Presentation on theme: "EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES"— 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 INTRODUCTIONMultiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countriesNo known incidence of such presentationsNot much literature available on how to tackle these multiple pathologiesNo set rules laid out for approaching these multiple pathologies endoscopically in one sitting
3 Problems in Developing Countries Presentation is relatively lateEconomic considerations of the patient population plays a pivotal role in this delayed presentation“cure all one sitting” Pressure on clinicians more in following situation:WomenChildrenOld PeopleSole earning memberPoor or lower middle class peoplePatient coming from a distance for treatment
4 ANALYSIS OF MULTIPLE ENDO- PROCEDURES Incidence of multiple procedures at presentationVarious combinations of these Pathologies at presentationEndourological algorithms devised where applicable to tackle these problems effectivelyStudy Group - SRMC – Urology Unit 1Period to 2002Exclusions- Local Anaesthesia casesDiagnostic procedures- open with endoscopicE.g Hernias with TURP
5 INCIDENCETotal number of endourological procedures since –Multiple pathologies at presentations 239Incidence of presentations %
6 MOST COMMON MULTIPLE PATHOLOGIES 239 (11.1 %) Bilateral Ureteral calculusVesical calculus + BPHVesical calculus + Ureteral calculus - 41BPH + Ureteral calculusBPH + Bladder tumourStricture Urethra with bladder and ureteral calculusHello
7 Endoscopic Clearance of easier / less demanding pathologies first EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIESEndoscopic Clearance of easier / less demanding pathologies firstLower tract to be cleared first before proceeding to upper tractCompletely clear one entity first -exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURPExcept for Some Exceptions
8 Lower tract stone disease before upper tract Stone disease EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIESLower tract stone disease before upper tract Stone diseaseChronological order of Intervention helps in maintaining vision till the end of such multiple proceduresLitholapaxy-> Lithotripsy> Incisions> Resections
10 COMMOM SENSE ALGORITHMS INTERNAL URETHROTOMYBNITURPTUIP
11 BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!! Lower Ureteric Calculus firstLesser Impacted calculus firstBilateral safety guide wires firstSide needing stents only first.
12 CYSTOLITHOLAPAXY/TRIPSY + TURP/TUIP Cystolithotripsy -36Using 27fr nephroscope,2 mm Swiss Litho probeCystolitholapaxy -18Using 25Fr Sheath &Mechanical LithotriteExtra operative times minMorbidity-nilFew patients had increased Irritative LUTS
13 CYSTHOLAPAXY/TRIPSY +TURP CALCULUS FIRST ! AdvantagesBladder free of fragments of the calculusGood vision still being maintained-Preventing inadvertent bladder injuryAny 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 VESICAL CALCULUS + URETERAL CALCULUS Combination-41Majority of vesical calculus were cmMajority of ureteral calculus were in the lower ureter -26WHICH FIRST!!OPTIONS------1.Placing guide wire-cystolithotrripsy-URS2.Cystolithotripsy-URS+ DJ Stenting
15 VESICAL+URETERAL CALCULUS Advantageous to complete the ureteral calculus first Exceptions- large bladder calculusfragments of ureteral calculus and vesical calculus can be evacuated at the same time from the bladderless chances of ureteric orifice injury preventing upper tract intervention
17 TURP +TURBT Total number of cases-6 Maurmayer et al- 7% Blandy et al %TURP FIRST !Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa2.Easy instrumentation.TURBT FIRST!Advantages-1.Resection occurs in clearer access2.Preventing massive absorption of irrigant as can happen from prostatic fossa.
18 BPH + URETERAL CALCULUS NUMBER OF CASES- 31Ureteral calculus first!! ( Exceptions-Large median lobe preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injuryTURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice )Advantages – Allows ease of instrumentation of the upper tract
19 BPH WITH VESICAL & URETERAL CALCULUS 19 casesLarge median lobe-4, B/L ureteral calculi-1Calculi first ! !May need TUIP for larger prostateslesser extravasation/absorptionUreteral first ! !Advantage- Prevents oedema/injury to ureteral orifice- Easier access with best vision
20 PREREQUISITES FOR “CURE ALL” ENDOSCOPIC APPROACH Use of Endovision cameraServices of Experienced OperatorPerceive limitations of Combination proceduresPreference for general anaesthesia over regionalPatients to be well counselled and appreciate combinationsWarm Irrigant fluids to avoid hypothermia
21 Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation Candidates must be relatively ‘fit’ for extended proceduresPresence of experienced assistant desirable
22 TURP + HERNIORRAPHY / HERNIOPLASTY (guidelines ) TURP F IRST !Avoid liberal TUIP / BNIAvoid mesh Repair in presence of Infected UrinePostpone herniorraphy in case of gross ExtravasationAvoid Bilateral herniorraphy with TURP / TUIP
23 AVOID ……TURP & PCNL both accompanied with considerable haemorrhage - !!B/L Upper tract procedure if-1.First side is difficult / prolonged procedure2.Pus seen on clearing calculus on one side
24 THERE IS ALWAYS A SECOND CHANCE !!! REMEMBER ………THERE IS ALWAYSA SECOND CHANCE !!!