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Performing flexible ureteroscopy through a cystoscopy introducer sheath
SURGEON’S WORKSHOP
PERFORMING FLEXIBLE URETEROSCOPY THROUGH A CYSTOSCOPY INTRODUCER SHEATH HYUNG L. KIM
AND
GLENN S. GERBER
ABSTRACT Performing flexible ureteroscopy through a cystoscope sheath positioned with its tip near the orifice of the ureter prevents buckling of the ureteroscope and decreases the friction against the ureteroscope. This results in more precise translation of the surgeon’s movements to the tip of the instrument and facilitates the procedure. UROLOGY 54: 557–558, 1999. © 1999, Elsevier Science Inc.
W
ith the trend toward minimally invasive surgical procedures, ureteroscopic procedures are performed with increasing frequency.1,2 The flexible ureteroscope makes virtually every region of the ureter and renal pelvis accessible.3,4 We describe a simple technique that can increase the maneuverability of the ureteroscope within the upper tract. This technique only requires instruments that are already available for standard ureteroscopic procedures. TECHNIQUE After the patient is placed in a dorsal lithotomy position, an appropriately sized cystoscope is advanced into the bladder. The ureteral orifice on the involved side is cannulated, and a retrograde pyelogram is performed to outline the anatomy of the upper urinary tract. A standard guide wire is then positioned within the renal pelvis. The cystoscope sheath is left in position within the bladder, and the remaining portions of the cystoscope are removed. A sterile towel is looped under the sheath and then secured to the drapes overlying the lower abdomen using a hemostat (Fig. 1). This prevents the sheath from slipping out of the bladder during the course of the procedure. The flexible ureteroscope is advanced over the guide wire into the bladder through the cystoscope sheath (Fig. 2). FluoroDr. G. S. Gerber is a paid consultant to Richard Wolf, Inc., makers of endoscopic equipment relevant to this study. From the Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, Illinois Reprint requests: Glenn S. Gerber, M.D., Section of Urology, MC 6038, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, Chicago, IL 60637 Submitted: February 18, 1999, accepted: March 22, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. External setup showing the sterile towel holding up the cystoscope sheath.
FIGURE 2. Fluoroscopic image of the cystoscope sheath positioned near the ureteral orifice.
scopic imaging is used to position the sheath in line with the ureter based on the position of the guide wire. The flexible ureteroscope is advanced over the wire using continuous fluoroscopic imaging. The sheath facilitates passage of the ureteroscope, especially in men with an enlarged prostate, and allows for more precise control of the instrument. 0090-4295/99/$20.00 PII S0090-4295(99)00173-9 557
In addition, the sheath allows for continuous bladder drainage during the course of the procedure, which may help avoid excessive bladder distension. After the ureteroscopic portion of the procedure is completed, ureteral stent insertion, if necessary, is facilitated, since the cystoscope sheath is already in position within the bladder.
of the ureteroscope and the ureteral orifice, the surgeon’s movements do not have to overcome the friction in the urethra. We find that, especially in male patients, performing flexible ureteroscopy through a cystoscope sheath results in more precise translation of the surgeon’s movements to the tip of the ureteroscope by preventing buckling and eliminating friction from the urethra.
COMMENT Performing flexible ureteroscopy through a cystoscope sheath positioned near the ureteral orifice offers several advantages. The sheath allows the bladder to drain throughout the procedure. A decompressed bladder in turn helps keep the ureteroscope from buckling in the bladder. The sheath itself when properly positioned will also prevent buckling in the bladder and penis. Finally, by providing a rigid conduit between the external portion
558
REFERENCES 1. Lyon ES, Banno JJ, and Schoenberg HW: Transurethral ureteroscopy in men using juvenile cystoscopy equipment. J Urol 122: 152–153, 1979. 2. Lyon ES, Huffman JL, and Bagley DH: Ureteroscopy and pyeloscopy. Urology 23(suppl): 29 –36, 1984. 3. Takagi T, Go T, Takayasu H, et al: Fiberoptic pyeloureteroscope. Surgery 70: 661– 663, 1971. 4. Bagley DH: Ureteropyeloscopy with flexible fiberoptic instruments, in Huffman JL, Bagley DH, and Lyon ES (Eds): Ureteroscopy. Philadelphia, WB Saunders, 1988, pp 131–155.
UROLOGY 54 (3), 1999
PERFORMING FLEXIBLE URETEROSCOPY THROUGH A CYSTOSCOPY INTRODUCER SHEATH HYUNG L. KIM
AND
GLENN S. GERBER
ABSTRACT Performing flexible ureteroscopy through a cystoscope sheath positioned with its tip near the orifice of the ureter prevents buckling of the ureteroscope and decreases the friction against the ureteroscope. This results in more precise translation of the surgeon’s movements to the tip of the instrument and facilitates the procedure. UROLOGY 54: 557–558, 1999. © 1999, Elsevier Science Inc.
W
ith the trend toward minimally invasive surgical procedures, ureteroscopic procedures are performed with increasing frequency.1,2 The flexible ureteroscope makes virtually every region of the ureter and renal pelvis accessible.3,4 We describe a simple technique that can increase the maneuverability of the ureteroscope within the upper tract. This technique only requires instruments that are already available for standard ureteroscopic procedures. TECHNIQUE After the patient is placed in a dorsal lithotomy position, an appropriately sized cystoscope is advanced into the bladder. The ureteral orifice on the involved side is cannulated, and a retrograde pyelogram is performed to outline the anatomy of the upper urinary tract. A standard guide wire is then positioned within the renal pelvis. The cystoscope sheath is left in position within the bladder, and the remaining portions of the cystoscope are removed. A sterile towel is looped under the sheath and then secured to the drapes overlying the lower abdomen using a hemostat (Fig. 1). This prevents the sheath from slipping out of the bladder during the course of the procedure. The flexible ureteroscope is advanced over the guide wire into the bladder through the cystoscope sheath (Fig. 2). FluoroDr. G. S. Gerber is a paid consultant to Richard Wolf, Inc., makers of endoscopic equipment relevant to this study. From the Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, Illinois Reprint requests: Glenn S. Gerber, M.D., Section of Urology, MC 6038, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, Chicago, IL 60637 Submitted: February 18, 1999, accepted: March 22, 1999 © 1999, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
FIGURE 1. External setup showing the sterile towel holding up the cystoscope sheath.
FIGURE 2. Fluoroscopic image of the cystoscope sheath positioned near the ureteral orifice.
scopic imaging is used to position the sheath in line with the ureter based on the position of the guide wire. The flexible ureteroscope is advanced over the wire using continuous fluoroscopic imaging. The sheath facilitates passage of the ureteroscope, especially in men with an enlarged prostate, and allows for more precise control of the instrument. 0090-4295/99/$20.00 PII S0090-4295(99)00173-9 557
In addition, the sheath allows for continuous bladder drainage during the course of the procedure, which may help avoid excessive bladder distension. After the ureteroscopic portion of the procedure is completed, ureteral stent insertion, if necessary, is facilitated, since the cystoscope sheath is already in position within the bladder.
of the ureteroscope and the ureteral orifice, the surgeon’s movements do not have to overcome the friction in the urethra. We find that, especially in male patients, performing flexible ureteroscopy through a cystoscope sheath results in more precise translation of the surgeon’s movements to the tip of the ureteroscope by preventing buckling and eliminating friction from the urethra.
COMMENT Performing flexible ureteroscopy through a cystoscope sheath positioned near the ureteral orifice offers several advantages. The sheath allows the bladder to drain throughout the procedure. A decompressed bladder in turn helps keep the ureteroscope from buckling in the bladder. The sheath itself when properly positioned will also prevent buckling in the bladder and penis. Finally, by providing a rigid conduit between the external portion
558
REFERENCES 1. Lyon ES, Banno JJ, and Schoenberg HW: Transurethral ureteroscopy in men using juvenile cystoscopy equipment. J Urol 122: 152–153, 1979. 2. Lyon ES, Huffman JL, and Bagley DH: Ureteroscopy and pyeloscopy. Urology 23(suppl): 29 –36, 1984. 3. Takagi T, Go T, Takayasu H, et al: Fiberoptic pyeloureteroscope. Surgery 70: 661– 663, 1971. 4. Bagley DH: Ureteropyeloscopy with flexible fiberoptic instruments, in Huffman JL, Bagley DH, and Lyon ES (Eds): Ureteroscopy. Philadelphia, WB Saunders, 1988, pp 131–155.
UROLOGY 54 (3), 1999