Ureteroscopy

Ureteroscopy entails the passage of a small telescope, called the ureteroscope, through the urethra and bladder and up the ureter to the point where the stone is located. The stone is visualized & fragmented with a laser/lithoclast. Once the stone is broken into tiny pieces, these pieces are removed from the patient. In most cases, a double J stent is left in place temporarily following Ureteroscopy, to ensure that the kidney drains urine well.

Ureteroscopy usually can be performed as an outpatient procedure however; patients may require an overnight hospital stay if the procedure proves lengthy or difficult or if your insurance policy so mandates.

Advantages of Ureteroscopy                                                         

Ureteroscopy can treat stones located at any position in the ureter. Upper third ureteric calculi can be difficult & at times may need staging of the procedure. Ureteroscopy also allows the treatment of radiolucent stones that cannot be seen on an x-ray. Patients who cannot be treated with ESWL or PCNL such as those who cannot safely stop taking blood thinners, women who are pregnant, and the morbidly obese, can be treated by Ureteroscopy.

Ureteroscopy is NOT a particularly good treatment for:

Large stones (> 1 cm)– Treatment of very large stones may yield so many

fragments that complete removal becomes impractical leaving residual stones.

Patients with a history of urinary tract reconstruction– the anatomy may not allow the passage of  ureteroscope.

Preoperative workup

What to expect during you preoperative consultation

During your initial consultation, your medical history, reports, records, and outside Xray films (e.g. CT scan, IVU/Usg) are reviewed. A brief physical examination may be performed if required. If your reports suggest that you are a candidate for this procedure, you will then meet with our Urology Coordinator to arrange for the date of your procedure.

NOTE: It is very important that you gather and bring all of your Xray films and reports to your initial consultation with your urologist.

What to expect prior to the surgery

If insurance (Mediclaim)  patient – You will need TPA clearance

If Cash patient – You will need Financial clearance at the time of Admission (Billing desk )

Test required :

• Uro Pre op panel (CBC, Blood Urea, Creatnine, Sodium, Potassium, Calcium, Phosphorus, Albumin, Alkaline, Phosphatase, Uric Acid (Serum), Bicarbonate, Urine Analysis, Urine Culture, PT / INR, APTT, HbsAg, HCV Antibody, HIV I & II)
• Comprehensive Metabolic Panel (blood chemistry profile)
• Chest X-ray and ECG
• PAC (Pre-anesthesia clearance) – 4^th Floor, Room No-18
• Cardiology/ Endocrinology/Physician/Nephrology or any other clearance as per PAC requirement

Preparation for surgery

Medications to Avoid Prior to Surgery

Aspirin, Ibuprofen, Vitamin E, Clopidogrel, Warfarin and some other arthritis medications can cause bleeding and should be avoided 5 days prior to the date of surgery (Please contact your urologist’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting theprescribing doctor to get their approval). Do enquire about stopping blood thinners / anticoagulants at time of Cardiology clearance / PAC.

 

Please Note: Failure to Stop anticoagulants / Blood thinners will lead to postponement of surgery, keeping in mind patient safety.

It is important that your last urine culture is negative prior to having this procedure. If you suspect that you may have a urinary tract infection, please inform your urologist immediately so that proper antibiotics can be prescribed before your surgery.

THE SURGERY

The Procedure

Ureteroscopy is a minimally invasive technique involving the passage of a ureteroscope up the ureter upto the place where the stone is located. The ureteroscope is passed to the stone by a combination of visual and x-ray guidance. Ureteroscopy is typically performed under general anesthesia, and the procedure usually lasts from30 minutesto 90 minutes.

Depending on the nature of the stone identified with the ureteroscope, the urologist will:

•      If the stone is small, grab it in a forecep and remove it intact.

•      If the stone is large, fragment it into tiny pieces with a laser/lithoclast.

Old impacted stone may cause the ureter to be swollen or inflamed. Therefore, it may be necessary to temporarily leave a small tube, called a Double J stent, inside the ureter.

Staged Ureteroscopy– If the urologist finds the stone badly impacted, severe inflammation or pus / turbid urine coming out, a Double J stent would be inserted andUreteroscopy will be performed after 7-10 days (Staged Ureteroscopy). This is done to reduce complications, like ureteric injury, sepsis etc. keeping patient safety in mind. Staged Ureteroscopy usually does not need DJ stent insertion at the time of stone removal. However final decision for stenting is done at the time of ureteroscopy.

Discharge instructions

After Discharge

• Pain Control: It is normal to have some pain that may require pain medication for a few days after discharge. Common pain killers like Paracetamol or Voveranusually suffice.
• Showering: There is no restriction to showering anytime after surgery.

• Activity: One can resume normal daily activities one day after surgery. In fact sedentary lifestyle may lead to complications & should be avoided.  Climbing stairs is allowed. One should avoid driving upto 1-2 days after the procedure. One can expect to return to work in 5-7 days time.
• Diet: None. Increase your fluid intake until your stent is removed.

Followup

• Follow-up Appointment:

We make our utmost effort to arrange a follow-up appointment in the discharge slip itself.

The appointments can be scheduled by contacting

Urology Coordinator or mailing at  – info@urofort.com

• Double J Stent Removal: The length of time the stent remains in place is variable. The urologist decides its removal within 5 days to a four week period. This can be removed as a daycare procedure or in the doctor’s office setting. It is critical that patients return to have their stent removed as instructed by their physician as a prolonged indwelling Double J stent can result in encrustation by stone debris, infection, obstruction and loss of kidney function.
• Stent Dysuria– It is common to feel increased sense of urgency, frequency & some amount of flank fullness as a result of the stent. These symptoms often improve over time as the body adjusts to the indwelling stent. Persistent symptoms may merit initiation of some medications for symptomatic relief. Don’t hesitate to contact your urologist for same.

Course after Discharge

 

• To take appointment for DJ stent removal – Please call Urology Department coordinator – 9560398967.

 

• DJ stent removal will be a Daycare procedure if it is done under local anesthesia

 

• Daycare would entail admission for 6-8 hrs, if insurance policy mandates then admission will be for 24 hrs

 

• If DJ stent removal / Check Ureteroscopy is planned under G.A

◦     Check date of surgery

◦     Come fasting for 6 hrs prior to the procedure

 

• Patient needs to follow up for metabolic evaluation after surgery with report of stone analysis (if done) with the Urologist.