Ureteroscopy + laser lithotripsy

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Watch the two wires: the teal safety wire goes up first, the white working wire through the scope. The card under the animation gives the scope, channel and wire sizes.

Operative steps

1. Bladder view: cystoscopy and the safety wire A septic or obstructed system is drained first and the stone left for another day; the urine is known to be sterile or the infection treated before any scope goes up. Cystoscopy is performed and the bladder surveyed: the trigone, both orifices, the left one the target. A 0.035 inch safety wire is advanced up the orifice under fluoroscopy, its course read against each narrowing, until it curls in the renal pelvis. It is the centre wire, placed first, and it stays for the whole case, so that whatever happens to the scope, the stone or the wall, access to the upper tract is never lost. Its position is confirmed on screening before the cystoscope comes out.
2. Second wire through the semirigid scope, tent and railroad The semirigid ureteroscope goes in with a second, working wire already through its channel and is brought to the orifice beside the safety wire. The working wire is advanced up the ureter through the scope; it exists only to guide the scope and is withdrawn once the stone is seen. With both wires held gently taut the ureter tents and straightens, and the scope is railroaded over the working wire with every level of the lumen entered under direct vision. The physiological narrowings each announce themselves as a catch and are crossed by withdrawing slightly, realigning and advancing, not by pushing. A tight orifice yields to rotating the scope through 180 degrees; a sheath rarely helps in the ureter. Never advance against resistance: that is how the wall tears.
   where it bites: never advance against resistance - that is how the wall tears.
3. Laser: dust it, never chunk it The working wire is pulled once the stone is in view and the safety wire kept. The holmium or thulium fibre is passed down the working channel and advanced a short distance beyond the scope before firing, its tip kept visibly on the stone and off the mucosa and well clear of the lens. Irrigation is kept to a trickle so the stone is not flushed back to the kidney. The stone is dusted at low energy, face by face, painted rather than cracked. Never fragment in the ureter into large pieces: they scatter, they do not pass, and they invite the pull that avulses. Firing on the wall rather than the stone perforates within seconds.
   where it bites: firing on the wall, not the stone, perforates within seconds.
4. Clearance: gravity first, basket if needed Dust and fine fragments are left to clear downwards by gravity and the trickle of irrigation. A fragment too big to clear on its own is taken with a nitinol basket opened beyond the scope, one piece at a time, and drawn back only after the test before any pull: the engaged piece comes to the scope tip without the basket bowing or the wall dimpling. One representative fragment goes for analysis. A fragment that resists is released and lasered smaller, never pulled. Pulling an over-large fragment in a basket is the classic route to avulsion, and it happens at the thin proximal wall where nothing can be repaired from below.
   where it bites: pulling an over-large fragment in a basket is the classic route to avulsion.
5. Exit + selective JJ stent The scope is withdrawn under vision with the whole length of the ureter inspected on the way out for a tear, a flap or extravasation. An uncomplicated ureteroscopy needs no routine stent; one is placed over the safety wire under screening for wall injury, oedema, residual fragments, bleeding, infection, a solitary kidney or uncertain drainage. Its length is matched to the patient and the treated segment so neither coil sits under tension, the wire is withdrawn under screening as the proximal coil forms, and the position is confirmed by the distal coil seen in the bladder and the proximal coil on the screen rather than assumed. Every stent leaves theatre with a removal date written in the note and the stent register, because a forgotten stent is the complication that follows the operation home.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance