- Visual inspection of upper urinary tract
- Biopsy of upper urinary tract
- Upper urinary tract lithiasis (ureters, renal pelvis and calyces)
- Urothelial tumor ablation
- Rigid URS
- 1.Positioning of patient – Lithotomy position
- 2.Urethrocystoscopy and identification of ureteral orifices
- 3.Insertion of hydrophyllic guidewire into orifice under fluoroscopic control
- 4.Insertion of double lumen ureteral catheter and injection of contrast solution for retrograde urography
- 5.Substitution of hydrophyllic guidewire for stiff safety guidewir
- 6.Insertion of “zebra” working guidewire
- 7.Advancement of rigid ureteroscope over/along guidewire
- 8.Visual identification of stone/tumor
- 9.Stone destruction /tumor ablation using laser fiber—or biopsy of suspect lesion
- 10.Retrieval of stone fragments using endoscopic basket and/or forceps
- 11.Insertion of double j ureteral stent
- 12.Insertion of bladder catheter
- Flexible URS
Steps 1-4 similar to Rigid URS
- 5.Insertion of ureteroscopic access sheath (9.5 or 12Fr) over guidewire under fluoroscopic control
- 6. Visual identification of stone/tumor
- 7. Stone destruction /tumor ablation using laser fiber—or biopsy of suspect lesion
- 8. Retrieval of stone fragments using endoscopic basket and/or forceps
- 9. Insertion of double j ureteral stent
- 10. Insertion of bladder catheter
Tips and tricks for rigid ureteroscopy
- Dilation of the ureteral orifice is very rarely necessary. If there is difficulty in entering the orifice with the semirigid scope, insert two stiff guide wires through orifice. They will open up the orifice and one of them can be used as a guide for the scope. The other remains as a safety wire.
- Rotation of the scope’s tip may be necessary in order to enter the ureteral orifice. Rotation to a medial direction is done, orifice is entered and then re-rotated to original position
- Irrigation with a pump significantly improves clarity of visual field and provides for dilation of orifice and ureter. However, fragments may be dislocated to upper ureter or pelvis if one is not careful.
- Ureteral sheaths are of great value especially when multiple passes of the scope are anticipated. Sheath may be placed in close contact to the stone and aid in the removal of larger fragments. Furthermore, a sheath ensures that pressures in the collecting system will never be high, as it serves as a passive drain. A first pass through the ureter (without the sheath) to identify the stones is recommended , as sometimes the sheath may pass over a small stone and embed it into the ureteral wall.
- Ureteral sheaths may be moved caudally without the introducer tip, but NEVER cranially. The edges of the sheath will «catch» on the ureteral wall and cause significant damage
- When using a basket for retrieval of a stone, it is seldom necessary to close the wire mechanism. Removing a stone with an open basket minimizes the risk of enclosing a portion of the ureteral wall along with the stone
- When a fragment is too large to be removed through the sheath, it may be carefully removed together with the sheath and scope. The sheath provides dilation of the caudal ureteral section to ease the passage of the stone. However, If tension is encountered, the stone should be left in place and further diminished using the laser or US lithotripter. To regain access to the ureter, the dual lumen catheter should be inserted over the safety wire and a second working stiff wire should be inserted. Then the dual lumen catheter is removed and the ureteral sheath is placed over the working wire.
- Occasionally, a stone in the pelvis, superior or even middle calyces may be found and removed using the semirigid ureteroscope. Stones in the lower calyces are impossible to treat with the semirigid scope.
- If a stone obstructs the ureter to the extent that a stiff wire cannot pass through, try to pass a hydrophyllic wire. If this passes, (hydrophyllic wires almost always pass any obstruction), place a hydrophyllic 4 Fr angiography catheter over the hydrophyllic wire. It should now be possible to insert a stiff wire to straighten the ureter and provide passage to the ureteroscope
- When using the laser fiber to disintegrate a stone, make sure to keep the plastic sheath in the scope’s view. This will ensure a proper distance between the laser and the scope’s lens, minimizing the risk of damage to the optics.
- «Blind» activation of the laser could easily result in ureteral wall perforation. The laser fiber should always be kept in view, and on stand-by until ready to fire at stone.
- Stones should be disintegrated from the periphery to the center
Tips and Tricks for Flexible Ureteroscopy
Rigid Flexible Ureteroscopy – Semi Rigid Ureteroscopy
Rigid Flexible Ureteroscopy – Basic techniques for flexible ureteroscopy
Rigid Flexible Ureteroscopy – Insertion of a semi-rigid ureteroscope using a ureteral sheath