mechanism (2)
• Unable to reach lower pole –
changed to Disposable 1 (1)
Immediate complication 3 (5%) 0 1 (2%) NS
• Procedure ceased due to • Procedure ceased due to
bleeding and loss of vision (2) bleeding and loss of vision (1)
• Mild charring from scope (1)
Complications/representation 8 (15%) 9 (29%) 12 (19%) NS
(30 days)
Clavien 1 6 (11%) 6 (19%) 8 (13%) NS
• Stent irritation (5) • Flank pain post stent removal (2) • Chest pain (1)
• Prolonged stay (1) • Rapid AF (1) • Stent displacement (4)
• Stent displaced (2) • Stent irritation (3)
• Urinary retention (1)
Clavien 2 2 (4%) 3 (10%) 4 (6%) NS
• UTI (2) • Cholecystitis (1) • UTI (4)
• Epididymo-orchitis (1)
• UTI (1)
Clavien 3–5 0 0 0 NS

Table 3 Operative outcomes

Mean (95% CI) Disposable 1 (n = 55) Disposable 2 (n = 31) Reusable (n = 64) P-value

Visibility score 4.2 (4.0–4.5) 3.9 (3.44–4.4) 4.8 (4.7–5.0) P < 0.001
Disposable 1 < Reusable (P = 0.02)
Disposable 2 < Reusable (P < 0.001)
Disposable 2 < Disposable 1 (P = 0.009)
Maneuverability score 4.7 (4.5–5.0) 4.1 (3.9–4.3) 4.9 (4.8–5.0) P < 0.001
Disposable 2 < Disposable 1 (P = 0.001)
Disposable 2 < Reusable (P < 0.001)
Operative outcomes for patients undergoing retrograde stone surgery (n = 137)
No. patients 51 27 59
Visibility score (retrograde stone 4.5 (4.3–4.64) 3.9 (3.5–4.2) 4.8 (4.6–4.9) P < 0.001
surgery only) Disposable 1 < Reusable (P = 0.049)
Disposable 2 < Reusable (P < 0.001)
Disposable 2 < Disposable 1 (P < 0.001)
Maneuverability score (retrograde 4.7 (4.5–4.8) 4.2 (4.0–4.3) 4.8 (4.7–4.9) P < 0.001
stone surgery only) Disposable 2 < Disposable 1 (P = 0.002)
Disposable 2 < Reusable (P < 0.001)
Operative time (min) 86.1 (68.0–104.3) 87.0 (73.2–100.8) 72.3 (63.3–81.3) NS
Total time in operating theatre (min) 112.8 (91.4–134.2) 114 (98.2–129.8) 95.6 (85.7–105.4) NS
Total radiation screening time (s) 51.5 (35.4–67.5) 46.6 (31.4–61.8) 38.7 (10.6–66.8) NS
Radiation exposure – dose area 368.0 (193.0–545.0) 235.6 (173.2–298.0) 284.0 (150.2–417.7) NS
product (cGycm2)
Relook pyeloscopy required 7 (13%) 2 (7%) 6 (10%) NS

© 2019 The Japanese Urological Association 5

J KAM ET AL.
Cost per case
$3000
$2500
$2000
$1500
$1000
$500
1st year 2nd year 3rd year
High volume (200 cases/year) Intermediate volume (100 cases/year)
Low volume (50 cases/year)
theoretical cost analysis has shown that disposable fURS are
more economical for low-volume centers, although the cost
savings diminish over time as more cases are performed. Our
calculation showed that for low-volume centers (<50 cases/
year) disposable fURS would need to be priced <$1200 if
they replaced reusable fURS completely to be economical,
which is similar to the cost derived in the recent Australian
cost-analysis paper.19 Further studies will be required to
determine if single-use fURS can be used cost-effectively to
decrease the repair costs of expensive reusable fURS by uti-
lizing them for cases where damage to the fURS might be
expected. These would include cases such as treatment of
large calculi, inferior pole calculi, ECIRS or patients with
complicated pelvicalyceal anatomy.
One weakness of the present study is the selection of the
fURS for each case was non-randomized. Each surgeon
would select a scope based on scope availability, personal
preference and clinical case characteristics. Although there
was no significant difference in the preoperative characteris-
tics between the groups, there is a selection bias with sur-
geons choosing to use the single-use scopes for more
complex or larger stones (Disposable 1 had a higher percent-
age use for ECIRS). Furthermore, there were slightly more
single-use fURS used for lower pole calculi than reusable
fURS. This selection bias might have resulted in lower visi-
bility and maneuverability scores for the single-use fURS
groups.
A further weakness is that there is no consistently used,
validated scoring system for assessing the performance of
fURS. The 5-point Likert scale we used in the present study
was adapted from the 5-point scoring system used by Doizi
et al. for evaluation of the Disposable 1.2 Further studies will
be required to validate the use of this scoring system for
assessing fURS, as well as assessing for interobserver varia-
tion, which might confound these results.
In conclusion, the present study has that shown the perfor-
mance of single-use digital fURS is approaching that of reu-
sable digital fURS. As the cost for these single-use scopes
continues to decrease and performance improves, they offer a
feasible alternative to reusable fURS, especially in complex
stone cases where the risk of scope damage is high.
6 © 2019 The Japanese Urological Association
Fig. 4 Cost analysis per case of reusable fURS
for different volume institutions over time. This is
calculated for an institution with four
4th year
ureteroscopes with a purchase cost of $26 000
per ureteroscope and a repair cost of $625 per
case.
Acknowledgments
Boston Scientific provided five LithoVues, and CR Kennedy,
as the Australian Distributor for Pusen, provided five
PU3022As for this study. No further financial funding was
provided by any external sources. We thank Dr Sunny Nala-
venkata and Dr Nicola Jeffery from the Nepean Urology
Research Group (NURG) for their scientific support for this
study.
Conflict of interest
Dr Raymond Ko is a scientific advisor for Boston Scientific.
The other authors declare no conflict of interest.
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Supporting information
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site:
Table S1. Operative characteristics by surgeon (retrograde
stone cases only).
7