URETERORENOSCOPY

Indication
Calculi:
• lower, upper ureteric calculi
• renal calculi
• post ESWL steinstressae
• obstruction
• carcinoma plus suspicious of urothelial tumour
• diagnosis –unilateral gross haematuria
unilateral malignant cytology
therapeutic procedures- ureteral catheter
removal of foreign body
dilatation
preoperative management:
1. history and physical examination
2. informed consent from the patient
3. preoperative antibiotics
4. anaesthetic
diagnosis :
• evaluation of obstruction
• evaluation of unilateral gross haematuria
• evaluation of malignant cytology
urological procedure :
HISTORY:
Rigid Ureteroscope: the small rigid ureteroscope include those with a dimension of8.5 fr or less. These instrument were originally designed for use in the

distal ureter but some are long enough to pass to the renal pelvis in certain patients. The small diameter usually permits their passage into the ureter

without prior dilatation.

Flexible ureteroscope:
The possessively deflectable designed ureteroscopes possesses no mechanism for changing the direction of the tip and is of limitedclinical value.

The actively deflectable instruments possess an intrinsic mechanism for changing the direction of the tip of the endoscopes.

Procedure:
1. Apply 2%xylocaine jelly per urethrally
2. Take the cystoscopy sheath 22fr and make the following connection:
• Insert 30 degree telescope inside the cystoscopy sheath
• Connect the endo-camera to the telescope
• Connect the light source to the cystoscopy sheath
• Connect the irrigation source
3. after all connections have been made, the cystoscopy sheath with all the connections is inserted per urethrally
4. The urethra, the bladder and the ureteric orifices are visualized.
5. Take he ureteroscopes and make the following connections
• The endocamera
• The light source
• The irrigation source
6. some times the ureteroscope can be passed freely into the ureter without prior dilatation
7. in somecases urethral dilatation may be required, sometimes with the endoscope itself, by passive dilatation of the ureter with a ureteric catheter

or stent or by active dilatation-using graduated dilators or ballon dilating catheters.
8. ballon dilating catheters offer a convenient and effective technique for dilatation at any level in the ureter
9. several different types of ballons are available; the usual size employed are 15fr and 18fr, which offer adequate dilatation without ureteric damage
10. to use a ballon dilating catheter a guide wire is first placed cystoscopically. The ballon catheter is then advanced over the guide wire and the

ballon is placed to give full dilatation of the desire region
11. to expand the ballon and dilate the ureter, the ballon is filled with normalsaline and contrast medium in sufficient concentration to demonstrate the

ballons presence fluoroscopically.
12. the presence in the ballon is then increased and carefully monitored with an in-line gauge and should not exceed the manufactures recommended

specifications.
13. a ballon should then be deflated fully by aspirating the contrast-containing solution before the catheter is removed.
14. after dilation of the ureter the guide is placed cystoscopically and left in-situ.
15. then the ureteroscopy is inserted under vision and continuous irrigation.
16. the calculu can be either grasped by passing a stone grasper through the ureteroscope.
17. in case of an impacted stone, it can be broken with the help of the lithoclast, by passing the lithoclast probe through the ureteroscope and

fragmenting.
18. the big fragments can be removed with the help of a grasper.
19. the small fragments could be left to drain automatically.
20. the ureteroscope is removed and the cystoscopy sheath is inserted per-uretherally.
21. through the cystoscopy sheath the stent is inserted into the ureter and left insitu for about 2 weeks to facilitate complete drainage of the

remaining fragments.
22. the cystoscopy sheath is removed and a Foley’s catheter is left insitu.




Precaution :
Proceeding through guidewire
Deflating ballon before removal
Complication

Urethral stricture
Bladder perforation

OPEN VESICOLITHOTOMY

Antibiotic

Anaesthesia
Spinal anaesthesia
Position
Patient is positioned on the operating table in a supine position.
Skin preparation
In males: begin at the suprapubic region extending from 7.5cms(3 inches) above the umbilicus to the lower thighs, and down to the table at the

sides, the genitalia are also included

In females:begin at the pubic symphysis and extend downward over the labia. Clean each inner thighs, the vaginal vault, cervix upto the perineum and

anus.

Draping:
4 small sheets
2 large laprotomy
Required for the procedure:
1. Disposable gloves
2. OT guaze
3. Abdominal swab
4. Diathermy cable
5. Suction tube
6. Thoracic drain
7. 16fr foleys catheter
8. Urobag
9. Retractors
o Millin’s retractor
o Langenberg retractor
o Kelly’s retractor
o Deavers retractor
o Morris retractor
Forceps
o Toothed artery forceps
o Non toothed artery forceps
o Adson’s forceps (toothed)
Scissors
o Metzenbaum
o Straight mayo
Clamps
o Mosquito straight artery
o Mosquito curved artery
o Allis
o Babcock
o Kochear
o Towel clips
o Needle holder
Miscellaneous
o B.P. handle
o Suction yanker
Suture material
o 3-0 chronic catgut
o 2-0 ethilon
o Mersilk

Urological procedure
Exposure of the bladder
? The best approach to the blade is provide by the Pfannestiel’s incision.
? The incision is made on the skin using 11-size sterile blade just above the pubis symphysis.
? Following the same line of incision, the fat, the sub-cutaneous tissue and muscle are dissected respectively.
? A Millin’s self retaining rectractor is inserted to retract the muscle bellies.
? The bladder is filled with normal saline/antibiotic (500ml normal saline with inj. Gentmycin 80mg) and distend it if necessary.
? The peritoneum is pushed away from the bladder using a sponge on an artery forceps.
? Sometimes an 18G venflon is used for aspiration, to make sure the location of the bladder, before making the incision.
? The bladder is then incised, preferably using the diathermy needle to avoid loss of the blood.
? The urine is aspirated with the sucker.
? The Millin’s retractor is then readjusted so as to reveal the calculus.
? For removal of the calculus, a finger is introduced into the bladder t determine whether the stone is lying free in the bladder or is impacted in a

diverticulum’s.
? Free stones are removed with a lithotomy forceps or scoopes.
? Impacted calculi should be dislodged first and then removed.
? A bladder biopsy can be taken of any area of adjacent vesical mucosa in view of the occational complication of squamous cell carcinoma
? A self retaining foleys catheter of appropriate size(e.g. 18 or 20fr) is left in the bladder which is closed in one or two layers of continuous 3-0

chromic catgut
? A tube drain (about 20fr) is led out through the upper skin flap from the suture line in the wall of the bladder and secured with a stitch
? Themuscle bellies of the rectus are approximated with one or two loosely tied catgut sutures
? The appropriate of the rectus is then closed with a continuous or interrupted 3-0 catgut or 2-0 vicryl
? Lastly the skin is sutured with interrupted silk or nylon
? The suprapubic wound drain would be removed on the 2nd post operative drain
? A per urethral catheter is usually placed in the bladder and removed onteh 8th post operative day
? The skin sutures are usually removed on the 7th or 8th post operative day
? Sometimes cystoscopy may be necessary before doing an open vesicolithotomy hence check with the urologist before setting the trolley.



. electrodes. The strength and frequency can be varied. Care must be taken not to discharge the probe when it is incontact

with the bladder wall.
At the end of any procedure for crushing bladder stones, all the fragments must be removed using a ellick evacuator, bladder outflow obstruction must

subsequently be treated.

Post operative care:
An indwelling urethral catheter is necessary as much for the management of the bladder outflow obstruction as for the lithotripsy itself.

Complication :
? trauma to the urethra can occur because the instruments used are large and …………….
? Damage to the bladder wall may arise if the bladder wall is included in the famous of the instrument. This is a particular risk when the blind

lithotrite is used.
? Electrohydraulic disintegration causes damage of the probe and discharged when lying against the bladder wall.
? Extraperitoneal distruptions of the bladder may be treated by an indwelling catheter but intraperitoneal holes must be closed at Laprotomy