Principles of Endourology

Principles of Endourology, Equipment and Technique

1. Principles of Endourology dr. Eko Indra Pradono

2. CYSTOURETHROSCOPY Provides direct visualization of the anterior – posterior urethra and bladder Rigid or flexible Rigid provides larger workshing channels, easier to control, and better visualization Flexible provides patient comfort

3. What is Cystoscope? Thin Telescope 2 types: Flexible  flexible, fibre -optic scope Rigid  solid, straight scope

4. Lens O  for urethroscopy 30 O  visualization of the base and anterolateral aspect of the bladder 70-90 O  to view the bladder dome Retrograde lenses with an angle of view > 90 O  visualize the anterior bladder neck Size 1 Fr =0.3 mm 9 Fr = 3 mm

5. Basic components Telescope lens Cystoscope bridge Sheath & obturator

6. Rigid Cystoscope Optical lenses come with tip angles ranging from 0 to 120 degrees. Visualization of the urethra is best performed with a 0- or 12-degree lens. A 25- or 30-degree lens is commonly used for therapeutic purposes. A 70- or 120-degree lens may be required to completely inspect the anterior and inferolateral walls, dome, and neck of the bladder.

7. Flexible Cystoscopes Contain fiberoptic bundles for illumination and visualization Has an irrigating channel and a working channel for passage of instruments Can be deflected 180-220 o Digital Flexible cystoscopes eliminate the need for fiber bundles and the honeycomb pattern of the image

8. What to choose? Advantages of rigid endoscope: Better optics Larger working channel allows greater versatility in passage of instruments Larger lumen for water flow, thus improving visualization Ease of manipulation and maintaining orientation during inspection within the bladder Better for evacuating clots Advantages of flexible endoscope: Greater comfort for the patient Ability to perform the procedure with the patient in the supine position Ease of passing the instrument over an elevated bladder neck Ability to inspect at any angle with deflection of the tip of the instrumen

9. UPPER URINARY TRACT ENDOSCOPY Direct visualization of the upper urinary tract, facilitating both diagnostic and therapeutic interventions Indication : Treatment of nephrolithiasis Evaluation of lateralizing hematuria , abnormal urinary cytology, and abnormal upper tract i maging studies

10. Equipment Ureteroscopes Ancillary Equipment : - Wires Ureteral Dilators Irrigation Systems Ureteral Access Sheaths Intracorporeal Lithotriptors Stone Migration Devices

11. Instruments Telescope adapter Alligator Forceps Biopsy Forceps Scissor Hook Scissor

12. Lithotripsy Optical stone punch + adapter Working element Lithotripsy sheath obturator

13. Common Supplies for Ureteroscopy

14. Patient Preparation Informed consent must be obtained A urinalysis and urine culture, if indicated, should be completed before cystoscopy  UTI must be treated AUA : prophylaxis antibiotic is not recommended for routine diagnostic procedure. For therapeutic  TMP-SMX Chlorhexidine gluconate and alcohol-based solutions are not recommended for use on the genitalia

15. Patient Preparation

16. In women, rigid cystourethroscope insertion is safest using the sheath obturator In men, the penis should be angled 45 - 90° relative to the abdominal wall while the scope is passed through the anterior urethra. Visualization of the lateral walls is accomplished by rotating the cystoscope while keeping the camera orientation fixed. If a Foley catheter is to be placed after the procedure, it is best to leave the bladder at least partially full before removing the cystoscope. Ureteroscopy Technique

17. Ureteroscopy Technique Upper tract imaging  IVP or helical CT scan UTI are treated preoperatively Routine preoperative antibiotic is give to all patients  fluoroquinolones or based on antibiotic sensitivity test Patient in cystolithotomy position

18. Semirigid Ureteroscopy Technique Maneuvering the tip of the ureteroscope next to the guidewire posterolaterally and elevate the wire  propping the ureteral orifice open to allow scope passage. If the intramural ureter is too tight to allow safe passage of the ureteroscope , a dilating balloon catheter can be used.

19. If the ureteroscope does not pass easily 1) rotate the beak of the ureteroscope while engaging the ureteral orifice and providing adequate irrigation ; 2 ) pass a super-stiff wire into the ureter through the working channel, rotate the ureteroscope so that the tip lies between the two wires, and guide the ureteroscope into the ureter between the two “railroading” wires (Fig. 8–10); 3) Dilate the ureteral orifice with a 6/10-Fr coaxial dilator over a guidewire ; 4 ) dilate the ureteral orifice with a 4-mm radially expanding balloon dilator; or 5 ) if the preceding measures fail , place an indwelling ureteral stent and allow for passive dilation for 2 weeks.

20. Normal saline should be used for irrigation to prevent accumulation and absorption of hypotonic solution and resultant TUR syndrome. Do not activate the laser unless the tip of the fiber is seen to be contact with the stone Flexible Ureteroscopy Technique

21. References Duty BD, Conlin MJ. Principles of Urologic Endoscopy. In: Campbell-Walsh’s Urology. Netherland: Elsevier. 2015 Hofenfellner R, Stolzenburg JU. Manual Endourology. Leipzig: Springer. 2005 Smith A, Badlani G, Preminger GM, Kavoussi LR (editors). Smith’s Textbook of Endourology. 3 rd ed. Oxford: Wiley – Blackwell. 2007 University college hospital at Westmoreland street. Cystoscopy: urology directorate.University colleg London Hospital. NHS foundation trust. Chancellor MB, Steers WD. Cystoscopy and ureteroscopy. NIH publication. 2014 Narance D. Urology Overview: part II. Cystoscope processing and handling procedures. CIS self study lesson plan. Med Central Health System.

22. Care and Sterilization Scraped inner working channel  deflection of flexible ureteroscope when the fiber is introduced Fired fiber within the working channel  to prevent the tip must be seen in the central portion of the field of view Should be cleased with warm water and a non abrasive detergent after each use

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