1. Ureteroscopy: Instruments, Indications, and Outcomes
Gregory S. Adey, MD
Residents’ Conference
2 April 2003

2. History of Ureteroscopy
1912: Hugh Hampton Young using 9.5Fr pediatric cystoscope
1970’s: Routine rigid ureteroscopy
1964: Marshall reports first flexible ureterscopy (diagnostic only)
No deflecting mechanism
No working channel

3. Fiberoptics
1854: John Tyndall (London) demonstrates internal reflection allows bending of light within flexible glass
1927: First patent granted for light transmission using flexible glass fibers

4. Fiberoptics Molten glass drawn into small diameter fibers
Fibers arranged with identical orientation at each end
Clad each fiber with 2nd outer layer of glass improves transmission, reflection, and durability
Honeycomb or mesh appearance

5. Flexible Ureteroscopes
1980’s:Bagley, Huffman, Lyon (U Chicago)
Small lenses permit magnification and angles of view
Active deflection mechanism
Logical or intuitive movement
Passive deflection (secondary)
Inherent weakness in durometer of sheath
Enables lower pole access
Durometer is a measure of surface resistivity or material hardness

6. Flexible Ureteroscopes

7. Indications & Applications of Ureteroscopy
Urolithiasis
Upper tract TCC
Ureteropelvic junction obstruction
Ureteral stricture
Hematuria or abnormal cytology evaluation
Iatrogenic foreign bodies

8. Urolithiasis Semi-rigid below iliac vessels
Flexible ureteroscopy above iliacs
Pre-operative and peri-operative Abx

9. Dealing with the Intramural Ureter
Semi-rigid Ureteroscopy
Catheter Dilatation
Balloon Dilatation
Ureteral Access Sheath

10. Semi-rigid Ureteroscopy
Tapered scope
6.9Fr to 7.5Fr (older scopes 9Fr-12Fr)
Gentle dilation under direct vision

11. Catheter Dilatation Guide wire in place 10Fr dual lumen catheter
Gentle dilatation over wire
Used to place 2nd wire
Graduated dilators
I.e. Nottingham dilators
+/- ureteral stent

12. Balloon Dilatation
Varying diameters and lengths of balloons (10-18Fr, 4-10 mm)
Dilation usually maintained at atm for 2 minutes
Almost always stented post-operatively for risk of obstruction
Cost $225

13. Ureteral Access Sheath
Hydrophilic sheath, tapered inner dilator
Inserted under fluoroscopy
20 cm, 28 cm, or 35 cm lengths
10/12Fr, 12/14Fr (inner/outer) diameter, 14/16Fr now available
Cost: $100

14. Ureteral Access Sheath

15. Grasso M and Bagley DH. J Urology: 160(5), 1998.
Bagley and Grasso
584 procedures, 2 institutions
Grasso M and Bagley DH. J Urology: 160(5), 1998.

16. Ureteral Access Sheath
Does the access sheath facilitate ureteroscopy?
Prospective, randomized, 62 patients
47 patients required no dilatation
24 unaided URS, 23 URS via UAS
15 patients required ureteral dilation
7 dilated with UAS, 8 with balloon
Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001

17. Ureteral Access Sheath
100% of balloon dilated patients stented, 43% of UAS patients stented
No significant differences in post-op symptoms, complication rate or stone-free status
Time savings of 10 min in UAS group (43 min vs. 53 min)
OR cost savings $350/case
Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.

18. Ureteral Access Sheath
Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.

19. Ureteral Access Sheath
Does the UAS cause ureteral ischemia?
Swine animal model, n=11
3 ureteral units per sheath size, pigs without sheath (control)
Laser doppler flowmetry every 5 min for 70 min
Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.

20. Ureteral Access Sheath
Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.

21. Segura JW, Preminger GM, Assimos DG, et al. J Urology: 158(5), 1997.
Urolithiasis
AUA Ureteral Stones Clinical Guidelines:
98% of all calculi < 5 mm will pass spontaneously
ESWL 1st line therapy for calculi 1 cm or less in proximal ureter
ESWL or URS 1st line for calculi 1 cm or less in distal ureter
Segura JW, Preminger GM, Assimos DG, et al. J Urology: 158(5), 1997.

22. Urolithiasis AUA Ureteral Stones Clinical Guidelines:
Blind basket extraction is not recommended
Open surgery is appropriate as a salvage procedure or in unusual circumstances

23. Urolithiasis Most common reason for URS
Electrohydraulic lithotripsy (EHL)
Holmium: Yttrium-Aluminum-Garnet laser (Ho:YAG)

24. EHL Cheaper than laser lithotripsy 1.9F probe
Shock-wave production fragments stone
Narrow margin of safety

25. EHL Can cause extensive local tissue damage including perforation
Can propel fragments through ureteral wall
Contraindicated in patients with bleeding diathesis

26. Ho:YAG More expensive than EHL Thermal reaction with stone matrix
Vaporizes all stone compositions
2100 nM wavelength
Frequency 5 to 10 Hz
Power 0.6 to 1.2 J

27. Ho:YAG Quartz laser fibers (reusable) Helium-neon aiming beam
200, 365, 400, 800, 1000 micron fibers
Cost $750-$1000/fiber
Energy absorbed in 3 mm of water, Tissue penetration of 0.4 mm
Risk is mainly thermal injury

28. Ho:YAG with Bleeding Diathesis
25 patients:
17 taking coumadin
4 with thrombocytopenia (< 50 k/mm3)
3 with liver dysfunction
1 with von Willebrand’s disease
1 complication: RP hemorrhage after combined EHL with Ho:YAG
Ho:YAG alone: safe in patients with bleeding diathesis
Watterson JD, Girvan AR, Preminger GM, Denstedt JD. J Urology: 168(2), 2002.

29. Teichman JM, Rao RD, Rogenes RV, et al. J Urology: 158(4), 1997.
EHL vs. Holmium
UT San Antonio
Teichman JM, Rao RD, Rogenes RV, et al. J Urology: 158(4), 1997.

30. Laser Lithotripsy Proximal ureteral calculi: Distal ureteral calculi:
100% stone free (Gupta, < 1 cm, n=46)
93% stone free (Gupta, > 1 cm, n=35)
89% stone free (Wolf, n=81)
Distal ureteral calculi:
100% stone free (Bartsch, n=40)
99% stone free (Kane, n=113)
95% stone free (Jenkins, n=96)
Gupta from Columbia-Presbyterian hosp

31. Laser Lithotripsy Renal calculi: 91% stone free (Grasso, n=45)
85% stone free (Preminger, n=36)
80% stone free (Bagley, n=59)
77% stone free (Elakkad, n=30)
Elakkad from Egypt

32. Lingeman JE, et al. J Endourology: 151, 1997.
Laser Lithotripsy
Lower Pole Study Group1:
ESWL < 10 mm (63% stone free)
ESWL 10 to 20 mm (23% stone free)
Negative predictors of success:
Previous failed ESWL
Cystine stone
Anatomic considerations
Infundibulopelvic angle, infundibular length and infundibular width
Lingeman JE, et al. J Endourology: 151, 1997.

33. Laser Lithotripsy Lower pole stones difficult to visualize
200 micron fiber has least reduction in deflection (7 to 16% loss)
Newer scopes (Storz Flex-X 270°, ACMI Dur-8 Elite) facilitate access

34. Laser Lithotripsy
Relocate LP stones to pelvis, mid- or upper pole location
3.2Fr nitinol basket vs. 2.6Fr nitinol grasper
Less chance of entrapment with grasper, but caution with each

35. Laser Lithotripsy
Kourambas J, Delvecchio FC, Munver R, Preminger GM. Urology: 56(6), 2000.

36. Stent?
Prophylactic stenting prior to ESWL does NOT lead to higher stone free rates
Multiple, prospective, randomized, stones of all sizes
Indications prior to ESWL
Obstructive pyelonephritis
ARF secondary to obstruction
Refractory colic
Relief of high-grade or long-term obstruction

37. Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS. Urology: 57(4), 2001.
Stent?
Yes:
Balloon dilatation
Excessive ureteral wall trauma
Impacted stone
Ureteroscopy > 90 min1
Solitary kidney
Incomplete fragmentation
Cost: $130
Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS. Urology: 57(4), 2001.

38. Stent? Prospective, randomized study 53 patients stented, 54 without
Patients with stents had significantly more flank pain, bladder pain, narcotic use
No difference in stone free rates
4 patients (7.4%) without stents required re-admission for pain
Naval base san diego
Borboroglu PG, Amling CL, Schenkman NS, et al. J Urology: 166(5), 2001.

39. Hosking DH, McColm SE, Smith WE. J Urology: 161(1), 1999.
Stent?
93 patients with distal calculi, no stents placed
Basket (70 patients), EHL (23)
Balloon dilatation to 15Fr (80)
Post-operative pain:
40 patients (43%) no pain
45/53 patients (85%) mild pain
5 patients (5%) required IV narcotics & overnight admission
Manitoba, canada
Hosking DH, McColm SE, Smith WE. J Urology: 161(1), 1999.

40. Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.
Stent?
Multi-institutional, prospective, randomized study (58 patients)
29 stented, 29 without stents
Holmium laser (57 patients), EHL (1)
London, toronto, edmonton
Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.

41. Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.
Stent?
Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.

42. Upper Tract TCC
Nephro-ureterectomy with bladder cuff remains gold standard
Distal or segmental ureterectomy acceptable in certain situations
What is the role of endoscopic treatment for upper tract TCC?

43. URS and Upper Tract TCC
Can URS cause local tumor seeding from pyelovenous, pyelotubular, and pyelolymphatic backflow?
2 case reports of tumors cells within submucosal lymphatic and vascular space following URS

44. Kulp DA, Bagley DH. J Endourology: 8(2), 1994.
URS and Upper Tract TCC
13 patients with upper tract TCC
Diagnostic URS followed by subsequent nephrectomy (later date)
No free tumor cells seen within vascular or lymphatic spaces of the submucosa
Kulp DA, Bagley DH. J Endourology: 8(2), 1994.

45. Hendin BN, Streem SB, Novick AC. J Urology: 161(3), 1999.
URS and Upper Tract TCC
96 patients had nephro-ureterectomy for upper tract TCC
48 patients had pre-operative URS immediately prior to NU (48 controls)
No significant differences in recurrence rates, time to recurrence, or mortality
Hendin BN, Streem SB, Novick AC. J Urology: 161(3), 1999.

46. Endoscopic Treatment of Upper Tract TCC
21 patients with upper tract TCC
8 pelvic, 13 ureteral (<2 cm), Gr 1 or 2
All received endoscopic treatment:
Electrocautery (13), Nd:YAG (8)
Cautery penetrates 4 mm
Neodymium used for larger tumors
Mean follow-up: 6 years
Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.

47. Endoscopic Treatment of Upper Tract TCC
7 patients (33%): local recurrences, patient (5%) two local recurrences
17 kidneys (81%) were preserved, (19%) had NU for recurrence
None of 4 NU specimen > pT1
Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.

48. Endoscopic Treatment of Upper Tract TCC
Range of recurrence: 2 to 24 months Mean time to recurrence: 7 months
No strictures
1 patient died from invasive bladder TCC
Kaplan-Meier 10-yr survival: 70%
Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.

49. Endoscopic Treatment of Upper Tract TCC
38 patients, all tx endoscopically
All TCC grade 1 or 2
Mean follow-up: 35 months
11 patients (29%) have recurrence
30/38 kidneys (78%) salvaged
Keeley F, Bibbo M, Bagley DH. J Urology: 157, 1997.

50. Upper Tract TCC
Select situations where endoscopic ablation of upper tract TCC is now acceptable:
Solitary kidney
Renal insufficiency
Bilateral synchronous tumors
Poor operative risk

51. Chen GL, El-Gabry EA, Bagley DH. J Urology: 164(6), 2000.
Surveillance
23 patients with endoscopically treated low-grade TCC
Chen GL, El-Gabry EA, Bagley DH. J Urology: 164(6), 2000.

52. UPJ Obstruction Open pyeloplasty Laparoscopic pyeloplasty
Endopyelotomy
Antegrade
Retrograde
Acucise

53. UPJ Obstruction Predictors of poor outcome for endopyelotomy:
Severe hydronephrosis
Pre-operative renal insufficiency
Poorly functioning kidney
Strictures > 2 cm in length

54. Acucise Endopyelotomy Catheter
Developed initially for cutting the anterior commisure of the prostate
Procedure not durable in humans
1st Acusize of UPJ 1993 (Wash U)
Initially 14Fr profile (required pre-op stent), now 10Fr profile
Over 20,000 performed (2000)

55. Acucise Endopyelotomy Catheter
Indications:
Stricture of UPJ, proximal or distal ureter, or ureteral orefice
Stricture of uretero-enteric anastamosis
Stricture length < 2 cm
Contraindications:
Mid-ureteral stricture
Stricture> 2cm
Uretero-enteric anastamosis crossing aorta

56. Acucise Endopyelotomy Catheter
0.035” tri-coated guide wire
Ureteral access sheath
Balloon (24Fr expanded, 2.2cc capacity)
Cutting Wire (3 cm long, 150 microns wide)
7/10Fr tapered stent

57. Acucise Endopyelotomy Catheter
Primary UPJ: lateral cut
Secondary UPJ: postero-lateral cut (CT w/ contrast and reconstructions)
Pure cutting current – 75 W
0.5 cc in balloon to start (see waist)
Slowly inflate balloon, continuous fluoroscopy, while applying a maximum seconds of cutting current

58. Acucise Endopyelotomy Catheter
Should see immediate extravasation
Acucise removed over wire
Flexible ureteroscope alongside wire to visualize incision (if needed)
Possible additional laser cut?
7/10Fr tapered stent over wire (through access sheath)

59. Acucise Endopyelotomy Catheter
Bleeding:
Insert 30Fr tamponade balloon catheter placed to straddle UPJ
Immediate insertion of percutaneous nephrostomy tube
POD#2, in IR suite balloon is deflated, if bleeds, involved artery embolized, otherwise place 7/10Fr stent

60. Acucise Results Success Rates: Cost: $1150
43/56 (77%): Preminger et al {1997}
60/77 (78%): Albala et al {1998}
21/26 (81%): Clayman et al {1996}
Cost: $1150

61. Endopyelotomy Stenting
Classic teaching: 6 weeks
7/10Fr or 7/14Fr stent
Davis Intubated Ureterotomy (1948)
90% of muscle 6 wks
No prospective data on earlier removal

62. Retrograde Ureteroscopic Endopyelotomy
1986: first peformed
Improved results with improved technology
Advantages:
Endoluminal ultrasound
Cutting under direct vision
Control length and depth of incision

63. Retrograde Ureteroscopic Endopyelotomy
Endoluminal ultrasound:
6.2 Fr catheter
12.5 MHz transducer
30 revolutions per second for 360º, real time, cross-sectional imaging
Identifies crossing vessels in 53%1
Bagley DH, Liu JB, Grasso M, et al. J Endourology: 8, 1994.

64. Retrograde Ureteroscopic Endopyelotomy
Cautery:
2 Fr pencil tip or hook electrode
45 W pure cutting current
Ho:YAG
200 micron fiber, 1.2 J energy, Hz
Nd:YAG
Less commonly used

65. Retrograde Ureteroscopic Endopyelotomy
Success Rates:
88% (n=8) Biyani et al {1997}
83% (n=28) Grasso et al {2000}
82% (n=86) Van Cangh et al {1996}
81% (n-21) Bagley et al {1998}

66. Cost-Effective Treatment of UPJ Obstruction
Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA, Pearle MS. J Urology: 169 (1), 2003.