Ureteroscopy and ureterorenoscopy
With the advent of fibre-optic technology, endoscopes have become smaller and smaller. It is commonplace to be able to pass a 2-3mm semi-rigid ureteroscope to the renal pelvis via the urethra with excellent views and with an instrument channel large enough to be able to both deliver energy sources capable of fragmenting stones and also to pass retrieval devices to harvest the stone fragments. Moreover, the recent introduction of the flexible ureterorenoscope combined with intracorporeal laser technology has allowed small intrarenal calculi to be treated from below, thus challenging the role of percutaneous renal surgery for such calculi.
Ureteroscopy with laser lithotripsy is highly successful for all ureteric stones and, although ESWL remains the first choice for treatment of most renal and ureteric calculi, lower success rates and the problems associated with this treatment preclude it as an option for every single patient. In addition, problems with access to ESWL facilities encourage the use of endoscopic stone treatments. Ureteroscopy should be considered first line therapy in the obese patient, those on anticoagulation therapies and in pregnancy.
Ureteroscopy is typically performed under general anaesthetic and is slowly being introduced as a day case procedure. Previously, all patients would receive a ureteric stent post-operatively for a variable period of time but the trend is moving away from routine stenting and an increasing number of both ureteroscopy and ureterorenoscopy can be performed “stentless”.
Occasionally, the stone cannot be located easily at the first attempt and in this situation it is entirely reasonable to place a stent to allow passive ureteric dilatation, allowing easier ureteroscopic stone removal a week or two later.
The commonest problem after ureteroscopy is post-operative loin discomfort, which may last for a few days and is treated with simple analgesia. Urinary tract infections are less common and can be treated with standard antibiotic therapy. Longer term problems such as ureteric stricture are increasingly uncommon with narrower endoscopes and are now anticipated in less than 1% of cases.