Flexible Ureteroscopy

Clinical history:

• 38 y.o. female patient.
• No relevant past medical history besides urolithiasis and 2 previous PCNLs.
• While under observation due to small fragments, constant stone growth was found, even though the patient was asymptomatic.
• When the stone reached 1.5 cm it was decided to perform a flexible ureteroscopy.

Technique description:

• After placing the patient under general anesthesia, she is placed in the lithotomy position, sterilized and draped.
• A table is set below the patient’s left leg, the monitors are set at the patient’s left side and the C arm on the patient’s right side.
• On the table, we keep dry gauzes and wet gauzes in a surgical dish.
• Also in the dish, we open the guidewire, a syringe and scissors.
• Placing the irrigation bag 40 cm above the patient the surgery begins with the small, 9.5 Fr semirigid ureteroscope to perform the initial cystoscopy, and a guide wire is placed in the renal cavities, keeping it as a safety wire.
• Then a semirigid ureteroscopy is performed to check the ureter for stones and for passive dilation. A second guidewire is placed in the kidney.
• Then the ureteral access sheath is passed though one of the wires (working wire), keeping the second as a safety wire. The access sheath should be inserted gently without forcing entry.
• Then the flexible ureteroscopy is performed with systematic renal inspection. Once the stone is identified, the laser is set, a small 200 micron fiber is placed and low energy, long pulse, and high frequency settings are used for dusting.
• The stone is dusted from the periphery to the middle. If breathing movements are intense, episodes of apnea can help stabilize the kidney. After completing the dusting, the basket is inserted, preferring small <2.2 Fr baskets to remove a fragment for further analysis. Final stone dusting is performed using the popcorn technique until complete dust is achieved.
• The access sheath is removed and a ureteral inspection is performed at the end of the procedure. A double J stent is finally placed with a bladder catheter.

Steps in the procedure:

• Cystoscopy.
• Guidewire placement in the renal cavities and keeping it as a safety wire.
• Semirigid ureteroscopy and placement of second guidewire.
• reteral access sheath placement.
• Flexible ureteroscopy with renal inspection.
• Dusting of the stone until small fragments are achieved.
• Stone removal with basket.
• Final stone dusting with pop corn technique.
• Access sheath removal and ureteral inspection.
• Double J and bladder catheter placement.

Learning points:

• Be systematic with the procedure, patient placement and setting.
• Never force the entry of instruments.
• Always plan ahead for possible complications and make choices based on what you can resolve.
• Plan the fragmentation technique in order to accomplish a stone-free status.
• Extract a stone fragment for analysis.