EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES

1. EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of Urology & Renal Transplantation, Sri Ramachandra Medical College and Research Institute, Chennai, India

2. INTRODUCTION • No known incidence of such presentations • Not much literature available on how to tackle these multiple pathologies • No set rules laid out for approaching these multiple pathologies endoscopically in one sitting Multiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countries

3. Problems in Developing Countries “cure all one sitting” Pressure on clinicians more in following situation: • Women • Children • Old People • Sole earning member • Poor or lower middle class people • Patient coming from a distance for treatment • Presentation is relatively late • Economic considerations of the patient population plays a pivotal role in this delayed presentation

4. ANALYSIS OF MULTIPLE ENDO- PROCEDURES • Incidence of multiple procedures at presentation • Various combinations of these Pathologies at presentation • Endourological algorithms devised where applicable to tackle these problems effectively • Study Group - SRMC – Urology Unit 1 • Period - 1996 to 2002 • Exclusions - Local Anaesthesia cases • Diagnostic procedures - open with endoscopic • E.g Hernias with TURP

5. INCIDENCE • Total number of endourological procedures since 1996 – 2002 2176 • Multiple pathologies at presentations 239 • Incidence of presentations 11.1 %

6. MOST COMMON MULTIPLE PATHOLOGIES239 (11.1 %) • Bilateral Ureteral calculus - 81 • Vesical calculus + BPH - 54 • Vesical calculus + Ureteral calculus - 41 • BPH + Ureteral calculus - 39 • BPH + Bladder tumour - 06 • Stricture Urethra with bladder and ureteral calculus - 05

7. EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES • Endoscopic Clearance of easier / less demanding pathologies first • Lower tract to be cleared first before proceeding to upper tract • Completely clear one entity first - exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURP

8. EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES • Lower tract stone disease before upper tract Stone disease • Chronological order of Intervention helps in maintaining vision till the end of such multiple procedures Litholapaxy-> Lithotripsy> Incisions> Resections

9. Simple “common sense” Algorithms Complex EndourologicAlgorithms ALGORITHMS

10. COMMOM SENSE ALGORITHMS INTERNAL URETHROTOMY BNI TURP TUIP

11. BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!! • Lower Ureteric Calculus first • Lesser Impacted calculus first • Bilateral safety guide wires first • Side needing stents only first.

12. Cystolithotripsy-36 Using 27fr nephroscope, 2 mm Swiss Litho probe Cystolitholapaxy-18 Using 25Fr Sheath &Mechanical Lithotrite Extra operative times-10-45 min Morbidity-nil Few patients had increased Irritative LUTS CYSTOLITHOLAPAXY/TRIPSY+TURP/TUIP

13. CYSTHOLAPAXY/TRIPSY+TURP CALCULUS FIRST ! • Advantages • Bladder free of fragments of the calculus • Good vision still being maintained-Preventing inadvertent bladder injury • Any untoward incident forcing abandonment of surgery-May end up with a resected lobe and calculus free status!! • Preventing Absorption/Extravasation of irrigant when calculus is dealt before

14. Combination-41 Majority of vesical calculus were 2-2.5 cm Majority of ureteral calculus were in the lower ureter -26 WHICH FIRST!! OPTIONS------ 1.Placing guide wire-cystolithotrripsy-URS 2.Cystolithotripsy-URS+ DJ Stenting VESICAL CALCULUS+ URETERAL CALCULUS

15. VESICAL+URETERAL CALCULUS • Advantageous to complete the ureteral calculus first Exceptions- large bladder calculus • fragments of ureteral calculus and vesical calculus can be evacuated at the same time from the bladder • less chances of ureteric orifice injury preventing upper tract intervention -

17. Total number of cases-6 Maurmayer et al- 7% Blandy et al -5.2% TURP FIRST ! Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa 2.Easy instrumentation. TURBT FIRST! Advantages-1.Resection occurs in clearer access 2.Preventing massive absorption of irrigant as can happen from prostatic fossa. TURP +TURBT

18. BPH + URETERAL CALCULUS • NUMBER OF CASES- 31 • Ureteral calculus first!! ( Exceptions-Large median lobe preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injury 2. • TURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice ) Advantages – Allows ease of instrumentation of the upper tract

19. BPH WITH VESICAL & URETERAL CALCULUS • 19 cases • Large median lobe-4, B/L ureteral calculi-1 • Calculi first ! ! May need TUIP for larger prostates lesser extravasation/absorption Ureteral first ! ! Advantage- Prevents oedema/injury to ureteral orifice - Easier access with best vision

20. PREREQUISITES FOR “CURE ALL” ENDOSCOPIC APPROACH • Use of Endovision camera • Services of Experienced Operator • Perceive limitations of Combination procedures • Preference for general anaesthesia over regional • Patients to be well counselled and appreciate combinations • Warm Irrigant fluids to avoid hypothermia

21. Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation • Candidates must be relatively ‘fit’ for extended procedures • Presence of experienced assistantdesirable

22. TURP + HERNIORRAPHY / HERNIOPLASTY (guidelines ) • TURP F IRST ! • Avoid liberal TUIP / BNI • Avoid mesh Repair in presence of Infected Urine • Postpone herniorraphy in case of gross Extravasation • Avoid Bilateral herniorraphy with TURP / TUIP

23. AVOID …… • TURP & PCNL -- both accompanied with considerable haemorrhage - !! • B/L Upper tract procedure if- • 1.First side is difficult / prolonged procedure • 2.Pus seen on clearing calculus on one side

24. REMEMBER ……… THERE IS ALWAYS A SECOND CHANCE !!!