Treatment
Surgical Therapy
Ureteroscopy can be divided into diagnostic endoscopy and therapeutic treatments.
Diagnostic ureteroscopy
Diagnostic endoscopy is performed with the least possible trauma to the upper urinary tract. Ureteroscopic access is obtained with a wireless ureteroscopy technique, if possible. The ureteral orifice is visualized and intubated without the assistance of a guidewire. The ureter is traversed in a no-touch technique, and the ureter and renal collecting system are mapped. In a recent prospective study of 460 consecutive upper-tract endoscopies, no-touch ureteroscopy was successfully performed in most patients without prior stenting (24%) or ureteral dilation (11%).3 This wireless form of flexible ureteroscopy eliminates the potential trauma, mucosal irritation, and inadvertent manipulation of stones or tumors caused by guidewires and is particularly helpful when the collecting system is evaluated for mucosal lesions.
Fluid irrigation facilitates passage of a rigid ureteroscope. Although automatic pumps are available for this purpose, hand irrigation is often preferred because of the flexibility this offers. The use of a video camera can allow the surgical technicians to better assist the urologist and prevents the surgeon from assuming unusual or uncomfortable positions. Another suggestion is to pass the tip of a closed basket or a guidewire just beyond any lip of tissue, blockage, or kink in the ureter and then to turn the ureteroscope 180°. This tends to stretch and open such areas, allowing easier passage of the endoscope.
When wireless ureteroscopy is not feasible, a small-diameter rigid ureteroscope is passed up the ureter as far as technically feasible to inspect and map this portion of the collecting system. A guidewire is then placed only to the area that already has been inspected, and a flexible instrument is the passed over it in a monorail fashion, under fluoroscopic guidance, to complete the mapping. The flexible ureteroscope is passed from calyx to calyx, and, frequently, dilute contrast material is injected through the working channel of the endoscope to help ensure the entire collecting system is inspected.
Therapeutic ureteroscopy
Therapeutic ureteroscopy is used in diverse applications, including in the treatment of stones, urothelial tumors, and stricture disease.
Ureteroscopy is a safe and minimally invasive method of treating stone disease in the kidneys and ureter. It can be used either as primary therapy or as salvage therapy for residual stones following treatment with other modalities such as extracorporeal shockwave lithotripsy. Success rates following such therapy are shown in Table 2 and Table 3. Furthermore, in select cases, ureteroscopy has been shown to be a viable and effective means of treating stone disease in pregnant women and in pediatric patients.
Ureteroscopy has also become a powerful tool in the treatment and surveillance of transitional cell tumors of the upper tracts, especially bilateral disease processes and tumors in solitary kidneys.4,5
Preoperative Details
Prior to ureteroscopic examination, the surgeon must have the appropriate instrumentation available. This includes endoscopes, accessories, appropriate energy sources, and fluoroscopy.
Rigid ureteroscope specifications include the following:
- Tip diameter - 4.5-9.5F (6.9F most common)
- Optics - Fiberoptic bundles
- Working channels - One, 2, or 3 (2 channels preferred)
- Accessory length - Average, 40 cm
Flexible ureteroscope specifications include the following:
- Tip diameter - 6.9-9.8F (7.5F most common)
- Optics - Fiberoptic bundles
- Working channel - Single, 3.6F
- Access - Guidewire (0.035 in nitinol or 0.038 in stainless steel)
- Accessory length - Average, 100 cm
Energy sources include the following:
- Holmium:yttrium-aluminum-garnet (Ho:YAG) laser
- Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
- Electrocautery
- Electrohydraulic lithotripsy
- Mechanical impactor (ie, Lithoclast)
Prophylaxis is as follows:
- All patients receive a preoperative dose of a broad-spectrum parenteral antibiotic.
- Most frequently, a first-generation cephalosporin or fluoroquinolone is administered, unless prior culture results or anaphylaxis dictates otherwise.
Intraoperative Details
When therapeutic ureteroscopy is performed, a safety guidewire is essential. This allows for multiple passes of the instrument while maintaining access to the upper urinary tract. For example, during treatment of a distal ureteral stone, a rigid ureteroscope is passed up the ureter beside the safety guidewire and laser energy is delivered through a small quartz fiber to fragment the stone. An accessory such as a wire prong grasper or basket then can be used to extract fragments with multiple passes of the endoscope. In such situations, The use of a ureteral sheath minimizes trauma to the ureteral meatus and intramural ureter.
In many situations, a backstop may be useful to prevent proximal migration of distal ureteral stones. The Stone Cone and Parachute kidney-stone baskets are both useful for this purpose. Variations in basket designs make them suitable for different situations. The Segura and Bagley type baskets are composed of 4 or 6 flat wires arranged spherically. They tend to have good radial opening force so are useful in tight quarters but are not intended to be rotated because of the sharp edges of the flat wires. The Dormia or spiral type baskets are good general-purpose designs that have been around for years. When paired wires are used, they are also suitable for use in areas of narrow ureteral diameters.
The Parachute type design is asymmetrical with 2 paired wires that split into a canopy or net of 8. This type is particularly useful in holding larger stones for lithoclast or laser lithotripsy and can also be used like a net to sweep the ureter, as it can capture many smaller fragments in one pass. It works best when it can be fully deploy or opened, which requires a relatively normal or dilated ureter. Fortunately, this is commonly found proximal to most stones.
Traditionally, 2 guidewires were required to perform flexible ureteroscopy. The first is a safety guidewire, while the second is used to facilitate endoscope placement. For example, this working guidewire can be replaced with a dual-lumen catheter after a stone fragment or biopsy specimen is extracted. Conversely, ureteroscopic access can now be obtained by using a wireless ureteroscopy technique in which the ureteral orifice is visualized and intubated without the assistance of a guidewire and the ureter is traversed in a no-touch technique.
If electrocautery is to be used, special attention to the guidewire choice helps prevent an intraoperative complication. If a standard stainless steel guidewire is used, electrical current may inadvertently arc to the wire during cautery use and may cause excessive ureteral coagulation with subsequent fibrosis and stricture formation. This can be prevented by using an insulated guidewire such as a Teflon-sheathed nitinol guidewire (eg, Zebra wire, Boston Scientific, Natick, Mass).
Intraluminal ultrasonography has also been used in various applications. It offers enhanced diagnostic yield in the evaluation of disease processes such as ureteropelvic junction obstruction, tumors of the upper tract, and anatomic anomalies (eg, crossing renal vessels). It has also improved treatment of submucosal ureteral calculi.
Postoperative Details
When the ureteroscopy is completed, internal ureteral stents are commonly placed to facilitate healing and to ensure drainage, particularly if vigorous therapeutic maneuvers were performed. However, simple diagnostic ureteroscopy without ureteral dilation does not require postoperative ureteral stenting.
Internal ureteral stents are associated with lower urinary tract symptomatology, including urinary frequency, urgency, and mild-to-moderate hematuria, which is transient. Ureteral stents are removed after a period of healing that can range from a few days to 6-8 weeks, depending on the complexity of the treatment. Stents are usually removed in the office with either an attached nylon suture left through the urethra postoperatively or cystoscopically.
Most ureteroscopic procedures are performed as day surgery outpatient procedures. Patients are discharged and are given oral quinolone-based antibiotics and analgesics. Anticholinergic medications and alpha-blockers may be used to minimize frequency, urgency, and discomfort often associated with ureteral stents; however, individual patient tolerance widely varies. Careful selection of the best stent length and optimal positioning help to minimize these unpleasant symptoms.
Follow-up
Most patients are return after 1-2 weeks following the ureteroscopic procedure for stent removal and surgical follow-up. If endoscopic lithotripsy was performed, appropriate imaging consisting of either plain radiography or ultrasonography can be performed to define residual stone burdens.
Subsequent imaging is required weeks to months after the procedure depending on the underlying disease process. If, for example, a ureteral stricture is incised ureteroscopically, serial follow-up imaging studies defining drainage and renal function (eg, IVP, nuclear medicine renal scan) should be performed periodically, particularly during the first year to ensure an acceptable surgical outcome.
Complications
Minor intraoperative complications
Minor ureteroscopic complications are those that have no long-term deleterious effects and, if treated promptly, cause only minimal or transient postoperative problems. Table 1 chronologically lists 4 studies spanning the 10-year evaluation of ureteroscopic equipment and technique. In the initial series from the Mayo Clinic, large-diameter endoscopes were used,6 while, in the last series, the smallest-diameter ureteropyeloscopes were used, with a noticeable decrease in complication rates.7
In general, the minor complication rate associated with ureteropyeloscopy was decreased based on refined technique, experience of the operators, and prompt treatment or prevention of intraoperative problems. Prophylactic parenteral antibiotics, careful guidewire placement, minimization of excessive ureteral dilation, and postoperative ureteral stenting all affected the rate of postoperative problems. This, combined with better surgical training and improved instrumentation, resulted in this very positive trend.
Major intraoperative complications
Major intraoperative problems include excessive trauma to tissues leading to large wall perforations, avulsions, or foreign body (eg, stone) migration into the ureteral wall. The major complication rate has markedly decreased (now occurring in approximately 1% of all ureteroscopic procedures). As with the minor problems, major complications are less common for basically the same reasons. However, when they do occur, treatment is often more complex.
In addition to major intraoperative problems, other complications that occur during upper urinary tract endoscopy may begin as minor events and, if left untreated or if addressed incorrectly, can progress to more serious conditions.
Major ureteral wall perforations can be the product of a heavy-handed endoscopist and improper application of a semirigid ureteroscope. The forceful positioning of a semirigid ureteroscope above the iliac vessels, particularly in young male patients, is associated with a significant risk of ureteral wall trauma unless the collecting system is hydronephrotic or has been stented prior to endoscopy. Routine use of a double-J stent is unnecessary in most patients but is recommended when unusual difficulty is encountered or when extensive strictures are found. Usually, 1-2 weeks of stenting greatly facilitates ureteroscopy, particularly if proximal access is desired.
Ureteral wall tears may lead to stone migration through the tear. Subsequently, this may result in the formation of a stone granuloma or ureteral wall stricture. In addition, large tears can lead to ureteral avulsion if the offending maneuver is repeated at the same sitting (eg, large ureteral wall perforation with subsequent vigorous attempts at accessing a calculus). In these settings, stopping the procedure and stenting the ureter, to return days later to perform subsequent maneuvers in a staged fashion after a period of healing, is wiser.
When a minor problem is encountered during ureteroscopy, taking appropriate measures to prevent progression is essential. Additionally, the inappropriate application of endoscopes, lithotrities, and accessories can lead to surgical misadventure. An example would be basketing a relatively large renal stone with a retrograde-placed ureteroscope and attempting extraction.
A basic concern is that, if the stone was too large to pass, how does engagement in a basket and application of tension along the long axis of the ureter have merit? Surgeons can find themselves in a tenuous situation in which extraction is impossible; stone disengagement is difficult, and, with a single endoscopic working channel, simultaneous placement of an endoscopic lithotrite is difficult or impossible. Excessive tension on the ureter then leads to an avulsion with disastrous complications that could have been prevented.
Surgeons should anticipate such possible difficulties and allow themselves additional options. For example, a basket or grasper can be passed alongside the ureteroscope, leaving the central channel free to use a lithoclast or laser fiber for stone fragmentation. If this type of access is not possible, a Tuohy-Borst adaptor can allow both irrigation and passage of a laser fiber for stone fragmentation, if necessary. The possibility that a stone is more difficult or larger than expected should always be anticipated, particularly in the proximal ureter. Allowances or contingencies should be made for stone fragmentation if extraction is deemed too difficult or dangerous. If all else fails, leave a stent and return another day with a better plan or consider an alternative technique such as percutaneous access or extracorporeal shockwave lithotripsy. Such planning can prevent disastrous consequences and outcomes.
If ureteral avulsion develops in the distal segment, repair is based on the standard open surgical techniques of ureteral reimplantation. Ureteroneocystostomy can be performed for most distal ureteral avulsions, with a psoas bladder hitch used, if necessary, to create a tension-free anastomosis. A Boari bladder wall flap can increase the proximal extent of the repair to the middle third of the ureter. These repairs are usually performed over a ureteral catheter with perianastomotic drainage. This can be performed short-term at the time of the injury or in a staged fashion after proximal percutaneous drainage is obtained.
The more proximal ureteral avulsions require the most complex surgical repairs. If a proximal ureteral avulsion is encountered intraoperatively and most of the ureter is intact, primary repair over a ureteral catheter can be performed. Unfortunately, in this setting, most of the ureter is often devitalized, leading to an extremely morbid complication. If the entire devitalized ureteral segment is brought into the bladder, it is of no value in subsequent repair. Percutaneous renal drainage should be obtained immediately for this type of ureteral injury. Subsequent therapy is based on either bowel interposition (ie, ileal ureter) or renal autotransplantation to a pelvic position. Both procedures are highly complex and have their own inherent risks, so the patient must be counseled appropriately.
Table 1. Comparison of Complication Rates Associated With Ureteroscopy, Emphasizing the Noticeable Decrease in the Major Complication Rate With Greater Experience and Endoscope MiniaturizationOpen table in new window
Table
| Author | Blute et al 6 | Abdel-Razzak and Bagley 8 | Harmon et al 9 | Grasso and Bagley 7 |
|---|---|---|---|---|
| Year Published | 1988 | 1992 | 1997 | 1998 |
| Procedures | 346 | 290 | 209 | 584 |
| Minor Complications, % | ||||
| Colic/pain | --- | 9 | 3.5 | 5.5 |
| Fever | 6.2 | 6.9 | 2 | 1.4 |
| False passage | 0.9 | --- | --- | 0.4 |
| Hematuria | ||||
Minor Prolonged | 0.5 0.3 | 2.1 1 | 0 0 | 0.7 0.2 |
| Extravasation | 0.6 | 1 | --- | --- |
| Urinary tract infection | --- | 1 | --- | 1.6 |
| Pyelonephritis | --- | --- | --- | 0.5 |
| Major Complications, % | ||||
| Perforation | 4.6 | 1.7 | 1 | 0 |
| Stricture | 1.4 | 0.7 | 0.5 | 0.5 |
| Avulsion | 0.6 | 0 | 0 | 0 |
| Urinoma | 0.6 | --- | 0 | 0 |
| Urosepsis | 0.3 | 0 | 0 | 0 |
| Cardiovascular accident | --- | --- | 0.5 | 0.2 |
| Deep vein thrombosis | --- | --- | --- | 0.2 |
| Author | Blute et al 6 | Abdel-Razzak and Bagley 8 | Harmon et al 9 | Grasso and Bagley 7 |
|---|---|---|---|---|
| Year Published | 1988 | 1992 | 1997 | 1998 |
| Procedures | 346 | 290 | 209 | 584 |
| Minor Complications, % | ||||
| Colic/pain | --- | 9 | 3.5 | 5.5 |
| Fever | 6.2 | 6.9 | 2 | 1.4 |
| False passage | 0.9 | --- | --- | 0.4 |
| Hematuria | ||||
Minor Prolonged | 0.5 0.3 | 2.1 1 | 0 0 | 0.7 0.2 |
| Extravasation | 0.6 | 1 | --- | --- |
| Urinary tract infection | --- | 1 | --- | 1.6 |
| Pyelonephritis | --- | --- | --- | 0.5 |
| Major Complications, % | ||||
| Perforation | 4.6 | 1.7 | 1 | 0 |
| Stricture | 1.4 | 0.7 | 0.5 | 0.5 |
| Avulsion | 0.6 | 0 | 0 | 0 |
| Urinoma | 0.6 | --- | 0 | 0 |
| Urosepsis | 0.3 | 0 | 0 | 0 |
| Cardiovascular accident | --- | --- | 0.5 | 0.2 |
| Deep vein thrombosis | --- | --- | --- | 0.2 |
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Further Reading
Keywords
ureteroscopy, ureteropyeloscopy, upper urinary tract endoscopy, diagnostic endoscopy, distal ureteral calculi, ureter instrumentation, ureteral instrumentation, cytoscopy, endoscopy, endoscopic lithotripsy, distal ureteral stones, flexible ureteroscopy, rigid ureteroscopy, fiberscope, distal ureteral calculus, upper urinary tract disorders, urothelial malignancies, stricture disease, unilateral essential hematuria, ureteral injury, retrograde endopyelotomy, calyceal drainage, calyceal diverticular lesion, malignant urothelial tumor, secondary deflection, therapeutic ureteroscopy, diagnostic ureteroscopy
