Tips and tricks of ureteroscopy: consensus statement. Part II. Advanced ureteroscopy.

Our "tips and tricks" focuses on all aspects of upper tract endourology and we hope these will be of use to all trainees and consultants who perform ureteroscopy. We report an "expert consensus view" from experienced endourological surgeons, on all aspects of advanced ureteroscopic techniques, with a particular focus on avoiding and getting out of trouble while performing ureteroscopy. In this paper we provide a summary of placing ureteric access sheath, flexible ureteroscopy, intra renal stone fragmentation and retrieval, maintaining visual clarity and biopsy of ureteric and pelvicalyceal tumours.

Combined antegrade and retrograde endoscopic retroperitoneal bypass of ureteric strictures: a modification of the 'rendezvous' procedure.

OBJECTIVE: To evaluate our experience of treating complicated iatrogenic ureteric strictures with a combined antegrade and retrograde endoscopic retroperitoneal bypass technique, a modification of the so-called 'rendezvous' procedure. PATIENTS AND METHODS: Seven patients presented to our institution between 2004 and 2008 after developing a complicated iatrogenic ureteric stricture, impassable with solitary antegrade or retrograde stenting techniques. In most cases there was a significant loss of ureteric continuity, with some strictures of up to 10-12 cm. After initial temporizing management with a percutaneous nephrostomy, each patient had a radiological 'rendezvous' procedure to insert a JJ stent and restore ureteric continuity. After 6 months, the JJ stents were removed and the patients evaluated by symptom assessment, serial measurements of serum creatinine and diuretic renography (F-15 mercaptoacetyl triglycine). RESULTS: All seven 'rendezvous' procedures were successful and a ureteric stent was inserted across or around the stricture in all cases. Five of seven patients whose follow-up was >6 months had their stent removed successfully. At a median follow-up of 21 months, all patients are alive and none has required subsequent surgery. Six of the seven patients presented with significant symptoms and they are all currently symptom-free, which we consider to be a successful clinical outcome. No patient has developed significant renal impairment (estimated glomerular filtration rate (<30 mL/min) but we could only confirm successful unequivocal renographic drainage in one patient. CONCLUSION: Combining antegrade radiological and retrograde endourological techniques, it is possible to restore ureteric continuity with a JJ stent, even in situations with extensive loss of the ureteric lumen. This reduces the need for morbid open surgical repair and offers a long-term solution to patients who might otherwise be consigned to less favourable conservative measures.

Refractive and reflective image distortion during lower tract endoscopy--a potential cause of misdiagnosis.

Flexible cystoscopy is well established in urological practice. We present a unique image obtained during bladder inspection, illustrating visual refractive distortion, which highlights the potential difficulty in optical interpretation.

Ureteric embolization: an alternative treatment strategy for urinary fistulae complicating advanced pelvic malignancy.

OBJECTIVE: To report experience with a minimally invasive technique for palliation of urinary fistula/incontinence complicating advanced pelvic malignancy or its treatment. PATIENTS AND METHODS: We used ureteric embolization with permanent nephrostomy drainage in eight renal units in five patients for palliation of symptoms. All procedures were done under local anaesthesia as day-case procedures. Nephrostomy tubes were changed at regular intervals on an outpatient basis. Embolization was repeated when required. RESULTS: The follow-up was 2-84 months; four patients died from the underlying malignancy during the follow-up. All patients were continent and had effective palliation of their symptoms. Two patients required repeat embolization. There were no embolization-related complications. CONCLUSIONS: Ureteric embolization is a safe and effective minimally invasive palliative treatment option in urinary fistulae or incontinence complicating advanced pelvic malignancy.

Long-term 5-year followup of the results of the vesica procedure.

PURPOSE: We evaluated the long-term results of Vesica (Boston Scientific Corp., Watertown, Massachusetts) percutaneous bladder neck suspension for stress urinary incontinence. MATERIALS AND METHODS: A total of 40 women with urodynamically proven stress urinary incontinence (SUI) underwent Vesica percutaneous bladder neck suspension between 1994 and 1997. Patients were assessed at 6 months, 12 months and 5 years with a simple questionnaire to elicit whether they had experienced any adverse effects, whether they were dry and whether further investigation or a surgical incontinence procedure was offered. RESULTS: Only 1 of the 40 women was lost to long-term followup. Initial results were excellent with 85% of women reporting complete dryness at 6 months. However, wound infections developed in 16% of patients secondary to hematomas in the suprapubic incisions and 10% required a period of intermittent self-catheterization. By 12 months only 46% of women remained dry, although most only reported occasional leakage. At 5 years 69% of patients had recurrent SUI and more than two-thirds of this group (70%) had symptoms severe enough to be offered a further surgical procedure. Patients undergoing subsequent secondary procedures were found to have fraying of the suspensory sutures at the bone anchor. CONCLUSIONS: Initial results of this minimally invasive procedure were excellent and despite the lack of long-term data the technique rapidly came into widespread use. The 5-year outcome shows a 31% continence rate. We no longer advocate this particular form of bladder neck suspension for SUI.