Ureteroscopy:

Instruments, Indications,
and Outcomes
Gregory S. Adey, MD
Residents’ Conference
2 April 2003
 History of Ureteroscopy
• 1912: Hugh Hampton Young using
9.5Fr pediatric cystoscope
• 1970’s: Routine rigid ureteroscopy
• 1964: Marshall reports first flexible
ureterscopy (diagnostic only)
– No deflecting mechanism
– No working channel
 Fiberoptics
• 1854: John Tyndall (London)
demonstrates internal reflection
allows bending of light within flexible
glass
• 1927: First patent granted for light
transmission using flexible glass
fibers
 Fiberoptics
• Molten glass drawn into small
diameter fibers
• Fibers arranged with identical
orientation at each end
• Clad each fiber with 2nd outer layer of
glass improves transmission,
reflection, and durability
– Honeycomb or mesh appearance
 Flexible Ureteroscopes
• 1980’s:Bagley, Huffman, Lyon (U Chicago)
• Small lenses permit magnification and
angles of view
• Active deflection mechanism
– Logical or intuitive movement
• Passive deflection (secondary)
– Inherent weakness in durometer of sheath
– Enables lower pole access
Flexible Ureteroscopes
 Indications & Applications
of Ureteroscopy
• Urolithiasis
• Upper tract TCC
• Ureteropelvic junction obstruction
• Ureteral stricture
• Hematuria or abnormal cytology
evaluation
• Iatrogenic foreign bodies
 Urolithiasis
• Semi-rigid below iliac vessels

• Flexible ureteroscopy above iliacs

• Pre-operative and peri-operative Abx

 Dealing with the Intramural
Ureter
• Semi-rigid Ureteroscopy
• Catheter Dilatation
• Balloon Dilatation
• Ureteral Access Sheath
 Semi-rigid Ureteroscopy
• Tapered scope

• 6.9Fr to 7.5Fr (older scopes 9Fr-12Fr)

• Gentle dilation under direct vision

 Catheter Dilatation
• Guide wire in place
• 10Fr dual lumen catheter
– Gentle dilatation over wire
– Used to place 2nd wire
• Graduated dilators
– I.e. Nottingham dilators
• +/- ureteral stent
 Balloon Dilatation
• Varying diameters and lengths of
balloons (10-18Fr, 4-10 mm)
• Dilation usually maintained at 10-14
atm for 2 minutes
• Almost always stented post-
operatively for risk of obstruction
• Cost $225
 Ureteral Access Sheath
• Hydrophilic sheath, tapered inner
dilator
• Inserted under fluoroscopy
• 20 cm, 28 cm, or 35 cm lengths
• 10/12Fr, 12/14Fr (inner/outer)
diameter, 14/16Fr now available
• Cost: $100
Ureteral Access Sheath
 Bagley and Grasso
• 584 procedures, 2 institutions

Grasso M and Bagley DH. J Urology: 160(5), 1998.

 Ureteral Access Sheath
• Does the access sheath facilitate
ureteroscopy?
• Prospective, randomized, 62 patients
• 47 patients required no dilatation
– 24 unaided URS, 23 URS via UAS
• 15 patients required ureteral dilation
– 7 dilated with UAS, 8 with balloon

Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001

 Ureteral Access Sheath
• 100% of balloon dilated patients
stented, 43% of UAS patients stented
• No significant differences in post-op
symptoms, complication rate or
stone-free status
• Time savings of 10 min in UAS group
(43 min vs. 53 min)
– OR cost savings $350/case

Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.

Ureteral Access Sheath

Kourambas J, Byrne RR, Preminger GM. J Urology: 165(3), 2001.

 Ureteral Access Sheath
• Does the UAS cause ureteral
ischemia?
• Swine animal model, n=11
• 3 ureteral units per sheath size,
2 pigs without sheath (control)
• Laser doppler flowmetry every 5 min
for 70 min

Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.
Ureteral Access Sheath

Lallas CD, Auge BK, Raj GV, et al. J Endourology: 16(8), 2002.
 Urolithiasis
• AUA Ureteral Stones Clinical
Guidelines:
– 98% of all calculi < 5 mm will pass
spontaneously
– ESWL 1st line therapy for calculi 1 cm or
less in proximal ureter
– ESWL or URS 1st line for calculi 1 cm or
less in distal ureter

Segura JW, Preminger GM, Assimos DG, et al. J Urology: 158(5), 1997.
 Urolithiasis
• AUA Ureteral Stones Clinical
Guidelines:
– Blind basket extraction is not
recommended
– Open surgery is appropriate as a
salvage procedure or in unusual
circumstances
 Urolithiasis
• Most common reason for URS

• Electrohydraulic lithotripsy (EHL)

• Holmium: Yttrium-Aluminum-Garnet
laser (Ho:YAG)
 EHL
• Cheaper than laser lithotripsy
• 1.9F probe
• Shock-wave production fragments
stone
• Narrow margin of safety
 EHL
• Can cause extensive local tissue
damage including perforation
• Can propel fragments through
ureteral wall
• Contraindicated in patients with
bleeding diathesis
 Ho:YAG
• More expensive than EHL
• Thermal reaction with stone matrix
• Vaporizes all stone compositions
• 2100 nM wavelength
• Frequency 5 to 10 Hz
• Power 0.6 to 1.2 J
 Ho:YAG
• Quartz laser fibers (reusable)
• Helium-neon aiming beam
• 200, 365, 400, 800, 1000 micron fibers
• Cost $750-$1000/fiber
• Energy absorbed in 3 mm of water,
Tissue penetration of 0.4 mm
• Risk is mainly thermal injury
 Ho:YAG with Bleeding
Diathesis
• 25 patients:
– 17 taking coumadin
– 4 with thrombocytopenia (< 50 k/mm3)
– 3 with liver dysfunction
– 1 with von Willebrand’s disease
• 1 complication: RP hemorrhage after
combined EHL with Ho:YAG
• Ho:YAG alone: safe in patients with
bleeding diathesis

Watterson JD, Girvan AR, Preminger GM, Denstedt JD. J Urology: 168(2), 2002.
 EHL vs. Holmium

Teichman JM, Rao RD, Rogenes RV, et al. J Urology: 158(4), 1997.
 Laser Lithotripsy
• Proximal ureteral calculi:
– 100% stone free (Gupta, < 1 cm, n=46)
– 93% stone free (Gupta, > 1 cm, n=35)
– 89% stone free (Wolf, n=81)
• Distal ureteral calculi:
– 100% stone free (Bartsch, n=40)
– 99% stone free (Kane, n=113)
– 95% stone free (Jenkins, n=96)
 Laser Lithotripsy
• Renal calculi:
– 91% stone free (Grasso, n=45)
– 85% stone free (Preminger, n=36)
– 80% stone free (Bagley, n=59)
– 77% stone free (Elakkad, n=30)
 Laser Lithotripsy
• Lower Pole Study Group1:
– ESWL < 10 mm (63% stone free)
– ESWL 10 to 20 mm (23% stone free)
• Negative predictors of success:
– Previous failed ESWL
– Cystine stone
– Anatomic considerations

Lingeman JE, et al. J Endourology: 151, 1997.

 Laser Lithotripsy
• Lower pole stones difficult to
visualize
• 200 micron fiber has least reduction
in deflection (7 to 16% loss)
• Newer scopes (Storz Flex-X 270°,
ACMI Dur-8 Elite) facilitate access
 Laser Lithotripsy
• Relocate LP stones to pelvis, mid- or
upper pole location
• 3.2Fr nitinol basket vs. 2.6Fr nitinol
grasper
• Less chance of entrapment with
grasper, but caution with each
 Laser Lithotripsy

Kourambas J, Delvecchio FC, Munver R, Preminger GM. Urology: 56(6), 2000.

 Stent?
• Prophylactic stenting prior to ESWL does
NOT lead to higher stone free rates
– Multiple, prospective, randomized, stones of
all sizes
• Indications prior to ESWL
– Obstructive pyelonephritis
– ARF secondary to obstruction
– Refractory colic
– Relief of high-grade or long-term obstruction
 Stent?
• Yes:
– Balloon dilatation
– Excessive ureteral wall trauma
– Impacted stone
– Ureteroscopy > 90 min1
– Solitary kidney
– Incomplete fragmentation
• Cost: $130
Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS. Urology: 57(4), 2001.
 Stent?
• Prospective, randomized study
• 53 patients stented, 54 without
• Patients with stents had significantly
more flank pain, bladder pain,
narcotic use
• No difference in stone free rates
• 4 patients (7.4%) without stents
required re-admission for pain
Borboroglu PG, Amling CL, Schenkman NS, et al. J Urology: 166(5), 2001.
 Stent?
• 93 patients with distal calculi, no stents
placed
• Basket (70 patients), EHL (23)
• Balloon dilatation to 15Fr (80)
• Post-operative pain:
– 40 patients (43%) no pain
– 45/53 patients (85%) mild pain
– 5 patients (5%) required IV narcotics &
overnight admission

Hosking DH, McColm SE, Smith WE. J Urology: 161(1), 1999.

 Stent?
• Multi-institutional, prospective,
randomized study (58 patients)
• 29 stented, 29 without stents
• Holmium laser (57 patients), EHL (1)

Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.

 Stent?

Denstedt JD, Wollin TA, Sofer M, et al. J Urology: 165(5), 2001.

 Upper Tract TCC
• Nephro-ureterectomy with bladder
cuff remains gold standard
• Distal or segmental ureterectomy
acceptable in certain situations
• What is the role of endoscopic
treatment for upper tract TCC?
 URS and Upper Tract TCC
• Can URS cause local tumor seeding
from pyelovenous, pyelotubular, and
pyelolymphatic backflow?

• 2 case reports of tumors cells within

submucosal lymphatic and vascular
space following URS
 URS and Upper Tract TCC
• 13 patients with upper tract TCC
• Diagnostic URS followed by
subsequent nephrectomy (later date)
• No free tumor cells seen within
vascular or lymphatic spaces of the
submucosa

Kulp DA, Bagley DH. J Endourology: 8(2), 1994.

 URS and Upper Tract TCC
• 96 patients had nephro-ureterectomy
for upper tract TCC
• 48 patients had pre-operative URS
immediately prior to NU (48 controls)
• No significant differences in
recurrence rates, time to recurrence,
or mortality

Hendin BN, Streem SB, Novick AC. J Urology: 161(3), 1999.

 Endoscopic Treatment of
Upper Tract TCC
• 21 patients with upper tract TCC
• 8 pelvic, 13 ureteral (<2 cm), Gr 1 or 2
• All received endoscopic treatment:
– Electrocautery (13), Nd:YAG (8)
– Cautery penetrates 4 mm
– Neodymium used for larger tumors
• Mean follow-up: 6 years
Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
 Endoscopic Treatment of
Upper Tract TCC
• 7 patients (33%): local recurrences,
1 patient (5%) two local recurrences

• 17 kidneys (81%) were preserved,

4 (19%) had NU for recurrence

• None of 4 NU specimen > pT1

Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
 Endoscopic Treatment of
Upper Tract TCC
• Range of recurrence: 2 to 24 months
Mean time to recurrence: 7 months
• No strictures
• 1 patient died from invasive bladder
TCC
• Kaplan-Meier 10-yr survival: 70%

Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Urology: 58(2), 2001.
 Endoscopic Treatment of
Upper Tract TCC
• 38 patients, all tx endoscopically
• All TCC grade 1 or 2
• Mean follow-up: 35 months
• 11 patients (29%) have recurrence
• 30/38 kidneys (78%) salvaged

Keeley F, Bibbo M, Bagley DH. J Urology: 157, 1997.

 Upper Tract TCC
• Select situations where endoscopic
ablation of upper tract TCC is now
acceptable:
– Solitary kidney
– Renal insufficiency
– Bilateral synchronous tumors
– Poor operative risk
 Surveillance
• 23 patients with endoscopically treated
low-grade TCC

Chen GL, El-Gabry EA, Bagley DH. J Urology: 164(6), 2000.

 UPJ Obstruction
• Open pyeloplasty
• Laparoscopic pyeloplasty
• Endopyelotomy
– Antegrade
– Retrograde
– Acucise
 UPJ Obstruction
• Predictors of poor outcome for
endopyelotomy:
– Severe hydronephrosis
– Pre-operative renal insufficiency
– Poorly functioning kidney
– Strictures > 2 cm in length
 Acucise Endopyelotomy
Catheter
• Developed initially for cutting the
anterior commisure of the prostate
• Procedure not durable in humans
• 1st Acusize of UPJ 1993 (Wash U)
• Initially 14Fr profile (required pre-op
stent), now 10Fr profile
• Over 20,000 performed (2000)
 Acucise Endopyelotomy
Catheter
• Indications:
– Stricture of UPJ, proximal or distal ureter, or
ureteral orefice
– Stricture of uretero-enteric anastamosis
– Stricture length < 2 cm
• Contraindications:
– Mid-ureteral stricture
– Stricture> 2cm
– Uretero-enteric anastamosis crossing aorta
 Acucise Endopyelotomy
Catheter
• 0.035” tri-coated guide wire
• Ureteral access sheath
• Balloon (24Fr expanded, 2.2cc
capacity)
• Cutting Wire (3 cm long, 150 microns
wide)
• 7/10Fr tapered stent
 Acucise Endopyelotomy
Catheter
• Primary UPJ: lateral cut
• Secondary UPJ: postero-lateral cut
(CT w/ contrast and reconstructions)
• Pure cutting current – 75 W
• 0.5 cc in balloon to start (see waist)
– Slowly inflate balloon, continuous
fluoroscopy, while applying a maximum
5 seconds of cutting current
 Acucise Endopyelotomy
Catheter
• Should see immediate extravasation
• Acucise removed over wire
• Flexible ureteroscope alongside wire
to visualize incision (if needed)
– Possible additional laser cut?
• 7/10Fr tapered stent over wire
(through access sheath)
 Acucise Endopyelotomy
Catheter
• Bleeding:
– Insert 30Fr tamponade balloon catheter
placed to straddle UPJ
– Immediate insertion of percutaneous
nephrostomy tube
– POD#2, in IR suite balloon is deflated, if
bleeds, involved artery embolized,
otherwise place 7/10Fr stent
 Acucise Results
• Success Rates:
– 43/56 (77%): Preminger et al {1997}
– 60/77 (78%): Albala et al {1998}
– 21/26 (81%): Clayman et al {1996}

• Cost: $1150
 Endopyelotomy Stenting
• Classic teaching: 6 weeks
– 7/10Fr or 7/14Fr stent
• Davis Intubated Ureterotomy (1948)
– 90% of muscle regenerated @ 6 wks
• No prospective data on earlier
removal
 Retrograde Ureteroscopic
Endopyelotomy
• 1986: first peformed
• Improved results with improved
technology
• Advantages:
– Endoluminal ultrasound
– Cutting under direct vision
– Control length and depth of incision
 Retrograde Ureteroscopic
Endopyelotomy
• Endoluminal ultrasound:
– 6.2 Fr catheter
– 12.5 MHz transducer
– 30 revolutions per second for 360º, real
time, cross-sectional imaging
• Identifies crossing vessels in 53%1

Bagley DH, Liu JB, Grasso M, et al. J Endourology: 8, 1994.

 Retrograde Ureteroscopic
Endopyelotomy
• Cautery:
– 2 Fr pencil tip or hook electrode
– 45 W pure cutting current
• Ho:YAG
– 200 micron fiber, 1.2 J energy, 15-20 Hz
• Nd:YAG
– Less commonly used
 Retrograde Ureteroscopic
Endopyelotomy
• Success Rates:
– 88% (n=8) Biyani et al {1997}
– 83% (n=28) Grasso et al {2000}
– 82% (n=86) Van Cangh et al {1996}
– 81% (n-21) Bagley et al {1998}
Cost-Effective Treatment of
UPJ Obstruction

Gettman MT, Lotan Y, Roerhborn CG, Cadeddu JA, Pearle MS. J Urology: 169 (1),
2003.