Ureteroscopy: Meaning, Procedure, and Cost

Contents

Procedures For Kidney Stone Removal - An Overview

Lithotripsy

Percutaneous Nephrolithotomy

Percutaneous Nephrolithotripsy

Ureteroscopy

Open Surgery


What is ureteroscopy?


A minimally invasive method of treating kidney stones, ureteroscopy is an endoscopic procedure, which helps the urologist to view the inside of your ureter. An instrument called ureteroscope is used for this purpose.
Much like a cystoscope, though longer and thinner, the ureteroscope and can be used to see beyond the bladder into the ureter. The ureter is the duct through which the urine passes into the bladder from the kidney. Using the ureteroscope, the urologist can locate stones lodged in the ureter.  He can remove the stones with the help of a small basket attached to the end of a wire inserted through an extra channel in the ureteroscope.


Ureteroscopy is often considered to be a good option to remove small stones lodged in the ureter or kidney. The success rate of ureteroscopy in clearing small stones, up to the size of 15 mm (0.6 inches), is generally 50%-80% higher than that of lithotripsy. This procedure, however, does not work well with large stones. 

Ureteroscopy can be performed in 1 hour and usually costs between Rs. 70,000 to Rs.1,00,000 depending on the size of the stones. 

Usually, general anesthesia (under which the patient remains asleep) or spinal anesthesia (under which the patient is numb from the chest down) is administered for this procedure.



How is ureteroscopy performed? 


The ureteroscopy procedure involves the following steps:

  • Depending on your condition, the anesthetist administers you with the required dosage of general, regional, or local anesthesia.
  • You are made to lie on your back with your knees raised and apart.
  • A nurse cleans the area near your urethral opening with an antiseptic solution and places sterile towels around the area.
  • Once the anesthesia takes effect, the urologist gently inserts the tip of the ureteroscope into the urethra and guides it up towards the bladder.
  • He then injects some sterile liquid such as water, or salt water, called saline, through the scope to gradually fill the bladder and stretch it so that he gets a better view of the bladder wall.
    (Please Note: If you feel any discomfort or an urgency to urinate, the urologist may release some of the fluid.)
  •  Once he sees the stone, the urologist can proceed to remove the stone using any one of the procedures given below:

    • The urologist inserts a wire with a small basket attached to its tip, through another channel in the ureteroscope.
      With the help of the basket, he grasps the stone and removes it from your body.


    • The urologist inserts a flexible fiber through another channel in the ureteroscope. By directing laser beams through the fiber, he breaks the stone into small pieces that can easily pass out from the body while urinating.


Post the operation, if your urologist thinks that the urine may not drain well through your ureter, due to a blockage or as a reaction to the surgery, a stent called ureteral stent (a soft plastic tube) will be placed in your ureter to facilitate drainage of urine down to the bladder. 

One end of the tube sits inside the kidney, and the other end sits in the bladder.

The stent keeps the ureter open and maintains drainage of the urine. It is usually placed for a temporary period, although, in some cases of ureter blockage, it may need to be in the ureter for a longer period of time. 

Generally, a stent is removed (or exchanged) within 3 months. 


Am I eligible for ureteroscopy? 


You are eligible for ureteroscopy if :


  • your kidney stones smaller than 2 cms
  • you are pregnant
  • you are overweight
  • you suffer from blood-clotting problems


You are not eligible for ureteroscopy if :


  • your  kidney stones are larger than 2 cms


  • you have undergone ureteral or bladder reconstruction


  • you are intolerant to stents


Please Note: Eligibility criteria for various medical procedures differs from patient to patient and depends on their general health, medical history, and medical conditions. Please consult a doctor to know more about your eligibility or ineligibility for any medical procedure. 


What risks will I face while undergoing the ureteroscopy procedure?


The risks of undergoing a ureteroscopy include:

  • risks associated with anesthesia
  • urinary tract infection
  • difficulty in entering the ureter
  • mild burning sensation or bleeding while passing urine for a short period after the operation.
  • Temporary insertion of a bladder catheter which can cause pain and bleeding while passing urine. Insertion of a ureteric stent again requires a further procedure to remove it.


How will I benefit after undergoing a ureteroscopy procedure?


The benefits of ureteroscopy include:


  • Visual inspection of the ureter and kidney in a way not possible with other techniques.
  • Very efficient method to remove ureteral stones, and especially small stones.
  • Injuries and strictures in the ureter can easily be spotted and biopsies too can be performed, if needed.
  • Laser fibers and stone capturing baskets can be inserted through the scope permitting procedures like lithotripsy and basket extraction of stones.


What are my alternatives to ureteroscopy?


The alternatives to ureteroscopy include:



What are the pre-operative guidelines I should follow for ureteroscopy? 


Some of the standard pre-operative guidelines of ureteroscopy include:


  • A discussion with your doctor about your complete medical history. You need to especially let the doctor know if you:

    • are allergic to any medicines, especially antibiotics
    • have missed your periods and are pregnant
    • take any blood thinners


  • Tests are done to determine the number, location, and size of the stone(s). The tests performed include:

    • blood test
    • an electrocardiogram (EKG)
    • a comprehensive set of metabolic tests
    • a urine test
    • and tests that measure the speed of blood clotting


  • Notify your doctor if you have a history of bleeding disorders.


  • A discussion with the anesthetist to find out the type of anesthesia that will suit you the most.


  • Sign a consent form expressing your consent for the procedure by taking responsibility for the risks related to it. You will be made aware of any risks related to the procedure by your doctor.


  • As any medical procedure whether minor or major is associated with a certain amount of risk, you need to sign a consent form, expressing your consent for the surgery.


  • You may be asked by your doctor to fast for a certain period before the procedure.


  • You will need to remove your jewellery before the surgery as they can increase your risk of infections. You will also need to remove items such as contact lenses if you wear any.


  • A day prior to the surgery,  your ‘private parts’ or genitalia may be shaved. In some clinics, they do not shave or do it just before the surgery.


  • You will be given an enema or some other medicine which will clear your bowels before the surgery.


  • If you take blood thinners you may be asked to discontinue them for a period of a week to 10 days before the surgery.


  • Based on your medical condition, your doctor may request other specific preparations.


  • If you smoke or drink alcohol regularly, you will be advised by the doctor to stop smoking and drinking alcohol at least a week or two prior to the procedure.



What are the complications of ureteroscopy?


The complications of ureteroscopy include:


  • Inadvertent perforation of the bladder or ureter, which may occur when the stone is either sharp or stuck in one location. In most cases, a temporary stent can tide over the problem. A major perforation may require an open surgical re-implant of the ureter.


  • Formation of a stricture (narrowing) or scar tissue weeks, or months, after a significant perforation. This may be related to the perforation caused by the stone, or due to the insertion of the ureteroscope, or due to thermal injury caused by a laser probe.


  • Avulsion of the ureter which is a major complication and requires a replacement of the ureter with a part of the intestine. An open surgery is required for this.


  • A common complication of ureteroscopy is stent pain. About 50% of the patients who undergo ureteroscopy complain of pain which can be caused if the stent “rubs” against the walls inside the bladder, or if the stent allows urine to pass up from the bladder to the kidney while urinating. A warm tingling sensation can also accompany the pain.


  • An increased urgency to urinate frequently can arise due to stent placement in the ureter.


  • At times, following a ureteroscopy procedure stone fragments may remain within the kidney. They are usually detected during follow-up imaging and can be addressed by the doctor.



What are post-operative guidelines I need to follow after undergoing a ureteroscopy procedure?


  • You need to take the pain medication, antibiotics and anti-nausea medications, as prescribed by your doctor religiously.


  • If deemed necessary by your surgeon, you may have a stent placed in your ureter, between the kidney and the bladder to promote drainage from the kidney. It will be removed at your clinic one to two weeks following the surgery at the discretion of your doctor
  • If you have a stent, you may experience a sense of increased urgency to urinate. Your urologist will prescribe medications to counter the tendency.


  • It is common to have a pink tinge to your urine for about 24 hours after the procedure or the entire time a stent remains in the ureter. However, if you notice any blood clots you need to notify your doctor.


  • For the first 24 hours after the surgery, it is recommended you take only clear liquids since your intestines will be a little sensitive. Following the 24 hour period, you can resume your normal diet based on what you can tolerate.


  • You will be advised to drink extra fluids to maintain good kidney health. It will help to dilute your urine and reduce your discomfort when the stone fragments pass. Drinking plenty of water will also prevent kidney stones from recurring.  Most doctors recommend about 14 glasses a day. So, make water your most frequent drink. Lemonade, made of real lemons can also greatly reduce the chance of future kidney stones.


  • You may experience constipated bowel movements for several days or weeks following the surgery. Stool softeners prescribed by the doctor can help with this problem.


  • You will be advised by the doctor to refrain from smoking and drinking alcohol for several weeks. Smoking and drinking alcohol can impede the healing process.



What is the recovery period after undergoing a ureteroscopy procedure? 


Usually, patients rejoin work after approximately 9 days of surgery. Complete healing based on the patient’s overall health can take from 15 days to 3 months.  


Are the results of ureteroscopy permanent? 


In some cases, kidney stones which are too large to pass spontaneously may remain in the urinary tract. Such cases require repeat ureteroscopy procedures. 

Another strong probability is the formation of new kidney stones if proper preventive care is not taken after the kidney stone removal procedure. Such a case may again require a ureteroscopy procedure. 




How do I know if the ureteroscopy procedure I underwent is a success? 


Medical imaging is performed immediately following the surgery to assess stone clearance. During more follow-up visits, your urologist will perform X-rays, which will show whether all the stones have passed out of your kidney. If there are no signs of stones, the procedure has been a success. 

In some cases, however, a few stone pieces may at times remain in the urinary tract. In that case, you may require undergoing a repeat kidney stone removal procedure.  


References


1. Aboumarzouk O, Kata S, Keeley F, McClinton S, Nabi G. People who undergo ureteroscopy for the treatment of stones achieve a higher stoneā€free rate but have more complications and longer hospital stay. 2018. Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013680/. Accessed March 5, 2018.


2. Grasso M, Rajamahanty S. Flexible ureteroscopy update: indications, instrumentation and technical advances. 2018. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684394/. Accessed March 5, 2018.


3. El-Qadhi M. Outcome of ureteroscopy for the management of distal ureteric calculi: 5-years’ experience. 2018. Available at: https://www.sciencedirect.com/science/article/pii/S1110570414000873. Accessed March 5, 2018.

 

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