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RETROGRADE URETEROSCOPY
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Retrograde Ureteroscopy: Handbook of Endourology
Petriș or A. Geavlete, Editor
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RETROGRADE
URETEROSCOPY
HANDBOOK OF ENDOUROLOGY
Edited by
Petris¸ttor A. GeAvlete
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Contributors
Petris¸or A. Geavlete, (Editor), MD, PhD Professor of Victor Mirciulescu, MD, PhD Researcher grade III, Saint John
Urology, Academician (Corresponding member) Romanian Emergency Clinical Hospital, Bucharest, Romania
Academy of Medical Sciences, Head and Chairman of Urological Cristian Moldoveanu, MD, PhD Saint John Emergency
Department, Saint John Emergency Clinical Hospital, Bucharest,
Clinical Hospital, Bucharest, Romania
Romania
Ra˘zvan Mult¸escu, MD, PhD Saint John Emergency Clinical
Emanuel Alexandrescu, MD Saint John Emergency Clinical Hospital, Bucharest, Romania
Hospital, Bucharest, Romania
Gheorghe Nit¸a˘, MD, PhD Assistant-Professor of Urology,
Bogdan Geavlete, MD, PhD Lecturer of Urology, Saint John Saint John Emergency Clinical Hospital, Bucharest, Romania
Emergency Clinical Hospital, Bucharest, Romania
Dorel Soroiu, MD, PhD Saint John Emergency Clinical
Dragos¸ Georgescu, MD, PhD Associate Professor, Chief of Hospital, Bucharest, Romania
Urological Department, Saint John Emergency Clinical Hospital,
Bucharest, Romania
ix
Preface
This fourth book in the series Handbook of Endourology: The volume starts with the history of the proce-
Retrograde Ureteroscopy continues with the procedures dures and the description of the various endoscopes
designed for ureteral approach, being the first of two (semirigid or flexible, conventional or digital), energy
volumes dedicated to the upper urinary tract. sources, ancillary instruments, and stents available
Within the pages of the handbook, the technological for clinical use. It seems that the variety of these in-
progress of the past decades becomes maybe even more struments developed for the upper urinary tract is
evident. Miniaturization, development of lasers, special even more diverse than those for the endourological
materials for flexible scopes, and image chips, etc., have approach of the lower urinary tract.
allowed the continuous reshaping of this field. This volume continues with the description of di-
This process is continuing, each year bringing new agnostic ureteroscopy and then presents, in detail, the
developments in the field, new endoscopes or instru- therapeutic approach for upper urinary tract lithiasis;
ments aiming to improve the efficacy and safety of the caliceal diverticulum; upper urinary tract tumors; ure-
procedures, or the broadening of the indications. Today, teral, uretero-pelvic junction, and infundibular stenosis;
the retrograde approach is seriously challenging the other iatrogenic lesions; and finally, the ureteroscopic approach
minimally invasive options for upper urinary tract pathol- in selected situations (pediatric cases, pregnant women,
ogy treatment, percutaneous approach, and SWL. anomalous ureters, or kidneys).
This volume is based on a broad experience of more than The indications, technique, limitations, complications,
11,500 rigid and semirigid ureteroscopies and more than and results are thoroughly described for each of these
2,500 procedures using flexible ureteroscopes performed pathological entities.
in the last 25 years. All this experience has allowed us to ap- Being one of the most experienced centers in the world
ply retrograde ureteroscopy in almost all the situations that in ureteroscopy, with a unanimous national and interna-
can be approached in this fashion, with all the challenges, tional recognition, we consider that this volume can guide
particular situations and, why not, most of the complica- the diagnostic and therapeutic conduct for any urologist,
tions that can be encountered. Today, all this experience, as well as for other specialists.
carefully recorded, can be passed on to the readers. As in Ureteroscopy has presently become one of the most
the previous books, the theoretical notions are supported frequently used minimally invasive methods in urology.
by more than 1500 images captured during personal inter- The impressive technology that is under constant evolu-
ventions, in the previously mentioned situations. tion, as well as the experience of many renowned urology
At the beginning, retrograde approach of the upper centers, recommend the publishing of this book.
urinary tract was performed only for diagnostic purposes
or for treatment of stones. Now, selected cases of patients
with other upper urinary tract conditions can be treated Editor
using these techniques. Professor Petris¸or Aurelian Geavlete, MD, PhD
xi
Acknowledgments
Great appreciation for the wonderful support of Karl Storz Endoskope GmbH & Co. KG. Also, many thanks to the
Olympus Medical System Europe GmbH and especially to Sanador Hospital for its major scientific contribution with
regard to the publication of the handbook.
xiii
C H A P T E R
1
History
Dragos¸ Georgescu, Ra˘zvan Mulţescu,
Petris¸or A. Geavlete, Bogdan Geavlete
1.1 HISTORY
Initially developed as an extension of cystoscopy, ureteroscopy has become a major technique for the diagnosis
and treatment of upper urinary tract disorders. At the end of the 1970s, the method was limited to the management of
only a small number of lesions of the distal ureter (Lyon et al., 1979; Perez-Castro Ellendt and Martinez-P ineiro, 1980);
today the entire upper urinary tract can be approached for diagnosis and treatment by using retrograde ureteros-
copy. This progress is a result of the development of rigid and flexible ureteroscopes and of adequate accessory
instruments. The first endoscopic explorations were performed by Bozzini in 1806, using small caliber cannulas, the
light source being a candle (Greene and Segura, 1979). It was only at the end of the nineteenth century that the first
cystoscope with a warm light source was created by Nietze.
The first description of the retrograde endoscopic approach of the upper urinary tract came from Hugh H. Young
(Fig. 1.1) who, in 1912, explored the dilated distal ureter of a patient with posterior urethral valves using a 9.5 F pe-
diatric cystoscope (Young and McKay, 1929). This method had obvious limitations, making it necessary to develop
specific instruments that allowed for the easy approach of the upper urinary tract, including the pyelocaliceal sys-
tem. Significant advances occurred half a century later, leading to the appearance of modern rigid ureteroscopes.
The most important role was the development by Hopkins in 1960 of cylindrical lens systems that allowed for a
significant increase of light transmission along endoscopes. This made possible the appearance of low-caliber rigid
ureteroscopes.
The pioneering period in the field of optical fibers started in 1854 when John Tyndall (Fig. 1.2), resuming one of
Colladon’s experiments from 1841, demonstrated in London the possibility of guiding light through a curved jet
of water, due to the phenomenon of total internal reflection. The first patent for the transmission of light through
optical fibers was granted in 1972, legitimizing this scientific breakthrough that paved the way for the construction
and development of flexible endoscopes.
The first flexible ureteroscopy was reported by Marshall in 1964 (Marshall, 1964). He used a 9 F instrument
produced by “American Cystoscopes Makers Inc.,” without a working channel and active deflection possibilities,
being a purely diagnostic procedure. Takagi in 1966 and then Bush also reported the successful achievement of ure-
teropyeloscopies using flexible instruments with the same technical characteristics as that of Marshall. Without a
proper irrigation system, they used forced diuresis in order to obtain a clearer image of the endoscopic field (Takagi
et al., 1968).
Further technical advances allowed for the development of ureteroscopes and the improvement of accessory in-
struments necessary for the endoscopic procedures in the upper urinary tract (Fig. 1.3).
Rigid ureteroscopy entered current urological practice only at the end of the 1970s. Goodman (1977) and
Lyon et al. (1978) achieved the assessment of women’s distal ureter using a pediatric cystoscope. However,
the reduced length of the instrument did not allow for its routine use. Lyon et al. (1979), in cooperation with
Richard Wolf Instruments (Rosemont, IL), developed a ureteroscope with a length of 23 cm that allowed for
the approach of the distal ureter, both in women and in men. The diameter of the ureteroscope’s sheath ranged
Retrograde Ureteroscopy. http://dx.doi.org/10.1016/B978-0-12-802403-4.00001-2
Copyright © 2016 Elsevier Inc. All rights reserved.
1
2 1. History
FIGURE. 1.1 Hugh Hampton Young (1870–1945). FIGURE. 1.2 John Tyndall (1820–1893).
FIGURE. 1.3 Landmarks in the development of ureteroscopy.
from 13 F to 16 F and allowed the use of telescopes with 0–70° lenses. This diameter facilitated the use of acces-
sory instruments with dimensions of over 5 F. On the other hand, the relatively large diameter of the endoscope
continued to create difficulties in approaching the ureteral orifice and the intramural ureter. Subsequently, Karl
Storz Instruments (Culver City, CA) and Richard Wolf Instruments developed a ureteroscope with a length of
40 cm and a caliber of 9–11 F. The development of these endoscopes marked the beginning of the modern era
of ureteroscopy.
Until the 1980s, the design of the ureteroscope underwent continuous development; a reduced diameter and
working channels allowed for the use of accessory instruments. With the advances regarding optical fibers tech-
nology and with the appearance of reduced diameter working instruments, the diameter of modern ureteroscopes
1.1 History 3
was reduced to 6.9–9.4 F, with an integral sheath and two working channels of 2.1–5.4 F. These miniature semi-
rigid ureteroscopes use 5° telescopic lenses and have a length of 33 cm and 41 cm, respectively. The reduced
caliber facilitated the access to the upper urinary tract, reducing the aggression on the ureter (Abdel-Razzak and
Bagley, 1994).
Until 1981, the treatment of ureteral lithiasis was represented by surgical ureterolithotomy or by endoscopic ma-
nipulation of stones under cystoscopic control. The disadvantages of these methods were represented by the mor-
bidity of open surgery, respectively by the reduced success rate of “blind” extraction of stones. The first endoscopic
extraction of ureteral stones under ureteroscopic control was achieved by Das (1981). Initially, the technical and
safety difficulties of the intervention prevented the widespread use of ureteroscopy, the major disadvantage being
the dimensions of the instruments.
The development of ureteroscopes with a length of 50 cm allowed the retrograde approach up to the level of the
pyelocaliceal system. This development was produced by Karl Storz Endoscopy, and was based on the research con-
ducted together with Perez-Castro Ellendt and Martinez-Pineiro (Perez-Castro Ellendt and Martinez-Pineiro, 1982;
Huffman et al., 1982). These represented the basis for the subsequent evolution and progress of ureteroscopes with
different lengths (25–54 cm), optical systems, and diameters (9–16 F).
The technical difficulties in achieving a rigid ureteroscopic approach are determined by the need for ureteral
dilation and by the impediments in advancing the instruments along the ureter, in overcoming the sinuosities, and
the areas with a reduced caliber. The modalities for overcoming these impediments represented the object of many
studies regarding how to facilitate advancing the rigid ureteroscope into the middle ureter, especially in men. The
attempt to solve these problems, as well as the desire to retrogradely approach the entire upper urinary tract, led
to the introduction of semirigid and flexible ureteroscopes into current practice (Marshall, 1964). Their use implied
the progress of accessory instruments, with the development of extracting forceps, basket catheters, and lithotripsy
probes with calibers of 1.9–2 F.
In the early 1980s, at Chicago University, Bagley, Huffman, and Lyon started the development of the flexible ure-
teroscope, adding three essential technical features: the working channel, the irrigation system, and active deflection
(Bagley et al., 1987).
In 1990, flexible ureteroscopes had a 10 F diameter, a standard working channel of 3.6 F, and a unidirectional active
deflection. Today, due to the miniaturization of optical fibers, the average dimensions of the instruments have been
reduced to 7.5 F; the deflection system has also been enhanced, with the increase of amplitude and even the presence
of two active areas.
With the technological development, the indications for the ureteroscopic approach have also been diversified.
Thus, in 1982 Goodman described the retrograde ureteroscopic approach as a conservative method for treating up-
per urinary tract urothelial tumors (Goodman, 1984).
Together with the development of endoscopes, a similar evolution of the energy sources was recorded.
The first attempt of intracorporeal lithotripsy belongs to Mulvaney (1953) who used a 0.8 kHz ultrason-
ic lithotripter. In 1955, Coates managed to obtain a partial fragmentation of stones using a 15 kHz device
(Coates, 1956). In 1983, Huffman reported the use of ultrasonic lithotripsy during ureteroscopic interventions
(Johnston et al., 2004).
The elecrohydraulic lithotripter was invented by Yutkin in 1955, at Kiev University. However, the political situa-
tion at that moment initially limited its use to within the East-European Bloc only (Grocela and Dretler, 1997). In 1985,
Green and Lytton reported the use of electrohydraulic lithotripsy in the ureteroscopic treatment of ureteral lithiasis
(Green and Lytton, 1985), while Begun, in 1988, used this method during flexible ureteroscopy.
Languetin et al. (1990) described the Swiss lithoclast, a pneumatic lithotripsy device whose development was
based on the principles stated by Heurteloup in 1932 for bladder stones fragmentation (Johnston et al., 2004). The
main disadvantage of this type of safe and efficient lithotripsy is the impossibility of using it on the increasingly
popular flexible ureteroscopes. In 1994, Grasso and Loisides published the experimental results of a pneumatic litho-
tripter with nitinol flexible probes (Loisides et al., 1995; Grasso et al., 1994). Mulvaney and Beck (1968) attempted
the lithotripsy of a bladder stone using a ruby laser. Initially used by Watson in 1984, pulsed-dye laser was the first
type of laser that positioned itself as a source of energy for lithotripsy (Watson et al., 1997). Subsequently, other la-
sers were developed and used: Alexandrite, Nd:YAG, Ho:YAG, etc. The first description of the potential for using
the Ho:YAG laser in urology belongs to Johnson, in 1992 (Johnston et al., 2004). The first results of this type of laser
in intracorporeal lithotripsy were published in 1995, demonstrating its efficacy and safety (Erhard and Bagley, 1995;
Matsuoka et al., 1995).
The development of accessory instruments was dictated by the features of the endoscopes and energy sources. In
1983, Huffman introduced the balloon dilation of the ureteral orifice. Honey (1998) published the first results of nitinol
