Complications of ureteroscopy
Intra-operative:
- Bleeding and loss of vision
- Loss of access
- Ureteric injury and rarely avulsion
- Failure to access or clear stone, needing additional procedures
- Equipment malfunction
- Risks of general anaesthesia and positioning
Early post-operative:
- Infection and sepsis (5 % significant infection)
- Haematuria
- Pain including stent irritation and passage of fragments
- Ureteric oedema and obstruction
Late post-operative:
- Ureteric stricture
Access sheath
Pros:
- Allow continuous outflow and stops bladder from overfilling
- Allows ease of in and out access
- Reduces intra-renal pressures
- Reduces operative time
- Improves vision
Cons:
- Potential injury more likely
- Higher pain post-operatively if not stented
- May not allow increased drainage if scope in lumen of access sheath
Stenting
Post URS stent can be omitted if:
- No suspected injury
- No ureteric stricture or anatomical impedance to fragment clearance
- Good fragmentation / no significant residual fragments
- No significant bleeding
- Normal contra-lateral kidney
- No renal impairment
- No plan for re-look procedure
EAU “stents should be inserted in patients at increased risk of complications … and in all doubtful cases, to avoid stressful emergencies”
Pre-ureteroscopy stenting can be omitted routinely – however pre-stented ureteroscopy does increase SFR and reduces complications (at cost of 2 x procedures and stent morbidity).
Submucosal ureteric stones
These should probably be lasered out and retrieved – risk of stricture very high if left in situ.
Strategies to minimise ureteroscopy complications:
Pre-op:
- Urine culture and treat any infection
- Pre-stenting an option especially for larger stones
- Prophylactic antibiotics
Intra-op:
- Minimum operating time
- Reduce intra-renal pressures
- Safety wires
- If in doubt, stent and come back
- Saline irrigation (not water)
Post-op:
- Alpha blockers to reduce stent morbidity
- Reduce stent dwell time
Care of the ureteroscope
Damage can occur:
- Intra-operatively
- Between procedures
Strategies to prevent damage:
- Move lower pole stones to upper pole to avoid prolonged deflection
- Keep laser in vision out of the scope tip
- Laser on standby when not in use
- Keep scope straight when passing over wire
- Keep scope straight when not in use (on scrub table etc)
- Pressure leak testing after each procedure before being sent for cleaning
- Cleaning and sterilisation as per manufacturer instructions by dedicated staff
- Keep stored carefully in dedicated cases
- Consider use of disposable ureteroscopes for appropriate cases