Contributors of Campbell-Walsh-Wein, 12th edition
Brian Duty, Michael Joseph Conlin Roshan M. Patel, Kamaljot S. Kaler, and Jaime Landman
Cystoscopy preparation and tips
Before cystourethroscopy, the skin is prepared with an antiseptic agent. Both chlorhexidine gluconate and alcohol-based solutions can damage mucous membranes and therefore are not recommended for use on the genitalia. Aqueous-based iodophor containing products such as Betadine are safe on all skin surfaces. Plain or lidocaine gel is then injected into the urethra, though meta-analyses have found no difference in procedure tolerance. The most uncomfortable part of the procedure is when the scope passes through the membranous urethra. A randomized trial showed a significant improvement in pain after manual compression of the irrigation bag during passage of the scope. Patients, in particular young men, should be encouraged to relax as much as possible as the scope is advanced through the membranous urethra. Other strategies to decrease pain are allowing patients to observe the monitor or listen to classical music.
Ureteroscopy tips and key points
Basic principles to keep in mind are the importance of access to the upper tract, good visualization, and maintenance of low pressures. In general, semi-rigid ureteroscopy is best below the iliac vessels and flexible ureteroscopy above the vessels. Normal saline should be used as irrigation. Irrigation systems allow visualization, lubrication, and stone manipulation and consist of pressure bags, hand pumps, or foot pumps. The former provides constant flow, and the latter allows for more control. Mobile C-arm fluoroscopy should be used because it provides better image quality and less scatter than fixed units. Before the ureteroscopy proceeds, the bladder is drained to permit accumulation of irrigation fluid during ureteroscopy and minimize buckling of the flexible ureteroscope into the bladder ( Fig. 3.1 ). If a longer rigid ureteroscope is being used, the contralateral leg can be elevated to allow for easier introduction of the ureteroscope. A safety guide is critical during rigid ureteroscopy to maintain access and allow placement of a ureteral stent if any problems are encountered. Following the guidewire permits easy identification of the ureteral orifice. By maneuvering the tip of the ureteroscope next to the guidewire posterolaterally, the physician can elevate the wire, thereby propping open the orifice. If necessary, an additional guidewire can be passed and the ureteroscope is then rotated until it is directly between the two wires, which will hold the orifice wide open ( Fig. 3.2 ). When the ureteroscope or access sheath is safely in the intramural ureter, the additional guidewire can be removed.
Care must be taken when trying to gain access around an impacted stone because of perforation. An angled hydrophilic-coated (tipped or complete) wire, an angled torqueable catheter placed in close proximity to the stone, or both can be helpful. If a guidewire cannot be safely passed beyond the stone, direct inspection of the ureter up to the stone with the rigid ureteroscope may permit passage of the wire under direct vision. If the stone is impacted, it can be helpful to gently manipulate it and/or treat well-exposed areas of the stone with the laser, allowing for improved visibility and safer completion of the lithotripsy. When the proximal ureter is visualized, pass the wire under direct vision prior to completing the lithotripsy.
If there is any suspicion about possible infection above the stone, a urine culture through an open-ended catheter passed antegrade to the obstruction should be sent and a drainage established with a stent or percutaneous nephrostomy. The ureteroscopy should be postponed until the infection has been treated.
A dual-lumen catheter can be advanced over the initial guidewire to gently dilate the ureteral orifice and to introduce a second wire to pass the ureteroscope or a ureteral access sheath over. If the flexible ureteroscope does not pass the orifice, the scope should be rotated 90 to 180 degrees on the guidewire to better position the tip of the ureteroscope. It is important to pass the laser fiber through a straightened flexible ureteroscope to prevent damage to the working channel.
Guidewires – Many are available and offer differing diameters, rigidity, tip design, materials and coating. In general, stiffer wires are better for passing sheaths, dilation systems, and scopes over. Floppy tip, J tip, and double-floppy configurations can be used in certain cases. Guidewires range from 0.018 to 0.038 in size and range from 80 to 260 cm in length. Hydrophilic coated wires are best for establishing challenging access around an obstruction but can easily slide out. New hybrid wires allow for some advantages of both.
Ureteral Access Sheaths – Allow for repeated access to the intrarenal collecting system without having to replace the working guidewire. They have been shown to decrease intrarenal pressure and facilitate fragment retrieval. They come in a range of sizes from 10/12F (inner/outer diameter) up to 14/16F and lengths from 28 cm up to 55 cm. There is a small risk of injury to the ureter from the use of a ureteral access sheath ( Table 3.1 ).
| MANUFACTURER | SHEATH NAME | DILATOR/SHEATH (Fr) | LENGTHS (cm) | UNIQUE FEATURES |
|---|---|---|---|---|
| Boston Scientific | Navigator | 11/13 13/15 | 28, 36, 46 | |
| Navigator HD | 11/13 12/14 13/15 | 28, 36, 46 | ||
| Applied | Forte (AxP and HD) | 10/12–16; 12/14–18; 14/16–18 | 20, 28, 35, 45, 55 | |
| Forte Plus | 10/14 | 35, 55 | Active deflecting mechanism | |
| Bard | Proxis | 10/12 12/14 | 25, 35, 45 | |
| Cook | Flexor | 9.5/11; 12/13.7; 14/16 | 13, 20, 28, 35, 45, 55 | |
| Flexor DL | 9.5/14; 12/16.7 | 13, 20, 28, 35, 45, 55 | Dual-lumen design | |
| Flexor Parallel | 9.5/11; 12/13.7; 14/16 | 13, 20, 28, 35, 45, 55 | Rapid release design for single wire external to sheath | |
| Olympus | UroPass | 10/12 11/13 12/14 13/15 | 24, 38, 46, 54 |
Other Devices – Ureteral dilation, stone retrieval, and antiretropulsion and ureteral biopsy devices are available and useful for ureteroscopic procedures ( Table 3.2 ). New nitinol baskets have provided increased durability and usability.
| Ureteroscopes |
|
| Disposable Supplies |
|
|
| Intraluminal Lithotripsy Devices |
|
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
