Ureteroscopy is a modern endoscopic method of finding and effectively (97%) removing (crushing) concretions in the lower or middle third of the ureter without a single incision. Ureteroscopy is used for a comprehensive assessment of the condition of the ureter and the renal cavity system, for the correction of anatomical disorders. Depending on the localization and nature of the pathological process, ureteroscopy is performed in a special X-ray endoscopic operating room under local, epidural or general anesthesia using a ureteroscope (rigid or flexible), on an empty stomach. Ureteroscopy requires a preliminary examination of the patient to obtain a complete picture of the state of the urinary tract, as well as preventive antibacterial therapy.
Endoscopic diagnostics began to be used since the end of the XVIII century. In 1806, the Austrian doctor F. Bozzini invented the first candle-illuminated endoscope, but for a dangerous technique (“curiosity”) he was punished by suspension from practice by the Medical Faculty of the City of Vienna. The founding father of endoscopy is considered to be A. Desormu, who created an endoscope with an alcohol lamp in 1853. The same age as this endoscope, in fact, is a rigid ureteroscope, since the invention of the French surgeon was intended for the examination of the urogenital system. However, the birth of modern ureteroscopy can be considered the end of the 80s of the last century, when fiber optics and video endoscopes were invented.
A modern ureteroscope can be either rigid or semi-rigid, or flexible (fiber-fiber). The indisputable advantage of flexible ureteroscopes is the movable design of their head, which allows you to overcome anatomical obstacles. Ureteroscopy performed with such a tool not only helps to carry out a visual revision of the ureter, pelvis and cups, but also makes it possible to determine the exact location of their damage or narrowing, localization of concretions, tumors. In addition, contact lithotripsy, ureterolithoextraction and biopsy of the lesion are performed using ureteroscopy.
The most common indication for the diagnosis and treatment of diseases of the urinary system using ureteroscopy is the presence of stones in the VMP or the suspicion of the formation of concretions in this area. Ureteroscopy in this situation is the most accurate diagnostic method that allows you to clarify not only the location of the concretion, its shape and size, but even the structure of the formation, as well as to remove it with or without preliminary destruction by laser (ultrasound). Such ureteroscopy is most effective in the distal part of the ureter.
Another indication for ureteroscopy is the need to remove diverticula or foreign bodies. Ureteroscopy is used to diagnose and treat chronic inflammatory diseases of the urethra and VMP tumors (electrocoagulation of hemangioma), to search for the source of bleeding of unclear genesis with confirmed hematuria. In addition, ureteroscopy is used to determine malformations, dissection of pathological constrictions. Ureteroscopy is also performed during balloon dilation of ureteral stenosis, pelvis and endoscopic ureteropyeloplasty. With the help of ureteroscopy, the pathology of the seminal tubercle is corrected, a biopsy of the neoplasm is performed.
Ureteroscopy is usually not performed in the presence of a large stone (with a diameter of more than 1 cm), since the removal of the concretion in parts requires repeated manipulation, which can cause complications. Ureteroscopy is also not indicated for acute inflammation of the prostate, upper and lower urinary tract. In addition, contraindications to ureteroscopy are anomalies of the development of the mouth and vesicoureteral anastomosis, “fixed” or postoperative ureter, reconstructive interventions, large adenoma, cancer – that is, pathologies in which it is impossible to bring the ureteroscope to the desired area. Ureteroscopy has a number of advantages, since it allows you to simultaneously diagnose the pathology of the ureters, bladder and urethra, it is performed without incisions, does not leave scars.
Preparation for ureteroscopy
A referral for a diagnostic procedure is issued by a urologist. Before ureteroscopy, the patient undergoes a special clinical and laboratory examination designed to give a complete objective picture of the state of his urinary tract. A comprehensive examination includes blood test, urinalysis, urine culture for flora and determination of its sensitivity to antibiotics, urographic examination to determine the size of stones, their localization and shape, as well as to assess kidney function. Based on the results of these procedures, the doctor decides which manipulation should be performed by the patient for diagnostic or therapeutic-diagnostic purposes: ureteroscopy, lithotripsy or endoscopic surgery, and if a urinary tract infection is detected, prescribes a course of antibacterial therapy. Sometimes antimicrobial therapy is carried out proactively.
A feature of the preparation for ureteroscopy is the exclusion of the patient taking drugs containing acetylsalicylic acid a week before the manipulation. On the day of ureteroscopy, the patient does not take food, immediately before the procedure, he should empty his bladder.
Methodology of conducting
Ureteroscopy is performed by a urologist with a special instrument – a ureteroscope. Local, epidural or general anesthesia is used for anesthesia. Ureteroscopy is performed in stages. The patient is on a special manipulation table, in a horizontal position – a standard lithotomy position (with the hip removed to the side and lowered, opposite to the examined ureter). First, the patient is put on an antibiotic drip. Then anesthesia is performed, and only then the doctor inserts a ureteroscope with a built-in microcamera into the ureter, having previously expanded the mouth of the organ. The camera transmits the image to the monitor, which allows you to monitor the progress of ureteroscopy, to visually assess the condition of the patient’s urinary tract.
During ureteroscopy, it is possible to carry out crushing of concretions, removal of stones, identify and, if possible, eliminate other pathological changes, take a biopsy. Small stones are removed with forceps, placed in a basket (ureteroscopic instruments). Large concretions are crushed with an electrohydraulic probe, ultrasound, laser, then bringing the fragments out using suction. After removal, a temporary (for a day or a week) stent is installed, which guarantees an unhindered outflow of urine and a painless discharge of micro-fragments.
In the postureteroscopic period, the patient has frequent urge to urinate, accompanied by aching pain in the lower back before and at the time of urine discharge. Blood impurities may be detected in the urine. To relieve pain after ureteroscopy, painkillers, copious drinking and hot baths are prescribed. Antibiotics are indicated for 3-5 days. The entire course of ureteroscopy is recorded in detail in the medical history, an extract from which is given to the patient in his hands. After discharge from the hospital, it is recommended to move more, limit heavy physical activity, follow a diet, drink herbal tea. After a certain time, the stent is removed. However, ureteroscopy does not treat ICD radically. Over time, stones form again if you do not follow the recommendations of the attending physician and, above all, a special diet.
Ureteroscopy may be complicated by insufficient expansion of the ureter, which prevents the introduction of the ureteroscope and manipulation of the device, requires repeated bougie. When performing ureteroscopy, injury or perforation of the ureter is possible. In this case, the procedure is immediately stopped, the ureter is drained. If drainage is not possible, nephropyelostomy is performed. The main danger after ureteroscopy is considered to be the possibility of acute pyelonephritis, obstruction of the VMP, urinary congestion due to injury to the urinary tract. Complications are stopped by a course of antibiotic therapy or surgical intervention. Over time, strictures or obliteration of the ureter may occur at the site of injury, as well as inflammation with the development of vesicoureteral reflux.