This document provides guidance on ureteroscopic lithotripsy (URSL) for treating ureteral stones. It discusses pre-treatment assessment factors like stone location, size and composition as well as patient factors. It outlines proper patient and equipment positioning. It describes guidewires, catheters, dilation devices, ureteral access sheaths, ureteroscopes, lithotriptors, stone retrieval devices and stents used in the procedure. It provides details on accessing and treating stones in the lower and upper ureters and discusses complications like perforation, stricture and stone extrusion that may occur.

1. Operative Chat
Ureteroscopic Lithotripsy
URSL
Dr. Abhishek Pandey

2. Pre-Treatment Assessment
• Stone Factors –
– Location – Proximal-Mid vs Distal
– Stone Burden – 97% success for ≤1cm; 93% success for >1cm
– Stone Composition – success not affected
• Anatomical Factors –
– Megaureter – Endoureterotomy in <3cm segment → URSL
– Duplicated Collecting System – RGP → URSL
– Ureteral Stricture / Stenosis – Dilatation / Endoureterotomy

3. • Patient Factors –
– UTI – negative culture obtained before procedure
– Renal Function – symptomatic upper tract stones + ≤15% spilt function
consider nephrectomy
– Solitary Kidney – treat asymptomatic stones
– Morbid Obesity – URSL success & safety independent of BMI
– Spine deformity / Limb contracture – Flexible URS
– Coagulopathy – URS + Ho:YAG lithotripsy → Rx of choice
– Duration of obstructing ureteral stone – treat if persistent for 4w

4. Patient & Equipment positioning
• Lithotomy position with liberal padding
• Flexible URS feasible in supine / lateral decubitus positions
• Table should be radiolucent
• Fluoroscopy – Fixed all-in-one table / Portable C-arm unit
• Two irrigation bags – 1 ↓ gravity & 1 in pressure bag
• Laser console as close to surgeon as possible
• Surgeon can sit / stand

6. Guidewires
• Guide to access / dilation / stent placement.
• Diameter – 0.018-0.038 inch – most common 0.038inch
• Length – 80-260 cm – most common 145cm
• Distal tip – Straight / Angled / J-tipped ; floppy for 1-3cm
• Nitinol core wire – kink-resistant & stiffer
• Glide wires – Hydrophilic coated wires instead of PTFE
• Hybrid guidewires – hydrophilic tip & PTFE shaft

7. Ureteral Catheters
• Length usually 70cm with markings at every 5cm.
• Straight tip catheters – 5 or 6 Fr

8. Dilation devices
• Passive dilation – pre-stenting for
≥ 7days before URSL
• Active dilation –
– Dilating catheters – hydrophilic
coated polyurethane tapered
catheters
– Balloon dilator – filled with diluted
radiocontrast

9. Ureteral Access Sheath
• Placed over guidewire under fluoroscopic guidance
• Facilitate flexible URS
• Useful for repeated entries – stone fragment retrieval
• Decrease renal perfusion pressure
• Increase irrigation flow → improve vision
• Inner dilator & outer sheath

10. Ureteroscopes
• Semirigid Ureteroscope
– Larger working channels
– Less prone to damage
– Length – Short (females) or Long (males)
– Tip diameter ≤7Fr
– Eye-piece – in-line / off-set (straight working channel in off-set)
– Working channel – single / double
– Easy to reach till ureter cross iliac vessels

11. Flexible ureteroscopes
• Types –
– Fiberoptic – Fiberoptic bundles carry light & image
– Digital – “Chip on tip” – digital image, ↑ tip diameter
• Deflection mechanism –
– plane of deflection marked by reticle – scope rotated to align the
plane of deflection with the intended target
– Intuitive or counter-intuitive deflection with respect to the lever
• Deflection ≥180° achieved

12. Intracorporeal Lithotriptors
• Pneumatic – requires semirigid URS with a straight working
channel (offset eye-piece) – retropulsion
• EHL – Flexible but more damaging
• Ho:YAG laser – Intraluminal lithotripsy energy of choice –
dusting of stone by photothermal effect

13. Stone retrieval devices
• Three-pronged stone grasping forceps – safest
• Stone baskets – Helical baskets / Flat-wire baskets
• Surgeon should be able to see the endoscope, stone & ureter
during extraction
• Nitinol alloy baskets – memory, maintain shape, resist kinking

14. Retropulsion prevention devices
• prevent migration of distal ureter stones (semirigid URS) into
proximal ureter (flexible URS)

15. Ureteral stents - Drainage
• Double-J (DJ) stents
• Routine stenting has no beneficial effect on stone-free rates
or ureteral stricture rates
• Quality of life better in non-stented patients
• Indwelling-time <14days → fewer adverse effects
• Placing stent for 1-2 weeks after initial unsuccessful URSL
leads to higher success rate of secondary URSL

16. URSL Procedure
• Rigid cystoscopy to identify ureteral orifice
• 5Fr open ended catheter over guidewire → Perform RGP
• Place a safety guidewire up to kidney ↓ fluoroscopic guidance
• If a glidewire is used, replace with stiffer wire
• If pus encountered – send culture, abandon & place a stent
• Drain the bladder before commencing URS
• Intermittent / continuous bladder drainage during procedure

17. Access in narrow ureteral orifice
• Railroad technique – second guidewire passed to tent open
the narrow ureteral orifice ↓ fluoroscopic guidance →
ureteroscope advanced between the wires

18. • Dilation – if access unsuccessful after rail-road technique
• Do NOT dilate over the stone → ureteral trauma, stone
extrusion
• If unsuccessful dilation → 2° URSL after ≥1w stenting

19. Lower Ureteral stones
• Semirigid Ureteroscope
• Ureteral occluding devices used to prevent retropulsion of
calculi into proximal ureter → deployed above the stone
under vision → URS repassed alongside it
• Lithotripsy –
– Dusting – Ho:YAG laser
– Fragmentation → complete basket extraction under direct vision
without using undue force

20. • Laser lithotripsy – activate when tip in contact with stone
– Soft stones – start at 0.2 J & 50 Hz → Dusting
– Hard stones – start at 0.6 J & 6 Hz → gradual fragmentation,
minimising retropulsion
• Inspect ureter after lithotripsy –
– verify stone clearance
– Identify ureteral injury
• RGP at the end of procedure
• Stent may be placed with / without tether

21. Upper Ureteral stones
• Semirigid often not practical in males
• For flexible URS → place 2 guidewires – safety & working
• Pass flexible URS over working wire ↓ fluoroscopic guidance
• Ureteral access sheaths used for high proximal stones →
passed over guidewire ↓ fluoroscopic guidance
• Access sheath should NOT be forced Or passed over the
stone; risk of ureteral trauma & stone extrusion
• If access sheath not passable → proceed without it / stent

22. Complications
• Perforation – 0-4% case
– Splitting after balloon dilation
– Forceful placement of ureteral access sheath
– Placing dilator / access sheath over stone
– Forceful pulling of basket devices
– Direct injury by lithotrites – highest with EHL
– Pressurized irrigation – perforation / calyceal rupture
– Abandon the procedure & place a stent over safety guidewire

23. • Stricture – 3-6%
– Impacted stones
– Ureteral perforation – 6% stricture rates
– Prior ureteral surgery
– Pelvic radiation
– 0.4-4% are asymptomatic
– Recommendation for all patients to undergo postoperative imaging
after ureteroscopic instrumentation

24. • Stone extrusion – 2%
– Submucosal stone – laser excision → ureteral stent
– Complete extrusion / lost stone – in ureteral perforation → abandon &
place stent (do NOT attempt to retrieve the stone)
• Avulsion – 0.06-0.5%
– Forceful manipulation of large / impacted stone
– Avulsion at scope withdrawal (scabbard effect)

25. Thank You