Endoscopic vesico-ureteric reflux surgery (STING)

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Indication:

  • Vesical-ureteric reflux. It is a minimally invasive procedure performed with endoscopy.
  • A synthetic material (Bulkamid) is injected at the ureteric opening to prevent reflux
  • Grade 3-4 Vesical-Ureteric Reflux where conservative management has failed with a progressive deterioration in renal function.

How is it done?

  • Patients will receive a general anaesthesia.
  • Prophylactic antibiotics is given.
  • The correct ureteric system is identified and marked while you are awake.
  • This will be an endoscopic procedure.
  • A cystoscopy will be done with injection of Bulkamid just under the affected ureteric orifice.
  • Enough Bulkamid will be injected to partially close the ureteric opening yet not obstructing the orifice.
  • An indwelling catheter is placed.

What next?

  • You may be in hospital the day or overnight.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged.
  • Review in 6 weeks.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

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Wes Cystoscopy RGP and STING anti-reflux VUR procedure

Pelvi-Ureteric Junction Repair (PUJ) – Robotic Assisted

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A congenital or acquired narrowing in the ureteric pelvis junction. This narrowing is excised with a reconnection. There are several techniques described in repairing this: I prefer the Dismembered Pyeloplasty

Why is it done?

  • High grade obstruction.
  • Causing deterioration of renal function.
  • Thinning of renal cortex.
  • Chronic pain.
  • Chronic infection.
  • Recurrent renal calculi.

Causes

  • Congenital lack of muscle, or neuro transmission in this area, causing a non-functioning part leading to obstruction.
  • Vesico-ureteric reflux, longstanding can also cause this.
  • Usually diagnosed in kids.
  • Crossing vessel.

How is it done?

Robotic assisted pyeloplasty.

  • Types
      • Dismembered.
      • Foley’s Y-V Pyeloplasty.
      • Culp-Dewierd.
      • Pelvi-calyceal pyeloplasty.
      • Endopyelotomy with laser.
    • Patients will receive a general anaesthesia.
    • Prophylactic antibiotics is given.
    • The correct ureteric system is identified and marked while you are awake.
    • This will be mostly a robotic / laparoscopic procedure.
    • The endoscopic procedure is reserved as a second line in my practice.
    • Laparoscopic ports are placed
    • The affected ureter is exposed, the defect cut out with a re-anastomosis of a spatulated ureter to a trimmed renal pelvis over a ureteric stent.
    • An indwelling catheter is placed. A drain is placed.

What next?

  • You may be in hospital for 3 days
  • Your drain will be removed when there is no urine draining.
  • Your catheter will be removed the following day.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged
  • A ward prescription may be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anaesthesia with a Flexible Cystoscope.
  • A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
  • Any pain or signs of fever require an urgent review.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Possible Complications

  • Re-stenosis with recurrent obstruction.
  • Second procedure.
  • With further deterioration of renal function, you may require a nephrectomy where affected kidney contributes < 15-20% of total renal function.
  • Urine leak, Urinoma, requiring drainage.
  • Infection possible sepsis requiring long-term antibiotics.

 

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Laser Endo-Pyelotomy

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Endoscopic opening of pelvi-ureteric junction stricture.

Endoscopic technique of incising a short stricture with a laser. A stent remains 6 weeks post operatively

Why is it done?

  • Stricturing or narrowing of the ureter causing significant hydronephrosis.
  • Leading to chronic infection.
  • End-result is loss of renal function.
  • An end-to-end anastomosis can be considered in the mid ureter.
  • A Reimplantation into the bladder with lower ureteric strictures.
  • A pelvi-ureteric junction repair in higher ureteric strictures.
  • A trans uretero-ureteric anastomosis joining one ureter to the other where long defects are present.
  • Renal Auto Transplantation where ureter is completely damaged or.
  • An ileal ureteric substitution where to whole ureter is damaged.

How is it done?

  • Endoscopic technique.
  • Patients will receive a general anesthesia.
  • Prophylactic antibiotics is given.
  • The correct ureteric system is identified and marked while you are awake.
  • This will be mostly an endoscopic procedure.
  • A cystoscopy will be done with placement of ureteric guidewires.
  • The affected ureter is entered with ureteroscopy. Laser is used to cut through the short stricture until peri-ureteric fat is observed.
  • This is not an advisable procedure where the stricture overlies vascular structures.
  • A ureteric stent is placed.
  • An indwelling catheter is placed.

What next?

  • You may be in hospital for 3 days.
  • Your drain will be removed when there is no urine draining.
  • Your catheter will be removed the following day.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged.
  • A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anesthesia with a Flexible Cystoscope.
  • A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
  • Any pain or signs of fever require an urgent review.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

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Wes Laser Endo-Pyelotomy

Rigid Cystoscopy, Retrograde Pyelogram, Stent Management

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A therapeutic procedure under general anaesthetic, where a rigid cystoscopy is done in the bladder via the urethra, ureteric catheters are placed to enable imaging of the upper tracts with/without insertion or removal of ureteric stents

Why is it done?

To investigate:

  • Hematuria (blood in the urine)
  • Recurrent upper urinary tract infections
  • Space occupying lesions in the kidneys and ureters
  • Abnormal cells suggestive of urothelial carcinoma, on urine cytology

 

Risk factors:

  • Strong family history of bladder cancer
  • Smokers or passive smokers
  • Factory workers: dyes, paints, etc
  • Exposure to Schistosoma (Bilharzia)
  • Renal stone disease, bladder stones

 

How is it done?

  • This is done under General anaesthesia.
  • A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant gel and saline irrigation.
  • The bladder is then distended with saline.
  • The inside of the bladder is viewed for pathology.
  • A retrograde pyelogram is done at the same time, (placement of small silicone catheters up the kidney pipes). Through this iodine contrast is injected up into the kidney collecting systems. This facilitates the viewing of kidney pipes and kidney collecting systems on X-ray to exclude any upper tract pathology.
  • If any abnormalities are found in the kidney/ ureters, a ureteroscopy (which is the placement of a long thin camera up the ureter) will be performed.
  • If any suspicious lesions are seen, a biopsy will be taken.
  • A ureteric stent may be placed
  • Urine would have been sent for cytology, to rule out the existence of cancer.

Antibiotics may be given to prevent infection

Complications

What to expect after the procedure?

  • Pain on initial passing of urine
  • Bladder infection ranging from a burning sensation to, fever, to puss (rare)
  • Bloodstained urine
  • Lower abdominal discomfort which will persist for a few days
  • Pain radiating from bladder to renal angle associated with urinating.
  • An infection could present with a stent being present.

 

Indications for a Ureteric stent

· Hematuria from upper tracts

· Dis-obstruction of the ureter caused either calculus, blood clot or tumour

· External compression of the ureter by retro-peritoneal pathology i.e.: Fibrosis, retroperitoneal lymph node compression

· Reduced renal function associated with hydronephrosis

· Sepsis associated with hydronephrosis

 

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Wes Cystoscopy RGP and Ureteric stents

Copyright 2019 Dr Jo Schoeman

Uretero-Renoscopic Stone Extraction with Laser (URSE)

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A ureteric or renal calculus is removed with technique and may require a laser. A rigid/ flexible ureteroscope can be used.

Stones in the kidney, urinary bladder and ureter. medical illustration with a cross section of the kidney and bladder. anatomy of the urinary system. Human kidney.

Why is it done?

  • Removal of renal or ureteric stones.
  • Ureteric stones can vary from 5mm to over 1 cm in size.
  • You may present with excruciating pain on the affected side. (This pain may be worse than childbirth).
  • Renal stones usually larger than 1cm obstructing the renal pelvis.
  • Or renal stones not causing any symptoms.
  • Any fevers or a single kidney is deemed an emergency!

Two Treatment Options

  • Ureteric Calculi.
    • Managed with rigid ureteroscopy.
    • Prior stenting with a ureteric stent,
    • 7-10 days after stenting the stent is removed, and the stone is addressed with laser
  • Renal Calculi.
    • Prior stenting for 7-10 days.
    • After stent removal the kidney is accessed with a flexible uretero-renoscope and the stone is fragmented with laser

How is it done?

    • Patients will receive a general anesthesia.
    • Prophylactic antibiotics is given.
    • The correct kidney is identified and marked while you are awake.
    • You would have had a cystoscopy with retrograde pyelogram 10 days prior with placement of ureteric stent to prepare your ureter.
    • A cystoscopy will be done first to remove the stent, and 2 guidewires will be placed to enable access up the ureter.
    • Depending on the position of the stone, either a rigid or flexible uretero-renoscope will be used.
    • If a stone is in the kidney a flexible uretero-renoscope will be used with access obtained with an access sheath to protect the ureter from damage.
    • Laser will be used to fragment the stone.
    • All fragments will be attempted to be cleared. Small 1-2 mm fragments may be left as “Clinically Insignificant Fragments (CISF)” and will pass spontaneously.
    • A Ureteric catheter with an indwelling catheter is left post-operatively overnight.
    • Catheters will be removed the next morning depending on the presence of blood in the urine.

What next?

  • You will spend at least one night in hospital.
  • You will have a catheter for that time.
  • On removal of your catheter, you may experience sharp colicky pain, exactly the same as your presenting renal colic. This is due to your ureter contracting back to its usual size. (The stent has dilated this to 5X its usual size).
  • You will be discharged as soon as your pain has stabilized and you can function independently.
  • Allow for a few days for stabilization of symptoms.
  • A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 6 weeks. Stone analysis results will then be discussed in order to formulate a plan to proven recurrences
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

 

Types of Stones:

  • Calcium Oxalate.
  • Uric Acid.
  • Calcium Phosphate.
  • Struvite (Infection stones).
  • Cystine.

 

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Wes Uretero-Renoscopic Stone Extraction with Laser URSE

Ureteric Injury

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Infrequently ureteric injuries can occur with other abdominal surgery i.e.:

  • Hysterectomy.
  • Ovarian mass resection.
  • Bowel resections.
  • Sacro Colpopexy.

If the injury is below the pelvic brim, then a re-implantation with is recommended with Boari-flap, otherwise a primary end-to-end anastomosis

Why is it done?

  • Stricturing or narrowing of the ureter causing significant hydronephrosis.
  • Injury to ureter with Urological surgery can cause this: Ureteroscopy.
  • Injury to the ureter from other surgeries: Colorectal, Gynecological.
  • This injury if not noted may lead to chronic infection, peritonitis, sepsis etc.
  • End-result is loss of renal function and an ICU stay.
  • An end-to-end anastomosis can be considered in the mid ureter.
  • A Reimplantation into the bladder with lower ureteric strictures.
  • A pelvi-ureteric junction repair in higher ureteric strictures.
  • A trans uretero-ureteric anastomosis joining one ureter to the other where long defects are present.
  • Renal Auto Transplantation where ureter is completely damaged or an ileal ureteric substitution where the whole ureter is damaged.

How is it done?

Robotic technique.

  • Patients will receive a general anesthesia.
  • Prophylactic antibiotics is given.
  • The correct ureteric system is identified and marked while you are awake.
  • Robotic ports are placed,
  • The affected ureter is exposed, the defect cut out with a re-anastomosis of a spatulated proximal ureter to the distal ureter over a ureteric stent.
  • An indwelling catheter is placed.
  • A drain is placed.

What next?

  • You may be in hospital for a few days
  • A drain will be left overnight and removed the next day if not draining any fluid.
  • Your catheter will be removed the following day. Or as soon as your urine is clear.
  • As soon as you are comfortable with no signs of pain and emptying your bladder sufficiently, you will be discharged.
  • A ward prescription may be issued on your discharge, for your own collection at any pharmacy.
  • A follow-up appointment will be scheduled for 6 weeks to remove your ureteric stent under local anesthesia with a Flexible Cystoscope.
  • A review with a CT IVP will be scheduled 6 weeks after this to check on the end result of the ureter.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

 

Wes Ureteric Injury

Ureteric Reimplantation

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  • Surgical repair of VUJ obstruction, robotic or open
  • Mainly a procedure for pediatric urology to correct grade 4-5 vesicoureteral reflux
  • Distal ureteric injuries.

Why is it done?

  • Grade 4-5 Vesical-Ureteric Reflux where conservative management has failed with a progressive deterioration in renal function.
  • Distal ureterectomy due to stricture disease.
  • Iatrogenic injury to lower ureter during surgical procedure: hysterectomy, colectomy, sacrocolpopexy etc.
  • Ureteric involvement in pelvic oncological (cancer) conditions, i.e.: colon cancer, rectal cancer, ovarian cancer, etc.
  • Ureteric involvement in pelvic inflammatory conditions: Diverticular abscesses, Pelvic Inflammatory disease etc.

How is it done?

  • Patients will receive a general anesthesia.
  • Prophylactic antibiotics is given.
  • The correct kidney is identified and marked while you are awake.
  • This will be a combined robotic and endoscopic procedure.
  • A cystoscopy will be done with placement of ureteric catheter or stent, if not already done.
  • Patients with complete closure of the ureter may have a nephrostomy tube into their kidney via the back.
  • An indwelling catheter is placed.
  • Robotic ports are placed, and the pelvic cavity is entered.
  • The ureter is identified, and the affected area of the lower ureter is identified and cut off above the injury / diseased area.
  • The bladder is opened, bi-valved and the ureter is re-implanted either as refluxing or non-refluxing.
  • A Psoas-hitch procedure will be performed where the bladder is fixed onto the affected side’s Psoas muscle as to take off tension from the anastomosis / reimplantation.
  • A Boari-flap may be considered with considerable length of defect.
  • In the case of VUR, the ureter is not cut, rather loosened in the bladder and re-tunneled in a non-refluxing technique under the mucosa of the bladder. Several techniques have been described.
  • A ureteric stent is placed for 6 weeks and an indwelling catheter for 10 days.
  • A drain is also placed for post-operative drainage for a couple of days.

What next?

  • You may be in hospital for at least 3-5 days.
  • You may have continuous intravenous antibiotics on board.
  • You will have a drain and an indwelling catheter.
  • The drain will be removed on D2-3 as soon as the drainage is less than 20-30cc per 24 hours.
  • The indwelling catheter will remain for 10-14 days until a cystogram reveals no leaks.
  • Your stent will be removed on a separate occasion in 6 weeks after all the fibrosis has settled.
  • A follow-up appointment will be scheduled for 6 weeks to remove the stent.
  • A further follow-up is arranged with a CT IVP to check on the end result of the ureter.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Possible complications:

  • Vesical Ureteric Reflux.
  • Stricturing / Narrowing of the implanted ureter.
  • Persistent Reflux.
  • Re-implantation.
  • VUR.
  • Stenosis and narrowing with persistent hydronephrosis.

 

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Wes Ureteric Reimplantation VUR

Ureteroscopy and Fulguration Lesion

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Why is it done?

  • Viewing suspicious lesions in upper urinary tracts (ureter and renal pelvis)
  • Flexible uretero-renoscopy to review inside of the renal pelvis and renal calyces
  • Removal of the lesion using laser
  • Rigid is better for the ureteric inspection

 

How is it done?

  • Patients will receive general anaesthesia.
  • Prophylactic antibiotics are given.
  • The correct kidney is identified and marked while you are awake
  • You would have had a cystoscopy with retrograde pyelogram 10 days prior with the placement of a ureteric stent to prepare your ureter
  • A cystoscopy will be done first to remove the stent, and 2 guidewires will be placed to enable access up the ureter
  • Depending on the position of the lesion, either a rigid or flexible uretero-renoscope will be used.
  • Suspicious lesions may be biopsied and fulgurated.
  • Laser fulguration or Diathermy may be used.
  • Catheters will be removed the next morning depending on the presence of blood in the urine
  • Extended use of a ureteric stent may be advised, depending on the degree of bleeding

 

Complications

  • Ureteric perforation
  • Stricturing / Narrowing
  • Disruption of ureter
  • Stent Irritation
  • Procedure abandoned due to bleeding

 

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Wes Ureteroscopy and Fulgeration lesion

Copyright 2019 Dr Jo Schoeman

Ureterotomy

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What is it?

  • Opening up of a very narrowed/ obstructed ureteric opening. Either by cold knife or laser.
  • Where a congenital / acquired narrowing in the ureteric opening occurs.
  • This procedure is used to open the ureter and ease the urine flow. It can cause Vescio ureteric reflux.

Why is it done?

  • Congenital narrowing of the ureteric opening in the bladder as per a Ureterocele.
  • Previous bladder surgery where the ureteric orifice was involved: i.e. Bladder tumour resection.
  • Where conservative measures have failed: i.e. Stenting, Dilatation etc.
  • To prevent renal function deterioration.
  • Stenting or nephrostomy placement would have been done in the acute state to relief an obstructed and infected system.

How is it done?

  • Patients will receive a general anesthesia.
  • Prophylactic antibiotics is given.
  • The correct kidney is identified and marked while you are awake.
  • This will be an endoscopic procedure.
  • A cystoscopy will be done with placement of ureteric guidewire.
  • Laser will be used to cut the stricture open.
  • The alternative is using endoscopic scissors (when available).
  • A ureteric stent is left with an Indwelling Urethral catheter.
  • A ureteric stent is placed for 6 weeks and an indwelling catheter overnight.

What next?

  • You may be in hospital for 1-2 days.
  • You may have continuous intravenous antibiotics on board.
  • You may have persistent hematuria.
  • The stent may be uncomfortable with pain radiating to your affected kidney every time you urinate.
  • Your stent will be removed on a separate occasion in 6 weeks with a flexible cystoscopy under Local Anesthesia.
  • A follow-up appointment will be scheduled for 6 weeks to review your symptoms.
  • A further follow-up may be arranged with a CT IVP to check on the end result of the ureter.
  • DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

 

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Wes Ureterotomy