BackTable / Urology / Podcast / Transcript #13

Podcast Transcript: Tips & Tricks for Difficult Ureteroscopy

with Dr. Jodi Antonelli and Dr. Aditya Bagrodia

UT Southwestern endourologist Dr. Jodi Antonelli shares her tips and tricks for difficult ureteroscopy cases. Listen to learn about pre-op and post-op medication, dealing with large prostates and narrow ureters, variations in baskets, access sheaths, and ureteroscopes, dusting vs. basket retrieval, and performing ureteroscopies on pregnant women. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Initial Work-Up of Renal Colic

(2) Nephrostomy vs. Stent for Pyelonephritis

(3) Trial of Passage Indications for Nephrolithiasis

(4) Ureteroscopy: Indications, Imaging, and Antibiotics

(5) Ureteroscopy: Technique and Challenges

(6) Ureteroscopy: Fragmenting, Dusting, and Scope Options

(7) Ureteroscopy: Disposable Scopes, Lasers, and Baskets

(8) Ureteroscopy: Ureteral Injury Management

(9) Post-Op Management: Stents, Pain Management, and Recurrence Risk

Listen While You Read

Tips & Tricks for Difficult Ureteroscopy with Dr. Jodi Antonelli and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 13 Tips & Tricks for Difficult Ureteroscopy with Dr. Jodi Antonelli and Dr. Aditya Bagrodia
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[Dr. Aditya Bagrodia]
Hello, everyone, and welcome back to the BackTable Podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com.
This is Aditya Bagrodia as your host this week, and I'm very excited to introduce our guest today, Jodi Antonelli from UT Southwestern Department of Urology. Jodi is an Associate Professor here. She's an excellent clinician, tremendous surgeon. Patients love her, and really, really happy to have you. Jodi, how's the day going?

[Dr. Jodi Antonelli]
Hey, Aditya. I'm doing great. Thank you so much for the invitation. I really appreciate it. I'm honored to be able to participate. So, thank you.

[Dr. Aditya Bagrodia]
Perfect, perfect. All right, Jodi. So, a lot to unpack today, and I thought that we would maybe just start out in the ER, where so much happens at our end as it pertains to stones. So, a patient is coming in concerned for renal colic. You get a call from the ED. What's the basic bare bones information that you want to hear here?

(1) Initial Work-Up of Renal Colic

[Dr. Jodi Antonelli]
I'd like to know about the patient's vital signs. Do they have a temperature, tachycardia, hypotension? Did they do any preliminary blood work, specifically with an interest in knowing their creatinine, their serum white blood cell count, and then a urinalysis, and then, obviously, have they obtained imaging at that point? I'd go and see the patient myself, but getting a little bit more history as well from the provider who has seen them, presenting symptoms, duration of the pain, if they have a history of stones previously, and do they appear toxic, non-toxic, is their pain controlled now, are they tolerating PO.

[Dr. Aditya Bagrodia]
Okay. Yeah. Clearly, a comprehensive history, physical, review of information. What are going to be your dead ringers, "This is a sick patient. Time to do something, urgent decompression"?

[Dr. Jodi Antonelli]
The immediate triggers to want to intervene and do something to drain the kidney would be if the patient is febrile, if they're at all hemodynamically unstable, and sometimes pain can give you tachycardia, but tachycardia coupled with hypotension certainly is worrisome. Then from the standpoint of the objective lab work that you get, putting that in the context of the patient's presentation and elevated white blood cell count in isolation sometimes could be just due to inflammation, but that coupled with a patient who may have some of those other signs, again, certainly heightens my concern.
Then the urinalysis. So, the urinalysis is tricky. Some of the parameters could be elevated in the setting of inflammation. Additionally, sometimes surprisingly, the urinalysis is not that impressive if a stone is truly obstructing. Sometimes it doesn't look as bad as you would expect, but if you have a urinalysis with positive nitrate, that really heightens my concern. Very severe gross hematuria or Pyridium, things that change the color of the urine can sometimes falsely elevate a nitrite that isn't actually a sign of infection, but a positive nitrite is worrisome. Then Leukocyte esterase I think more often can be elevated with just pure inflammation, and then elevated white cells or presence of bacteria on a UA can also be worrisome.

[Dr. Aditya Bagrodia]
Okay. So, clearly, these are going to have to be patient-specific indications, but a couple of scenarios that you touched on. So, isolated leukocytosis, blood pressure, heart rate, temperature, all of that's checking out, looking fine. It's caught a white blood cell count of 15. UA looks pretty good. Patient is reliable. Can you just give us a broad strokes of how you might manage that patient and say that the pain has been fairly well-controlled with medications in the ER?

[Dr. Jodi Antonelli]
Yeah. I mean, I think in that situation if the patient, like you said, is reliable, they seem hemodynamically stone cold stable, UA doesn't look particularly concerning, I mean, those people I'd more suspect that white count is due to inflammation. Those are people that obviously I'd want to have pretty close followup back in the office with, but people that I would probably at that point feel comfortable sending home to follow back up as an outpatient. I certainly would make sure that the ER not only sent a urinalysis but sent a urine culture. Sometimes they won't do that if the urinalysis looks pretty benign.
Then plus/minus, I'm sending the person home on empiric antibiotics. I think you're never going to be faulted for that, but in those situations, I think that elevation is typically more due to inflammation.

[Dr. Aditya Bagrodia]
Perfect. What about a UA? Clearly, we see ureteral stones with cystitis, maybe less of a concern for obstructive pyelonephritis.

[Dr. Jodi Antonelli]
The difficult patients to determine what to do aren't the people who come in to the ER febrile, tachycardic, hypotensive, and those are a no-brainer. It's these patients who do come in pretty rock stable in terms of hemodynamics, they're not febrile, but the urinalysis looks worrisome, even frankly worrisome for an infection.
I mean, if the patient has an obstructing stone, I think looking at some other parts of that person's presentation and their history are important. I mean, if they're presenting, and it's not necessarily a significant amount of back pain that they're having, it's more cystitis symptoms, if they don't have other comorbidities, it would potentially cause immunosuppression, things like diabetes or on immunosuppressing medications.
I mean, those are patients that perhaps I'd be more inclined to say it's more likely a cystitis as opposed to an obstructive pyelonephritis. I think this even comes up more often for me. Sometimes I'll have a patient that I'm working up for an elective ureteroscopy and their urinalysis comes back positive, and it was a urinalysis that was just obtained purely for a preop evaluation. I mean, those people, for sure, I'm not going to run off and stent. I would just put them on a course of antibiotics and be treating their cystitis.
Then a patient presenting to the ER probably has had at least some degree of flank pain if they're presenting unlikely just cystitis symptoms. If that urinalysis is concerning, and there's a select few patients that I think I would just treat with antibiotics, but the great majority I would be inclined to stent.
The issue is just the stakes are so high. If you send a patient home who could have any component of obstructive pyelo, it's hard to justify that. So, I'd say erring on the side of caution and draining those patients is certainly probably the way to go.

[Dr. Aditya Bagrodia]
Absolutely. Yeah. I think we can all appreciate how quickly things can turn for a patient with obstructive pyelo. So, the folks that are coming in pretty sick, some tachycardia, hypotension, elevated lactate and so forth, again, I know it's hard to bin people in one versus the other, but general preference, nephrostomy tube versus stent.

(2) Nephrostomy vs. Stent for Pyelonephritis

[Dr. Jodi Antonelli]
Yeah. Dr. Pearle actually did a nice study in the late 1990s and was essentially a randomized trial where she assigned folks to either a stent or a nephrostomy tube. They actually found that there wasn't any significant difference in terms of outcomes, having a normal temperature, normalization of white count between those two groups. So, I think there is this thought that if a patient comes in more on the curve of sepsis that a nephrostomy tube is really what's warranted, her data would suggest otherwise.
My points that I use in deciding whether to go with a nephrostomy tube or a stent have a lot to do with the stone and the anatomy. If it's an extremely large ureteral stone, I mean, I'd say over a 1-1.5 cm and I'm concerned that I'm not going to be able to get a wire and a stent passed it, certainly those patients I'd prefer have a nephrostomy tube. Anybody with any difficult anatomy in the pelvis, bladder, a very large prostate, if I'm going to consider an older gentleman just maybe difficult to find the ureteral orifice. So, those patients, for sure, I think do much better with a nephrostomy tube.
The difference is in what you have to have a patient undergo to get either tube. So, general anesthesia versus some sort of sedation. I mean, if a patient is really hemodynamically unstable, theoretically, you can have a nephrostomy tube without a general. Again, it's really a conversation that has to happen with IR and whoever anesthetist at your facility as to how comfortable they are with doing that. That's also I think just the patient stability and a discussion with those groups is definitely something to undertake when you're deciding between which tube is better.

[Dr. Aditya Bagrodia]
Yeah. I remember one time being on call and there's a lady that came in with a pretty dramatic presentation, and we just did it without general anesthesia, which had to be done, and it worked out. Once upon a time, we used to do some stenting in clinic and it's full spectrum in terms of patient tolerability, but I suppose it's an option.
Well, thanks for that, Jodi. So, fortunately, I would say that the majority of the patients aren't coming in acutely septic, ill, they've got flank pain, they've gotten some medications in the emergency department. Can you talk to us about your medication regimen, timeframe for patients that you're going to counsel for a trial of passage?

(3) Trial of Passage Indications for Nephrolithiasis

[Dr. Jodi Antonelli]
Yeah. So, I think it's important to get an idea from the patient how long had they been having symptoms when they are presenting to the ER because that's where your clock starts in terms of how long you want to attempt a trial of passage. So, I mean, the limited data that's out there, obviously, there's not a real ethical way to test this in humans, it's basically animal data, is we try not to leave a stone in a location that could potentially be obstructing or partially obstructing for more than six weeks.
So, typically, I'll make sure a patient has pain medication. There's a lot of emerging data now that NSAIDs actually may be better in terms of pain control than narcotics. So, if a patient has a normal renal function, no contraindications to NSAIDs, I actually prefer a ketorolac or diclofenac over narcotics. Sometimes I'll give the patient a breakthrough narcotic prescription as well like Tylenol 3 or tramadol or occasionally hydrocodone, but recommend that the patient uses the NSAIDs as our first line.
Then there's a lot of mixed data, and I think a lot of differing opinions around the globe about medical expulsive therapy, so the use of alpha blockers for promoting stone passage. The US versus Europe, and specifically the UK, I think, have very different thoughts on what should be done. So, there's a large trial, probably 2015, that was conducted in the UK and they had a very different outcome measure than many of the other studies that were done that was basically not a radiographic outcome in terms of stone passage, but lack of needed intervention.
Based on that trial, I think, the UK and most Europe are les inclined to prescribe alpha blockers for medical expulsive therapy. I think in the US it's still recommended in our AUA guidelines specifically for larger distal stones. The data is greatest there. So, I think prescribing a patient an alpha blocker is something that even if it's a proximal stone I tend to do.
My thought is that potentially some of these studies may not actually be powered to really show a difference that maybe matters clinically. I mean, if taking a pretty well-tolerated medication even has a 1% chance of preventing me from needing a surgery and a stent. I think it's worth it. So, certainly for larger distal stones over 5 mm distally I would definitely recommend an alpha blocker, but I'm usually inclined to prescribe it for any ureteral stone, and then plus/minus on anti-emetics depending on how the patient is feeling.

[Dr. Aditya Bagrodia]
Steroids at all, is that a part of your passage regimen?

[Dr. Jodi Antonelli]
Yeah. I don't typically for the time during a trial of passage.

[Dr. Aditya Bagrodia]
Okay. Okay. So, I think, historically, it was this one minus stone size formula, where you get about a 90% chance for the 1 mm stone, 80% with the 2 mm. Of course, it's going to be patient anatomy-specific, but are there patients when they started approaching a certain threshold that you're like, "Yeah, this is going to be something that requires a surgery," and go ahead and start that process?

(4) Ureteroscopy: Indications, Imaging, and Antibiotics

[Dr. Jodi Antonelli]
Yeah. It's a good question. I mean, the AUA guidelines say a trial of passage is reasonable up to a centimeter. I mean, obviously, your success, particularly if you haven't passed the number of stones before, passing a 1 cm stone is going to be pretty darn low like below 10%.
So, I usually once the size gets over 5 mm, you do get progressively less and less likely that you're going to pass that stone. So, certainly, getting over 6-7 mm in a patient who does not have a history of repeated stone passages previously, I'll talk with the patient about probably limited utility and waiting and perhaps better to just go for with planning a surgery for removal.

[Dr. Aditya Bagrodia]
Do you send these patients home with strainers or get KUBs at the time of presentation to see if they're radiopaque?

[Dr. Jodi Antonelli]
Yeah. Unfortunately, many of the patients are seen in the ER, and then the first time that I actually get to interact with them will be in the clinic, but I think your first contact with that patient it's definitely helpful to get a KUB. I mean, it just helps you know a little bit about potential stone type, allows you to know whether you can follow that patient to determine if they passed it with the KUB as opposed to a CT, which obviously is a lot less radiation, less cost. Then I think a strainer is always good to give a patient.

[Dr. Aditya Bagrodia]
Okay. A couple of scenarios that we sometimes come across, solitary kidney still making urine, ureteral stone, where does that sit in terms of anxiety provoking?

[Dr. Jodi Antonelli]
I'd say pretty high. I think if you have, again, a very reliable patient, I don't think you have to run off and deal with the patient immediately. However, I think if you were not going to, the patient better be somebody that is incredibly reliable. I mean, if it's a very, very small stone, 2 mm or something, that person, again, is incredibly reliable, you've checked the serum creatinine and it's normal, you could potentially attempt a trial of passage in them, but I think solitary kidneys or bilateral ureteral stones are certainly situations where erring on the side of caution and taking those patients to the OR fairly urgently is certainly prudent.

[Dr. Aditya Bagrodia]
Okay. If they haven't caught a stone in the strainer or directly observed the passage of the stone, do you routinely get a CT scan or a KUB if it was in fact documented to be radiopaque before surgery?

[Dr. Jodi Antonelli]
Yeah, absolutely. I mean, I think just going on symptoms you will absolutely run the risk that that stone is still there in the ureter. Over time, a stone can actually just slowly grow. If a kidney is put in a situation I think where there's a decreased drainage over a long period of time, sometimes it's not a symptomatic thing. So, I think you want to be able to document that that stone has in fact passed if the patient comes to you several weeks later just hasn't had pain at all.
So, again, it's nice if you have the KUB. You can get another KUB and see. Even if I have a KUB that shows the stone is radiopaque, I will typically, and I get a repeat KUB and it shows that it's no longer there, I'll often also get an ultrasound if the original imaging was a CT that showed hydronephrosis. I like to be able to document resolution of that hydronephrosis with the ultrasound.
I think we all want to limit radiation exposure as much as possible. So, if you can avoid a CT as repeat imaging and get the majority of your information through KUB and ultrasound, that's certainly the best way to go. Some situations, either due to patient body habitus or the stone not being radiopaque, then in those situations getting a repeat CT, I think, is certainly that's recommended. If it's a distal stone, sometimes I'll just do a CT of the pelvis to avoid as much radiation.

[Dr. Aditya Bagrodia]
Okay. So, a nontoxic patient, trial of passage, repeat imaging in about maybe three to six weeks, I guess depending on stone size, pain, et cetera. Can you describe what's your standard preoperative antibiotics are? Maybe just walk us through a garden variety ureteroscopy in your hands.

[Dr. Jodi Antonelli]
Sure. So, 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.
I typically start with a PTFE 035 wire. I know many people will start with a hybrid wire that has a hydrophilic tip. Sometimes it will help get around stones in the ureter. Then I do use a device called an 8/10 dilator. I think it's incredibly helpful for dilating the ureter, and it gives you the ability to place a second wire.

(5) Ureteroscopy: Technique and Challenges

[Dr. Aditya Bagrodia]
A couple of quick questions, Jodi. What about large prostates? Those are tricky to see. Any tips and tricks on that one?

[Dr. Jodi Antonelli]
I mean, sometimes a 70-degree lens could help. It could be very difficult to pass a wire through there, but at least give you an idea where the UO could be. A flexible cystoscope is also sometimes something that could be helpful. The real tricky thing is the more you look sometimes you end up really stirring up bleeding, and then the visibility just gets more and more difficult. The other thing like a methylene blue or indocyanine green sometimes will allow you to get an idea where efflux is happening so that you can direct your wire at that spot.

[Dr. Aditya Bagrodia]
Speaking of bleeding, patients on anticoagulation, is that something clearly you want to get cardiac clearance, but are you okay, comfortable with Plavix, Coumadin, next generation antiplatelet medications?

[Dr. Jodi Antonelli]
Yeah. It's a good question. For ureteroscopy, yes. I mean, they've published a number of series that ureteroscopy on aspirin or other anticoagulation medication can be done safely. You're not cutting the patient anywhere. So, I think the risk to the patient coming off those medications is probably greater than any risk of significant hematuria. I do counsel patients after that they may have more hematuria than the average patient, and certainly to have a little threshold to call us if they're passing large clots or anything like that. I have not had that issue in a number of patients that I've operated on with essentially all anticoagulation or antiplatelet agents.
Now, PCNL is a different story. So, for PCNL, there had been a number of studies on doing PCNL and aspirin, 81 mg aspirin, and I do do that and have had good success without any significant issues with bleeding, but aspirin 325 or pretty much any other anticoagulation agents I don't do PCNLs, and I'd say most people on the country feel that way.

[Dr. Aditya Bagrodia]
Do you always shoot a retrograde when you ureteroscopy? Is it case-by-case?

[Dr. Jodi Antonelli]
Yeah, case-by-case. I know there are lots of folks who do, and I certainly don't think it's wrong. It gives you a nice roadmap of things. I typically don't do it unless I'm having difficulty getting a wire to traverse the direction or the pathway that I anticipate the ureter to be going.

[Dr. Aditya Bagrodia]
Okay. So, you talked about getting your first wire up. What about you get that wire up and not frank pus but it looks a little cloudy, a little turbid urine culture preoperatively and UA were clear? Does that put you on high alert?

[Dr. Jodi Antonelli]
Yeah. It's tough. Sometimes turbid from infection and turbid from just stagnant urine could be difficult to discern. So, if really stuff is coming out around that looks at all worrisome, I would put an open-ended 5 French catheter up, try and get it up into the renal pelvis, pull out the wire, and really aspirate some urine from up there, and try to get a better look.
I mean, if it is anything that looks like frank purulent urine, for sure, at that point I would stop and just stent the patient. If it's just a darker red or some debris, again, on a case-by-case basis, but in a patient with incredibly low, low risk in my mind of infection, I would proceed at that point with the ureteroscopy.

[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 pass 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.

[Dr. Aditya Bagrodia]
Right. What about semi-rigid ureteroscopes just trying to get in and create some channel? Do you recommend that at all?

[Dr. Jodi Antonelli]
Yeah. I mean, certainly if it's a distal stone. In a woman, you could get a semi-rigid ureteroscope fairly far up. I think sometimes those scopes give you a little bit more, again, rigidity. There's obviously less degrees of freedom, and so it gets you to where the stone is a little bit easier. So, I think that that's certainly an option. I think at least getting a wire coiled under the stone helps straighten the ureter whether you do semi-rigid or flexible ureteroscopy.

[Dr. Aditya Bagrodia]
What if you can't get your scope in whether that's your 8/10 dilator, whether it's a semi-rigid or a flexible? Some options for navigating the UO or when you say, "All right. Let's get a stent in and come back and fight this battle another day."

[Dr. Jodi Antonelli]
Yeah. I think tight ureters are certainly a challenge. In my hands or in my opinion, if the ureter appears to be tight, pretty much distal to the pelvic inlet or iliac vessels and distal, and I'm sure that the stone is not in that location in the ureter, the stone is more proximal, I'll balloon dilate the ureter. So, I'm going to at this point if I've tried the 8/10 dilator and it's pretty tight, I've shot a retrograde, and I have an idea where this narrowing is and I'm confident that the stone, again, is not in that area, then balloon dilation in the distal ureter I'm comfortable with.
Then as the ureter tunnels through the intramural part of the ureter, it's three layers, so I think it tolerates balloon dilation better with a lower chance of any issues with stricture. There've been series published on balloon dilation throughout the entire ureter with success, and there are some folks who feel comfortable with that. I don't like to balloon dilate the proximal ureter just because my fear at that point, it's two layers, it's thinner, and I just worry about a higher likelihood of stricture in those locations.

[Dr. Aditya Bagrodia]
Okay. Is that a 4 cm balloon? What French and what pressure do you typically go with when you're dilating?

[Dr. Jodi Antonelli]
So, I usually do a 15 French 4 cm balloon, and I usually will go to 14 atmosphere, and I go slowly. I start at two, and then wait a couple of second, go to four. I don't just slam it up to 14 atmospheres immediately. Then sometimes you see a waist, sometimes you don't. Certainly, if you do see a waist, you can go up to, the balloons are rated to 20, so you could go up a little bit higher if you need to to get that waist to open. Usually, at 14 atmospheres I've had pretty good success with opening those areas in the ureter.

[Dr. Aditya Bagrodia]
When is it that you stent and get out and come back?

[Dr. Jodi Antonelli]
Yeah. So, it's tricky. I mean, in my practice I prefer to use an access sheath and I like to actually fragment and extract. So, without an access sheath, that's obviously a challenge. So, for me, if I can't get our smallest diameter access sheath up a 9.5, 11.5 French, then I try to decide on my mind what I think would be best. So, one option is to just put the ureteroscope up without an access sheath and dust the stone. If I feel like the stone is small enough, if the situation with the patient I'm comfortable with dusting as opposed to fragment extraction, then I'll do that.
I tend to feel like dilating them with a stent for a week and bringing them back and being able to extract the fragments like I typically do is often the better approach. I'm just happier with that. So, if I have difficulty getting that 9.5, 11.5 sheath safely in, then I'll typically stent and bring them back.

(6) Ureteroscopy: Fragmenting, Dusting, and Scope Options

[Dr. Aditya Bagrodia]
What are your typical dusting settings, Jodi?

[Dr. Jodi Antonelli]
So, it depends on the laser that is available, but as a general rule, if you're dusting, you essentially want a very low energy because you just want to be chipping off little pieces at a very high rate. So, if I have a 100-Watt laser, I'll do 0.2 Joules and 50 Hertz. Sometimes doing a 0.4 Joule and 50 Hertz to move through it a little bit faster. The issue is you end up with a little bit larger chunks of "dust".

[Dr. Aditya Bagrodia]
What about if you're fragmenting? What's your work course list or settings?

[Dr. Jodi Antonelli]
So, again, depending on the laser that I have, but, typically, 0.8 and 8 is my starting point, and then depending on the hardness of the stone, I'll sometimes modify things from there. Sometimes if it's a real dense hard stone, I'll go up to 1 and 10. If I have a 100-Watt laser, sometimes doing a 0.6 and 20 or even a 0.4 and 50 depending on the properties of the stone. Sometimes we'll generate more fragments than dust, then it moves through it a little bit quicker than the 0.8 and 8.

[Dr. Aditya Bagrodia]
Okay. So, you mentioned for your second wire you typically use an 8/10 dilator. Any strong opinions on dual lumen introducers versus serial dilators?

[Dr. Jodi Antonelli]
Yeah. I think the issue I have with dual lumens is just sometimes if the ureter is a little bit tighter, you have a very short distance of tapering where you're jumping to the 10 French pretty quickly. So, oftentimes, it just it won't go in as easily. So, the advantage I see with the 8/10 is that you really get the 8 French dilation and then the 10. So, it's a little more gentle, sequential dilation, which I like.

[Dr. Aditya Bagrodia]
Makes sense. So, access sheaths, you've mentioned them several times. Those are your preferred way to go. What are your work courses in terms of inner/outer diameter? Any ones that you find to be particularly effective in your hands?

[Dr. Jodi Antonelli]
Yeah. Just within the last, I don't know, I'd say maybe three years, I've changed my go-to sheath size. So, prior to that, if I could get it to go, I would do a 12 slash 14 French. I transitioned to 10-12 French more recently. I mean, if a stone is over a centimeter, then I'll try for the 12-14 because, obviously, the larger diameter sheath I can get in, the larger fragments I can extract, and the more efficiently I could do that, but I've been really impressed with the ability to extract fragments through the 12 French sheath. I mean, it's two French smaller, but it really doesn't limit, really, my ability to extract as much as I expect it.
I do find that the appearance of the ureter on the way out is a lot more favorable. Sometimes you get that real tight, pale appearance with larger ureteral access sheaths, and that the 10-12, the ureter just looks less stretched.

[Dr. Aditya Bagrodia]
Is there any impact on the type of scope you can get up?

[Dr. Jodi Antonelli]
Yeah. That's a great question. So, the newer generation digital ureteroscopes and the disposable ureteroscopes will fit through a 10-12 access sheath. Older generation digital ureteroscopes will not. So, for example, Olympus has a V and V2. The V is the older generation. That won't fit through a 10-12. So, certainly, your availability of scopes is something to consider with your access sheath size.

[Dr. Aditya Bagrodia]
For you, is it always digital preferred bigger is better?

[Dr. Jodi Antonelli]
Yeah. It's a good question. I mean, no, not necessarily. The one advantage I find with the fiber optic scope is actually a little bit more flexion. So, sometimes a stone in a very dependent lower pool calyx I find an advantage to the fiber optic scope. Obviously, you're trading off some clarity of image to a few more degrees of flexion, which sometimes those few degrees can make all the difference in the case.
The other thing that I find sometimes I'll choose one scope over another is where the laser or the basket comes out. If you're looking at the screen and you think of it like a clock face, some companies the laser comes out at 9:00. Some companies it comes out at 3:00. We're fortunate here to have several different options to choose from. So, sometimes going up and determining what approach will allow me to get to the stone in terms of where that equipment comes out is the decision point for me on which scope to use.

[Dr. Aditya Bagrodia]
Got it. Yeah, I certainly would say that sometimes when we're taking a look up for upper tract tumors, I think that the P6 is a pretty decent option if you're not planning on using an access sheath in my hands and in that clinical scenario.

[Dr. Jodi Antonelli]
Yes. I've been very impressed. I mean, even though it's a fiber optic scope, the visibility with that particular scope is excellent and it's very atraumatic. It's tiny, and it allows you to get good flow. It's a great scope.

[Dr. Aditya Bagrodia]
Speaking of flow, handheld pressure irrigator versus pressure bags?

[Dr. Jodi Antonelli]
Great question. I think the irrigation in a case could really make or break you. I actually think that the most important job in a ureteroscopy is the person, if you are doing handheld irrigation, is the person holding that irrigator. I mean, they could probably cause close to as much damage as anybody can during that procedure. So, I think if you are going to do handheld irrigation, it has great advantages. It allows you to modify. You can prevent blowing around pieces if you're grabbing things. You can use a little bit more irrigation to see things or get through areas, but you really have to, I think, be careful who's holding that irrigator, and are they understanding the power that they have.
So, during most cases, if I'm operating with a fellow or a resident, I actually prefer to be holding the irrigation because if somebody irrigates too hard and say an infundibulum, a calyx with a very narrow infundibulum without good outflow, you can cause a significant amount of bleeding and then difficulty actually with visibility for the remainder of the case. We don't, obviously, routinely image people after ureteroscopy with CTs, but a handheld irrigation that's too powerful without good outflow can actually cause pretty significant subcapsular hematomas and things like that.
So, I think pressurized irrigation is probably, obviously, a little bit less modifications you're able to make to it, but in some ways could potentially be a bit safer than handheld irrigation if you don't have the right person doing it.

[Dr. Aditya Bagrodia]
Okay. Good. I think some good things to consider there. So, we talked again about a typical, you got two wires up, you've got an access sheath up, and we've lasered away, basketing fragments. What are your go-to baskets and pros and cons of some of the various ones that exist.

[Dr. Jodi Antonelli]
Yeah. I mean, my favorite tool I would say disposable tool for ureteroscopy is a basket or a grasper made by Cook called the NGage. Boston Scientific has a similar one called the Coda, and it is almost like a three-dimensional triangle. It's like a fish mouth, where the front of it is open. I think for ureteroscopy, it offers two advantages. One, you're typically grabbing fragments that are in front of you. So, having the grasper or the basket open in the front really helps you to advance the basket out, grab something and retract. You're not having to catch the fragments on the side of a basket.
The other nice thing I think with those designs is it allows you to disengage the basket easier than with a zero tip basket or an NCircle basket that tends to be more oval shaped. So, if you pull out a fragment that's too large and it's stuck in the ureter, I think it's easier to disengage those triangular baskets like an NGage.

[Dr. Aditya Bagrodia]
I know that's something that we use fairly extensively in training. I think my ability to estimate a stone's size is pretty terrible. Anytime I use the 1 cm basket or so forth, I was a little overambitious. So, I thought the NGage does keep you honest. So, you mentioned that you prefer basket retrieval versus dusting. I imagine there are scenarios that we come across where dusting may be preferred. Maybe a further word about that, Jodi.

[Dr. Jodi Antonelli]
Yes. I would say this is a great debate in endourology. In any meeting you go to this is always a plenary topic. So, it is something that is certainly one approach has not been proven to be superior to the other. To be honest, I think the right answer is a combination of using both approaches in your practice, and sometimes a combination of both approaches in a single case.
Certainly, if I have a larger stone that I'm trying to treat ureteroscopically, 1-1.5 cm for example, I mean, it's pretty ridiculous to try to purely fragment that stone and extract it. I mean, you will be there a long time. Actually, we've looked at success rates of extraction for stones over a centimeter, and despite the most meticulous attempts, it's about 30%-35% that you aren't getting a patient completely stone-free with pure fragment extraction with these larger stones.
So, I tend to do more of a combination, dusting-fragmenting approach for those larger stones, again 1-1.5 cm, try and dust it down and then extract fragments. I think the biggest issue I have with the concept of dusting, and I think many people also feel this way is that our laser technology hasn't really gotten us to a point where we really generate true dust. I mean, I think we just generate small fragments.
So, the concern is are those small fragments can act as a nidus to cause a recurrence of a stone in a shorter amount of time. So, that's something that has never been proven and something that a multi-centered group called the Edge Consortium that's looking at that, there's been some short-term studies that have been published looking at the differences between dusting and fragmenting. I think that these groups are looking to follow these patients longer term, and I think that data will be really interesting.
Then the advantages of dusting, obviously, have been shown to be potentially shorter OR times, less cost because you're not opening as many disposable items, but the issue is you're potentially leaving that patient with some higher likelihood of stones or fragments or dust left that maybe won't pass out of the collecting system like we expect it will.
The other issue with dusting, too, is that sometimes if you have a larger stone and you generate so much test, it's hard to see the bigger pieces that may be there within the dust. Fragmenting does have a higher stone-free rate, but it's not perfect. The other issue with fragmenting is it does have a higher cost. You're opening more items and you're usually in the operating room longer to perform that technique.

(7) Ureteroscopy: Disposable Scopes, Lasers, and Baskets

[Dr. Aditya Bagrodia]
So, you mentioned disposables and cost. Disposable ureteroscopes coming through the pipeline, what do you think? Do you use those in your practice? Is this going to be something that's going to be primetime in the next decade or so?

[Dr. Jodi Antonelli]
I think it's certainly something that is becoming more and more available, and I think depending on your practice situation could potentially make a lot of sense. They've looked at cost analysis of disposables versus reusables and maintenance costs and repair costs and things like that. I mean, I think there's some sweet spot in terms of volume where probably disposables make more sense. I have used disposable ureteroscopes, had been incredible impressed with the digital quality image that you get. It's amazing considering that you throw the item away.
So, yeah, I don't use it routinely in my practice, but I think there are certain scenarios where you can argue if you have the availability to use it, it may be better, lower pole stones where you're concerned potentially you're going to really max out your reusable scope and could potentially damage or break it. Better to use a disposable scope in those situations.
A patient with numerous ESPL or multi-drug resistant urinary organisms, maybe those people are better off with a disposable scope rather than a reusable scope that there's been some studies to show our sterilization isn't always what we expect it to be. So, those are probably the two scenarios where I think disposable scopes have their best benefit, but I certainly think as your go-to scope, it's also a very feasible good option, particularly if the volume of ureteroscopy that you do fits in the cost scheme.

[Dr. Aditya Bagrodia]
So, for some of these lower pole stones, tough to access, what are some of the things that you'll do to make it a little bit easier or fair?

[Dr. Jodi Antonelli]
I think looking at the stone and the size of the infundibulum are key. If you think you can get that stone out of the lower pole through the infundibulum without getting stuck, I try to do that, I think whether you're going to dust or fragment, it's hard to get stuff out of the lower pole, and it's hard for a patient to pass anything out of the lower pole just because of the dependence of that area.
So, the one concern with that, though, is, really, if a stone at all looks like it will be too large to get out of there, you don't want to get a basket stuck on the stone in the lower pole. That's a real tough spot to be in. So, I had mentioned the NGage as a go-to fragment extractor. If I am going to displace a stone from the lower pole to the upper pole or the renal pelvis, in those situations I actually tend to use a more oval-shaped basket like an NCircle. I think it's easier to just catch those stones from the side and bring them up.
If possible, I try to displace the entire stone. If it looks like it's too large to bring out, then I'll fragment it as minimally as possible in the lower pole and then bring up the fragments to the upper pole, and then further either dust or fragment in that more favorable location.

[Dr. Aditya Bagrodia]
Okay. When you're going back and forth between basketing and lasers, do you use a laser and a basket in the same port or are you typically switching those instruments in and out?

[Dr. Jodi Antonelli]
I do use them in the same port. That's another thing I started to do a couple of years ago, and I think it's really helped decrease the amount of time. So, none of the lasers that I'm aware of on the market come in any real that's able to contain the laser well once it's out of the scope. So, you spend so much time pulling the laser out, wrapping it up under a towel or a mosquito or something, and just all that back and forth between laser and basket I think is some of what increases the operative time with fragmentation.
So, I found that a UreSil device or a SureSil device can accommodate a 270 micron laser fiber, and a grasper or a basket. The 1.8 French graspers or baskets and the 270 lasers tend to fit in there together better than a 2.4 French. Those can be a little bit more drag when you're trying to move basket and the laser back and forth. It could also decrease your irrigation flow, but the combination of a 1.8 French like an NGage and a 270 laser I found excellent flow and really nice maneuverability.
So, I'll pull the basket back into the scope, I'll laser, and then once I'm happy with the fragments, pull the laser back in to the scope. Make sure you're no longer on ready or no longer pressing the pedal and then advance the basket out and extract. Sometimes you extract something too large and you cant pass the laser out and whittle it down a little bit and get it out without having to disengage the basket. So, I think it really is a huge time-saver as long as you have sizing that makes sense for maneuverability.

[Dr. Aditya Bagrodia]
Okay. You'd mentioned the lasers maybe aren't quite there to be true dusting lasers. You hear at meetings and so forth that there's some pretty exciting things coming through, MOSES lasers, holmium lasers. Have you used any of those? Do you have any experience on that front?

[Dr. Jodi Antonelli]
Great question. Yes, yes. So, you're exactly right. I mean, I think laser technology really hadn't changed a whole lot, and then within the last couple of years, there's been some tremendous changes and improvements. So, high-power holmium laser like 120-Watt lasers, and then with the addition of these pulse modulation and pulse length variations that could be delivered. Speaking specifically to MOSES, I mean, not only can you alter the pulse length, but MOSES is a specific technology. Lumenis has that. You're also modulating the pulse delivery.
So, you're essentially trying to modulate that energy so that you get a combination of stone stabilization and improved delivery of energy. Other companies have similar, different terms that they've coined, but for this pulse modulation, holmium laser technology has a ceiling in terms of where you can go with energy generation. Some of it has to do with the fact that the cooling system that has to be in place for that laser to function.
So, the next generation that's come along in the last year or two is thulium fiber laser. That laser works in an entirely different way, but it allows for a much higher energy generation, and the cooling system within it is very different and requires much less space.
So, there's, I think, a lot of excitement about what thulium fiber laser may be able to offer particularly for dusting, and I think the idea is that the ability to really alter your power delivery, both the amount and the way it's delivered may help us to actually truly generate dust from a stone.
So, there's a lot of work being done now because, obviously, there's going to be some upper limit to this energy generation and the concerns of maybe a downside to that energy generation in the collecting system in terms of potential damage to the urothelium with heat generation and things like that. So, I think there's a lot more to come and I think it's an exciting time for laser technology for stones.

[Dr. Aditya Bagrodia]
Got it. All right. So, let's say we've done our combination of dusting, fragmenting, extraction, we've taken a nice tour of the kidney, we feel that things are pretty much cleared out. Just walk us through maybe how you remove your access sheaths and potentially what you would do if you identified a little perf linear tear on your way out.

(8) Ureteroscopy: Ureteral Injury Management

[Dr. Jodi Antonelli]
Yes. Great question. 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.

[Dr. Aditya Bagrodia]
Okay. Do you ever go in with a plan for serial ureteroscopies?

[Dr. Jodi Antonelli]
Great question as well. Typically, no. I think in those situations, I think, in my hands, I do PCNL as well. So, if I really have a patient with a larger stone burden, there's few times, few instances where I wouldn't proceed with the PCNL as opposed to ureteroscopy.

(9) Post-Op Management: Stents, Pain Management, and Recurrence Risk

[Dr. Aditya Bagrodia]
What about pre-stenting? Do you ever do planned pre-stents?

[Dr. Jodi Antonelli]
I don't, typically. I will say as part of my informed consent for ureteroscopy, I tell all patients that there is a chance that the ureter will be tight, and the safest thing to do in that situation is often to stent and come back. So, I had mentioned earlier in the talk if I can't get that smaller access sheath up, in most cases I'll stent and bring patients back. I just think that the ultimate outcome for them is best, but I rarely bring a patient in just for a stent. I mean, I at least attempt to do the ureteroscopy.
I should say it's certainly not wrong. I think that if you have a larger stone burden and you want to get a bigger access sheath up or for various reasons like that, you want to avoid a PCNL. Stenting and bringing somebody back is certainly a reasonable option.

[Dr. Aditya Bagrodia]
Uncomplicated ureteroscopy, access sheath went up well, does everybody get a stent in your practice?

[Dr. Jodi Antonelli]
Great question as well. So, the AUA guidelines in the surgical management of stones has one statement in 50 that has level grade A evidence, and it's that you do not have to stent patients after ureteroscopy. 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]
Makes sense. Typical duration for an uncomplicated ureteroscopy for the stent?

[Dr. Jodi Antonelli]
So, usually five to seven days. I mean, to be honest, it really depends on when I operated versus the next clinic that I can have the patient come to. We and others have looked at sometimes a shorter duration with the stent can actually lead to more discomfort after it's removed, but I tend to go around five to seven days.

[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.

[Dr. Aditya Bagrodia]
Okay. Okay. Yeah. I think that you hit the nail on the head. Managing patient expectations, trying to stick to a non-narcotic backbone and really prophylactically managing the full spectrum of potential side effects makes it a better patient experience, and keeps folks out of the ER and calling the clinic. Okay. So, stents come out, post op imaging followup. Is everybody getting a metabolic evaluation?

[Dr. Jodi Antonelli]
So, the AUA, it's not truly a guidelines, it's a clinical effectiveness protocol on imaging ureteral stones. I follow that for my postop imaging after ureteroscopy. The recommendation is an ultrasound and then a KUB if you fragmented the stone. If you're able to remove the stone intact, the KUB isn't necessary. The reason behind that imaging is just that there is a risk of potential silent obstruction after ureteroscopy. So, patient could develop a stricture that they don't have pain from, and you don't recognize that and they can ultimately going to lose that kidney.
So, interestingly, a group has looked recently at the actual utilization of imaging after ureteroscopy and it's sadly pretty low, but the recommendation absolutely is about four to six weeks later I get an ultrasound and a KUB.
In terms of 24-hour urine, metabolic management, I look at the patient and determine their risk. If they're low-risk, if it's a single stone, they have no positive family history, they have no comorbidities that would predispose to stone disease, then I don't automatically recommend that and give the patient general dietary recommendations. Even if it's a first stone and that patient really wants a metabolic evaluation, then obviously I'll do it. Pretty much everybody else I'll do the metabolic evaluation, so high-risk stone formers, either positive family history, comorbidities that would predispose to stones or recurrent stones.
I think it's important to note recurrent stones aren't just people who are presenting more than one time with a stone. It's somebody who presents the first time with multiple stones would still be considered recurrent.

[Dr. Aditya Bagrodia]
Okay. Good point. Good point. A clinical scenario that I think gets everybody's blood pressure up a little bit are pregnant women coming in. So, maybe let's just briefly touch base on a noninfectious ureteral stone.

[Dr. Jodi Antonelli]
Yes. So, typically, the point at which you're getting involved, the OB calls you and tells you there's a pregnant woman who's having flank pain. They probably have gotten an ultrasound at that point, may show hydro. So, hydro of pregnancy is common on the right side, particularly as the pregnancy progresses and the uterus gets larger. So, that's one thing to consider.
If the patient is far along in pregnancy like in third trimester, they could also have a small amount of hydro on the left side just as part of hydro of pregnancy. The big trick is imaging, obviously, and that's a big question with pregnancy. So, I think as much information as you can possibly get out of imaging that does not involve radiation is key. So, the AUA guidelines will say the progression of imaging. First line is ultrasound. Sometimes utilizing other techniques of ultrasound like transvaginal images or transabdominal images can help.
If you can't get the information you need in terms of a stone diagnosis from ultrasound, you can try an MRI. MRIs, obviously, don't show stone, but they'll show a filling defect, particularly on the T2 weighted images. They also can show the level of obstruction. Usually with MRIs, obviously, cost and availability.
So, the AUA does condone usage of low-dose protocol CTs, particularly after organogenesis completes. So, safest to do after 15 to 20 weeks while, obviously, it is radiation to the fetus, the idea is that if the diagnostic accuracy is so much higher compared to MRI or ultrasound. So, having the actual diagnosis will potentially prevent that patient from unnecessary procedures. So, in that sense, the pros outweigh the cons, but, obviously, the gestational age is key. So, it's hard to justify a CT scan before 15 weeks.
Once you've diagnosed the stone, then I think not every stone in pregnancy has to be operated on by any means. I mean, obviously, trial of passage is the key if you can get a patient's symptoms under control. If you can't get a patient's symptoms under control, then you obviously have to make a decision between draining that kidney versus intervening surgically. I think stone size, location, complexity of anatomy is important. If it's under a centimeter ureteral stone, something that's of a reasonable size and the patient's pain is not under control, deciding between stenting or nephrostomy tube with usually frequent exchanges versus ureteroscopy.
I think it has to really depend on the comfort level of the urologist, the resources available at that hospital. Specifically ureteroscopy in pregnancy, best time to do it is second trimester. First trimester, there's just a higher risk of miscarriage for various reasons. So, intervening at that time is just considered riskier. Late third trimester, you have a higher chance of preterm labor. So, second trimester, early third trimester is your best window.
Again, I really think you want to choose wisely in terms of who you're going to tackle stone volume, you're going to tackle ureteroscopically in pregnancy, and then certainly involving OB and having a multidisciplinary approach. OB, anesthesia, and urology is key, but there have been 20 plus case series published on the safety of ureteroscopy, again, at the right institution with the right providers, and at the right gestational age and with the right stone burden.

[Dr. Aditya Bagrodia]
Jodi, well, I got to say my mind's blown just the wealth of information in terms of diagnosis, common scenarios, uncommon scenarios, dangerous scenarios. I think you really walked us through the whole journey of ureteroscopy, and certainly appreciate it and learned a lot. Any other just parting thoughts for trainees, for practicing folks that do ureteroscopy or anything that we might not have covered?

[Dr. Jodi Antonelli]
Great, great question. I mean, I think, ultimately, in your practice, a word, I guess, to trainees, I mean, stones have been one of the most common things you see. So, gaining as much experience as you can during training with ureteroscopy and management of stone patients I think really will benefit you in your practices, particularly as a general urologist because it certainly has to be, of my colleagues and friends who practice general urology, I mean, they all tell me stones is probably the number one thing that they treat in their practices.
With regard to the practicing urologists out there, I mean, I think it's an exciting time for endourology. I think there's, as I touched on earlier, the laser technology and also additional other surgical technologies are continuing to improve, and I think that our ability to manage stones in a way that is least invasive and most effective for patients is just continuing to improve and improve.

[Dr. Aditya Bagrodia]
Perfect, Jodi. If I could, one thought that I have before we wrap up, having done ureteroscopies and trained under the likes of yourself and Peggy Pearle, ureteroscopy comes in a lot of shapes and flavors, and I think really doing our absolute best to make sure all fragments are out, that dust really resembles dust, it's critical. Return trips to the ED, a second operation, these are going to be suboptimal outcomes.
So, thanks again for your insight, for your opinions, and all the little tips and tricks. Jodi, it's fantastic.

[Dr. Jodi Antonelli]
Aditya, thank you so much for the invitation. It was truly an honor to be able to participate and I really appreciate it. Thank you so much.

[Dr. Aditya Bagrodia]
Have a wonderful day.

Podcast Contributors

Dr. Jodi Antonelli discusses Tips & Tricks for Difficult Ureteroscopy on the BackTable 13 Podcast

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 discusses Tips & Tricks for Difficult Ureteroscopy on the BackTable 13 Podcast

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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