Patent Publication Number: US-2022218367-A1

Title: Devices, systems, and methods for treating kidney stones

Description:
CROSS REFERENCE TO RELATED APPLICATION 
     This application claims priority to and the benefit of U.S. Provisional Application No. 62/841,635, filed May 1, 2019, and U.S. Provisional Application No. 62/915,149, filed Oct. 15, 2019, the contents of which are hereby incorporated by reference in their entireties. 
    
    
     FIELD 
     Provided herein are devices, systems, and methods for treating kidney stones. In particular, provided herein are endoscopic (e.g., ureteroscope) devices with improved properties, as well as systems, and related methods for use in treating kidney stones and other applications. 
     BACKGROUND 
     Kidney stone disease, also known as urolithiasis, is characterized by the presentation of a solid piece of material (known as a calculus or kidney stone) in the urinary tract. Kidney stones typically form in the kidney and leave the body in the urine stream. A small stone may pass without causing symptoms. If a stone grows to more than 5 millimeters (0.2 inches), it can cause blockage of the ureter resulting in severe pain in the lower back or abdomen. A stone may also result in blood in the urine, vomiting, or painful urination. About half of people who experience a kidney stone will have another stone within ten years. 
     Treatments for kidney stories include medical expulsive therapy (e.g., using alpha adrenergic blockers (such as tamsulosin) or calcium channel blockers (such as nifedipine)), extracorporeal shock wave lithotripsy (ESWL), ureteroscopic surgery, and percutaneous nephrolithotomy surgical procedures. 
     However, existing technologies are limited by potential side effects and incomplete stone removal. Accordingly, a need exists for improved methods of treating kidney stones. 
     SUMMARY 
     Provided herein are devices, systems, and methods for treating kidney stones. In particular, provided herein are endoscopic (e.g., ureteroscope) devices with improved properties, as well as systems, and related methods for use in treating kidney stones and other applications. 
     The devices described herein solve a number of problems with existing endoscopic devices, for example, by improving visualization of stones when an instrument is in the working channel, reducing intrarenal pressure, eliminating the need for a basket for stone repositioning, providing the option of symmetrical working channels for better targeting stones, and providing suction that sucks the stone, stabilizes the stone, and evacuates stone dust and debris. 
     For example, in some embodiments, provided herein is an endoscopic device (e.g., ureteroscope) comprising an end (e.g., tip) (e.g., defined herein as the distal end but also can be defined as the proximal end, depending on perspective), the distal end comprising: a) a first channel (e.g., configured for delivery and/or removal of fluid and a laser or configured for suction); and b) a second channel (e.g., configured for delivery of fluid and a laser or configured to remove fluid via suction), wherein the second channel exits the distal end on a different plane than the first channel (e.g., the first and second channel exits are in different planes with respect to the plane created by the distal end of the endoscopic device), and wherein the exit of the first or second channel comprises a suction port. In some embodiments, each channel has an opening substantially planar (i.e., greater than 90% of its area is on the single plane). In some embodiments, the plane of the first channel exit is in the plane of the distal end. In some embodiments, the plane of the distal end is perpendicular to the longitudinal axis of the endoscopic device. In some embodiments, the plane of the distal end is substantially perpendicular (+/−10 degrees of perpendicular) to the longitudinal axis of the longitudinal axis of the endoscopic device. 
     Further provided is an endoscopic device comprising a working (e.g., tip or distal) end, the distal end comprising: a) a first channel configured for delivery of fluid and optionally a laser; and b) a second channel configured to remove fluid via suction and optionally delivery of a laser, wherein the second channel exits the end on a different plane than the first channel and wherein the exit of the second channel comprises a suction port, and wherein the first and second channels are configured to prevent stones from occluding the suction port. 
     Also provided is an endoscopic device comprising a distal end, the distal end comprising: a) a first channel configured for delivery of fluid and optionally a laser; and b) a second channel configured to remove fluid via suction and optionally delivery of a laser, wherein the second channel exits the distal end on a different plane than the first channel and wherein the exit of the second channel comprises a suction port, wherein the suction port comprises a plurality of protrusions and/or depressions. 
     Yet other embodiments provide an endoscopic device comprising a distal end, the distal end comprising: a) a first channel configured for delivery of fluid and optionally a laser; and b) a second channel configured to remove fluid via suction and optionally delivery of a laser, wherein the second channel exits the distal end on a different plane than the first channel and wherein the exit of the second channel comprises a suction port, and wherein the suction port is on a protrusion. 
     Certain embodiments provide an endoscopic device comprising a distal end, the distal end comprising: a) a first channel having an exit in a first plane configured for delivery of fluid and optionally a laser; and b) a second channel having an exit in a second plane and wherein the exit of the second channel comprises a suction port and wherein said second channel is optionally configured for delivery of a laser. 
     In some embodiments, the distal end of the endoscopic device further comprises one or more additional components, for example, a camera and/or a light. In some embodiments, the camera is positioned above the suction port, partially above the suction port, level, partially below the suction port or below the suction port (e.g., in a cut out of the distal region). In some embodiments, the location of the camera and the light are interchangeable. In some embodiments, the light comprises a fiber optic filament or one or more LEDs. In some embodiments, the camera and the light are located proximal or distal to each other. In some embodiments, the camera is located on a plane above the plane of the working channel and/or suction port. In some embodiments, the working channel and/or suction port are angled out and away from the camera (e.g., at an angle of 20-160 degrees about an X-axis of the endoscopic device and/or 5-25 degrees about a line on the YZ-plane of the endoscopic device, although other angles are specifically contemplated). 
     In some embodiments, the endoscopic device further comprises a laser slider configured to move the laser about the longitudinal axis of the endoscopic device. In some embodiments, actuation of the laser slider unclogs stone fragments stuck in the working channel. 
     In some embodiments, the suction port comprises one or more anti-clog elements (e.g., including but not limited to, one or more of the port or channel in operable communication with the port comprising a smaller inner diameter than suction tubing in operable communication with the port, a mesh material that covers the opening, a bar or beam that covers the opening, and/or one or more protrusions or depressions adjacent to the opening). In some embodiments, the anti-clog elements prevent occlusion of the suction port, working channel or suction channel by a kidney stone or fragments thereof. In some embodiments, the distal opening of the first and/or second channel comprises a mesh or filter. In some embodiments, the filter is pivotable and/or flexible (e.g., to allow an instrument to fit through the opening) or comprises an opening for an instrument. 
     In some embodiments, the region of the distal end surrounding the suction port is flat, rounded, concave, or protruded. In some embodiments, the first and second channels are located adjacent or distal to each other. In some embodiments, the exit of the first channel and/or exit of second channel is substantially planar or substantially in the first and/or second plane. In some embodiments, the suction port and working channel are on symmetrical planes relative to the longitudinal axis of the endoscopic device. In some embodiments, the suction port and working channel are on asymmetrical planes relative to the longitudinal axis of the endoscopic device. In some embodiments, the suction port and working channel are interchangeable. In some embodiments, the channel configured for a laser is also used for removal of fluid via suction. 
     In some embodiments, the distal end further comprises one or more flow diverters configured to direct fluid flow towards the second or suction channel. In some embodiments, the flow diverter is located at the opening of the first or second channel. Devices may comprise one or more (e.g., 1, 2, 3, 4, or more) flow diverters of the same or different types located at the same or different locations relative to the first and second channels. In some embodiments, the flow diverters are in fluid communication with the first and/or second channels. 
     In some embodiments, the first and second channels have the same or different diameters. For example, in some embodiments, the first channel has an inner diameter of 0.4 to 0.6 mm (e.g., sized for a laser) and the second channel has an inner diameter of 1.1 to 1.3 mm sized for suction and/or irrigation). 
     The present disclosure is not limited to particular materials for constructing endoscopic devices or an end of the endoscopic device. In some embodiments, at least a portion of the distal end is constructed of a compliant material (e.g., including but not limited to, a silicone elastomer, a thermoplastic elastomer, or a foam). In some embodiments, the compliant material surrounds or comprises the suction port. In some embodiments, the compliant material is configured to deform to fit the shape of a kidney stone. In some embodiments, the compliant material has a Shore hardness of between OO10 and A40. In some embodiments, at least a portion of the distal end is constructed of a material selected from, for example, a thermoplastic, a metal, or a combination thereof (e.g., a material with a hardness of greater than A40 on the Shore hardness scale). 
     In some embodiments, the endoscopic device comprises an outer housing (e.g., outer housing and/or outer jacket) surrounding an interstitial space, wherein the distal end or distal portion of the endoscopic device comprises one or more interstitial flow openings in fluid communication with the interstitial space, wherein the interstitial flow openings are configured to deliver fluids or suction through such interstitial space; and a fluid port and/or suction component (e.g. located at the proximal end of the endoscopic device (e.g., in the handle) or another location). 
     Also provided herein is an endoscopic device, comprising: a) an outer housing surrounding an interstitial space, wherein the distal end or distal portion of the endoscopic device comprises one or more interstitial flow openings in fluid communication with the interstitial space, wherein the interstitial flow openings are configured to deliver fluids or suction through the interstitial space. In some embodiments, the outer housing further comprises a fluid port in fluid communication with the interstitial space. In some embodiments, the fluid port is located at the proximal end of the endoscopic device (e.g., in the handle). In some embodiments, the endoscopic device further comprises a working channel. In some embodiments, the interstitial space comprises one or more of a sensor wire, a camera wire, a pull wire, a light wire, or a fiber optic cable or wire. 
     Further provided is an endoscopic device comprising a distal end, the distal end comprising: a) a first channel or opening configured for delivery of fluid; and b) a second channel or opening configured to remove fluid via suction, wherein the second channel exits the distal end on a different plane than said first channel, and wherein the distal end further comprises one or more flow diverters, wherein the flow diverters are configured to direct fluid flow from the first channel or opening towards the second channel or opening. 
     Further embodiments provide a system, comprising: a) an endoscopic device as described herein; and b) an irrigation delivery system and a suction system. In some embodiments, the system further comprises a temperature sensor and/or pressure sensor at the distal end. In some embodiments, the system further comprises a computer system configured to adjust the irrigation delivery system and the suction system based on readings from the temperature and pressure sensors. In some embodiments, the adjusting maintains temperature and pressure of the fluid at the distal end within a range that reduces or prevents side effects due to excess pressure and/or temperature during use. In some embodiments, the adjusting increases or decreases suction to securely hold a stone and/or release a stone for repositioning within the kidney or extraction through the ureter. 
     Yet other embodiments provide a method of ablating a kidney stone, comprising: introducing an endoscopic device as described herein into the ureter of a subject; b) advancing the endoscopic device to a kidney or ureteral stone; and c) ablating the stone using the endoscopic device. 
     Additional embodiments are described herein. 
    
    
     
       DESCRIPTION OF THE DRAWINGS 
         FIG. 1A-D  show exemplary devices of embodiments of the present disclosure. 
         FIG. 2A-C  show alternative embodiments of devices of the present disclosure. 
         FIG. 3A-B  show alternative embodiments of devices of the present disclosure comprising compliant regions. 
         FIG. 4A-B  show alternative embodiments of devices of the present disclosure comprising symmetrical channels. 
         FIG. 5  shows an alternative embodiment of a device of the present disclosure. 
         FIG. 6A-C  show alternative embodiments of devices of the present disclosure comprising planar channels. 
         FIG. 7A-E  show alternative embodiments of devices of the present disclosure. 
         FIG. 8A-D  show alternative embodiments of devices of the present disclosure. 
         FIG. 9A-B  show alternative embodiments of devices of the present disclosure. 
         FIG. 10  shows a comparison of suction of model kidney stones using an existing ureteroscope (A) and a device of embodiments of the present disclosure. 
         FIG. 11  shows an exemplary system of embodiments of the present disclosure. 
         FIG. 12A-J  show alternative embodiments of devices of the present disclosure. 
         FIG. 13A-C  show an alternative embodiment of a device of the present disclosure. 
         FIG. 14  shows an alternative embodiment of a device of the present disclosure. 
         FIG. 15A-B  show alternative embodiments of devices of the present disclosure. 
         FIG. 16A-B  show alternative embodiments of devices of the present disclosure. 
         FIG. 17A-B  show alternative embodiments of devices of the present disclosure. 
         FIG. 18A-C  show alternative embodiments of devices of the present disclosure. 
         FIG. 19  shows that suction enables better stone outcomes during kidney stone removal. 
     
    
    
     DESCRIPTION 
     Provided herein are devices, systems, and methods for treating kidney stones. In particular, provided herein are endoscopic (e.g., ureteroscope) devices with improved properties, as well as systems, and related methods for use in treating kidney stones and other applications. 
     Significant absorption of irrigation fluid may occur during endoscopic stone surgery and cause hypothermia, pain, and fluid overload. Maintenance of a low intrarenal pressure may decrease the risks of these occurrences. In addition, with increasing use of high-power laser settings for lithotripsy, the potential exists to induce thermal tissue damage. In vitro studies have demonstrated that temperature elevation sufficient to cause thermal tissue damage can occur with certain laser and irrigation settings. 
     Clinicians currently address this by using a ureteral access sheath to allow fluid drainage between the sheath and the ureteroscope, as these procedures can be lengthy and prolonged high intra-renal pressures can increase the risk of hemorrhage, infection, sepsis, collecting system perforation, and fluid absorption. Other techniques, including repositioning of kidney stones from the lower pole location into an upper pole location before fragmentation and optionally extraction of the generated fragments, may improve results, as well as provide a stone sample for analysis obviating the need to employ a stone basket. 
     However, the use of a ureteral access sheath is associated with risk of injury to the ureter, extra costs and time to insert this device, and need for ureteral stent placement after its use, causing significant pain and urinary symptoms for the patient. Furthermore, use of a basket for stone repositioning and retrieval can be difficult and time consuming. 
     The present disclosure addresses these limitations by providing suction, stone stabilization, and stone removal through a suction channel of a ureteroscope. In some embodiments, provided herein is a ureteroscope comprising a distal end, the distal end comprising: a) a channel configured for delivery of one or more of fluid, suction, or a laser; and b) a further channel comprising a suction port that is configured to remove fluid via suction. In some embodiments, the channels exit the distal end of the ureteroscope on the same or different planes of plane of the distal end of the device (e.g., the plane of the distal end perpendicular to the longitudinal axis of the ureteroscope). The ureteroscope, through the configuration of the channel exits, reduces clogging of the suction port by stones or stone fragments. 
     While the present disclosure is exemplified with a ureteroscope, the compositions and methods described herein find use with any minimally invasive medical device, including but not limited to, endoscopic devices (e.g., flexible endoscopes), ureteroscopes, and the like. Exemplary devices and their use are shown in  FIGS. 1-18 . Referring to  FIG. 1A , shown is a ureteroscope tip comprising light  1 , suction port  2 , anti-clog inlet or feature  3 , working (e.g., laser and/or irrigation) channel  4 , camera  5 , and region  6 , which optionally may be made of compliant material. The dashed line represents the longitudinal axis of the ureteroscope. The working channel  4  is presented on the distal end of the ureteroscope tip in a plane perpendicular to the longitudinal axis of the ureteroscope. Suction port  2  is presented on a different plane that the working channel  4 , for example at a 20 to 70 degree angle relative to the plane of the working channel  4  (although the invention is not limited to these particular dimensional relationships). In some embodiments, the suction port  2  is on a different plane from the camera  5 . In some embodiments, this prevents the camera image from becoming blocked by a stone or stone fragments during fluid suction through the suction channel. As a stone or stones collect in front of the suction channel, they will tend to angle away from the camera field of view, helping to mitigate the full camera obstruction so the clinician can continue to see where they are in the kidney. In some embodiments, region  6  is not made of compliant material, but rather a non-compliant material. In the device shown in  FIG. 1A , the face surrounding the suction port is flat. The light  1  serves to illuminate the working area. 
     In  FIG. 1  and other images described herein, working channel  4  and other channels are exemplified as having circular, oval, or other geometries. However, the present disclosure is not limited to a particular geometry of channel, channel openings, or ports. Other shapes are specifically contemplated. For example, in some embodiments, to minimize the outer diameter of the insertable portion while maximizing the open area of the working or other channel, it may be preferable to use a non-circular cross-sectional shape. 
     The present disclosure is not limited to a particular lighting technology. In some embodiments, commercially available lights are utilized, including, for example, one or more LED lights or fiber optic filaments. In some embodiments, the light illuminates the entire circumference of ureteroscope (e.g., using fiber optic technology to generate a ring of light). 
     The working channel  4  provides a port for a laser and/or fluid delivery. In some embodiments, the channel  4  is able to accommodate both a laser and a fluid delivery component (e.g., during ablation). The present disclosure is not limited to particular types and/or sources of lasers. In some embodiments, the laser is a Holmium: Ytrrium Aluminium Garnet (Ho:YAG) laser, although other lasers such as the Thulium Fiber Laser (TFL) may be used. In some embodiments, the laser fiber is a 230 μm or 365 μm fiber, or a 150 μm fiber or smaller if using the TFL. 
     In some embodiments, the fluid delivery component is saline (e.g., in a bag) delivered via tubing. In some embodiments, the fluid delivery component is held on a stand, pressurized, or connected to an automated delivery system. 
     In some embodiments, the camera  5  provides a real-time view of the working area to the operator of the device, displayed on a user interface that may be connected by wire or wirelessly to the camera. In some embodiments, the camera is a video camera. The present disclosure is not limited to particular camera technologies. 
     In some embodiments, where the region  6  is made of compliant material, the material is selected to provide a level of compliance that allows region  6  to conform to the shape of a stone when a stone contacts region  6 . 
     The anti-clog inlet  3  (described in more detail below) prevents clogging of the suction port and/or suction channel (not shown in  FIG. 1A ) by large stones or stone fragments. 
       FIG. 1B  shows a cross-section cut-out view of the device of  FIG. 1A . Shown is light  1 , suction port  2 , anti-clog inlet  3 , working channel  4 , and suction channel  11 . The suction channel  11  and working channel continue through the device and exit the proximal end of the device (not shown). In some embodiments, the diameter of the suction channel  11  and/or working channel  4  are narrower near the distal opening as shown in  FIG. 1B . This first narrowing can assist with device assembly, providing a hard stop for tubing used for the suction channel  11  and/or working channel  4 . In some embodiments, this first narrowing matches the inner diameter of the tubing connected to the ureteroscope tip. In some embodiments, the tubing has metallic braiding (e.g., stainless steel or nitinol) in the wall to prevent distal channel kinking during ureteroscope articulation. An additional narrowing, such as seen with anti-clog inlet  3 , can be utilized to prevent stone fragments of a certain size from entering suction channel II. This can act to reduce the chances for suction channel  11  to clog with fragments during the procedure. In other embodiments, channel diameters are constant throughout the device. 
       FIG. 1C  shows an exemplary device similar to  FIG. 1A  with a rounded, concave face surrounding the suction port  2  rather than a flat face as shown in  FIG. 1A . Shown is light  1 , suction port  2 , anti-clog inlet  3 , working channel  4 , and camera  5 . In this embodiment, the working channel  4  on the rounded surface is presented on a plane substantially perpendicular to the longitudinal axis of the ureteroscope with the suction port  2  residing on a different plane. 
       FIG. 1D  shows an exemplary device similar to  FIG. 1A  where the suction port is presented on a protrusion  7  comprising suction port  2  and anti-clog inlet  3 . Placing the suction port on a protrusion aids in isolating the suction port from the camera and reduces the risk of a stone obstructing the view of the camera. In some embodiments, protrusion  7  is constructed of a compliant material. The protrusion  7  may be of any shape or length that accommodates the inlet  3 . 
     Still referring to  FIG. 1A-C , in some embodiments, the camera  5  is positioned above the surface of the suction port  2  and the suction port  2  is angled such that if a stone attaches to the suction port there is a reduced risk of vision impairment. The tip of the ureteroscope is preferably rounded and smooth to make insertion into the ureter easier. 
     Now referring to  FIG. 2A , shown is an alternative design, where a camera  5  is positioned below the suction port  2 . This allows the user to see when a stone is engaged with the suction port. Still referring to  FIG. 2A , in some embodiments, the camera is in camera cut-out region  8 . As desired, multiple cameras may be employed. Also shown in  FIG. 2A  is anti-clog inlet  3 , suction ports  2 , light  1 , and laser  9  residing in working channel  4 . Still referring to  FIG. 2A , the camera cut-out region  8  is shown as a notch in the distal end of the device. The camera  5  is shown placed at the bottom of cut-out region  8  below suction port  2 . Still referring to  FIG. 2A , suction port  2  and anti-clog inlet  3  are shown as separate openings separated by a bar  16  that lead to suction channel  11  (not shown). Still referring to  FIG. 2A , the working channel  4 , shown with laser  9 , exits the device on a different plane than suction port  2 . In this instance, suction port  2  is in a plane substantially perpendicular to the longitudinal axis of the ureteroscope and the working channel is in a non-perpendicular plane. In some embodiments, (not shown in  FIG. 2A ), the working channel is on the perpendicular plane and on a different plane than the suction port. 
       FIG. 2B  provides a transparent view of embodiment shown in  FIG. 2A , showing positioning of laser  9  in working channel  4 . Also shown is camera  5 , camera cut-out region  8 , anti-clog inlet  3 , suction ports  2 , suction channel  11 , light  1 , and laser  9 . As shown in  FIG. 2B , suction port  2  and anti-clog inlet  3  are both in fluid communication with suction channel  11 . Still referring to  FIG. 2B , laser  9  is shown inserted in working channel  4 . 
       FIG. 2C  shows an alternative embodiment where the anti-clog feature comprises a plurality of protrusions or depressions  10  surrounding the entrance of the suction port  2  that prevents the suction port from getting occluded by a kidney stone or fragment thereof. In FIG. 
       2 C, two protrusions and I depression are shown, although other configurations are specifically contemplated. The present disclosure is not limited to a particular shape or configuration of protrusions/depressions  10 . 
     In some embodiments, devices comprise symmetrical (e.g., comprising symmetry around the bending axis of the device) working channels  4  that interchangeably serve as suction or laser/irrigation channels (See e.g., below descriptions of  FIG. 3A-B  and  4 A-B). For example, in some embodiments, a user can select either channel for suction or laser/irrigation use depending on the laterality of the kidney (e.g. right or left side), region of the kidney, shape or location of stone, or other factors. This provides for improved visibility and access to stones using a single device. In some embodiments, channels are used interchangeably during a single procedure (e.g., a user switches the function of a channel during a single procedure on a single stone or multiple stones) 
     Now referring to  FIG. 3A-B , shown is an alternative embodiment of a device comprising a compliant region  6  in a suction cup shape. In some embodiments, suction cup shaped compliant region  6  is designed to conform to irregularly shaped kidney stones so they can be secured and moved to a desired location in the kidney. 
       FIG. 3A  shows a device where the compliant region  6  in a suction cup shape surrounds or comprises suction port  2 . As shown in  FIG. 3A , working channel  4  does not include a compliant region  6 . Still referring to  FIG. 3A , the suction port comprising a suction cup shaped compliant region is on a different plane than the exit of working channel  4 . Also shown is light  1  and camera  5 , which are on a different plane than suction port  2  and the same plane as the exit of working channel  4 . 
       FIG. 3B  shows an alternative device with two symmetrical working channels  4  that each comprise a suction cup shaped compliant region  6 . As shown in  FIG. 3B , the exits of symmetrical working channels  4  are on different, but symmetrical planes. In this embodiment, the exits of working channels  4  are on a plane that is not perpendicular to the longitudinal axis of the device. Also shown are light  1  and camera  5 , which are on a different plane than the exits of working channels  4 . 
     Now referring to  FIG. 4A-B , shown are exemplary devices with symmetrical working channels  4  and interchangeable light  1  and camera  5  locations. In some embodiments, the light  1  and camera  5  are independently placed in either of the locations shown as  1 ,  5  in  FIG. 4A-B . While not being limited to specific device designs, it is contemplated that devices described herein independently comprise both a camera  5  and light  1 . In symmetrical devices such as those shown in  FIG. 4A-B , the device is constructed in either of the two possible configurations for light  1  and camera  5  (e.g., the light is located at either the top or bottom location of  FIG. 4A  labeled as  1 ,  5  and the camera  5  is located at the other location not comprising a light  1 ). 
       FIG. 4A  shows a device with symmetrical working channels/suction ports  4  and interchangeable light  1  and camera  5  locations. As shown in  FIG. 4A , the exits of working channels  4  are in different, symmetrical planes on opposite sides of the device, although other symmetrical configurations are specifically contemplated. Still referring to  FIG. 4A , the exits of working channels  4  are in a plane that is not perpendicular to the longitudinal axis of the device, although other plane geometries are specifically contemplated. Still referring to  FIG. 4A , interchangeable light  1  and camera  5  locations  1 ,  5  are shown on the same plane, although other configurations are specifically contemplated. In  FIG. 4A , the light  1  and camera  5  locations are in a plane perpendicular to the longitudinal axis of the device, although other geometries are specifically contemplated. 
       FIG. 4B  shows a side view of the device of  FIG. 4A . Shown are working channels  4  and interchangeable light  1  and camera  5  locations. The side view of  FIG. 4B  illustrates the symmetry of the exits of working channels  4  around the longitudinal axis of the device. The exits of working channels  4  are perpendicular to the plane of view and are thus not visible, however the locations of the exits are labelled. Still referring to  FIG. 4B , the light  1  and camera  5  locations are also perpendicular to the plane of view and are thus not visible (see labels on  FIG. 4B  that mark the interchangeable locations of light  1  and camera  5 ). The side view further illustrates that light  1  and camera  5  are on a plane perpendicular to the longitudinal axis of the device. 
     Now referring to  FIG. 5 , shown is an alternative embodiment of a device comprising suction port  2 , working channel  4  and interchangeable light  1  and camera  5  locations that exit the distal end on a single plane that is not perpendicular to the longitudinal axis of the device. In some embodiments, the light  1 , suction port  2 , working channel  4 , and camera  5  all exit the device on the same plane. In some embodiments, the top edge of camera  5  protrudes from the plane in a perpendicular direction and thus is on a plane parallel to and above the plane that the suction port  2  and working channel  4  exit the device on, although the device is not limited to such a configuration. In some embodiments, the location of the suction port  2  and working channel  4  are switched. 
     Now referring to  FIG. 6A-C , shown is an alternative embodiment of a device where the suction port  2  and exit of working channel  4  are each substantially in a plane or are planar. As used herein, the term “substantially in a plane” or “substantially in the plane” in reference to an opening or exit of a channel or port of a device described herein refers to an opening or exit that is at least 90% (e.g., at least 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%) in a single plane (or substantial plane). For example, as shown in  FIG. 6A , the exits of working channels  4  are substantially in a single plane because the entire exit area of working channels  4  shown in  FIG. 6A  are in the plane that the opening exits the device on. This is further illustrated in the side view shown in  FIG. 6B  and the cut-out view of  FIG. 6C , where the entire opening of working channel  4  is in the plane that working channel  4  exits the device on. 
     As used herein, the term “substantially planar” when used in reference to an opening or exit of a channel or port of a device described herein refers to an opening or port that is at least 90% (e.g., at least 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%) planar throughout the entire opening or port. For example, the exits of working channels  4  shown in  FIG. 6A-C  are substantially planar (e.g., substantially in the same plane across the entire exit or opening). This definition tolerates some curvature of the opening around a plane (e.g., a curvature that follow the shape of a curved surface of the device). 
     Not all openings on the single device need to be in the same plane or a plane with the same angle relative to the longitudinal or perpendicular axis of the device in order to be individually substantially in a plane or planar. For example, in the device shown in  FIG. 6A , each of the planes that the two working channels  4  exit the device on could be at a different angle relative to the longitudinal or perpendicular axis of the device (not shown in  FIG. 6A ), and each be considered to be substantially in the plane and substantially planar. 
       FIG. 6A  shows a device comprising symmetrical working channels  4  and interchangeable light  1  and camera  5  locations. In this embodiment, the working channels are planar and substantially in a plane, although exits need not be symmetrical to be planar or in a plane. As shown in  FIG. 6A , the exits of working channels  4  are in different, symmetrical planes on opposite sides of the device, although other symmetrical (or non-symmetrical) configurations are specifically contemplated. Still referring to FIG. CA, the exits of working channels  4  are in a plane that is not perpendicular to the longitudinal axis of the device, although other plane geometries are specifically contemplated. Still referring to FIG. CA, interchangeable light  1  and camera  5  locations  1 ,  5  are shown on the same plane, although other configurations are specifically contemplated. In  FIG. 6A , the light  1  and camera  5  locations are in a plane perpendicular to the longitudinal axis of the device, although other geometries are specifically contemplated. 
       FIG. 6B  shows a side view of the device of  FIG. 6A . The exits of working channels  4  are shown as substantially in the plane. As shown, the entire exit of both working channels  4  are planar and in the plane of device. The opening or exit of working channels  4  is flush with the plane across the entire plane. The light  1  and camera  5  are in a plane perpendicular to the longitudinal axis of the device and are thus out of the field of view. 
       FIG. 6C  shows a cut-out view of the device of  FIG. 6A-B . Shown are working channels  4  and channels  11 . In this embodiment, because the working channels  4  are symmetrical, channels  11  serve interchangeably as channels for laser/irrigation or suction.  FIG. 6C  additionally illustrates that the exits of working channels  4  are planar and in the plane of the exit. Still referring to  FIG. 6C , shown is an embodiment where working channels  4  narrow near the exit, although other channel configurations are specifically contemplated. 
     Now referring to  FIG. 7A-E , shown is an alternative embodiment of a device where the camera  5  is on a plane above the working channels  4  and the working channels  4  are angled out and away from the camera (e.g., at an angle of 120-160 degrees (e.g., +/−1, 5, 10, 15, or 20%) about the X-axis, and/or 5-25 degrees (e.g., +/−1, 5, 10, 15, or 20%) about the YZ-plane, although other degrees of rotation are specifically contemplated (See e.g.,  FIG. 7C-D  for an illustration of rotations around axes of an exemplary device). In some embodiments, this configuration prevents the stone from impeding the view from the camera when the stone is engaged with the suction port or working channel. 
       FIG. 7A  shows a device with symmetrical working channels  4 , light  1 , and camera  5 . The camera  5  is on its own plane above the plane of the working channels  4  and perpendicular to the longitudinal axis of the device, although the camera need not be on a perpendicular plane. In the view shown in  FIG. 7A , the light is shown as recessed below the working channels  4  and camera  5 , although other configurations of light  1  are specifically contemplated. 
       FIG. 7B  shows a further view of the device of  FIG. 7A  from the side looking from the perspective of camera  5  down to light  1 . The view of  FIG. 7B  illustrates that the plane of camera  5  is above the plane of the light  1  and working channels  4 . The exits of working channels  4  shown in  FIG. 7A-B  are shown as symmetrical and substantially planar and substantially in the plane. 
       FIG. 7C  shows a side view of the device of  FIG. 7A-B  illustrating the 140 degree rotation of the exits of working channels  4  away from the camera  5  about the X-axis. In  FIG. 7C , the Y-axis, as labelled, points in the plane of the camera view. The X-axis, as labelled, points into the page. As shown in  FIG. 7C , the plane  18  of the exit of working channel  4  is rotated 140 degrees about the X-axis (see labels of  FIG. 7C  for directions of each axis). 
       FIG. 7D  shows a view of the device of  FIG. 7A-B  showing a 15 degree rotation of the exits of working channels  4  about a line positioned on the YZ-plane (see labels of  FIG. 7D  for directions of each axis). In order to illustrate rotation around a line on the YZ-plane, the device of  FIG. 7D  is rotated to a different view than the device of  FIG. 7C . The rotation is marked with a curve.  FIG. 7D  illustrates the rotation of the working channel  4  away from camera  5 . In combination with the rotation around the X-axis shown in  FIG. 7C , the working channel is angled and moved to improve the view from camera  5  when a stone is engaged with the working channel  4 . For example, when a stone is engaged with working channel  4 , it will not obstruct or completely obstruct the view obtained from camera  5 . 
       FIG. 7E  shows the device of FIG. A-D with a stone  19  engaged in the exit of working channel  4 . As shown, the placement of the camera  5  above the plane of the working channel  4  results in the camera having an unobstructed view of the field even when a stone  19  is engaged with the device. 
     Now referring to  FIG. 8A-D , shown are detailed schematics of the rotation angles of the device of  FIG. 7A-E  in different planes. The present disclosure is not limited to particular angles or direction of rotation of various device components. The configurations shown in  FIGS. 7 and 8  are for illustrative purposes only. Nor is it necessary that the exit of the working channel in devices shown in  FIGS. 7 and 8  be on a plane or planar. 
       FIG. 8A  shows a view of the device of  FIG. 7A-E  in two dimensions on the XY plane. The exit of the working channel  4  is on a plane  18 . The angle where plane  18  intersects the XY plane of view is labelled as α. The change in height of plane  18  relative to the plane of the camera  5  is shown as ΔY. 
       FIG. 8B  shows a view of the device of  FIG. 7A-E  in two dimensions on the XZ plane. The angle where plane  18  intersects the XZ plane of view is labelled as θ. 
       FIG. 8C  shows a view of the device of  FIG. 7A-E  in two dimensions on the YZ plane. The angle where plane  18  intersects the YZ plane of view is labelled as λ. 
       FIG. 8D  shows a three-dimensional view of the device with the working channel plane  18  shown with the XY, XZ, and YZ, planes. This image shows the rotation and corresponding rotation angles of the working channel plane  18  relative to each of the other planes. 
     Now referring the  FIG. 9A-B , shown are alternative embodiments of devices with different configurations of light  1 . In  FIGS. 1-8 , the light is illustrated as a circular light in a discrete location. However, additional shapes, designs, and configurations of lighting for devices described herein are specifically contemplated. Some examples are described herein. 
       FIG. 9A  shows a top view of a device with a non-circular shaped light  1  (shown in  FIG. 9A  as a triangle, although other shapes are specifically contemplated). Still referring to  FIG. 9A , the light is shown adjacent to camera  5 , although other locations are specifically contemplated. It is contemplated that placing the light  1  adjacent to the camera  5  (e.g., on a plane above the working channels) may improve illumination of the field of view when a stone is engaged with the suction port. 
       FIG. 9B  shows a side view of the device of  FIG. 9A . The light  1  is shown as a triangle adjacent to camera  5 . In  FIG. 9B , the exit of working channel  4  is shown on a different plane than light  1  and camera  5 . In this embodiment, the light  1  and camera  5  are on a plane perpendicular to the longitudinal axis of the device and the exit of working channel  4  is on a different plane, although other configurations are specifically contemplated. 
     The present disclosure is not limited to the light configurations shown in the drawings. In some embodiments, all or part of the device tip is illuminated instead of having a discrete light port. In some embodiments, fiber optics where the light is transmitted through the scope to the distal end of the tip are utilized to illuminate all or part of the device tip. In some embodiments, at least part of the tip is constructed from a translucent or transparent material (e.g., a colorless thermoplastic), such that the light is transmitted through the tip and illuminates the kidney for visualization. Different areas of the tip may also have a frosted surface such that the light from the fiberoptic fiber strategically disperses out and illuminates the kidney. 
     The ureteroscope tip is constructed of any suitable material. In some embodiments, the tip is constructed of rigid materials such as including but not limited to, a thermoplastic, metal, or a combination thereof. Alternatively, at least part of the ureteroscope tip may be constructed of a compliant softer material such as, including but not limited to, a silicone elastomer, thermoplastic elastomer, or a foam. For example, in some embodiments, the region around the entrance of the suction port is constructed from a compliant material (shown as optional element  6  in  FIG. 1A and 3A -B), which can at least partially deform to fit the shape of the kidney stone the user is manipulating for repositioning. In some embodiments, this region is raised up from the ureteroscope tip surface ( FIG. 1D ) or integrated into the tip surface ( FIG. 1A ). 
     In some embodiments, the compliant material has a Shore Hardness of between OO10 and A40 (See e.g., U.S. Pat. Nos. 1,770,045 and 2,421,449; each of which is herein incorporated by referent in its entirety for a discussion of Shore hardness). The Shore hardness is determined using a Shore durometer, which is a device for measuring the hardness of a material, typically of polymers, elastomers, and rubbers. Higher numbers on the scale indicate a greater resistance to indentation and thus harder materials. Lower numbers indicate less resistance and softer materials. The ASTM D2240-00 testing standard calls for a total of 12 scales, depending on the intended use: types A, B, C, D, DO, E, M, O, OO, OOO, OOO-S, and R. Each scale results in a value between 0 and 100, with higher values indicating a harder material. Each scale uses a different testing foot on the duronieter. 
     In some embodiments, other parts of the tip have a hardness greater than A40. The compliant region is, for example, formed out of a solid piece of material or have porosity or be hollow or a combination thereof. 
     In some embodiments, the suction port comprises one or more anti-clog elements. In some embodiments, the suction port comprises an anti-clog inlet shaped such that it impedes or prevents stone fragments that may get clogged within the suction tubing. This can be done, for example, by making the suction port opening more restrictive than the inside diameter of the suction tubing (e.g., by narrowing the opening, having a mesh across the opening, or having a bar or beam in front of the opening). In some embodiments (e.g.,  FIG. 2C ), the anti-clog element comprises a plurality of protrusions or depressions  10  that prevent stones from occluding the suction port  2 . 
     The suction port  2  and working channel  4  can be in any configuration or used interchangeably. For example, they can be oriented across or distal from each other ( FIG. 1A-D ) or next to each other ( FIG. 2C ) or another configuration. 
     Existing ureteroscopes and other devices rely on dedicated channels for either irrigation or suction of fluid. Especially for ureteroscopes, there is a need to minimize the outer diameter of the device since a smaller diameter ureteroscope reduces the trauma to the patient when the device is inserted into the ureter. Ureteroscope devices typically have outer diameters of approximately between 7-10 (e.g., 8-10) French (Fr). However, the smaller the outer diameter becomes, the less room there is to fit multiple dedicated working channels (e.g., one for irrigation and one for suction) 
     Accordingly, in some embodiments, provided herein is a device that overcomes this limitation by utilizing the interstitial space inside an outer housing of the device to deliver irrigation fluid at or near the tip of the device while simultaneously using the working channel for fluid suction and/or other device components. This greatly improves visualization for the procedure while enabling a smaller device outer diameter. In practice, irrigation fluid can be pressurized and flow from an inlet port in the device handle, through the interstitial space within the ureteroscope outer housing, and exit the device through the one or more interstitial flow openings. In some embodiments, these openings are at the tip of the device to help clear away debris from the field of view, although the present disclosure is not limited to a particular location. Examples include, but are not limited to, on the top surface of the tip, the side surface of the tip, through an opening on the outer housing, or a combination thereof. 
     Now referring to  FIGS. 12-13 , shown is an alternative device configuration that utilizes an outer housing and interstitial fluid openings. In some embodiments, this configuration utilizes cutouts (e.g., interstitial flow openings) placed at or near the tip (e.g., distal end) of the device to direct pressurized irrigation fluid into the kidney without disturbing the small stone fragments (e.g., improving popcorn lithotripsy efficiency). In some embodiments, this configuration utilizes cutouts (e.g., interstitial flow openings) placed at or near the tip of the device to direct pressurized irrigation fluid into the kidney to clear the small stone fragments (e.g., improving visualization). The outer housing serves as a pseudo-working channel for fluid delivery or suction. Herein, a pseudo-working channel is a channel that allows for fluid delivery and/or suction but cannot accommodate instrumentation exchanges such as passing a laser fiber or basket through the channel during the procedure since there is not a direct channel or tube connecting the interstitial flow opening(s) to a port outside of the patient (e.g. in the device handle). In some embodiments, irrigation fluid is pumped in between the inner surface of an outer housing and the outer surface of an inner working channel (e.g., via a fluid port). In some embodiments, fluid is removed through the interstitial space between the outer housing and the inner working channel (e.g., via a suction port). In some embodiments, both irrigation and suction are interchangeably applied through the interstitial space between the outer housing and the inner working channel. In some embodiments, the interstitial space and the working channel are substantially (e.g., completely or partially) fluidly separate. 
       FIG. 12A  shows perspective (left panel) and top (right panel) views of a device comprising interstitial flow openings  20 .  FIG. 12  shows two interstitial flow openings  20  located on the distal end of the device and one on the side. However, the present disclosure is not limited to such a number or configuration of interstitial flow openings  20 . For example, in some embodiments, devices comprise one or more (e.g., 1, 2, 3, 4, 5, or more) interstitial flow openings  20 . The interstitial flow openings are placed in any suitable location including but not limited to, on the tip or side of the device.  FIG. 12A  further shows outer housing  25 , light  1 , working channel  4 , camera  5 , and pressure sensor  12 . 
     The present disclosure is not limited to a particular material for outer housing  25 . In some embodiments, outer housing is constructed of one or more materials commonly used in ureteroscopes (e.g., a flexible polymer, a metal such as stainless steel, a rigid plastic, and/or a laser cut or electrical discharge manufacturing (EDM) cut hypotube). 
       FIG. 12B  shows a cut-out view of the tip of the device shown in  FIG. 12A .  FIG. 12B  illustrates an outer housing  25  surrounding interstitial space  21 . As described above, in some embodiments, the interstitial space  21  serves as a conduit to deliver irrigation to the working field (e.g., through interstitial openings (not shown in  FIG. 12B ) or to provide suction. The interstitial space  21  further provides a location for device components such as, for example, including but not limited to, pressure sensor wire  23 , camera wire  22 , and pull wires  24  (e.g., articulation pull wires). In some embodiments, interstitial space  21  further provides a location for articulation elements to allow the navigation of the tip via pull wires  24 . Also shown is working channel  4  and light  1 . 
       FIG. 12C  shows a view of the device of  FIG. 12A-B  with stone  19  engaged with working channel  4 . As shown in  FIG. 12C , an interstitial flow opening  20  is placed on the side of the device. In the embodiment shown in  FIG. 12C , the interstitial flow opening  20  is outside the area where the stone is engaged with the device, although the flow opening  20  may be placed in other suitable locations. 
       FIG. 12D  shows a view of the device of  FIG. 12A  with laser fiber  9  protruding from working channel  4  and suction port  2 .  FIG. 12D  further shows interstitial flow openings  20 , light  1 , camera  5 , and pressure sensor  12 . When in use, the laser  9  does not block camera  5  or light  1 . Interstitial openings  20  can provide irrigation and/or suction when laser  9  is in use. 
       FIG. 12E  shows a view of the device of  FIG. 12B  with laser fiber  9  protruding from working channel  4 . Working channel  4  is distinct from interstitial space  21 , which provides a location for light  1 , pressure sensor wire  23 , camera wire  22 , and pull wires  24 . Thus, the design of  FIG. 12A-E  provides two distinct channels suitable for suction and/or fluid delivery (e.g., working channel  4  and interstitial space  21 ) that are not in fluid communication with each other. 
       FIGS. 12F-J  show a device that utilizes multiple working channels and an interstitial space. In some embodiments, by way of example, a first, smaller working channel with an inner diameter channel of ˜1.5 Fr or 0.5 mm (e.g., plus or minus 5, 10, 15, 20, or 25%) is utilized for a laser fiber (˜0.4 mm OD). This working channel is of small diameter (e.g., just large enough for a laser fiber) since fluid does not need to pass through this working channel. This allows the scope outer diameter to remain small. In some embodiments, a second, larger, working channel is utilized, ˜3.6 Fr or 1.2 mm (e.g., plus or minus 5, 10, 15, 20, or 25%) inner diameter, to suck fluid through. In some embodiments, the interstitial flow opening includes a flow diverter (e.g., as shown in  FIG. 15-17 ) to help prevent clogging of the larger working channel. 
     In some embodiments, the working channel optionally includes a fragment filter/mesh to prevent fragments from entering the working channel, which may clog it. In some embodiments, the filter/mesh is optionally recessed to allow for larger fragment grabbing and extraction. In some embodiments, (e.g., as shown in  FIG. 12F ), the filter/mesh is pivotable and/or flexible to allow an instrument to pass through/past the filter unimpeded. Then when the instrument is removed, the filter/mesh moves back into place to prevent clogging in the working channel. While the filter is illustrated on the configuration shown in  FIG. 12F-J , the filter is suitable for use on any device configurations described herein. 
     In an alternative embodiment (not shown in  FIG. 12F-J ), the laser fiber is separate from any working channel and resides in the interstitial space within the pseudo working channel. In some embodiments, the laser fiber extends past the distal tip of the endoscope. 
       FIG. 12F  shows an embodiment where the device comprises interstitial openings and more than one working channel  4  (e.g., 2, 3, 4, or more).  FIG. 12F  shows a cut-out view of the distal end of such a device, For illustrative purposes,  FIG. 12F  shows two working channels  4 . Shown in  FIG. 12F  is one working channel  4  comprising laser  9  and a second working channel  4  (e.g., for suction) comprising an optional fragment filter/mesh  32  to prevent fragments from entering the working channel  4 , which may clog it. The filter/mesh  32  shown in  FIG. 12F  is optionally able to pivot (e.g., around axis  33 , although other configurations are specifically contemplated) to allow an instrument to pass through working channel  4 . Also shown is interstitial opening  20 , camera wire  22 , light  1 , and senor wire  23 . 
       FIG. 12G  shows a further cut-out view of the distal tip shown in  FIG. 12F . Shown is first working channel  4  comprising laser  9  and second working channel  4  (e.g., for providing suction and/or a basket). Interstitial space  21  is in fluid communication with interstitial opening  20  (not shown in  FIG. 12G ). 
       FIG. 12H  shows a top view of the device of  FIG. 12F . Shown is first working channel  4  comprising laser  9  and second working channel  4  (e.g., for providing suction). Also shown is interstitial opening  20 . The second working channel  4  further comprises optional filter  32 . 
       FIG. 12I  shows an additional configuration of filter  32  that allows an instrument to pass through. Shown is first working channel  4  comprising laser  9  and second working channel  4  comprising filter  32 . In  FIG. 121 , filter  32  has a narrowed rigid opening that allows an instrument to pass through. Also shown in interstitial opening  20 . 
       FIG. 12J  shows a further configuration of filter  32  that allows an instrument to pass through. Shown is first working channel  4  comprising laser  9  and second working channel  4  comprising filter  32 . In  FIG. 12J , filter  32  comprises one or more elastic elements  34  that protrude in the channel. In  FIG. 12J , 6 protrusions are shown, although other numbers may be utilized. The left panel shows working channel  4  and filter  32  without an instrument. When an instrument like a basket  35  is inserted (right panel), it pushes the elastomeric elements  34  out of the way so the instrument can pass in and out. Then, when no instrument is in place, the elastomeric elements spring back into place acting to partially occlude the channel opening minimizing clogging within working channel  4 . In some embodiments, the elastomeric elements are composed of a material such as a thermoplastic elastomer or silicone elastomer, and have a. shore A hardness between approximately  10 A and  50 A. 
     In some embodiments (e.g., those described in  FIG. 12 ), working channel  4  is used to deliver a laser  9 . However, the working channel  4  (and other channels) are also suitable for delivery of additional device components (e.g., a basket or a pair of graspers). In addition, in embodiments that utilize the interstitial space for irrigation, the working channel can be fully or partially occluded with one or more instruments while still delivering adequate irrigation at the tip of the device. 
     Now referring to  FIG. 13A , shown is a section view of an exemplary device comprising an outer housing  25  and interstitial flow openings (not shown in  FIG. 13A ). Shown are working channel  4 , suction port  2 , laser  9 , suction connection  30 , and camera  5 . Also shown in  FIG. 13A  is one or more fluid ports  26 . The one or more fluid ports  26  are located at any suitable or convenient location on the device (e.g., the handle (not shown) or other portion of the proximal (e.g., handle) or distal (e.g., tip) end). In some embodiments, devices comprise one or more fluid ports  26  that are in fluid communication with the working channel  4  and/or interstitial space  21 . For example, in some embodiments (e.g., the left fluid port  26  shown in  FIG. 13A ) the fluid port  26  is in fluid communication with the interstitial space  21  (not shown in  FIG. 13A ). The fluid port  2 . 6  provides an inlet to provide fluid and/or suction at or near the tip of the device via fluid port  26 . In some embodiments, the fluid port (e.g., the right fluid port  26  shown in  FIG. 13A ) is in fluid communication with working channel  4 . 
     Still referring to  FIG. 13A , in some embodiments, the internal components are sealed to allow irrigation to flow through the device without damaging any internal components of the device. For example, in some embodiments, a fluid port  26  in fluid communication with the interstitial space  21  comprises a fluid seal  29  between the fluid port  26  and the outer diameter of working channel  4 . Pull wires  24 , camera wire  22 , light  1 , sensor  23  (not shown in  FIG. 13A ), and other components can pass through this seal. The seal prevents fluid in interstitial space  21  from flowing into the handle of the endoscope/ureteroscope device and focuses the fluid pressure toward interstitial flow opening(s)  20 . Fluid seal  29  can be composed of multiple suitable materials such as, for example but not limited to, conformable elastomeric element(s), adhesive resin, adhesive resin with internal channels and sealant, or other combinations thereof. Some elements passing through fluid seal  29 , such as a camera wire, may not need to translate and thus are glued/sealed into place at fluid seal  29 . Other elements passing through fluid seal  29 , for example pull wires for device articulation, may need to repeatedly translate proximally and distally with respect to fluid seal  29 . In that scenario, it may be preferable to utilize, for example, elastomeric elements and/or a tubing channel with tight tolerance to the pull wire(s) and optionally a sealing lubricant (e.g., medical grade silicone grease), to generate a fluid tight seal that still allows translation of select components about the fluid seal  29 . In some embodiments, a fluid port  26  in fluid communication with working channel  4  comprises laser fiber seal  28 . In some embodiments, laser fiber seal  28  provides a fluid seal between the laser  9  and working channel  4 . This focuses the vacuum pressure at the fluid port  26  to pull fluid through the suction port  2  opening, through the working channel  4 , and into a fluid collection tank (not shown in  FIG. 13A ). In some embodiments, laser fiber seal  28  is composed of an elastomeric element and can be selectively loosened or tightened to allow repositioning of the laser  9 . 
     Still referring to  FIG. 13A , shown is laser slider  27  (described in detail in  FIG. 14 ). In some embodiments, laser slider  27  is used to optionally linearly actuate the laser fiber (e.g., in the plane of the ureteroscope). This can help unclog any stone fragments from the working channel  4  that may potentially build up and limit the suction flow. 
       FIG. 13B  shows a close-up view of fluid seal  29 . Fluid seal  29  fluidly isolates working channel  4  from the labeled fluid port  26 . In  FIG. 13B , fluid port  26  is in fluid communication with interstitial space  21  and is fluidly sealed to outer housing  25 . 
       FIG. 13C  shows a close-up view of suction connection  30 . Suction connection  30  fluidly connects working channel  4  (comprising laser fiber  9  in  FIG. 13C ) to a fluid port  26  (not shown in  FIG. 13C ). Suction connection  30  isolates working channel  4  from interstitial space  21 . In the embodiments shown in  FIG. 13C , fluid port  26  is not in fluid communication with interstitial space  21 . 
     In some embodiments, devices of the present disclosure (e.g., comprising outer housings, fluid ports, and interstitial spaces and other element described herein) are constructed de novo. In some embodiments, a commercially available ureteroscope or other devices designed to be used laparoscopically are modified to include such elements (e.g., including but not limited to, those available from Dornier MedTech, Munich, Germany or Richard Wolf, Vernon Hills, Ill.). In some embodiments, existing devices that comprise outer housings are utilized. In some embodiments, a fluid port is added to the device and the internal components are sealed to allow irrigation to flow from the fluid port (e.g., located on the handle) to the tip of the scope through the existing interstitial space. In some embodiments, one or more interstitial flow openings are added to the tip of the device to allow irrigation to be pumped into the kidney or other location. In some embodiments, this irrigation is pumped in without disturbing any stones or stone fragments present. 
     Now referring to  FIG. 14 , shown is an embodiment of a device comprising a laser slider  27 .  FIG. 14  shows a device of  FIG. 12-13  comprising a laser slider. However, the laser slider can be integrated into any number of devices described herein. The top view of  FIG. 14  shows a device comprising laser slider  27 , fluid ports  26 , working channel  4 , outer housing  25 , and laser  9 . The middle view of  FIG. 14  shows laser slider  27  in normal configuration (e.g., not in use). It is pushed forward and the tip of laser  9  extends beyond the distal tip of the ureteroscope so it can ablate kidney stones. In the bottom view of  FIG. 14 , laser slider  27  is actuated to move laser fiber  9  proximally toward the ureteroscope handle. The laser slider  27  can then be returned to its original position to move the laser fiber back into proper position for kidney stone ablation. In some embodiments, the actuation is repeated one or more times in order to dislodge any stones in working channel  4 . 
     Now referring to  FIG. 15-18 , shown are alternate configurations of devices that comprise flow diverters in or adjacent to the irrigation/suction/working channels. In some embodiments, the flow diverter directs irrigation flow towards, across, and/or through a suction opening (e.g., working channel). In some embodiments, the flow diverter functions as a fluidic particle filter. For example, directing irrigation flow near or across the suction opening redirects or filters out larger stone particles or fragments, which could tend to clog or obstruct the suction channel. For example, with a 3.6 Fr (1.2 mm) diameter working channel, a 0.4 mm diameter laser fiber inserted into the working channel, and suction being pulled on the working channel, it is advantageous to only allow stone fragments or particles that are below approximately 0.3 mm in diameter to enter the device working channel, although different size channels are specifically contemplated. This helps to ensure that the particles are sucked through the working channel and out of the scope without having to remove the laser fiber. This is advantageous from a procedural standpoint since the clinician does not have to pause the lithotripsy procedure in order to clear their vision of particles floating in their field of view. 
     It is also useful to balance the irrigation flowrate and the suction flowrate. A higher irrigation rate pushes particles and fragments away from the scope/suction opening, while a higher suction flowrate pulls particles and fragments toward the scope/suction opening. For kidney stone dusting, preferred irrigation rates are approximately 15-30 ml/min and preferred suction rates are approximately 8-17 ml/min. However, these rates can change depending on the geometry of the tip and the procedural scenario in which the device is used. 
       FIG. 15A  shows a device comprising exemplary flow diverters  31 . In  FIG. 15A , the flow diverters  31  are located adjacent working channel  4  comprising laser fiber  9 .  FIG. 15A  also shows interstitial openings  20  (e.g., to provide irrigation). In  FIG. 15A , flow diverter  31  are located at the opening of interstitial opening  20 . Flow diverters  31  are configured to direct irrigation (e.g., provided through interstitial openings  20 ) towards the suction opening (e.g., working channel  4  comprising laser  9 ). In the embodiment shown in  FIG. 15A , two interstitial openings  20  and 2 flow diverters  31  are shown, although other configurations are specifically contemplated. 
       FIG. 15B  shows a cut-out side view of  FIG. 15A . As shown, the flow diverters  31  are located at the interstitial opening  20 . However, the present disclosure is not limited to interstitial openings. Other channels may be utilized to deliver irrigation and/or suction. In the embodiments shown in  FIG. 15B , irrigation is provided through the interstitial opening  20  adjacent flow diverters  31  and is directed by flow diverter  31  towards working channel  4 . 
       FIG. 16A  shows an embodiment where the flow diverter  31  protrudes from the distal face of the tip of the device to direct the irrigation flow across or partially across the working/suction channel  4 . The flow diverter  31  shown in  FIG. 16A  is flush with the outside face of the tip of the device and has perpendicular sides adjacent to working channel  4 . However, the present disclosure is not limited to the geometry shown in  FIG. 16A . It is contemplated that other shapes of flow diverter  31  are functionally equivalent. Also shown in  FIG. 16A  is interstitial opening  20  and laser  9 . 
       FIG. 16B  shows a cut-out side view of  FIG. 16A . Flow diverter  31  is located at interstitial opening  20  on the left side of the view shown in  FIG. 16B . The flow diverter  31  does not block opening  20 . In the embodiments shown in  FIG. 16B , irrigation is provided through the interstitial opening  20  adjacent flow diverter  31  and is directed by flow diverter  31  towards working channel  4 . 
       FIG. 17A  shows an embodiment where flow diverter  31  opens up to the working/suction channel  4  (e.g., comprising laser  9 ). Also shown in  FIG. 17A  are two interstitial openings  20 . Flow diverter  31  directs fluid from interstitial opening  20  on the left side in fluid communication with flow diverter  31  to working channel  4 . 
       FIG. 17B  shows a cut-out side view of  FIG. 17A . Flow diverter  31  is located at interstitial opening  20  on the left side of the view shown in  FIG. 17B , which is in fluid communication with working channel  4 . In the embodiment shown in  FIG. 17B , irrigation is provided through the interstitial opening  20  adjacent flow diverter  31  and is directed by flow diverter  31  towards working channel  4 . In some embodiments, flow diverter  31  is composed of similar materials to that of the ureteroscope/endoscope tip. For example, this material may be a form of thermoplastic or metal. In some embodiments, flow diverter  31  is molded integrally with the rest of the device tip or is attached as a separate component. 
       FIG. 18A  shows a side cut-out view of a device comprising a flow diverter  31  that links two working channels  4 . The device shown in  FIG. 18A  lacks interstitial openings. Instead, irrigation is provided via a working channel  4 . The flow diverter then directs flow of irrigation fluid from one working channel  4  towards the second working channel (e.g., comprising a suction component). In the embodiment shown in  FIG. 18A , the flow diverter is angled from an upper opening to a lower opening. 
       FIG. 18B  shows a top view of the device of  FIG. 18A . Shown is the lower opening of flow diverter  31  into working channel  4  (the upper opening of flow diverter  31  in the second working channel  4  is not shown). Also shown are light  1  and camera  5 . 
       FIG. 18C  shows a top view of the device of  FIG. 18A . Shown is the upper opening of flow diverter  31  into working channel  4  (the lower opening of flow diverter  31  in the second. working channel  4  is not shown). Also shown are light  1  and camera  5 . 
     The present disclosure is not limited to the flow diverters described herein. In some embodiments, additional geometries and configurations of flow diverters are utilized. For example, in some embodiments, a combination of two or more (e.g., 2, 3, 4, 5, or more) flow diverters are utilized. In some embodiments, if more than one flow diverter is utilized, they are the same or different. In some embodiments, flow diverters are symmetrically or asymmetrically located on the distal tip of the device. In some embodiments, flow diverters are located adjacent an interstitial opening and/or working or other channel or port. In some embodiments, a device comprises channels with and without flow diverters. 
     The present disclosure is not limited to geometries or physical features of flow diverters. In some embodiments, the flow diverter comprises one or more physical features that divert an irrigation fluid stream in a direction other than perpendicular to the long axis of the device tip. In some embodiments, a flow diverter includes a. structure, such as, for example, an angled channel opening, overhang, undercut, channel link (e.g., where one working channel or “pseudo working channel” is linked to another working channel or “pseudo working channel” at or near the tip), or other structure, that acts to increase flow and/or turbulence at, near, within, or across a suction inlet on the endoscope. 
     In some embodiments, the ureteroscopes described herein are provided as part of a system. An exemplary system is shown in  FIG. 11 . Referring to  FIG. 11 , shown is a system comprising ureteroscope tip  17 , temperature and/or pressure sensor  12 , ureteroscope handle  13 , suction port distal end  14 , and working channel distal end  15 . In some embodiments, the system includes an irrigation delivery system, laser, and camera (not shown in  FIG. 11 ). In some embodiments, the system includes a mechanism to articulate the ureteroscope tip  17 . In some embodiments, systems include a component configured to move suction and/or laser/irrigation delivery systems between symmetrical working channels. In some embodiments, the handle/system includes a mechanism to linearly translate the laser forward and backward with respect to the long axis of the device. This can be accomplished through a manual sliding mechanism or other means. This can be useful to unclog the device when suction is applied through working channel  4  with laser included. If a clog occurs, it will tend to occur near the entrance of the tip. By moving the laser fiber backward then forward (by about an inch), one can quickly clear any stone fragments that may have clogged or partially clogged working channel  4 . 
     In some embodiments, the devices and systems described herein are used in combination with laser lithotripsy systems. Lasing may be performed with a pulsed Ho:YAG laser coupled to a fiber optic that can be passed through the working channel of the ureteroscope, although other systems such as a TFL system are specifically contemplated. 
     In use, the ureteroscope tip is inserted in the ureter of a subject. The camera and articulation mechanism is used to advance the ureteroscope to the vicinity of a stone. Once a stone is visualized, laser ablation, in combination with irrigation and suction is performed. Once the stone has been ablated and debris fragments and stone dust have been satisfactorily removed via suction, the ureteroscope is removed. 
     In some embodiments, the irrigation flows through the working channel/laser port in a controlled manner. In some embodiments, a component for controlling the flowrate and total amount of irrigation fluid is included. The suction port can also be dynamically adjusted to control the flowrate and total amount of fluid that is removed from the kidney. These two systems work in unison to maintain a safe pressure balance within the kidney. For example, if the tip of the ureteroscope has engaged a stone for relocation, the tip may become occluded, thus reducing the amount of fluid that can be sucked out of the kidney. In some embodiments, the system senses this reduction of fluid removal and adjusts the amount of irrigation flowing into the kidney automatically. The suction intensity can also be adjusted. For example, if more suction force is needed to pick up a kidney stone or large fragment for relocation or extraction, the vacuum pressure is increased. Alternatively, once a stone has been moved to the desired location, the vacuum pressure is reduced or eliminated so the stone is released from the ureteroscope tip. The device can also include a pressure sensor to monitor the pressure within the kidney and adjust the in/out flow of fluid accordingly. 
     Additionally, in some embodiments, a temperature sensor is included on the tip or near the tip to measure the temperature of fluid within the kidney. If the temperature gets too warm due to laser dusting lithotripsy, the irrigation and suction intensity automatically respond to flow in colder fluid and remove warmer fluid. 
     In some embodiments, systems further comprise a side port to maintain suction even when a stone is engaged. In some embodiments, the side port comprises an actuation mechanism to selectively open and close the suction side port. In some embodiments, a computer processor, computer, and display (e.g., monitor, smart phone, tablet, or smart watch) is used to operate one or more functions of the device, including but not limited to, to monitor and report temperature and/or pressure and/or move irrigation/laser and suction components between interchangeable channels. In some embodiments, a user reads the pressure and/or temperature and manually adjusts suction and/or irrigation to maintain an appropriate temperature and/or pressure. In some embodiments, the system adjusts suction and/or pressure automatically. For example, in some embodiments, the computer system both reads pressure and/or temperature, determines appropriate action, and instructs the suction and/or irrigation systems to make adjusts in flow and/or suction rate. In some embodiments, the computer system reads the temperature and/or pressure at regular intervals (e.g., multiple times per second, once per second, once every 5, 10, 30, 45, or 60 seconds, once per minute, or less often). In some embodiments, adjustments to flow and suction are continuously performed in order to keep temperature and pressure parameters within an acceptable range. For example, in some embodiments, temperature is maintained below 43 to 50° C. and intrarenal pressure is maintained below 40 cm H 2 0. 
     The pressure sensor can be used to monitor the balance between fluid irrigation and suction. For example, it may be preferable to maintain a certain pressure in the kidney to distend the kidney prior to laser lithotripsy. However, too much pressure in the kidney can be detrimental to the patient. During kidney stone laser lithotripsy, it is preferable to maintain a suction at or below approximately 40 ml/min. In general, the greater the suction rate, the larger the size of stone fragment that will get sucked into the working channel. By keeping the suction rate at or below 40 ml/min (e.g., below 20 ml/min), the stone fragments or particles that are sucked into the working channel will tend not to clog the device, hence it is preferably not to exceed this suction rate. By measuring the pressure at or near the tip, the system can adjust the suction and irrigation to the desired level. The system can also include an option to momentarily increase the suction amount (for example by pressing a button on the handle of the ureteroscope) to a pressure capable of exceeding a suction rate of, for example, 40 ml/min. This momentary high suction amount can potentially be ideal for the picking and placing of stone fragments to different areas of the kidney. During this time, the irrigation flow could automatically compensate for any changes in suction flowrate to maintain an ideal pressure. Then when the doctor wants to release the stone fragment, they can select to reduce or eliminate the suction flow, thus releasing the stone. 
     EXAMPLES 
     The following examples are illustrative, but not limiting, of the devices, systems, and methods of the present invention. Other suitable modifications and adaptations of the variety of conditions and parameters normally encountered in clinical therapy and which are obvious to those skilled in the art are within the spirit and scope of the invention. 
     Example 1 
     An experiment was performed that compared a Richard Wolf Cobra ureteroscope (See e.g., U.S. Pat. No. 9,089,297) to a ureteroscope of embodiments of the present disclosure. A variety of different stone sizes were tested. The suction rate was set to 60 ml/rain through the suction channel. Then, the ureteroscope tip was lowered down to the stone such that the suction channel was in contact with the stone. The ureteroscope tip was then raised up and whether or not the stone was held onto the tip was recorded. This test was repeated 10 times with the stone being in a random orientation each time. The number of times the stone was held securely out of 10 was recorded. 
     The results show that while it is possible to reposition some stones using suction through the Richard Wolf Cobra scope, due to the tip shape there is difficulty picking up larger and more contoured stone fragments (particularly those above ˜400 mg) ( FIG. 10A ). In contrast, using the device of embodiments of the present disclosure, the ability to pick up stones was significantly improved ( FIG. 10B ). 
     Further experiments demonstrated that, by removing the small particulates in a kidney stone simulation model, there is an improvement in not only vision but stone removal from the kidney over baseline that doesn&#39;t use suction. For example, in trials using a traditional kidney stone dusting procedure with no suction, approximately 75-80% of the stone mass was removed from the kidney model. In trials that utilized the suction between about 90-99% of the stone mass was removed from the kidney ( FIG. 19 ). 
     All publications and patents mentioned in the above specification are herein incorporated by reference as if expressly set forth herein. Various modifications and variations of the described method and system of the invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention that are obvious to those skilled in relevant fields are intended to be within the scope of the following claims.