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![• If a false passage is created, a retrograde study
[instilling contrast under continuous
fluoroscopy]
• if resistance is encountered and only
extravasation of contrast is seen, then it is
best not to pursue any further.](https://image.slidesharecdn.com/tipsandtrickssemirigidursfinal-181117215453/85/Tips-and-tricks-semirigid-urs-final-75-320.jpg)
Uploaded byAhmed Eliwa
Tips and tricks semirigid urs final
This document provides tips and tricks for performing semirigid ureteroscopy. It discusses preoperative preparation including reviewing imaging and planning the procedure. Patient positioning and access to the ureter are important considerations. Negotiating the ureteric orifice may require dilatation for difficult cases. Advancing the scope can be challenging in tortuous ureters and kinks may need to be straightened. Stone manipulation involves techniques to fragment and extract stones while preventing migration. Completing the procedure involves ensuring drainage with stenting when needed. Troubleshooting tips address problems that may arise like false passages or difficult baskets. Safety and recognizing complications early are emphasized.
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Similar to Tips and tricks semirigid urs final
Tips and tricks semirigid urs final
- 1. Tips and Tricksof Semirigid Ureteroscopy
- 2. Semirigid URS • mostcommonly used type of scope for access to the upper urinary tract. Krambeck AE, Murat FJ, Gettman MT, et al. The evolutionof ureteroscopy: a modern single-institution series. Mayo Clin Proc 2006;81(4):468–73
- 3. • Despite theversatility of modern URS, definitive treatment of urinary stones remains the most common indication for performing ureteroscopic techniques Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW. Ureteroscopy: current practice and long-term complications. J Urol 1997;157:28–32 (R)
- 4.
- 7. Tips and Tricks •Preoperative Preparation • Patients positioning • Operative Tricks and trouble shooting
- 8. Tips and Tricks PreoperativePreparation • Review patients radiology and radiologic abnormalities Stone : size location density Urinary tract: hydroureteronephrosis • Plan your procedure
- 9. Tips and Tricks PreoperativePreparation • Stop anticoagulants • Any urinary tract infection (UTI) should be treated • Consider presenting and staged procedures
- 10. Tips and Tricks PreoperativePreparation • Check the Instruments • Lithotripsy • C arm , technician and contrast material • Wires and graspers
- 11. Tips and Tricks •Preoperative Preparation • Patients positioning • Operative Tricks and trouble shooting
- 12. Tips and Tricks PatientPositioning • Maintenance of mobility • Fluoroscopic Imaging • Access to instrumentation • Visualization
- 16. Tips and Tricks •Preoperative Preparation • Patients positioning • Operative Tricks and trouble shooting
- 17. • The mostcritical step in uneventful completion of the procedure is the cannulation of the ureteric orifice. • Care must be taken to ensure a very gentle and atraumatic entry.
- 18. • standard cystourethroscopyis performed and the anatomic landmarks delineated.
- 19. STEPS • Negotiation ofthe orifice ± dilatation • Advancing the scope • Stone manipulation and fragmentation • Termination and stenting
- 20. PROBLEMS OF UOACCESS Ureteric Orifice Problems of Access • Pinpoint • Trabeculated Bladder • UV Junction calculus • Large median lobe • Ectopic orifice • Duplex system • Ureterocoele • Diverticulum
- 21. Negotiation of theorifice ± dilatation
- 22. Negotiation of theorifice ± dilatation
- 24. Negotiation of theorifice ± dilatation Cant find the ureteric orifice
- 25. Negotiation of theorifice ± dilatation Cystoscopy showing protuberance at the level of Left vesico ureteric junction
- 27. • Sometimes theureteric orifice is located at a difficult location. • Albarran lever • A narrowstenotic ureteric orifice can be managed by balloon dilatation or graduated metallic dilators.
- 30. Negotiation of theorifice ± dilatation
- 31. Alternatives for facilitatingthe insertion of the guidewire in difficult cases. Directing it through a ureteral catheter (a), under direct ureteroscopic control (b). Negotiation of the orifice ± dilatation
- 32. View from aureteroscope as it is being inserted into the left ureteric orifice between two guidewires (railroading) Negotiation of the orifice ± dilatation
- 33. Negotiation of theorifice ± dilatation Passing the ureteral orifice with two guidewires.
- 35. Negotiation of theorifice ± dilatation
- 36.
- 37. Negotiation of theorifice ± dilatation Incision of the stenosed ureteral orifice using a Collins loop
- 40. URETERAL DILATATION Non guidedsystems •Hydrodilation (ureteromat or use of high pressure bag) Guided systems •Graduated ureteral dilators •Flexible, coaxial, sequential dilators •Dilating balloon catheters •Ureteral access sheath
- 41. Negotiation of theorifice ± dilatation Dilation of the ureteral orifice using a cone ureteral catheter.
- 42. Dilatation of theureteric orifice
- 43. Ureteral orifice passivelydilated with a JJ stent.
- 44. Problems which canoccur due to the use of dilators • Failure of dilatation • Perforation • Submucosal tunneling
- 45. Negotiation of theorifice ± dilatation
- 47. When a guidewireor stent cannot get pass a Steinstrasse or stone impacted in the distal ureter, a ureteroscope can be used to fragment or dis-impact the stone, or flush it with saline (introduced through its irrigation channel). The guidewire can then be passed between the stone and the mucosa under vision
- 48. STEPS • Negotiation ofthe orifice ± dilatation • Advancing the scope • Stone manipulation and fragmentation • Termination and stenting
- 49. Entry of thedistal ureter with the ureteroscope in difficult cases: Left side: dilatation of the orifice with ureteral bougies (9–11 CH). Middle: insertion of the ureteroscope. Before the ostium, the ureteroscope is rotated for 180 degrees, this avoids the stucking of the oblique ureteroscope with the cranial lip of the ostium.
- 50. Advancing the scope Advancingthe ureteroscope into the ureter.
- 51.
- 53.
- 54. Advancing the scope Negotiatingthe ureteral kinks with the Semirigid ureteroscope.
- 55. Straightening of aureteral kinking: the ureteral kinking (left) is straightened with the help of a ureteral catheter and allows the ureteroscopy into the renal pelvis (right)
- 56. • Mertz maneuveris a useful trick that involves pushing the kidney upwards and medially, using a closed fist on the flank beneath the costal margin, to straighten the ureter. Schwalb DM, Eshghi M. Techniques to negotiate the tortuous ureter. J Urol. 1994;151(4):939–42.
- 58. URETERAL SPASM • Inan acute ureteric colic, severe spasm can make even passing a preliminary guidewire difficult. The following options can help relieve ureteral spasm. • Local instillation • Lidocaine Jelly (2 ml) • Aminophylline 0.5% (3 ml) • Intravenuous Buscopan • Indwelling Stent
- 59. • Negotiation ofthe orifice ± dilatation • Advancing the scope • Stone manipulation and fragmentation • Termination and stenting
- 60. Stone Manipulation The extractionof small ureteral calculi with a forceps.
- 61.
- 62. Stone Manipulation Large obstructiveleft lumbar ureteral stone (a), balistically fragmented between the spirals of the basket catheter (b–f).
- 65. Stone Manipulation • Preventionof stone migration • surgeon experience • Location • size of the stone • patient positioning • Irrigation pressures • energy source (i.e., laser, pneumatic, electrohydraulic lithotrites) • energy settings of the fragmentation device FixedfactorsModifiablefactors 2. Dretler SP. The stone cone: a new generation of basketry. J Urol. 2001;165(5):1593–6. 3. Finley DS, et al. Effect of holmium:YAG laser pulsewidth on lithotripsy retropulsion in vitro. J Endourol. 2005;19(8):1041–4. 4. Lee H, et al. Stone retropulsion during holmium:YAG lithotripsy. J Urol. 2003;169(3):881–5.
- 66. Stone Manipulation • Preventionof stone migration
- 67.
- 68. Which Technique isBest? • active extraction or dusting • study by the Endourology Disease Group for Excellence (EDGE) comparing dusting to active extraction
- 71. • Cant findthe stone
- 75. • If afalse passage is created, a retrograde study [instilling contrast under continuous fluoroscopy] • if resistance is encountered and only extravasation of contrast is seen, then it is best not to pursue any further.
- 76. • If theguidewire gets arrested in a false passage, a smaller caliber ureteroscope can be introduced as far as easily possible; while withdrawing the scope, use irrigation under pressure and have the guidewire ready, positioned in the channel. • On withdrawing the scope, sometimes ureteral limen is seen and quickly cannulate it.
- 79. Basket problem • Perforation •Stuck basket • Breakage • Stone impacted within the basket
- 81. STEPS • Negotiation ofthe orifice ± dilatation • Advancing the scope • Stone manipulation and fragmentation • Termination and stenting
- 82. • If thestent is not sliding over the guidewire, the beak of the cystoscope should be kept close to ureteric orifices
- 83. • If itis still not sliding into the ureter, then use a smaller caliber stent. • The guidewire should be held tight by the assistant to avoid looping in the bladder, and the bladder should not be overdistended
- 85. THE TEN COMMANDMENTS 1.Safety use of visors, glasses, endovision camera, water proof gown, gum boots. 2. Use of Image Intensifier. And do retrograde urography 3. Make sure accessories are available. 4. call for help 5.Regular use of glidewire 6. Dilatation of orifice helpful 7. Take measures to improve vision 8. Be ready to stage procedure - DJ Stenting 9. Picking up fragments not important 10. Recognize and correct complication early
Editor's Notes
- #6 Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW.Ureteroscopy: current practice and long-termcomplications. J Urol 1997;157 :28–32 (R) Weinberg JJ, Ansong K, Smith AD. Complications of ureteroscopy in relation to experience: report of survey and author experience.J Urol1987;137: 384–5: (4/C) Blute ML, Segura JW, Patterson DE.Ureteroscopy. J Urol 1988; 139: 510–2 (4/C) Leijte JA, Oddens JR, Lock TM. Holmium laser lithotripsy for ureteric calculi: predictive factors for complications and success.J Endourol2008;22: 257–60 (4/ Abdelrahim AF, Abdelmaguid A, Abuzeid H, Amin M, Mousa E, Abdelrahim F. Rigid ureteroscopy for ureteral stones: factors associated with intraoperative adverse events. J Endourol 2008; 22: 277–80 (4/C) El-Nahas A, El-Tabey N, Eraky I et al .Semirigid ureteroscopy for ureteral stones: a multivariate analysis of unfavorable results. J Urol 2009; 181: 1158–62 (4/C)
- #13 Especially during rigid ureteroscopy or proximal ureteroscopy, the surgeon’s ability to manipulate the endoscope extracorporeally is paramount to a swift and successful outcome.
- #14 When appropriately positioned, the hip and knee joints are fl exed approximately 90 ° and the great toe and ipsilateral knee are aligned with the contralateral shoulder. The lower legs are well padded and secured snugly
- #15 In the extended leg dorsolithotomy position, the leg ipsilateral to the stone is straightened and slightly abducted compared to the contralateral leg. This puts the ipsilateral psoas on stretch and improves access to the mid and proximal ureter by a rigid ureteroscope
- #57 Another useful trick is to pass a guidewire halfway up to the kink; then advance an open-ended ureteric catheter over it and pull both as a unit in order to straighten it by traction. Keeping the open-ended catheter at this position, now the guidewire is pushed in. This traction maneuver can perhaps be done better with the help of a balloon catheter inflated and pulled just below the kink. • Passing a slippery hydrophilic (glide) wire that glides through the kink can also be used. • The ureteroscope can be used to bypass the kink under direct vision and maneuver the guidewire through its working channel. If available, a specialized (angled) ureteric catheter—e.g., Cobra catheter—can be used in combination with hydrophilic guidewire under fluoroscopic guidance. • A conventional guidewire can cause trauma to the mucosa and is more likely to kink or bend rather than curl against the obstruction [5]. Issa described a glide wire loop technique by using a hydrophilic-coated floppy-tipped guidewire that binds water to create a well-lubricated coating, which diminishes friction [6]. This is passed under fluoroscopic control to form a wedge between the stone and the wall of the ureter. It is further manipulated to form a curl that then forces the walls of the ureter to stretch at the site of impaction, resulting in the entry of this loop into the renal pelvis. The ureteric catheter is then passed over the guidewire into the pelvis. The wire is pulled back and redirected to curl in the renal pelvis, over which the stent can be advanced.