ENDOUROLOGY AND OTHER UROLOGIC ANCILLARY PROCEDURES Department of Urosurgery

1. ENDOUROLOGY AND OTHER UROLOGIC ANCILLARY PROCEDURESDepartment of Urosurgery Dellosa, Miguel LeeChuy, Katherine Lee, Sidney Albert Legaspi, Roberto Jose Lerma, Daniel Joseph Li, Henry Winston Jerry Santos, MD Facilitator

2. PercutaneousEndourology The use of closed procedures via needle and guidewire access to visualize and manipulate the kidneys and upper urinary tract.

3. Techniques • Patient in prone position • Local anesthesia – lidocaine hydrochloride • Ultrasonographic or fluoroscopic guidance • Standard puncture site – posterior axillary line, midway between 12th rib and iliac crest into a dorsal calyx • Fluoroscopic guidance after successful puncture

4. Ultrasound Guided Puncture • Place transducer cephalad to the puncture site • Incise skin and fascia • Shift transducer over incision to measure distance to the target • Blind insertion of 16-18 gauge needle through abdominal wall • Visualize both target and needle in same plane before puncturing collecting system

5. Fluoroscopy Guided Puncture • Intravenous or retrograde administration of contrast dye • Insert 16-18 gauge needle through abdominal wall • Insert fine needle through larger needle to the collecting system • Advance larger needle over fine needle • Remove fine needle and insert guidewire

6. Indications Diagnostic • Antegrade pyelography • Pressure/perfusion study (Whitaker test) Therapeutic • Nephrostomy catheter drainage • Antegrade ureteral stenting • Dilation of ureteral strictures • Perfusion chemolysis of renal stones • Percutaneous nephrolithotomy • Percutaneous resection and coagulation of urothelial tumors

7. Contraindication Blood clotting anomalies

8. AntegradePyelography • Obtaining radiograph after antegrade injection of contrast dye (20-30% diluted) • Simultaneously done with Whitaker’s test

9. Percutaneous Pressure/Perfusion Study (Whitaker Test) • Assess pyeloureteral resistance by differentiating an obstructed from non-obstructed dilated system • Simultaneous measurements of intrapelvic and intravesical pressures during antegrade perfusion at 5, 10, 15, and 20mL/min flow rates via a manometer • Differential pressure = renal pelvic – bladder pressure • Flow rate 10mL/min: normal < 13 cmH2O; mild obstruction 14-22 cmH2O; moderate to severe obstruction > 22 cmH2O • Flow rate 15mL/min: normal < 18 cmH2O • Flow rate 20mL/min: normal < 21 cmH2O

10. PercutaneousNephrostomyCatheter Placement • Drainage and decompression of upper urinary tract if retrograde ureteral catheterization cannot be done • Insertion of guidewire, dilator, then nephrostomy catheter • Can do antegrade ureteral stenting and balloon dilation through catheter

11. Perfusion-Chemolysis ofRenal Stones • Adjunct treatment for residual stones after surgery, PNL, or ESWL • Use of double-catheter system for simultaneous irrigation and drainage • Flow rate 100-120mL/hr • Uric acid: Na+ or K+ bicarbonate • Cystine: D-penicillamine, acetylcysteine, tromethamine-E • Struvite/apatitie: Suby’s solution G or M or hemiacidrin • Complications: pyelotubular/pyelovenous reflux of chemolytic agent; infected urine; hypermagnesemia; sepsis

12. Endoscopic Intrarenal Instrumentation • Nephroscopes – endoscopic instruments, 15-26F sheaths, inserted percutaneously • Standard rigid instruments available in sizes 24-26F, have telescopes with offset eyepieces • Smaller working channel allows insertion of flexible intruments • Instrumentation through flexile nephroscopes is limited by size and flexibility of working instruments

13. Nephroscopy • Rarely indicated for diagnostic purpose • Mostly performed for percutaneous lithotripsy • ESWL has gradually replaced PNL for renal stone treatment • PNL used in: • Urinary obstruction not caused by stone itself • Large volume stones • Stones that cannot be positioned within SW focus

14. Renal Stones • PNL is limited to specific stone diseases • Large stones must be disintegrated using mechanical, ultrasonic, electrohydraulic, or laser energy • For soft stones - continuous disintegration and evacuation of fragments • Hard stones – broken up into largest possible fragments that can be extracted

15. Ureteropelvic Stenosis • Direct-vision internal incision (pyelolysis, endopyelotomy, endopyeloplasty) • Offers advantage of an incision under direct vision

16. Renal Pelvis Tumor • Electroresection, electrocoagulation, electrovaporization, neodymium:YAG laser coagulation • Percutaneous management may be an alternative to nephroureterectomy for patients with grade I disease, and for palliative tratment

17. Percutaneous Aspiration & Biopsy • Usually perfomed for diagnostic purposes • In combination with therapeutic intentions • Ultrasound and CT are imaging techniques of choice

18. Renal Cysts • Indications of diagnostic puncture of cystic lesion: • Irregular, thick wall, internal echoes on ultrasound exam • Density numbers on CT higher than serous fluid • Hematuria • Indications of puncture for therapy: • Cyst causes compression

19. Renal Biopsy • Performed percutaneously or open surgery • Bleeding is expected due to vascularity of parenchyma • Open surgical biopsy rather than percutaneous biopsy is indicated in patients with solitary kidneys or uncontrolled hypertension

20. KUB XRAY

22. The Kidneys • The normal kidneys are bean-shaped • Located between the upper border of T11 and lower border of L3 • The right kidney lies approximately 2 cm lower than the left. • The normal range of renal length in adults is 11 to 15 cm. • The increased radiolucency of the fat makes the outline of the kidney standout from the soft tissues

24. The Kidneys • The kidneys are contained within the renal capsule and surrounded perirenal fat, which is enclosed within Gerota’s fascia. • There are 3 anatomic spaces around each kidney: • Perirenal • Anterior pararenal • Posterior pararenal

26. Anterior Layer of the renal fascia Perirenal fat Fibrous capsule of the kidney Left Kidney Posterior Layer of the renal fascia

27. The Kidneys • The leaves of the Gerota’s fascia fuse superiorly, medially and laterally, enclosing the kidney, adrenal gland, renal vasculature and emerging portion of the proximal ureter.

28. The Kidneys • In theory fluid collections are more likely to collect in spaces between tissue planes rather than in the perirenal and pararenal spaces.

29. The Ureters • The ureters cannot be defined on plain KUB film however radioopaque calculi may be detected along the course of the ureter.

31. The Ureters • 3 areas of normal narrowing • Ureteropelvic junction • Ureterovesical junction • Bifurcation of the iliac vessels These are sites where calculi often lodge in the course of passage

32. The Urinary Bladder • The shadow of the urinary bladder can often be identified. • The urinary bladder is a muscular hollow viscus which lies in the pelvis but balloons upward when distended.

33. Psoas muscle shadows • The psoas muscle shadows are usually well outlined. • Assymmetry or other abnormalities are noted. • In perirenal abscess, the psoas muscle shadow is enlarged and its margin is indistinct adjacent to the area of infection. • Psoas abscess may displace the kidney and ureter

35. Pelvic Calcifications • Vesical calculi can be outlined. • Vascular calcifications, including phleboliths and arterial plaques are frequently seen.

37. (EXU) OR INTRAVENOUS UROGRAPHY (IVU) • Assessment of GUT requiring IV injection of contrast to visualize renal collecting systems, ureters and UB • Indications: • Urinary stones • Neoplasia • Urinary inflammations • Urinary trauma and obstruction • Miscellaneous: congenital anomalies, GUT fistula formation, patent urachus, etc.

38. Patient preparation • NPO • Bowel cleansing • Some cases: adequate hydration (MM, IDDM and renal failure)

40. Contrast material • Organic iodides: radiopacity depends on its iodine content • 2 types: • Ionic • Non-ionic: lower osmolality • Advantages: less toxicity and less reactions • Disadvantage: more expensive • Mechanism of exretion: • Almost entirely by glomerular filtration little or no tubular resorption

41. Contraindications • hypersensitivity to contrast • combined hepatic and renal disease • oliguria • serum creatinine >2.5-3.0 mg/dl • IDD with renal insufficiency (serum crea > 1.5 mg/dl) • Multiple myeloma • Hx of severe allergy • Use of metformin (within previous 48hrs) • ++ value of INFORMATION obtained must be weighed against the risk

42. Adverse contrast reactions • Minor: urticaria, sweating , nausea, vomiting • Major: laryngeal edema, hypotension, bradycardia, shock, seizure, anaphylactoid rxn, such as cardio-respi arrest

43. RETROGRADE UROGRAM -minimally invasive procedure that requires cystoscopy and the placement of catheters in the ureters -radiopaque contrast medium is introduced into the ureters or renal collecting structures through the ureteral catheters, and radiographs of the abdomen are taken.

44. RETROGRADE UROGRAM • Retrograde Urogram INDICATIONS: a.)excretory urograms or CT urogram (CTU) are unsatisfactory b.) history of adverse reaction to intravenouscontrast media

45. Nephrogram • Diffuse opacification of the renal parenchyma • Reflects the ability of proximal tubules to reabsorb water and concentrate the contrast • Visualize renal outline Pyelogram • Visualization of the pelvocalyceal complex and ureters • Contrast has reached the collecting tubules and excretory passages • Information on architecture and function of kidney Cystogram -Visualization of the lower part of ureters and UB

46. CYSTOGRAPHY • Visualization of the UB wherein a urethral catheter is inserted and the UB is filled with contrast • usually instilled via a transurethral catheter, but when necessary can be administered via percutaneous suprapubic bladder puncture

47. Indications: • suspected UB rupture in trauma patients • suspected UB tumors • diverticula • calculi

48. URETHROGRAPHY • imaged radiographically by retrograde injection of radiopaque fluid or in antegrade fashion with voiding cystourethrography, or with voiding following EU. • antegrade technique is required when lesions of the posterior urethra, for example, posterior urethral valves, are suspected.

49. URETHROGRAPHY • retrograde technique is more useful for examining the anterior (penile) urethra

50. Ultrasound