Ureteroscopy & Stent Placement
Ureter = tube that connects your kidney to your bladder
Oscopy = procedure done through a scope as opposed to an incision
Stent = thin plastic tube that can be placed in the ureter
The ureter is a tube that connects each kidney with your urinary bladder. It is the most common site in which a kidney stone gets caught and consequently often causes severe pain. There are other reasons that a ureter may become blocked. There could be narrowing scar tissue inside the ureter (termed a stricture). There could be compression from outside the ureter due to a tumor or inflammatory response somewhere in the abdominal cavity or pelvis. There can be congential (something you are born with) defects in the ureter. The ureter can also be a site for tumors of the urinary tract. When there is a problem within the ureter, we can usually approach it with a small telescope that is inserted through the urethra (tube through which you urinate), into your bladder, and then into the ureter. This instrument is called a ureteroscope. The scope can usually be advanced all the way into the inside of the kidney. Ureteroscopy is performed under anesthesia so that you do not feel any discomfort, and because it is necessary that you are very still during the procedure.
Once in the ureter or in the kidney, we can break up a stone using different instruments. We can take biopsies as well. In addition, we can open up strictures (scar tissue) if the system is blocked. After any of these procedures, it may be necessary to leave a stent (plastic drainage tube) in the ureter for a few days to a few weeks (depending on your particular situation) to allow adequate drainage and resolution of inflammation of the tract. This tube is not visible on the outside of the body as one end is in the kidney, and the other in the bladder. Sometimes, a thin string is attached to the end of the stent in the bladder, and this string is left hanging out of the urethra. The stent can then be removed by pulling on the string. In the absence of the string, the stent can be removed with a small scope in the office. Sometimes, we use injection of x-ray contrast up the ureter to help diagnose a problem or to help guide the path of theureteroscope. This special x-ray is called a retrograde pyelogram. Patients who are allergic to x-ray dye can usually have this procedure because the dye does not enter the bloodstream.
There is no particular preparation for ureteroscopy. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood ("blood thinners, aspirin, anti-inflammatory medicines, etc..."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter).
Please refer to the attached list and tell us if you took any of these within the past 10days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
To review the basics of what we discussed in the
office: The actual procedure can take anywhere from 15
minutes to a couple of hours depending on the particulars
of the case and the individual's anatomy. You will be
placed in lithotomy position (lying down on your back
with your legs gently elevated in holsters called stirrups).
First, a scope is inserted into the bladder and the bladder is examined. The ureteral orifice(hole where the ureter enters the bladder) on the side of concern is then identified. Occasionally, a retrograde pyelogram (see above) is performed prior to the insertion of theureteroscope. Sometimes, one or more wires is/are placed into the ureter to help guide the passage of the scope. Then, the scope is inserted into the ureter and advanced to the area of concern. Depending on the location, size, and type of stone, the surgeon may elect to use one or a combination of instruments to break the stone and remove any significant fragments. If the fragments are very small, they may pass on their own over the next few days or following removal of the stent. Sometimes when some of the fragments are larger, the surgeon may elect to extract some of them from the ureter using any one of a number of available devices(grasping tools). If a stricture (scar tissue) is identified, it may be spread open with a balloon device or cut open with a small knife or laser. If abnormal tissue is identified, a biopsy can betaken and/or the tissue can be cauterized. This can be done with laser or other technology.
After the indicated procedure is complete, a stent may be inserted and the patient is awakened.
After the procedure, you will be in the recovery room until you are ready to be discharged. It is uncommon for a patient to be admitted to the hospital afterward, but certain circumstances could make admission necessary for your own safety.
It is common and even expected to have some discomfort while urinating. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood usually disappears in a few days. You may also notice stone fragments in the urine. Because they are small, a patient typically does not feel them as they pass in the urine. As a result of the instrumentation, it is common to have discomfort in the back or groin region much like the pain from the stone. This, too, will gradually disappear.
Although the stent is soft plastic, any degree of sensation from its presence is possible. Some patients have no feeling, while on the other extreme, some have very bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort (like still having a stone), urinary frequency, urgency or burning. The symptoms may last only one day, or persist for the duration of the presence of the stent. Most patients, however, have very mild symptoms that are tolerable.
Expectations of Outcome
It is important that you understand the possible outcomes of the procedure. While our intent is to fragment a stone into small pieces, this is not always possible. There are occasional instances in which the scope cannot be passed safely into the ureter. Common reasons include a very large prostate, scarring at the orifice (small entrance) of the ureter, or that the stone is impacted (embedded in the tissue and causing a lot of inflammation) in the orifice.
Sometimes the presence of a dense stricture prevents passage of the scope up the ureter. Not all strictures can be dilated or cut. In this case, we might just try to pass a stent to unblock the kidney. The next step would be discussed in a follow-up consultation.
Another obstacle may be that the composition of the stone is too hard to break. The stone (or tumor in those cases in which ureteroscopy is being done for biopsy) may also be situated in an area that is not readily or safely approachable.
Sometimes a stone that is in the ureter is pushed back into the kidney by the water current(from the scope) or from the attempt to break it. If it cannot be accessed or adequately broken, a stent may be placed and a different type of procedure might be planned for another day.
Possible Complications of the Procedure
ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate .This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. We also see infections more commonly in patients who already have a stent in place prior to this procedure. *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Blood Clots in the Urine: Rarely, a small blood vessel can be cut in the ureter, in the bladder, or more commonly in the prostate in males. If the bleeding is significant, it can cause clots that can block the urine flow. A catheter may need to be inserted to flush out the clots. Significant blood loss is very rare as is need for transfusion.
- Urinary Retention: Even in the absence of bleeding, the prostate in males can become swollen from the scopes pressing against it or less commonly secondary to infection. In this instance, a catheter would be placed and your doctor would discuss the next step. Patients at greater risk are those who already have difficulty urinating before the procedure due to BPH (benign prostatic hyperplasia). Ureteral Injury: Despite precautionary measures, the ureter may be injured from the scope or from the instruments used to break/remove your stone or take a biopsy. Usually, we will end the procedure, place a stent in the ureter if possible and allow the tissue to heal itself over the next week or two. A more severe injury (while very rare)may require placement of a nephrostomy tube (different type of tube placed through the back and into the kidney as a temporary means of kidney drainage). A complete ureteral avulsion (separation of the ureter from the bladder or kidney) is a very rare occurrence and requires open surgery through an incision to repair.
- Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This would be quite unusual following a ureteroscopy procedure unless the operative time was long. Following any long procedure, and more commonly following those in which your legs are elevated in stirrups, you can develop a clot in a vein of your leg (DVT). Typically this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office.
Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.