TECHNIQUE

Before undergoing ureteroscopy, the patient should have a documented negative urinalysis and urine culture, so as to reduce the risk of urosepsis.

The majority of ureteroscopic procedures are performed in a specialized cystoscopy suite. The patient is placed in a dorsal lithotomy position, with the lower extremities in stirrups. Either general or regional anesthesia is employed.

The procedure is typically initiated by visualizing the bladder lumen with a cystoscope (see Plate 10-37) and then deploying a guide wire into the ureteric orifice. The guidewire may be placed with either a rigid or flexible cystoscope, depending on surgeon preference. Next, a ureteral catheter is inserted over the wire, and a retrograde pyeloureterogram is performed to evaluate the anatomy of the upper tract and provide a map for deployment of the ureteroscope.

After the ureteral catheter has been withdrawn, the ureteroscope can be deployed. A semirigid ureteroscope is inserted adjacent to the wire. The wire, which provides a map of the upper urinary tract, can remain in place throughout the procedure. A flexible ureteroscope, in contrast, is deployed over the wire. Once it is in position, the wire must be withdrawn from the working channel to permit normal deflection and the introduction of devices. Thus before deployment of a flexible ureteroscope, a second guide wire is typically inserted to act as a “safety” wire, which remains present throughout the entire procedure and provides access to the upper urinary tract should normal anatomy become disrupted. To place a safety wire, a coaxial dilator/sheath is introduced over the first wire. The inner dilator is removed, the safety wire is introduced through the sheath, and then the sheath is removed.