WIRELESS URETEROSCOPY IS FEASIBLE AND SAFE

Transcription

1 WIRELESS URETEROSCOPY IS FEASIBLE AND SAFE Scott G. Hubosky, MD The Demetrius H. Bagley Jr., MD Associate Professor of Urology Director of Endourology Vice Chair of Quality and Safety Thomas Jefferson University Hospital Philadelphia, PA, USA

2 DISCLOSURES I HAVE NO FINANCIAL INTERESTS OR RELATIONSHIPS TO DISCLOSE

3 Controversies in Endourology FOIU 2016

4 Why do we use wires during Ureteroscopy? Upper Tract Access Semi-Rigid Ureteroscopy Flexible Ureteroscopy Ultimate Safety Mechanism Allows stent placement at any time Ureteral Perforation Excessive Bleeding Any adverse event precluding the completion of ureteroscopy

5 Problems with Safety Wires During Ureteroscopy IMPAIRS VISUSALIZATION BY CAUSING BLEEDING PROVIDE RESISTANCE TO URETEROSCOPE PASSAGE Sometimes adjacent safety wire prohibits access! MORE TORQUE NEEDED FOR URETEROSCOPE ROTATION INHIBITS APPLICATION OF LASER FIBER OR BASKET TO TARGET

6 THE PROBLEM WITH SAFETY WIRES...

7 IMPAIRED VISUALIZATION!

8 REMEMBER: WIRELESS URETEROSCOPY IS NOT NEW No-Touch technique during ureteroscopic evaluation of upper tract urothelial carcinoma Evaluate distal ureter with semi-rigid ureteroscope (without wire) Leave wire to level evaluated Place flexible ureteroscope over wire, then remove wire AVOID WIRE TRAUMA during delicate diagnostic ureteroscopy

9 EVOLUTION

10 From Ham-Fisted.

11 .To Elegant

12 From Ham-fisted to Elegant Johnson et al J Endourol 20(8)

13 EX VIVO ANALYSIS OF FORCE REQUIRED TO PLACE FLEXIBLE URETEROSCOPE IN PORCINE MODEL Eandi et al 2008 J Endourol 22(8)

14 Evaluating the Need for Use of a Safety Guidewire during Ureteroscopy Initial Hybrid wire placed to aid in advancement of flexible ureteroscope over the guidewire in a monorail fashion. Further steering of the ureteroscope directed by endoscopic vision avoids unnecessary trauma to the ureter. Once pathology encountered, guidewire was removed. Procedures all done to completion. No patient treated without a safety wire needed percutaneous intervention for inability to place an intraoperative stent when desired. Eandi et al 2008 J Endourol 22(8)

15 Evaluating the Need for Use of a Safety Guidewire during Ureteroscopy (DUR-8 fiberoptic) Safety Wires used in 8% of cases (30/391) Cases in which safety wire is used: Endopyelotomy or Endoureterotomy Higher risk of luminal bleeding- may impair visualization Impacted ureteral stone Instances where wire can straighten the ureter Eandi et al 2008 J Endourol 22(8)

16 Is a Safety Wire necessary during Routine Flexible Ureteroscopy? Flexible URS done on 305 renal units in 246 consecutive cases (59 bilateral) All cases were Renal or UPJ stones Authors admit to always using a safety wire for ureteral stones 270 cases (88%) were classified as uncomplicated No safety wire used Basketing not routinely done No complications related to lack of safety wire No lost access No perforations or avulsions No need for percutaneous access 35 cases were complicated Safety wire was utilized (Only 12%) Average stone size 9 mm SFR 88% Dickstein et al 2010 J Endourol 22(8)

17 Is a Safety Wire necessary during Routine Flexible Ureteroscopy? Dickstein et al 2010 J Endourol 22(8)

18 The Ureteroscope as a Safety Wire for Ureteronephroscopy 268 retrograde ureteroscopies for renal stones without a safety wire Guidewire used for initial access Ureteral Access Sheath placed when basketing fragments Smaller stones just dusted Mean stone size 12 mm No perforations or avulsions Patel, Nakada et al J Endourol 26 (4) 351-4

19 The Ureteroscope as a Safety Wire for Ureteronephroscopy Situations where a safety wire is needed Treatment of ureteral stones (mucosal edema) Basketing stones Need to dilate the ureter Any incisional procedure Abnormal anatomy Patel, Nakada et al J Endourol 26 (4) 351-4

20 2016 AUA / Endourological Society Guideline Statement on Safety Wires Safety wire is particularly valuable during ureteroscopy when the ureter is at risk. Ureteral pathology exists (ureteral stone, ureteral stricture) OK to omit safety wire in certain situations When safety can t be placed all the way past ureteral stone When treating intrarenal stone through a ureteral access sheath Expert Opinion = There is no evidence Assimos et al

21 2015 European Guidelines on Urolithiasis Turk, Knoll et al

22 SUMMARY NO SAFETY WIRE (sometimes) No-touch technique for tumor cases (UTUC) Renal stones with no ureteral pathology SMART TO USE SAFETY WIRE If basketing stones or tumors Incisional procedures Primary ureteral pathology Ureteral stone UTUC Need for dilation Presence of a stricture GOOD ALTERNATIVE: INCH PTFE-coated wire

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