Endoscopic Surgeries Endoscopic Surgeries Endoscopic Surgeries

Indications

Removal of stones from renal pelvis and calyces.

  1. On preoperative day 1- Placement of ipsilateral ureteral and bladder catheter.
  2. Positioning of the patient (prone position, bolsters elevating flank)
  3. Opacification of upper urinary tract and identification of stones
  4. Planning of access route with fluoroscopy head at 90°
  5. Puncture of collecting system with fluoroscopy head at 30° using 18 Ga needle (“bull’s eye”–needle tip and hub superimposition).
  6. Assessment of depth of puncture with fluoroscopy head at 90°.
  7. Introduction of hydrophilic guidewire (0.035) through needle sheath and passage past UPJ or into calyces.
  8. Skin incision at puncture site and dilation of access tract using axial dilators (Amplatz) or dilation balloon (Nephromax) to 30Fr.
  9. Introduction of nephroscope, inspection of pelvicalyceal system.
  10. Retrieval of proximal end of ureteral catheter with forceps, and introduction of stiff guide wire (0.035) through it.
  11. Advancement of stiff guide wire to exteriorization through distal tip of ureteral catheter, and removal of catheter over wire. Stiff guide wire now provides maximum safety and access to urinary tract through distal (urethra) and proximal points (nephrostomy tract).
  12. Nephroscope introduced once more, and destruction of stones with ultrasonic lithotripter. Retrieval of stone fragments with endoscopic forceps or basket.
  13. If stones are located in calyces that cannot be accessed by rigid nephroscope, then flexible ureteroscope can be used.
  14. Upon clearance of stone burden, inspection of pelvicalyceal system for hemorrhage. Removal of nephroscope and sheath, insertion of Malecot self-retaining catheter. In selected cases, nephrostomy tubes inserted.

Diagnostic

Visual inspection of upper urinary tract
Biopsy of upper urinary tract

Therapeutic

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)

  1. Insertion of ureteroscopic access sheath (9.5 or 12Fr) over guidewire under fluoroscopic control
  2. Visual identification of stone/tumor
  3. Stone destruction /tumor ablation using laser fiber—or biopsy of suspect lesion
  4. Retrieval of stone fragments using endoscopic basket and/or forceps
  5. Insertion of double j ureteral stent
  6. Insertion of bladder catheter

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 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» 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 hydrophilic wire. If this passes, (hydrophilic wires almost always pass any obstruction), place a hydrophilic 4 Fr angiography catheter over the hydrophilic 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.

Introduction

Minimally invasive relief of uretero-pelvic junction obstruction, especially in conjunction with renal pelvic stones.

  • On preoperative day #1 –Placement of ipsilateral ureteral and bladder catheter.
  • Positioning of patient (prone position, bolsters elevating flank).
  • Opacification of upper urinary tract and identification of obstructed UPJ and possible stones.
  • Planning of access route with fluoroscopy head at 90°.
  • Puncture of collecting system with fluoroscopy head at 30° using 18 Ga needle (“bull’s eye”–needle tip and hub superimposition), ideally through upper or middle calyceal group, for easier visualization and access to UPJ. Assessment of depth of puncture with fluoroscopy head at 90°.
  • Introduction of hydrophilic guidewire (0.035) through needle sheath and passage past obstructed UPJ.
  • Skin incision at puncture site and dilation of access tract using axial dilators (Amplatz) or dilation balloon (Nephromax) to 30Fr.
  • Introduction of nephroscope, inspection of pelvicalyceal system and obstructed UPJ.
  • Retrieval of proximal end of ureteral catheter with forceps, and introduction of stiff guide wire (0.035) through it.
  • Advancement of stiff guidewire to exteriorization through distal tip of ureteral catheter, and removal of catheter over wire. Stiff guidewire now provides maximum safety and access to urinary tract through distal (urethra) and proximal points (nephrostomy tract).
  • Introduction of endoscopic scissors through nephroscope, full thickness section of obstructed UPJ at lateral aspect.
  • Placement of 14/7Fr endopyelotomy double J stent over guidewire.
  • Placement of nephrostomy tube for adequate urine drainage.

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Indications

Removal of stones from renal pelvis and calyces.

  1. On preoperative day 1- Placement of ipsilateral ureteral and bladder catheter.
  2. Positioning of the patient (prone position, bolsters elevating flank)
  3. Opacification of upper urinary tract and identification of stones
  4. Planning of access route with fluoroscopy head at 90°
  5. Puncture of collecting system with fluoroscopy head at 30° using 18 Ga needle (“bull’s eye”–needle tip and hub superimposition).
  6. Assessment of depth of puncture with fluoroscopy head at 90°.
  7. Introduction of hydrophilic guidewire (0.035) through needle sheath and passage past UPJ or into calyces.
  8. Skin incision at puncture site and dilation of access tract using axial dilators (Amplatz) or dilation balloon (Nephromax) to 30Fr.
  9. Introduction of nephroscope, inspection of pelvicalyceal system.
  10. Retrieval of proximal end of ureteral catheter with forceps, and introduction of stiff guide wire (0.035) through it.
  11. Advancement of stiff guide wire to exteriorization through distal tip of ureteral catheter, and removal of catheter over wire. Stiff guide wire now provides maximum safety and access to urinary tract through distal (urethra) and proximal points (nephrostomy tract).
  12. Nephroscope introduced once more, and destruction of stones with ultrasonic lithotripter. Retrieval of stone fragments with endoscopic forceps or basket.
  13. If stones are located in calyces that cannot be accessed by rigid nephroscope, then flexible ureteroscope can be used.
  14. Upon clearance of stone burden, inspection of pelvicalyceal system for hemorrhage. Removal of nephroscope and sheath, insertion of Malecot self-retaining catheter. In selected cases, nephrostomy tubes inserted.

Diagnostic

Visual inspection of upper urinary tract
Biopsy of upper urinary tract

Therapeutic

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)

  1. Insertion of ureteroscopic access sheath (9.5 or 12Fr) over guidewire under fluoroscopic control
  2. Visual identification of stone/tumor
  3. Stone destruction /tumor ablation using laser fiber—or biopsy of suspect lesion
  4. Retrieval of stone fragments using endoscopic basket and/or forceps
  5. Insertion of double j ureteral stent
  6. Insertion of bladder catheter

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 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» 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 hydrophilic wire. If this passes, (hydrophilic wires almost always pass any obstruction), place a hydrophilic 4 Fr angiography catheter over the hydrophilic 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.

Introduction

Minimally invasive relief of uretero-pelvic junction obstruction, especially in conjunction with renal pelvic stones.

  • On preoperative day #1 –Placement of ipsilateral ureteral and bladder catheter.
  • Positioning of patient (prone position, bolsters elevating flank).
  • Opacification of upper urinary tract and identification of obstructed UPJ and possible stones.
  • Planning of access route with fluoroscopy head at 90°.
  • Puncture of collecting system with fluoroscopy head at 30° using 18 Ga needle (“bull’s eye”–needle tip and hub superimposition), ideally through upper or middle calyceal group, for easier visualization and access to UPJ. Assessment of depth of puncture with fluoroscopy head at 90°.
  • Introduction of hydrophilic guidewire (0.035) through needle sheath and passage past obstructed UPJ.
  • Skin incision at puncture site and dilation of access tract using axial dilators (Amplatz) or dilation balloon (Nephromax) to 30Fr.
  • Introduction of nephroscope, inspection of pelvicalyceal system and obstructed UPJ.
  • Retrieval of proximal end of ureteral catheter with forceps, and introduction of stiff guide wire (0.035) through it.
  • Advancement of stiff guidewire to exteriorization through distal tip of ureteral catheter, and removal of catheter over wire. Stiff guidewire now provides maximum safety and access to urinary tract through distal (urethra) and proximal points (nephrostomy tract).
  • Introduction of endoscopic scissors through nephroscope, full thickness section of obstructed UPJ at lateral aspect.
  • Placement of 14/7Fr endopyelotomy double J stent over guidewire.
  • Placement of nephrostomy tube for adequate urine drainage.

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