Edward S. Lyon

Endoscopic diagnosis and treatment of upper‐tract urothelial tumors. A preliminary report

The technique of transurethral ureteropyeloscopy allows many standard cystoscopic procedures to be extended into the upper urinary tract. This endoscopic method was used to evaluate 31 patients suspected to have urothelial malignancies of the ureter or renal pelvis. Twenty‐eight of the patients had the procedure successfully completed (90%), 11 of whom were found to have urothelial tumors. Diagnostic ureteroscopic biopsy in three of these patients revealed high‐grade, multifocal tumors and was followed by nephroureterectomy (two patients) or partial ureterectomy (one patient). However, in eight patients, ureteroscopy and biopsy revealed apparently localized, low‐grade tumors which were treated by ureteroscopic fulguration or resection. The latter patients have undergone endoscopic surveillance every 3 months (average follow‐up, 21 months). The technique of ureteropyeloscopy permits endoscopic access into the ureter and renal pelvis, enabling tissue diagnosis and better preoperative cancer staging without surgical exploration. Although follow‐up is short, selected patients with low‐grade tumors may be treated primarily by endoscopic means. Cancer 55:1422‐1428, 1985.

Flexible ureteropyeloscopy: diagnosis and treatment in the upper urinary tract.

Flexible ureteropyeloscopy was performed on 59 patients with 2.7, 3.2 or 3.6 mm. endoscopes with a deflectable tip. Techniques for use of these flexible endoscopes are discussed in detail. The endoscope could be passed into the ureter in 58 patients and into the kidney in 52 (88 per cent). The entire collecting system was visualized in 23 of the most recent 29 patients (79 per cent). A diagnosis was achieved in all 23 patients with an intrarenal filling defect demonstrated radiographically. The source of gross hematuria alone could be defined in 9 of 17 patients. Surveillance for tumor was achieved in 5 of 5 patients and for residual calculus in 4 of 4. The endoscope was used to establish continuity successfully in 3 patients with an obstructed ureteropelvic junction. An instrument with a deflectable tip and some technique for irrigation are essential for intrarenal inspection and complete visualization of the ureter. This procedure is valuable in selected patients and it rapidly may become the technique of choice for the diagnosis of intrarenal filling defects. It also is of value in patients with benign, essential hematuria.

Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy.

Transurethral ultrasonic fragmentation of stones allows successful endoscopic removal of upper urinary calculi that otherwise would be considered too large to extract. We successfully extracted endoscopically 2 large renal pelvic and 5 large ureteral stones using transurethral ureteropyeloscopy and ultrasonic lithotripsy. The stone is visualized first with the ureteropyeloscope, and then engaged in a basket and either fragmented or disintegrated with the ultrasonic transducer. Any remaining small stone fragments can be retrieved with a stone basket or forceps. There has been little morbidity with this procedure and patients can return to normal activity after discharge from the hospital.

Transurethral ureteroscopy in women: A ready addition to the urological armamentarium

Ureteroscopy via the transurethral route and limited to the terminal ureter in women lends itself to inclusion in the urological armamentarium. The technique requires no equipment other than routine urological instruments and makes endoscopic inspection, biopsy and resection within the distal ureter possible. The procedure is done with the patient under anesthesia, following urethral dilation to 32F. With the aid of a small caliber cystoscope, 20F or smaller, straight Jewett sounds can be passed into the urethra alongside the cystoscope and directed under cystoscopic control into the ureteral orifice. The orifice is then dilated gently, using 12, 14 and, if necessary, 16F sounds. One of the standard pediatric cystoscopes can then be introduced easily into the orifice. Currently, the technique is being used routinely in women with transitional cell carcinoma involving the ureteral orifice or intramural ureter. In 1 patient a tumor arising from within the lower ureter was resected successfully using a pediatric resectoscope.

Treatment Options for Proximal Ureteral Urolithiasis: Review and Recommendations

The treatment of proximal ureteral calculi has been altered markedly by recent developments in shock wave lithotripsy (bypass, pushback and in situ), ureterorenoscopy and percutaneous stone removal. In an effort to discern the proper role of these newer treatment options with respect to ureterolithotomy (flank approach or dorsal lumbotomy), we completed a multicentered study in which 142 upper ureteral stone patients in 7 different treatment categories were reviewed retrospectively and contacted for convalescence data. From these data we conclude that before extracorporeal shock wave lithotripsy an upper ureteral stone should be manipulated until it is either pushed back to the kidney or bypassed with a stent. This maneuver should result in successful extracorporeal shock wave lithotripsy in more than 90 per cent of the patients. For those few patients with an impacted upper ureteral calculus ureterorenoscopy is recommended. Given the presently available treatment modalities we conclude that less than 3 per cent of all upper ureteral calculi will require ureterolithotomy. In this last circumstance a dorsal lumbotomy incision appears to be less morbid and yet as effective as anterior ureterolithotomy.

Endourological Management of Upper Tract Urothelial Tumors

Advances in ureteroscopic and percutaneous techniques have made it possible to treat many upper tract malignancies by conservative, parenchyma sparing surgery. Percutaneous techniques generally allow for easier and better access to the renal pelvis and improved tumor resection. However, concerns for tumor spillage and nephrostomy tract seeding make the ureteroscopic approach best for initial management of accessible renal pelvic lesions, particularly when the diagnosis is unclear. Ureteral tumors, especially those arising in the lower third of the ureter, are technically easier to treat endoscopically than are renal pelvic tumors. Fulguration or laser photocoagulation may be used to ablate the tumor following cold-cup biopsy for histological diagnosis. Supplemental therapy using laser treatment of the tumor base, and postoperative instillation of BCG and mitomycin C offer great potential benefit in terms of improved tumor control. Confirmation of such benefit awaits the results of larger trials. Presently, standard nephroureterectomy remains the procedure of choice for most transitional cell carcinomas of the upper urinary tract in patients with a normal contralateral kidney. For those with a solitary kidney, renal insufficiency, bilateral tumors or severe intercurrent disease preventing a major open operation conservative management using endoscopic techniques is a viable alternative. Overall, it appears that grade and stage are far more important determinants of long-term out-come than the type of operation in those with transitional cell carcinoma of the upper urinary tract. For this reason, some physicians have recommended conservative management of low grade, noninvasive lesions even in the face of a normal opposite kidney. However, the majority of patients with upper tract urothelial tumors are best treated by nephroureterectomy, which leads to a low risk of local recurrence and obviates the need for rigorous postoperative upper tract surveillance.

Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents

Of 6,275 pregnancies seen at our institution over a two-year period, 5 patients required operative intervention for acute urinary obstruction unresponsive to medical management. Ultrasonography was able to definitively diagnose the presence of an obstructing calculus in 4 of 5 patients. Using ultrasound guidance, 7 indwelling ureteral stents were successfully placed with local anesthesia supplemented by intravenous sedation. Complications consisted of distal stent migration in 1 patient. This method of management was successful for symptomatic nephrolithiasis in a pregnant renal transplant patient. Endoscopic placement of ureteral stents under ultrasound guidance is an effective, safe method of urinary decompression, with no radiation risks imparted to the mother or fetus. Definitive therapy then can be safely deferred to the post-partum period.

Ureteroscopy and ureteropyeloscopy

Transurethral endoscopic access to the upper urinary tract using rigid optics is evolving into a significant addition to the specialty of urology. The basic endoscopic expertise urologists have perfected for use in the urethra, prostate, and bladder is readily transposed to the ureter and renal pelvis. Indications, precautions, instrumentation, and procedural techniques are detailed.

Treatment of distal ureteral calculi using rigid ureteroscope

Abstract Rigid transurethral ureteroscopy has been utilized on sixteen occasions for the treatment of distal ureteral calculi. This resulted in successful stone removal and avoidance of an open operation in 69 per cent of the cases. The advantages of this type of treatment are that it enables endoscopic access to a surgically difficult portion of the ureter and allows direct visualization during basket manipulation of ureteral calculi.

Combined Rigid and Flexible Uretergpyeloscopy

The development of rigid and flexible ureteropyeloscopes has provided the means for direct visualization of the upper urinary collecting system. Each instrument has its own advantages and disadvantages. The combined use of these instruments extends the range of endoscopy throughout the intrarenal collecting system, permits irrigation and provides a working channel.