AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Ureteroscopy is defined as upper urinary tract endoscopy performed most commonly with an endoscope passed through the urethra, bladder, and then directly into the upper urinary tract. Indications for ureteroscopy have broadened from diagnostic endoscopy to various minimally invasive therapies.

Endoscopic lithotripsy, treatment of upper urinary tract urothelial malignancies, stricture incisions, and ureteropelvic junction obstruction repair are all current treatments facilitated by contemporary ureteroscopic techniques. Because the application of ureteroscopic procedures has evolved from a diagnostic tool to a facilitator in complex therapeutic interventions, a proportional increase in the rate and severity of complications would be expected. However, with improved instrumentation and evolution of surgical technique, the complication rate associated with ureteropyeloscopy has actually decreased significantly.

History of the Procedure

The progression from cystoscopy to upper urinary tract endoscopy was natural, with pediatric cystoscopes being used as the first rigid rod-lens ureteroscopes. Relatively large rod-lens endoscopes, averaging 12F (3F = 1 mm) in diameter, combined with ultrasonic and electrohydraulic lithotripsy probes became the first commonly accepted ureteroscopic equipment combination used to treat distal ureteral calculi.

Ureteroscopic treatment of calculi and, in particular, distal ureteral stones was the first common application of upper urinary tract endoscopy. Early in this evolution, smaller and more precise instrumentation was obviously found to cause less trauma to normal tissues. Rigid ureteroscopes progressed from rod-lens imaging to fiberoptic imaging with outer-diameter miniaturization. The narrow and delicate distal ureter once required vigorous balloon dilation for ureteroscopic access; however, by 1989, the fiberoptic-based rigid endoscopes were small enough (averaging 7F in diameter) for frequent placement in the distal ureter under direct vision. The small rigid ureteroscopes combined with both laser and pneumatic lithotriptors are currently used to treat distal ureteral calculi in both university and community settings.

Flexible ureteroscopy was an attractive alternative to rigid ureteroscopy in that the more proximal ureter and intrarenal collecting system was theoretically more easily accessible with this type of instrument. The application of flexible ureteroscopy was first reported by Marshall in 1964.¹ A 9F fiberscope manufactured by American Cystoscope Makers (Pelham Manor, NY) was passed into the ureter to visualize an impacted ureteral calculus. These first flexible ureteroscopes were not capable of being directed and did not have a working channel, thus permitting only the most primitive diagnostic maneuvers. The subsequent addition of a cystoscopically placed guide tube facilitated placement of the first flexible ureteroscopes. In addition, irrigant then could be passed through the guide tube to displace the ureteral mucosa and debris from the distal endoscopic lens.

In the early 1980s, Bagley, Huffman, and Lyon began work at the University of Chicago to develop an improved flexible fiberoptic ureteropyeloscope.² Three major design changes improved the potential of the flexible ureteroscope. First, the addition of a working channel allowed irrigant and endoscopic accessories to be passed directly through the endoscope rather than through an operating sheath. Second, active tip deflection allowed the endoscope to be directed or steered to areas of interest. Finally, by altering the stiffness (ie, based on durometer measurements) of the endoscope shaft, the actively deflecting portion could be combined with passive buckling of the endoscope (ie, secondary deflection), which facilitated lower-pole intrarenal access.

The first steerable, actively deflectable, flexible ureteropyeloscopes were equipped with relatively large fiberoptic bundles for imaging and illumination. The addition of the working channel and a cable-and-pulley system used for active tip deflection required on outer diameter of 3.6 mm. By the late 1980s, optical fiber miniaturization and improved geometrical pixel packing produced a smaller fiberoptic bundle and thus, a smaller-diameter endoscope. Flexible ureteroscope specifications in 1990 included a 10F outer diameter, a standard 3.6F working channel, and unidirectional active tip deflection. Working sheaths were abandoned for direct guidewire endoscope placement, but intramural ureteral dilation was often required for placement of the flexible ureteroscope into the upper urinary tract. These endoscopes were used to inspect the entire intrarenal collecting system and became part of the standard evaluation of filling defects of the upper urinary tract defined using contrast imaging studies.

The introduction of a new generation of flexible ureteroscopes, which offer greater active deflection, has significantly advanced the therapeutic and diagnostic efficacy of the flexible ureteroscope, allowing for greater access to all aspects of the upper urinary tract.

Currently, rigid and flexible ureteroscopes average 7.5F in tip diameter and are passed atraumatically into the upper urinary tract without intramural dilation. These endoscopes are used to treat various upper urinary tract disorders, including stones, urothelial malignancies, stricture disease, and bleeding lesions. The addition of laser energy applied through optical quartz fibers passed through the working channel of the endoscope has facilitated these treatments. Specific treatments are discussed further in subsequent sections of this article.

Problem

Ureteroscopy is used as a diagnostic tool in situations such as investigating abnormal imaging findings, assessing obstruction or unilateral essential hematuria, or localizing the source of positive urinary cytology results.

Therapeutic uses of ureteroscopy have broadened to include various minimally invasive therapies. Endoscopic lithotripsy (treating stones), treatment of upper urinary tract urothelial malignancies, stricture incisions, and ureteropelvic junction obstruction repair are all current treatments facilitated by contemporary ureteroscopic techniques.

Frequency

Ureteroscopy is a routine procedure performed by urologists. The most common indication is to treat upper urinary tract calculi, particularly those that are either unsuitable for extracorporeal shockwave lithotripsy or are refractory to that form of treatment. Other common indications include evaluation of an abnormal lesion revealed by less invasive imaging tools (eg, intravenous pyelography [IVP], MRI, CT scanning) or localization of the source of positive urine culture or cytology results. Thus, ureteroscopy is often an essential part of the diagnostic algorithm and can also be used to treat the underlying disorder.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Diagnostic indications for ureteropyeloscopy are as follows:

• Abnormal imaging findings - Filling defect
• Obstruction - Determination of etiology
• Unilateral essential hematuria
• Localizing source of positive urinary cytology results, culture results, or other test results
• Evaluation of ureteral injury

Therapeutic indications for ureteropyeloscopy are as follows:

• Endoscopic lithotripsy
• Retrograde endopyelotomy
• Incision of ureteral strictures
• Improvement of calyceal drainage
• Treatment of calyceal diverticular lesions
• Treatment of malignant urothelial tumors
• Treatment of benign tumors and bleeding lesions

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The segments of the ureter in which calculi can become lodged are also natural barriers for the ureteroscope. The intramural ureter is the narrowest segment and can prohibit endoscope passage. Guidewires are often passed into the ureteral orifice cystoscopically and are then directed into the renal pelvis with fluoroscopic assistance. These safety guidewires straighten the ureter and facilitate (1) the dilation of obstructed segments with balloon or graduated dilators and (2) the placement of internal stents used after many therapeutic procedures.

The intramural ureter once required balloon dilation for endoscope access. Currently, the small-diameter semirigid ureteroscopes are often narrower than 7.5F in tip diameter, while their shaft is straight or graduated. This allows for tip access, and, when advanced, the intramural segment may also be modestly dilated (ie, dilation under direct vision). Use of a dilator or sheath to facilitate passage of the ureteroscope beyond the intramural ureter is recommended when repeated access to the ureter is expected or if the intramural ureter is unusually tight or restrictive. Otherwise, the use of such sheaths is optional and generally not required.

As the fiberoptic-based rigid ureteroscope continues proximally past the ureteral orifice, it then is inhibited by the natural curvature of the ureter as it crosses the iliac vessels, psoas muscle, and the ureteropelvic junction. If the ureter is dilated, the rigid endoscope may be safely passed proximally. If not, then conversion to an actively deflectable flexible endoscope is indicated.

Flexible ureteroscopes are passed into the upper urinary tract over a guidewire with a wireless technique. Some authors have espoused the use of a 12F or 14F operating sheath to facilitate placement of this instrument. In a recent study of 1000 consecutive flexible ureteroscopic procedures using 7.5F instruments, this was not required. The flexible ureteroscope is a particularly useful instrument, especially when a rigid endoscope cannot be placed safely into the more proximal ureter or if intrarenal inspection is required. In these cases, active and passive endoscope tip deflection is essential to completely inspect the calyces.

Lower-pole intrarenal access performed with a flexible ureteroscope is often difficult and requires both active and passive flexible ureteroscope deflections. To place the tip of the endoscope into the lower pole, the instrument must first be actively deflected and then advanced to allow the shaft below to buckle. This maneuver, termed secondary deflection, is required in 60% of traditional flexible ureteroscopies for a complete inspection. The increased active deflection offered by new-generation flexible ureteroscopes significantly decreases the need for secondary deflection and enhances the surgeon’s ability to inspect all aspects of the renal collecting system.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Diagnostic ureteroscopy has few contraindications. Untreated urinary tract infection, endoscopy without appropriate antibiotic coverage, and uncorrected bleeding diathesis are relative contraindications.

Contraindications to therapeutic ureteroscopy (eg, lithotripsy, endopyelotomy, tumor therapy) are more numerous and can mirror those associated with the corresponding more invasive open surgical intervention. In general, the major contraindications are related to untreated infections and uncorrected bleeding diathesis prior to therapeutic endoscopy.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Coagulation factors
• • Prothrombin time
  • Activated partial thromboplastin time
  • Platelet count
• Urinalysis for urine culture
• Standard preoperative laboratory workup
• • CBC count
  • Electrolyte levels
  • Serum creatinine and BUN determination

Imaging Studies

• Useful preoperative imaging studies depending on the clinical presentation include the following:
• • Renal ultrasonography
  • IVP
  • CT scanning
  • MRI

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Surgical therapy

Ureteroscopy can be divided into diagnostic endoscopy and therapeutic treatments.

Diagnostic ureteroscopy

Diagnostic endoscopy is performed with the least possible trauma to the upper urinary tract. Ureteroscopic access is obtained with a wireless ureteroscopy technique, if possible. The ureteral orifice is visualized and intubated without the assistance of a guidewire. The ureter is traversed in a no-touch technique, and the ureter and renal collecting system are mapped. In a recent prospective study of 460 consecutive upper-tract endoscopies, no-touch ureteroscopy was successfully performed in most patients without prior stenting (24%) or ureteral dilation (11%).³ This wireless form of flexible ureteroscopy eliminates the potential trauma, mucosal irritation, and inadvertent manipulation of stones or tumors caused by guidewires and is particularly helpful when the collecting system is evaluated for mucosal lesions.

Fluid irrigation facilitates passage of a rigid ureteroscope. Although automatic pumps are available for this purpose, hand irrigation is often preferred because of the flexibility this offers. The use of a video camera can allow the surgical technicians to better assist the urologist and prevents the surgeon from assuming unusual or uncomfortable positions. Another suggestion is to pass the tip of a closed basket or a guidewire just beyond any lip of tissue, blockage, or kink in the ureter and then to turn the ureteroscope 180°. This tends to stretch and open such areas, allowing easier passage of the endoscope.

When wireless ureteroscopy is not feasible, a small-diameter rigid ureteroscope is passed up the ureter as far as technically feasible to inspect and map this portion of the collecting system. A guidewire is then placed only to the area that already has been inspected, and a flexible instrument is the passed over it in a monorail fashion, under fluoroscopic guidance, to complete the mapping. The flexible ureteroscope is passed from calyx to calyx, and, frequently, dilute contrast material is injected through the working channel of the endoscope to help ensure the entire collecting system is inspected.

Therapeutic ureteroscopy

Therapeutic ureteroscopy is used in diverse applications, including in the treatment of stones, urothelial tumors, and stricture disease.
 
Ureteroscopy is a safe and minimally invasive method of treating stone disease in the kidneys and ureter. It can be used either as primary therapy or as salvage therapy for residual stones following treatment with other modalities such as extracorporeal shockwave lithotripsy. Success rates following such therapy are shown in Table 2 and Table 3. Furthermore, in select cases, ureteroscopy has been shown to be a viable and effective means of treating stone disease in pregnant women and in pediatric patients.
 
Ureteroscopy has also become a powerful tool in the treatment and surveillance of transitional cell tumors of the upper tracts, especially bilateral disease processes and tumors in solitary kidneys.^{4, 5}

Preoperative details

Prior to ureteroscopic examination, the surgeon must have the appropriate instrumentation available. This includes endoscopes, accessories, appropriate energy sources, and fluoroscopy.

Rigid ureteroscope specifications include the following:

• Tip diameter - 4.5-9.5F (6.9F most common)
• Optics - Fiberoptic bundles
• Working channels - One, 2, or 3 (2 channels preferred)
• Accessory length - Average, 40 cm

Flexible ureteroscope specifications include the following:

• Tip diameter - 6.9-9.8F (7.5F most common)
• Optics - Fiberoptic bundles
• Working channel - Single, 3.6F
• Access - Guidewire (0.035 in nitinol or 0.038 in stainless steel)
• Accessory length - Average, 100 cm

Energy sources include the following:

• Holmium:yttrium-aluminum-garnet (Ho:YAG) laser
• Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
• Electrocautery
• Electrohydraulic lithotripsy
• Mechanical impactor (ie, Lithoclast)

Prophylaxis is as follows:

• All patients receive a preoperative dose of a broad-spectrum parenteral antibiotic.
• Most frequently, a first-generation cephalosporin or fluoroquinolone is administered, unless prior culture results or anaphylaxis dictates otherwise.

Intraoperative details

When therapeutic ureteroscopy is performed, a safety guidewire is essential. This allows for multiple passes of the instrument while maintaining access to the upper urinary tract. For example, during treatment of a distal ureteral stone, a rigid ureteroscope is passed up the ureter beside the safety guidewire and laser energy is delivered through a small quartz fiber to fragment the stone. An accessory such as a wire prong grasper or basket then can be used to extract fragments with multiple passes of the endoscope. In such situations, The use of a ureteral sheath minimizes trauma to the ureteral meatus and intramural ureter.

In many situations, a backstop may be useful to prevent proximal migration of distal ureteral stones. The Stone Cone and Parachute kidney-stone baskets are both useful for this purpose. Variations in basket designs make them suitable for different situations. The Segura and Bagley type baskets are composed of 4 or 6 flat wires arranged spherically. They tend to have good radial opening force so are useful in tight quarters but are not intended to be rotated because of the sharp edges of the flat wires. The Dormia or spiral type baskets are good general-purpose designs that have been around for years. When paired wires are used, they are also suitable for use in areas of narrow ureteral diameters.

The Parachute type design is asymmetrical with 2 paired wires that split into a canopy or net of 8. This type is particularly useful in holding larger stones for lithoclast or laser lithotripsy and can also be used like a net to sweep the ureter, as it can capture many smaller fragments in one pass. It works best when it can be fully deploy or opened, which requires a relatively normal or dilated ureter. Fortunately, this is commonly found proximal to most stones.

Traditionally, 2 guidewires were required to perform flexible ureteroscopy. The first is a safety guidewire, while the second is used to facilitate endoscope placement. For example, this working guidewire can be replaced with a dual-lumen catheter after a stone fragment or biopsy specimen is extracted. Conversely, ureteroscopic access can now be obtained by using a wireless ureteroscopy technique in which the ureteral orifice is visualized and intubated without the assistance of a guidewire and the ureter is traversed in a no-touch technique.

If electrocautery is to be used, special attention to the guidewire choice helps prevent an intraoperative complication. If a standard stainless steel guidewire is used, electrical current may inadvertently arc to the wire during cautery use and may cause excessive ureteral coagulation with subsequent fibrosis and stricture formation. This can be prevented by using an insulated guidewire such as a Teflon-sheathed nitinol guidewire (eg, Zebra wire, Boston Scientific, Natick, Mass).

Intraluminal ultrasonography has also been used in various applications. It offers enhanced diagnostic yield in the evaluation of disease processes such as ureteropelvic junction obstruction, tumors of the upper tract, and anatomic anomalies (eg, crossing renal vessels). It has also improved treatment of submucosal ureteral calculi.

Postoperative details

When the ureteroscopy is completed, internal ureteral stents are commonly placed to facilitate healing and to ensure drainage, particularly if vigorous therapeutic maneuvers were performed. However, simple diagnostic ureteroscopy without ureteral dilation does not require postoperative ureteral stenting.

Internal ureteral stents are associated with lower urinary tract symptomatology, including urinary frequency, urgency, and mild-to-moderate hematuria, which is transient. Ureteral stents are removed after a period of healing that can range from a few days to 6-8 weeks, depending on the complexity of the treatment. Stents are usually removed in the office with either an attached nylon suture left through the urethra postoperatively or cystoscopically.

Most ureteroscopic procedures are performed as day surgery outpatient procedures. Patients are discharged and are given oral quinolone-based antibiotics and analgesics. Anticholinergic medications and alpha-blockers may be used to minimize frequency, urgency, and discomfort often associated with ureteral stents; however, individual patient tolerance widely varies. Careful selection of the best stent length and optimal positioning help to minimize these unpleasant symptoms.

Follow-up

Most patients are return after 1-2 weeks following the ureteroscopic procedure for stent removal and surgical follow-up. If endoscopic lithotripsy was performed, appropriate imaging consisting of either plain radiography or ultrasonography can be performed to define residual stone burdens.

Subsequent imaging is required weeks to months after the procedure depending on the underlying disease process. If, for example, a ureteral stricture is incised ureteroscopically, serial follow-up imaging studies defining drainage and renal function (eg, IVP, nuclear medicine renal scan) should be performed periodically, particularly during the first year to ensure an acceptable surgical outcome.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Minor intraoperative complications

Minor ureteroscopic complications are those that have no long-term deleterious effects and, if treated promptly, cause only minimal or transient postoperative problems. Table 1 chronologically lists 4 studies spanning the 10-year evaluation of ureteroscopic equipment and technique. In the initial series from the Mayo Clinic, large-diameter endoscopes were used,⁶ while, in the last series, the smallest-diameter ureteropyeloscopes were used, with a noticeable decrease in complication rates.⁷

In general, the minor complication rate associated with ureteropyeloscopy was decreased based on refined technique, experience of the operators, and prompt treatment or prevention of intraoperative problems. Prophylactic parenteral antibiotics, careful guidewire placement, minimization of excessive ureteral dilation, and postoperative ureteral stenting all affected the rate of postoperative problems. This, combined with better surgical training and improved instrumentation, resulted in this very positive trend.

Major intraoperative complications

Major intraoperative problems include excessive trauma to tissues leading to large wall perforations, avulsions, or foreign body (eg, stone) migration into the ureteral wall. The major complication rate has markedly decreased (now occurring in approximately 1% of all ureteroscopic procedures). As with the minor problems, major complications are less common for basically the same reasons. However, when they do occur, treatment is often more complex.

In addition to major intraoperative problems, other complications that occur during upper urinary tract endoscopy may begin as minor events and, if left untreated or if addressed incorrectly, can progress to more serious conditions.

Major ureteral wall perforations can be the product of a heavy-handed endoscopist and improper application of a semirigid ureteroscope. The forceful positioning of a semirigid ureteroscope above the iliac vessels, particularly in young male patients, is associated with a significant risk of ureteral wall trauma unless the collecting system is hydronephrotic or has been stented prior to endoscopy. Routine use of a double-J stent is unnecessary in most patients but is recommended when unusual difficulty is encountered or when extensive strictures are found. Usually, 1-2 weeks of stenting greatly facilitates ureteroscopy, particularly if proximal access is desired.

Ureteral wall tears may lead to stone migration through the tear. Subsequently, this may result in the formation of a stone granuloma or ureteral wall stricture. In addition, large tears can lead to ureteral avulsion if the offending maneuver is repeated at the same sitting (eg, large ureteral wall perforation with subsequent vigorous attempts at accessing a calculus). In these settings, stopping the procedure and stenting the ureter, to return days later to perform subsequent maneuvers in a staged fashion after a period of healing, is wiser.

When a minor problem is encountered during ureteroscopy, taking appropriate measures to prevent progression is essential. Additionally, the inappropriate application of endoscopes, lithotrities, and accessories can lead to surgical misadventure. An example would be basketing a relatively large renal stone with a retrograde-placed ureteroscope and attempting extraction.

A basic concern is that, if the stone was too large to pass, how does engagement in a basket and application of tension along the long axis of the ureter have merit? Surgeons can find themselves in a tenuous situation in which extraction is impossible; stone disengagement is difficult, and, with a single endoscopic working channel, simultaneous placement of an endoscopic lithotrite is difficult or impossible. Excessive tension on the ureter then leads to an avulsion with disastrous complications that could have been prevented.

Surgeons should anticipate such possible difficulties and allow themselves additional options. For example, a basket or grasper can be passed alongside the ureteroscope, leaving the central channel free to use a lithoclast or laser fiber for stone fragmentation. If this type of access is not possible, a Tuohy-Borst adaptor can allow both irrigation and passage of a laser fiber for stone fragmentation, if necessary. The possibility that a stone is more difficult or larger than expected should always be anticipated, particularly in the proximal ureter. Allowances or contingencies should be made for stone fragmentation if extraction is deemed too difficult or dangerous. If all else fails, leave a stent and return another day with a better plan or consider an alternative technique such as percutaneous access or extracorporeal shockwave lithotripsy. Such planning can prevent disastrous consequences and outcomes.

If ureteral avulsion develops in the distal segment, repair is based on the standard open surgical techniques of ureteral reimplantation. Ureteroneocystostomy can be performed for most distal ureteral avulsions, with a psoas bladder hitch used, if necessary, to create a tension-free anastomosis. A Boari bladder wall flap can increase the proximal extent of the repair to the middle third of the ureter. These repairs are usually performed over a ureteral catheter with perianastomotic drainage. This can be performed short-term at the time of the injury or in a staged fashion after proximal percutaneous drainage is obtained.

The more proximal ureteral avulsions require the most complex surgical repairs. If a proximal ureteral avulsion is encountered intraoperatively and most of the ureter is intact, primary repair over a ureteral catheter can be performed. Unfortunately, in this setting, most of the ureter is often devitalized, leading to an extremely morbid complication. If the entire devitalized ureteral segment is brought into the bladder, it is of no value in subsequent repair. Percutaneous renal drainage should be obtained immediately for this type of ureteral injury. Subsequent therapy is based on either bowel interposition (ie, ileal ureter) or renal autotransplantation to a pelvic position. Both procedures are highly complex and have their own inherent risks, so the patient must be counseled appropriately.

Table 1. Comparison of Complication Rates Associated With Ureteroscopy, Emphasizing the Noticeable Decrease in the Major Complication Rate With Greater Experience and Endoscope Miniaturization

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The outcome of a ureteroscopic procedure is based on the underlying disorder and whether a diagnostic or therapeutic endoscopy was performed. In diagnostic ureteroscopy, finding the source of bleeding or defining the nature of a filling defect is usually the end point.

Therapeutic ureteroscopy for the treatment of upper urinary tract calculi should resolve ureteral obstruction and decrease the stone burden. Endoscopic treatment of stricture disease should also improve drainage. Thus, ureteroscopy is a surgical platform from which various disease processes can be treated, each with their own specific postoperative expectations and outcomes.

The following tables show success rates of ureteroscopic lithotripsy.

Table 2. New York University Experience With Ureteroscopic Treatment of Ureteral Calculi Using the Holmium:YAG Laser 

Table 3. New York University Experience With Ureteropyeloscopic Treatment of Intrarenal Calculi Using the Holmium:YAG Laser

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Miniaturization of ureteroscopic instrumentation will continue, with smaller fiberoptics, improved accessories, and new energy sources. As the instrumentation becomes smaller and more refined, it also will become more delicate. Thus, manufacturers are challenged to develop new, smaller instruments that will also survive the rigors of surgical therapy.

Today, a rigid ureteroscope may require repair after 3-6 months of vigorous use. This is in contrast to small flexible ureteroscopes, which may survive only approximately 20 cases. The lifespan-limiting factor for these instruments is usually the trauma of sterilization. The future should hold a more resilient flexible ureteroscope that requires infrequent repairs while still facilitating the most complex endoscopic procedures.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Flexible fiberoptic ureteropyeloscope.
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Media file 2:  Secondary endoscope deflection that allows lower-pole intrarenal access.
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Media file 3:  Plain radiograph that defines a large renal pelvic calculus with the flexible ureteroscope passed beyond the stone burden.
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Media file 4:  The instillation of radiopaque contrast material through the working channel of the flexible ureteroscope defines the lower-pole location of the tip of the endoscope.
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Media file 5:  Ureteroscopic image of an impacted jack stone in the ureter. These calculi are composed of calcium oxalate monohydrate.
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Media type:  Photo

Media file 6:  Ureteroscopic image of a papillary transitional cell carcinoma of the ureter.
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Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

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2. Bagley DH, Huffman JL, Lyon ES. Combined rigid and flexible ureteropyeloscopy. J Urol. Aug 1983;130(2):243-4. [Medline].
3. Johnson GB, Portela D, Grasso M. Advanced ureteroscopy: wireless and sheathless. J Endourol. Aug 2006;20(8):552-5. [Medline].
4. Chen GL, Bagley DH. Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management. J Endourol. May 2001;15(4):399-404; discussion 409. [Medline].
5. Lee D, Trabulsi E, McGinnis D, Strup S, Gomella LG, Bagley D. Totally endoscopic management of upper tract transitional-cell carcinoma. J Endourol. Feb 2002;16(1):37-41. [Medline].
6. Blute ML, Segura JW, Patterson DE. Ureteroscopy. J Urol. Mar 1988;139(3):510-2. [Medline].
7. Grasso M, Bagley D. Small diameter, actively deflectable, flexible ureteropyeloscopy. J Urol. Nov 1998;160(5):1648-53; discussion 1653-4. [Medline].
8. Abdel-Razzak OM, Bagley DH. Clinical experience with flexible ureteropyeloscopy. J Urol. Dec 1992;148(6):1788-92. [Medline].
9. Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW. Ureteroscopy: current practice and long-term complications. J Urol. Jan 1997;157(1):28-32. [Medline].
10. Bagley D. Active versus passive deflection in flexible ureteroscopy. J Endourol. 1987;1:15.
11. Bagley DH. Intrarenal access with the flexible ureteropyeloscope: effects of active and passive tip deflection. J Endourol. Jun 1993;7(3):221-4. [Medline].
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13. Bagley DH. Ureteral endoscopy with passively deflectable, irrigating flexible ureteroscopes. Urology. Feb 1987;29(2):170-3. [Medline].
14. Bagley DH, Allen J. Flexible ureteropyeloscopy in the diagnosis of benign essential hematuria. J Urol. Mar 1990;143(3):549-53. [Medline].
15. Bagley DH, Huffman JL, Lyon ES. Flexible ureteropyeloscopy: diagnosis and treatment in the upper urinary tract. J Urol. Aug 1987;138(2):280-5. [Medline].
16. Bagley DH, Liu JB, Goldberg BB, Grasso M. Endopyelotomy: importance of crossing vessels demonstrated by endoluminal ultrasonography. J Endourol. Dec 1995;9(6):465-7. [Medline].
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Article Last Updated: Jan 22, 2008