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BackTable / Urology / Article
Ureteroscopy: Technique & Management
Ishaan Sangwan • Oct 7, 2021 • 168 hits
Once it’s apparent that a stone will not pass a trial of passage, a patient must be prepped for a ureteroscopy. This procedure requires thorough perioperative care, good technique, and certain post-op considerations.
Dr. Jodi Antonelli breaks down her process for ureteroscopies on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Several urine cultures should be taken prior to ureteroscopy, and treated with an antibiotic like a cephalosporin if they come back positive.
• If a stone is difficult to get a wire past, several techniques with slurry, contrast, and lasering can be attempted, and a nephrostomy can be performed if all else fails.
• Ureteral injuries rarely lead to strictures, but if a perforation occurs before a stone is removed, a stent should be placed, and the procedure should be postponed to a later date.
• Post-op management of a ureteroscopy involves prescribing an effective post-op cocktail, and deciding if the patient needs a stent.
Table of Contents
(1) Ureteroscopy Peri-Operative Procedures
(2) Ureteroscopy Techniques and Challenges
(3) Ureteral Injury Management During Ureteroscopy
(4) Ureteroscopy Post-Op Management
Ureteroscopy Peri-Operative Procedures
Once a stone has failed trial of passage, and it is clear that the patient needs a ureteroscopy, urine cultures should be taken 1-2 weeks prior to the procedure. Antibiotics should be started if the culture comes back positive, and may be considered if it comes back negative but there is high suspicion of a UTI. Usually the perioperative dose of a cephalosporin is sufficient, provided that the patient is not allergic. Good communication with anesthesia is important to minimize the narcotic requirement. NSAIDs, gabapentin, and IV Tylenol can also be helpful.
[Dr. Jodi Antonelli]
If I have a patient that I see has failed a trial of passage, I like to make sure that they have at least a urinalysis or a urine culture about two weeks to a week before surgery. I mean, the AUA guidelines would say at least a urinalysis. Then I don't put patients on antibiotics preoperatively if they have a negative culture. If they have, like I mentioned earlier, patient gets a preop culture, they're asymptomatic and it comes back positive, I'll start that patient on antibiotics. Ideally, I mean, there's no right answer with this, but I usually typically make sure the patient is on an antibiotic at least five to seven days culture-specific before proceeding.
If I have a patient who's had a history of recurrent UTIs, and maybe that very last culture prior to surgery is negative, but I'm concerned that they could have issues with bacteria that's present there, I have a low threshold to put those people on antibiotics preoperatively, maybe three to five days.
In terms of perioperative antibiotics, at the time of surgery, I certainly do give typically a cephalosporin if they don't have any issue with allergy at the time of surgery, and then I don't prescribe antibiotics beyond that. The AUA guidelines would say that that perioperative dose is sufficient. So, again, unless the patient has a history of recurrent UTIs or issues with infections, then I won't prescribe an antibiotic postoperatively.
Then just in terms of the ureteroscopy itself, we actually instituted a multimodal pathway with the help of anesthesia here to decrease the narcotic requirement around the time of surgery, and also to have the patient, hopefully, waking up from surgery and ultimately being discharged with their pain under as good a control as possible, so they're not leaving the hospital having to play catch up. That pathway has been incredibly helpful.
So, utilizing things other than narcotics, things like NSAIDs, gabapentin, IV Tylenol, we've looked at this and it's really decreased morphine-equipment usage in the PACU. It's decreased patient calls in the time between surgery and stent removal. So, that has really been a successful thing for us here.
In terms of the surgery itself, the ureteroscopy itself, typically, the first step putting in the cystoscope, I always talk with the residents about the importance of doing a really thorough cystoscopy. You don't want to be the person who misses a bladder tumor that somebody diagnoses a couple of months later. So, getting a good look around the bladder, being sure that there's nothing that looks suspicious there, and then placing a guide wire.
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Ureteroscopy Techniques and Challenges
A common challenge during a ureteroscopy is getting a wire past a large stone. Trying a wire with greater rigidity alone can help, and passing some contrast or slurry past the stone can help in visualizing the path of the ureter. Dr. Antonelli recommends the 5 French open-ended catheter and a hydrophilic wire as her tools of choice. If the wire still does not go past the stone at this point, the operator can try lasering the stone to find a window to pass the wire. If all else fails, a nephrostomy tube can be placed and dealt with at a later date.
[Dr. Aditya Bagrodia]
Okay. Great, Jodi. So, you talked about getting your first wire up. Let's just say you're having a hard time getting it past a stone. Some options that typically have worked, and I've heard of slurries, a combination of lube and contrast, various wires. Can you talk us through your algorithm for that clinical scenario?
[Dr. Jodi Antonelli]
Yeah. First thing I will do is pass a 5 French open-ended ureteral catheter up to the point of the stone. Sometimes just having that additional rigidity or that backing at that point could help. I'll take out the standard double floppy tip PTFE wire that I use and I'll try instead a hydrophilic wire, usually just a pure hydrophilic wire or occasionally a hybrid wire.
I think injecting at least a contrast, and I actually do sometimes do the slurry with a little bit of lubrication and saline. Sometimes if you can just get a little bit of contrast or some of that slurry to get pass the stone, number one, you'll see the path where the ureter goes more approximately, and sometimes that could be helpful. I think sometimes it also does just help that hydrophilic wire to get by.
So, that's my two tools, the 5 French open-ended catheter and the hydrophilic wire just gently trying repeatedly to see if there's some angle or some corner I can catch where that angle glide wire will get pass the stone.
[Dr. Aditya Bagrodia]
Okay. Say you've really spent your time, nothing's getting by. What do you recommend at that point?
[Dr. Jodi Antonelli]
So, in those situations, I think it depends on your comfort level. I mean, there's certainly no one would fault you for, again, depending on the scenario, having the patient have a nephrostomy tube placed, and dealing with this at a later date. The other option that I will do is I'll basically put back in that double floppy wire. I'll coil it under the stone. I'll reintroduce my 8/10 dilator and coil a second wire under the stone, and then I'll advance an access sheath up distal to the stone. You obviously don't have a wire past the stone and in those situations, it could be a little bit hair-raising if the stone is really impacted because you just don't want to lose your lumen.
Lasering the stone to get a window where you can get a sense for where the remainder of the ureter goes approximately. Then as soon as you see any light at the end of the tunnel, getting a wire up pass the stone. Then at that point, you have a wire through the access sheath. So, you're not going to be able to introduce a ureteroscope back through the access sheath. So, then take out the access sheath, get a second wire back in, and then put your access sheath back up to continue treating the stone.
Ureteral Injury Management During Ureteroscopy
While strictures due to ureteral injury are a potential complication of this procedure, they occur only about 1% of the time, even at the highest grade of ureteral injury. It’s important to catch these injuries when they happen, and place a stent. Dr. Antonelli recommends leaving the stent in for at least four weeks if fat is visible, although exact guidelines have not been established. However, if a complete perforation occurs, and there is a stone present, it’s best to place a stent and remove the stone at a later date, as there is a risk of stone fragments extravasating if the procedure is attempted.
[Dr. Jodi Antonelli]
So, certainly, always as you're exiting the kidney, withdrawing the access sheath under vision and examining the ureter is key. So, Dr. Traxer published a paper that graded ureteral injury. There's actually a followup to that paper published a few years ago looking at what were the outcomes of these patients who had these different grades of ureteral injury. They essentially found even at the highest grade of ureteral injury, not a complete avulsion, but a tear of the ureter to fat, there was only a 1% chance of an ultimate stricture later.
So, there's no question that it's obviously a concern when you see a tear within the ureter, but recognizing that, obviously, absolutely stenting the patient in those situations, and then nobody knows the exact length of time that these stents should be in, but I'd say if it is a tear of the urothelium or you're seeing fat, I'll typically leave a stent for at least four weeks to allow that area to heal.
[Dr. Aditya Bagrodia]
Okay. What about a perf? Maybe you get up, things look a little off, you shoot a retrograde, and you've got some significant extrav. Is that a get out and come back another day or-
[Dr. Jodi Antonelli]
It's a good question. I mean, there's a lot of reasons why you can have extravasation. So, sometimes it's merely the wire poking through the papilla that can cause that. I mean, if you see an area where there's a gross disruption of the urothelium and then you're going to be attempting to laser fragment, my worry in those situations is just particularly say it's a ureteral stone and you have a perforation there that you're going to have to drag fragments through, you just don't want to get the fragments out into that area, and you also don't want to worsen that.
So, in those situations, if you haven't, especially if you haven't even started treating the stone yet, maybe you see an injury that occurred due to the access sheath, your better bet in those situations is to stent the patient and come back so that you don't run the issue of extravasated stone fragments, and that actually can really increase your likelihood of a stricture development at that spot.
Ureteroscopy Post-Op Management
For post-op management, many urologists leave a stent, especially if there is any ureteral injury. However, if the procedure went well, many urologists don’t stent patients routinely, and these individuals also do well. Dr. Antonelli prefers to not leave danglers in women, as they can be bothersome and do not provide great benefit, and leaves the choice up to the patient for men. For the post-op cocktail, it is best to lean towards NSAIDs and other non-narcotics for pain management. Often the cocktail also includes an anticholinergic, unless the patient is older or has significant concerns about bladder emptying.
[Dr. Jodi Antonelli]
I think most people or maybe not most, many urologists around the country do routinely stent people. So, I do in part because I use an access sheath. I think people have shown with the smaller access sheath it's also the ureter looks okay on the way out. Some people will not leave a stent in those situations, but I do leave a stent.
I mean, I have a few select patients who don't tolerate stents well, and in those folks I don't. What I have found in patients that I don't stent, they tend to have more severe pain immediately after the ureteroscopy, but it tends to go away quicker. I will say that the practice is very variable with this. So, there are lots of folks around the country I know who don't stent people routinely, and I think people do well. I just think it's a little bit different postoperative course in terms of intensity and duration of discomfort after.
[Dr. Aditya Bagrodia]
Dangler, no danglers?
[Dr. Jodi Antonelli]
I don't typically leave a dangler on women. My thought is just that a cysto in them is usually pretty well-tolerated and dealing with a string for a week to me would be more bothersome. I tend to leave the option or the decision up to men. Most younger guys I'll leave a dangler, and then older gentlemen often prefer not to have one.
One thing with older gentlemen, if I have a patient who's older that I'm worried maybe will have difficulties voiding after ureteroscopy, I tend to not leave a dangler there because it's just more difficult dealing with that if they have to have a Foley placed after surgery.
[Dr. Aditya Bagrodia]
I recall when I was a resident, there's a pretty impressive postop cocktail for ureteroscopy patients. Can you tell us what you're giving patients today?
[Dr. Jodi Antonelli]
Yes. Great question. We really do, again, try to extend this multimodal pain control approach that we do during the operation with anesthesia into the postop and the discharge meds for home. So, we do prescribe pain medication. We've actually tried to lean more toward NSAIDs instead of narcotics, again, mounting evidence to show it actually works better and obviously has less side effects.
Then we also give an anticholinergic unless they're older or has significant concerns about bladder emptying to just help with some of the lower urinary tract symptoms from a stent, an alpha blocker to, again, help relax the ureter, and there's some evidence to show that that can make the stent more comfortable, some urinary tract anesthetic like Azo or Pyridium. Then if we send them home with a narcotic, a stool softener as well.
Podcast Contributors
Dr. Jodi Antonelli
Dr. Jodi Antonelli is a practicing Endourologist and Associate Professor in the Department of Urology at UT Southwestern Medical Center.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 12). Ep. 13 – Tips & Tricks for Difficult Ureteroscopy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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