Key Points

• The aim of this procedure is to fragment stones in the ureter (the tube that drains urine from the kidney into the bladder) using a thin telescope passed into the bladder through the urethra (waterpipe)
• We use a “semi-rigid” telescope (ureteroscope) for stones in the ureter and a flexible ureteroscope to treat stones in the kidney
• Stones are usually broken up using laser energy passed through a small laser fibre
• Ureteroscopy has largely eliminated the need for open surgery to remove stones
• Laparoscopic (keyhole), or open surgery can be used if the stone is too large to be fragmented with a ureteroscope

What does this procedure involve?

This involves using a telescope (semi-rigid or flexible) passed into your bladder through your urethra (waterpipe) to fragment and/or remove stones from your ureter or kidney. We sometimes need to leave a temporary stent in your ureter after the procedure.

What are the alternatives?

• Observation – most stones smaller than 5mm in diameter pass by themselves but larger stones (greater than 7mm diameter) rarely do
• Extracorporeal shockwave lithotripsy (ESWL) – by “firing” shock waves generated under water through the skin to break the stone into fragments which you then pass yourself
• Antegrade ureteroscopy – stones in the upper ureter (close to the kidney) can be treated by percutaneous (keyhole) puncture of the kidney so that a ureteroscope can be passed down to the stone from above
• Laparoscopic (keyhole) stone removal – for extremely large or impacted stones in the ureter
• Percutaneous nephrolithotomy (PCNL) – for large stones in the kidney which may not be suitable for flexible ureteroscopy
• Open stone removal – although very unusual nowadays, if all the above techniques fail we may need to resort to open surgery, through an incision in your side, to remove your stone(s)

What happens on the day of the procedure?

Your urologist (or a member of their team) will briefly review your history and medications, and will discuss the surgery again with you to confirm your consent. An anaesthetist will see you to discuss the options of a general anaesthetic or spinal anaesthetic. The anaesthetist will also discuss pain relief after the procedure with you. We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home. If you have a stone in your ureter, we usually arrange a plain abdominal X- ray for you on the day of the operation, to be sure that the stone has not passed by itself.

Details of the procedure

• we normally use a full general anaesthetic and you will be asleep throughout the procedure
• we usually give you an injection of antibiotics before the procedure, after you have been checked for any allergies

• we put a telescope into your bladder, through your urethra (waterpipe), and use it to put a guidewire up into your kidney, past the stone in the ureter, using X-ray control.
• we then put the ureteroscope (semi-rigid or flexible) up to the level of the stone by following the guidewire
• we fragment the stone using an energy source; this is usually a laser but, occasionally, we use a lithoclast (a tiny pneumatic drill)
• using the laser, we either “dust” the stone, leaving tiny fragments which can pass by themselves, or break it into smaller pieces (pictured) which can be removed using special grasping devices
• we usually insert a temporary drainage tube (a ureteric catheter, or a stent with a string attached) into the ureter at the end of the procedure; this is normally removed on the first post- operative morning
• occasionally, we need to perform a “second-look” ureteroscopy at a later stage to treat residual stones; if this is needed, we leave a stent in your ureter until the second procedure
• occasionally, we put in a bladder catheter which is removed the following morning
• most patients go home on the same day as their procedure or early on the first post-operative morning

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. The impact of after- effects can vary a lot from patient to patient;

After-effect

Risk

Mild burning or bleeding on passing urine for a short time after the procedure (especially if you have a ureteric stent) Temporary insertion of a ureteric stent which needs to be removed later Recurrent (new) stone formation over the next five to 10 years, requiring further surgery or other treatment Residual stones requiring further surgery or other treatment (more likely for stones closer to the kidney) Failed to access the ureter (or reach the stone) requiring further surgery or other treatment Temporary insertion of a bladder catheter Infection requiring antibiotic treatment Minor damage to the wall of the ureter (small perforation, mucosal abrasion, bleeding) requiring stenting or percutaneous nephrostomy Narrowing of the ureter due to delayed scar formation (stricture) which may require further treatment Major damage to the wall of the ureter (large perforation, avulsion of the ureter) requiring further surgery Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death) Between 1 in 50 & 1 in 250 patients (your anaesthetist can estimate your individual risk)

What can I expect when I get home?

• • you should drink twice as much fluid as you would normally for the

first 24 to 48 hours, to flush your system through and reduce the risk of infection

• • recovery from ureteroscopy is usually rapid; you may return to work

when you are comfortable enough and when your GP is satisfied with your progress

• • if you have had a stent put in, it may cause pain in your kidney area

when you pass urine, or pain in your bladder; this usually settles quickly but, if you feel unwell or feverish, you should contact your GP to check for a urine infection if you develop a fever, pain in the area of the affected kidney, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your GP immediately