EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES

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EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE
UROLOGICAL PATHOLOGIES

• Pandey S, Shroff S.
• Department of Urology Renal Transplantation,
• Sri Ramachandra Medical College and Research
  Institute, Chennai, India

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INTRODUCTION

• No known incidence of such presentations
• Not much literature available on how to tackle
  these multiple pathologies
• No set rules laid out for approaching these
  multiple pathologies endoscopically in one
  sitting

• Multiple Urological pathologies at presentation
  are not unusual on the same patient especially
  in the developing countries

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Problems in Developing Countries

• Presentation is relatively late
• Economic considerations of the patient
  population plays a pivotal role in this delayed
  presentation

• cure all one sitting Pressure on clinicians
  more in following situation
• Women
• Children
• Old People
• Sole earning member
• Poor or lower middle class people
• Patient coming from a distance for treatment

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ANALYSIS OF MULTIPLE ENDO- PROCEDURES

• Incidence of multiple procedures at
  presentation
• Various combinations of these Pathologies at
  presentation
• Endourological algorithms devised where
  applicable to tackle these problems effectively

• Study Group - SRMC Urology Unit 1
• Period - 1996 to 2002
• Exclusions
• - Local Anaesthesia cases
• Diagnostic procedures
• - open with endoscopic
• E.g Hernias with TURP

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INCIDENCE

• Total number of endourological procedures since
  1996 2002 2176
• Multiple pathologies at presentations 239
• Incidence of presentations 11.1

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MOST COMMON MULTIPLE PATHOLOGIES 239 (11.1
)

• Bilateral Ureteral calculus - 81
• Vesical calculus BPH - 54
• Vesical calculus Ureteral calculus - 41
• BPH Ureteral calculus - 39
• BPH Bladder tumour - 06
• Stricture Urethra with bladder and ureteral
  calculus - 05

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EVOLVING ENDOSCOPIC PROCEDURE GUIDELINES FOR
TACKLING MULTIPLE URO - PATHOLOGIES

• Endoscopic Clearance of easier / less demanding
  pathologies first
• Lower tract to be cleared first before proceeding
  to upper tract
• Completely clear one entity first -
• exceptions to rule - may need TUIP for a large
  median lobe to proceed for URS, followed by TURP

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EVOLVING ENDOSCOPIC PROCEDURE GUIDELINES FOR
TACKLING MULTIPLE URO - PATHOLOGIES

• Lower tract stone disease before upper tract
  Stone disease
• Chronological order of Intervention helps in
  maintaining vision till the end of such multiple
  procedures
• Litholapaxy-gt Lithotripsygt Incisionsgt
  Resections

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ALGORITHMS

• Simple common sense Algorithms

• Complex Endourologic Algorithms

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COMMOM SENSE ALGORITHMS
INTERNAL URETHROTOMY
BNI
TURP
TUIP
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BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!!

• Lower Ureteric Calculus first
• Lesser Impacted calculus first
• Bilateral safety guide wires first
• Side needing stents only first.

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CYSTOLITHOLAPAXY/TRIPSYTURP/TUIP

• Cystolithotripsy -36
• Using 27fr nephroscope,
• 2 mm Swiss Litho probe
• Cystolitholapaxy -18
• Using 25Fr Sheath Mechanical Lithotrite

• Extra operative times-10-45 min
• Morbidity-nil
• Few patients had increased Irritative LUTS

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CYSTHOLAPAXY/TRIPSYTURP CALCULUS FIRST !

• Advantages
• Bladder free of fragments of the calculus
• Good vision still being maintained-Preventing
  inadvertent bladder injury
• Any untoward incident forcing abandonment of
  surgery-May end up with a resected lobe and
  calculus free status!!
• Preventing Absorption/Extravasation of irrigant
  when calculus is dealt before

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VESICAL CALCULUS URETERAL CALCULUS

• Combination-41
• Majority of vesical calculus were 2-2.5 cm
• Majority of ureteral calculus were in the lower
  ureter -26

• WHICH FIRST!!
• OPTIONS------
• 1.Placing guide wire-cystolithotrripsy-URS
• 2.Cystolithotripsy-URS DJ Stenting

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VESICALURETERAL CALCULUS

• Advantageous to complete the ureteral calculus
  first Exceptions- large bladder calculus
• fragments of ureteral calculus and vesical
  calculus can be evacuated at the same time from
  the bladder
• less chances of ureteric orifice injury
  preventing upper tract intervention
  -

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TURP TURBT
Total number of cases-6 Maurmayer et
al- 7 Blandy et al -5.2 TURP
FIRST ! Advantages-1.Resection of Bladder tumour
in inaccesible locations facilitated in empty
prostatic fossa 2.Easy instrumentation. TURBT
FIRST! Advantages-1.Resection occurs in clearer
access 2.Preventing massive absorption of
irrigant as can happen from prostatic fossa.
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BPH URETERAL CALCULUS

• NUMBER OF CASES- 31
• Ureteral calculus first!! ( Exceptions-Large
  median lobe preventing upper tract access TUIP
  and proceed)
  Advantages-1. prevents ureteric orifice injury
  
  2.
• TURP first !! ( with guide wire in situ to
  keep the vision of Ureteric orifice )
• Advantages Allows ease of instrumentation
  of the upper tract

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BPH WITH
VESICAL URETERAL CALCULUS

• 19 cases
• Large median lobe-4, B/L ureteral calculi-1
• Calculi first ! !
• May need TUIP for larger prostates
• lesser extravasation/absorption
• Ureteral first ! !
• Advantage- Prevents oedema/injury to
  ureteral orifice
  
• - Easier access with
  best vision

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PREREQUISITES FOR CURE ALL
ENDOSCOPIC APPROACH

• Use of Endovision camera
• Services of Experienced Operator
• Perceive limitations of Combination procedures
• Preference for general anaesthesia over regional
• Patients to be well counselled and appreciate
  combinations
• Warm Irrigant fluids to avoid hypothermia

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• Aim towards minimal morbidity-
  keeping the patients stable
  haemorrhage and
  extravasation
• Candidates must be relatively fit for extended
  procedures
• Presence of experienced assistant desirable

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TURP
HERNIORRAPHY / HERNIOPLASTY
(guidelines )

• TURP F IRST !
• Avoid liberal TUIP / BNI
• Avoid mesh Repair in presence of Infected
  Urine
• Postpone herniorraphy in case of gross
  Extravasation
• Avoid Bilateral herniorraphy with TURP /
  TUIP

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AVOID

• TURP PCNL -- both accompanied with
  considerable haemorrhage - !!
• B/L Upper tract procedure if-
  
• 1.First side is difficult / prolonged
  procedure
• 2.Pus seen on clearing calculus on one
  side

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REMEMBER

• THERE IS ALWAYS
• A SECOND
  CHANCE !!!