Flexible Ureteroscopy

Contents
History of Ureteroscopy
	References
Anatomical Considerations During Flexible Ureteroscopy
	1	 Introduction
	2	 Urinary Tract Anatomy
	3	 Anatomic Considerations Within Ureteroscope Technology
	4	 Urinary Tract Angles and Lengths
	5	 Calyx Location
	6	 Variations in Calyceal Anatomy
	7	 Duplicated Urinary Systems
	8	 Alternative Renal Anatomy
	9	 Ectopic Kidneys
	10	 Surgical Anatomic Variations
	11	 Summary
	References
Armamentarium and Endoscopes
	1	 Introduction
	2	 Access to the Ureter
	3	 General Information on Ureteral Access Sheaths
		3.1	 Insertion of the Ureteral Access Sheath
		3.2	 Different Diameters of the Ureteral Access Sheaths
		3.3	 Types of Ureteral Access Sheaths
	4	 General Information on Flexible Ureterorenoscopes
		4.1	 Reusable Flexible Ureterorenoscope
		4.2	 Disposable Ureteroscopes
	5	 General Information on Disposables for the Removal of Urinary Stones
		5.1	 Tipless Baskets
		5.2	 Graspers
		5.3	 Forceps
		5.4	 Biopsy Forceps
		5.5	 Guidewires
		5.6	 Irrigation
		5.7	 Suction
	6	 General Information on Lithotripsy in Flexible Ureterorenoscopy
		6.1	 Holmium Laser
		6.2	 Thulium Fiber Laser
	7	 Summary
	References
Accessories, Sterilization, and Instrument Care in Flexible Ureteroscopy
	1	 Guidewires
	2	 Ureteral Access Sheath
		2.1	 Size and Length
		2.2	 Innovations in UAS Design
		2.3	 Advantages of Using a UAS
		2.4	 Disadvantages of Using a UAS
		2.5	 Conclusion
	3	 Baskets and Biopsy Devices
		3.1	 Baskets
		3.2	 Biopsy Forceps
	4	 Endoscopic Sterilization and Care
		4.1	 Decontamination Efficacy
		4.2	 Effect on Ureteroscope Durability
	5	 Conclusion
	References
Lasers in Flexible Ureteroscopy
	1	 Introduction
	2	 Background and Brief History
	3	 Mechanistic Aspects of Laser Lithotripsy
		3.1	 Fiber to Stone Distance
	4	 Holmium Laser
		4.1	 Laser Settings and Parameters
			4.1.1	 Pulse Energy
			4.1.2	 Frequency
			4.1.3	 Pulse Duration
			4.1.4	 Pulse Modulation
			4.1.5	 Power and Heat Generation
	5	 Stone Retropulsion
	6	 Laser Fibers
		6.1	 Laser Fiber Tip Configuration
		6.2	 Laser Fiber-Tip Degradation
	7	 Surgical Strategies for Laser Lithotripsy: Dusting vs. Fragmentation
		7.1	 Dusting: Contact Laser Lithotripsy
		7.2	 Dusting: Non-Contact Laser Lithotripsy
	8	 Thulium Fiber Laser
	9	 Conclusion
	References
Preoperative Assessment, Patient Preparation and Anaesthesia for Flexible Ureteroscopy
	1	 Preoperative Assessment
	2	 MSU and Management of UTI Preoperatively
	3	 Patient Preparation
	4	 Anaesthetic Management
		4.1	 Local Anaesthetics
		4.2	 Spinal Anaesthesia
		4.3	 General Anaesthesia
		4.4	 Patient Positioning
		4.5	 Laser Precautions
		4.6	 Autonomic Dysreflexia
		4.7	 Postoperative Management
	5	 Planning and Safety Meeting
	6	 Summary
Indications and Contraindications of Flexible Ureteroscopy
	1	 Introduction
	2	 Anatomy
		2.1	 Ureter
			2.1.1	 Are Blockers Useful to Prepare the Ureter?
		2.2	 Renal Pelvis
	3	 Indications
		3.1	 Distal and Mid Ureteral Stones
		3.2	 Proximal Ureteral Stones
		3.3	 Intrarenal Stones Less Than 20 mm
		3.4	 Lower Pole Stones
		3.5	 Intrarenal Stones Larger Than 20 mm
		3.6	 Endoscopic Combined Intrarenal Surgery
		3.7	 Flexible Ureteroscopy in Special Situations
			3.7.1	 Anticoagulated Patients
	4	 Contraindications
	5	 Conclusions
	References
Clinical and Operating Room Setup for Flexible Ureteroscopy
	References
How to Perform Flexible Ureteroscopy for Renal Stones
	1	 Preoperative Planning
	2	 Informed Written Consent
	3	 Anesthesia
	4	 Preoperative Checklist
	5	 Ergonomics
		5.1	 Cysto-Urethroscopy
		5.2	 Semirigid Ureteroscopy
		5.3	 Ureteric Dilatation
		5.4	 Ureteral Access Sheath (UAS) Placement
		5.5	 Stone Disintegration
			5.5.1	 Popcorning
		5.6	 Exit Strategy
	6	 Postoperative Monitoring
	7	 Special Situations
	8	 Summary
	References
Irrigation Mechanisms and Intrarenal Pressure in Flexible Ureteroscopy
	1	 Introduction
	2	 Irrigation Methods and Mechanisms in Flexible Ureteroscopy
	3	 Methods of Irrigation
	4	 Irrigation Flow: Endoscopes, Baskets, and Laser Fibers
	5	 Irrigation, Pressure Monitoring and Control
	6	 Intrarenals Pressure Values (IRP) During Ureterorenoscopy
		6.1	 Intrarenal Pressure
	7	 Intrarenal Pressure During Ureterorenoscopy
	8	 Intrarenal Pressure Values During PCNL
	9	 Ureteral Access Sheaths
	10	 Pharmacological Modulation of the Intrarenal Pressure
	11	 Future Perspectives
	References
Double J Stents in Flexible Ureteroscopy: Rationale and Indications of Ureteric Stenting Before and After Flexible Ureteroscopy
	1	 Introduction
	2	 Rationale, Indications, and Alternatives
	References
Flexible Ureteroscopy for Large Renal Stones
	1	 Introduction
	2	 Indications and Contraindications
	3	 Current Results and Comparison with PCNL
	4	 Limitations of f-URS in the Treatment of Large Stones
	5	 How to Improve the Surgical Technique
	6	 How to Improve Discharge of Stone Fragments After Flexible Ureteroscopy
	7	 Future Perspectives
	8	 Summary
	References
Around Endoscopic Combined IntraRenal Surgery (ECIRS) in 80 Papers
	1	 Introduction
	2	 Conclusions
	References
Flexible Ureterorenoscopy in the Treatment of Childhood Stone Disease
	1	 Management of Renal Stones in Pediatric Cases with Flexible Ureteroscopy
	References
Flexible Ureteroscopy in Special Situations
	1	 Diverticular Stones
		1.1	 Management of Diverticular Stones
		1.2	 Endoscopic Management
		1.3	 Treatment Selection
	2	 Horseshoe, Pelvic, and Transplanted Kidneys
		2.1	 Horseshoe Kidneys
		2.2	 Flexible Ureteroscopy in Horseshoe Kidney
		2.3	 Ectopic Kidneys
		2.4	 Transplantation Kidneys
		2.5	 Technique
	3	 Management of Encrusted Stents
		3.1	 Preoperative Considerations
		3.2	 Procedure Technique
	4	 Obese Patients
		4.1	 Preoperative Considerations
		4.2	 Technical Considerations
	5	 Flexible Ureteroscopy in Urinary Diversions
		5.1	 Technical Aspects
	6	 Flexible Ureteroscopy in Pregnancy
		6.1	 Stones in Pregnant Patients
		6.2	 Presentation
		6.3	 Diagnosis and Natural History of Pregnancy Stones
		6.4	 Definitive Treatment
		6.5	 The Evolution of fURS in Pregnancy
		6.6	 Procedure
		6.7	 Results
	References
Complications of Flexible Ureteroscopy
	1	 Introduction
	2	 Classification Systems
	3	 Overall Risk Factors Related to Complications from Ureteroscopy
		3.1	 Operative Time
	4	 Infectious Complications
		4.1	 Fever and Urinary Tract Infection
		4.2	 Urosepsis
		4.3	 Perirenal Abscess
		4.4	 Prevention of Infectious Complications
		4.5	 Treatment of Infectious Complications
	5	 Hematologic and Vascular Complications
		5.1	 Bleeding and Hematuria
		5.2	 Prevention of Bleeding Complications
		5.3	 Treatment of Bleeding Complications
			5.3.1	 Subcapsular, Perirenal and Retroperitoneal Hematoma Formation
			5.3.2	 Endoureterotomy or Endopyelotomy
			5.3.3	 Renal Pseudoaneurysm
			5.3.4	 Arteriovenous Fistula
			5.3.5	 Ureteroiliac Fistula
		5.4	 Deep-Vein Thrombosis
		5.5	 Cerebrovascular Accident and Transient Ischemic Attack
	6	 Organ Injuries
		6.1	 Kidney Injury
			6.1.1	 Fornix Rupture
			6.1.2	 Transient Serum Creatinine Elevation
			6.1.3	 Post-Obstructive Diuresis
		6.2	Ureteral Injury
			6.2.1	 Difficult Ureteral Access
			6.2.2	 Classification of Ureteral Wall Injuries
			6.2.3	 Ureteral Wall Injuries
			6.2.4	 Extraureteral Stone Migration
			6.2.5	 Ureteral Avulsion
			6.2.6	 Ureteral Intussusception
			6.2.7	 Vesicoureteral Reflux
			6.2.8	 Ureteral Stricture
		6.3	 Bladder Injury
			6.3.1	 Urinary Retention
		6.4	 Urethra Injury
			6.4.1	 Urethral Injury
		6.5	 Other Organ Dysfunctions
			6.5.1	 Bowel
	7	 Instrument-Related Complications
		7.1	 Instrument Malfunction and Damage
		7.2	 Locked Instruments
		7.3	 Damages from Lithotripters
	8	 Implant-Related Complications
		8.1	 Ureteral Stent Migration
		8.2	 Intravascular Ureteral Stent Migration
		8.3	 Forgotten Ureteral Stent
		8.4	 Ureteral Access Sheaths
	9	 Pregnancy-Related Complications
		9.1	 Preterm Labor
	10	 Mortality
	11	 Patient-Reported Outcomes
		11.1	 Pain and Renal Colic
		11.2	 Ureteral Stent Discomfort
	12	 Readmission and Secondary Intervention
		12.1	 Hospital Readmission
		12.2	 Secondary Intervention
			12.2.1	 Stone Migration and Residual Fragments
			12.2.2	 Ureteral Obstruction and Steinstrasse
	13	 Conclusion
	References
Postoperative Care and Quality of Life After Flexible Ureteroscopy
	1	 Postoperative Care Following fURS
		1.1	 Introduction
		1.2	 Postoperative Care of Patients with Infectious Complications Following fURS
			1.2.1	 Risk Factors and Diagnosis
			1.2.2	 Treatment
			1.2.3	 Summary
		1.3	 Postoperative Care of Patients with Ureteral Injuries Following fURS
			1.3.1	 Risk Factors and Diagnosis
			1.3.2	 Summary
		1.4	 Postoperative Care of Patients with Hemorrhagic Complications Following fURS
			1.4.1	 Risk Factors and Diagnosis
			1.4.2	 Treatment
			1.4.3	 Summary
		1.5	 Pain Management Following fURS
		1.6	 Postoperative Drainage Care Following fURS
		1.7	 Residual Fragments Following fURS
	2	 Quality of Life (QoL) Following fURS
	3	 Patient Education and Decision-Making
	4	 Conclusions
	References
Disposable Flexible Ureteroscopes
	1	 Introduction
	2	 Disposable Flexible Ureteroscopes: From Past to Present
	3	 Image Quality
	4	 Performance
	5	 Ergonomics
	6	 Cost-Effectiveness
	7	 Environmental Impact
	8	 Single-Use Flexible Ureteroscopes: Clinical Indications
	9	 Conclusion
	References
Robotic Flexible Ureteroscopy (Robotic fURS)
	1	 Introduction
	2	 The “Avicenna Roboflex” Robotic System
	3	 Current Evidence of the Roboflex
	4	 Future
	5	 Conclusions
	References
Diagnostic Flexible Ureteroscopy
	1	 Introduction
	2	 Indications
		2.1	 Unilateral Hematuria
		2.2	 Upper Tract Urothelial Carcinoma (UTUC)
	3	 Diagnostic Findings
		3.1	 Upper Urinary Tract Tumors
		3.2	 Benign Upper Tract Lesions
	4	 Others
	5	 Guidelines
		5.1	 Microhematuria
	6	 Novel Technologies and Future Directions
		6.1	 Photodynamic Diagnosis
		6.2	 Narrow-Band Imaging
		6.3	 Optical Coherence Tomography
		6.4	 Confocal Laser Endomicroscopy
	7	 Conclusion
	References
Flexible Ureteroscopy in UPJ and Ureteral Stenosis
	1	 Etiology
	2	Indications
	3	 Methods
		3.1	 Preparation
		3.2	 Technique
	4	 Results
	5	 Complications
	References
Flexible Ureteroscopy for Upper Tract Urothelial Carcinoma
	1	 Flexible Ureteroscopy for UTUC: When to Perform It
	2	 Flexible Ureteroscopy for UTUC: The Risk of Delayed Treatment and Intravesical Recurrence
	3	 Flexible Ureteroscopy for UTUC: How to Perform It
	4	 Selective Urine Cytology During Ureteroscopy: Yes or No
	5	 Ureteral Access Sheath to Optimize Biopsy Sampling: Yes or No
	6	 Digital vs. Fiber-Optic Ureteroscopy
	7	 Enhanced Imaging Technology: Sense or Nonsense
	8	 Guidelines Recommendations about Flexible Ureteroscopy in UTUC
	9	 Highlights
	References
Training
	1	 Introduction
	2	 Concept of Learning Curve and Its Implications
	3	 Importance of Structured Training and Recommendations for Training
	4	 E-Learning
	5	 Simulation in Training
	6	 Benchtop Models
		6.1	 K-Box
		6.2	 Advanced Scope Trainer (AST)
		6.3	 Cook URS Trainer
		6.4	 The Smart Simulator
		6.5	 Adult Ureterorenoscopy Trainer (Ideal Anatomic Modelling, Holt, MI)
	7	 Virtual-Reality Simulators
	8	 Animal or Cadaveric Models
	9	 Assessment
	10	 Nontechnical Skills Training
	11	 Further Aids
	12	 Conclusion
	References