Tips & Tricks for Difficult Ureteroscopy

In this episode of BackTable Urology, Dr. Aditya Bagrodia interviews UT Southwestern endourologist Dr. Jodi Antonelli about her tips and tricks for difficult ureteroscopy cases.

First, the doctors discuss the treatment of acute patients presenting with flank pain in the emergency department. In these cases, it is important to obtain a comprehensive patient history complete with vitals, temperature, bloodwork, urinalysis, and appropriate imaging. Indications for intervention include: febrile state, hemodynamic instability, severe pain, and a combination of tachycardia and hypertension. Dr. Antonelli advises urologists to avoid relying solely on urinalysis, as a patient with inflammation may present similar results to one with ureteral stones. In patients who require drainage, Dr. Antonelli prefers to use a nephrostomy tube instead of a stent if the ureteral stone exceeds 1.5 centimeters or if she encounters difficulty in the prostate or bladder anatomy.

For non-acute patients, a trial of passage is recommended if the stone has not occupied an obstructive position for more than 6 weeks. For stone passage patients, Dr. Antonelli prescribes NSAIDS, which she has found to be more effective than narcotics in pain management. If she decides that medical expulsive therapy is appropriate for a ureteral stone patient, she prescribes alpha blockers for both proximal and distal stones. Finally, she notes that relying on the disappearance of symptoms to confirm stone passage is insufficient; before declaring a patient stone-free, imaging, such as a KUB X-ray, must be performed.

If the trial of passage fails, surgical intervention is the next step. Ureteroscopy is an ideal minimally invasive method of extracting ureteral stones. Dr. Antonelli’s pre-operative regimen consists of obtaining a urinalysis and urine culture at least 2 weeks before surgery. She recommends at least 5 to 6 days of culture-specific antibiotics if the patient has a positive urine culture. In the context of the ureteroscopy procedure, Dr. Antonelli emphasizes the importance of being very thorough with ureteroscopy to find tumors in the bladder. Furthermore, Dr. Antonelli discusses her approaches to getting a wire past a difficult stone and dealing with anatomically complex cases that involve large prostates and narrow ureters. She acknowledges that in some cases, the best option is to place a stent to dilate the ureter and attempt the surgery again in the next week.

One method of surgically removing ureteral stones is through the use of a basket. Dr. Antonelli discusses the different basket shapes and manufacturers she prefers to use. However, if the stone is too big or positioned at an unfavorable angle for basket retrieval, dusting the stone is a possible alternative. Although Dr. Antonelli addresses the rapid advancement of dusting laser technology, she also discusses potential risks of dusting--the creation of small stone fragments increases the likelihood of stone recurrence and reduces intraoperative visibility.

The post-operative medications Dr. Antonelli prescribes are: NSAIDS, anticholinergics to help with LUTS, alpha blockers to relax ureter, urinary tract anesthetic, and stool softener. She recommends ordering a post-operative metabolic evaluation, an ultrasound, and a KUB six weeks after surgery.