1. EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES
Pandey S, Shroff S.
Department of Urology & Renal Transplantation,
Sri Ramachandra Medical College and Research Institute, Chennai, India

2. INTRODUCTION
Multiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countries
No known incidence of such presentations
Not much literature available on how to tackle these multiple pathologies
No set rules laid out for approaching these multiple pathologies endoscopically in one sitting

3. Problems in Developing Countries
Presentation is relatively late
Economic considerations of the patient population plays a pivotal role in this delayed presentation
“cure all one sitting” Pressure on clinicians more in following situation:
Women
Children
Old People
Sole earning member
Poor or lower middle class people
Patient coming from a distance for treatment

4. ANALYSIS OF MULTIPLE ENDO- PROCEDURES
Incidence of multiple procedures at presentation
Various combinations of these Pathologies at presentation
Endourological algorithms devised where applicable to tackle these problems effectively
Study Group - SRMC – Urology Unit 1
Period to 2002
Exclusions
- Local Anaesthesia cases
Diagnostic procedures
- open with endoscopic
E.g Hernias with TURP

5. INCIDENCE
Total number of endourological procedures since –
Multiple pathologies at presentations 239
Incidence of presentations %

6. MOST COMMON MULTIPLE PATHOLOGIES 239 (11.1 %)
Bilateral Ureteral calculus
Vesical calculus + BPH
Vesical calculus + Ureteral calculus - 41
BPH + Ureteral calculus
BPH + Bladder tumour
Stricture Urethra with bladder and ureteral calculus
Hello

7. Endoscopic Clearance of easier / less demanding pathologies first
EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES
Endoscopic Clearance of easier / less demanding pathologies first
Lower tract to be cleared first before proceeding to upper tract
Completely clear one entity first -
exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURP
Except for Some Exceptions

8. Lower tract stone disease before upper tract Stone disease
EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES
Lower tract stone disease before upper tract Stone disease
Chronological order of Intervention helps in maintaining vision till the end of such multiple procedures
Litholapaxy-> Lithotripsy> Incisions> Resections

9. Complex Endourologic Algorithms
Simple “common sense” Algorithms
Complex Endourologic Algorithms

10. COMMOM SENSE ALGORITHMS
INTERNAL URETHROTOMY
BNI
TURP
TUIP

11. BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!!
Lower Ureteric Calculus first
Lesser Impacted calculus first
Bilateral safety guide wires first
Side needing stents only first.

12. CYSTOLITHOLAPAXY/TRIPSY + TURP/TUIP
Cystolithotripsy -36
Using 27fr nephroscope,
2 mm Swiss Litho probe
Cystolitholapaxy -18
Using 25Fr Sheath &Mechanical Lithotrite
Extra operative times min
Morbidity-nil
Few patients had increased Irritative LUTS

13. CYSTHOLAPAXY/TRIPSY +TURP CALCULUS FIRST !
Advantages
Bladder free of fragments of the calculus
Good vision still being maintained-Preventing inadvertent bladder injury
Any untoward incident forcing abandonment of surgery-May end up with a resected lobe and calculus free status!!
Preventing Absorption/Extravasation of irrigant when calculus is dealt before

14. VESICAL CALCULUS + URETERAL CALCULUS
Combination-41
Majority of vesical calculus were cm
Majority of ureteral calculus were in the lower ureter -26
WHICH FIRST!!
OPTIONS------
1.Placing guide wire-cystolithotrripsy-URS
2.Cystolithotripsy-URS+ DJ Stenting

15. VESICAL+URETERAL CALCULUS
Advantageous to complete the ureteral calculus first Exceptions- large bladder calculus
fragments of ureteral calculus and vesical calculus can be evacuated at the same time from the bladder
less chances of ureteric orifice injury preventing upper tract intervention

17. TURP +TURBT Total number of cases-6 Maurmayer et al- 7%
Blandy et al %
TURP FIRST !
Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa
2.Easy instrumentation.
TURBT FIRST!
Advantages-1.Resection occurs in clearer access
2.Preventing massive absorption of irrigant as can happen from prostatic fossa.

18. BPH + URETERAL CALCULUS
NUMBER OF CASES- 31
Ureteral calculus first!! ( Exceptions-Large median lobe preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injury
TURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice )
Advantages – Allows ease of instrumentation of the upper tract

19. BPH WITH VESICAL & URETERAL CALCULUS
19 cases
Large median lobe-4, B/L ureteral calculi-1
Calculi first ! !
May need TUIP for larger prostates
lesser extravasation/absorption
Ureteral first ! !
Advantage- Prevents oedema/injury to ureteral orifice
- Easier access with best vision

20. PREREQUISITES FOR “CURE ALL” ENDOSCOPIC APPROACH
Use of Endovision camera
Services of Experienced Operator
Perceive limitations of Combination procedures
Preference for general anaesthesia over regional
Patients to be well counselled and appreciate combinations
Warm Irrigant fluids to avoid hypothermia

21. Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation
Candidates must be relatively ‘fit’ for extended procedures
Presence of experienced assistant desirable

22. TURP + HERNIORRAPHY / HERNIOPLASTY (guidelines )
TURP F IRST !
Avoid liberal TUIP / BNI
Avoid mesh Repair in presence of Infected Urine
Postpone herniorraphy in case of gross Extravasation
Avoid Bilateral herniorraphy with TURP / TUIP

23. AVOID ……
TURP & PCNL both accompanied with considerable haemorrhage - !!
B/L Upper tract procedure if-
1.First side is difficult / prolonged procedure
2.Pus seen on clearing calculus on one side

24. THERE IS ALWAYS A SECOND CHANCE !!!
REMEMBER ………
THERE IS ALWAYS
A SECOND CHANCE !!!