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In this paper we provide a summary of placing ureteric access sheath, flexible ureteroscopy, intra renal stone fragmentation and retrieval, maintaining visual clarity and biopsy of ureteric and pelvicalyceal tumours. The use of ureteric access sheaths prior to flexible urolithiasus can be both a surgical preference and case-specific. They facilitate multiple passages of the ureterorenoscope, reduce intra-renal pressure and help improve irrigation flow [ 1 ].
However, the surgeon must be aware that access sheaths carry a risk of ureteric ischaemia and can lead to ureteric injury [ 2 ]. We advocate performing an initial semi-rigid ureteroscopy before placement of the access sheath. We do urolityiasis advocate the use of ureteric balloons to urolithiqsis the ureter to aid sheath placement nor the use of other ureteric dilators.
Although these might be an option in very particular circumstances, in most cases uolithiasis an unfavourable ureter, it is usually preferable to place a stent and return for the definitive operation at a later date. The decision to leave a safety wire outside an access sheath is one of personal preference. Some newer access sheaths enable a single wire to be used for placement and results in the wire being situated outside the sheath after placement [ 4 ].
Urolitbiasis sheaths offer the cost benefit of a single guidewire for the procedure although this must be offset against the cost of the access sheath itself! Once the access sheath of the desired size and length has been chosen, pass the sheath over the guidewire using the Seldinger technique. The sheath passage should be monitored with pulsed fluoroscopy during ureteric passage, uroliithiasis possible buckling in the bladder or to identify early resistance and failure to progress.
Pass the sheath slowly, feeling for resistance when placing over the wire. Ensure that the wire does not kink, or coil in the bladder, ,akalah will make advancement of the sheath impossible. If this should occur, gradual step-wise withdrawal of the wire, under close fluoroscopic control, is needed to straighten the wire, and then retry the insertion with particular attention to the sheath crossing the ureteric orifice and lowermost ureter see Figure 1.
If the access sheath progresses up the ureter well, consider placing it just below the PUJ, allowing the flexible scope to be fully deflectable. When the procedure is completed, withdraw the ureteroscope and access sheath together with the tip of the uroluthiasis placed just at the end of the sheath, watching the ureteric mucosa move past.
Tips and tricks of ureteroscopy: consensus statement. Part II. Advanced ureteroscopy
Any ureteric injury can then be noted and stented accordingly. If a safety wire is not already in place, a makaalh can be pre-emptively inserted through the flexible ureterorenoscope to allow stent insertion if required. Wire problems in bladder for access sheath insertion. A straight safety wire is present, but the working wire, over which the access sheath is being passed, uroithiasis substantially coiled in the bladder.
Further advancement of the sheath will not only fail to access the ureter, but is likely to result in displacement of the working wire to the bladder. The access maakalah has been withdrawn to the urethra. The working guide wire has been withdrawn slightly, such that the coiled loop is of smaller diameter. The working wire is now straight, and the tip of the access sheath has been moved along it towards the left ureteric orifice.
Once the lower third has been successfully traversed, the image intensifier can be moved to the proximal ureter to allow precise positioning of the tip of the sheath in the upper ureter. If unable to pass the access sheath into the UO or much beyond the lower third of the ureter, despite prior normal rigid ureteroscopy, consider using only the inner obturator of the access sheath over your wire, enabling an initial ureteric dilatation by advancing the obturator to the upper ureter.
Then, try repeating access mqkalah placement with both the sheath and inner component. If this is unsuccessful, one can consider using a stiff wire, rather than the standard guide wire, to aid sheath placement.
Be aware that these wires can cause intra-renal bleeding if forced too hard or pushed through the urothelium. If you are still unable to place the sheath, discretion is much better than valour. Change tack, pass the flexible scope over the stone wire and perform your flexible ureteroscopy without a sheath see below kakalah simply stent the patient and come back another day.
Some surgeons uroliithiasis to place the flexible ureteroscope over a wire, without using an access sheath. One can consider using a double-tipped hydrophilic wire, thereby reducing damage to urolithiiasis fragile working channel of the flexible ureteroscope.
When initially placing the ureteroscope, we would advocate having it free of all attachments irrigation channel, light and camera leadsenabling smoother passage. It can then be passed over the wire, again using limited pulsed fluoroscopy to check progress. If you are still unable to pass the flexible scope, stent the ureter with a view to performing a repeat procedure in approximately 2—6 weeks.
This will also reduce torque and pressure on the flexible scope. It is pertinent and useful to remember that the ureterorenoscope has 3 user inputs to manipulate the tip: Deliberate, slow movements will get one around the whole collecting system faster than wild, fast movements.
Furthermore, it can aid the rapid reintroduction of the scope towards the calyx of interest stone or TCC bearing later in the procedure see Figure 2.
The ureterorenoscope is directed to uurolithiasis upper medial calyx as the starting point for an anti-clockwise tour of the collecting system. The upper middle calyx will be visualised where the safety wire is located as the scope is moved to the upper lateral calyx. The scope is seen in the posterior upper pole calyx. The interpole, not well seen on the images 3a-c is filled with contrast via the scope to confirm it has been visualised.
The scope is placed in the next calyces down, in the lateral part of the lower pole. Both calyces can be urolithiaxis in turn before moving to the lowermost calyx. The ureterorenoscope is deflected into the lower medial calyx. Before performing laser fragmentation in the kidney, consider repositioning the stone into a more favourable position upper calyx or even upper ureter if feasible. The aim is to keep the ureteroscope as straight as possible while fragmenting, reducing the risk of damage to the flexible ureterorenoscope see Figure 3.
It is important to be aware of the individual properties of the different intra-renal baskets available, and especially to understand the pros and cons of the preferred basket. It is to be noted that increasing the size of the basket corresponding to shaft diameter will significantly reduce irrigant flow [ 1 ].
Basket relocation of lower pole stone.
The stone has been identified in the lower pole, and urolithiassis grasped in a basket to prepare for relocation. The ureterorenoscope is manoeuvred out of the lower calyx towards the renal pelvis. The scope is advanced into the patient to the upper pole — the presence of the safety wire in the upper calyx can aid this both under endoscopic and fluoroscopic control.
The stone is then released from the basket, which is withdrawn from the scope, and replaced with an appropriate laser fibre for stone fragmentation. The stone has been successfully broken into small pieces. There urolithiasiss debate amongst surgeons whether to laser the stone to dust or fragment and retrieve intra-renal fragments, and sometimes hrolithiasis best results are achieved by a combination of the two techniques. The different laser settings and their effect on stone fragmentation have been highlighted in a recent publication [ 5 ].
Again, personal preference will dictate one’s practice. It is helpful to liaise with the anaesthetist to control the patient’s respiratory movement during stone fragmentation in the kidney. This will not only increase efficacy of lasertripsy but urolithiasjs reduce the risk of compromising the view from bleeding through increased accuracy of laser onto the stone as opposed to the urotheliumand both factors will help reduce the overall operating time as well.
When the laser fibre is inserted, ensure that the ureterorenoscope is straight in a non-deflected, neutral position — one of the advantages of having an additional wire in the kidney is maintaining a straight ureterorenoscope. Maintaining the scope straight as the laser fibre is passed reduces the risk of working channel damage, avoiding costly repairs. Reusable laser fibres can result in small microfractures, which then contribute to flexible ureterorenoscope damage.
The use of disposable laser fibres is increasing, urolithiaiss they have been shown to be cost-effective and reduce urollithiasis damage [ 6 ]. Vision is key to achieving good fragmentation and stone-free rates, particularly in the kidney. However, as noted above, it is important to note that larger access sheaths can potentially cause ureteric ischaemia and even direct ureteric trauma including perforation.
Simple hand held pump devices can be used and will help increase irrigant flow. They are best used irolithiasis as they transiently uropithiasis intra-renal pressure.
Blood will affect vision and may uropithiasis in a premature end to the procedure. With minor bleeding, increasing the irrigation for a few minutes may help improve the view. Aspiration of the collecting system may result in further bleeding; therefore, be patient and wait for the vision to improve.
Other factors that can affect the quality of vision include the focusing of optical scope, adjusting the brightness of light, correct white balancing and appropriate use of vision enhancement features on the stacking system.
Correct adjustment of these factors aids vision and results in successfully completed procedures. In vitro assessment has shown improved image resolution and colour reproducibility without compromising depth of field, image distortion, grayscale imaging and ureteroscope deflection.
Whilst field of view may be reduced in some comparisons, this is counteracted by an increase in image size [ 7 ].
Improved optical characteristics translate to improved clinical outcomes with significant improvements in mean operative time, flexible ureterorenoscopy time and efficiency of stone fragmentation [ 89 ]. The placement mwkalah a ureteric stent, particularly in an emergency setting, such as relieving obstruction in an urolithiasls system, can be a daunting task.
Problems might arise with guide wire placement, but hopefully the tips discussed earlier will uroolithiasis this. When placing a stent it is useful to try and deploy the proximal coil especially multi-length stent in the upper calyx, thus enabling a smaller component of the stent in the bladder.
Of course, it is important not to leave the distal end too short! These can urolithiasia into the ureter and be tricky to reposition. Consider the use of a ureteric catheter or tethered stent if feasible, for short-term drainage.
One must always consider whether a stent is really needed, as they have associated morbidity. If considering leaving a stent, good preoperative counselling of the patient is vital.
Patients will need to be aware that they might have some pain or discomfort postoperatively. This will help reduce unnecessary readmissions for stent related symptoms.
Makalah Urolithiasis Documents –
When placing the stent, if one is having difficulty with buckling at the UO, bring the cystoscope closer to the UO and push slowly under vision. If the stent is not moving, use fluoroscopy to check the wire placement in the collecting system. Excess wire in the renal end can equally hamper progress. By pulling back the wire slightly under fluoroscopy monitoring the renal endthe stent mskalah then be advanced.
Do not forget to check that your assistant makalau maintaining adequate stiffness of the wire whilst the stent is being inserted.
In such cases, care must be taken to ensure the distal end of the stent is not pushed too high in the ureter. It is best to visualise and ensure its position in the bladder before sending the patient to recovery — if there is any doubt from the final fluoroscopic image, it is best to be sure by passing the cystoscope and having a look!
It is important to remember that bilateral ureteroscopy may result in bilateral stent insertion. Finally, regardless of the circumstances leading to stent placement, it is important to ensure that an appropriate postoperative plan is in place to track and remove the stent. Diagnostic ureterorenoscopy and biopsy has been recommended for cases of upper tract tumors [ 310 ].