1. Ureteroscopy – Technical Aspects
V Hopkinson
September 2015

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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?

10. 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)

11. Medical Expulsive Therapy

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. SUSPEND trial poll results, BJUI (July 2015)