Complications of Ureteroscopic Approaches, Including Incisions

18 Complications of Ureteroscopic Approaches, Including Incisions Farjaad M. Siddiq, MD and Raymond J. Leveillee, MD CONTENTS INTRODUCTION PREPARATION FOR URETEROSCOPY URETERAL ACCESS DILATION OF THE URETERAL ORIFICE: IS IT NECESSARY? COMPLICATIONS OF URETEROSCOPY URETERAL STENTS: ARE THEY NECESSARY? POSTOPERATIVE IMAGING COMPLICATIONS OF URETEROSCOPIC MANAGEMENT OF UPPER TRACT TCC COMPLICATIONS OF URETEROSCOPIC INCISIONS CONCLUSION REFERENCES SUMMARY Ureteroscopy has progressed from cystoscopic examination of a dilated ureter in a child in 1929 and the initial use of rigid ureteroscopes in the 1980s, to its current state of small caliber semirigid and flexible instruments. In this chapter the authors review complications of ureteroscopy including those associated with incisional techniques where one would anticipate a higher incidence of complications. They review the his- tory and development of modern ureteroscopes, focusing on engineering advances. Clinical points made include proper patient selection and preparation; proper use of dilators, wires, and ureteral access sheaths; and the incidence, identification, and management of complications associated with ureterorenoscopy (both intraopertively and postoperatively). Key Words: Ureteroscopy; calculi; urinary stones; stricture or ureter; urothelial carcinoma; surgical complications. From: Advanced Endourology: The Complete Clinical Guide Edited by: S. Y. Nakada and M. S. Pearle © Humana Press Inc., Totowa, NJ 299 300 Siddiq and Leveillee INTRODUCTION Ureteroscopy has progressed from cystoscopic examination of a dilated ureter in a child with posterior urethral valves by Young and McKay (1) in 1929 and the initial use of a rigid ureteroscope by Perez-Castro Ellendt and Martinez-Pineiro (2,3) in the early 1980s, to its current state of small caliber semirigid and flexible instruments. In addition, there has been a concurrent improvement in endoscopic lithotrites and other ureteral access and interventional accessories. This has facilitated retrograde endoscopic diagno- sis as well as therapeutic intervention for a multitude of upper tract disease processes. Indeed, while the most common application of ureteroscopy remains the management of urinary calculi, treatment of strictures, upper tract transitional cell carcinoma (TCC), and essential hematuria has become commonplace. Although ureteroscopy has come to be considered a relatively benign procedure with an acceptably low complication rate, major and minor complications do occur. This chapter provides a summary of various complications associated with ureteroscopic access, treatment of calculi, TCC, and strictures, as well as historical perspectives on the trends in complications of ureteroscopy since its inception. In addition, technical hints to prevent complications and manage them once they occur will be offered in a timeline extending from patient selection and preoperative preparation to long-term postoperative care. PREPARATION FOR URETEROSCOPY Sepsis, active urinary tract infection, and untreated bleeding diatheses are absolute contraindications to ureteroscopy. All patients should have sterile preoperative urine cultures. In addition, broad spectrum prophylactic antibiotics covering common geni- tourinary pathogens should be administered. In most instances, the use of sufficient anesthesia is critical. Although general anesthesia is preferred, use of local anesthetic with sedation may be adequate in some situations. For therapeutic procedures, we pre- fer a general anesthetic as a sudden move by a lightly sedated patient can be cata- strophic with the ureteroscope in situ. Although regional anesthesia (i.e., spinal) may be safely utilized for distal ureteroscopic procedures, it may not provide adequate analgesia during ureterorenoscopy where renal distention may occur. URETERAL ACCESS Access failure prohibits ureteroscopy and is a significant complication. The initial step once the patient is anesthetized and positioned is cystoscopy followed by a retrograde pyelogram to “roadmap” the collecting system. Care must be taken at this seemingly simple initial step as trauma to the ureteral orifice or intramural mucosa may make sub- sequent ureteroscopy difficult. Ureteral orifices may be difficult to visualize, much less canulate, in men with large intravesical prostates. Even if the ureter can be accessed and a wire placed, “J-hooking” of the distal ureter may preclude the insertion of a ureteroscope. Further, the angulation between the bladder neck and the ureteral orifice may be too severe to negotiate with a semirigid ureteroscope. In this situation, attempting to straighten the ureter with a super-stiff wire or using a flexible ureteroscope may be helpful. Women with large cystoceles offer a similar challenge. These ureters, nevertheless, can be canulated if the bladder is lifted transvaginally. Previous pelvic or retroperitoneal surgery or radiation therapy can fix the ureter in the deep pelvis. This increases the risk of perforation significantly, particularly when a rigid instrument is used. Orthopedic abnormalities and contractures, which limit hip mobility and contralateral lower extremity Chapter 18 / Complications of Ureteroscopic Approaches 301 Fig. 1. (A) Scout film demonstrates two large distal ureteral calculi, known to be present for several months. (B) Retrograde ureterography demonstrated failure of contrast to bypass the obstructing calculi. (C) The Glidewire coiled at the level of the stones and could not be passed proximally. (D) Ureteroscopy was performed up to the level of the stone, but the Glidewire could not be placed. In order to avoid ureteral trauma, no further attempts at retrograde manipulation and ureteroscopy were hyperflexion, may hinder the introduction of a ureteroscope. Previously reimplanted ureters, ectopic ureters, and duplicated ureters may be difficult to access as well. If the ureteral orifice can be identified and accessed, a floppy tipped guidewire should be placed in the renal pelvis under cystoscopic and fluoroscopic guidance. If resistance is encountered, other options should be sought. The wire should never be forced. On occasion, if a mucosal flap has been raised, the guidewire may need to be placed under vision through a ureteroscope. Ureteral stricture, ureteral tortuosity, or an impacted stone may hinder insertion of a wire or ureteroscope. A hydrophilic Angled Glidewire (Terumo, Japan; Microvasive, Boston Scientific Corporation, Watertown, MA) is relatively atraumatic and may safely negotiate a strictured or tortuous ureter. Once wire access is obtained, the stricture can be dilated and the wire exchanged with a super-stiff wire through a ureteral catheter to straighten a tortuous ureter. Impacted stones may be negotiated by injection of lidocaine jelly into the ureter (4). However, systemic absorption of the lidocaine must be considered. An Angled Glidewire may be helpful. This can be exchanged with a stiffer and more secure wire prior to lithotripsy. The exchange may be facilitated by an angled hydrophilic Glide Catheter (5). Nevertheless, if contrast does not bypass the obstruction, it is unlikely that a wire will 302 Siddiq and Leveillee Fig. 1. (Continued) Chapter 18 / Complications of Ureteroscopic Approaches 303 Fig. 1. (Continued) find the right path (Fig. 1). In this instance, aggressive wire manipulation will only lead to ureteral trauma. A safety guidewire should be in place prior to instrumentation. This will allow stent placement in case of ureteral injury. If a wire cannot be placed, further ureteroscopy should not be attempted. Percutaneous renal access or extracorporeal shockwave lithotripsy (in case of stone disease) remains an option in case of failed ureteroscopic access. DILATION OF THE URETERAL ORIFICE: IS IT NECESSARY? Although routine ureteral dilation was necessary for ureteroscopy using the early model larger (>10 Fr) ureteroscopes, this “dogma” has been brought into question with the advent of smaller caliber rigid and flexible ureteroscopes. Prior to the advent of balloon dilators, ureteral dilation was performed with serial dilators. Sequential fascial dilators, bougies, or olive-tipped dilators were often used and dilation to 16 to 18 Fr was necessary to allow introduction of the larger ureteroscopes. The shearing forces applied by these dilators often resulted in linear tears of the mucosa and significant tissue trauma. High-pressure balloon dilators have largely replaced these dilators. Most commercially available balloons are 4 to 10 cm long and inflate to 4 to 6 mm in diameter (12–18 Fr). They are placed over a wire under fluoroscopic and cystoscopic 304 Siddiq and Leveillee guidance, taking care to remain distal to the stone if one is present. If the balloon is deployed alongside the stone, the stone may become impacted or may be extruded through a perforation. Further, the balloon may be ruptured by a sharp stone. The balloon can also rupture with overinflation or if the inflation is performed too rapidly. This can be severely traumatic given the pressure (18 atm/~265psi) under which contrast will exit through a “pinhole” resulting in bleeding, mucosal tearing, and extravasation. Mucosal injury is less likely with slow radial balloon dilation until the “waist” is elim- inated, never exceeding manufacturer specified tolerances. Garvin and Clayman (6) demonstrated no strictures and a 20% incidence of transient vesicoureteral reflux from balloon dilation of the ureteral orifice to 24 Fr at 6 weeks. Nevertheless,

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