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Flexible ureteroscopy update: indications, instrumentation and technical advances

Retrograde ureteroscopy has recently gained a broadened indication for use from diagnostic to a variety of complex minimally invasive therapies. This review aims to look at the recent advances in the instrumentation and accessories, the widened indications of its use, surgical techniques and complications. With minimization of ureteroscopic instruments manufacturers are challenged to develop new, smaller and sturdier instruments that all will also survive the rigors of surgical therapy.

Ureteroscopy is defined as retrograde instrumentation performed with an endoscope passed through the lower urinary tract directly into the ureter and calyceal system.[1] With the addition of actively deflectable, flexible endoscopes the indications for ureteral access sheath have broadened from diagnostic to a variety of complex minimally invasive therapies. Current ureteroscopic treatments include intracorporeal lithotripsy (by far the most common), treatment of upper urinary tract urothelial malignancies, incising strictures, evaluation of ureteral trauma, and repairing ureteropelvic junction obstructions.[2,3] With improved instrumentation and incorporation of technologies such as a large endoscope working channel and active tip deflection, the evolution of surgical techniques have broadened while the complications noted with ureteropyeloscopy have actually decreased significantly.

The application of flexible fiber ureteroscope was first reported by Marshall in 1964. A 9F fiberscope manufactured by American Cystoscope Makers (Pelham Manor, NY) was passed into the ureter to visualize an impacted ureteral calculus. Subsequently, Bagley, Huffman, and Lyon began work at the University of Chicago to develop an improved flexible fiberoptic ureteropyeloscope in the 1980s.

The optical system consists of fiberoptic light bundles created from molten glass. Each glass fiber is cladded with a second layer of glass of different refractive index to improve the internal reflection, light transmission and also the durability of the endoscope. When the fibers are bundled randomly, they provide excellent light transmission for illumination, but no image. However, if the fibers are placed in a coherent fashion, the light from each fiber will coalesce to transmit images. Small lenses placed proximally and distally enable a telescopic effect with image magnification, increased field of view and focusing ability. A recent modification is the splitting of the light bundle distally to enable a more central placed working channel and better distribution of light within the working field of view.[5]

The deflection mechanism of the flexible ureteroscope permits maneuverability within the collecting system of the kidney. This deflection is usually provided by several wires running down the length of the endoscope and attached to a lever which is manually operated. Manipulating the lever will deflect the tip. If the tip moves in the same direction of the lever, the defection is described as “intuitive”- i.e. down is down and up is up. In the past, prior to 1992, deflection was active at the tip and secondary deflection along the shaft was passive. To obtain lower pole access, the urologist would maximally deflect and advance the tip of the endoscope.[6] The secondary deflection was achieved by the endoscope passively buckling at a set designed point along the shaft. In 1992, Karl Storz (KSEA, Tuttilegan, Germany) was able to downsize the flexible endoscope from 9.8 Fr to 7.5 Fr while maintaining the same 3.6 Fr working channel. This milestone event allowed all urologists to more easily pass the endoscope and in so doing broaden the therapeutic applications. The current instruments have continuous controlled dual deflection with increased downward and upward deflection up to 270 degrees, referred to as “exaggerated deflection” in both directions. This deflection is performed with a single more ergonomic lever as compared to the cumbersome two separate levers employed by the ACMI DUR 8 (Gyrus Inc, London, England). The radius of deflection is also broader, thereby enabling more maneuverability and permitting placement of instruments in the lower pole. The most modern endoscopes also incorporate a shock absorbing system (a form of secondary deflection) which is located proximal to the active deflecting system and allows for gentle rolling of the distal end for approximately ten centimeters enabling access more deeply into the calyces.[7]

The working channel permits placement under direct vision of a variety of accessories including graspers, baskets, wires and laser fibers through the endoscope. All current endoscopes have a channel of at least 3.6 Fr which allows the use of instruments up to 3 Fr while still permitting concurrent irrigation. The composition material of the accessory influences tip deflection. For example, graspers and baskets with a shaft composed of polyamide tend to be stiffer and inhibit deflection as compared to Teflon sheathed accessories.[8]

Many ureteroscope repairs are due to damage to the working channel from malfunction or incorrect use of the holmium laser. This is often a technical issue when the fiber firing end is located too close to the endoscope tip. The new-generation Storz endoscopes incorporate a bead-like sequence of hollow ceramic rings in the distal end of the working channel for 1.5 cm. This protects the instrument from thermal or electrocautery damage and allows the endourologist to work closer to the tumor, stricture or stone while using laser energy.

White and Moran reported the need for major urteroscope repairs after only 12 endoscope usages.[9] Afane et al., demonstrated that flexible ureteroscopes from four major manufacturers required major repairs after only 15 procedures or 13 h of usage.[10] Traxer et al., from Paris performed 50 flexible ureterosopies using the Karl Storz Flex-X ureteroscope. They evaluated the maximal active ventral and dorsal deflection, irrigation flow at 100 cm H20 and number of broken optical fibers. The maximal ventral deflection deteriorated from 270 degrees initially to 208 following the last procedure; the maximal dorsal deflection decreased from 270 to 133 degrees. The irrigation flow at 100 cm H20 decreased from 50 to 40 after the last procedure. They concluded that the need for repair occurred less frequently with the newer generation endoscopes and when used by an experienced endourologist.[11] In general most centers can employ these instruments for approximately 50 cases between repairs with damage and breakage occurring most often during sterilization.

Irrigating fluids are employed to clear the optical field of view and to cool the tip of energy-delivering devices. The irrigant is delivered through the same channel used for working instruments, often through a side arm adapter (Urolock – Boston Scientific, Natick Mass. and Check flow, Cook Urologic, Spencer, Indiana). The simplest and most cost-effective means of delivering continuous irrigant is to employ two 60 cc syringes connected to a three-way stopcock with arterial line tubing. Normal saline is the irrigation standard solution for diagnostic ureteral stent and lithotripsy. When electrocautery is employed sorbitol or small aliquots of sterile water may be used.[12]

In a recent prospective study of 460 consecutive upper-tract endoscopies at our center, “no-touch” direct access ureteroscopy (i.e. placement of the endoscope into the ureter under direct vision without the assistance of a guide wire and without dilation) was successfully performed in the majority of patients. This wireless form of flexible digital ureteroscope system or “no touch technique” is technically challenging but eliminates the potential trauma, mucosal irritation and inadvertent manipulation of stones or tumors caused by guide wires and is particularly helpful when mapping the collecting system for mucosal lesions or upper tract transitional cell cancers.[20]

The major complication rate associated with therapeutic visual ureteroscope series has decreased markedly and currently occurs in less than 1% of all procedures. As with the minor problems, major complications occur less frequently for basically the same reasons – better surgeon skills and improved instrumentation. However, when they do occur treatment is often more complex. In addition to major intraoperative problems, other complications that occur during upper urinary tract endoscopy may begin as minor events and, if left untreated or if addressed incorrectly, can progress to more serious conditions.

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