Operative note 10 Core

Ureteroscopy for ureteric stones

What it does: up the ureter with a thin rigid scope over two wires. Dust the stone.

Cystoscopy first. See the trigone and both orifices.
2 wires. The first is the safety wire: up the centre, to the kidney, under screening. It stays until the end.
Cystoscope out. Semirigid scope in with the second (working) wire through its channel. Wire 2 up the ureter through the scope. It only guides the scope.
Hold both wires gently taut. Railroad the scope over wire 2 to the stone. Advance only under vision. See the lumen always. A semirigid scope barely bends: the ureter straightens over it. The iliac crossing is where it catches.
Orifice too tight? Rotate the scope 180 degrees.
Sheaths rarely help in the ureter.
Finger on the water valve. Minimum flow. Hard flow flushes the stone back to the kidney.
Going over the wire shields the stone.
Stone seen: water off, pull the working wire. Keep the safety wire. Laser or pneumatic in.
Laser tip well clear of the scope lens. Fire against the lens = cracked lens.
Laser: dust it, do not chunk it. Paint the stone. Never leave large pieces in the ureter: they scatter and they do not pass. Dust clouds: wash out, refire.
Let dust and fine fragments clear by gravity. A piece too big to clear: basket it, test the pull first. Resists? Release, laser it smaller. Never drag. Scope and basket come out together, fragment at the tip, wall inspected all the way down. One fragment out is not stone-free: the dust stays to pass.
Stent after if: hole in the ureter, torn mucosa, leftover fragments, dilated stricture, 1 kidney, both sides done, or case over ~45 min.
Simple low stone? No routine stent. (CROES data.)

2026 update: No change. This is still current practice.

Watch: Scope sizes: tip 6 to 8 Fr, shaft 7.5 to 10 Fr, channel 3.6 Fr (or 2.4 and 3.4 Fr), wires 0.035 or 0.038 inch, fibre 200 to 365 micron. Owner-confirmed typical sizes.

Wire will not pass a stone: Catheter up to just below the stone: its support often lets the sensor wire through. No? A little contrast: is the stone blocking? None passes? Terumo hydrophilic wire. Terumo up: follow with the catheter, exchange to a sensor wire. Stenting over a Terumo is hard. Still stuck: call the consultant. Semirigid scope fragments the stone so the wire passes.

JJ over the wire: Four thin black dashes, then the thick band. Band going into the orifice: scope back to the bladder neck. Push till the golden pusher tip shows. Stop. Wire out completely. Curl in the kidney on the screen. In the bladder the stent's own end drops and curls on the base: one open coil in line with the shaft, not a separate loop out of the orifice. Lateral orifice: right side arrow to 3 o'clock, wire angles to 9; left side arrow to 9, wire to 3.

Catheter will not go up the orifice: Guidewire through the ureteric catheter, soft tip just beyond the end. Lead the tip into the orifice. The catheter follows over it. Contrast on the screen only: it is not seen through the scope.

From the UroRef Operative Quick Guide.