Comparison of the safety of flexible ureteroscopy with the different irrigation methods in a 3D print kidney model

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Methods A 3D print silica gel model was used to simulate the kidney. The ureteral access sheath(UAS) was connected to the kidney model and positioned at the ureteropelvic junction. Central venous pressure tubing was connected to monitor the pressure in the renal pelvis under different conditions. 12Fr and 14Fr sheath sizes were tested with different flexible ureteroscope(fURS) sizes of 7.5, 8.5, and 9.5Fr, respectively. The irrigation was gravity-based, and the hung water heights were set at 60, 90, 120, 150, and 180 cm. A manual pumping group was also measured. Results Using a 12Fr sheath with a 9.5Fr fURS loading with no accessories resulted in IRP ranging from 8.4–17.5 cmH2O while manual pumping perfusion pressure exceeded 60 cmH2O. Loading a 200um laser fiber decreased the pressure to 6.4–10.5 cmH2O and 4.0–5.0 cmH2O when loading a stone basket. Using a 14Fr sheath with a 9.5Fr fURS resulted in an IRP of 2.5-6.0 cmH2O, compared to 17cmH2O with manual pumping. With a 12Fr sheath and a 7.5Fr fURS, the IRP ranged from 5.4–8.2 cmH2O, while manual pumping resulted in 25.5 cmH2O. With a 14Fr sheath and a 7.5Fr fURS, the IRP ranged from 1.5-4.3cmH2O, while manual pumping resulted in 9.0 cmH2O. Conclusion When using a UAS in a flexible ureteroscopy, the IRP can be maintained in a safe range with different fURS/UAS combos with a suspended water height of less than 180cm. While in specific fURS/UAS(9.5Fr/12Fr) combos, the IRP exceeded the safe limit when using manual pumping. Gravity irrigation of less than 180cm hung water height is safe in this simulated clinical experiment environment. Flexible ureteroscopy Outfow Ureteral access sheath intrarenal pressure Figures Figure 1 Figure 2 Introduction Over the last two decades, there have been significant improvements in the design and function of flexible ureteroscopes (fURS). The advances in minimally invasive endoscopy, imaging quality, and operation techniques have resulted in low complication rates and high success rates, even for kidney stones larger than 2cm dealt with fURS. As a result, flexible ureteroscopy has become the first-line treatment for kidney stones in some countries [ 1 – 3 ]. Since the introduction of the ureteral access sheath (UAS) for flexible ureteroscopy in 1974, it has been possible to quickly insert and remove the fURS from the collecting system. This results in lower intrarenal pressure and leads to a higher postoperative stone-free rate [ 4 ]. The new generation of UAS has made the procedure safer and easier to perform technically, leading to increased utilization of flexible ureteroscopy [ 5 ]. Flexible ureteroscopy is considered safe and effective, but it may cause notable intrarenal pressure(IRP), which could lead to the backflow of irrigated fluid into the pyelovenous and pyelolymphatic systems, and even retroperitoneal extravasation[ 6 ]. During the use of UAS, ureteral ischemia may occur, and the long-term clinical consequence of UAS is attributed to ureteral stenosis [ 7 , 8 ]. This study assessed the renal pelvis pressure under different working conditions using an in vitro model, considering the various fURS and UAS available in the market. The results of the in vitro model experiment will provide a reliable reference for the intrarenal pressure changes during real clinical surgery. Method The 3D silica gel kidney was printed from a high-resolution CT scan of a patient. Ethical approval for the study was obtained from the Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-sen University [2023]526 and provided written informed consent. The UAS was connected to the kidney and positioned at the junction of the ureteropelvic region. Watertightness was checked around the connection. An 18G puncture needle punctured to the renal pelvis through the upper calyx was connected to an extension tube which was routinely used to measure the central venous pressure to measure the pressure inside the model, which was considered as the IRP. The IRP was directly measured in cmH2O when the pressure reached a steady level. A plate was put under the outlet of the UAS to gather the water flushing out of the system to measure the flush rate in mL/min. (Fig. 1 ) We tested three different sizes of disposable digital fURSs with two commonly used sizes of UASs. The three ureteroscopes are Pusen PU3022A, Pusen PU3033A, and INNOVEX US31B-12 201402US. The UASs are COOK 12/14Fr and COOK 14/16Fr (Table 1 ). Table 1 Characteristics of Different Ureteroscopes and Accessories Used in the Study Ureteroscope Working channel(F) Diameter(F) Tip Shaft Proximal PU3022A 3.6 9 9.5 9.5 INNOVEX US31B-12 3.6 9.3 8.7 8.7 PU3033A 3.6 7.5 7.5 7.5 UAS Outer diameter(F) Inner diameter(F) Length(cm) COOK 14 12 45 COOK 16 14 45 Accessories True outer diameter(F) Lumenis Slimline 200 1.35 COOK NGE-022115 2.2 After the model was set up, the ureteroscope was inserted into the kidney through the UAS with the flexible part kept straight. The ureteroscope was connected to the 3000mL saline bag which was hung on the gravity stand tower to provide the gravity infusion. The gravity stand could hang the saline at different heights from 60cm to 180cm above the model to provide different pressure. Besides gravity infusion, we also tested hand-held pump infusion. With either type of infusion, we tested the intrarenal pressure when the ureteroscope was unloaded, loaded with a COOK 2.2Fr stone basket, and loaded with Lumenis SlimLine 200 laser fiber. All the tests were repeated three times. The data are presented as mean values and analyzed with GraphPad Prism 9 and IBM SPSS Statistics Version 26. Descriptive statistics are given to demonstrate the differences between each combination. Result The statistical analyses were performed to compare the measured pressure values in different infusion heights of every ureteroscope. For each ureteroscope, the Kruskal Wallis test was performed to see if there was a significant relationship, which showed that for each ureteroscope, there was a significant statistical difference (P < 0.05). Afterward, the Mann-Whitney U test was performed to reveal individually the significant differences for each infusion height and UAS combos. The intrarenal pressures and flow rates data when using different ureteroscopes in UAS of different sizes with different infusion pressures are listed in Table 2 . Table 2 The IRP when using different UAS Hung height 60 90 120 IRP FR IRP FR IRP FR UAS diameter 14 12 14 12 14 12 14 12 14 12 14 12 PU3022A Unloaded 2.5 ± 0.1 8.4 ± 0.4 27 ± 0 20 ± 0 3.0 ± 0.0 10.8 ± 0.3 39 ± 0 30 ± 0 4.0 ± 0.0 13.3 ± 0.4 48 ± 0 43 ± 0 Lumenis Slimline 200 2.0 ± 0.0 6.4 ± 0.1 14 ± 0 13 ± 0 3.0 ± 0.0 7.3 ± 0.4 18 ± 0 18 ± 0 4.0 ± 0.0 8.5 ± 0.1 24 ± 0 23 ± 0 COOK NGE-022115 1.0 ± 0.0 4.0 ± 0.0 9 ± 0 4 ± 0 1.0 ± 0.0 4.0 ± 0.1 9 ± 0 6 ± 0 1.2 ± 0.1 4.6 ± 0.0 9 ± 0 8 ± 0 PU3033A Unloaded 1.5 ± 0.1 5.4 ± 0.2 27 ± 0 21 ± 0 2.0 ± 0.1 6.1 ± 0.2 39 ± 0 31 ± 0 2.3 ± 0.1 7.7 ± 0.4 48 ± 0 43 ± 0 Lumenis Slimline 200 1.0 ± 0.0 3.6 ± 0.1 14 ± 0 14 ± 0 1.5 ± 0.1 4.6 ± 0.2 18 ± 1 18 ± 0 1.5 ± 0.0 5.2 ± 0.2 24 ± 0 24 ± 0 COOK NGE-022115 1.0 ± 0.0 3.5 ± 0.0 9 ± 0 3 ± 0 1.0 ± 0.0 3.5 ± 0.3 9 ± 0 4 ± 0 1.0 ± 0.0 3.7 ± 0.2 10 ± 1 5.5 ± 0 INNOVEX Unloaded 1.8 ± 0.1 6.5 ± 0.2 27 ± 0 22 ± 0 2.5 ± 0.0 8.4 ± 0.1 39 ± 0 32 ± 1 3.0 ± 0.0 9.6 ± 0.1 48 ± 0 43 ± 0 Lumenis Slimline 200 1.6 ± 0.1 4.8 ± 0.1 14 ± 0 14 ± 0 2.5 ± 0.0 5.8 ± 0.3 17 ± 0 18 ± 0 3.0 ± 0.0 7.0 ± 0.1 24 ± 0 24 ± 0 COOK NGE-022115 1.0 ± 0.0 3.5 ± 0.3 9 ± 0 3 ± 0 1.0 ± 0.0 4.0 ± 0.0 9 ± 0 4 ± 0 1.0 ± 0.0 4.0 ± 0.0 10 ± 1 6 ± 1 Hung height 150 180 Hand pump PU3022A Unloaded 5.2 ± 0.1 15.0 ± 0.2 59 ± 0 48 ± 1 6.0 ± 0.1 17.5 ± 0.4 61 ± 0 60 ± 0 17.0 > 60.0 Lumenis Slimline 200 4.5 ± 0.1 9.7 ± 0.1 32 ± 0 28 ± 0 5.0 ± 0.0 10.5 ± 0.3 32 ± 0 30 ± 0 17.0 48.0 ± 4.5 COOK NGE-022115 1.5 ± 0.0 5.0 ± 0.0 9 ± 1 10 ± 0 2.1 ± 0.1 5.0 ± 0.0 9 ± 1 11 ± 1 6.5 15.0 ± 2.1 PU3033A Unloaded 2.6 ± 0.1 7.6 ± 0.1 60 ± 0 52 ± 1 4.3 ± 0.1 8.2 ± 0.4 60 ± 0 61 ± 0 9.0 25.5 ± 3.1 Lumenis Slimline 200 1.8 ± 0.0 5.2 ± 0.1 30 ± 1 28 ± 0 2.2 ± 0.1 6.2 ± 0.2 30 ± 1 30 ± 0 4.5 18.0 ± 2.1 COOK NGE-022115 1.0 ± 0.0 4.0 ± 0.4 10 ± 0 8 ± 1 1.5 ± 0.0 4.0 ± 0.0 10 ± 0 8 ± 1 3.5 8.0 ± 1.0 INNOVEX Unloaded 3.5 ± 0.1 10.6 ± 0.1 59 ± 0 52 ± 1 4.3 ± 0.1 11.5 ± 0.3 61 ± 1 59 ± 0 13.5 45.0 ± 3.1 Lumenis Slimline 200 3.5 ± 0.2 8.2 ± 0.4 30 ± 0 30 ± 0 4.0 ± 0.0 8.8 ± 0.3 30 ± 1 30 ± 0 12.0 27.0 ± 2.2 COOK NGE-022115 1.6 ± 0.1 4.2 ± 0.0 10 ± 0 10 ± 0 1.7 ± 0.1 4.6 ± 0.1 10 ± 0 11 ± 1 5.5 12.0 ± 1.2 IRP, intrarenal pressures are given in cm H2O; FR, flow rates are given in mL/min; Hung heights are given in cm; UAS diameters are given in Fr The hand-held pump gets the highest IRP in all the ureteroscope and UAS combos either with or without the working accessories. When the unloaded 9.5Fr PU3022A works in the 12Fr UAS, the hand-held pump can push the IRP to over 60.0 cmH2O, which is the highest of all the groups. The unloaded INNOVEX US31B-12/12Fr UAS hand-held pump group also gets a relatively high IRP of 45.0 cmH2O while the unloaded PU3033A/12Fr UAS group reaches 25.5 cmH2O(P < 0.05). For the 14Fr hand-held pump group, all the IRP is less than 30 cmH2O. The IRP grows higher when the infusion height is higher. When using 12Fr UAS, the unloaded IRPs are 17.5, 8.2, and 11.5 cmH2O for the PU3022A, PU3033A, and INNOVEX US31B-12 ureteroscopes, when the infusion height is 180cm, which is supposed to be the highest working IRP of the model(P < 0.05). For the 14Fr UAS group, the highest IRPs are 6, 4.3, and 4.3 cmH2O for the PU3022A, PU3033A, and INNOVEX US31B-12 ureteroscopes (P < 0.05). The IRP decreases when loaded with bigger accessories. The highest IRPs of gravity infusion present in the 12Fr UAS/180cm height group, which are 10.5, 6.2, 8.8 cmH2O when loaded with laser fiber and 5.0, 4.0, 4.6 cmH2O when loaded with a stone basket or the PU3022A, PU3033A, INNOVEX US31B-12 ureteroscopes (P < 0.05). For the 12Fr/hand-held pump groups with accessories, the IRPs are 48.0, 18.0, 27.0 cmH2O when using laser fiber and 15.0, 8.0, 12.0 cmH2O when using a stone basket for the PU3022A, PU3033A, INNOVEX US31B-12 ureteroscopes. The flow rates of the same UAS for different ureteroscopes have no significant difference in the same height group (P < 0.05), and the FR becomes higher when the height is higher. The FR also decreases to a lower level when the ureteroscopes are loaded with bigger accessories. Between the 12 and 14 Fr UAS groups, the FR has a significant difference in the same height group when the ureteroscope is unloaded, and the bigger UAS has a higher FR (P 0.05). (Fig. 2 ) DISCUSSION Flexible ureteroscopy has gained popularity for the treatment of urinary stones due to its safety and flexibility. Several studies have demonstrated that fURS can achieve a comparable stone clearance rate to percutaneous nephrolithotomy in patients with multiple kidney stones of ≤ 2 cm [ 3 , 9 ]. During the procedure, a 3-liter saline bag is typically suspended to regulate the flow rate by adjusting the saline's height, which enhances visibility and clarity. Nevertheless, this practice may result in increased pressure in the renal pelvis, which can be harmful to patients. Normally, the IRP ranges from zero to a few centimeters of water columns, which is similar to the results measured in previous experiment [ 10 ]. However, when IRP exceeds 13.6 to 27.2 cmH2O, it can trigger renal-pelvic venous reflux [ 11 ]. The 18G needle was inserted into the kidney model and connected to the air through a prolonged tube to measure the IRP for its broad inner diameter which can lead to a rapid reaction to the IRP. The IRP was mainly decided on the infusion of saline into the entire upper urinary tract through the fURS and flow out of the UAS, that is the pressure needed to push the flow through the urinary system at a fixed flow rate [ 10 ]. Silica gel was chosen for its elastic modulus closest to renal tissue [ 12 ]. A study conducted by Eisner BH on the correlation between IRP and fluid absorption during ureteroscopy found that fluid absorption increased significantly when the renal pelvic pressure exceeded 55mmHg. Higher pressure during ureteroscopy was linked to higher fluid absorption [ 13 ]. These outcomes offer valuable insights into fluid dynamics throughout ureteroscopy procedures, thereby facilitating informed clinical decision-making in managing urinary stone disease. Dr. Steeve Doizi found that reducing IRP during retrograde intrarenal surgery can be achieved by using low perfusion pressure, the appropriate size of UAS or percutaneous sheath, and a skilled surgeon. Their study compared IRP during flexible ureteroscopy, mini-percutaneous nephrolithotomy, standard percutaneous nephrolithotomy, and endoscopic combined intrarenal surgery in a kidney model [ 14 ]. One step forward, our investigation presents a comprehensive analysis of the relationship between different perfusion pressures, UAS sizes, and scope size combinations. We observed that all combinations maintained a safe working intrarenal pressure of lower than 55mmHg without a hand-held pump. Our results align with those of Roshan M. Patel et al.'s study, which found that using a 12/14Fr or 14/16Fr UAS significantly reduced IRP compared to ureteroscopy without a UAS [ 15 ]. Besides, we sequentially compared the tests of gravity irrigation under different hung conditions including 60, 90, 120, 150, and 180 cm, even with a hand-held pump group, enriching the results compared with previous studies. Adequate fluid irrigation during the Holmium laser stone crushing process not only enhances visualization but also absorbs excess heat that can potentially damage the kidney. In the study conducted by Peteinaris A, it was observed that the use of a high-power Ho: YAG laser under gravity perfusion can lead to destructive thermal damage to the kidney, even with enough fluid irrigation [ 16 ]. Additionally, the use of a higher laser power results in increased heat production, which necessitates increased fluid perfusion. Consequently, increasing the height of the saline bag to enhance perfusion flow or utilizing a larger UAS with a smaller scope to increase perfusion outflow may be considered. However, our study indicates that only a larger UAS size enhances outflow, while a smaller scope size does not. However, this conclusion is only responsible for the experiment fURS/UAS combos. A bigger working channel and UAS/fURS ratio may change the conclusion. To maintain a safe internal renal temperature range, it is recommended to use cooling perfusion fluid and intermittently excite the laser or employ a low-power laser with optimal parameters to avoid an increase in internal renal temperature without requiring high perfusion flow. It has been demonstrated that using a UAS and artificial perfusion is the safest method to prevent heat damage to the kidney during surgery [ 16 ]. However, NoureldinY A, et al found in their study that artificial perfusion significantly increased the maximum intrarenal pressure during retrograde intrarenal surgery (RIRS), which can be hazardous for the patient. Additionally, the size of the UAS was found to be a factor, with larger sheaths being associated with lower maximum IRP [ 17 ]. This suggests that increasing the outer diameter of the space surrounding the flexible ureteroscope by using a larger UAS can lower the IRP, but there is also a risk of ureteric injury. Therefore, choosing an appropriate UAS size is crucial to avoid ureteral damage and maintain a low IRP while ensuring adequate flow for irrigation during RIRS [ 15 , 18 , 19 ]. Our study provides safe combinations for hand-held pumps. In detail, using a 14Fr UAS is always safe whatever the size of the fURS, while the combination of a 9.5Fr fURS and 12Fr UAS gets the highest IRP of over 60mmHg, which is unsafe. Our findings are limited by certain factors that should be taken into consideration. Firstly, this investigation utilized an in vitro simulation model of the kidney, which cannot fully represent pressure changes in real kidney. Secondly, we only examined the effects of five distinct irrigation pressures on platform IRP and FR, which only shows the IRP and FR when the system is running steady. Further research could examine the influences of alternative irrigation techniques such as automatic irrigation pumps, or study real-time IRP. In our study, we measured IRP and FR solely using three common ureteroscope sizes and two UAS sizes. Although our findings have important implications for clinical practice, including hand pumping combined with basketing to maintain safe IRP, by using a ureteral access sheath the irrigation bag is hung at different heights to maintain safe IRP, the IRP decreases lower when loaded with bigger accessories, the FR of the same UAS for different ureteroscopes have no significant difference in the same height group, the FR between 12 and 14 Fr UAS has no significant difference in different height groups, their significance requires more comprehensive research to provide clinicians with vital information for making informed decisions. Conclusion When using a UAS in a flexible ureteroscopy, the IRP can be maintained in a safe range with all tested fURS/UAS combos with a suspended water height of less than 180cm. While in specific fURS/UAS combos, the IRP exceeded the safe limit when using manual pumping. Gravity irrigation of less than 180cm hung water height is safe in this simulated clinical experiment environment. Abbreviations IRP= intrarenal pressure fURS= flexible ureteroscope UAS= ureteric access sheath RIRS=retrograde intrarenal surgery Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-sen University (IRB approval number [2023]526) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors Consent for publication Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no conflict of interest. Funding This study was funded by Key Clinical Technique of Guangzhou, China (2024CL-ZD04). Authors' contributions Baohua Bai.Shuangjian Jiang.and Junlong Zhang.Qinsong Zeng. wrote the main manuscript text and Qinsong Zeng.Chengqiang Mo. prepared figures and tables. Rongpei Wu analysed and interpreted the data. All authors reviewed the manuscript. Acknowledgements We are grateful to the Precision Medicine Laboratory for helpful discussions and helpful comments. References Sorokin I, Mamoulakis C, Miyazawa K, Rodgers A, Talati J, Lotan Y. Epidemiology of stone disease across the world. World J Urol. 2017;35(9):1301–20. Thongprayoon C, Krambeck AE, Rule AD. Determining the true burden of kidney stone disease. Nat Rev Nephrol. 2020;16(12):736–46. 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Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 20 Aug, 2024 Reviewers agreed at journal 18 Aug, 2024 Reviews received at journal 17 Aug, 2024 Reviewers agreed at journal 13 Aug, 2024 Reviews received at journal 07 Aug, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers invited by journal 29 Jul, 2024 Editor invited by journal 10 Jun, 2024 Editor assigned by journal 10 Jun, 2024 Submission checks completed at journal 10 Jun, 2024 First submitted to journal 18 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4441354","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314832184,"identity":"9f662170-9b5c-4aa2-8b79-9228eb918c92","order_by":0,"name":"Baohua Bai","email":"","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Baohua","middleName":"","lastName":"Bai","suffix":""},{"id":314832185,"identity":"a3cd8d46-813b-4f41-a5c2-d90876d32073","order_by":1,"name":"Shuangjian Jiang","email":"","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shuangjian","middleName":"","lastName":"Jiang","suffix":""},{"id":314832186,"identity":"ccc5f608-2f2c-4a72-8db2-5204f3fa8030","order_by":2,"name":"Junlong Zhang","email":"","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Junlong","middleName":"","lastName":"Zhang","suffix":""},{"id":314832187,"identity":"0d5d9e14-0d07-4329-86d5-e2a5d8b79edf","order_by":3,"name":"Qinsong Zeng","email":"","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qinsong","middleName":"","lastName":"Zeng","suffix":""},{"id":314832188,"identity":"17087a1b-735a-48a9-a09f-5b9f4f2b9a29","order_by":4,"name":"Chengqiang Mo","email":"","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chengqiang","middleName":"","lastName":"Mo","suffix":""},{"id":314832189,"identity":"c3ed05dd-6310-4126-a48f-b2401e5109fa","order_by":5,"name":"Rongpei Wu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYLCCDwwMPHxw3gEidDDOAGphI0kLMw+QIF6LwY3cZ49tc+xk2BjYn0n+bGOQ47uRwPi5AK+WdHPj3G3JQIfxmEnztjEYS95IYJaegUeL2Y00NuncbcwgLWzSjG0MiRtuJLCBnYpXi+W2eh6Yw+qJ08K47TAoxMwkgA5LMCCkxf7MM3bD3m3HeYDKjK15zkkYzjzzsFkanxbJ9jS2Bz+3Vdvzs7c/vPmjzEae73jywc/4tDDAY4SZgUWCgQGIGBgb8GtAikTmD4SUjoJRMApGwcgEAJprPgfEAM/zAAAAAElFTkSuQmCC","orcid":"","institution":"Sun Yat-sen University First Affiliated Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Rongpei","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-05-18 14:15:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4441354/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4441354/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01638-x","type":"published","date":"2024-11-06T15:58:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59046793,"identity":"de09f673-cd4c-45c6-8dd2-07b2dd1766cf","added_by":"auto","created_at":"2024-06-25 18:51:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":135078,"visible":true,"origin":"","legend":"\u003cp\u003eStudy setting\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4441354/v1/288e3db2253bd559b660b27b.jpg"},{"id":59046548,"identity":"bca68dc2-a932-4b6f-babe-2022a3485b54","added_by":"auto","created_at":"2024-06-25 18:43:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":193027,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4441354/v1/fe891a95451ddf26e7530802.jpg"},{"id":68750241,"identity":"25b2aa67-db8a-408c-8abc-42b3b7861f1b","added_by":"auto","created_at":"2024-11-11 16:11:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":879330,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4441354/v1/f60768fc-fdb3-46f5-a92f-61d713b82e21.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the safety of flexible ureteroscopy with the different irrigation methods in a 3D print kidney model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver the last two decades, there have been significant improvements in the design and function of flexible ureteroscopes (fURS). The advances in minimally invasive endoscopy, imaging quality, and operation techniques have resulted in low complication rates and high success rates, even for kidney stones larger than 2cm dealt with fURS. As a result, flexible ureteroscopy has become the first-line treatment for kidney stones in some countries [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Since the introduction of the ureteral access sheath (UAS) for flexible ureteroscopy in 1974, it has been possible to quickly insert and remove the fURS from the collecting system. This results in lower intrarenal pressure and leads to a higher postoperative stone-free rate [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The new generation of UAS has made the procedure safer and easier to perform technically, leading to increased utilization of flexible ureteroscopy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Flexible ureteroscopy is considered safe and effective, but it may cause notable intrarenal pressure(IRP), which could lead to the backflow of irrigated fluid into the pyelovenous and pyelolymphatic systems, and even retroperitoneal extravasation[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. During the use of UAS, ureteral ischemia may occur, and the long-term clinical consequence of UAS is attributed to ureteral stenosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This study assessed the renal pelvis pressure under different working conditions using an in vitro model, considering the various fURS and UAS available in the market. The results of the in vitro model experiment will provide a reliable reference for the intrarenal pressure changes during real clinical surgery.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThe 3D silica gel kidney was printed from a high-resolution CT scan of a patient. Ethical approval for the study was obtained from the Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-sen University [2023]526 and provided written informed consent. The UAS was connected to the kidney and positioned at the junction of the ureteropelvic region. Watertightness was checked around the connection. An 18G puncture needle punctured to the renal pelvis through the upper calyx was connected to an extension tube which was routinely used to measure the central venous pressure to measure the pressure inside the model, which was considered as the IRP. The IRP was directly measured in cmH2O when the pressure reached a steady level. A plate was put under the outlet of the UAS to gather the water flushing out of the system to measure the flush rate in mL/min. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) We tested three different sizes of disposable digital fURSs with two commonly used sizes of UASs. The three ureteroscopes are Pusen PU3022A, Pusen PU3033A, and INNOVEX US31B-12 201402US. The UASs are COOK 12/14Fr and COOK 14/16Fr (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Different Ureteroscopes and Accessories Used in the Study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eUreteroscope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWorking channel(F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eDiameter(F)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTip\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShaft\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProximal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePU3022A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINNOVEX US31B-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePU3033A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUAS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOuter diameter(F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eInner diameter(F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eLength(cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccessories\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTrue outer diameter(F)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter the model was set up, the ureteroscope was inserted into the kidney through the UAS with the flexible part kept straight. The ureteroscope was connected to the 3000mL saline bag which was hung on the gravity stand tower to provide the gravity infusion. The gravity stand could hang the saline at different heights from 60cm to 180cm above the model to provide different pressure. Besides gravity infusion, we also tested hand-held pump infusion. With either type of infusion, we tested the intrarenal pressure when the ureteroscope was unloaded, loaded with a COOK 2.2Fr stone basket, and loaded with Lumenis SlimLine 200 laser fiber. All the tests were repeated three times.\u003c/p\u003e \u003cp\u003eThe data are presented as mean values and analyzed with GraphPad Prism 9 and IBM SPSS Statistics Version 26. Descriptive statistics are given to demonstrate the differences between each combination.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eThe statistical analyses were performed to compare the measured pressure values in different infusion heights of every ureteroscope. For each ureteroscope, the Kruskal Wallis test was performed to see if there was a significant relationship, which showed that for each ureteroscope, there was a significant statistical difference (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Afterward, the Mann-Whitney U test was performed to reveal individually the significant differences for each infusion height and UAS combos.\u003c/p\u003e \u003cp\u003eThe intrarenal pressures and flow rates data when using different ureteroscopes in UAS of different sizes with different infusion pressures are listed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe IRP when using different UAS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHung height\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003eIRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e \u003cp\u003eFR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUAS diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePU3022A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e23\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e8\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePU3033A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e31\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e24\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eINNOVEX\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e7.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e24\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e24\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e6\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHung height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003eHand pump\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePU3022A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e32\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e48.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e9\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePU3033A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e18.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eINNOVEX\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnloaded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e45.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumenis Slimline 200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e27.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOOK NGE-022115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIRP, intrarenal pressures are given in cm H2O; FR, flow rates are given in mL/min; Hung heights are given in cm; UAS diameters are given in Fr\u003c/p\u003e \u003cp\u003eThe hand-held pump gets the highest IRP in all the ureteroscope and UAS combos either with or without the working accessories. When the unloaded 9.5Fr PU3022A works in the 12Fr UAS, the hand-held pump can push the IRP to over 60.0 cmH2O, which is the highest of all the groups. The unloaded INNOVEX US31B-12/12Fr UAS hand-held pump group also gets a relatively high IRP of 45.0 cmH2O while the unloaded PU3033A/12Fr UAS group reaches 25.5 cmH2O(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For the 14Fr hand-held pump group, all the IRP is less than 30 cmH2O. The IRP grows higher when the infusion height is higher. When using 12Fr UAS, the unloaded IRPs are 17.5, 8.2, and 11.5 cmH2O for the PU3022A, PU3033A, and INNOVEX US31B-12 ureteroscopes, when the infusion height is 180cm, which is supposed to be the highest working IRP of the model(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For the 14Fr UAS group, the highest IRPs are 6, 4.3, and 4.3 cmH2O for the PU3022A, PU3033A, and INNOVEX US31B-12 ureteroscopes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The IRP decreases when loaded with bigger accessories. The highest IRPs of gravity infusion present in the 12Fr UAS/180cm height group, which are 10.5, 6.2, 8.8 cmH2O when loaded with laser fiber and 5.0, 4.0, 4.6 cmH2O when loaded with a stone basket or the PU3022A, PU3033A, INNOVEX US31B-12 ureteroscopes (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For the 12Fr/hand-held pump groups with accessories, the IRPs are 48.0, 18.0, 27.0 cmH2O when using laser fiber and 15.0, 8.0, 12.0 cmH2O when using a stone basket for the PU3022A, PU3033A, INNOVEX US31B-12 ureteroscopes.\u003c/p\u003e \u003cp\u003eThe flow rates of the same UAS for different ureteroscopes have no significant difference in the same height group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and the FR becomes higher when the height is higher. The FR also decreases to a lower level when the ureteroscopes are loaded with bigger accessories. Between the 12 and 14 Fr UAS groups, the FR has a significant difference in the same height group when the ureteroscope is unloaded, and the bigger UAS has a higher FR (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). When the ureteroscope is loaded with laser fiber, the FR between 12 and 14 Fr UAS has no significant difference in different height groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFlexible ureteroscopy has gained popularity for the treatment of urinary stones due to its safety and flexibility. Several studies have demonstrated that fURS can achieve a comparable stone clearance rate to percutaneous nephrolithotomy in patients with multiple kidney stones of \u0026le;\u0026thinsp;2 cm [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. During the procedure, a 3-liter saline bag is typically suspended to regulate the flow rate by adjusting the saline's height, which enhances visibility and clarity. Nevertheless, this practice may result in increased pressure in the renal pelvis, which can be harmful to patients. Normally, the IRP ranges from zero to a few centimeters of water columns, which is similar to the results measured in previous experiment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, when IRP exceeds 13.6 to 27.2 cmH2O, it can trigger renal-pelvic venous reflux [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 18G needle was inserted into the kidney model and connected to the air through a prolonged tube to measure the IRP for its broad inner diameter which can lead to a rapid reaction to the IRP. The IRP was mainly decided on the infusion of saline into the entire upper urinary tract through the fURS and flow out of the UAS, that is the pressure needed to push the flow through the urinary system at a fixed flow rate [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Silica gel was chosen for its elastic modulus closest to renal tissue [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA study conducted by Eisner BH on the correlation between IRP and fluid absorption during ureteroscopy found that fluid absorption increased significantly when the renal pelvic pressure exceeded 55mmHg. Higher pressure during ureteroscopy was linked to higher fluid absorption [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These outcomes offer valuable insights into fluid dynamics throughout ureteroscopy procedures, thereby facilitating informed clinical decision-making in managing urinary stone disease. Dr. Steeve Doizi found that reducing IRP during retrograde intrarenal surgery can be achieved by using low perfusion pressure, the appropriate size of UAS or percutaneous sheath, and a skilled surgeon. Their study compared IRP during flexible ureteroscopy, mini-percutaneous nephrolithotomy, standard percutaneous nephrolithotomy, and endoscopic combined intrarenal surgery in a kidney model [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne step forward, our investigation presents a comprehensive analysis of the relationship between different perfusion pressures, UAS sizes, and scope size combinations. We observed that all combinations maintained a safe working intrarenal pressure of lower than 55mmHg without a hand-held pump. Our results align with those of Roshan M. Patel et al.'s study, which found that using a 12/14Fr or 14/16Fr UAS significantly reduced IRP compared to ureteroscopy without a UAS [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Besides, we sequentially compared the tests of gravity irrigation under different hung conditions including 60, 90, 120, 150, and 180 cm, even with a hand-held pump group, enriching the results compared with previous studies.\u003c/p\u003e \u003cp\u003eAdequate fluid irrigation during the Holmium laser stone crushing process not only enhances visualization but also absorbs excess heat that can potentially damage the kidney. In the study conducted by Peteinaris A, it was observed that the use of a high-power Ho: YAG laser under gravity perfusion can lead to destructive thermal damage to the kidney, even with enough fluid irrigation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Additionally, the use of a higher laser power results in increased heat production, which necessitates increased fluid perfusion. Consequently, increasing the height of the saline bag to enhance perfusion flow or utilizing a larger UAS with a smaller scope to increase perfusion outflow may be considered. However, our study indicates that only a larger UAS size enhances outflow, while a smaller scope size does not. However, this conclusion is only responsible for the experiment fURS/UAS combos. A bigger working channel and UAS/fURS ratio may change the conclusion. To maintain a safe internal renal temperature range, it is recommended to use cooling perfusion fluid and intermittently excite the laser or employ a low-power laser with optimal parameters to avoid an increase in internal renal temperature without requiring high perfusion flow.\u003c/p\u003e \u003cp\u003eIt has been demonstrated that using a UAS and artificial perfusion is the safest method to prevent heat damage to the kidney during surgery [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, NoureldinY A, et al found in their study that artificial perfusion significantly increased the maximum intrarenal pressure during retrograde intrarenal surgery (RIRS), which can be hazardous for the patient. Additionally, the size of the UAS was found to be a factor, with larger sheaths being associated with lower maximum IRP [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This suggests that increasing the outer diameter of the space surrounding the flexible ureteroscope by using a larger UAS can lower the IRP, but there is also a risk of ureteric injury. Therefore, choosing an appropriate UAS size is crucial to avoid ureteral damage and maintain a low IRP while ensuring adequate flow for irrigation during RIRS [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our study provides safe combinations for hand-held pumps. In detail, using a 14Fr UAS is always safe whatever the size of the fURS, while the combination of a 9.5Fr fURS and 12Fr UAS gets the highest IRP of over 60mmHg, which is unsafe.\u003c/p\u003e \u003cp\u003eOur findings are limited by certain factors that should be taken into consideration. Firstly, this investigation utilized an in vitro simulation model of the kidney, which cannot fully represent pressure changes in real kidney. Secondly, we only examined the effects of five distinct irrigation pressures on platform IRP and FR, which only shows the IRP and FR when the system is running steady. Further research could examine the influences of alternative irrigation techniques such as automatic irrigation pumps, or study real-time IRP. In our study, we measured IRP and FR solely using three common ureteroscope sizes and two UAS sizes. Although our findings have important implications for clinical practice, including hand pumping combined with basketing to maintain safe IRP, by using a ureteral access sheath the irrigation bag is hung at different heights to maintain safe IRP, the IRP decreases lower when loaded with bigger accessories, the FR of the same UAS for different ureteroscopes have no significant difference in the same height group, the FR between 12 and 14 Fr UAS has no significant difference in different height groups, their significance requires more comprehensive research to provide clinicians with vital information for making informed decisions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhen using a UAS in a flexible ureteroscopy, the IRP can be maintained in a safe range with all tested fURS/UAS combos with a suspended water height of less than 180cm. While in specific fURS/UAS combos, the IRP exceeded the safe limit when using manual pumping. Gravity irrigation of less than 180cm hung water height is safe in this simulated clinical experiment environment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\n \u003cdiv class=\"DefinitionListEntry\"\u003e\n \u003cp\u003eIRP= intrarenal pressure fURS= flexible ureteroscope\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUAS= ureteric access sheath\u003c/p\u003e\n \u003cp\u003eRIRS=retrograde intrarenal surgery\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"DefinitionListEntry\"\u003e\n \u003cdiv class=\"Description\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with Clinical Research and Animal Trials of the First Affiliated Hospital of Sun Yat-sen University (IRB approval number [2023]526) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by Key Clinical Technique of Guangzhou, China (2024CL-ZD04).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaohua Bai.Shuangjian Jiang.and Junlong Zhang.Qinsong Zeng. wrote the main manuscript text and Qinsong Zeng.Chengqiang Mo. prepared figures and tables. Rongpei Wu analysed and interpreted the data. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the Precision Medicine Laboratory for helpful discussions and helpful comments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSorokin I, Mamoulakis C, Miyazawa K, Rodgers A, Talati J, Lotan Y. Epidemiology of stone disease across the world. World J Urol. 2017;35(9):1301\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThongprayoon C, Krambeck AE, Rule AD. Determining the true burden of kidney stone disease. Nat Rev Nephrol. 2020;16(12):736\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaria-Costa G, Tsaturyan A, Peteinaris A, Faitatziadis S, Liatsikos E, Kallidonis P. Determinants of outflow rate through the ureteral access sheath during flexible ureteroscopy: an experimental in vivo study in an anesthetized porcine model. Urolithiasis, 51(1):18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakayasu H, Aso Y. Recent Development for Pyeloureteroscopy: Guide Tube Method for Its Introduction into the Ureter. J Urol. 1974;112(2):176\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazarus J, Kaestner L. Novel syphon ureteric access sheath has the potential to improve renal pressures and irrigant flow. BJU Int, 129(5):642\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBidgood WD Jr., Cuttino JT Jr., Clark RL, Volberg FM. Pyelovenous and pyelolymphatic backflow during retrograde pyelography in renal vein thrombosis. Invest Radiol. 1981;16(1):13\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTraxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol. 2013;189(2):580\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLallas CD, Auge BK, Raj GV, Santa-Cruz R, Madden JF, Preminger GM. Laser Doppler flowmetric determination of ureteral blood flow after ureteral access sheath placement. J Endourol. 2002;16(8):583\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLv G, Zhang Z, Du F, Qi W, Zhong M, Zhou Y, Zhou C, Li Y, Zhang D. Comparison of flexible ureteroscopy and mini-percutaneous nephrolithotomy in the treatment for multiple nephrolithiasis. Front Surg. 2022;9:1004432.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiil F. Pressure recordings in the upper urinary tract. Scand J Clin Lab Invest. 1953;5(4):383\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTokas T, Herrmann TRW, Skolarikos A, Nagele U, Training, Research in, Urological S, Technology G. Pressure matters: intrarenal pressures during normal and pathological conditions, and impact of increased values to renal physiology. World J Urol. 2019;37(1):125\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams F, Qiu T, Mark A, Fritz B, Kramer L, Schlager D, Wetterauer U, Miernik A, Fischer P. Soft 3D-Printed Phantom of the Human Kidney with Collecting System. Ann Biomed Eng. 2017;45(4):963\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKottooran C, Twum-Ampofo J, Lee J, Saunders J, Franco M, Budrewicz J, Eisner BH. Evaluation of fluid absorption during flexible ureteroscopy in an in vivo porcine model. BJU Int. 2023;131(2):213\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoizi S, Uzan A, Keller EX, De Coninck V, Kamkoum H, Barghouthy Y, Ventimiglia E, Traxer O. Comparison of intrapelvic pressures during flexible ureteroscopy, mini-percutaneous nephrolithotomy, standard percutaneous nephrolithotomy, and endoscopic combined intrarenal surgery in a kidney model. World J Urol. 2021;39(7):2709\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel RM, Jefferson FA, Owyong M, Hofmann M, Ayad ML, Osann K, Okhunov Z, Landman J, Clayman RV. Characterization of intracalyceal pressure during ureteroscopy. World J Urol. 2021;39(3):883\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeteinaris A, Pagonis K, Vagionis A, Adamou C, Tsaturyan A, Ballesta Mart\u0026iacute;nez B, Karpetas G, Farsari E, Liatsikos E, Kallidonis P. What is the impact of pulse modulation technology, laser settings and intraoperative irrigation conditions on the irrigation fluid temperature during flexible ureteroscopy? An in vivo experiment using artificial stones. World J Urol, 40(7):1853\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNoureldin YA, Kallidonis P, Ntasiotis P, Adamou C, Zazas E, Liatsikos EN. The Effect of Irrigation Power and Ureteral Access Sheath Diameter on the Maximal Intra-Pelvic Pressure During Ureteroscopy: In Vivo Experimental Study in a Live Anesthetized Pig. J Endourol. 2019;33(9):725\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonga M, Bodie J, Ercole B. Is there a role for small-diameter ureteral access sheaths? Impact on irrigant flow and intrapelvic pressures. Urology, 64(3):439\u0026ndash;41; discussion 441\u0026thinsp;\u0026ndash;\u0026thinsp;432.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang L, Xie G, Zheng Z, Liu W, Zhu J, Huang T, Lu Y, Cheng Y. The Effect of Ratio of Endoscope- Sheath Diameter on Intrapelvic Pressure During Flexible Ureteroscopic Lasertripsy. J Endourol. 2019;33(2):132\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Flexible ureteroscopy, Outfow, Ureteral access sheath, intrarenal pressure","lastPublishedDoi":"10.21203/rs.3.rs-4441354/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4441354/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo compare intrarenal pressure(IRP) and irrigation flow at various suspended water heights and use hand pumping during flexible ureteroscopy in an ex vivo 3D print kidney model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 3D print silica gel model was used to simulate the kidney. The ureteral access sheath(UAS) was connected to the kidney model and positioned at the ureteropelvic junction. Central venous pressure tubing was connected to monitor the pressure in the renal pelvis under different conditions. 12Fr and 14Fr sheath sizes were tested with different flexible ureteroscope(fURS) sizes of 7.5, 8.5, and 9.5Fr, respectively. The irrigation was gravity-based, and the hung water heights were set at 60, 90, 120, 150, and 180 cm. A manual pumping group was also measured.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eUsing a 12Fr sheath with a 9.5Fr fURS loading with no accessories resulted in IRP ranging from 8.4\u0026ndash;17.5 cmH2O while manual pumping perfusion pressure exceeded 60 cmH2O. Loading a 200um laser fiber decreased the pressure to 6.4\u0026ndash;10.5 cmH2O and 4.0\u0026ndash;5.0 cmH2O when loading a stone basket. Using a 14Fr sheath with a 9.5Fr fURS resulted in an IRP of 2.5-6.0 cmH2O, compared to 17cmH2O with manual pumping. With a 12Fr sheath and a 7.5Fr fURS, the IRP ranged from 5.4\u0026ndash;8.2 cmH2O, while manual pumping resulted in 25.5 cmH2O. With a 14Fr sheath and a 7.5Fr fURS, the IRP ranged from 1.5-4.3cmH2O, while manual pumping resulted in 9.0 cmH2O.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhen using a UAS in a flexible ureteroscopy, the IRP can be maintained in a safe range with different fURS/UAS combos with a suspended water height of less than 180cm. While in specific fURS/UAS(9.5Fr/12Fr) combos, the IRP exceeded the safe limit when using manual pumping. Gravity irrigation of less than 180cm hung water height is safe in this simulated clinical experiment environment.\u003c/p\u003e","manuscriptTitle":"Comparison of the safety of flexible ureteroscopy with the different irrigation methods in a 3D print kidney model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 18:43:02","doi":"10.21203/rs.3.rs-4441354/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-20T18:24:47+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"156303854455728732494558631082055919244","date":"2024-08-18T10:02:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-17T08:37:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313880697449827265697001184780400422153","date":"2024-08-13T10:22:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-07T09:18:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98789192729685844796759613537884270439","date":"2024-07-29T09:49:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-29T08:51:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-10T14:39:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-10T14:37:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T14:36:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-05-18T14:14:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3c0e875-b523-4082-a38e-9fda0b0fd87d","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T16:06:47+00:00","versionOfRecord":{"articleIdentity":"rs-4441354","link":"https://doi.org/10.1186/s12894-024-01638-x","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-11-06 15:58:19","publishedOnDateReadable":"November 6th, 2024"},"versionCreatedAt":"2024-06-25 18:43:02","video":"","vorDoi":"10.1186/s12894-024-01638-x","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01638-x","workflowStages":[]},"version":"v1","identity":"rs-4441354","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4441354","identity":"rs-4441354","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}