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In vitro studies have evaluated a biogel polymer that is delivered using a 3F ureteral catheter above the stone to occlude the more proximal ureter allergy medicine reactine order clarinex 5mg line. The triblock polymer of polyethylene oxide is a liquid at low tem- Chapter 35 Ureteroscopy Working Instruments 391 retrieval of stones in hard to reach calyces and stone release if needed [42] allergy medicine benadryl buy cheapest clarinex. However other investigators have reported that this affords no advantage for either stone capture or release [43] allergy symptoms wasp sting order 5mg clarinex mastercard. It has been proposed that they provide a better ability to grasp and release the stone [44] allergy quotes sayings buy clarinex cheap online. In addition, it allows rotation of an engaged stone via a rotary wheel on the basket handle, and simultaneous laser lithotripsy, as a 200-m laser fiber can be passed alongside the Halo basket; a technique that is utilized if a stone is too large for removal down the ureter. These two devices are of particular interest in cases of entrapped ureteral or renal stones where laser lithotripsy prior to stone capture cannot be accomplished. This endoscope offers superior deflection and irrigation characteristics, in particular when larger 2. A comparative study of available flexible ureteroscopes showed that the Wolf Viper provides superior irrigant flow, and better visualization through the unique fused quartz bundle compared to glass fiberoptic bundles [49]. The absence of optic fibers in the shaft of the flexible scope allows for better deflection and simplifies the instrument, which may lower costs, and improves maneuverability and durability [54]. The authors concluded that Ureteral balloon dilators Ureteral balloon dilation is utilized in approximately 5% of cases, when the ureteral access sheath will not advance to the site of pathology due to ureteral stricture, spasm, or a tight ureteral orifice. Ideally, a ureteral balloon would dilate to 100% of the expected diameter regardless of any amount of radial constrictive force. The Bard X-force balloon dilator, the only balloon rated to 30 atm inflation pressure, was not evaluated in this study. Flexible ureteroscopes (see also Chapter 34) Current flexible ureteroscopes offer increased lower pole access through exaggerated active deflection compared to older passively deflecting scopes. Some achieve this by incorporating separate dual-lever primary and secondary active deflection that offers increased unidi- 392 Section 3 Ureteroscopy: General Principles exerted the least impulse on a stone, decreasing the likelihood of dislocating the stone during the endoscopic surgery [58]. Though pressurized saline bags were not as efficient at clearing the operative field, they did result in less migration than hand-held or foot pedal devices. Disposable flexible ureteroscopes A new cost-effective technology is available for retrograde access to the upper urinary tract, based on the premise of a single-use flexible endoscope, which eliminates the need for sterilization between cases. Basically, the disposable flexible ureteroscope comprises a reusable 10 000-pixel fiberoptic attached to a hand-held with a deflection lever, detachable light source, and irrigation source. For every new case a sterile 8F sheath is snuggly advanced over the fiberoptic shaft, keeping the later from touching the patient. This sterile sheath contains a 3F working channel and is capable of being deflected along with the fiber optic. Investigators are developing iron-oxide microparticles that bind to the calcium component of stones and provide the opportunity for expeditious extraction with a magnet-tip retrieval device [59]. These are a few futuristic concepts that may lead to better outcomes for the patient and facilitate the procedure for the endourologist. Driven by innovation, endourology will remain a dynamic field, with evolving improvements towards the best clinical practice. Endoirrigation systems the passage of instruments through the working channel of a flexible ureteroscope can significantly decrease irrigant flow and result in poor visualization. Gravity with or without the assistance of pressure-bag compression is commonly utilized. With the use of a ureteral access sheath, intrarenal pressures can be maintained below 30 cmH2O even with systems pressurized to 200 cmH2O [57]. Alternatively hand-held, foot pedal, or automated irrigation systems may be utilized. The Boston Scientific single-action pump is a 10-mL vacuum syringe that has one-way valves that provide automatic refill of the syringe for immediate access to irrigation fluid. Recently, an in vitro study evaluated the impact of stone migration with each system as well as the efficiency of irrigation to clear the operative field of blood, as measured by number of pulses and duration of irrigation. Intramuscular and blood pressures in legs positioned in the hemilithotomy position: clarification of risk factors for well-leg acute compartment syndrome. Best practice statement for theprevention ofdeep vein thrombosis in patients undergoing urologic surgery. Effects of lithotomy position and external compression on lower leg muscle compartment pressure. Characterization of intrapelvic pressure during ureteropyeloscopy with ureteral access sheaths. Prospective randomized comparison of 2 ureteral access sheaths during flexible retrograde ureteroscopy. From bench to ureteroscopy: a comparison of ureteral access sheath physical properties. Physical characteristics of next-generation ureteral access sheaths: Buckling and kinking. Ex vivo comparison of four lithotriptors commonly used in the ureter: what does it take to perforate Experimental utilization of the holmium laser in a model of ureteroscopic lithotripsy: energy analysis.

This perforation occurred at the end of instrumentation due to surgeon error while retracting the robotic catheter in the flexed position allergy forecast charlottesville va purchase clarinex overnight. At autopsy allergy forecast akron ohio order clarinex visa, significant extravasation of irrigant was found in the retroperitoneum and peritoneal cavity in all five animals allergy shots gain weight buy clarinex 5 mg mastercard. Following this modification allergy testing joplin mo cheap clarinex 5mg free shipping, ureterorenoscopy was performed in an additional animal and no retroperitoneal extravasation of irrigant at autopsy was observed. Furthermore, in the same animal, the measured volume of outflow (irrigant + urine) was slightly higher than the volume of inflow, thereby indicating adequacy of irrigant drainage. Endoscopic and fluoroscopic views can be seen simultaneously on the same or adjacent screens on the workstation. Patients with solitary unilateral renal calculi measuring from 5 to 15 mm in size were included. The mean visual analog scale rating (from 1, worst, to 10, best) for ease of stone localization was 8. Complications included pyelonephritis in two patients, pyrexia in one patient, and temporary positional limb paresis in one patient. There was negligible fluid absorption, based on calculated inflow and egress and on ethanol fluid absorption testing. The robotic catheter system was introduced manually into the renal collecting system under fluoroscopic guidance over a guidewire. A calculus in the right kidney was located and fragmented with a holmium laser by the surgeon comfortably seated at the robotic workstation far from the radiation source Future directions the results of the initial porcine experiments and clinical trial are encouraging, although considerable refine- A B Figure 48. The system used for these experiments was not specifically designed for endourologic applications. Whether or not industry will invest in this is dependent largely on market forces, and not so much on technologic limitations. The ideal diameter of the outer sheath and consequently the other components is a matter of much debate. Remote robotic control of irrigation flow rate, introduction of wires, baskets, graspers, and laser fibers, as well as injection of iodinated contrast can potentially be incorporated into the system. Further refinements in robotic technology have the potential to provide additional benefits, such as automated movements and realtime surgical navigation utilizing realtime as well as archived imaging studies. Potential advantages of robotic ureteroscopy include precise control of the scope as well as enhanced stability, superior ergonomics, and decreased radiation exposure. The cost of ownership of the system for endourologic use is not known at this time since the system is not commercially available at this point. Nevertheless, it appears likely that the role of flexible catheter-based robotics in urology and other specialties is poised to expand for various intraluminal, transluminal, and laparoscopic applications. Further studies are necessary to determine the future role of emerging flexible robotic technology in surgical endoscopy. Initial experience with remote catheter ablation using a novel magnetic navigation system: magnetic remote catheter ablation. Novel robotic catheter remote control system: feasibility and safety of transseptal puncture and endocardial catheter navigation. Remote robotic ureteroscopic laser lithotripsy for renal calculi: initial clinical experience with a novel flexible robotic system. Over the years lithotripsy has undergone several waves of technologic advance, but with little change in the fundamentals of shock-wave generation and delivery. That is, lithotripters have changed in form and mode of operation from a user perspective, and in certain respects the changes have been dramatic, but the lithotripter pressure pulse is still essentially the same. Lithotripters produce a powerful acoustic field that results in two mechanical forces on stones and tissue: (1) direct stress associated with the high amplitude shock wave; and (2) stresses and microjets associated with the growth and violent collapse of cavitation bubbles. Recent research has made significant advances in determining the mechanisms of shock-wave action, but the story is by no means complete. What fuels this effort is the realization that a totally safe, yet effective lithotripter has yet to be developed. In the past few years, manufacturers have started to widen the focal zone of their lithotripters, a move that takes advantage of new findings on the mechanisms of stone breakage with the potential to improve performance (see Focal zone of the lithotripter, below). The perfect lithotripter may not exist, so urologists are left to determine how best to use the machines at hand. Our aim is to give the background necessary to appreciate how the design features of a lithotripter can affect its function. We also present a synopsis of current theories of shock-wave action in stone breakage and tissue damage and summarize recent developments in lithotripter technology. It can be seen that both waveforms have a form that is common to all shock waves used in lithotripsy: a high amplitude compressive phase of extremely rapid transition (<1 ns) and short duration (1 s) followed by a trailing tensile phase (3 s). In this case the amplitude of the peak positive pressure of the electromagnetic lithotripter is 2. Further, the spatial dependence of the pressure field is also machine and setting specific and this will be discussed below.

In the case of uric acid stones allergy medicine zantac order clarinex 5 mg otc, patients may be prescribed a urinary alkalinizing agent to dissolve any remaining fragments allergy symptoms lilies 5 mg clarinex with visa. Common indications for unplanned admission post procedure include flank or bladder pain not manageable with oral analgesics allergy testing zurich buy generic clarinex 5mg on-line, fever allergy medicine green bottle cheap clarinex 5 mg with amex, urinary retention, or significant hematuria. In addition, management of the uncommon procedural complications of ureteral perforation or avulsion account for a small percentage of admissions. In common with other planned outpatient procedures, late procedure start times and social circumstances precluding early discharge may result in overnight admission [1]. Many Antibiotics Patients are often prescribed antibiotics following surgery to prevent infection. The decision on whether to prescribe antibiotics should balance the risk of infection with the risk of adverse effects of antibiotics and the induction of antibiotic-resistant bacterial strains. Alpha-antagonists for stone expulsion Alpha-antagonists inhibit smooth muscle contraction and have been used extensively in the treatment of benign prostatic hyperplasia. In the endourologic world, they have found two further purposes: as medical therapy to facilitate stone expulsion and to relieve ureteral stent symptoms. The theory underlying these observations is relaxation of ureteral smooth muscle to allow ureteral stones to pass, and in the case of stents, to prevent ureteral spasm. This is done by inhibiting selective alpha(1)-adrenergic receptors and reducing ureteral contractility [11, 12]. Medical expulsive therapy has been found to increase the stone passage rate as well as hasten the time to stone passage, and reduce pain, narcotic requirement, and hospitalizations for renal colic [13, 14]. The number needed to treat in this analysis was only 4, indicating that this is a worthwhile and effective treatment for ureteral stones. Most studies have evaluated stones in the distal ureter, but what about proximal ureteral stones A study evaluating stone passage rate in patients administered placebo versus tamsulosin also found an increased stone passage rate, as well as quicker stone passage time in those given tamsulosin with proximal ureteral stones [16]. Stones between 5 and 10 mm tended to migrate into the distal ureter more readily in those patients given the alpha-blocker (39. A randomized placebo controlled trial evaluating tamsulosin, terazosin, or doxazosin found equal rates of stone passage among all medications [17]. Different alphablockers, including the alpha (1A) selective antagonist, silodosin, and the alpha (1D) selective antagonist, naftopidil, have also been shown to inhibit ureteral contrac- Table 46. In cases where there is a low risk of infection, then the utility of postoperative antibiotic prophylaxis becomes less clear. As mentioned above, there is no guideline or strong evidence in the literature for using antibiotic prophylaxis in the postoperative period. Analgesics Analgesics for renal colic and passage of fragments the options for treating postoperative pain range from the commonly used analgesics, which target pain at the central nervous system, to medications that target specific receptors in the urothelium. Naftopidil has been used clinically for stone expulsion with positive results, yielding a spontaneous stone passage rate of 90% versus 27% in controls for an increased probability of stone expulsion of 5. Analgesics for stent-related pain Phenazopyridine and oxybutynin have been administered orally in an attempt to relieve stent-related symptoms. A trial involving 60 patients randomized to phenazopyridine, oxybutynin, or placebo recorded the following measures: narcotic use, flank pain, suprapubic pain, urinary frequency, urgency, dysuria, and hematuria [20]. There was a trend, although statistically insignificant due to the small group numbers, for a reduction in narcotic usage in the oxybutynin group. Phenazopyridine significantly reduced the amount of hematuria patients had on postoperative day 1 compared to placebo. Perhaps a larger study would discern if either of these medications would be helpful in relieving stent symptoms. It would appear that alpha-blocker administration post ureteral stent insertion is an excellent way to prevent and relieve symptoms. Stented patients with botulinum toxin A experienced significantly less pain than controls and required less narcotic usage. This lends evidence to the theory that detrusor muscle spasm around the intramural ureter is a cause of ureteral stent pain. Most interestingly, the stent used in this study was a multilength ureteral stent [23]. There is a belief that more significant material in the bladder leads to more significant symptoms, but there are no randomized clinical data to support this anecdotal belief. The future and feasibility of delivering botulinum toxin A to patients with ureteral stents cannot be foreseen, but there is good evidence that it helps relieve stent symptoms. In addition, the vast majority of patients treated on a "stentless" basis have no obvious preprocedure predictor of subsequent flank pain or obstruction. Supporting the role of postprocedure ureteral stenting is the study by Borboroglu et al. However, the overall cohort of unstented patients had substantially less flank pain. Although the avoidance of a postprocedure ureteral stricture is commonly encountered in the literature as a justification for ureteral stenting, the meta-analysis of randomized controlled trials by Nabi et al. While some studies have shown fewer symptoms and less pain in those patients without a stent, a meta-analysis found a trend towards fewer urologic Table 46. Ureteral perforation intraoperatively Ureteral dilation greater than 10F (either coaxial or balloon dilator) Significant ureteral edema due to stone. The Polaris stent is a dual durometer stent with a stiffer renal curl to prevent migration, but a softer curl in the bladder in an attempt to decrease bladder irritation and symptoms.

Additionally allergy medicine homeopathy clarinex 5 mg with visa, posterior calyces offer the shortest access path to the collecting system [3] allergy shots one time generic 5mg clarinex. Needle 208 Section 2 Percutaneous Renal Surgery: Selection of Access and Dilation punctures should be directed along the axis of the renal calyx through the center of the renal papilla to avoid infundibular or renal pelvic puncture allergy symptoms to shellfish purchase 5 mg clarinex amex. The concern for intrathoracic injury following upper calyceal access is secondary to the close relationship of the upper kidney to the lungs and pleura food allergy symptoms 2 year old generic 5mg clarinex visa. The upper portions of both kidneys are located anterior to the posterior portion of the 11th and 12th ribs. A review of 90 normal supine intravenous urograms during full expiration noted that 85% of upper renal calyces are located above the 12th rib [5]. In the prone position, further cephalad movement of the kidney occurs in 80% of patients [6]. Despite controlled maximal expiration, this cephalad movement results in an estimated likelihood of lung injury following supracostal access of 29% on the right side and 14% on the left [7]. The posterior diaphragm arises from the distal ends of the 11th and 12th ribs, the tip of the L1 transverse process, and the anterior aspect of the upper lumbar vertebral body [8]. During full inspiration, the posteroinferior margin of the lung expands to fill the posterior costophrenic recess. During expiration, the lung retracts and the pleura ascends cranially and laterally on the ribs [9]. The lower limit of the posterior parietal pleura crosses the 12th rib obliquely near the lateral border of the erector spinae muscles. In the midscapular line, the visceral pleura has a similar relationship at the 10th rib [10]. The initial needle puncture for a supra-12th rib access is advocated at maximal expiration and lateral to the erector spinae muscles in the 11th and 12th interspace to avoid lung and pleural injury. Supra-11th rib access can be performed in a similar fashion between the 10th and 11th rib interspace [11]. Using biplanar fluoroscopy, we perform either the "bullseye" or "triangulation" technique for percutaneous access. The bullseye technique is described in Chapter 13 and here we will detail our supracostal approach using the triangulation technique. Triangulation technique For upper calyceal access, we generally prefer a puncture site within the 11th and 12th intercostal space, just lateral to the erector spinae muscles. Following identification of the targeted upper pole calyx under fluoroscopy, the triangulation technique is started with an 18G diamond-tipped access needle puncture in the inferior border of the 11th rib at the skin (Figure 16. The needle is angled acutely so that it enters at the center of the intercostal space, thus avoiding the intercostal nerve and vessels of the 11th rib. Biplanar fluoroscopy is performed using the C-arm in two positions, anteroposterior and oblique. Ventilation is suspended in full expiration as the access needle is advanced towards the desired calyx. The C-arm is maintained in the oblique position in order to gauge the depth of puncture. At the onset of the procedure, the patient is placed in the dorsal lithotomy position. Using rigid cystoscopy, we place a 5F open-ended ureteral catheter to allow opacification of the renal collecting system. A chest roll is placed horizontally to facilitate ventilation, with the neck maintained in a neutral position. An additional roll is used to slightly elevate the side of interest in order to align the posterior calyces in a more vertical position. Particular attention is given to properly pad all pressure points Chapter 16 Upper Calyx Access for Percutaneous Nephrolithotomy 209 Figure 16. Simultaneous retrograde instillation of contrast via the open-ended catheter allows for collecting system opacification and identification. After entry into the renal calyx, aspiration of fluid is performed to confirm the needle position in the collecting system. If entry to the ureter is prohibited, the wire is coiled in the renal pelvis or in the calyx that is accessible and furthest away from the calyx of puncture. An 8F fascial dilator and subsequently a 5F Cobra-tipped angiographic catheter are sequentially passed over the glidewire in order to facilitate wire positioning in the ureter. A second standard guidewire is placed as a safety wire into the ureter and secured to the drape following placement of an 8/10F coaxial dilator over the super-stiff wire. A NephroMax balloon is advanced over the super-stiff wire until the radio-opaque marker is noted just inside the collecting system. Some patients, such as those with complete staghorn calculi, may require additional access into a different calyx following initial percutaneous tract placement in the upper calyx. In this situation, the Amplatz sheath is left in the upper pole while working through the second access tract in order to prevent excessive extravasation from the upper pole calyx into the pleural cavity. At the conclusion of the procedure, fluoroscopy is performed over the ipsilateral chest and lung fields to exclude the presence of hydrothorax. In the operating room, a pigtail catheter is inserted into the chest under fluoroscopic guidance in patients noted to have significant hydrothorax or pleural effusion. Patients who are symptomatic or for whom there is concern for a hydrothorax in the postoperative period are followed with an upright chest X-ray in the recovery room and monitoring of clinical respiratory vital signs.

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