Ureteroscopic laser fragmentation of kidney stone

What is Ureteroscopy?

Rigid Ureteroscopy (RURS) is a treatment option for stones in the ureter and Flexible ureterorenoscopy is a treatment option for kidney stones.It is performed under general anaesthesia. The thin telescopes allow a minimally invasive telescopic access to the ureter +/- kidney and are designed to allow visualisation of the stone which can then be fragmented using a Holmium-YAG laser. The resultant fragments are then washed out (dust) or removed with a fine basket device (fragment). The procedure often also involves the use of Xrays and the insertion of a soft plastic tube (stent) between the kidney and the bladder. This allows drainage of the kidney to ensure stone fragments pass. Unless there are medical reasons or there is no adult at home on the evening of surgery, the majority of patients are treated as a daycase and are admitted to and discharged from hospital on the same day. Working with the various healthcare providers, Manchester Urology have constantly innovated and are keen to embrace technological advances to the benefit of their patients. Not only do Manchester Urology have access to Flexible Ureterorenoscopes, which not all private providers do, but they are one of the few practices in the North of England to offer the improves optics associated with digital ureterorenoscopy.

What are the alternatives?

Your Manchester Urology stone specialist will discuss the pros and cons of all the treatment options available to you. These may include:

Observation – This is attractive to many patients as it doesn’t expose them to any potential risks associated with intervention. However, this benefit must be weighed against the level of symptoms experienced and the chance of any stones passing spontaneously from their position in the ureter or if they moved to the ureter from the kidney in the future. Not only can stones that block the drainage from the kidney cause pain but poor drainage can predispose to infection or deterioration in kidney function. 

Lithotripsy – Offers a less invasive option than ureteroscopy without the need for anaesthesia however the patient/treatment pathway may be longer than that for ureteroscopy.

Percutaneous Nephrolithotomy (PCNL) – is often reserved for larger and more complex stones and boasts superior stone free rates in a single treatment session but again requires general anaesthesia and whilst still regarded as a minimally invasive technique, is the most invasive of all the options.  

Having decided on Ureteroscopy, what can I expect?

Having discussed the procedure in detail with your Manchester Urology stone specialist, you will be given a date to attend for a pre-op assessment and subsequently for admission. The pre-op assessment identifies any medical issues that are impritant for the anaesthetist and is an opportunity to undertake blood and urine tests ahead of the surgery. On the day of surgical admission, you will be greeted by the hospital staff and shown to your private room. It is helpful to attend with a comfortably-full bladder in case any further urine samples are required. Ladies may also be required to have a urinary pregnancy test. You will be reviewed by one of the Manchester Urology stone specialists and the procedure discussed again and the consent process completed.

You need to be nil by mouth for 6 hours prior to the procedure but can drink water ONLY up to 2 hours before the procedure. Within two hours of your admission time you must not eat or drink anything or your surgery may have to be postponed.

Whilst you are asleep, the surgeon will insert a telescope into the bladder through the water pipe (urethra). Under X-ray guidance, a flexible guidewire will be inserted into the tube that runs to the kidney (ureter), on the affected side. A longer telescope will then be guided by the wire and passed up to locate the stone(s). The stone(s) will be disintegrated using a laser and the fragments extracted with special retrieval devices. A ureteric stent is normally left in place, together with a bladder catheter, after the procedure.

What can I expect after the treatment?

After the treatment, the Manchester Urology stone specialist will give you an initial impression of how the treatment went and you will be given instruction about what to do should you have any problems after the procedure and a provisional plan made for follow up Xrays, scans or further review/treatment. You will be offered painkillers to take home with you and sometime antibiotics.

Are there any side-effects?

Most procedures have possible side-effects. But, although the complications listed below are well-recognised, most patients do not suffer any problems.

Common (greater than 1 in 10)

• Mild burning or bleeding on passing urine for short period after operation.
• Insertion of a stent with a further procedure (under local anaesthesia) to remove it usually 4-7 days later.
• Stent symptoms – stents may cause pain, frequent urine passage and bleeding in the urine. Recurrence of stones in the future.

Occasional (between 1 in 10 and 1 in 50)

• Failure - it may not be possible to retrieve the stone due to a narrow ureter, or stone displacement into an inaccessible site in the kidney.
• Kidney damage or infection needing further treatment.

Rare (less than 1 in 50)

• Damage to the ureter, with need for an open operation or tube placed into kidney directly from back (nephrostomy) to allow any leak to heal.
• Scarring or stricture of the ureter needing further procedures to widen it.

What can I expect at home?

It is your responsibility to make sure you are fit to drive following your surgery. You do not normally need to tell the DVLA that you have had surgery, unless you have a medical condition that will last for longer than three months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving.

It is common to see blood in the urine for 48-72 hours after the procedure though this may not entirely settle until the stent is removed. It is advisable that you drink plenty of fluids to try and flush the stone fragments and clear the urine. If you develop a fever, severe pain, you cannot pass urine or your bleeding increases, you should seek medical advice immediately. Small blood clots or stone fragments can pass down from the kidney, resulting in kidney pain. This is a sign that the stone is attempting to pass yet it is advisable you seek medical attention if you have intolerable pain despite painkillers or the pain is associate with a temperature.

It is very important that you know whether there has been a stent placed and if so, when the plan is to have it removed. There are two methods employed to remove stents. Firtly, a flexible cystoscope (telescope) may be passed down the urethra to the bladder and a grasper used to remove it. Secondly, strings attached to the stent may be left hanging outside the body and taped to the lower abdomen, groin or penis. These can be used to remove the stent. Stents must be removed and must not be left in long term without changing them (unless otherwise directed by your doctor).

Links:

Ureteroscopic laser fragmentation of kidney stone

http://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Ureteroscopy_stone.pdf

http://www.baus.org.uk/patients/information_leaflets/185/rigid_ureteroscopy_for_stones

http://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Stent_advice.pdf

http://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Stone_diet.pdf