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Ureteroscopy Treatment & Management

  • Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Oct 22, 2014
 

Surgical Therapy

Ureteroscopy can be divided into diagnostic endoscopy and therapeutic treatments.

Diagnostic ureteroscopy

Atraumatic diagnostic endoscopy minimizes mucosal distortion, allowing for complete mapping of the upper urinary tract. Ureteroscopic access is obtained with a wireless technique, if possible. The ureteral orifice is visualized and intubated without the assistance of a guidewire. The intramural ureter is traversed employing a "no-touch" technique, and the more proximal ureter and renal collecting system are then mapped. In a recent prospective study of 460 consecutive upper-tract endoscopies, no-touch ureteroscopy was successfully performed in most patients without prior stenting or ureteral dilation.[5] 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/intra-luminal lesions.

Fluid irrigation facilitates passage of the ureteroscope while simultaneously clearing the optical field. Sterile saline is the preferred irrigant. Although automatic pumps are available for this purpose, hand irrigation is preferred for its precise control of volume dispensed.

When wireless flexible ureteroscopy is not feasible, a small-diameter rigid ureteroscope can be employed first to inspect and map the ureter. A guidewire is then placed only to the area that already has been inspected, and then a flexible instrument is the passed over it in a monorail fashion, under fluoroscopic guidance, to complete the mapping. The flexible ureteroscope is directed 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 as depicted below.

Therapeutic ureteroscopy

Therapeutic ureteroscopy is used in varied 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 as shown below. 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 (ESWL) and/or percutaneous nephrolithotomy (PCNL). Compared with ESWL, ureteroscopic lithotripsy achieves a greater stone-free state.[6] Success rates following ureteroscopy are shown in Table 2 and Table 3 in the Outcome and Prognosis section below. Furthermore, in select cases, ureteroscopy has been shown to be a viable and effective means of treating stone disease where ESWL may be contraindicated (eg. pregnant women and pediatric patients).

Ureteroscopic image of an impacted jack stone in t Ureteroscopic image of an impacted jack stone in the ureter. These calculi are composed of calcium oxalate monohydrate.

Ureteroscopy is also a powerful tool in the diagnosis, treatment, and surveillance of transitional cell tumors of the upper tracts.[7, 8]

See image below.

Ureteroscopic image of a papillary transitional ce Ureteroscopic image of a papillary transitional cell carcinoma of the ureter.

In addition, ureteroscopy can be employed to treat ureteral stenosis/stricture and ureteropelvic junction obstruction. In each setting, an energy source is delivered through the working channel of the endoscope to fragment, ablate, and/or incise. Additional accessories can also be passed through the standard 3.6F working channel to remove stone fragments or to obtain biopsy samples (see Intraoperative details).

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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 or digital imager
  • Working channels - One, 2, or 3 (2 channels preferred)
  • Accessory length - 40 - 60 cm

Flexible ureteroscope specifications include the following:

  • Tip diameter - 6.9-9.8F (7.5F most common)
  • Optics - Fiberoptic bundles or digital imager
  • Working channel - Single, 3.6F
  • Access - Guidewire (0.035 in nitinol or 0.038 in stainless steel)
  • Accessory length - 100 - 120 cm

Energy sources include the following:

  • Holmium:yttrium-aluminum-garnet (Ho:YAG) laser
  • Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
  • Thulium 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 hypersensitivity dictates otherwise.
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Intraoperative Details

When therapeutic ureteroscopy is performed, a guidewire can be useful. It can halp facilitate 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 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 (see video below). A ureteral sheath can be employed, but its relatively large diameter may potentiate ureteral wall trauma as described earlier.[4]

Wireless ("no touch") ureteroscopy, laser lithotripsy and stone extraction technique performed with the digital ureteroscope.

There are a variety of stone extraction devices available. Those composed of nitinol, which maintains its shape and rarely kinks, are preferred- as depicted in the video above.

If electrocautery is to be employed, special attention to the guidewire choice helps minimize energy scatter. If a standard stainless steel guidewire is used, electrical current may inadvertently arc to the wire and result in thermal injury. 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 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 hidden or submucosal ureteral calculi.

Special Consideration: The Impacted Distal Calculus/The Tight Intramural Ureter

A particular therapeutic quandary can be the impacted distal ureteral stone. When a guidewire cannot be passed cystoscopically, employing a small diameter semi-rigid ureteroscope is useful in gaining access to the proximal ureter. The tip of the endoscope is placed into the edema and a guidewire is passed proximally beyond the obstruction under direct vision.

In the case of a tight intramural ureteral tunnel, after a guide wire is passed into the proximal collecting system, a two wire access technique is often helpful. In this setting a small caliber, two-channel semi-rigid ureteroscope is passed just to the ureteral orifice beside the pre-placed safety guide wire. A second guide wire is passed through the working channel proximally under direct endoscopic and fluoroscopic guidance. Irrigation is administered thru the second endoscopic working channel to clear the optical field and the endoscope rotated placing its tip between the two guide wires. The semi-rigid ureteroscope is then gently passed proximally between the two wires, compressing the edema and gently dilating the distal segment until the calculus is encountered. Once at the level of the calculus the second wire is removed and lithotripsy can commence.

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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 and/or the ureter required dilation for access. However, simple diagnostic ureteroscopy without ureteral dilation does not routinely 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 trailor or cystoscopically.

Most ureteroscopic procedures are performed as day surgery outpatient procedures. On discharge prophylactic oral (quinolone-based) antibiotics and analgesics are frequently prescribed. Anticholinergic medications and alpha-blockers can be used to minimize frequency, urgency, and discomfort often associated with ureteral stents; however, individual patient tolerance varies widely. Careful selection of the best stent length and optimal positioning help to minimize these unpleasant symptoms.

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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, serial imaging (eg, plain radiography or ultrasonography) is performed to define residual stone burden.

Subsequent imaging is required and tailored to the clinical presentation and underlying disease process. If, for example, a ureteral stricture is incised ureteroscopically, serial follow-up imaging studies defining drainage and renal function (eg, IVP or CT urography and nuclear medicine renal scan) are performed periodically, particularly during the first year to ensure an acceptable surgical outcome.

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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 (below) chronologically lists 5 studies spanning the almost 20-year evaluation of ureteroscopic equipment and technique. In the initial series from the Mayo Clinic, large-diameter endoscopes were used,[9] while, in the last two series, the smallest-diameter ureteropyeloscopes were used, with a noticeable decrease in complication rates.[10, 11]

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, endoscope minimization preventing excessive ureteral dilation, and postoperative ureteral stenting all have decreased the rate of postoperative problems. This, combined with better surgical training and improved instrumentation, has resulted in this very positive trend.

Major intraoperative complications

Major intraoperative problems associated with ureteroscopy include trauma to tissues leading to significant ureteral wall perforations, avulsions, or foreign body (eg, stone) migration into the ureteral wall. The major complication rate has markedly decreased (now occurring in less than 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 more complex.

Major ureteral wall perforations can be the product of improper application of an endoscope, dilator, or sheath. The forceful positioning of any device, particularly in young patients with a small caliber ureter, can lead to ureteral wall trauma. Pre-operative placement of a double-J stent is often unnecessary, but is recommended when unusual difficulty in access is encountered, or when a strictures is found. Pre-stenting greatly facilitates complex ureteroscopy.

Ureteral wall trauma may lead to stone migration into the wall or outside the urinary tract. Subsequently, this may result in the formation of a stone granuloma and ureteral wall strictures. Meticulous clearance of stone fragments in this setting and stent drainage will minimize the risk of subsequent stricture.

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 rather than fragmentation.

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 can lead to an avulsion, with disastrous complications.

Allowances or contingencies should be made for stone fragmentation if extraction is deemed too difficult or dangerous. If treatment is challenging and/or access difficult, placing a stent and returning another day is a better plan, or consider an alternative technique such as percutaneous access or extracorporeal shockwave lithotripsy. Such planning can prevent complications and poor outcomes.

If ureteral avulsion occurs in the distal segment, repair is based on standard open or laparoscopic surgical technique 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 at the time of the injury or in a staged fashion after proximal percutaneous drainage is obtained.

The more proximal ureteral avulsion requires the most complex surgical repair. 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 the ureter is often devitalized. 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.

Table 1. Comparison of Complication Rates Associated With Ureteroscopy, Emphasizing the Noticeable Decrease in the Major Complication Rate With Greater Experience and Endoscope Miniaturization (Open Table in a new window)

  Blute, et al. [9] Abdel-Razzak and Bagley [12] Harmon, et al. [13] Grasso [10] Jiang, et al. [11]
Year 1988 1992 1997 2000 2007
Number of Procedures 346 290 209 1000 697
Minor Complications (%) (%) (%) (%) (%)
Colic/pain -- 9.0 3.5 4.2 --
Fever 6.2 6.9 2.0 1.3 --
False passage 0.9 -- -- 0.4 0.4
Hematuria



Minor



Prolonged



0.5



0.3



2.1



1.0



0



0



0.8



0.2



 
Extravasation 0.6 1.0 -- -- --
UTI -- 1.0 -- 1.7 --
Pyelonephritis -- -- -- 1.0 --
           
Major Complications (%) (%) (%) (%) (%)
Major perforation 4.6 1.7 1.0 0 0.3
Stricture 1.4 0.7 0.5 0.4 0.3
Avulsion 0.6 0 0 0 0
Urinoma 0.6 -- 0 0 --
Urosepsis 0.3 0 0 0 --
CVA -- -- 0.5 0.1 --
DVT -- -- -- 0.1 --
MI -- -- -- 0.1 --

 

UTI= urinary tract infection; CVA= cerebrovascular accident; DVT= deep vein thrombosis; MI= myocardial infarction

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Outcome and Prognosis

The outcome of a ureteroscopic procedure is based on the underlying disorder and whether a diagnostic or therapeutic endoscopy was performed. In diagnostic ureteroscopy, finding the source of bleeding, or defining the nature of a filling defect (with tissue sampling for biopsy) is usually the end point.

Therapeutic ureteroscopy for the treatment of upper urinary tract calculi should resolve ureteral obstruction and decrease the stone burden. Endoscopic treatment of stricture disease should improve drainage. Treatment of urothelial tumors has the same goals and end points as endoscopic treatment of bladder tumors. Thus, ureteroscopy is a surgical platform from which various disease processes can be treated, each with their own specific postoperative expectations and outcomes.

The following tables show success rates of ureteroscopic lithotripsy.

Table 2. New York University Experience With Ureteroscopic Treatment of Ureteral Calculi Using the Holmium:YAG Laser (Open Table in a new window)

Segment Number of Cases Mean Diameter,



mm (range, mm)



Success Rate,



First-Stage Treatment



and Second -Stage Treatment



Proximal third 75 11.3 (30-5) 95% and 96%
Middle third 45 10.7 (60-5) 98% and 100%
Distal third 91 10.3 (50-4) 99% and 100%
Totals 211   97% and 99%

Table 3. New York University Experience With Ureteropyeloscopic Treatment of Intrarenal Calculi Using the Holmium:YAG Laser (Open Table in a new window)

Location Number of Cases Mean Diameter,



mm (range, mm)



Success Rate, Treatment



and Multistage Treatment



Upper pole 58 10.6 (35-4) 90% and 97%
Middle pole 30 11.1 (23-4) 90% and 93%
Lower pole 103 14.8 (40-3) 79% and 85%
Renal pelvic 37 20.5 (60-6) 78% and 95%
Totals 228   81% and 90%

 

Advances in technology and surgical technique have paved the way for the endoscopic treatment of larger stone burdens. The ureteroscopic treatment of large upper urinary tract calculi was first described in patients with comorbidities prohibiting percutaneous nephrostolithotomy in 1998.[14] Over the last 15 years multiple centers have presented their experience with similar large stones treated ureteroscopically with excellent stone free rates and minimal morbidity as exhibited in Table 4.[15]

Table 4. Review of Studies on Ureteroscopic Management of Upper Urinary Tract Calculi > 2 cm (Open Table in a new window)

STUDY Date Number of Patients Mean Stone Diameter (mm) Mean number of procedures Stone Free (%) Complications number (%)
Grasso et al.[14] 1998 51 24.9 1.3 93 3 (3)
El-Anany et al.[16] 2001 30 >20 1 77 3 (10)
Ricchiuti et al.[17] 2007 23 30.9 1.4 74 0 (0)
Breda et al.[18] 2008 15 22 2.3 93 3 (9)
Riley et al.[19] 2009 22 30 1.8 91 4 (10)
Hyams et al.[20] 2010 120 24 1.2 83 8 (6)
Takazawa et al.[21] 2011 20 31 1.4 90 3 (5)
Cohen et al.[15] 2012 145 29 1.6 87 5 (2)

 

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Future and Controversies

Miniaturization of ureteroscopic instrumentation will continue, with smaller fiberoptics and enhanced digital imagers, improved accessories, and new energy sources. As the instrumentation becomes smaller and more refined, it also will become more delicate. Thus, manufacturers are challenged to develop new, smaller instruments that will also survive the rigors of surgical therapy.

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Contributor Information and Disclosures
Author

Michael Grasso, III, MD Professor and Vice Chairman, Department of Urology, New York Medical College; Director, Living Related Kidney Transplantation, Westchester Medical Center; Director of Endourology, Lenox Hill Hospital

Michael Grasso, III, MD is a member of the following medical societies: Medical Society of the State of New York, National Kidney Foundation, Society of Laparoendoscopic Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Medical Association, American Urological Association, Endourological Society

Disclosure: Received consulting fee from Karl Storz Endoscopy for consulting.

Coauthor(s)

G Blake Johnson, MD Consulting Staff, Middleton Urology Associates

G Blake Johnson, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association

Disclosure: Nothing to disclose.

Paul Pyo, MD Staff Physician, Department of Urology, New York Medical College

Disclosure: Nothing to disclose.

Bobby S Alexander, MD Fellow in Endourology, Lenox Hill Hospital, Long Island Jewish Medical Center

Bobby S Alexander, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society, Phi Beta Kappa, Golden Key International Honour Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

Daniel B Rukstalis, MD Professor of Urology, Wake Forest Baptist Health System, Wake Forest University School of Medicine

Daniel B Rukstalis, MD is a member of the following medical societies: American Association for the Advancement of Science, American Urological Association

Disclosure: Nothing to disclose.

Acknowledgements

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

References
  1. Marshall VF. Fiber Optics in Urology. J Urol. 1964 Jan. 91:110-4. [Medline].

  2. Bagley DH, Huffman JL, Lyon ES. Combined rigid and flexible ureteropyeloscopy. J Urol. 1983 Aug. 130(2):243-4. [Medline].

  3. Grasso M, Fishman AI, Alexander B. Ureteropyeloscopic Management of Upper Urinary Tract Calculi. Grasso M and Goldfarb D. Urinary Stones – Medical and Surgical Management. 1. USA: Wiley Blackwell; 2014. 243-263/20.

  4. Traxer O, Thomas A. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. J Urol. 2013 Feb. 189(2):580-4. [Medline].

  5. Johnson GB, Portela D, Grasso M. Advanced ureteroscopy: wireless and sheathless. J Endourol. 2006 Aug. 20(8):552-5. [Medline].

  6. Aboumarzouk OM, Kata SG, Keeley FX, Nabi G. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev. 2011 Dec 7. 12:CD006029. [Medline].

  7. Chen GL, Bagley DH. Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management. J Endourol. 2001 May. 15(4):399-404; discussion 409. [Medline].

  8. Lee D, Trabulsi E, McGinnis D, Strup S, Gomella LG, Bagley D. Totally endoscopic management of upper tract transitional-cell carcinoma. J Endourol. 2002 Feb. 16(1):37-41. [Medline].

  9. Blute ML, Segura JW, Patterson DE. Ureteroscopy. J Urol. 1988 Mar. 139(3):510-2. [Medline].

  10. Grasso M. Ureteropyeloscopic treatment of ureteral and intrarenal calculi. Urol Clin North Am. 2000 Nov. 27(4):623-31. [Medline].

  11. Jiang H, Wu Z, Ding Q, Zhang Y. Ureteroscopic treatment of ureteral calculi with holmium: YAG laser lithotripsy. J Endourol. 2007 Feb. 21(2):151-4. [Medline].

  12. Abdel-Razzak OM, Bagley DH. Clinical experience with flexible ureteropyeloscopy. J Urol. 1992 Dec. 148(6):1788-92. [Medline].

  13. Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW. Ureteroscopy: current practice and long-term complications. J Urol. 1997 Jan. 157(1):28-32. [Medline].

  14. Grasso M, Conlin M, Bagley D. Retrograde ureteropyeloscopic treatment of 2 cm. or greater upper urinary tract and minor Staghorn calculi. J Urol. 1998 Aug. 160(2):346-51. [Medline].

  15. Cohen J, Cohen S, Grasso M. Ureteropyeloscopic treatment of large, complex intrarenal and proximal ureteral calculi. BJU Int. 2013 Mar. 111(3 Pt B):E127-31. [Medline].

  16. El-Anany FG, Hammouda HM, Maghraby HA, Elakkad MA. Retrograde ureteropyeloscopic holmium laser lithotripsy for large renal calculi. BJU Int. 2001 Dec. 88(9):850-3. [Medline].

  17. Ricchiuti DJ, Smaldone MC, Jacobs BL, Smaldone AM, Jackman SV, Averch TD. Staged retrograde endoscopic lithotripsy as alternative to PCNL in select patients with large renal calculi. J Endourol. 2007 Dec. 21(12):1421-4. [Medline].

  18. Breda A, Ogunyemi O, Leppert JT, Lam JS, Schulam PG. Flexible ureteroscopy and laser lithotripsy for single intrarenal stones 2 cm or greater--is this the new frontier?. J Urol. 2008 Mar. 179(3):981-4. [Medline].

  19. Riley JM, Stearman L, Troxel S. Retrograde ureteroscopy for renal stones larger than 2.5 cm. J Endourol. 2009 Sep. 23(9):1395-8. [Medline].

  20. Hyams ES, Munver R, Bird VG, Uberoi J, Shah O. Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience. J Endourol. 2010 Oct. 24(10):1583-8. [Medline].

  21. Takazawa R, Kitayama S, Tsujii T. Successful outcome of flexible ureteroscopy with holmium laser lithotripsy for renal stones 2 cm or greater. Int J Urol. 2012 Mar. 19(3):264-7. [Medline].

  22. Bagley D. Active versus passive deflection in flexible ureteroscopy. J Endourol. 1987. 1:15.

  23. Bagley DH. Intrarenal access with the flexible ureteropyeloscope: effects of active and passive tip deflection. J Endourol. 1993 Jun. 7(3):221-4. [Medline].

  24. Bagley DH. Removal of upper urinary tract calculi with flexible ureteropyeloscopy. Urology. 1990 May. 35(5):412-6. [Medline].

  25. Bagley DH. Ureteral endoscopy with passively deflectable, irrigating flexible ureteroscopes. Urology. 1987 Feb. 29(2):170-3. [Medline].

  26. Bagley DH, Allen J. Flexible ureteropyeloscopy in the diagnosis of benign essential hematuria. J Urol. 1990 Mar. 143(3):549-53. [Medline].

  27. Bagley DH, Huffman JL, Lyon ES. Flexible ureteropyeloscopy: diagnosis and treatment in the upper urinary tract. J Urol. 1987 Aug. 138(2):280-5. [Medline].

  28. Bagley DH, Liu JB, Goldberg BB, Grasso M. Endopyelotomy: importance of crossing vessels demonstrated by endoluminal ultrasonography. J Endourol. 1995 Dec. 9(6):465-7. [Medline].

  29. Bagley DH, Rivas D. Upper urinary tract filling defects: flexible ureteroscopic diagnosis. J Urol. 1990 Jun. 143(6):1196-200. [Medline].

  30. Berci G. Instrumentation: flexible fiber endoscopes. Berci G, ed. Endoscopy. New York, NY: Appleton-Century-Crofts; 1976.

  31. Bierkens AF, Hendrikx AJ, De La Rosette JJ, Stultiens GN, Beerlage HP, Arends AJ, et al. Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness. Br J Urol. 1998 Jan. 81(1):31-5. [Medline].

  32. Conlin M, Bagley DH. Incisional treatment of ureteral strictures. Smith AD, Lingeman JE, Bagley DH, Preminger GM, Clayman RV, Badlani GH, Jordan GH, Kavoussi LV, Segura JW, eds. Smith's Textbook of Endourology. St Louis, Mo: Quality Medical Publishing; 1996. Vol 1: 497-505.

  33. Conlin MJ, Bagley DH. Ureteroscopic endopyelotomy at a single setting. J Urol. 1998 Mar. 159(3):727-31. [Medline].

  34. Denstedt JD, Clayman RV. Electrohydraulic lithotripsy of renal and ureteral calculi. J Urol. 1990 Jan. 143(1):13-7. [Medline].

  35. Elbahnasy AM, Shalhav AL, Hoenig DM, Elashry OM, Smith DS, McDougall EM, et al. Lower caliceal stone clearance after shock wave lithotripsy or ureteroscopy: the impact of lower pole radiographic anatomy. J Urol. 1998 Mar. 159(3):676-82. [Medline].

  36. Erhard M, Salwen J, Bagley DH. Ureteroscopic removal of mid and proximal ureteral calculi. J Urol. 1996 Jan. 155(1):38-42. [Medline].

  37. Fabrizio MD, Behari A, Bagley DH. Ureteroscopic management of intrarenal calculi. J Urol. 1998 Apr. 159(4):1139-43. [Medline].

  38. Goodman TM. Ureteroscopy with pediatric cystoscope in adults. Urology. 1977 Apr. 9(4):394. [Medline].

  39. Grasso M. Experience with the holmium laser as an endoscopic lithotrite. Urology. 1996 Aug. 48(2):199-206. [Medline].

  40. Grasso M. Resecting upper-tract urothelial Ca by ureteroscopy. Contemp Urol. 1993 Dec. 5(12):52-9. [Medline].

  41. Grasso M. Flexible Fiberoptic Ureteropyeloscopy. Smith AD, Lingeman JE, Bagley DH, Preminger GM, Clayman RV, Badlani GH, Jordan GH, Kavoussi LV, Segura JW, eds. Smith's Textbook of Endourology. St Louis, Mo: Quality Medical Publishing; 1996. Vol 1: 443-54.

  42. Grasso M, Bagley D. A 7.5/8.2 F actively deflectable, flexible ureteroscope: a new device for both diagnostic and therapeutic upper urinary tract endoscopy. Urology. 1994 Apr. 43(4):435-41. [Medline].

  43. Grasso M, Bagley D. Small diameter, actively deflectable, flexible ureteropyeloscopy. J Urol. 1998 Nov. 160(5):1648-53; discussion 1653-4. [Medline].

  44. Grasso M, Bagley DH. Flexible ureteroscopic lithotripsy using pulsed-dye laser. J Endourol. 1990. 4:155.

  45. Grasso M, Ficazzola M. Retrograde ureteropyeloscopy for lower pole caliceal calculi. J Urol. 1999 Dec. 162(6):1904-8. [Medline].

  46. Grasso M, Fraiman M, Levine M. Ureteropyeloscopic diagnosis and treatment of upper urinary tract urothelial malignancies. Urology. 1999 Aug. 54(2):240-6. [Medline].

  47. Grasso M, Lang G, Loisides P, Bagley D, Taylor F. Endoscopic management of the symptomatic caliceal diverticular calculus. J Urol. 1995 Jun. 153(6):1878-81. [Medline].

  48. Grasso M, Liu JB, Goldberg B, Bagley DH. Submucosal calculi: endoscopic and intraluminal sonographic diagnosis and treatment options. J Urol. 1995 May. 153(5):1384-9. [Medline].

  49. Grasso M, Loisides P, Beaghler M, Bagley D. The case for primary endoscopic management of upper urinary tract calculi: I. A critical review of 121 extracorporeal shock-wave lithotripsy failures. Urology. 1995 Mar. 45(3):363-71. [Medline].

  50. Grotas A, Grasso M. Endoluminal sonographic imaging of upper urinary tract: three-dimensional reconstruction. J Endourol. 2001 Jun. 15(5):485-8. [Medline].

  51. Hudson RG, Conlin MJ, Bagley DH. Ureteric access with flexible ureteroscopes: effect of the size of the ureteroscope. BJU Int. 2005 May. 95(7):1043-4. [Medline].

  52. Johnson GB, Fraiman M, Grasso M. Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies. BJU Int. 2005 Mar. 95 Suppl 2:110-3. [Medline].

  53. Johnson GB, Grasso M. Exaggerated primary endoscope deflection: initial clinical experience with prototype flexible ureteroscopes. BJU Int. 2004 Jan. 93(1):109-14. [Medline].

  54. Keeley FX Jr, Bibbo M, Bagley DH. Ureteroscopic treatment and surveillance of upper urinary tract transitional cell carcinoma. J Urol. 1997 May. 157(5):1560-5. [Medline].

  55. Keeley FX, Kulp DA, Bibbo M, McCue PA, Bagley DH. Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J Urol. 1997 Jan. 157(1):33-7. [Medline].

  56. Kumon H, Tsugawa M, Matsumura Y, Ohmori H. Endoscopic diagnosis and treatment of chronic unilateral hematuria of uncertain etiology. J Urol. 1990 Mar. 143(3):554-8. [Medline].

  57. Lam JS, Gupta M. Ureteroscopic management of upper tract transitional cell carcinoma. Urol Clin North Am. 2004 Feb. 31(1):115-28. [Medline].

  58. Liu JB, Bagley DH, Conlin MJ, Merton DA, Alexander AA, Goldberg BB. Endoluminal sonographic evaluation of ureteral and renal pelvic neoplasms. J Ultrasound Med. 1997 Aug. 16(8):515-21; quiz 523-4. [Medline].

  59. Lyon ES, Banno JJ, Schoenberg HW. Transurethral ureteroscopy in men using juvenile cystoscopy equipment. J Urol. 1979 Aug. 122(2):152-3. [Medline].

  60. McMurtry JM, Clayman RV, Preminger GM. Endourological diagnosis and treatment of essential hematuria. J Endourol. 1987. 1:145.

  61. Preminger GM, Kennedy TJ. Ureteral stone extraction utilizing non-deflectable flexible fiberoptic ureteroscopes. J Endourol. 1987. 1:31.

  62. Razdan S, Johannes J, Cox M, Bagley DH. Current practice patterns in urologic management of upper-tract transitional-cell carcinoma. J Endourol. 2005 Apr. 19(3):366-71. [Medline].

  63. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol. 1994 Jun. 151(6):1648-51. [Medline].

  64. Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association. J Urol. 1997 Nov. 158(5):1915-21. [Medline].

  65. Soderdahl DW, Fabrizio MD, Rahman NU, Jarrett TW, Bagley DH. Endoscopic treatment of upper tract transitional cell carcinoma. Urol Oncol. 2005 Mar-Apr. 23(2):114-22. [Medline].

  66. Stoller ML, Wolf JS Jr, Hofmann R, Marc B. Ureteroscopy without routine balloon dilation: an outcome assessment. J Urol. 1992 May. 147(5):1238-42. [Medline].

  67. Streem SB, Pontes JE, Novick AC, Montie JE. Ureteropyeloscopy in the evaluation of upper tract filling defects. J Urol. 1986 Aug. 136(2):383-5. [Medline].

  68. Suh RS, Faerber GJ, Wolf JS Jr. Predictive factors for applicability and success with endoscopic treatment of upper tract urothelial carcinoma. J Urol. 2003 Dec. 170(6 Pt 1):2209-16. [Medline].

  69. Takagi T, Go T, Takayasu H, Aso Y, Hioki R. Small-caliber fiberscope for visualization of the urinary tract, biliary tract, and spinal canal. Surgery. 1968 Dec. 64(6):1033-8. [Medline].

  70. Tawfiek ER, Liu JB, Bagley DH. Ureteroscopic treatment of ureteropelvic junction obstruction. J Urol. 1998 Nov. 160(5):1643-6; discussion 1646-7. [Medline].

  71. Teichman JM, Champion PC, Wollin TA, Denstedt JD. Holmium:YAG lithotripsy of uric acid calculi. J Urol. 1998 Dec. 160(6 Pt 1):2130-2. [Medline].

  72. Wollin TA, Teichman JM, Rogenes VJ, Razvi HA, Denstedt JD, Grasso M. Holmium:YAG lithotripsy in children. J Urol. 1999 Nov. 162(5):1717-20. [Medline].

 
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Flexible fiberoptic ureteropyeloscope.
Secondary endoscope deflection that allows lower-pole intrarenal access.
Plain radiograph that defines a large renal pelvic calculus with the flexible ureteroscope passed beyond the stone burden.
Ureteroscopic image of an impacted jack stone in the ureter. These calculi are composed of calcium oxalate monohydrate.
Ureteroscopic image of a papillary transitional cell carcinoma of the ureter.
A parapelvic cyst (star) causes splaying of the middle and lower pole calyces making access to a lower pole stone (arrow) very difficult.
Comparison of the semi-rigid Karl Storz ureteroscope and tip (above) with that of the ACMI MR6 endoscope (below).
Using secondary deflection, access to this lower pole stone burden is made possible.
The use of dilute contrast injected through the ureteroscope ensures adequate mapping and inspection of all calyces
Wireless ("no touch") ureteroscopy, laser lithotripsy and stone extraction technique performed with the digital ureteroscope.
Table 1. Comparison of Complication Rates Associated With Ureteroscopy, Emphasizing the Noticeable Decrease in the Major Complication Rate With Greater Experience and Endoscope Miniaturization
  Blute, et al. [9] Abdel-Razzak and Bagley [12] Harmon, et al. [13] Grasso [10] Jiang, et al. [11]
Year 1988 1992 1997 2000 2007
Number of Procedures 346 290 209 1000 697
Minor Complications (%) (%) (%) (%) (%)
Colic/pain -- 9.0 3.5 4.2 --
Fever 6.2 6.9 2.0 1.3 --
False passage 0.9 -- -- 0.4 0.4
Hematuria



Minor



Prolonged



0.5



0.3



2.1



1.0



0



0



0.8



0.2



 
Extravasation 0.6 1.0 -- -- --
UTI -- 1.0 -- 1.7 --
Pyelonephritis -- -- -- 1.0 --
           
Major Complications (%) (%) (%) (%) (%)
Major perforation 4.6 1.7 1.0 0 0.3
Stricture 1.4 0.7 0.5 0.4 0.3
Avulsion 0.6 0 0 0 0
Urinoma 0.6 -- 0 0 --
Urosepsis 0.3 0 0 0 --
CVA -- -- 0.5 0.1 --
DVT -- -- -- 0.1 --
MI -- -- -- 0.1 --
Table 2. New York University Experience With Ureteroscopic Treatment of Ureteral Calculi Using the Holmium:YAG Laser
Segment Number of Cases Mean Diameter,



mm (range, mm)



Success Rate,



First-Stage Treatment



and Second -Stage Treatment



Proximal third 75 11.3 (30-5) 95% and 96%
Middle third 45 10.7 (60-5) 98% and 100%
Distal third 91 10.3 (50-4) 99% and 100%
Totals 211   97% and 99%
Table 3. New York University Experience With Ureteropyeloscopic Treatment of Intrarenal Calculi Using the Holmium:YAG Laser
Location Number of Cases Mean Diameter,



mm (range, mm)



Success Rate, Treatment



and Multistage Treatment



Upper pole 58 10.6 (35-4) 90% and 97%
Middle pole 30 11.1 (23-4) 90% and 93%
Lower pole 103 14.8 (40-3) 79% and 85%
Renal pelvic 37 20.5 (60-6) 78% and 95%
Totals 228   81% and 90%
Table 4. Review of Studies on Ureteroscopic Management of Upper Urinary Tract Calculi > 2 cm
STUDY Date Number of Patients Mean Stone Diameter (mm) Mean number of procedures Stone Free (%) Complications number (%)
Grasso et al.[14] 1998 51 24.9 1.3 93 3 (3)
El-Anany et al.[16] 2001 30 >20 1 77 3 (10)
Ricchiuti et al.[17] 2007 23 30.9 1.4 74 0 (0)
Breda et al.[18] 2008 15 22 2.3 93 3 (9)
Riley et al.[19] 2009 22 30 1.8 91 4 (10)
Hyams et al.[20] 2010 120 24 1.2 83 8 (6)
Takazawa et al.[21] 2011 20 31 1.4 90 3 (5)
Cohen et al.[15] 2012 145 29 1.6 87 5 (2)
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