Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks
EDITORIAL COMMENT The prevalence of urinary stone disease is increasing worldwide. The dissemination of the clinical use of the ultrasound has increased the rate of diagnosis of stones at an earlier stage, thus, has increased the expansion of the indications for flexible ureterorenoscopy (fURS)....
| Main Author: | |
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| Format: | Article |
| Language: | English |
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Galenos Yayinevi
2016-12-01
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| Series: | Journal of Urological Surgery |
| Online Access: | http://jurolsurgery.org/article_10916/Re-Current-Standard-Technique-For-Modern-Flexible-Ureteroscopy-Tips-And-Tricks |
| _version_ | 1797919051065851904 |
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| author | Emre Selçuk Keskin |
| author_facet | Emre Selçuk Keskin |
| author_sort | Emre Selçuk Keskin |
| collection | DOAJ |
| description | EDITORIAL COMMENT
The prevalence of urinary stone disease is increasing worldwide. The dissemination of the clinical use of the ultrasound has increased the rate of diagnosis of stones at an earlier stage, thus, has increased the expansion of the indications for flexible ureterorenoscopy (fURS). With the advancements in flexible ureteroscopy (FU), more successful outcomes are being reported. The most recent EAU guidelines state that fURS can be the first choice of treatment for all stones smaller than 2 cm. Especially for the lower pole stones, the stone-free rate is better than that with extracorporeal shock wave lithotripsy. For stones larger than 2 cm, staged procedures may be necessary. This paper recommends a standardized technique for fURS which is aimed to decrease the rate of possible complications and increase the success rate. Endourological techniques are widely adopted by most of the urological surgeons, hence fURS is an expansion of our surgical armamentarium. In this paper, an experienced group recommended some tips and tricks for each step of the procedure.
The authors recommended general anesthesia over spinal anesthesia for two reasons: larger tidal volume during spinal anesthesia may cause movement, which can make the procedure harder. Secondly, the duration of the spinal anesthesia may be too short for some cases.
Placement of ureteral access sheath (UAS) should be done under fluoroscopic guidance and proper force should be applied. Ideally, the distal tip of the UAS should be just below the ureteropelvic junction.
For preventing functional deterioration of the FU, the tip of the laser probe should be out of the scope as far as one-quarter of the screen diameter. For preventing excessive prolonged deflections, the stones in the lower pole should be repositioned in order to allow a more straight working channel.
Pulverization of the stone is preferred over fragmentation since it decreases the operative time and risk of injury during removal of the fragments. A power setting of low frequency (10-15 Hz) and high energy (1-2 J) is recommended for kidney stones. It is advised to keep the laser tip 1-2 mm to the stone and start from the outer part of the stone rather than causing holes and tunnels in the center, which leads to larger fragments. The use of small fiber diameters (200-275 nm) is recommended. However, since they are more prone to fiber degradation, it should be cleaved at each 10 minutes of firing with a simple metallic scissor by protruding from the tip of the FU without removing and replacing the laser probe.
When extraction of fragments is necessary, zero tip nitinol baskets are recommended.
The most important exit strategy is endoscopic inspection of the ureter wall during the removal of UAS by keeping the tip of the scope a few centimeters out of the UAS. Routine stenting whenever a UAS has been used is recommended. When the surgery is uneventful, and the endoscopic examination of the ureter seems normal, short-term stenting is offered. |
| first_indexed | 2024-04-10T13:39:18Z |
| format | Article |
| id | doaj.art-b7bd0aaf0e4e4875a89f192fd10eaa69 |
| institution | Directory Open Access Journal |
| issn | 2148-9580 |
| language | English |
| last_indexed | 2024-04-10T13:39:18Z |
| publishDate | 2016-12-01 |
| publisher | Galenos Yayinevi |
| record_format | Article |
| series | Journal of Urological Surgery |
| spelling | doaj.art-b7bd0aaf0e4e4875a89f192fd10eaa692023-02-15T16:11:16ZengGalenos YayineviJournal of Urological Surgery2148-95802016-12-013415015010.4274/jus.2016.03.034Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and TricksEmre Selçuk KeskinEDITORIAL COMMENT The prevalence of urinary stone disease is increasing worldwide. The dissemination of the clinical use of the ultrasound has increased the rate of diagnosis of stones at an earlier stage, thus, has increased the expansion of the indications for flexible ureterorenoscopy (fURS). With the advancements in flexible ureteroscopy (FU), more successful outcomes are being reported. The most recent EAU guidelines state that fURS can be the first choice of treatment for all stones smaller than 2 cm. Especially for the lower pole stones, the stone-free rate is better than that with extracorporeal shock wave lithotripsy. For stones larger than 2 cm, staged procedures may be necessary. This paper recommends a standardized technique for fURS which is aimed to decrease the rate of possible complications and increase the success rate. Endourological techniques are widely adopted by most of the urological surgeons, hence fURS is an expansion of our surgical armamentarium. In this paper, an experienced group recommended some tips and tricks for each step of the procedure. The authors recommended general anesthesia over spinal anesthesia for two reasons: larger tidal volume during spinal anesthesia may cause movement, which can make the procedure harder. Secondly, the duration of the spinal anesthesia may be too short for some cases. Placement of ureteral access sheath (UAS) should be done under fluoroscopic guidance and proper force should be applied. Ideally, the distal tip of the UAS should be just below the ureteropelvic junction. For preventing functional deterioration of the FU, the tip of the laser probe should be out of the scope as far as one-quarter of the screen diameter. For preventing excessive prolonged deflections, the stones in the lower pole should be repositioned in order to allow a more straight working channel. Pulverization of the stone is preferred over fragmentation since it decreases the operative time and risk of injury during removal of the fragments. A power setting of low frequency (10-15 Hz) and high energy (1-2 J) is recommended for kidney stones. It is advised to keep the laser tip 1-2 mm to the stone and start from the outer part of the stone rather than causing holes and tunnels in the center, which leads to larger fragments. The use of small fiber diameters (200-275 nm) is recommended. However, since they are more prone to fiber degradation, it should be cleaved at each 10 minutes of firing with a simple metallic scissor by protruding from the tip of the FU without removing and replacing the laser probe. When extraction of fragments is necessary, zero tip nitinol baskets are recommended. The most important exit strategy is endoscopic inspection of the ureter wall during the removal of UAS by keeping the tip of the scope a few centimeters out of the UAS. Routine stenting whenever a UAS has been used is recommended. When the surgery is uneventful, and the endoscopic examination of the ureter seems normal, short-term stenting is offered.http://jurolsurgery.org/article_10916/Re-Current-Standard-Technique-For-Modern-Flexible-Ureteroscopy-Tips-And-Tricks |
| spellingShingle | Emre Selçuk Keskin Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks Journal of Urological Surgery |
| title | Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks |
| title_full | Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks |
| title_fullStr | Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks |
| title_full_unstemmed | Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks |
| title_short | Re: Current Standard Technique for Modern Flexible Ureteroscopy: Tips and Tricks |
| title_sort | re current standard technique for modern flexible ureteroscopy tips and tricks |
| url | http://jurolsurgery.org/article_10916/Re-Current-Standard-Technique-For-Modern-Flexible-Ureteroscopy-Tips-And-Tricks |
| work_keys_str_mv | AT emreselcukkeskin recurrentstandardtechniqueformodernflexibleureteroscopytipsandtricks |