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The pulsed dye laser has proved to be an effective and safe method of treating ureteric stones; 120 patients have been treated. Ureteroscopic lasertripsy (107 cases) had an overall success rate of 84%. The failures were due to mobile stones inadvertently flushed back into the kidney (14%) and 2% of patients required open ureterolithotomy after failure of two ureteroscopic procedures. "Blind" lasertripsy (13 cases) was safe but not as efficient, the success rate being only 23%.

BackgroundWhether explicit or implicit, models of value are fundamental in quality improvement (QI) initiatives. They embody the desirability of the impact of interventions—with either foresight or hindsight. Increasingly impact is articulated in terms of outcomes, which are often prescribed and sometimes inappropriate. Currently, there is little methodological guidance for deriving an appropriate set of outcomes for a given QI initiative. This paper describes a structured approach for identifying and mapping outcomes.Overall approachCentral to the approach presented here is the engagement of teams in the exploration of the system that is being designed into. This methodology has emerged from the analysis and abstraction of existing methods that define systems in terms of outcomes, stakeholders and their analogues. It is based on a sequence of questions that underpin these methods.Outcome elicitation toolsThe fundamental questions of outcome elicitation can be concatenated into a structured process, within the Outcome Identification Loop. This system-analysis process stimulates new insights that can be captured within a System Impact Model.The System Impact Model reconciles principles of intended cause/effect, with knowledge of unintended effects more typically emphasised by risk approaches. This system representation may be used to select sets of outcomes that signify the greatest impact on patients, staff and other stakeholders. It may also be used to identify potential QI interventions and to forecast their impact.Discussion and conclusionsThe Outcome Identification Loop has proven to be an effective tool for designing workshops and interviews that engage stakeholders, critically in the early stages of QI planning. By applying this process in different ways, existing knowledge is captured in System Impact Models and mobilised towards QI endeavours.

A series of experiments has transformed a kitchen blender into an instrument worthy of evaluation in all forms of endoscopie surgery, namely the patented Endoscopie Tissue Liquidiser and Aspirator (ELSA). Robotic integration has been a successful academic exercise and could be the starting point for a new initiative (e.g., robot-guided biopsy of various organs). For soft, nonfibrous tissues, the ELSA is superior to the widely acclaimed Cavitron ultrasonic surgical aspirator in open surgery and is capable of being used endoscopically. Although prostatic tissue removal is difficult, it has been accomplished clinically in four cases. Urinary stones can also be destroyed.

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