Ureteroscopy – Technical Aspects V Hopkinson September 2015

Ureteroscopy Review imaging/consent/mark Check urine culture/pregnancy test if appropriate WHO checklist Radiographer/C-arm/x-ray table (extensions) Imaging in theatre Antibiotic prophylaxis Lithotomy position GA Cystoscopy Retrograde pyelogram Ureteric catheter (5 Fr) Contrast e.g. Niopam 300 = Iopamidol – non-ionic monomer (300 mg iodine/mL)

Ureteroscopy Guidewires Semi-rigid ureteroscope alongside guidewire Standard = stainless steel core with PTFE coating Hydrophilic = nitinol with hydrophilic coating Straight, angled or J-shaped tip Length: 150 cm, diameter .035 or .038 in Always have safety wire Semi-rigid ureteroscope alongside guidewire Second guidewire to negotiate narrowing 7 – 10 Fr Working channel 3.4 Fr 34 cm long

Ureteroscopy Laser Holmium:YAG 365 μm or 200 μm fibre (200 μm allows better deflection for lower pole stones) Start with 5 Hz, 0.5 J Laser safety: Safety certificates Laser safety officer present Goggles Windows covered Doors locked Check fibres prior to use Machine on standby when not in use

Ureteroscopy Baskets Ureter Kidney Tipped Stainless steel Straight or spiral wires Three-pronged graspers Kidney Zero tip Nitinol 1.3 – 3 Fr NGage™ 1.7 – 2.2 Fr, 115 cm

Ureteroscopy Flexible scope Stents 5.4 – 9 Fr 70 – 80 cm long Working channel 3.6 Fr Stents 4.8 Fr – 8 Fr 18 – 30 cm Polymers e.g. polyurethane, polyethylene e.g. Percuflex™ Plus Boston Scientific Percuflex with HydroPlus™ coating Base polymer = polyethylene

Stenting? Indications: Ureteric trauma/perforation Bleeding Significant oedema Impacted stone Failure to pass scope or complete treatment Infection Obstruction Large stone burden Single kidney Renal impairment Pregnancy Transplant kidney

Stenting if uncomplicated? Tang et al. Urology (2011) Meta-analysis of randomised trials of stent vs. no stent 14 trials Heterogeneity in pain assessment, therefore difference in post-op pain between groups not clear Incidence of dysuria, frequency and haematuria significantly higher in stent group No difference in post-op analgesia requirement, UTIs, post-op fever, stone-free rate and ureteric stricture between the groups Decreased tendency towards unplanned medical visits or hospital readmission in stent group (not statistically significant) Increased cost in 5 studies Increased operative time Also: Risk of encrustation Risk of ‘forgotten stent’ Alternative: Ureteric catheter for 24 h BUT – involves overnight stay

Problems… What do you do if a basketed stone is stuck in the ureter? What do you do with a basket with a broken wire?

Problems… Basketed stone stuck in ureter: Basket with broken wire Try to advance proximally, open basket and remove stone Fragment stone within basket Disassemble basket by unscrewing handle Replace scope alongside basket and laser stone Leave basket and stone in ureter, wake patient up and observe – may fall out spontaneously Basket with broken wire Can cause ureteric trauma If tipless: Advance 7 Fr ureteric catheter or access sheath over basket and withdraw Otherwise: Withdraw under vision grasping distal broken wire with forceps Transect remaining wires, remove proximal basket, advance distal portion into renal pelvis, turn it around with forceps and withdraw tip first From Le & Segura, BJUI (2006)

Medical Expulsive Therapy

Meta-analyses Hollingsworth et al. Lancet (2006) 9 trials 693 patients (individual studies 15 – 48 patients in each group) Calcium channel blockers or alpha blockers Primary endpoint: proportion of patients who passed stones Mean stone size 3.9 – 7.8 mm All stones in distal third of ureter except in one study Treatment duration 7 days – 6 weeks (or until stone passage) Follow-up 15 – 48 days 65% greater chance of passing stone with medical therapy ARR 0.31 (95% CI 0.25 – 0.38) NNT 4 Less need for analgesics in MET groups Limitations: Clinical heterogeneity Publication bias 8 trials not blinded 6 did not describe randomisation procedures in detail

Meta-analyses Campschroer et al. Cochrane Review (2014) 32 studies 7 double-blinded 2 incomplete data 1 high number of withdrawals 28 single-centre Most had small patient numbers 5864 patients Alpha-blockers Stone-free rates significantly higher in alpha-blocker group RR 1.48 (95% CI 1.33 – 1.64) Stone expulsion time 2.91 days shorter with alpha-blockers Reduced number of pain episodes, need for analgesia & need for hospitalisation Data limited on mid- and proximal ureteric stones

Meta-analyses Lu et al. Urol Int (2012) 29 trials 2763 patients 19% improvement in stone clearance with tamsulosin Higher expulsion rate with tamsulosin vs. Ca channel blockers Limitations: Some studies poor methodological quality Clinical heterogeneity e.g. Stone size, duration of follow-up, measurement of outcomes Insufficient allocation concealment and blinding Publication bias

Meta-analyses Fan et al. Int J Urol (2013) 14 studies Increase in expulsion rate in tamsulosin group of 51% Decrease in expulsion time of 2.63 days Reduce risk of requiring other procedures by 60% Increased incidence of side effects (mainly dizziness) in tamsulosin group Limitations: Clinical heterogeneity Publication bias Methodological quality

SUSPEND Spontaneous Urinary Stone Passage Enabled by Drugs Multicentre, randomised, double-blind, placebo-controlled trial 1167 participants (1136 analysed) Aged 18 – 65 years 1 stone, ≤ 10mm, any site within ureter Placebo vs. tamsulosin vs. nifedipine Exclusion criteria: those needing immediate intervention, sepsis, eGFR < 30 mL/min, already taking or unable to take an α-blocker or a Ca channel blocker, > 65 years Primary outcome: spontaneous stone passage in 4 weeks defined as the absence of the need for additional intervention to assist stone passage at 4 weeks after randomisation Other outcomes: pain, time to stone passage, health status & safety, health economic components

SUSPEND 80% placebo group needed no intervention compared to 81% in tamsulosin group and 80% in nifedipine group at 4 weeks No difference in stone passage at 12 weeks No differences in analgesic use, time to stone passage and health status Serious adverse events in 3 patients in nifedipine group and 1 in placebo group

SUSPEND trial poll results, BJUI (July 2015)