Ureteroscopy - Indications, Contraindications, Procedure, and Side Effects

Introduction:

Ureteroscopy aims to eliminate urinary tract problems, particularly kidney stones. It is both a diagnostic and a therapeutic tool used to address urinary tract disorders. The procedure gets completed in one hour and is performed under general anesthesia. The doctor inserts a small telescope, a ureteroscope, into the bladder to reach the ureter. Through this, the doctor gets an idea about the presence of stones within the ureter and helps him evaluate the reason for the urinary tract blockage.

What Is Ureteroscopy?

Ureteroscopy, in other words, involves the endoscopy of the urinary system because the procedure aims to look inside the body, recognize the disease, and treat it accordingly. Ureters are tube-like structures that transport urine from the kidneys to the urinary bladder. However, sometimes the urine does not flow to the urinary bladder and is left behind within the kidneys. This occurs mainly because of the stones present within the ureters that have blocked the urine flow. If the condition is left untreated, it can cause permanent damage to the kidneys and other organs.

What Are the Indications of Ureteroscopy?

As the name suggests, ureteroscopy is a procedure that aims to remove the stones that block the flow of urine from the ureters and the kidneys. The doctor will suggest the patient undergo the procedure under the following conditions:

• Ureteral or Kidney Stones: Kidney stones or nephrolithiasis are hard structures that form in the kidneys because of the deposition of salts and minerals. They can also move to the ureters, thereby blocking urine flow. Therefore, ureteroscopy becomes a treatment of choice because it can remove the stone located within the kidneys.

• Tumor in the Ureter or Pelvis: A tumor is a mass that forms due to the abnormal growth of cells. If the tumor is present within the kidneys or near the ureter, it can block urine flow. Ureteroscopy provides a conservative approach for treating tumors, especially in cases where surgical procedures have been contraindicated.

• Hematuria Due to Kidney Stones: The presence of blood in the urine is known as hematuria. Kidney stones are one of the causes of hematuria. Ureteroscopy helps remove the stones to get rid of hematuria.

• Presence of Foreign Bodies: The foreign bodies mainly involve the presence of catheter fragments or other devices which block the flow of urine. Ureteroscopy provides access to these fragments to retrieve them successfully.

• Biopsy: It is the procedure in which a piece of tissue is taken and sent to the laboratory for further evaluation. This procedure is mainly carried out when the doctor suspects the presence of a tumor in any organ. For example, instruments are inserted through a ureteroscope to conduct a biopsy if any cancerous growth is seen in the kidneys or ureters.

• Ureterovaginal Fistula: It is a condition in which there is communication between the vagina and ureters. The urine flows into the vagina from the ureters leading to urinary incontinence (urine leakage). Ureteroscopy is an effective and the most preferred method to diagnose the case of a ureterovaginal fistula.

• Pregnancy: Ureteroscopy is also useful for pregnant females and those who suffer from disorders in which blood fails to clot.

What Are the Contraindications of Ureteroscopy?

The conditions in which ureteroscopy should not be performed or is not the first line of treatment are listed below:

1. The patients suffering from urinary tract infection will require antibiotics and placement of a catheter to drain the urine before ureteroscopy.

2. If the stones present within the kidneys or ureters are large, they are broken down into pieces and then removed, but sometimes the fragments are more numerous. In such a situation, it becomes impossible to remove all the pieces with the help of a ureteroscopy.

3. If the ureters are narrow and the patient has undergone surgery where the ureters or bladder have been reconstructed, the passage of the ureteroscope becomes impossible.

What Happens Before the Procedure?

The following things are to be done before the surgery:

1. The doctor will review the X-rays and computed tomography (CT scans) before the procedure to ensure that the procedure can be safely performed on the patient without any complications.

2. The patient should also inform the doctor about the medications he is taking or any allergies or disorders he is suffering from. For example, the doctor might ask to stop taking drugs like Aspirin and Ibuprofen before the surgery, as they can cause excessive bleeding.

3. A urine test is carried out along with a blood test to rule out any infection in the urinary tract. Urine collected from the patient is sent to the laboratory for examination purposes, and the doctor checks the report of the same before starting the procedure.

4. Antimicrobial or antibiotic coverage is required before the surgery. The antibiotics most commonly administered before the surgery can be any one of these:

• Cephalosporins (usually first or second generation).

• Ampicillin and Gentamicin in combination.

• Amoxicillin and Clavulanic acid.

1. The antibiotics are administered either orally (by mouth) or parenterally (the medication is directly injected into the body).

2. The patient should not eat anything the night before the surgery and only take his prescribed medication in the morning before coming for the procedure.

3. Suppose the medicine is to be administered parenterally. In that case, it is injected into the veins of the patient an hour before the procedure so that sufficient levels of drugs are present in the blood.

4. Before the commencement of surgery, general anesthesia will be administered to the patient so that he falls asleep and the surgery is carried out smoothly without any pain or inconvenience.

What Happens in the Procedure?

The procedure begins as soon as the patient falls asleep, and the following steps are followed.

1. The patient is placed in a position where he lies on the back, and his legs are elevated at 90 degrees. This position is known as the lithotomy position. It is the most preferred one when any operative procedure is carried out in the lower abdominal region, such as removing kidney stones or bladder stones.

2. A tube known as a cystoscope is inserted into the bladder through the urethra. Since the tube has a camera attached, it will help the doctor examine the bladder internally.

3. A special type of liquid (contrast material) is injected into the ureters, and X-rays are taken to mark the exact location of the stone.

4. The doctor then inserts a telescope-like device through the urethra known as a ureteroscope with a lens at both the end, a tube in the middle, and light at the other end to examine the urinary system, including the kidneys, ureters, and urinary bladder.

5. The ureteroscope helps to locate the exact location of the stone, and one thing to be noted here is that the doctor does not make any cut to insert the instrument, so in a way, it is a conservative procedure.

6. After the stone has been located, a wire basket is passed through the channel within the ureteroscope to pull out the stone.

7. If the stone is large, it is broken into smaller pieces with the help of a laser, usually a Holmium laser, to facilitate the removal of the fragments (ureteroscopy lithotripsy).

8. The ureteroscope is then removed from the body, and the solution that was filled in the bladder earlier is drained out.

9. The entire procedure gets completed in one to two hours, and the condition of the patient is monitored until he comes out of the anesthesia.

What Happens After the Procedure?

• Some patients develop swelling of the urinary tract due to the insertion of a ureteroscope that might block the flow of urine, so the doctor inserts a tube called a stent after the procedure ends. It is left within the ureters for one to two weeks, and the urine will flow normally with the help of a stent.

• The doctor will prescribe Ibuprofen to control pain and inflammation after the surgery and Tamsulosin to relax the muscles of the ureters.

• The patient needs to drink sufficient water and avoid all the activities which require him to lift heavy objects or weights.

• The doctor will examine the condition after one week on follow-up and remove the stent if required.

What Are the Side Effects of the Procedure?

Patients experience pain and discomfort for one to two days after surgery. Blood is seen in the urine if the stent has been placed. Fever, nausea, and vomiting are commonly seen. Antibiotics need to be taken as prescribed to avoid infection. The patient has to frequently rush to the bathroom because of the constant feeling that he needs to urinate. A burning sensation upon urination is also one of the side effects.

Conclusion:

Ureteroscopy is a treatment of choice for the removal of kidney stones both by the patient and the doctor because it provides access to the internal organs of the urinary system. The doctor does not have to make any incision to reach the ureters making it less painful. There are risks and side effects associated with it, but if the condition of the patient has been assessed thoroughly before the procedure, it does not cause any harm. So this procedure should be opted to treat kidney stones and other conditions that block urine flow from the body. If the procedure is performed under proper care and training, the results are excellent.