Last Updated on Sep 13, 2020

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.

Ureteroscopy

Ureteroscopy - Anatomy & Function

The organs, tubes, muscles, and nerves that work together to make, store, and carry urine make up the urinary system. The urinary system consists of two kidneys, two ureters, the bladder, and the urethra.

"Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep without immediate danger to survival. But should the kidneys fail...neither bone, muscle, gland nor brain could carry on."Dr. Homer Smith in his book, "Fish to Philosopher."

Kidneys perform vital functions and many other organs in our body depend on the kidneys in order to function. A person normally has two kidneys, one on either side of the back under the lower ribs. They are shaped like kidney beans hence called “kidneys”. Each kidney is about 4 to 5 inches long and 2 to 3 inches wide. Each kidney is made up of small, complex units called nephrons. The two kidneys contain about two million nephrons. The nephrons work continuously to filter out waste products from the blood stream, all of which come from the food that one eats and the fluid that one drinks.

Kidneys are the master chemists of the body and regulate the amount of water that should stay in the body. The chemicals and wastes that accumulate have to be discarded and kidney tends to do this very precisely. Normally 200 liters of water are filtered through the kidney daily and only about 2 liters are passed as urine.

From the kidneys, urine travels down two thin tubes called ureters, leading away from each kidney to the urinary bladder. The ureters are about 24 – 30 cm long and the thickness is about 3 mm. The muscles in the walls of the ureter constantly tighten and relax to empty the urine from the kidneys. Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.

Ureter is divided into upper, middle and the lower third. It has a long course in the body by the side of the spinal cord. It has three narrow areas where the stones tend to get stuck. These narrow areas include –

Anatomy of the Kidney
  • The junction between the pelvis of the kidney and the ureter.
  • The middle third where it crosses over large vessels of the pelvis.
  • The lower third – where the ureter meets the urinary bladder.
The urinary bladder is responsible for storing the urine produced and for letting it out at regular intervals. It sits in your pelvis and it stores urine until you are ready to empty it. It swells into a round shape when it is full and gets smaller when empty. If the urinary system is healthy, the bladder can hold up to 450 – 500 ml of urine comfortably for 2 to 5 hours.

The nerves in the bladder tell you when it is time to urinate (empty your bladder). As the bladder first fills with urine, you may notice a feeling that you need to urinate. As the bladder fills with more and more urine over a period of time, sensation to urinate becomes stronger. At that point, nerves from the bladder send a message to the brain that the bladder is full, and your urge to empty your bladder intensifies. After the brain has received the signal, it sends back an message to the urinary bladder whether it can let out the urine or not. For example, if you feel like passing urine when you are in a important meeting, you will be able to control your desire to urinate or the urge to pass urine to some degree until it is convenient to pass urine. This is because the brain has given a signal to wait for some time till it is convenient to pass urine.

When it is convenient, the brain signals the muscles of the urinary bladder to tighten which would help to squeeze the urine into the urethra through which the urine is taken out from the body.

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.

Symptom of Kidney Stone - Severe Pain

The pain often begins suddenly as the stone moves in the urinary tract causing irritation and blockage. Typically, the person feels a sharp and twisting type of pain in the area of the kidney or in the lower abdomen, which may spread to the groin.

In a man, pain may move down to the side of the inner side of scrotum whereas in women it may radiate to the inner side of the vulva. If the stone is in the lower ureter or in the bladder the pain maybe felt on the tip of the penis.

Urgency and frequent urinations - If the stone is in the lower end of the ureter, at the point where the ureter enters the opening of urinary bladder, one may feel the need to urinate more often or feel a burning sensation during urination.

Strangury – This is a very distressing symptom that present as painful, frequent urination of small volumes that are expelled slowly only by straining. Sometimes despite a severe sense of urgency, usually with the residual feeling of incomplete emptying remains. Usually seen when the stone is in the lower end of the ureter and bulging out of the orifice to pass out.

Blood in Urine – This is an alarming symptom when the urine appears fully red. This is usually due to the mucosal damage of the ureter due to the spikes in the stone. If this occurs most patients will seeks immediate attention and visit the casualty.

Nausea and Vomiting - The acute pain  may  be associated with nausea and vomiting.

Fever & Chills - If fever or chills accompany any of these symptoms, then there may be an infection. One should contact an urologist immediately as this is an absolute emergency and even more so if you have associated diabetes.

Silent Stones and No Symptoms - Occasionally, stones do not produce any symptoms. But while they may be "silent," they can be growing, even causing damage to the function of the kidney. If the stone is too large to pass easily, pain continues as the thin muscular wall of the ureter try to squeeze the stone along into the bladder.

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.

Plain CT Scan Helps Diagnose 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 X-ray - 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?

The Treatment options for ureteral stones include -
  • Extra Corporeal Shock Wave Lithotripsy(ESWL)
  • Endoscopic removal - Ureteroscopy
  • Laparoscopy removal
  • Or Open surgery
Open surgery is rare for ureteric stones and is only done if there is a complication during the ureteroscopic procedure or if the hospital does not have an expert surgeon or it does not have the required instruments.

ESWL is a procedure where high intensity sound or acoustic waves are used to break the stones. However this will depend on the hardness of the stone, the location of the stone and the type of imaging facility that is available on the ESWL machine. The results are best for stones located in the upper ureter, using x-ray to localize the stone. However, more than one session maybe required for full clearance of the stone.




Extra Corporeal Shock Wave Lithotripsy Helps Treat Kidney 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.

5. Your genitalia or ‘private parts’ will be cleaned and the hair trimmed or shaved on the day before the surgery and you will be given an enema or other drugs, which help you to pass motion freely to keep the bowels empty before the surgery.

Some units do not shave or shave just before the time of surgery or do it in the operation theatre.

What Happens Inside the Operating Room When I 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.

Latest Publications and Research on Ureteroscopy for Stone

Comments

amit2 Friday, November 23, 2012

hi my age is 43yrs and i have stone of 9mm in L1 disc level in left upper ureteric so kindly advise me the proper way to remove stone without surgery

jemini Saturday, November 3, 2012

hi my age is 28yrs and i have stone of 9mm in L1 disc level in left upper ureteric so kindly advise me the proper way to remove stone without surgery

anoop77 Tuesday, November 29, 2011

hi dear sir i have stone in my right side uriter size is 4mm but it is not shown in ultra sound but i have pain too much please suggest me what should i do.

tomar Saturday, November 26, 2011

hi,i am vishal tomar 22m, my stone is 12mm in upper part of urater. tell me treatment.

Aroby Friday, September 9, 2011

My sister had stones, the ER sent her home told it would pass, 2 days later she's back in ER still in serve pain, they gave her more pain killers and sent her home. 2 days after that she's back in ER with sever pain still, each time they did CT scans. This time they tell her, her kidneys have shut down she's in failure, they admit her. 2 surgeys later she comes home. She has had serve pain in her feet and both of her legs are numb. She goes to the docter who says thats a good sign, if it dasn't go away in a few weeks he'll refer her to a Neuro Doc. She is still in terrible pain and is getting referred. My question is, when she had the surgeys could they have cut a nerve or is it damage from the acute kidney failure?

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