Nephroscopy & Ureteroscopy

Obstructing ureteral stones are notorious for causing severe pain. Stone related pain is caused renal colic. Most female patients describe the pain as being worse than child birth.

The pain results from back pressure in the kidney rather than than the direct effect of the stone on the ureter. Stones that are low down and in the process of passing into the bladder may cause urinary frequency and urgency - very similar to symptoms of a bladder infection.

Nausea and vomiting are common with stones.

Stones may incapacitate a person. Therefore, there are some professions in whom the presence of any stone, even if not causing symptoms may results in loss of occupation or reassignment. This includes airplane pilots and those in the military.

Stones may cause a number of diseases, some of which are life-threatening including:

1. Urosepsis and stones. The most serious complication of stone is obstruction by stone in the presence of infection. The can result in urosepsis - a condition where bacteria seed directly from the urinary tract into the blood stream. This may result in septic shock, multiorgan failure (including irreversible injury to multiple organs) and death. This may occur even in previously health patients and is a true urological emergency.

2. Infectious stones. While most stones are unrelated to infection, struvite stones are a direct consequence of infection. The infection cannot be eradicated until the stone is removed. The types of complications for struvite stones tend to not be as profound as with urosepsis but gradual scarring in the kidney and chronic illness may result.

3. Renal failure. Obstruction of both kidneys, a solitary kidney or one kidney when the other kidney is compromised may results in renal failure. This may be life-threatening. Diabetics and patients with poor health are most at risk. The injury to the kidney may become permanent.

4. Bleeding. Stones may cause visible hematuria. While rarely serious, the bleeding may result in anemia.

Endoscopy of the urinary system has several variants. It is not uncommon to use a couple of different instruments and sometimes multiple approaches.

1. Retrograde or antegrade: the scopes can be placed from the

2. Bottom up - in the reverse direction to the normal flow of urine = RETROGRADE. There is no cutting required. This is the most common approach by far - used for the majority of stones in the ureter.

3. Top down - in the normal direction of urine flow = ANTEGRADE. This requires going through the parenchyma of the kidney - and hence a small cut is necessary to introduce the scope through the skin. The most common type of procedure using this approach is called a Percutaneous NephroLithotomy (PNL) for stone. This is also rarely used to remove tumours of the collecting system.

Rigid or flexible scope.

The instruments that are used for this type of surgery depend on the goals and the underlying anatomy. In general, rigid scopes are more durable, have better clarity (optics) and have larger working channels (which allows larger instruments and greater flow of irritant). Their obvious disadvantage is that they are rigid - that is, they don't really bend. If the ureter is too curvy or if the surgery is being done from anywhere upstream of the ureter (that is, the renal pelvis and calyces) and the approach is retrograde then a flexible scope is required.

While there are obviously lots of different variations of these surgeries, there are a three common general approaches. 

1. Retrograde rigid/flexible ureteroscopy for ureteral stone

2. Retrograde intrarenal surgery (for stone)

3. Percutaneous Nephrolithotomy

Nephrouerteroscopy is used to relieve obstruction and the complications caused by obstructing stones.

The American Urological Association and Endourological Association recommend uretroscopy as the primary treatment for stones within the mid-distal ureter and for all ureteral stones that are not visible on plain film (these are difficult or impossible to target with shock wave lithotripsy). 

While obstruction of the kidney can be observed for up to 4-6 weeks with little risk of permanent injury, intervention is sometimes necessary. In general, surgery is indicated if a stone fails to pass within 4-6 weeks after it became obstructing, a complication develops (see Consequences of Stones) or if the symptoms are intolerable. When a stone is highly unlikely to pass (e.g. because it is large) then intervention may be undertaken sooner. Patient preference also plays a role.

Here are the reasons for proceeding with stone surgery:

• Intractable symptoms: pain, nausea, vomiting are intolerable and not controllable with medication

• Obstruction and infection. Surgery must be undertaken promptly as this is a life-threatening combination.

• Kidney failure.

• Prolonged obstruction - anything over about a month is felt to put the kidney at risk for irreversible injury

• Low probability of stone passage despite observation

Surgery has the benefit of relieving symptoms and preventing or reversing complications of stone when they are present (see above).

There are inherent risks with all surgery. Please see the description of risks below.

The options available to address stones fall into 2 general categories.

1. Medical expulsive therapy (MET).

2. Surgical intervention.

Medical expulsive therapy is an attempt to see if the stone will pass on its own. Several factors help predict the chances of stone passage including location (lower down is better), size (smaller is better) and duration of obstruction (stones that have not moved in several weeks may be impacted).

There are several options for surgical intervention. The preferred treatment takes into account stone location, stone size, stone composition and hardness, stone configuration, urgency of treatment, ease of access, patient preference and resource availability.

• Mid-distal ureteral stones: ureteroscopy is the recommended treatment. ESWL is a reasonable alternative but is less effective because of difficulty with targeting stone in the ureter and the presence of the pelvic ‘acoustic wall’ for distal stones.

• Extracorporeal shock wave lithotripsy. Can be utilized for stones in the kidney and ureter. Lower success rates. Largely limited to smaller renal and upper ureteral stones.

• Percutaneous nephroureteroscopy

• Percutaneous nephrolithotomy (PNL) is an option for large intrarenal stones. Highest single treatment success rate but associated with higher risk of complications including urine leak and urinoma (1:500), adjacent organ injury (e.g. colon 1:200) significant bleeding requiring transfusion (1-2:20), loss of kidney.

In cases where infection is present, the standard of care is antibiotics plus either stenting (internal drainage) or percutaneous nephrostomy (external drainage) and then to come back in 1-2 weeks after the infection has settled.

You will be provided a date and told to which medications to hold or continue. In general, patients may take all of their regular medications until the time of surgery with the EXCEPTION that you MAY be asked to stop blood thinners (anticoagulants and platelets) 3-7 days prior to surgery.

We will make arrangements for any necessary consultation and tests prior to surgery.

Patients coming for emergency surgery after hours or on weekends should review the how this works:

COMMUNITY EMERGENCY SURGERY INSTRUCTIONS

How the process works

• We contact the operating room and submit the requisite paperwork.

Please note that we cannot guarantee a time for surgery. Your case will be completed at the earliest available time taking into account availability of the operating room, your position in line for surgery and medical need. Some patients may be waiting for a few days for their surgery. We ask people waiting on the emergency list to be patient and considerate of the needs of others.

An anesthesiologist will discuss options for pain control during surgery along with risks and benefits of the various approaches. Please direct questions about the anesthetic to them. They will help you decide which anesthetic option is best for you. Whatever type of anesthetic you decide upon you should not experience pain during the surgery.

Ureteroscopy is usually done as an outpatient/day-care surgewry procedure in the hospital. People can usually go home 1-2 hours after completion. In some cases patients require admission for one or more day.

Most cases are done with a general anesthetic.

A 'general anesthetic' will put you completely asleep and you will be unconscious during the surgery.

A 'spinal anesthetic' freezes the area from the abdomen down but allows you to remain awake (something can be given to make you drowsy if you like). You are feel free to observe on the operating room screen but please keep conversation to a minimum.

The patient is positioned on their back with legs held in stirrups.

Surgery usually takes about 30 minutes and is done in the operating room.

There is not cutting with the procedure. Instruments are passed ‘upstream’ starting at the urethra - no new passages are created. The scope is passed to the level of the stone using video and fluoroscopy (motion X-ray) to ensure the stone is safely removed.

Larger stones are fragmented with a laser (Thulium or Holmium) into smaller stones to allow spontaneous passage of dust/debris or retrieval with a basket.

A stent (temporary 'straw' left within the ureter and not visible externally) may be left for a few days to a few weeks. A stent may NOT be left if the following criteria are met:

• No suspected ureteric injury during URS

• No evidence of ureteral stricture or other anatomical impediments to stone fragment clearance

• Normal contralateral kidney, those without renal functional impairment.

• No plan for a secondary URS procedure.

STENTS ARE TEMPORARY AND MUST ALWAYS BE REMOVED. FAILURE TO REMOVE THE STENT MAY RESULT IN SERIOUS COMPLICATIONS INCLUDING LOSS OF THE KIDNEY.

We may leave a ureteral stent which is a roughly 24 cm long temporary internal plastic straw. These facilitate drainage of urine and passage of stones fragments. If left in place, you will be informed.

When a stent is left in place, there will be 2 options for removal:

1. Pulling the string attached to the stent. In situations where the stent is required for less than a week we may leave a string attached and tape that string to your penis (for men) or area above the pubic bone (for women). Remove the stent on the date instructed by pulling the string in a smooth continuous motion. The stent will slide out easily.

2. Cystoscopy. For stents we plan to leave for more than a week, we will arrange for a cystoscopy to remove the stent. This is done at the hospital in ambulatory care. No preparation is necessary and the procedure usually takes 1-2 minutes.

Stents that are not removed in a timely manner (within 3-6 months of placement) may encrust. Encrustation is the formation of stone around the stent which typically requires shock wave therapy or other surgery to break to stone up prior to removal of the stent.

Patients may experience some incontinence as urine tracts along the pull string. You may require a small pad until the stent is removed.

TEMPORARY: usually days, but may last for weeks or until the ureteral stent is removed (if one is left after surgery).

All patients will have pain or discomfort following surgery. It may be severe immediately following the surgery but generally improves substantially over the first few hours. The types of symptoms that are normal and which should resolve include the following:

Back pain: virtually everyone will have some pain on the side(s) of their surgery lasting from a day or two to a couple of weeks following the procedure. In patients with ureteral stents, the back pain may become worse during urination as a result of reflux (back wash pressure) up the stent.

Urinary frequency, urgency, and inability to get to a bathroom in time (urgency and urgency incontinence). These are more common if a stent was left in position.

Dysuria: discomfort or burning with passage of urine.

Nausea: common following anesthetic and surgery. Should resolve in hours.

Incontinence: small amounts of urine leakage may occur in patients who have a stent to which a pull string is attached. The urine may track along the stent. This will resolve after the stent is removed. A small piece of tissue will usually be enough but wear a diaper or pad if necessary.

The ureter is a delicate small tubule and may be injured during attempted removal of the stone. The ureter itself is more prone to injury when the stone has been impacted for some time, the stone is in the upper ureter, if it is large and requires more manipulation.

Ureteral injury takes several forms with the incidence of serious injuries being less than 1%.

1. Perforation. A hole in the ureter may result from injury from the laser discharge, passage of the scope or guidewire. Leakage of urine may result. Large stones that have been impacted (stuck) for long periods of time may increase the risk as will conditions predisposing to poor tissue health (chronic steroid use, connective tissue diseases, etc.)

2. Laceration. This is a tear in the ureter - larger than a simple perforation. Usually occurs when an access sheath is utilized. The ureter may split open longitudinally, usually over a few centimeters.

3. Avulsion. This is when the ureter is torn apart and is by far the most serious complication of upper tract endoscopic surgery. This may result in loss of the kidney and always results in the need for a reconstructive surgery which will generally require a large incision. The risk of this type of injury is in the range of 1:500 to 1:1000.

4. Stricture. This is a scar that forms in the ureter. This may result from the stone itself or the surgery to remove the stone. These usually present on a delayed basis weeks to months after surgery and is one of the reasons for imaging following surgery. Often can be managed without major surgery (e.g. with endoureterotomy) but may take many months to resolve.

Every attempt is made to avoid injury, them most important is having a low threshold to ‘back out’, stent and come back another day.

Fortunately, most injuries can be managed by placement of a stent for several weeks while the ureter heals. In some cases reconstructive surgery is required and very, very rarely the kidney can be lost because of irreparable injury.

Prophylactic antibiotics are often given. Some types of stones harbour bacteria which can be released with stone fragmentation.

The risk of post-operative urosepsis is up to 5% despite prophylactic antibiotics. They are more common in females and those with a history of urinary tract infection.

Minor bleeding is very common - in fact virtually everyone has some blood in the urine for a few days after the surgery and everyone with a stent has periodic bleeding until the stent is removed. Major bleeding from the ureter or from the kidney can occur but is rare.

Blood/clot and debris in the urine. Expect this for as long as the stent is in place. It clears in a few days in most people but may last a couple of weeks in others - especially if you are on blood thinners or antiplatelet agents.

Ureteroscopy has the highest success rate for a single procedure for removal of stone - over 90%. However, large stones and those that are higher in the ureter may require more than one procedure. In some cases, the ureter is too small to accept the stone or the stone may be pushed back into the renal pelvis. Your urologist will determine if it is best to place a stent for 1-2 weeks and come back. The presence of a stent in the ureter will allow it to 'open up' (passively dilate) around the stent such that in most cases the second procedure will be successful because there will not be an issue with passage of the scope.

When there are very large stones in the kidney greater than 1.5 cm in diameter, the need for repeat surgery rises significantly (may be as high as 50%). However, most patients find the risk of nephroureteroscopy more acceptable than percutaneous nephrolithotomy (PNL).

Some men, especially those with pre-existing urinary obstruction, may require a temporary urethral catheter to drain the bladder. Any surgery the passes through the lower urinary tract or requires an anesthetic may worsen pre-existing obstruction to the point where a man man not be able to urinate.

If urinary retention happens after surgery, head to your nearest emergency for placement of a catheter and contact the office during business hours.

If you are taking prostate medications (e.g. Flomax, tamsulosin), ensure that your restart these after surgery.

In rare circumstances, the urinary retention may not resolve despite medication and repeat trials of void. Surgery with TURP may be required.

Advance to usual diet as tolerated. Avoid foods which constipate you.

Drink enough water to keep your urine reasonably clear, usually 8-10 glasses of water per day. This will also flush out any debris.

You can resume your regular diet and fluids as soon as you leave hospital. Feel free to drink coffee, tea, etc. unless you think it is causing you to urinate more frequently or causing pain (it causes no problems in most patients).

Be sure you are able to have easy bowel movements, as straining on a constipated stool may worsen symptoms.

Get up and about as soon as possible after surgery.

Walk as tolerated.

You may resume exercise and normal activity once you feel well enough to do so.

You may start showering anytime.

You may have a ureteric stent in place (tube inside the passage from kidney to bladder).  Symptoms related to the stent (see “what to expect”) may be triggered by vigorous activity or even constipation.  If this is the case, please limit your activity until the stent is removed – usually within a couple of weeks.

Take and medications as prescribed. Not all patients are prescribed antibiotics as you will have received a prophylactic dose prior to surgery.

Use prescription pain medication as needed. Non-steroidal anti-inflammatories (NSAIDS) such as Celebrex, Voltaren and Advil/Ibuprofen tend to work best.

Take a stool softener (obtain over the counter at local pharmacy) starting the night of your surgery. Stop taking stool softeners once having soft bowel movements. not take stool softeners if diarrhea occurs.

You may resume taking your regular medications when you leave the hospital unless instructed otherwise.

Patients who undergo surgery of any kind may need acute medical care during their recovery and are subject to temporary risks directly related to the surgery. Please note that the medical conditions that form the reason for such surgery also pose a number of specific risks.

We advice patients who undergo ureteroscopy to have readily accessible medical care for about 6 weeks following the procedure. For patients who develop a complication, this time may be longer.

Travel in country: Patients are generally able to travel by car or plane within days of surgery. They should have easy access to a washroom and follow the instructions as listed above. No heavy lifting, drink fluids and urinate frequently.

Travel out of country: The same advice any travel pertains here but it is very important that you have a good understanding of how you might obtain medical assistance while out of the country. Please review your travel insurance policy and we strongly recommend that you understand what disclosures are necessary under that policy. We are unable to ‘clear you for travel’ or determine if you are eligible for travel insurance but are happy to complete any forms that are necessary for the insurance company to assess your application or claim. Fees will apply.

Please note that most travel insurance policies require full disclosure of all pre-existing medical conditions and any recent changes (including but not limited to surgery and medications). Failure to disclose such information may render your policy void.

We recommend you speak with the insurance company and/or consult a lawyer to answer any questions you have.