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Ureteroscopy – Technical Aspects V Hopkinson September 2015.

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Ureteroscopy – Technical Aspects V Hopkinson September 2015
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Page 1: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy – Technical Aspects

V HopkinsonSeptember 2015

Page 2: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy• Review imaging/consent/mark• Check urine culture/pregnancy test if appropriate• WHO checklist• Radiographer/C-arm/x-ray table (extensions)• Imaging in theatre• Antibiotic prophylaxis• Lithotomy position• GA• Cystoscopy• Retrograde pyelogram

– Ureteric catheter (5 Fr)– Contrast e.g. Niopam 300 = Iopamidol – non-ionic monomer (300 mg

iodine/mL)

Page 3: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy• Guidewires– Standard = stainless steel core with PTFE coating– Hydrophilic = nitinol with hydrophilic coating– Straight, angled or J-shaped tip– Length: 150 cm, diameter .035 or .038 in– Always have safety wire

• Semi-rigid ureteroscope alongside guidewire – Second guidewire to negotiate narrowing– 7 – 10 Fr– Working channel 3.4 Fr– 34 cm long

Page 4: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy• Laser– Holmium:YAG– 365 μm or 200 μm fibre (200 μm allows better

deflection for lower pole stones) – Start with 5 Hz, 0.5 J– Laser safety:

• Safety certificates• Laser safety officer present• Goggles• Windows covered• Doors locked• Check fibres prior to use• Machine on standby when not in use

Page 5: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy• Baskets– Ureter

• Tipped• Stainless steel• Straight or spiral wires• Three-pronged graspers

– Kidney• Zero tip

– Nitinol– 1.3 – 3 Fr

• NGage™ – Nitinol– 1.7 – 2.2 Fr, 115 cm

Page 6: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Ureteroscopy• Flexible scope– 5.4 – 9 Fr– 70 – 80 cm long– Working channel 3.6 Fr

• Stents– 4.8 Fr – 8 Fr– 18 – 30 cm– Polymers

• e.g. polyurethane, polyethylene• e.g. Percuflex™ Plus

– Boston Scientific – Percuflex with HydroPlus™ coating– Base polymer = polyethylene

Page 7: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Stenting?• Indications:

– Ureteric trauma/perforation– Bleeding– Significant oedema– Impacted stone– Failure to pass scope or complete treatment– Infection– Obstruction– Large stone burden– Single kidney– Renal impairment– Pregnancy– Transplant kidney

Page 8: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Stenting if uncomplicated?• Tang et al. Urology (2011)

– Meta-analysis of randomised trials of stent vs. no stent– 14 trials – Heterogeneity in pain assessment, therefore difference in post-op pain between groups not

clear– Incidence of dysuria, frequency and haematuria significantly higher in stent group– No difference in post-op analgesia requirement, UTIs, post-op fever, stone-free rate and

ureteric stricture between the groups– Decreased tendency towards unplanned medical visits or hospital readmission in stent group

(not statistically significant)– Increased cost in 5 studies– Increased operative time

• Also:– Risk of encrustation– Risk of ‘forgotten stent’

• Alternative: – Ureteric catheter for 24 h

• BUT – involves overnight stay

Page 9: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Problems…

• What do you do if a basketed stone is stuck in the ureter?

• What do you do with a basket with a broken wire?

Page 10: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Problems…• Basketed stone stuck in ureter:

– Try to advance proximally, open basket and remove stone– Fragment stone within basket

• Disassemble basket by unscrewing handle• Replace scope alongside basket and laser stone

– Leave basket and stone in ureter, wake patient up and observe – may fall out spontaneously

• Basket with broken wire– Can cause ureteric trauma– If tipless:

• Advance 7 Fr ureteric catheter or access sheath over basket and withdraw– Otherwise:

• Withdraw under vision grasping distal broken wire with forceps• Transect remaining wires, remove proximal basket, advance distal portion into renal

pelvis, turn it around with forceps and withdraw tip first

– From Le & Segura, BJUI (2006)

Page 11: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Medical Expulsive Therapy

Page 12: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Meta-analyses• Hollingsworth et al. Lancet (2006)

– 9 trials– 693 patients (individual studies 15 – 48 patients in each group)– Calcium channel blockers or alpha blockers– Primary endpoint: proportion of patients who passed stones– Mean stone size 3.9 – 7.8 mm– All stones in distal third of ureter except in one study– Treatment duration 7 days – 6 weeks (or until stone passage)– Follow-up 15 – 48 days– 65% greater chance of passing stone with medical therapy – ARR 0.31 (95% CI 0.25 – 0.38)– NNT 4– Less need for analgesics in MET groups – Limitations:

• Clinical heterogeneity• Publication bias• 8 trials not blinded• 6 did not describe randomisation procedures in detail

Page 13: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Meta-analyses• Campschroer et al. Cochrane Review (2014)

– 32 studies• 7 double-blinded• 2 incomplete data• 1 high number of withdrawals• 28 single-centre• Most had small patient numbers

– 5864 patients– Alpha-blockers– Stone-free rates significantly higher in alpha-blocker group– RR 1.48 (95% CI 1.33 – 1.64)– Stone expulsion time 2.91 days shorter with alpha-blockers– Reduced number of pain episodes, need for analgesia & need for

hospitalisation– Data limited on mid- and proximal ureteric stones

Page 14: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Meta-analyses• Lu et al. Urol Int (2012)– 29 trials– 2763 patients– 19% improvement in stone clearance with tamsulosin– Higher expulsion rate with tamsulosin vs. Ca channel

blockers– Limitations:

• Some studies poor methodological quality• Clinical heterogeneity

– e.g. Stone size, duration of follow-up, measurement of outcomes• Insufficient allocation concealment and blinding• Publication bias

Page 15: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

Meta-analyses• Fan et al. Int J Urol (2013)– 14 studies– Increase in expulsion rate in tamsulosin group of 51%– Decrease in expulsion time of 2.63 days– Reduce risk of requiring other procedures by 60%– Increased incidence of side effects (mainly dizziness)

in tamsulosin group– Limitations:

• Clinical heterogeneity• Publication bias• Methodological quality

Page 16: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

SUSPEND• Spontaneous Urinary Stone Passage Enabled by Drugs• Multicentre, randomised, double-blind, placebo-controlled trial• 1167 participants (1136 analysed)• Aged 18 – 65 years• 1 stone, ≤ 10mm, any site within ureter• Placebo vs. tamsulosin vs. nifedipine• Exclusion criteria: those needing immediate intervention, sepsis,

eGFR < 30 mL/min, already taking or unable to take an α-blocker or a Ca channel blocker, > 65 years

• Primary outcome: spontaneous stone passage in 4 weeks defined as the absence of the need for additional intervention to assist stone passage at 4 weeks after randomisation

• Other outcomes: pain, time to stone passage, health status & safety, health economic components

Page 17: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

SUSPEND

• 80% placebo group needed no intervention compared to 81% in tamsulosin group and 80% in nifedipine group at 4 weeks

• No difference in stone passage at 12 weeks• No differences in analgesic use, time to stone

passage and health status• Serious adverse events in 3 patients in

nifedipine group and 1 in placebo group

Page 18: Ureteroscopy – Technical Aspects V Hopkinson September 2015.

SUSPEND trial poll results, BJUI (July 2015)


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