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EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of Urology & Renal Transplantation, Sri Ramachandra Medical.

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Presentation on theme: "EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of Urology & Renal Transplantation, Sri Ramachandra Medical."— Presentation transcript:

1 EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of Urology & Renal Transplantation, Sri Ramachandra Medical College and Research Institute, Chennai, India

2 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY INTRODUCTION No known incidence of such presentations Not much literature available on how to tackle these multiple pathologies No set rules laid out for approaching these multiple pathologies endoscopically in one sitting Multiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countries

3 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY Problems in Developing Countries Presentation is relatively late Economic considerations of the patient population plays a pivotal role in this delayed presentation cure all one sitting Pressure on clinicians more in following situation: Women Children Old People Sole earning member Poor or lower middle class people Patient coming from a distance for treatment

4 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY ANALYSIS OF MULTIPLE ENDO- PROCEDURES Study Group - SRMC – Urology Unit 1 Period - 1996 to 2002 Exclusions - Local Anaesthesia cases - Diagnostic procedures - open with endoscopic - E.g Hernias with TURP Incidence of multiple procedures at presentation Various combinations of these Pathologies at presentation Endourological algorithms devised where applicable to tackle these problems effectively

5 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY INCIDENCE Total number of endourological procedures since 1996 – 20022176 Multiple pathologies at presentations239 Incidence of presentations11.1 %

6 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY MOST COMMON MULTIPLE PATHOLOGIES 239 (11.1 %) Bilateral Ureteral calculus- 81 Vesical calculus + BPH- 54 Vesical calculus + Ureteral calculus- 41 BPH + Ureteral calculus- 39 BPH + Bladder tumour- 06 Stricture Urethra with bladder and ureteral calculus- 05

7 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY Endoscopic Clearance of easier / less demanding pathologies first Lower tract to be cleared first before proceeding to upper tract Completely clear one entity first - exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURP EVOLVING ENDOSCOPIC PROCEDURE GUIDELINES FOR TACKLING MULTIPLE URO - PATHOLOGIES

8 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY Lower tract stone disease before upper tract Stone disease Chronological order of Intervention helps in maintaining vision till the end of such multiple procedures Litholapaxy-> Lithotripsy> Incisions> Resections EVOLVING ENDOSCOPIC PROCEDURE GUIDELINES FOR TACKLING MULTIPLE URO - PATHOLOGIES

9 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY ALGORITHMS Simple common sense Algorithms Complex Endourologic Algorithms

10 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY COMMOM SENSE ALGORITHMS BNITURPTUIP INTERNAL URETHROTOMY

11 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!! Lower Ureteric Calculus first Lesser Impacted calculus first Bilateral safety guide wires first Side needing stents only first.

12 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY CYSTOLITHOLAPAXY/TRIPSY + TURP/TUIP Cystolithotripsy -36 Using 27fr nephroscope, 2 mm Swiss Litho probe Cystolitholapaxy -18 Using 25Fr Sheath &Mechanical Lithotrite Extra operative times-10-45 min Morbidity-nil Few patients had increased Irritative LUTS

13 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY CYSTHOLAPAXY/TRIPSY +TURP CALCULUS FIRST ! Advantages Bladder free of fragments of the calculus Good vision still being maintained-Preventing inadvertent bladder injury Any untoward incident forcing abandonment of surgery-May end up with a resected lobe and calculus free status!! Preventing Absorption/Extravasation of irrigant when calculus is dealt before

14 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY VESICAL CALCULUS + URETERAL CALCULUS Combination-41 Majority of vesical calculus were 2-2.5 cm Majority of ureteral calculus were in the lower ureter -26 WHICH FIRST!! OPTIONS------ 1.Placing guide wire- cystolithotrripsy-URS 2.Cystolithotripsy-URS+ DJ Stenting

15 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY VESICAL+URETERAL CALCULUS Advantageous to complete the ureteral calculus first Exceptions- large bladder calculus fragments of ureteral calculus and vesical calculus can be evacuated at the same time from the bladder less chances of ureteric orifice injury preventing upper tract intervention -

16 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY

17 TURP +TURBT Total number of cases-6 Maurmayer et al- 7% Blandy et al -5.2% TURP FIRST ! Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa 2.Easy instrumentation. TURBT FIRST! Advantages-1.Resection occurs in clearer access 2.Preventing massive absorption of irrigant as can happen from prostatic fossa.

18 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY BPH + URETERAL CALCULUS NUMBER OF CASES- 31 Ureteral calculus first!! ( Exceptions-Large median lobe preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injury 2. TURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice ) Advantages – Allows ease of instrumentation of the upper tract

19 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY BPH WITH VESICAL & URETERAL CALCULUS 19 cases Large median lobe-4, B/L ureteral calculi-1 Calculi first ! ! May need TUIP for larger prostates lesser extravasation/absorption Ureteral first ! ! Advantage- Prevents oedema/injury to ureteral orifice - Easier access with best vision

20 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY PREREQUISITES FOR CURE ALL ENDOSCOPIC APPROACH Use of Endovision camera Services of Experienced Operator Perceive limitations of Combination procedures Preference for general anaesthesia over regional Patients to be well counselled and appreciate combinations Warm Irrigant fluids to avoid hypothermia

21 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation Candidates must be relatively fit for extended procedures Presence of experienced assistant desirable

22 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY TURP + HERNIORRAPHY / HERNIOPLASTY (guidelines ) TURP F IRST ! Avoid liberal TUIP / BNI Avoid mesh Repair in presence of Infected Urine Postpone herniorraphy in case of gross Extravasation Avoid Bilateral herniorraphy with TURP / TUIP

23 ALGORITHMS FOR MULTIPLE URO PATHOLOGIES ENDOSCOPICALLY AVOID …… TURP & PCNL -- both accompanied with considerable haemorrhage - !! B/L Upper tract procedure if- 1.First side is difficult / prolonged procedure 2.Pus seen on clearing calculus on one side

24 REMEMBER ……… THERE IS ALWAYS A SECOND CHANCE !!!


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