- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
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406 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
Complications of PCNL |
with working channels to introduce fragmenta- |
|
|
|
tion and retrieval instruments. |
Leaving aside failed access, there a number of |
X-ray screening in theater is mandatory for |
|
potential complications which warrant mention. |
ureteroscopy. Initial placement of a guide wire |
|
PCNL tracts can bleed significantly at the time of |
ensures safety and allows placement of a stent if |
|
surgery or in the immediate postoperative period |
difficulties ensue. These wires should always be |
|
with a quoted transfusion rate of up to 6%.Acute |
placed under x-ray control. This ensures the |
|
bleeding is managed by tamponade of the tract |
wire is taking an appropriate course and if the |
|
with a nephrostomy tube. This can be supple- |
stone is visible, checks can be made to ensure |
|
mented by clamping the drain if bleeding per- |
the stone is not inadvertently pushed proximally. |
|
sists with the intention of promoting clotting |
Ideally, the wire should be placed beyond the |
|
within the system.If these conservative measures |
stone into the renal pelvis. If the wire cannot be |
|
fail, vascular radiological intervention with a |
negotiated past the stone, then a hydrophilic |
|
viewtoembolizationisthenextstep.Nephrectomy |
wire may be tried or a hybrid wire with a hydro- |
|
is rare but not unknown. Delayed bleeding |
philic tip may be used. If a hydrophilic wire is |
|
(<0.5%) suggests pseudoaneurysm or develop- |
used, it is recommended that it is changed for a |
|
ment of an A–V fistula with vascular emboliza- |
standard wire as soon as possible using an |
|
tion being the treatment of choice.The possibility |
exchange catheter as these wires are notorious |
|
of septicemia should be considered if the patient |
for falling out. |
|
is unwell in the immediate postoperative period. |
A number of techniques are available for |
|
Other tract-related complications include pleu- |
negotiating the ureteric orifice with the uretero- |
|
ral injury with hydrothorax or pneumothorax. |
scope. With the wire in situ, it may be relatively |
|
There is a complication rate of up to 16.3% for |
straightforward to access the ureter. The config- |
|
upper pole punctures compared to the lower pole |
uration of some ureteroscopes allows easier |
|
approach at 4.5% and the rate is strikingly higher |
insertion if the ureteroscope is rotated through |
|
after supra 11th rib punctures at 34.6% compared |
180 so that the smoother beak glides over the |
|
to 9.7% for the supra 12th rib approach with spe- |
trigone. Pushing the ureteroscope against the |
|
cific intrathoracic complication rates being 23.1% |
wire can tent the ureteric orifice open, but |
|
and 1.4%, respectively. A chest drain will be |
passage of a second wire is extremely useful if |
|
required for most thoracic complications.6 |
the surgeon is struggling. With one wire within |
|
Other adjacent structures may be at risk with |
the instrument channel and the other wire out- |
|
colonic injury being the most prevalent. |
side, the ureteroscope is rotated to“separate” the |
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Fortunately, these tend to settle conservatively |
wires and passage is achieved by aiming for the |
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as the injury is retroperitoneal. The nephros- |
gap between them. This technique is also invalu- |
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tomy drain often acts as a suitable drainage tube |
able to safely negotiate difficult areas with the |
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and if there are concerns that there may be a |
ureter. A number of ureteric dilatation devices |
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higher than usual chance of this injury, using |
are available commercially, but they are used |
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ultrasound at the time of puncture can be help- |
infrequently due to the narrow caliber of modern |
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ful in avoiding bowel. This complication is seen |
ureteroscopes. One of the major principles of |
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most frequently in thin patients and is com- |
ureteroscopy is that whenever resistance is |
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moner on the left side. |
noted, the safest course of action is to insert a |
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Retained fragments of stone can cause prob- |
ureteric stent and come back another day. This |
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lems particularly if they migrate into the ureter |
prevents major complications and should never |
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where they can obviously cause obstruction. |
be viewed as a failure. It must be remembered |
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that some ureteroscopes are graduated with a |
Semirigid Ureteroscopy |
larger caliber nearer the hilt. In a narrow ureter, |
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it is therefore possible for there to be no prob- |
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lem with tightness at the tip of the scope but the |
The first retrograde endoscopic examination of |
proximal scope can be gripped by ureter. The |
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the ureter using a specifically designed endo- |
ureter in this area can be concertinaed upward |
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scope was described by Perez-Castro Ellendt |
if the ureteroscope is advanced further with the |
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and Martinez-Pineiro in 1982.7 |
potential for avulsion of the ureter for the |
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Modern instruments have evolved with the |
unwary. If the operator feels that the scope is not |
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use of fiber optics allowing finer caliber scopes |
moving freely, stenting is strongly advised. |
407
thE rolE of intErvEntional ManagEMEnt for Urinary tract calcUli
Flexible Ureteroscopy
Modern flexible ureteroscopes have tip sizes of around 7–8 Fr and working channels of 3 Fr.They have active two-way deflection of a least 180° and secondary passive deflection which increases the potential for deflection further when the scope is deployed within the renal pelvis. All of the upper urinary tract is potentially reachable and a variety of flexible accessories and laser fibers are available to aid stone management.
As with all ureteroscopies, x-ray screening in theater and the use of guidewires are considered standard when using the flexible instrument. Some advocate the use of two wires, one for safety and the other as a working wire. The presence of a second wire can on occasions cause the ureter to become crowded. The introduction of the flexible scope can be a challenge, but access sheaths can be of use particularly if there is a need for repeated reinsertion of the scope. Access sheaths when deployed up to the kidney have the additional advantage of allowing flow of fluid around the scope with a resultant reduction in intrarenal pressure and a better view.8
When introducing the access sheath over a guidewire, it is important to position the image intensifier over the bladder in order to ensure that the access sheath does safely negotiate the ureteric orifice. If this step is omitted and the direction of the access sheath is not precise, advancing the sheath into the bladder can inadvertently cause the guidewire to flip out of the ureter. The same advice is appropriate if instead of using an access sheath, the scope is advanced into the ureter over the guidewire. This prevents the ureteroscope coiling into a loop within the bladder.
Intracorporeal Stone
Fragmentation Devices
Electrohydraulic Lithotripsy (EHL)
Although largely superseded, EHL has the advantage of excellent efficacy. The shock wave is generated by discharge across a coaxial probe ranging in size from 1.4 Fr to 5 Fr. A gaseous bubble is produced by the spark which vaporizes a small volume of water.
Within the confines of the ureter, however, the EHL device is potentially dangerous as any contact with the urothelium at the time of discharge inevitably leads to ureteric perforation with a complication rate of up to 15%. EHL can similarly damage the optical system of the endoscope.
Ultrasound
Safer than EHL, ultrasound may be used both within the ureter and percutaneously within the kidney. The stone is fragmented by transmission of high-frequency vibration through a rigid metal probe. The transfer of this vibration drills into the stone. This technology has largely been superseded for use within the ureter where the heat generated was an issue, but still has a role in percutaneous surgery where it has the distinct advantage of the sheath permitting suction of small fragments.
Ballistic Lithotripsy
In many ways the safest form of intracorporeal lithotripsy, this technique involves pulses of pressurized air propelling a mobile metal pellet within the handpiece onto a solid metal rod. The probes are produced in a number of sizes including those small enough to be used with modern ureteroscopes. Although efficacious, there is the potential for propulsion of the stone further up the ureter and possible loss of stone into the kidney. There is minimal danger to the urothelium and therefore if a ureteric stone is impacted and surrounded by urothelium, ballistic devices have significant advantages. Used percutaneously, ballistic devices are efficacious and have advantages over other techniques as the fragments generated are larger and more efficiently removed from the kidney.
An alternative to the lithoclast is electrokinetic lithotripsy. The principle is similar but the electromagnet within the handpiece moves the metal bearing.
More recently, a combination instrument has been introduced with both standard ballistic lithotripsy and ultrasound. As the latter has integral suction, this device is particularly useful at PCNL for large renal stones.9
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408 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
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Laser Lithotripsy |
grabbers with a range of configurations such as |
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tri-radiate forceps. |
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A number of lasers have been applied to stone |
Obviously, it may be tempting to basket a |
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fragmentation but the most notable is the |
stone without any attempt at fragmentation |
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Holmium YAG device. With a wavelength of |
and while this may be appropriate for the small- |
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2,100 nm, this pulsed dye laser fragments stones |
est of stones, it should be remembered that if |
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efficiently using heat. As the energy is rapidly |
stone is too small to pass spontaneously, it may |
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absorbed in water, it is ideal for endourological |
be too large to simply basket. Blind dormia bas- |
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use. The depth of penetration is of the order of |
keting of ureteric stones via a cystoscope is |
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0.4 mm and although pinpoint damage to the |
inappropriate. |
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urothelium is easily seen, with care, this device |
Trying to remove an unrealistic stone with a |
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is safe. As the laser fibers are flexible, they lend |
basket passed runs the potential risk of the |
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themselves to use with the flexible ureteroscope |
major complication of ureteric avulsion which |
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and the modern prominence of flexi URS is |
would require open repair. If a basket having |
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largely due to its combination with laser tech- |
engaged a stone becomes stuck, any thoughts of |
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nology which has opened up this technique for |
pulling hard must be resisted. The situation is |
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effective stone management within the kidney. |
easily resolved by dismantling the basket and |
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The laser is able to break stones into tiny frag- |
removing the ureteroscope. The scope is then |
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ments within the system and it is entirely rea- |
reinserted effectively using the basket as a guide |
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sonable to avoid the uses of stone retrieval |
wire. Any fragmentation device can then be |
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devices altogether. There is a danger of boring |
used to conveniently fragment the stuck stone |
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holes through larger stones and the technique |
with the advantage that the basket’s presence |
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advised is to allow the fiber to “dance” across |
minimizes any chance of retrograde propul- |
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the stone surface to avoid this. The size of frag- |
sion. It should be noted that although laser |
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ments and relative slowness makes the holmium |
technology is very useful in this circumstance, |
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device less useful with PCNL, unless flexible |
the Holmium laser will damage the wires of the |
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scopes have to be deployed to deal with stones |
basket in the same way as it will damage |
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in less accessible areas. |
guidewires. |
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If there is evidence of injury to the ureter dur- |
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Endoscopic Management |
ing the course of ureteroscopy other than full |
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avulsion then a stent can be placed over the |
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of Ureteric Stones |
guidewire. If there is doubt about the integrity |
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of the ureter, then radiographic contrast can be |
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injected via the irrigation channel of the instru- |
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The most commonly utilized intracorporeal |
ment to check this. Small perforations, trauma |
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lithotrites used with the ureteroscope are the |
to the urothelium, and small laser burns are eas- |
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Holmium YAG Laser and the lithoclast. Within |
ily managed by stenting without any concern for |
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the ureter, the holmium device (using a 365 mm |
long-term sequelae. |
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fiber) has the advantage of reducing the stone |
The flexible ureteroscope is a useful addition |
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to very small fragments with minimal risk of |
to the endourologist’s armamentarium in man- |
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propulsion of the stone. Effectively this energy |
aging ureteric stones. An obvious indication for |
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source will fragment all calculi. If there is con- |
its use is when a ureteric stone is inadvertently |
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siderable edema or mucosal growth around the |
allowed to migrate back into the kidney. When a |
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CALCULUS, ballistic devices using a 0.8 mm |
stone lies within a capacious ureter, there can be |
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probe may be safer. These tend to fragment |
difficulty in deploying the laser onto the stone |
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the stone into larger fragments and there is a |
with the semirigid instrument and going flexible |
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risk of retrograde propulsion of the stone. A |
can help. Other uses include where there has |
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number of equipment manufacturers market |
been significant prior reconstructive surgery to |
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devices which can be deployed within the ure- |
the urinary tract, with resulting anatomy pre- |
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ter to prevent the stone floating back into the |
cluding passage of the semirigid scope. Laser |
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kidney. |
technology is a prerequisite for stone fragmen- |
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A variety of stone retrieval devices are avail- |
tation when the flexible ureteroscopes is |
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able. These include an array of stone baskets and |
deployed using a 200 mm fiber. |
409
thE rolE of intErvEntional ManagEMEnt for Urinary tract calcUli
Ureteric Stents
These are frequently used in a wide range of endourological procedures and are widely utilized for safety after ureteroscopy where they can be invaluable. Although mandatory after a complicated ureteroscopy, routine stenting after all interventions is not advised.Although those complications such as obstruction which may necessitate a further intervention are avoided, in a straightforward case severe postoperative complications are unusual. Stents have significant symptomsforpatientswithqualityoflifeconsequences10 including frequency, urgency, hematuria, loin pain, and infection. The forgotten stent can be a disaster requiring endourological ingenuity to resolve the consequences. In addition, the presence of a stent does not facilitate ESWL in situ for ureteric stones and will not aid stone passage.11
Endoscopic Management
of Renal Stones
When approached percutaneously, ballistic devices with probes up to 2 mm are ideal for fragmenting renal stones. As large stone fragments are generated these are efficiently removed with retrieval devices. The temptation to fragment the stones to very small fragments must be resisted. Ultrasound is also recommended particularly because of the added advantage of suction and the hybrid ballistic/ultrasound device has the advantages of both. There is little place for using lasers with the rigid nephroscope as it is not only time consuming but there is a propensity for the laser to bore holes through the stone rather than causing efficient fragmentation.
The flexible ureteroscope is a useful addition to the established techniques of PCNL and ESWL for renal calculi.11 It is perhaps not the first choice therapy but has a role in the following scenarios.
First, for smaller renal stones which have been refractory to lithotripsy as a result of inability to target or failure to fragment. It can be indicated for larger stones where PCNL is undesirable (e.g., morbid obesity or patient fitness) or to manage multiple scattered renal stones. Clearly a very flexible fragmentation device is required. Fine (1.4 F) EHL probes are available, but the combination with laser technology has popularized flexible ureteroscopy.
Consideration should be given to injecting contrast into the pelvicalyceal system through the ureteroscope to give the operator a road map of the anatomy. There are difficulties in orientation when using the flexible instrument, but this is easily resolved by using the imagine intensifier rather than depending on the endoscopic view to move around the system systematically. The overriding principle of using the laser to fragment renal stones is to keep the instrument straight when introducing the fiber. If this safety maneuver is ignored, the damage to these delicate instruments is inevitable. The only way to be certain that the ureteroscope is straight is to use screening. This means, on occasions, deflecting the scope to locate the stone then losing position to insert the laser and then finding the stone again. The laser fiber does cause some loss of flexibility of the scope and can make fragmentation difficult. Many of these problems can be eased with small stones if they are picked up with grabbers or nitinol tipless baskets and relocated into an easier position in the renal pelvis or upper pole.
These are frequently used in a wide range of endourological procedures and are widely utilized for safety after ureteroscopy where they can be invaluable. Although mandatory after a complicated ureteroscopy, routine stenting after all interventions is not advised.Although those complications such as obstruction which may necessitate a further intervention are avoided, in a straightforward case,severe postoperative complications are unusual. Stents have significant symptomsforpatientswithqualityof lifeconsequences12 including frequency,urgency,hematuria,loin pain and infection.The forgotten stent can be a disaster requiring endourological ingenuity to resolve the consequences. In addition, the presence of a stent does not facilitate ESWL in situ for ureteric stones and will not aid stone passage.10
Outcome of Treatment
of Renal Stones
There is still a role for conservative therapy for small (0.5 cm) nonobstructing renal stones. The majority of simple renal stones less than 1.5 cm in size are appropriate for ESWL as first-line therapy with success rates for simple stones in excess of 80%.