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Flexible ureteroscopy update: indications, instrumentation and technical advances

Retrograde ureteroscopy has recently gained a broadened indication for use from diagnostic to a variety of complex minimally invasive therapies. This review aims to look at the recent advances in the instrumentation and accessories, the widened indications of its use, surgical techniques and complications. With minimization of ureteroscopic instruments manufacturers are challenged to develop new, smaller and sturdier instruments that all will also survive the rigors of surgical therapy.

Ureteroscopy is defined as retrograde instrumentation performed with an endoscope passed through the lower urinary tract directly into the ureter and calyceal system.[1] With the addition of actively deflectable, flexible endoscopes the indications for ureteral access sheath have broadened from diagnostic to a variety of complex minimally invasive therapies. Current ureteroscopic treatments include intracorporeal lithotripsy (by far the most common), treatment of upper urinary tract urothelial malignancies, incising strictures, evaluation of ureteral trauma, and repairing ureteropelvic junction obstructions.[2,3] With improved instrumentation and incorporation of technologies such as a large endoscope working channel and active tip deflection, the evolution of surgical techniques have broadened while the complications noted with ureteropyeloscopy have actually decreased significantly.

The application of flexible fiber ureteroscope was first reported by Marshall in 1964. A 9F fiberscope manufactured by American Cystoscope Makers (Pelham Manor, NY) was passed into the ureter to visualize an impacted ureteral calculus. Subsequently, Bagley, Huffman, and Lyon began work at the University of Chicago to develop an improved flexible fiberoptic ureteropyeloscope in the 1980s.

Irrigating fluids are employed to clear the optical field of view and to cool the tip of energy-delivering devices. The irrigant is delivered through the same channel used for working instruments, often through a side arm adapter (Urolock – Boston Scientific, Natick Mass. and Check flow, Cook Urologic, Spencer, Indiana). The simplest and most cost-effective means of delivering continuous irrigant is to employ two 60 cc syringes connected to a three-way stopcock with arterial line tubing. Normal saline is the irrigation standard solution for diagnostic ureteral stent and lithotripsy. When electrocautery is employed sorbitol or small aliquots of sterile water may be used

In a recent prospective study of 460 consecutive upper-tract endoscopies at our center, “no-touch” direct access ureteroscopy (i.e. placement of the endoscope into the ureter under direct vision without the assistance of a guide wire and without dilation) was successfully performed in the majority of patients. This wireless form of flexible digital ureteroscope system or “no touch technique” is technically challenging but eliminates the potential trauma, mucosal irritation and inadvertent manipulation of stones or tumors caused by guide wires and is particularly helpful when mapping the collecting system for mucosal lesions or upper tract transitional cell cancers.

Major intraoperative complications

The major complication rate associated with therapeutic visual ureteroscope series has decreased markedly and currently occurs in less than 1% of all procedures. As with the minor problems, major complications occur less frequently for basically the same reasons – better surgeon skills and improved instrumentation. However, when they do occur treatment is often more complex. In addition to major intraoperative problems, other complications that occur during upper urinary tract endoscopy may begin as minor events and, if left untreated or if addressed incorrectly, can progress to more serious conditions.

Major ureteral wall perforations occur infrequently and can be the product of a heavy-handed endoscopist and improper application of the ureteroscope. These complications are more common with the semi-rigid ureteroscopes rather than the flexible ureteroscopes. The forceful positioning of a semi-rigid ureteroscope above the iliac vessels, particularly in young male patients, is associated with a significant risk of ureteral wall trauma unless the collecting system is dilated or the ureter has been stented prior to endoscopy. Routine use of a double-J stent is not necessary in most patients but is recommended when unusual difficulty is encountered or when extensive strictures are noted. It is essential to note that if the endoscopic maneuvers are difficult, the surgeon can only be rewarded with an easier time in the future if he does not push the procedure but rather places a stent and returns another day. Usually, one to two weeks of stenting greatly facilitates ureteroscopy, particularly if proximal access is desired.