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URETEROSCOPY

Rajeev Joshi
Asst. Hon. Urologist, Bombay Hospital Institute of Medical Sciences, Mumbai 20.

In the last few years, there has been a growing trend in replacing the more conventional operative procedures by non operative or the minimally invasive procedures. The treatment of urinary stone disease has changed in the last 10-15 years to make the treatment options more patient friendly. However, there are a few exceptional cases where the more conventional open operative procedures are still advisable, where the more sophisticated fashionable "newer" techniques could be more risky.

Ureteroscopy is one such newer technique that enables us to visualize the ureter from within and helps us to treat and diagnose pathologies in the ureter. Ureteroscopy is an extension of the cysto-urethroscopy techniques used in the urethra and bladder, and involves similar indications. However as the ureter is narrow and thin walled ureteroscopy has a narrower safety margin for the prevention of complications.

With increasing experience, the chances of complications have decreased and these can be attributed to a better understanding of the anatomy of the ureter, better instrumentation, better methods to fragment stones and a clearer understanding of the indications for the procedures. The recognition and management of complications have also improved and infact the complications could be prevented by adopting a more conservative treatment option.

The Indian stone disease panorama is more exotic to look at, from a viewing chair but when the time comes to treat these exotic cases it takes a lot of thinking and attention. This is so because the stone disease is so common in the country as a whole and a few stone belts in particular. The rate of stone recurrence, associated infection and renal insufficiency are a few important facts that should be kept in nd. Another important aspect is the financial considerations that should be thought of in giving the patient a cure with least minimal cost and minimal disability.

Indications for ureteroscopy

  1. Calculus disease

    • Primary setting
    ....Lower ureteric calculi

    • Staged procedure
    ....Calculi with severe obstruction
    ....ESWL failures for ureteric calculi
    ....Post ESWL stein-strasse
    ....Calculi plus suspicion of urothelial tumour

  2. Diagnosis Evaluation of radiographic filling defects Surveillance after conservative treatment of upper tract tumour
  3. Therapeutic procedures other than calculi

    • Removal of foreign body
     • Passage of a ureteric stent for obstruction/fistula
     • Stricture dilation/incision
     • Resection of tumours - selected ureteral

Stones in the ureter, which are about 4mm, can pass spontaneously and usually do not require any active treatment. Stones larger than 8 mm usually do not pass spontaneously and do require some intervention. If a patient has passed a calculus in the past then he is likely to be a stone passer and a wait and watch policy could be adopted, as the spontaneous stone removal is least traumatic to the patient.

Ureteric stones which have not moved after a sufficiently long expectant wait; stones with back-pressure changes in the kidneys; stones causing repeated colics with non progression; stones with haematuria and stones with sepsis require surgical intervention. Stones in the upper ureter can betreated with ESWL with sufficient success of upto 80%. In case of ESWL failure of these cases, the option of an open operation or ureteroscopy should be kept in mind. In case of the lower and mid ureteral stones, ureteroscopic stone fragmentation is the preferred treatment option. Factors as stone size, composition, location, associated ureteral condition and past history of the patient should be borne in mind before deciding on the treatment option. In cases of calculi associated with severe obstruction it may be better to place a DJ stent for a few days to weeks prior to ureteroscopic stone fragmentation. This step decreases the renal congestion and passively dilates the ureter, and makes the subsequent ureteroscopic manipulations easy.

Following ESWL, there could occur a jamming of the stone powder in the ureter. This is called steine-strasse or a street of stones. Most of the times these fragments pass spontaneously with minimal discomfort, however at times intervention is necessary when there is fever, progressive obstruction or persistent pain. Often DJ stenting alone suffices as with the internal de-obstruction the stone fragments start moving down. However if DJ stenting fails to cause downward migration of calcu, then ureteroscopic stone manipulation is required.

Suspicion of a tumour

Primary urothelial tumours of the upper urinary tract often pose a challenge in their diagnosis, because in contrast to a bladder tumour where a cystoscopy is done easily to detect and treat bladder tumours, there has not been a satisfactory endoscopic method for similar conditions in the upper tract. Theoretically, tumours of the upper tract coul be diagnosed by ureteroscopy, but the endoscopic treatment of resection of these tumours is and can be achieved in only a few. Also the regular follow up surveillance that would be required in the form of check ureteroscopies would again be a cumbersome factor. This form of treatment could be reserved for a low grade, small growth in a solitary functioning renal unit and where the procedure is done in expert hands.

With the development of a flexible ureteroscope, the upper tract tumours can be diagnosed and followed up in a better manner.

Non malignant lesions as ureteritis cystica and fibro-epithelial polyps may also be biopsied and treated.

Retrieval of foreign body

Some times the DJ stents migrate up into the proximal ureter or a part of the DJ stent breaks and stays with the ureter. In these circumstances the ureteroscopy may be done to retrieve the stent or its fragments.

Incision and dilation of a stricture in the ureter

Short segment strictures of the ureter may be treated endoscopically by cutting with a cold knife and later dilating with a balloon, under vision and fluoroscopic control. Later a 5/6 Fr. Ureteric stent is kept for a period of 6 weeks. The long-term results are not known as yet but if encouraging this could avoid an open operation.

Stent placement

Usually the DJ stents are placed cystoscopically. However if the stent cannot be passed due to a false passage or a mucosal fold then the guide wire can be passed under vision through a ureteroscope over which a stent can be passed. This is done in cases of ureterocutaneous and ureterovaginal fistulae. In these conditions if mature fibrosis has not set in then the stenting can have good results on a long-term basis and an open operation can be avoided.

Preoperative patient management

Preoperative assessment of the patient is mandatory. Knowledge of a prior operation in the lower abdomen or on the ureter or prior radiation to the lower abdomen restricts the mobility of the ureter and manipulating the scope would be difficult thereby limiting the success of the procedure.

A thorough pelvic examination would help to rule out a pelvic mass or a frozen pelvis, which would again make the procedure difficult.

It is necessary to have sterile urine prior to the endoscopy procedure to decrease the chances of uro-sepsis. It is a good idea to give the patient broad-spectrum antibiotics prior to the procedure and to continue with it for a few days after. An intravenous urogram is essential to assess the renalfunction and get knowledge of the ureteral anatomy.

The procedure may be done under a general or a regional anaestsia. The general anaesthesia is preferred, as the breathing pattern can be controlled and injuries to the ureter can be prevented.

It is mandatory to do the procedure under fluoroscopy control.
Fig 1 Fig 3
Fig 4
Fig 5
Fig. 1 : Instruments for Ureteroscopy.
Fig 2
Fig. 2 : C Arm set up. Fig. 3,4 and 5 : Endoscopic view of Ureter, stone in the Ureter and after fragmentation.

PROCEDURE

Dr. HH Young did the first ureteroscopy in 1912 on a small boy with posterior urethral valves with dilated ureters. He used a paediatric cystoscope to visualize the ureter. e initial ureteroscopies were done using a paediatric cystoscope. The length of the scope was a limiting factor and so only the lower third of the ureter could be visualized.

Development in instrumentation has come a long way from the initial stages. The rod lens systems used now to relay light gives a brighter and a more true to life colours that makes visualization better. A second factor is the miniaturization of the telescopes that has enabled us to go up the ureter with causing any damage to the delicate ureter. Lastly, the accessory armamentarium that is used to break the stones or treat strictures etc have become more refined and can achieve good results with little injury to the ureteral wall.

As mentioned earlier, the procedure is to be done under fluoroscopy control.

Cystoscopy

Initially a cystoscopy is done. This is to be done with at least a 21 Fr. sheath, as this would enable us to pass the ureteral dilators under vision. After the preliminary inspection is over the ureter is cannulated with a 5/6 Fr. open ureteric catheter that is passed over a guide wire. Once we have ensured that the guide wire is parked in the renal pelvis then the intramural ureter is dilated.

Dilatation

The ureteral orifice is about 3 Fr. in diameter and so this would mean that we would have to dilate the orifice to allow easy passage of the ureteroscope without causing much trauma to the ureter, this would enable the stone fragments to move down. Routinely the dilation is done at the time of the ureteroscopy and this is called active dilation. This involves dilating the ureter from its original diameter to 12 to 14 Fr in one stage. Various dilators have been devised to achieve this goal. They range from metal bougies to sequential fascial Teflon dilators to single step fascial Teflon dilators to balloon dilators. By this method the fibers encircling the orifice are stretched in a matter of a few minutes and this coul|d lead to some oozing of blood due to the trauma. Of the above mentioned, the balloon dilation is the least traumatic. The advantage of active dilation is that as it is done at the time of ureteroscope it saves time and makes the procedure infection free.

At times the ureteral orifice is very tight or at times the stone is badly impacted in the ureter, in these circumstances it is advisable to keep an indwelling ureteric stent of a small caliber in for a few days and then go in for the ureteroscopy. A ureteric stent kept indwelling for a few days brings about a passive dilation of the ureter, this makes the subsequent ureteroscopy easy. The disadvantage is that it means an extra procedure and the risk of infection.

Ureteroscopy

Once the ureteral dilation is completed then a small sized feeding tube is kept per urethrally to drain the bladder at the time of the ureteroscopy. Thureteroscope is passed under vision into the bladder and later keeping the guide wire as a guide to advance the scope into the ureter. Passing the scope through the orifice is difficult as the orifice is at times obscured by a blood clot that comes in as a result of the dilation. Once the scope passes by the intramural part then the subsequent path is usually smooth. The landmarks mentioned earlier canthen be appreciated endoscopically. It is important to ensure that the guide wire is always coiled in the renal pels as this acts as a guide for the procedure. Another important aspect is to keep the scope in the centre of the lumen and to advance the scope keeping the lumen and the guide wire as controlling guides. By this method the ureter could not be damaged.

Treatment of calculus

Once a calculus is visualized, it is important to decide the method by which this calculus could be removed. Stones that are small can be got out by using a basket or a stone forceps. Larger stones need to be fragmented for their clearance. There are various energy sources with which the stone can be fragmented. One could use an electrohydraulic probe, an ultrasonic probe or a ballistic probe or a laser probe. The principle is that the stone is fragmented into fine particles, which would pass out into the bladder subsequently.

Treatment of tumours

Tumours in the ureter may be treated by ureteroscopy the same way as they are treated in the bladder i.e. by resection or fulguration. However due to the fact that the ureter is very thin the margin of safety is very low. The instruments used for this are a ureteric resectoscope or a bugbee electrode. The main danger lies in inadequate resection and perforation. This form of treatment is reserved for very selected cases like for low grade superficial tumours in a solitary functioning renal unit, where the patient is likely to follow up regularly.

Complications of ureteroscopy

The complications due to ureteroscopy arise due to the fact that the ureter has a delicate structure. They could be avoided if the procedure is done gently keeping to the guidelines. The early complications are bleeding, perforation, avulsion of the ureter and sepsis; and the delayed complication is stricture formation in the ureter bleeding, perforation, avulsion of the ureter and sepsis; and delayed complication is stricture formation in the ureter.

<6b>CONCLUSION

Ureteroscopy is a newer modality of approaching the pathologies in the ureter. While embarking on the procedure it is important to realize that the ureter is a slender organ and can get damaged easily. And so it is imperative to have a proper indication, adequate expertise and good instruments to perform the procedure well. The treatment of stones in the mid and lower ureter is done mostly by ureteroscopy, however the treatment of tumours by ureteroscopic techniques need better definition and is still in its infancy in our country.

REFERENCES
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  2. a>Bagley DH. Indications for ureteropyeloscopy Ureteroscopy, Philadelphia, WB Saunders. 1988; 17-30.
  3. Clayman RV, et al. Ureteronephroscopic endopyelotomy. J Urol 1990; 144 : 246-52.
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  5. Gittes RF, et al. Nephroscopy in unilateral haematuria. J Urology 1981; 126 : 2297.
  6. Hernandez D, et al. Ureteroscopy : Our results and complications. Arch Esp Urol 1993; 46 : 405-9.
  7. Huffman,
  8. et al. Ureteroscopy management of transitional cell carcinoma of the upper urinary tract. Urol Clin North Am 1988a; 15 : 419-24.
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  10. Kapoor DA, et al. Cost efficacy of extracorporeal shock wave lithotripsy versus ureteroscopy in the treatment of lower ureteric calculi. J Urol 1992; 148 : 1095-96.
  11. Koonings PP, et al. Ureteroscopy : A new asset in the management of post-operative ureterovaginal fistulas. Obstet Gynecol 1992; 80 : 548-49.

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