Patients should be prepared for ureteroscopy as for any surgical procedure that requires anesthesia. A complete history and physical examination should be obtained, and pertinent laboratory studies are usually ordered (a complete blood count and at least a basic chemistry, plus urinalysis). If the urinalysis shows pyuria, bacteriuria, positive nitrite, or otherwise is suggestive of a urinary tract infection, then a urine culture should be requested reporting any growth of uropathogens. Standard informed consent is obtained as per any surgical procedure, commensurate with the rules for the institution where the ureteroscopy is to be performed.

In select cases (patients with symptoms and/or comorbid medical conditions that increase the likelihood of heart disease), an electrocardiogram (EKG) should be ordered if one was not done within the preceding 6 months, and any major abnormalities should be addressed by the patient’s primary care physician, or by a cardiologist, to minimize any cardiac risk for surgery.

A preexisting urinary tract infection should be treated 24–48 h before surgery, or if bacteriuria cannot be completely eliminated, it should be suppressed. If the urine is sterile preoperatively, then prophylactic antibiotics should be administered before instrumentation of the upper urinary tract, according to the current American Urological Association (AUA) Guidelines [39]. In most cases, such will consist of a fluoroquinolone (FQL) or trimethoprim-sulfa (TMP-SMX), given with a sip of water an hour before surgery, or intravenously, so-as to enable adequate blood and urine levels before instrumentation. For patients allergic to these antibiotics, an aminoglycoside with a cell-wall inhibitor (i.e., a penicillin-type drug, a cephalosporin, or vancomycin) will provide good coverage of most uropathogens.

When a patient has had a joint replacement within the previous 2 years, when a patient is immunosuppressed (i.e., on chemotherapy, HIV positive, etc.), or when a patient has a prosthetic heart valve, he/she may be more susceptible to infection either of their implanted prosthetic device, or to urosepsis, so attention to the AUA Guidelines for Antimicrobial Prophylaxis is strongly recommended [39]. Anticoagulants are not routinely stopped prior to diagnostic ureteroscopy or laser lithotripsy of ureteral stones at our institution, but they might require temporary cessation if tissue is to be incised [40, 41].

Except in cases of pregnancy, fluoroscopy is routinely used for guidance of guidewires, ureteroscopic instruments, and stents during the procedure. Personnel should wear adequate protective coverage, including lead aprons, and the operating room should contain lead shielding in its walls and door(s). The operating surgeon(s) should additionally use protective eyewear (leaded glasses) if performing a high-volume of fluoroscopic procedures, as cataracts are a long-term risk after recurrent radiation exposure to one’s eyes [42, 43].

The patient should normally be in the dorsal lithotomy position (Fig. 22.4) or a modified dorsal lithotomy position where the ipsilateral leg (to the side being operated upon) is lowered and extended [44]. This latter position has been found by some to make the semirigid ureteroscopy easier and faster; it is thought that the ureter is better aligned for insertion of the instrument. The patient should not be able to move during insertion of a semirigid ureteroscope, as sudden patient movement could result in perforation or other complications. Thus, a good degree of muscle relaxation with general anesthesia or an adequate level of spinal or epidural anesthesia (with motor block) is preferred, although it has been reported that one can perform semirigid ureteroscopy under local anesthesia in very select patients [45].

A routine cystoscopy/panendoscopy set-up (flexible or rigid) is arranged on a sterile field with standard drapes and the following additional items: The surgeon’s preferred guide wires, 50 ml or more of radiographic contrast, an open-ended ureteral catheter (usually 5 or 6 F size), a 12 or 14 F foley catheter, 10 and 20 ml syringes, and a pressure irrigation system with room temperature or body temperature saline. A single-action pump system or a pressure bag surrounding the saline for irrigation is the most commonly used methods for pressure irrigation through the ureteroscope. At our institution, we have not found any observable difference in outcome with room temperature saline vs. warmed (body temperature) saline for irrigation.

The length and size/type of ureteroscope should be appropriate to the location of the stone (or lesion) and the patient’s anatomy. A video camera imaging system is almost mandatory; otherwise, the surgeon must be a “contortionist” to keep his or her eye at the ocular end of the semirigid ureteroscope while advancing it into the lower ureter. Further, a camera system facilitates teaching, permits an assistant to better coordinate manipulation of a basket or other instrument, and keeps the operator’s face away from the ureteroscope’s working port, thus reducing the possibility of being sprayed in the face with a mixture of saline and the patient’s bodily fluids. It is more helpful if the video monitor and fluoroscopy monitor can be in close proximity, but as long as they are both easily visible for the urologic surgeon while performing the procedure, they will be adequate to the task at hand.

With the patient prepped and draped in the dorsal lithotomy position, standard cystourethroscopy is performed and the anatomic landmarks delineated. Assuming no preexisting ureteral stent is in place, the ureteral orifice of interest is cannulated with a 5 Fr open-ended ureteral catheter and retrograde pyelography is performed using radiographic contrast (Renografin-60^®, Conray-60^®, Ultravist-300^®, Isovue-300^®, or equivalent) diluted 50:50 with sterile water or normal saline. This will verify the location of the stone(s) and demonstrate the presence of stricture or other lesions that might affect the surgeon’s ability to safely insert the semirigid ureteroscope. If the patient is morbidly obese, sometimes it is necessary to dilute the contrast less, or even to use undiluted contrast, just to properly see the ureter on the fluoroscope (not usually an issue with newer, more powerful fluoroscopes that have improved resolution but sometimes necessary with older units).

A 0.035″ stiff-shaft glide wire is then advanced through the ureteral catheter into the renal collecting system using fluoroscopic guidance. The cysto-panendoscope and ureteral catheter are both removed over the wire, leaving the wire in place. Usually with semirigid ureteroscopy, only one wire is needed as a safety, so this wire is clipped to the drapes as a safety wire. Should a second wire be needed for the “ladder technique” or some other purpose, a dual lumen catheter may be placed over the wire and a second, identical wire advanced through the second lumen using fluoroscopic guidance, the dual lumen catheter is removed over the two wires, and one wire is clipped to the drapes as a safety wire. The second wire can be used as a “working wire” to pass a balloon dilating catheter or even to pass the ureteroscope. Or, it can also be clipped to the drapes as a second safety or stabilizing wire, permitting the ureteroscope to be passed between the two glide wires into the distal ureter, as shown in Fig. 22.5 (“ladder technique”).

If a preexisting ureteral stent is present, then using graspers through the cystoscope, the stent is brought out to the urethral meatus and cannulated with a 0.035″ stiff-shaft glide wire, or other guide wire per surgeon’s preference. The stent is exchanged over the wire for a dual lumen ureteral catheter and a retrograde pyelo-ureterogram is performed via the second lumen. Once stone location is verified, a second identical glide wire, if needed, may be advanced through the dual lumen catheter as described above.

There are some surgeons who prefer to pass a safety wire alongside a preexisting stent before removing the stent, fearing possible loss of access if the stent is clogged with debris thus blocking advancement of a wire through the stent. The “alongside” technique usually works well, but on occasion a wire cannot be inserted alongside the stent and the stent must first be removed. This type of problem is sometimes encountered when the stent fits snugly through a tight ureteral stricture or alongside an impacted stone. Regardless, a safety wire is important in virtually all semirigid ureteroscopy cases, as it provides an exit strategy should one need to terminate the procedure prematurely, for any reason.