Ureteroscopy for Stone

What is Ureteroscopy Procedure?

Ureteroscopy is an endoscopic procedure to treats stone in the ureter. Ureteroscope is the instrument used for the procedure. This is a very fine instrument (only about 2 to 3 mm in diameter) that is made of either a semi-rigid long steel shaft or it maybe flexible.

Ureteroscopy is usually done to eliminate a stone either in the ureter or in the kidney by a surgeon called Urologist.

The flexible instrument is usually used for kidney stones that are located in the lower portion of the kidney. The rigid instrument is used to remove stones or other obstructing pathologies from the ureter.

Sometimes the ureteroscope is also used to find the cause of bleeding that is difficult to diagnose using the conventional tests.

Once the stone is identified, it can be removed totally or if it is too large to be removed, it can be broken down into smaller fragments using appropriate devices like a laser or a fine- fragmenting instrument. These fragments can be easily picked by a small, grasping instrument or basket and be removed.

After the stone has been removed, a stent (a synthetic tube which is left in between the kidney and the urinary bladder) is left in the ureter for a few days to allow healing.

It is possible for the stent to be provided with a nylon suture attached at the distal end. This is called a dangler and the fine nylon may dangle out of your penis. This facilitates its removal without the need for any additional procedure like a cystoscopy.

The stent can be left inside the system for a few days to 2 months depending on the complexity of the procedure. It is very important for this stent to be removed because if it is left in the urinary system for a longer time, stone can form on it.

A urinary catheter is kept after the procedure to drain the urine. The majority of ureteroscopic procedures can be performed as day surgery and most individuals can return to work within a few days following the procedure.

Ureteroscopy was developed in the 1970s and came into wide use during the 1980s. Previously a type of treatment called "blind basketing" was often used. A small basket-like device was passed � blindly, with no viewing instrument � through the urethra and bladder and into the ureter to pull out the stone. This type of "blind" treatment risked injury to the ureter and was less effective than other methods used today.

What are the Advantages of Ureteroscopy Procedure?

Instruments and accessories for ureteroscopy have improved over the years. Ureteroscopes have become thinner in diameter with better fibre-optics that provides excellent view of the inside of the organ. The ureter is a very delicate thin tubular structure that connects the kidneys to the bladder and requires gentle handling. It is about 25 cms or twelve inches in length. Ureteroscopy as a procedure has many advantages and include -

• No more open procedure for stones - Before the advent of ureteroscopes, the surgeons usually had to do an open operation that left the patient with a five to six inches scar and a long recovery time of a week or 10 days.
• Short Recovery Time - With ureteroscopy the patient is able to return home either on the same day or in a day or two. The procedure is usually done under general or spinal anesthesia.

Ureteroscopy - Ureteral Stone

Urinary stones are gravel and nearly always form in the kidney, where they may remain without symptoms and do not require treatment. The kidney stone will usually roll down and can cause blockage or obstruction.

The stone begins as a tiny grain of undissolved material located where urine collects in the kidney. Over time, more undissolved material is deposited and the stone becomes larger. The chemical deposited is usually a mineral called calcium oxalate. Other less common materials that may also form a stone include calcium phosphate, uric acid, infected or struvite stones and cystine stones.

Most stones enter the ureter when they are still small enough to move down into the bladder. From there, they pass out of the body with urination. However if the stone is larger than the diameter of the ureter they get stuck in the narrow passage and cause excruciating pain, called a colic, and obstruction. If this happens, treatment is required and, for some stones, ureteroscopy is the best form of treatment.

Ureteroscopy - Symptoms

Ureteric colic - due to the stone causes excruciating and unbearable pain and may last several minutes or hours.

The pain of a kidney stone has been described as the most severe pain that a person may experience. It has been described as being worse than child birth.

What are the Investigations Required for Ureteroscopy Procedure

If a patient has acute colic then a plain non contrast CT scan of the Kidney, Ureter and Bladder (KUB) area is the best single investigation to confirm the presence of a ureteric stone.

The usual initial investigations to confirm the presence of a ureteric stone include -

• Routine urine test to look for presence of RBCs or red blood cells in the urine. This is due to abrasion caused by the spikes of some stones like calcium oxalate.
• An ultrasound of the kidney, ureter and bladder - to look for stones and swelling of the kidney or hydronephrosis ( hydro- water, neprhrosis - kidney).
• Plain KUB Xray - If the ultrasound indicates presence of any hydronephrosis of the kidney but if the stone is not seen, than a plain X-ray is suggested. A stone that has calcium is usually seen on X-ray, however some stones like the ones with uric acid may not be picked up on X-ray.
  
• Plain CT KUB - as said earlier it is the quickest and most accurate way to diagnose ureteric stone and also to rule out other problems like an acute appendicitis.
  
• Intra-Venous Pyelography (IVP) - It is seldom done unless a hospitals lacks a CT scanner or if any abnormal development anatomy of the kidney is suspected along with a stone.
  

Other tests that maybe done and include-

• Complete blood count and Hemoglobin
• Biochemical parameters - Electrolytes, Urea and creatinine
• Blood sugar or glucose level
• If surgery is planned a chest X- ray and an ECG maybe required.
  

What are the Treatment Options for Ureteric Stones?

Laparoscopy maybe used for large stones of 2 to 3 cms in size in the upper or mid-ureter.

Ureteroscopy is usually best suited for stones in the lower or mid third of the ureter.

The chances of complete clearance of the stone with a single treatment are almost 98 to 99%.

Can Ureteric Stone pass spontaneously without any procedure or intervention?

Treating ureteric stones depend largely on the size, position and hardness of the stones.

Luckily, the majority of small stones of about 2 to 4 mm in diameter that do not cause infection, blockage or symptoms will pass if you simply drink plenty of fluids every day. Recent studies have suggested that the majority of stones (95 percent) that are capable of spontaneous passage will pass within six weeks.

Consuming about 2 .5 to 3 .5 litre of water increases urine production, which eventually washes kidney or other stones out of the system.

Once they have passed, no other treatment is necessary except continuing a high fluid intake to avoid further stones. The doctor usually asks one to save the passed out stone(s) for testing its chemical structure. Hence if you know you have a small stone try and collect the stone by urinating into a container or by using a tea strainer or filter.

To ease the passage of the stone the urologist may prescribe some tablet (an alpha-blocker like tamsulosin) and also may alkalinise the urine. Many people in south Asian countries use home remedies too to help in the passage of the stones. However these have not gone through any clinical trail to substantiate the claim. The most popular of these include drinking daily banana stem juice.

What are the Indications of Ureteroscopy?

Ureteroscopy is indicated if the stone is causing colicky pains and does not move down or pass out of the ureter.

The indications for ureteroscopy for the stones include the following factors:

• The stone does not pass after a reasonable period of time ( 2 to 3 weeks) and causes swelling of the kidney (also called hydro nephrosis)
• The stone is repeatedly causing pain or colic
• Stone is too large to pass on its own and blocks the flow or urine
• Stone causes urinary tract infection
• Damages kidney tissue
• Stone causing constant or recurrent bleeding
• Stone has grown larger over the period of time.(This can be found out from follow up of X-rays or ultrasound or CT scan)

The dictum for ureteric stones is as follows:

• Stones smaller than 4 mm have a 90% chance of passing out spontaneously.
• Stones between 4 to 7 mm have a 50% chance of spontaneous passage.
• Stones larger than 7 mm have only 10% chance of spontaneous passage.

What Happens When I get into the Hospital for Ureteroscopy Procedure

Ureteroscopy procedure requires hospital admission and it can be done as either a day procedure or you may need to stay for 2 to 3 days.

After admission the doctor will ask you to do some blood tests and urine tests if they were not done previously. In addition, you may have to get X-ray of the abdomen (called KUB - for Kidney, Ureter and Bladder) and an ultrasound examination to see the location of the stone in the urinary tract.

If the stone is found to be in the lower or mid portion of the ureter, then ureteroscopy is a good option.

It would be better if you bring your relative with you to get the things required for the surgery and to help in other admission formalities.

Sometimes it can be done as a day case - meaning that you get admitted in the morning and get discharged after the procedure in the evening.

The anaesthesia doctor will come and see you regarding the same the day before surgery.

Usually an X-ray or an ultrasound will be taken in the morning, on the day of surgery to see if you have silently passed the stone. If you have passed the stone, then surgery is not required.

What are Preparations Required in the Hospital before you have Ureteroscopy?

Before undergoing ureteroscopy procedure you must mention if you suffer from any allergies to medication to your doctor.

1. The doctor who is taking care of you will come and see you. He will explain to you about the surgery. If you have any doubts or questions regarding the same, you can discuss this with the doctor without hesitation.

Mention the following to the doctors when they visit you -

• Any allergies - especially to antibiotics
• If you have missed your period and are likely to be pregnant

2. The type and preference for anesthesia should be discussed before surgery with the anesthetist who sees you the day before surgery.

3. As any medical procedure whether minor or major is associated with some amount of risk, you have to sign a consent form, expressing your consent for the surgery.

4. You will be kept fasting for a few hours before the surgery. All jewellery will need to be removed. These items can increase the risks of infections. Other foreign items like dentures, contact lenses etc. have to be removed too. Your nails will also be trimmed.

What Happens Inside the Operating Room When You have Ureteroscopy?

Ureteroscopy can be done under either a general anesthesia or spinal anesthesia.

• Generally in some hospitals before surgery you will be waiting on the trolley bed in a waiting room area till the operating suite is ready for you.
• Once you are inside the operating room, you will be made to lie on the operating table and anaesthesia will be given.
  
  A general or spinal anesthesia maybe used for the procedure. The preference for anesthesia as said earlier should be discussed before surgery with the anesthetist who sees you the day before surgery.
• In spinal anesthesia, the lower section of your body is made numb by a small injection in your back.
• In general anesthesia you are put to sleep by injection and by making you inhale anesthetic gas.
• After the anaesthesia has been given, you will be made to lie on your back with your knees raised and apart.
• The lower section of your body will be undressed and the doctor or the nurse involved in the surgery will wash the area around the urethra with antiseptic solution and will place sterile towels around the area.
• You will be lying still during the procedure. An antibiotic maybe used just before the start of the procedure. If you suffer from any allergies due to antibiotic this should be mentioned to anesthetist and the surgeon before the surgery.

What Happens After the Ureteroscopy Procedure?

After ureteroscopy procedure you will be observed in the recovery room for an hour or two and then shifted to the ward or room.

In the recovery area you will be monitored and your vital signs like pulse, temperature, blood pressure and respiration will be checked periodically to ensure that oyu are safe to return to the ward.

Once you are stable, you will be shifted to the ward. Do not get alarmed by seeing blood in your urine-collecting bag after the surgery. As you keep taking water, during the course of the day, it will become lighter. Usually, you can have small drink and snack 3 to 4 hours after the surgery.

You may require one or two pain killers and a sedative in the night for sleep. Antibiotic injection maybe repeated if required.

If a stent has been placed in your system, a check X- ray will be done to see if it is in proper position the next day.

The catheter will be removed on the first or second post operative day and you will be treated with anti-biotics and pain killers after the surgery for a few days.

If all goes well and you are comfortable, you can be discharged on the same day or the second or third day following the surgery.

You will be asked to come for review after a week or two, to observe your progress after surgery. A decision about stent removal will be made at that time. You will also be given medicines which prevent further stone formation.

How Can Kidney or Ureteric Stone be Prevented?

Good hydration means plenty of water and other fluids and this can prevent further kidney stone formation.

• A good first step for prevention is to drink more liquids � water is the best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least two liters of urine in every 24-hour period.
• People who form calcium stones are usually told to avoid dairy products and other foods with high calcium content. However, recent studies have shown that foods high in calcium, including dairy foods, help prevent calcium stones.
• If you are at risk for developing stones, your doctor may perform certain blood and urine tests to determine which factors can best be altered to reduce the risk. Some people will need medicines to prevent stones from forming.