Ureteroscopy – Technical Aspects V Hopkinson September 2015

Ureteroscopy – Technical Aspects

V HopkinsonSeptember 2015

Ureteroscopy• Review imaging/consent/mark• Check urine culture/pregnancy test if appropriate• WHO checklist• Radiographer/C-arm/x-ray table (extensions)• Imaging in theatre• Antibiotic prophylaxis• Lithotomy position• GA• Cystoscopy• Retrograde pyelogram

– Ureteric catheter (5 Fr)– Contrast e.g. Niopam 300 = Iopamidol – non-ionic monomer (300 mg

iodine/mL)

Ureteroscopy• Guidewires– Standard = stainless steel core with PTFE coating– Hydrophilic = nitinol with hydrophilic coating– Straight, angled or J-shaped tip– Length: 150 cm, diameter .035 or .038 in– Always have safety wire

• Semi-rigid ureteroscope alongside guidewire – Second guidewire to negotiate narrowing– 7 – 10 Fr– Working channel 3.4 Fr– 34 cm long

Ureteroscopy• Laser– Holmium:YAG– 365 μm or 200 μm fibre (200 μm allows better

deflection for lower pole stones) – Start with 5 Hz, 0.5 J– Laser safety:

• Safety certificates• Laser safety officer present• Goggles• Windows covered• Doors locked• Check fibres prior to use• Machine on standby when not in use

Ureteroscopy• Baskets– Ureter

• Tipped• Stainless steel• Straight or spiral wires• Three-pronged graspers

– Kidney• Zero tip

– Nitinol– 1.3 – 3 Fr

• NGage™ – Nitinol– 1.7 – 2.2 Fr, 115 cm

Ureteroscopy• Flexible scope– 5.4 – 9 Fr– 70 – 80 cm long– Working channel 3.6 Fr

• Stents– 4.8 Fr – 8 Fr– 18 – 30 cm– Polymers

• e.g. polyurethane, polyethylene• e.g. Percuflex™ Plus

– Boston Scientific – Percuflex with HydroPlus™ coating– Base polymer = polyethylene

Stenting?• Indications:

– Ureteric trauma/perforation– Bleeding– Significant oedema– Impacted stone– Failure to pass scope or complete treatment– Infection– Obstruction– Large stone burden– Single kidney– Renal impairment– Pregnancy– Transplant kidney

Stenting if uncomplicated?• Tang et al. Urology (2011)

– Meta-analysis of randomised trials of stent vs. no stent– 14 trials – Heterogeneity in pain assessment, therefore difference in post-op pain between groups not

clear– Incidence of dysuria, frequency and haematuria significantly higher in stent group– No difference in post-op analgesia requirement, UTIs, post-op fever, stone-free rate and

ureteric stricture between the groups– Decreased tendency towards unplanned medical visits or hospital readmission in stent group

(not statistically significant)– Increased cost in 5 studies– Increased operative time

• Also:– Risk of encrustation– Risk of ‘forgotten stent’

• Alternative: – Ureteric catheter for 24 h

• BUT – involves overnight stay

Problems…

• What do you do if a basketed stone is stuck in the ureter?

• What do you do with a basket with a broken wire?

Problems…• Basketed stone stuck in ureter:

– Try to advance proximally, open basket and remove stone– Fragment stone within basket

• Disassemble basket by unscrewing handle• Replace scope alongside basket and laser stone

– Leave basket and stone in ureter, wake patient up and observe – may fall out spontaneously

• Basket with broken wire– Can cause ureteric trauma– If tipless:

• Advance 7 Fr ureteric catheter or access sheath over basket and withdraw– Otherwise:

• Withdraw under vision grasping distal broken wire with forceps• Transect remaining wires, remove proximal basket, advance distal portion into renal

pelvis, turn it around with forceps and withdraw tip first

– From Le & Segura, BJUI (2006)

Medical Expulsive Therapy

Meta-analyses• Hollingsworth et al. Lancet (2006)

– 9 trials– 693 patients (individual studies 15 – 48 patients in each group)– Calcium channel blockers or alpha blockers– Primary endpoint: proportion of patients who passed stones– Mean stone size 3.9 – 7.8 mm– All stones in distal third of ureter except in one study– Treatment duration 7 days – 6 weeks (or until stone passage)– Follow-up 15 – 48 days– 65% greater chance of passing stone with medical therapy – ARR 0.31 (95% CI 0.25 – 0.38)– NNT 4– Less need for analgesics in MET groups – Limitations:

• Clinical heterogeneity• Publication bias• 8 trials not blinded• 6 did not describe randomisation procedures in detail

Meta-analyses• Campschroer et al. Cochrane Review (2014)

– 32 studies• 7 double-blinded• 2 incomplete data• 1 high number of withdrawals• 28 single-centre• Most had small patient numbers

– 5864 patients– Alpha-blockers– Stone-free rates significantly higher in alpha-blocker group– RR 1.48 (95% CI 1.33 – 1.64)– Stone expulsion time 2.91 days shorter with alpha-blockers– Reduced number of pain episodes, need for analgesia & need for

hospitalisation– Data limited on mid- and proximal ureteric stones

Meta-analyses• Lu et al. Urol Int (2012)– 29 trials– 2763 patients– 19% improvement in stone clearance with tamsulosin– Higher expulsion rate with tamsulosin vs. Ca channel

blockers– Limitations:

• Some studies poor methodological quality• Clinical heterogeneity

– e.g. Stone size, duration of follow-up, measurement of outcomes• Insufficient allocation concealment and blinding• Publication bias

Meta-analyses• Fan et al. Int J Urol (2013)– 14 studies– Increase in expulsion rate in tamsulosin group of 51%– Decrease in expulsion time of 2.63 days– Reduce risk of requiring other procedures by 60%– Increased incidence of side effects (mainly dizziness)

in tamsulosin group– Limitations:

• Clinical heterogeneity• Publication bias• Methodological quality

SUSPEND• Spontaneous Urinary Stone Passage Enabled by Drugs• Multicentre, randomised, double-blind, placebo-controlled trial• 1167 participants (1136 analysed)• Aged 18 – 65 years• 1 stone, ≤ 10mm, any site within ureter• Placebo vs. tamsulosin vs. nifedipine• Exclusion criteria: those needing immediate intervention, sepsis,

eGFR < 30 mL/min, already taking or unable to take an α-blocker or a Ca channel blocker, > 65 years

• Primary outcome: spontaneous stone passage in 4 weeks defined as the absence of the need for additional intervention to assist stone passage at 4 weeks after randomisation

• Other outcomes: pain, time to stone passage, health status & safety, health economic components

SUSPEND

• 80% placebo group needed no intervention compared to 81% in tamsulosin group and 80% in nifedipine group at 4 weeks

• No difference in stone passage at 12 weeks• No differences in analgesic use, time to stone

passage and health status• Serious adverse events in 3 patients in

nifedipine group and 1 in placebo group

SUSPEND trial poll results, BJUI (July 2015)