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    Ureteroscopy G Adey

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    Centanarian
    This document discusses the history and development of ureteroscopy, including flexible ureteroscopes that allow for active deflection and working channels. It reviews the indications for ureteroscopy such as urolithiasis, upper tract tumors, and strictures. Laser lithotripsy is discussed as the preferred method for stone fragmentation, and outcomes data is presented showing high stone-free rates. The role of stents with ureteroscopy is reviewed, with some studies finding increased pain with stenting and no difference in stone-free rates. Endoscopic management of upper tract tumors is discussed, with some data suggesting it does not increase risk of tumor seeding when followed by nephroureterectomy.

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    Ureteroscopy G Adey

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    Centanarian
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    This document discusses the history and development of ureteroscopy, including flexible ureteroscopes that allow for active deflection and working channels. It reviews the indications for ureteroscopy such as urolithiasis, upper tract tumors, and strictures. Laser lithotripsy is discussed as the preferred method for stone fragmentation, and outcomes data is presented showing high stone-free rates. The role of stents with ureteroscopy is reviewed, with some studies finding increased pain with stenting and no difference in stone-free rates. Endoscopic management of upper tract tumors is discussed, with some data suggesting it does not increase risk of tumor seeding when followed by nephroureterectomy.

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    This document discusses the history and development of ureteroscopy, including flexible ureteroscopes that allow for active deflection and working channels. It reviews the indications for ureteroscopy such as urolithiasis, upper tract tumors, and strictures. Laser lithotripsy is discussed as the preferred method for stone fragmentation, and outcomes data is presented showing high stone-free rates. The role of stents with ureteroscopy is reviewed, with some studies finding increased pain with stenting and no difference in stone-free rates. Endoscopic management of upper tract tumors is discussed, with some data suggesting it does not increase risk of tumor seeding when followed by nephroureterectomy.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    61 views66 pages

    Ureteroscopy G Adey

    Uploaded by

    Centanarian
    This document discusses the history and development of ureteroscopy, including flexible ureteroscopes that allow for active deflection and working channels. It reviews the indications for ureteroscopy such as urolithiasis, upper tract tumors, and strictures. Laser lithotripsy is discussed as the preferred method for stone fragmentation, and outcomes data is presented showing high stone-free rates. The role of stents with ureteroscopy is reviewed, with some studies finding increased pain with stenting and no difference in stone-free rates. Endoscopic management of upper tract tumors is discussed, with some data suggesting it does not increase risk of tumor seeding when followed by nephroureterectomy.

    Copyright:

    © All Rights Reserved
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    of 66

    Ureteroscopy:

    Instruments, Indications,
    and Outcomes
    Gregory S. Adey, MD
    Residents’ Conference
    2 April 2003
    History of Ureteroscopy
    • 1912: Hugh Hampton Young using
    9.5Fr pediatric cystoscope
    • 1970’s: Routine rigid ureteroscopy
    • 1964: Marshall reports first flexible
    ureterscopy (diagnostic only)
    – No deflecting mechanism
    – No working channel
    Fiberoptics
    • 1854: John Tyndall (London)
    demonstrates internal reflection
    allows bending of light within flexible
    glass
    • 1927: First patent granted for light
    transmission using flexible glass
    fibers
    Fiberoptics
    • Molten glass drawn into small
    diameter fibers
    • Fibers arranged with identical
    orientation at each end
    • Clad each fiber with 2nd outer layer of
    glass improves transmission,
    reflection, and durability
    – Honeycomb or mesh appearance
    Flexible Ureteroscopes
    • 1980’s:Bagley, Huffman, Lyon (U Chicago)
    • Small lenses permit magnification and
    angles of view
    • Active deflection mechanism
    – Logical or intuitive movement
    • Passive deflection (secondary)
    – Inherent weakness in durometer of sheath
    – Enables lower pole access
    Flexible Ureteroscopes
    Indications & Applications
    of Ureteroscopy
    • Urolithiasis
    • Upper tract TCC
    • Ureteropelvic junction obstruction
    • Ureteral stricture
    • Hematuria or abnormal cytology
    evaluation
    • Iatrogenic foreign bodies
    Urolithiasis
    • Semi-rigid below iliac vessels

    • Flexible ureteroscopy above iliacs

    • Pre-operative and peri-operative Abx


    Dealing with the Intramural
    Ureter
    • Semi-rigid Ureteroscopy
    • Catheter Dilatation
    • Balloon Dilatation
    • Ureteral Access Sheath
    Semi-rigid Ureteroscopy
    • Tapered scope

    • 6.9Fr to 7.5Fr (older scopes 9Fr-12Fr)

    • Gentle dilation under direct vision


    Catheter Dilatation
    • Guide wire in place
    • 10Fr dual lumen catheter
    – Gentle dilatation over wire
    – Used to place 2nd wire
    • Graduated dilators
    – I.e. Nottingham dilators
    • +/- ureteral stent
    Balloon Dilatation
    • Varying diameters and lengths of
    balloons (10-18Fr, 4-10 mm)
    • Dilation usually maintained at 10-14
    atm for 2 minutes
    • Almost always stented post-
    operatively for risk of obstruction
    • Cost $225
    Ureteral Access Sheath
    • Hydrophilic sheath, tapered inner
    dilator
    • Inserted under fluoroscopy
    • 20 cm, 28 cm, or 35 cm lengths
    • 10/12Fr, 12/14Fr (inner/outer)
    diameter, 14/16Fr now available
    • Cost: $100
    Ureteral Access Sheath
    Bagley and Grasso
    • 584 procedures, 2 institutions

    Grasso M and Bagley DH. J Urology: 160(5), 1998.


    Ureteral Access Sheath
    • Does the access sheath facilitate
    ureteroscopy?
    • Prospective, randomized, 62 patients
    • 47 patients required no dilatation
    – 24 unaided URS, 23 URS via UAS
    • 15 patients required ureteral dilation
    – 7 dilated with UAS, 8 with balloon

    Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001


    Ureteral Access Sheath
    • 100% of balloon dilated patients
    stented, 43% of UAS patients stented
    • No significant differences in post-op
    symptoms, complication rate or
    stone-free status
    • Time savings of 10 min in UAS group
    (43 min vs. 53 min)
    – OR cost savings $350/case

    Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.


    Ureteral Access Sheath

    Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.


    Ureteral Access Sheath
    • Does the UAS cause ureteral
    ischemia?
    • Swine animal model, n=11
    • 3 ureteral units per sheath size,
    2 pigs without sheath (control)
    • Laser doppler flowmetry every 5 min
    for 70 min

    Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.
    Ureteral Access Sheath

    Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.
    Urolithiasis
    • AUA Ureteral Stones Clinical
    Guidelines:
    – 98% of all calculi < 5 mm will pass
    spontaneously
    – ESWL 1st line therapy for calculi 1 cm or
    less in proximal ureter
    – ESWL or URS 1st line for calculi 1 cm or
    less in distal ureter

    Segura JW, Preminger GM, Assimos DG, et al. J Urology: 158(5), 1997.
    Urolithiasis
    • AUA Ureteral Stones Clinical
    Guidelines:
    – Blind basket extraction is not
    recommended
    – Open surgery is appropriate as a
    salvage procedure or in unusual
    circumstances
    Urolithiasis
    • Most common reason for URS

    • Electrohydraulic lithotripsy (EHL)

    • Holmium: Yttrium-Aluminum-Garnet
    laser (Ho:YAG)
    EHL
    • Cheaper than laser lithotripsy
    • 1.9F probe
    • Shock-wave production fragments
    stone
    • Narrow margin of safety
    EHL
    • Can cause extensive local tissue
    damage including perforation
    • Can propel fragments through
    ureteral wall
    • Contraindicated in patients with
    bleeding diathesis
    Ho:YAG
    • More expensive than EHL
    • Thermal reaction with stone matrix
    • Vaporizes all stone compositions
    • 2100 nM wavelength
    • Frequency 5 to 10 Hz
    • Power 0.6 to 1.2 J
    Ho:YAG
    • Quartz laser fibers (reusable)
    • Helium-neon aiming beam
    • 200, 365, 400, 800, 1000 micron fibers
    • Cost $750-$1000/fiber
    • Energy absorbed in 3 mm of water,
    Tissue penetration of 0.4 mm
    • Risk is mainly thermal injury
    Ho:YAG with Bleeding
    Diathesis
    • 25 patients:
    – 17 taking coumadin
    – 4 with thrombocytopenia (< 50 k/mm3)
    – 3 with liver dysfunction
    – 1 with von Willebrand’s disease
    • 1 complication: RP hemorrhage after
    combined EHL with Ho:YAG
    • Ho:YAG alone: safe in patients with
    bleeding diathesis

    Watterson JD, Girvan AR, Preminger GM, Denstedt JD. J Urology: 168(2), 2002.
    EHL vs. Holmium

    Teichman JM, Rao RD, Rogenes RV, et al. J Urology: 158(4), 1997.
    Laser Lithotripsy
    • Proximal ureteral calculi:
    – 100% stone free (Gupta, < 1 cm, n=46)
    – 93% stone free (Gupta, > 1 cm, n=35)
    – 89% stone free (Wolf, n=81)
    • Distal ureteral calculi:
    – 100% stone free (Bartsch, n=40)
    – 99% stone free (Kane, n=113)
    – 95% stone free (Jenkins, n=96)
    Laser Lithotripsy
    • Renal calculi:
    – 91% stone free (Grasso, n=45)
    – 85% stone free (Preminger, n=36)
    – 80% stone free (Bagley, n=59)
    – 77% stone free (Elakkad, n=30)
    Laser Lithotripsy
    • Lower Pole Study Group1:
    – ESWL < 10 mm (63% stone free)
    – ESWL 10 to 20 mm (23% stone free)
    • Negative predictors of success:
    – Previous failed ESWL
    – Cystine stone
    – Anatomic considerations

    Lingeman JE, et al. J Endourology: 151, 1997.


    Laser Lithotripsy
    • Lower pole stones difficult to
    visualize
    • 200 micron fiber has least reduction
    in deflection (7 to 16% loss)
    • Newer scopes (Storz Flex-X 270°,
    ACMI Dur-8 Elite) facilitate access
    Laser Lithotripsy
    • Relocate LP stones to pelvis, mid- or
    upper pole location
    • 3.2Fr nitinol basket vs. 2.6Fr nitinol
    grasper
    • Less chance of entrapment with
    grasper, but caution with each
    Laser Lithotripsy

    Kourambas J, Delvecchio FC, Munver R, Preminger GM. Urology: 56(6), 2000.


    Stent?
    • Prophylactic stenting prior to ESWL does
    NOT lead to higher stone free rates
    – Multiple, prospective, randomized, stones of
    all sizes
    • Indications prior to ESWL
    – Obstructive pyelonephritis
    – ARF secondary to obstruction
    – Refractory colic
    – Relief of high-grade or long-term obstruction
    Stent?
    • Yes:
    – Balloon dilatation
    – Excessive ureteral wall trauma
    – Impacted stone
    – Ureteroscopy > 90 min1
    – Solitary kidney
    – Incomplete fragmentation
    • Cost: $130
    Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS. Urology: 57(4), 2001.
    Stent?
    • Prospective, randomized study
    • 53 patients stented, 54 without
    • Patients with stents had significantly
    more flank pain, bladder pain,
    narcotic use
    • No difference in stone free rates
    • 4 patients (7.4%) without stents
    required re-admission for pain
    Borboroglu PG, Amling CL, Schenkman NS, et al. J Urology: 166(5), 2001.
    Stent?
    • 93 patients with distal calculi, no stents
    placed
    • Basket (70 patients), EHL (23)
    • Balloon dilatation to 15Fr (80)
    • Post-operative pain:
    – 40 patients (43%) no pain
    – 45/53 patients (85%) mild pain
    – 5 patients (5%) required IV narcotics &
    overnight admission

    Hosking DH, McColm SE, Smith WE. J Urology: 161(1), 1999.


    Stent?
    • Multi-institutional, prospective,
    randomized study (58 patients)
    • 29 stented, 29 without stents
    • Holmium laser (57 patients), EHL (1)

    Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.


    Stent?

    Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.


    Upper Tract TCC
    • Nephro-ureterectomy with bladder
    cuff remains gold standard
    • Distal or segmental ureterectomy
    acceptable in certain situations
    • What is the role of endoscopic
    treatment for upper tract TCC?
    URS and Upper Tract TCC
    • Can URS cause local tumor seeding
    from pyelovenous, pyelotubular, and
    pyelolymphatic backflow?

    • 2 case reports of tumors cells within


    submucosal lymphatic and vascular
    space following URS
    URS and Upper Tract TCC
    • 13 patients with upper tract TCC
    • Diagnostic URS followed by
    subsequent nephrectomy (later date)
    • No free tumor cells seen within
    vascular or lymphatic spaces of the
    submucosa

    Kulp DA, Bagley DH. J Endourology: 8(2), 1994.


    URS and Upper Tract TCC
    • 96 patients had nephro-ureterectomy
    for upper tract TCC
    • 48 patients had pre-operative URS
    immediately prior to NU (48 controls)
    • No significant differences in
    recurrence rates, time to recurrence,
    or mortality

    Hendin BN, Streem SB, Novick AC. J Urology: 161(3), 1999.


    Endoscopic Treatment of
    Upper Tract TCC
    • 21 patients with upper tract TCC
    • 8 pelvic, 13 ureteral (<2 cm), Gr 1 or 2
    • All received endoscopic treatment:
    – Electrocautery (13), Nd:YAG (8)
    – Cautery penetrates 4 mm
    – Neodymium used for larger tumors
    • Mean follow-up: 6 years
    Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
    Endoscopic Treatment of
    Upper Tract TCC
    • 7 patients (33%): local recurrences,
    1 patient (5%) two local recurrences

    • 17 kidneys (81%) were preserved,


    4 (19%) had NU for recurrence

    • None of 4 NU specimen > pT1


    Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
    Endoscopic Treatment of
    Upper Tract TCC
    • Range of recurrence: 2 to 24 months
    Mean time to recurrence: 7 months
    • No strictures
    • 1 patient died from invasive bladder
    TCC
    • Kaplan-Meier 10-yr survival: 70%

    Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
    Endoscopic Treatment of
    Upper Tract TCC
    • 38 patients, all tx endoscopically
    • All TCC grade 1 or 2
    • Mean follow-up: 35 months
    • 11 patients (29%) have recurrence
    • 30/38 kidneys (78%) salvaged

    Keeley F, Bibbo M, Bagley DH. J Urology: 157, 1997.


    Upper Tract TCC
    • Select situations where endoscopic
    ablation of upper tract TCC is now
    acceptable:
    – Solitary kidney
    – Renal insufficiency
    – Bilateral synchronous tumors
    – Poor operative risk
    Surveillance
    • 23 patients with endoscopically treated
    low-grade TCC

    Chen GL, El-Gabry EA, Bagley DH. J Urology: 164(6), 2000.


    UPJ Obstruction
    • Open pyeloplasty
    • Laparoscopic pyeloplasty
    • Endopyelotomy
    – Antegrade
    – Retrograde
    – Acucise
    UPJ Obstruction
    • Predictors of poor outcome for
    endopyelotomy:
    – Severe hydronephrosis
    – Pre-operative renal insufficiency
    – Poorly functioning kidney
    – Strictures > 2 cm in length
    Acucise Endopyelotomy
    Catheter
    • Developed initially for cutting the
    anterior commisure of the prostate
    • Procedure not durable in humans
    • 1st Acusize of UPJ 1993 (Wash U)
    • Initially 14Fr profile (required pre-op
    stent), now 10Fr profile
    • Over 20,000 performed (2000)
    Acucise Endopyelotomy
    Catheter
    • Indications:
    – Stricture of UPJ, proximal or distal ureter, or
    ureteral orefice
    – Stricture of uretero-enteric anastamosis
    – Stricture length < 2 cm
    • Contraindications:
    – Mid-ureteral stricture
    – Stricture> 2cm
    – Uretero-enteric anastamosis crossing aorta
    Acucise Endopyelotomy
    Catheter
    • 0.035” tri-coated guide wire
    • Ureteral access sheath
    • Balloon (24Fr expanded, 2.2cc
    capacity)
    • Cutting Wire (3 cm long, 150 microns
    wide)
    • 7/10Fr tapered stent
    Acucise Endopyelotomy
    Catheter
    • Primary UPJ: lateral cut
    • Secondary UPJ: postero-lateral cut
    (CT w/ contrast and reconstructions)
    • Pure cutting current – 75 W
    • 0.5 cc in balloon to start (see waist)
    – Slowly inflate balloon, continuous
    fluoroscopy, while applying a maximum
    5 seconds of cutting current
    Acucise Endopyelotomy
    Catheter
    • Should see immediate extravasation
    • Acucise removed over wire
    • Flexible ureteroscope alongside wire
    to visualize incision (if needed)
    – Possible additional laser cut?
    • 7/10Fr tapered stent over wire
    (through access sheath)
    Acucise Endopyelotomy
    Catheter
    • Bleeding:
    – Insert 30Fr tamponade balloon catheter
    placed to straddle UPJ
    – Immediate insertion of percutaneous
    nephrostomy tube
    – POD#2, in IR suite balloon is deflated, if
    bleeds, involved artery embolized,
    otherwise place 7/10Fr stent
    Acucise Results
    • Success Rates:
    – 43/56 (77%): Preminger et al {1997}
    – 60/77 (78%): Albala et al {1998}
    – 21/26 (81%): Clayman et al {1996}

    • Cost: $1150
    Endopyelotomy Stenting
    • Classic teaching: 6 weeks
    – 7/10Fr or 7/14Fr stent
    • Davis Intubated Ureterotomy (1948)
    – 90% of muscle regenerated @ 6 wks
    • No prospective data on earlier
    removal
    Retrograde Ureteroscopic
    Endopyelotomy
    • 1986: first peformed
    • Improved results with improved
    technology
    • Advantages:
    – Endoluminal ultrasound
    – Cutting under direct vision
    – Control length and depth of incision
    Retrograde Ureteroscopic
    Endopyelotomy
    • Endoluminal ultrasound:
    – 6.2 Fr catheter
    – 12.5 MHz transducer
    – 30 revolutions per second for 360º, real
    time, cross-sectional imaging
    • Identifies crossing vessels in 53%1

    Bagley DH, Liu JB, Grasso M, et al. J Endourology: 8, 1994.


    Retrograde Ureteroscopic
    Endopyelotomy
    • Cautery:
    – 2 Fr pencil tip or hook electrode
    – 45 W pure cutting current
    • Ho:YAG
    – 200 micron fiber, 1.2 J energy, 15-20 Hz
    • Nd:YAG
    – Less commonly used
    Retrograde Ureteroscopic
    Endopyelotomy
    • Success Rates:
    – 88% (n=8) Biyani et al {1997}
    – 83% (n=28) Grasso et al {2000}
    – 82% (n=86) Van Cangh et al {1996}
    – 81% (n-21) Bagley et al {1998}
    Cost-Effective Treatment of
    UPJ Obstruction

    Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA, Pearle MS. J Urology: 169 (1),
    2003.

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