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Flexible ureteroscopy update: indications, instrumentation and technical advances Private

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Ureteroscopy is defined as retrograde instrumentation performed with an endoscope passed through the lower urinary tract directly into the ureter and calyceal system.[1] With the addition of actively deflectable, flexible endoscopes the indications for ureteral access sheath have broadened from diagnostic to a variety of complex minimally invasive therapies. Current ureteroscopic treatments include intracorporeal lithotripsy (by far the most common), treatment of upper urinary tract urothelial malignancies, incising strictures, evaluation of ureteral trauma, and repairing ureteropelvic junction obstructions.[2,3] With improved instrumentation and incorporation of technologies such as a large endoscope working channel and active tip deflection, the evolution of surgical techniques have broadened while the complications noted with ureteropyeloscopy have actually decreased significantly.

The application of flexible fiber ureteroscope was first reported by Marshall in 1964. A 9F fiberscope manufactured by American Cystoscope Makers (Pelham Manor, NY) was passed into the ureter to visualize an impacted ureteral calculus. Subsequently, Bagley, Huffman, and Lyon began work at the University of Chicago to develop an improved flexible fiberoptic ureteropyeloscope in the 1980s.

Irrigating fluids are employed to clear the optical field of view and to cool the tip of energy-delivering devices. The irrigant is delivered through the same channel used for working instruments, often through a side arm adapter (Urolock – Boston Scientific, Natick Mass. and Check flow, Cook Urologic, Spencer, Indiana). The simplest and most cost-effective means of delivering continuous irrigant is to employ two 60 cc syringes connected to a three-way stopcock with arterial line tubing. Normal saline is the irrigation standard solution for diagnostic ureteral stent and lithotripsy. When electrocautery is employed sorbitol or small aliquots of sterile water may be used.[12]In a recent prospective study of 460 consecutive upper-tract endoscopies at our center, “no-touch” direct access ureteroscopy (i.e. placement of the endoscope into the ureter under direct vision without the assistance of a guide wire and without dilation) was successfully performed in the majority of patients. This wireless form of flexible digital ureteroscope system or “no touch technique” is technically challenging but eliminates the potential trauma, mucosal irritation and inadvertent manipulation of stones or tumors caused by guide wires and is particularly helpful when mapping the collecting system for mucosal lesions or upper tract transitional cell cancers.[20]

Major intraoperative complications

The major complication rate associated with therapeutic visual ureteroscope series has decreased markedly and currently occurs in less than 1% of all procedures. As with the minor problems, major complications occur less frequently for basically the same reasons – better surgeon skills and improved instrumentation. 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.

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