2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2
3. INTRODUCTION
Miniaturization of instruments
• Smaller diameter ureteroscopes
• Less traumatic tips
Better technique
Development of safety principles
3
Dept of Urology, GRH and KMC, Chennai.
9. BLADDER DISTENTION
• Intraoperative overdistention can lead to postoperative urinary
retention and on rare occasions – bladder perforation
• Pre-existing outlet obstruction and prostatic enlargement may
contribute to post op retention
• Prevention
• Small calibre foley or red rubber catheter may be placed alongside
the ureteroscope for bladder drainage
• Monitoring bladder volume
• Ureteral access sheath
9
Dept of Urology, GRH and KMC, Chennai.
10. Failure To Access The Upper Tract
1.6 - 1.8% with flexible
8% semirigid
Risk factors
• >1.5cm stones and proximal stones
• intrinsic or extrinsic ureteral narrowing
• stone impaction
• genitourinary anatomy(cystocele, enlarged prostate, large intravesical median lobe, generalized
edema, trabeculations, cellules
• ureteral orifice location such as re-implanted, ectopic or duplicated ureters)
Best to abort procedure with ureteral stenting
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Dept of Urology, GRH and KMC, Chennai.
11. Tight Ureteral Orifice
• Telescoping wire - ureteral catheter for direction/stability
• Converting to straight/ curved hydrophilic wire
• Emptying/ filling the bladder
• Manually reducing cystocele/ vaginal prolapse
• IV methylene blue/ fluorescein
• Narrow or stenotic orifice – dilated with tapered dilators or balloons
• May lead to perforation, stone extrusion or avulsion
• Prevented by RGP preop and prestenting the ureter
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Dept of Urology, GRH and KMC, Chennai.
12. Difficult Ureter
• RGP – identify anatomy/ guide maneuvers
• Telescoping wire through ureteral catheter
• URS may be passed upto difficult ureteral segment and wire passed under direct vision
• 2 wires may be passed for difficult narrow ureter orifice and URS passed between them
(railroad technique)
• If stricture distal to stone it may be dilated with tapered dilators/ balloons
• Stone impaction or obstruction – Lignocaine jelly may be injected 1-2cm below it to dilate
the ureteral smooth muscle and separate stone and ureteral wall – excessive injection/
force may injure the ureter and cause extravasation
12
Dept of Urology, GRH and KMC, Chennai.
13. EQUIPMENT FAILURE
Abortion Rate
0.8%
Most common
cause: Iatrogenic
Fragile
Visual Field –
Perfectly round
(crescent shaped
- breakage)
Guide wire
breakage /
Balloon Dilator
Breakage
Prevention
• Maintenance/
Handling
• Sterilisation/
Storage
• Use
13
Dept of Urology, GRH and KMC, Chennai.
16. Retained Basket
• 0.5%
• Grasping a stone or Fragment too large for ureteric removal
• Forced Retraction – injury
• Gently advance the stone proximally – disengage
• Cut the handle – withdraw ureteroscope – Re-entry – Laser to cut the wire and disengage stone
• Nitinol Basket soft nature – hence easily withdrawn
• Steel Baskets
• Delayed Staged Removal
• Open surgery
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Dept of Urology, GRH and KMC, Chennai.
22. Proximal Migration
• 3.5 to 12.2%
• Increases operative/ anesthesia time and may prevent case completion necessitating
second procedure
• Risks – proximal stone location, degree of ureteral dilation, pneumatic or
electrohydraulic lithotrites and increased fluid irrigation.
22
Dept of Urology, GRH and KMC, Chennai.
23. Intra-Mural Stone Extrusion
• “Submucosal stone” extrusion through the ureteral mucosa injuring the inner ureteral lining
• Occurs with impacted stone
• Predisposing factor to stricture formation – nidus for stone growth
• Submucosal stones diagnosed as bulges endoscopically
• Observation leads to granuloma or stricture formation
• Extraction is difficult and may lead to worse outcomes
• Laser excision followed by stenting is recommended if identified during atraumatic URS
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Dept of Urology, GRH and KMC, Chennai.
25. Extra-Mural Stone Migration
• Lost stone
• Risk factors – improper technique, ureteral edema, poor blood supply of ureteral segment,
high intraluminal pressure from irrigation and outward compressive force on the stone from
scope
• Sequelae – stricture and fluid extravasation and rarely retroperitoneal abscess
• Stent should be placed for perforation
• Stone location should be documented as future imaging studies may falsely diagnose
ureteral calculus
• Follow Up Imaging
25
Dept of Urology, GRH and KMC, Chennai.
33. • Failed conservative management or high grade injuries need reconstruction
• Timing – Within 5 days or after 6 weeks
• With nephrostomy tube in place antegrade and retrograde studies are performed
• Cystogram for bladder involvement in reconstruction
• Optimal repair – injury location, degree of ureteral loss, surgeon comfort/ training
33
Dept of Urology, GRH and KMC, Chennai.
39. False Passage/ Mucosal Flap
• 1.1-2.8%
• When attempting to pass a wire past impacted stone or
• Semirigid scope advancement into ureteral wall
• Passing wire without smooth advancement or appearance of abnormal anatomy on
fluoroscopy should alert surgeon
• Wire may follow path of ureter/ collecting system -- flap
• Peri- adventitial extravasation confirms false passage or mucosal flap
• If injury occurs – stenting should be done
39
Dept of Urology, GRH and KMC, Chennai.
43. Perforation
• 0-18%
• Occur from passing wires, ureteral dilation, ureteroscope passage, instrument manipulation,
lithotripsy and unexpected patient movement
• Risk factors
• Increased operative time and procedure difficulty
• Ureteral tortuosity, periureteral fibrosis, stone impaction, ureteral stenosis
• patient movement
43
Dept of Urology, GRH and KMC, Chennai.
44. • Recognized endoscopically with visible disruption of ureteral wall or visible fat
• Radiographically as contrast extravasation
• Small perforation – stenting
• Large perforation -termination of case and stenting(2-4weeks)
• Urinomas drained percutaneously
• Bladder catheterized for maximum drainage
• Follow Up Imaging -- stricture
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Dept of Urology, GRH and KMC, Chennai.
48. Ureteral Access Sheath
• Low grade and self limiting
• RG urogram should be performed prior to UAS placement to r/o stone or stricture.
• If UAS does not pass freely – inner tapered dilator should be used to predilate the
ureter or sequential taper dilators or balloon dilators to be used
• Pre Stenting
• UAS larger than 12/14Fr should not be used without prior stenting/ dilation
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Dept of Urology, GRH and KMC, Chennai.
50. Ureteral Avulsion
• 0.1 to 0.5%
• Extensive degloving injury to ureter
• Full or partial thickness discontinuity of ureter
• Typically occurs from over stretching the ureter
• Proximal 1/3rd most prone as it is less muscular
• Removing a stone too large for the ureter to accommodate or
• Advancing a ureteral dilator, access sheath, or ureteroscope in a retrograde
manner
50
Dept of Urology, GRH and KMC, Chennai.
51. • Avulsion can occur during withdrawal of basket with unrecognized tissue
entrapment
• RGP will demonstrate extravasation of contrast without opacification of
ureter and collecting system proximal to the disruption
• Distal ureter may be avulsed upward with scope passage – recognized
on removing scope – scabbard injury
• Increased resistance may the only sign that impending ureteral injury is
about to occur
51
Dept of Urology, GRH and KMC, Chennai.
56. • Intraoperative Recognition – immediate Surgery
• Objective Restoring Ureteral Continuity
• Distal Ureter – Ureteroneocystomy/ Psoas Hitch/ Boari Flap
• Mid Ureter – end to end anastomosis
• Complete Avulsion // Scabbard – Autotransplantation / Illeum Interposition
• Rarely Nephrectomy – risk in preserving the kidney
56
Dept of Urology, GRH and KMC, Chennai.
57. Intussusception
• Only the inner layer is avulsed leaving muscularis
• Occurs in direction of scopes movement
• Often arises in a narrowed segment – with stone extraction or removal of polypoid
ureteral lesion
• RGP – contrast filling in a ragged lumen
• Immediate sequale less severe than complete avulsion
• Stent placement for 6 weeks/ follow up
• Rarely heals over stent and forms long segment strictures
• Usually staged ureteral reconstruction is necessary
57
Dept of Urology, GRH and KMC, Chennai.
59. Lithotrite Injury
• Mechanical / Thermal Injury – abrasion/bleeding/perforation
• Lithotripsy near crossing vessels – done carefully – catastrophic
• Small mucosal defects – large necrotic areas
• More with Pneumatic
• Prevention
• Limiting urothelial contact
• Short working distance
• Keeping laser fibre parallel to wall
• Visualzation of tip
59
Dept of Urology, GRH and KMC, Chennai.
60. Bleeding
• Instrumentation related trauma/ lithotripsy/ Forniceal Rupture
• Minor Bleed – self limiting
• Prolonged Bleed – vision obscured, Place ureteral stent and postpone
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Dept of Urology, GRH and KMC, Chennai.
64. Residual Stone
• Common
• Explain the possibility of multiple sittings/ ESWL
• Adjunctive Alpha Blockers
• Post URS stenting
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Dept of Urology, GRH and KMC, Chennai.
65. Urinary Extravasation/ Urinoma
• 0.6-1%
• Disruption of ureteral wall / collecting system
• Significant Extravasation – Max Urinary Diversion
• Stenting upto 6 weeks
• Nephrostomy Tube
• Foley Catheter
• Antibiotics
• Urinoma infected/ Symptomatic – percutaneous/open drainage
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Dept of Urology, GRH and KMC, Chennai.
67. Urinary Obstruction
• 4-9%
• Instrumentation – Ureteric Trauma
• Local edema/ Spasm/ Bleeding with clots – Obstruction
• Post URS colic and hydroureteronephrosis
• Self limiting/ conservative management
• Persistent pain – imaging and Stent Placement
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Dept of Urology, GRH and KMC, Chennai.
68. Stent Discomfort
• Stent Related Symptoms upto 88% of which 70% need treatment
• CROES – readmission due to stent discomfort in 1%
• ? Routine stenting needed
• Restrict to large stone size, longer operative time, prior ureteroscopy and complication
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Dept of Urology, GRH and KMC, Chennai.
69. Hemorrhage
• Minor and self limiting
• Significant Post-operative bleed with haematocrit drop
• Work Up
• Contrast imaging
• Embolisation
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Dept of Urology, GRH and KMC, Chennai.
70. Venous Thromboembolism
• Rare
• Pulmonary TE (0.02%)
• AUA – do not recommend DVT prophylaxis for URS procedures
• Mechanical Compression and Early Ambulation
• High risk Cases – consider Pharmacological Prohylaxis ???
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Dept of Urology, GRH and KMC, Chennai.
71. Infection/ Sepsis
• Seeding infectious pathogens in the upper urinary tract
• Handling potential infected calculi
• High irrigation pressure in a setting of UTI
• Complicated UTI post URS – 1-3.7%
• AUA – antibiotic prophylaxis for all cases undergoing URS
• UroSepsis – 0.3%
• Immunocompromised
• Elderly
• Recent UTI
• Infectious stone
• Prolonged indwelling stent
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Dept of Urology, GRH and KMC, Chennai.
73. Ureteral Stricture
• Miniaturization – Dramatic Decrease <1%
• Trauma – inflammatory process following devascularisation or ischaemic injury to
urothelium
• But some stricture develop without any precipitator
• Symptomatic or Asymptomatic (silent Obstruction)
• AUA – Routine Post Operative USG after 3 months
• <1cm – endoureterotomy/ balloon dilatation and stenting
• >1cm/ Failed – open/ Lap
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Dept of Urology, GRH and KMC, Chennai.
80. Persistent Vesicoureteral Reflux
• High as 10% within 24 hours
• Typically Resolve by 2 weeks
• In 5-10% ( ureteral dilatation, incision or excision at intramural ureter) demonstrate
reflux after 3-20months
• Grade 1-3 sterile reflux – no treatment
• Recurrent UTI/ high pressure voiding – bulking agents injected at 6’o clock beneath
ureteral orifice
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Dept of Urology, GRH and KMC, Chennai.
81. CONCLUSION
• Most complications minor
• Screen for UTI and start antibiotics if culture positive
• Use Safety Guide wire, Always Visualise
• Avoid force, Low threshold for stenting – Postpone by a week
• If difficulty persists – RGP – smallest scope – dilatation last resort
• Basket should be used with care
81
Dept of Urology, GRH and KMC, Chennai.
82. THANK YOU
WHEN IN DOUBT DON’T DO IT
WHAT IS DONE CANNOT BE UNDONE
WHAT IS NOT DONE, CAN ALWAYS BE DONE
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Dept of Urology, GRH and KMC, Chennai.
