Flexible ureteroscopy and RIRS

1. FLEXIBLE URETEROSCOPY AND RIRS
DR. Elsayed SALIH MD
Associate professor of urology
Al-Azhar university

2. INTRODUCTION
• Trend in surgical practice today is towards developing minimally invasive
techniques.
• Endoscopic surgery using minimally invasive techniques has been the frontier
of medical innovation in last two decades.
• Development of small calibre flexible instruments permits endoscopic surgery
of urinary tract to treat a wide variety of lesions/conditions within the kidney.

3. RISING TREND FOR URS...WHY???
• Shorter hospital stay
• Lower costs
• Improved cosmesis
• Earlier return to work
• Suboptimal results with ESWL(for renal stone disease)

4. HISTORY
1912: 1st Ureteroscopy by Hugh Hampton Young ("Father of Modern Urology"); a
rigid 12Fr cystoscope was advanced into massively dilated ureter of a pt. with
PUV.
• Late 1950's: development of first fiberoptic endoscope.
• 1964: first flexible ureterorenoscopy by Marshall via a ureterotomy using a 9Fr
flexible endoscope for diagnostic purposes.

5. 1977: Goodman & Lyon reported first rigid ureteroscopy for therapeutic purposes.
• 1990: Fuchs & Fuchs reported the first large series (208 patients) of renal calculi
treated by flexible ureteroscopy.
• 1998: contemporary RIRS using flexible ureterorenoscope and Holmium laser for
treatment of renal stones by Grasso & Chalik.

6. THE URETEROSCOPIC "EVOLUTION"
Rigid ureteroscopes with Rod-lens system & outer diameter 12-13.5Fr & US/EHL
probe
↓
Semirigid ureteroscopes containing fiberoptic illumination & outer diameter
miniaturization
↓
Laser & Pneumatic lithotripters
↓
Flexible URS
↓
Digital URS, Robotic URS & Virtual URS (future trends)

7. CURRENTLY
▪ types of fURS: fiberoptic and digital fURS.
▪ The difference between them is the image relay and light transmission.
▪ In fiberoptic fURS, light and image are transmitted in analog format through
fiberoptics bundles
▪ illumination in digital scopes is made by fiberoptics or by a diode (DEL) and image
capture charged by a digital sensor located at the tip of the endoscope: either
charged coupled device (CCD) or complementary metal oxide semiconductor
(CMOS).

8. DEFINITION...RIRS
▪ Surgery within the renal pelvicalyceal system and parenchyma performed
using instruments introduced in retrograde fashion through the ureter and lower
urinary tract.
▪ Advantage: more proximal ureter and intrarenal collecting system more easily
accessible than conventional URS.

9. INDICATIONS: DIAGNOSTIC
1. Evaluation of hematuria
2. Evaluation of positive upper tract cytology
3. Evaluation of radiographic filling defects or obstruction
4. Surveillance after conservative treatment of upper tract tumors

10. INDICATIONS: THERAPEUTIC
Stone Disease:
1. Failed ESWL (stones <1.5 cm)
2. RIRS assisted ESWL (stones upto 2.5 cm)
3. Radiolucent stones (stones <1.5 cm)
4. Concomitant renal and ureteral stones (renal stone <1 cm)
5. Calyceal diverticular stones
6. Stones with nephrocalcinosis
7. Stones with associated anatomic obstruction
8. Rarely, partial staghorn stones

11. INDICATIONS : OTHERS
1. Treatment of PUJ obstruction
2. Treatment of anastomotic strictures
3. Treatment of urothelial tumors
4. Fulguration of bleeding vessels
5. Retrograde percutaneous renal puncture

12. CONTRAINDICATIONS
▪ There are no specific contraindications
▪ general problems such as general anesthesia
▪ untreated preoperative positive urinalysis.

13. INSTRUMENTATION FOR RIRS
1. Newly designed flexible instrument with dual deflection
2. Energy sources (EHL, Holmium:YAG laser with small caliber
probes)
3. Flexible accessories including guidewires, dilators, access
sheaths, baskets, graspers, ureteric catheters and forceps
4. Suction pump
5. Video camera unit
6. Fluoroscopy unit

15. FLEXIBLE URETERORENOSCOPE
▪ Standard fibreoptic flexible ureterorenoscopes have a tip size in
the range of 6.75 - 9Fr.
▪ actively deflectable (primary deflection) with 120 to 170
degrees of deflection in one direction and 170 to 270 degrees
in other. Secondary deflection will be passive or active.
▪ active secondary deflection allows better maneuverability.
▪ Working channels of Fr 3.6 - 4 and standard instruments (e.g.
baskets) are Fr 2.2 - 3 in size.

16. ACTIVE DEFLECTIONS
▪ Lever controlled, which shortens or
lengthens wires running to metal
rings just proximal to the tip.
▪ Cause the deflection in both
directions in one plane.
▪ Essential to access the lateral and
inferior infundibula

17. ▪ “intuitive”:- when the tip moves in
the same direction as the lever (an
upward deflection on the handle
lever deflects the scope upwards,
and vice versa).
▪ “counterintuitive”:- (an upward
deflection on the handle deflects
the scope tip downward).

18. DIFFERENT SCOPES AVAILABLE

19. SECONDARY PASSIVE DEFLECTION
▪ Result of making the segment just
proximal to the point of active
deflection more flexible.
▪ Passive deflection off the wall of
the renal pelvis moves the point of
deflection proximally on the scope.

20. HOW TO IMPROVE ACTIVE DEFLECTION
▪ Straight alignment of proximal shaft of the ureteroscope.
▪ Access sheath in preventing buckling of the ureteroscope.
▪ Holding the ureteroscope taut by gentle manual back tension on
shaft.
▪ Placing a super-stiff guidewire in the working channel &
positioning the guidewire tip 2 cm proximal to the end of the
ureteroscope. (only in diagnostic procedures)

21. DEFLECTION IS INHIBITED
When larger-diameter accessories are passed through the working
channel.

22. WORKING CHANNEL
▪ Flexible ureteroscopes have a single
working channel.
▪ This allows fluid irrigation and
passage of instruments.
▪ A smooth cylindrical plastic tube that
travels trough the flexible
ureteroscope.
▪ Most working channels are 3.6F in
diameter and are eccentrically
located.

23. ▪ Passage of working instruments may be difficult when the
scope is maximally deflected.
▪ Working channel may be damaged if passage is attempted
while the scope is deflected.
▪ Passing instruments is best accomplished with the scope
straightened and adequately lubricating the instruments.

25. GUIDE WIRES
Traditionally, 2 guidewires were required to perform flexible
ureteroscopy.
1. Safety guidewire,
2. Second is used to facilitate endoscope placement.

26. URETERAL DILATORS
POLYETHYLENE OR PTFE COAXIAL DILATORS
▪ range in size from 6F to 18F
▪ sequentially passed over a wire
under fluoroscopic vision across the
narrow segment.

27. BALLOON DILATORS
▪ deflated shaft diameter of 5F,
▪ balloon lengths between 4 and 10 cm,
▪ Inflated profile of 12–30F.

28. ▪ Placed over a super-stiff or hybrid
wire across the area of interest.
▪ Inflated up to 20 atm of pressure
▪ with diluted contrast with a specially
designed [Le Veen (Boston Scientific)]
pressure gauge syringe.

31. OTHER METHODS
▪ Visual dilatation by Semirigid Ureteroscope.
▪ The inner dilator of access sheath can be used without the outer
sheath to dilate the ureter over a super-stiff guidewire.

32. URETERAL ACCESS SHEATHS
▪ Outer diameter:- 9 to 18 Fr
▪ Length:- 20 to 55 cm.
▪ 12/14F is the standard size (adults)
▪ If the goal is to reach the UPJ:
✓ 35-cm length sheath for women
✓ 45-cm length sheath for men

34. ADVANTAGES
▪ Facilitate expeditious and atraumatic entry and re-entry.
▪ Eliminating the risk of buckling of the endoscope in the bladder.
▪ Protects the upper urinary tract from increased peak intrarenal
pressure.
▪ Decreases the risk of endoscope damage.
▪ Decrease operative time and cost, minimize patient morbidity,
▪ Optimize overall success of flexible ureteroscopy.

35. INTRA CORPOREAL LITHOTRITES
HOLMIUM(HO):YAG LASER
▪ Shown to fragment all compositions of urinary calculi.
▪ produce smaller stone fragments than pneumatic or
electrohydraulic lithotripsy.
▪ energy is absorbed efficiently in a fluid medium, minimizing the
risk of urothelial injury.

36. EHL
▪ generates a spark which results in plasma expansion at
supersonic speed, Propagating a hydraulic shock wave and cavitation
bubble.
▪ Collapse of the cavitation bubble leads to a second shock wave, which if
asymmetric leads to the formation of a liquid jet.
▪ Each of these mechanisms results in stone fragmentation.

37. TIPLESS NITINOL BASKETS
Nitinol baskets preserve the tip
deflection.
tipless design reduces the risk of mucosal
injury.
Nitinol baskets are the only baskets
suitable for use in RIRS. [EAU]

39. COMPLICATIONS OF BASKETING
1. Ureteral avulsion
2. Intussusception
3. Abrasion
4. Perforation
5. Postoperative stricture formation
6. Basket breakage or entrapment

40. GRASPERS
▪ For the removal of
1. Retained stents,
2. Foreign bodies,
3. embedded stones.

42. 20 mL/min provide adequate visualization in most circumstances.
Types:
1. Gravity based: Gravity with or without the assistance of pressure-bag
compression is commonly utilized.
2. Hand held syringe
3. Automated irrigation system
ENDOIRRIGATION SYSTEMS

45. ▪ Patient history and Physical examination
▪ Platelet aggregation inhibitors/anticoagulants should be discontinued if possible.
▪ [URS can be performed in patients with bleeding disorders, with a moderate increase in
complications]
▪ Imaging. CT Urogram/IVU to assess stone load, stone location and pelvi-calyceal anatomy.
▪ Informed consent.
▪ Counselling on treatment options, procedure and potential complications, with possibilities of
requiring postop stenting, second-look procedure, auxiliary procedure and failed procedure
are all thoroughly explained.
▪ Preoperative urine cultures.
▪ antibiotic.
PRE OP EVALUATION

46. ANESTHESIA
▪ GA, preferred than regional anesthesia.
▪ provides better pain control when working in the proximal ureters or
collecting system.
▪ provides a relaxed patient, eliminating harmful sudden movements

47. POSITION
▪ Standard lithotomy position.
▪ The leg contralateral to the side of interest is slightly extended
and the hip abducted.
▪ This allows minimal angulation of the ureters.

48. URETERIC ACCESS
SAFE ACCESS
• Cystoscopy
• RGP– (to assess course of ureter)
• Manipulation of safety wire into kidney.
• 2nd working wire introduction.
• Administration of diuretic – (Reduces risk of pyelorenal reflux and septic
complications)

49. FLEXIBLE URS
▪ “Optical dilation” with 9.5 Fr. Semi rigid ureteroscope.
▪ Introduction of flexible ureteroscope into ureter alongside safety guide
wire over second working guide wire.
▪ Empty bladder if all else fails, consider dilation of ureteral orifice.
▪ the flexible ureteroscope is back loaded over the working guidewire in
a monorail fashion.

50. ▪ Straighten urethra and avoid
kinking.
▪ Advance scope with thumb and
index finger of left hand.

52. URETEROSCOPE TIP DESIGN
▪ When an eccentrically placed
working channel is present, rotation
of the shaft may be required to
orient the working channel of the
instrument to the 12-o’clock
position.
▪ prevent the lens from catching the
roof of the orifice & telescoping
the distal ureters during passage.

53. ACCESS TO LOWER POLE USING SECONDARY
DEFLECTION OF SCOPE

55. RIRS FOR RENAL CALCULI
PRIMARY RIRS INDICATIONS
<15 mm size:
1. Lower calyx.
2. ESWL not feasible (habitus,obesity, radiolucent)
3. Stricture below stone (Caliceal Diverticulum/Nephrocalcinosis)
4. Anticoagulated patients.
5. If there are negative predictors for SWL.
 Shockwave-resistant stones (calcium oxalate monohydrate, brushite, or cystine).
 Steep infundibular-pelvic angle.
 Long lower pole calyx (> 10 mm).
 Narrow infundibulum (< 5 mm).

56. SPECIAL SITUATIONS
▪ Residual after ESWL (not fragmented/not passed)
▪ Residual after PCNL (not passed/ no access)
▪ RIRS assisted ESWL (upto 2.5cm)
▪ Staghorn stones (RIRS + ESWL using holmium debulking)
▪ Staghorn stones when ESWL/PCNL not medically feasible.

57. LITHOTRIPTOR
Ho:YAG laser lithotripsy is the preferred method for (flexible) URS.
200 micron fibre.

59. POST OP STENTING
▪ Routine stenting after uncomplicated URS (complete stone removal) is not
necessary;
▪ A ureteric catheter with a shorter indwelling time (1 day) may be used as well, with
similar results.

60. Stents should be inserted in patients who are at increased risk of
complications:-
Residual fragments,
bleeding,
perforation,
UTIs,
Pregnancy
In all doubtful cases, to avoid stressful emergencies.
Duration of stenting favoured 1-2 weeks after URS.

61. UPPER URINARY TRACT UROTHELIAL
MALIGNANCIES
INDICATIONS
▪ Solitary kidney,
▪ Renal insufficiency,
▪ Synchronous bilateral tumors,
▪ High operative risk,
▪ Predisposition to form multiple recurrences, such as endemic Balkan nephropathy.

62. Patients must commit to a lifetime of follow-up:
 Urine cytologies,
 Endoscopy

63. DIAGNOSTIC URS
▪ Suspicious area biopsy or brush
cytology taken.

65. THERAPEUTIC
Debulking
 grasping forceps
 Flat wire basket
[Tumor base is treated with either
electrocautery or laser energy sources]
Resection by ureteroscopic resectoscope

66. Laser Fulguration:
 Ho: YAG laser:- 0.6 to 1 J with 10 Hz.
 Nd : YAG laser:- 15W for 2 seconds for ablation of tumor.

68. INCISION PROCEDURES
1. Ureterotomy: ureteral stricture
2. Endopylotomy: mainly for secondary PUJO
3. Intrarenal incision

69. TECHNIQUE
▪ Scope positioned at the proximal extent of the UPJ.
▪ 200- or 365-μ holmium fiber is placed through the working channel.
▪ UPJ is typically incised in a posterolateral direction
▪ while the scope is withdrawn back down across
▪ repeated and deepened to extend into the peripelvic and periureteral fat.
▪ Injection of contrast material demonstrate extravasation and confirm an
adequate depth of incision.
▪ Endopyelotomy stent/ 7-8F DJ stent is left across the UPJ for 4 to 8 wks.

71. COMPLICATIONS
1. Urosepsis
2. Bleeding
3. Ureteral perforation
4. Ureteral avulsion
5. Ureteral strictures

72. THANK YOU