EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES

Pandey S, Shroff S. Department of Urology & Renal Transplantation,

Sri Ramachandra Medical College and Research Institute, Chennai, India

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INTRODUCTION

No known incidence of such presentations Not much literature available on how to tackle these multiple pathologies No set rules laid out for approaching these multiple pathologies endoscopically in one sitting

Multiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countries

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Problems in Developing Countries

Presentation is relatively late

Economic considerations of the patient population plays a pivotal role in this delayed presentation

“cure all one sitting” Pressure on clinicians more in following situation:

Women Children Old PeopleSole earning member Poor or lower middle class people Patient coming from a distance for treatment

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ANALYSIS OF MULTIPLE ENDO- PROCEDURES

Study Group - SRMC – Urology Unit 1

Period - 1996 to 2002 Exclusions

- Local Anaesthesia cases- Diagnostic procedures

- open with endoscopic - E.g Hernias with TURP

Incidence of multiple procedures at presentation Various combinations of these Pathologies at presentation Endourological algorithms devised where applicable to tackle these problems effectively

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INCIDENCE

Total number of endourological procedures since 1996 – 2002 2176

Multiple pathologies at presentations 239 Incidence of presentations 11.1

%

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MOST COMMON MULTIPLE PATHOLOGIES239 (11.1 %)

Bilateral Ureteral calculus - 81 Vesical calculus + BPH - 54 Vesical calculus + Ureteral calculus - 41 BPH + Ureteral calculus - 39 BPH + Bladder tumour - 06 Stricture Urethra with bladder and ureteral

calculus - 05

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Endoscopic Clearance of easier / less demanding pathologies first

Lower tract to be cleared first before proceeding to upper tract

Completely clear one entity first - exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURP

EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES

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Lower tract stone disease before upper tract Stone disease

Chronological order of Intervention helps in maintaining vision till the end of such multiple procedures

Litholapaxy-> Lithotripsy> Incisions> Resections

EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES

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ALGORITHMS

Simple “common sense” Algorithms

Complex Endourologic

Algorithms

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COMMOM SENSE ALGORITHMS

BNI TURP TUIP

INTERNAL URETHROTOMY

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BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!!

Lower Ureteric Calculus first Lesser Impacted calculus first Bilateral safety guide wires first Side needing stents only first.

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CYSTOLITHOLAPAXY/TRIPSY+TURP/TUIP

Cystolithotripsy -36

Using 27fr nephroscope, 2 mm Swiss Litho probe

Cystolitholapaxy -18 Using 25Fr Sheath

&Mechanical Lithotrite

Extra operative times-10-45 min

Morbidity-nil Few patients had

increased Irritative LUTS

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CYSTHOLAPAXY/TRIPSY+TURP CALCULUS FIRST !

Advantages Bladder free of fragments of the calculus Good vision still being maintained-Preventing

inadvertent bladder injury Any untoward incident forcing abandonment of

surgery-May end up with a resected lobe and calculus free status!!

Preventing Absorption/Extravasation of irrigant when calculus is dealt before

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VESICAL CALCULUS+ URETERAL CALCULUS

Combination-41 Majority of vesical

calculus were 2-2.5 cm Majority of ureteral

calculus were in the lower ureter -26

WHICH FIRST!! OPTIONS------ 1.Placing guide wire-

cystolithotrripsy-URS 2.Cystolithotripsy-URS+

DJ Stenting

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VESICAL+URETERAL CALCULUS Advantageous to complete the ureteral calculus

first Exceptions- large bladder calculus fragments of ureteral calculus and vesical calculus

can be evacuated at the same time from the bladder

less chances of ureteric orifice injury preventing upper tract intervention -

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TURP +TURBT

Total number of cases-6

Maurmayer et al- 7%

Blandy et al -5.2%

TURP FIRST !

Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa

2.Easy instrumentation.

TURBT FIRST!

Advantages-1.Resection occurs in clearer access

2.Preventing massive absorption of irrigant as can happen from prostatic fossa.

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BPH + URETERAL CALCULUS

NUMBER OF CASES- 31 Ureteral calculus first!! ( Exceptions-Large median lobe

preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injury 2.

TURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice )

Advantages – Allows ease of instrumentation of the upper tract

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BPH WITH VESICAL & URETERAL CALCULUS

19 cases Large median lobe-4, B/L ureteral calculi-1

Calculi first ! !

May need TUIP for larger prostates

lesser extravasation/absorption

Ureteral first ! ! Advantage- Prevents oedema/injury to ureteral orifice

- Easier access with best vision

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

combinations Warm Irrigant fluids to avoid hypothermia

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Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation

Candidates must be relatively ‘fit’ for extended procedures

Presence of experienced assistant desirable

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

Extravasation Avoid Bilateral herniorraphy with TURP / TUIP

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AVOID …… TURP & PCNL -- both accompanied with

considerable haemorrhage - !! B/L Upper tract procedure if-

1.First side is difficult / prolonged procedure

2.Pus seen on clearing calculus on one side

REMEMBER ………

THERE IS ALWAYS

A SECOND CHANCE !!!