COMPLICATIONS OF URETEROSCOPY & ITS MANAGEMENT

1. COMPLICATIONS OF
URETEROSCOPY AND ITS
MANAGEMENT
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
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2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. INTRODUCTION
Miniaturization of instruments
• Smaller diameter ureteroscopes
• Less traumatic tips
Better technique
Development of safety principles
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Dept of Urology, GRH and KMC, Chennai.

4. Incidence
Minor – 0.5 - 20%
Major – 1.5-5%
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

7. PREDISPOSING FACTORS
• Impacted Stone
• Operative Time > 90 min
• Previous h/o ureteral surgery
• Stone Width > 5mm
• Lower Hospital Volume <15 case/year
• Female Gender
• Old Age > 80
• Surgeon Experience
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Dept of Urology, GRH and KMC, Chennai.

8. INTRAOPERATIVE
COMPLICATIONS
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Dept of Urology, GRH and KMC, Chennai.

9. BLADDER DISTENTION
• Intraoperative overdistention can lead to postoperative urinary
retention and on rare occasions – bladder perforation
• Pre-existing outlet obstruction and prostatic enlargement may
contribute to post op retention
• Prevention
• Small calibre foley or red rubber catheter may be placed alongside
the ureteroscope for bladder drainage
• Monitoring bladder volume
• Ureteral access sheath
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Dept of Urology, GRH and KMC, Chennai.

10. Failure To Access The Upper Tract
1.6 - 1.8% with flexible
8% semirigid
Risk factors
• >1.5cm stones and proximal stones
• intrinsic or extrinsic ureteral narrowing
• stone impaction
• genitourinary anatomy(cystocele, enlarged prostate, large intravesical median lobe, generalized
edema, trabeculations, cellules
• ureteral orifice location such as re-implanted, ectopic or duplicated ureters)
Best to abort procedure with ureteral stenting
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Dept of Urology, GRH and KMC, Chennai.

11. Tight Ureteral Orifice
• Telescoping wire - ureteral catheter for direction/stability
• Converting to straight/ curved hydrophilic wire
• Emptying/ filling the bladder
• Manually reducing cystocele/ vaginal prolapse
• IV methylene blue/ fluorescein
• Narrow or stenotic orifice – dilated with tapered dilators or balloons
• May lead to perforation, stone extrusion or avulsion
• Prevented by RGP preop and prestenting the ureter
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Dept of Urology, GRH and KMC, Chennai.

12. Difficult Ureter
• RGP – identify anatomy/ guide maneuvers
• Telescoping wire through ureteral catheter
• URS may be passed upto difficult ureteral segment and wire passed under direct vision
• 2 wires may be passed for difficult narrow ureter orifice and URS passed between them
(railroad technique)
• If stricture distal to stone it may be dilated with tapered dilators/ balloons
• Stone impaction or obstruction – Lignocaine jelly may be injected 1-2cm below it to dilate
the ureteral smooth muscle and separate stone and ureteral wall – excessive injection/
force may injure the ureter and cause extravasation
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Dept of Urology, GRH and KMC, Chennai.

13. EQUIPMENT FAILURE
Abortion Rate
0.8%
Most common
cause: Iatrogenic
Fragile
Visual Field –
Perfectly round
(crescent shaped
- breakage)
Guide wire
breakage /
Balloon Dilator
Breakage
Prevention
• Maintenance/
Handling
• Sterilisation/
Storage
• Use
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

16. Retained Basket
• 0.5%
• Grasping a stone or Fragment too large for ureteric removal
• Forced Retraction – injury
• Gently advance the stone proximally – disengage
• Cut the handle – withdraw ureteroscope – Re-entry – Laser to cut the wire and disengage stone
• Nitinol Basket soft nature – hence easily withdrawn
• Steel Baskets
• Delayed Staged Removal
• Open surgery
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

19. Ureteral Stent Malposition
• Ureteral Stenosis
• Tortuosity
• Avoided by placement of guide wire and advancement
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

21. STONE MIGRATION
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Dept of Urology, GRH and KMC, Chennai.

22. Proximal Migration
• 3.5 to 12.2%
• Increases operative/ anesthesia time and may prevent case completion necessitating
second procedure
• Risks – proximal stone location, degree of ureteral dilation, pneumatic or
electrohydraulic lithotrites and increased fluid irrigation.
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Dept of Urology, GRH and KMC, Chennai.

23. Intra-Mural Stone Extrusion
• “Submucosal stone” extrusion through the ureteral mucosa injuring the inner ureteral lining
• Occurs with impacted stone
• Predisposing factor to stricture formation – nidus for stone growth
• Submucosal stones diagnosed as bulges endoscopically
• Observation leads to granuloma or stricture formation
• Extraction is difficult and may lead to worse outcomes
• Laser excision followed by stenting is recommended if identified during atraumatic URS
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

25. Extra-Mural Stone Migration
• Lost stone
• Risk factors – improper technique, ureteral edema, poor blood supply of ureteral segment,
high intraluminal pressure from irrigation and outward compressive force on the stone from
scope
• Sequelae – stricture and fluid extravasation and rarely retroperitoneal abscess
• Stent should be placed for perforation
• Stone location should be documented as future imaging studies may falsely diagnose
ureteral calculus
• Follow Up Imaging
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

28. URETERAL INJURY
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Dept of Urology, GRH and KMC, Chennai.

29. Classification
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

33. • Failed conservative management or high grade injuries need reconstruction
• Timing – Within 5 days or after 6 weeks
• With nephrostomy tube in place antegrade and retrograde studies are performed
• Cystogram for bladder involvement in reconstruction
• Optimal repair – injury location, degree of ureteral loss, surgeon comfort/ training
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

35. Mucosal Abrasion
• Incidence 6-24%
• Postop – Obstruction from edema or clotted blood
• Multiple passes through the ureter increases likelihood
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

39. False Passage/ Mucosal Flap
• 1.1-2.8%
• When attempting to pass a wire past impacted stone or
• Semirigid scope advancement into ureteral wall
• Passing wire without smooth advancement or appearance of abnormal anatomy on
fluoroscopy should alert surgeon
• Wire may follow path of ureter/ collecting system -- flap
• Peri- adventitial extravasation confirms false passage or mucosal flap
• If injury occurs – stenting should be done
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

43. Perforation
• 0-18%
• Occur from passing wires, ureteral dilation, ureteroscope passage, instrument manipulation,
lithotripsy and unexpected patient movement
• Risk factors
• Increased operative time and procedure difficulty
• Ureteral tortuosity, periureteral fibrosis, stone impaction, ureteral stenosis
• patient movement
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Dept of Urology, GRH and KMC, Chennai.

44. • Recognized endoscopically with visible disruption of ureteral wall or visible fat
• Radiographically as contrast extravasation
• Small perforation – stenting
• Large perforation -termination of case and stenting(2-4weeks)
• Urinomas drained percutaneously
• Bladder catheterized for maximum drainage
• Follow Up Imaging -- stricture
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

48. Ureteral Access Sheath
• Low grade and self limiting
• RG urogram should be performed prior to UAS placement to r/o stone or stricture.
• If UAS does not pass freely – inner tapered dilator should be used to predilate the
ureter or sequential taper dilators or balloon dilators to be used
• Pre Stenting
• UAS larger than 12/14Fr should not be used without prior stenting/ dilation
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

50. Ureteral Avulsion
• 0.1 to 0.5%
• Extensive degloving injury to ureter
• Full or partial thickness discontinuity of ureter
• Typically occurs from over stretching the ureter
• Proximal 1/3rd most prone as it is less muscular
• Removing a stone too large for the ureter to accommodate or
• Advancing a ureteral dilator, access sheath, or ureteroscope in a retrograde
manner
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Dept of Urology, GRH and KMC, Chennai.

51. • Avulsion can occur during withdrawal of basket with unrecognized tissue
entrapment
• RGP will demonstrate extravasation of contrast without opacification of
ureter and collecting system proximal to the disruption
• Distal ureter may be avulsed upward with scope passage – recognized
on removing scope – scabbard injury
• Increased resistance may the only sign that impending ureteral injury is
about to occur
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

56. • Intraoperative Recognition – immediate Surgery
• Objective Restoring Ureteral Continuity
• Distal Ureter – Ureteroneocystomy/ Psoas Hitch/ Boari Flap
• Mid Ureter – end to end anastomosis
• Complete Avulsion // Scabbard – Autotransplantation / Illeum Interposition
• Rarely Nephrectomy – risk in preserving the kidney
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Dept of Urology, GRH and KMC, Chennai.

57. Intussusception
• Only the inner layer is avulsed leaving muscularis
• Occurs in direction of scopes movement
• Often arises in a narrowed segment – with stone extraction or removal of polypoid
ureteral lesion
• RGP – contrast filling in a ragged lumen
• Immediate sequale less severe than complete avulsion
• Stent placement for 6 weeks/ follow up
• Rarely heals over stent and forms long segment strictures
• Usually staged ureteral reconstruction is necessary
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

59. Lithotrite Injury
• Mechanical / Thermal Injury – abrasion/bleeding/perforation
• Lithotripsy near crossing vessels – done carefully – catastrophic
• Small mucosal defects – large necrotic areas
• More with Pneumatic
• Prevention
• Limiting urothelial contact
• Short working distance
• Keeping laser fibre parallel to wall
• Visualzation of tip
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Dept of Urology, GRH and KMC, Chennai.

60. Bleeding
• Instrumentation related trauma/ lithotripsy/ Forniceal Rupture
• Minor Bleed – self limiting
• Prolonged Bleed – vision obscured, Place ureteral stent and postpone
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Dept of Urology, GRH and KMC, Chennai.

61. Pressure Related Injury
• During URS/ RGP
• Calyceal Fornices rupture - Urinary extravasation – urinoma – sepsis
• Prevention
• Decrease irrigation fluid pressure
• SAPS/ PathFinder/ Endomat Select
• UAS
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

63. EARLY POST-OPERATIVE
COMPLICATIONS
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Dept of Urology, GRH and KMC, Chennai.

64. Residual Stone
• Common
• Explain the possibility of multiple sittings/ ESWL
• Adjunctive Alpha Blockers
• Post URS stenting
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Dept of Urology, GRH and KMC, Chennai.

65. Urinary Extravasation/ Urinoma
• 0.6-1%
• Disruption of ureteral wall / collecting system
• Significant Extravasation – Max Urinary Diversion
• Stenting upto 6 weeks
• Nephrostomy Tube
• Foley Catheter
• Antibiotics
• Urinoma infected/ Symptomatic – percutaneous/open drainage
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

67. Urinary Obstruction
• 4-9%
• Instrumentation – Ureteric Trauma
• Local edema/ Spasm/ Bleeding with clots – Obstruction
• Post URS colic and hydroureteronephrosis
• Self limiting/ conservative management
• Persistent pain – imaging and Stent Placement
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Dept of Urology, GRH and KMC, Chennai.

68. Stent Discomfort
• Stent Related Symptoms upto 88% of which 70% need treatment
• CROES – readmission due to stent discomfort in 1%
• ? Routine stenting needed
• Restrict to large stone size, longer operative time, prior ureteroscopy and complication
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Dept of Urology, GRH and KMC, Chennai.

69. Hemorrhage
• Minor and self limiting
• Significant Post-operative bleed with haematocrit drop
• Work Up
• Contrast imaging
• Embolisation
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Dept of Urology, GRH and KMC, Chennai.

70. Venous Thromboembolism
• Rare
• Pulmonary TE (0.02%)
• AUA – do not recommend DVT prophylaxis for URS procedures
• Mechanical Compression and Early Ambulation
• High risk Cases – consider Pharmacological Prohylaxis ???
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Dept of Urology, GRH and KMC, Chennai.

71. Infection/ Sepsis
• Seeding infectious pathogens in the upper urinary tract
• Handling potential infected calculi
• High irrigation pressure in a setting of UTI
• Complicated UTI post URS – 1-3.7%
• AUA – antibiotic prophylaxis for all cases undergoing URS
• UroSepsis – 0.3%
• Immunocompromised
• Elderly
• Recent UTI
• Infectious stone
• Prolonged indwelling stent
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Dept of Urology, GRH and KMC, Chennai.

72. LATE POST-OPERATIVE
COMPLICATIONS
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Dept of Urology, GRH and KMC, Chennai.

73. Ureteral Stricture
• Miniaturization – Dramatic Decrease <1%
• Trauma – inflammatory process following devascularisation or ischaemic injury to
urothelium
• But some stricture develop without any precipitator
• Symptomatic or Asymptomatic (silent Obstruction)
• AUA – Routine Post Operative USG after 3 months
• <1cm – endoureterotomy/ balloon dilatation and stenting
• >1cm/ Failed – open/ Lap
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

76. Urethral Stricture
• Transurethral Procedure – potential to injure
• Men>>Women
• H/o instrumentation + voiding symtpoms/ change in flow pattern
• Uroflowmetry/ Imaging – Cystoscopy and management
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Dept of Urology, GRH and KMC, Chennai.

77. Retained DJ Stent
• Forgotten indwelling ureteral stent – encrustation
• Poor Compliance
• Complications – retrograde migration, breakage, occlusion, stone formation
• Rate of encrustation>12 weeks – 76.3%
• Treatment – Multimodal Approach/ Multiple Sessions
• Preventable
• Stent Registry
• Email/ SMS
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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

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Dept of Urology, GRH and KMC, Chennai.

80. Persistent Vesicoureteral Reflux
• High as 10% within 24 hours
• Typically Resolve by 2 weeks
• In 5-10% ( ureteral dilatation, incision or excision at intramural ureter) demonstrate
reflux after 3-20months
• Grade 1-3 sterile reflux – no treatment
• Recurrent UTI/ high pressure voiding – bulking agents injected at 6’o clock beneath
ureteral orifice
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Dept of Urology, GRH and KMC, Chennai.

81. CONCLUSION
• Most complications minor
• Screen for UTI and start antibiotics if culture positive
• Use Safety Guide wire, Always Visualise
• Avoid force, Low threshold for stenting – Postpone by a week
• If difficulty persists – RGP – smallest scope – dilatation last resort
• Basket should be used with care
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Dept of Urology, GRH and KMC, Chennai.

82. THANK YOU
WHEN IN DOUBT DON’T DO IT
WHAT IS DONE CANNOT BE UNDONE
WHAT IS NOT DONE, CAN ALWAYS BE DONE
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Dept of Urology, GRH and KMC, Chennai.