**Treatment Overall Stone size < 10mm Stone size >10mm**

81% 89%

#### **Proximal ureter:**

Ureteroscopy overall Flexible ureteroscopy

**Table 4.** Proximal Ureter; stone clearance comparison between Ureteroscopy and ESWL.

ESWL 82% 90% 68%

#### **Mid Ureter:**

The reduced success for stone free rates using ESWL in the mid ureter is likely explained by the anatomical changes at this site. The mid-ureter is closely related to the transverse proc‐

80% 84% 79%

esses of the lumbar verterbrae and focus of the lithotripsy beam is more difficult due to the

91%

The reduced success for stone free rates using ESWL in the mid ureter is likely explained by the anatomical changes at this site. The mid-ureter is closely related to the transverse proc‐ esses of the lumbar verterbrae and focus of the lithotripsy beam is more difficult due to the

**Treatment Overall Stone size < 10mm Stone size >10mm**

97% 98%

The use of holmium laser lithotripsy via ureteroscopy is safe and effective in urinary stone management, particularly for larger calculi. It is associated with success rates of more than

In a study which described 300 procedures of ureteric stone lithotripsy with holmium la‐ ser, there was an overall complication rate of 10%. Their overall success rates were 90% and after the first episode, 86% were stone free [21]. In another series of 598 patients, the overall complication rate was 4%, with an overall the success rate of 97% and 94% after

Upper tract TCC accounts for approximately 10% of all renal tumors and 5% of all urothelial tumors. It is found to be more common in Caucasian, occurs more often in the sixth to sev‐ enth decade of life [26]. Worryingly there is evidence to suggest that the incidence of upper tract TCC is increasing [27]. The presentation is usually with haematuria and approximately 30% will have "ureteric colic" secondary to blood clot [28]. They occur more commonly in

**5. Upper tract Transitional Cell Carcinoma (TCC) / malignancy**

ESWL 74% 86% 74%

**Table 6.** Distal Ureter; stone clearance comparison between Ureteroscopy and ESWL.

Not documented

78%

93% 94%

Not documented

Modern Upper Urinary Tract Endoscopy http://dx.doi.org/10.5772/52750 377

**Treatment Overall Stone size < 10mm Stone size >10mm**

ESWL 73% 84% 76%

**Table 5.** Mid Ureter; stone clearance comparison between Ureteroscopy and ESWL.

86% 88%

94% 94%

90% and with complication rates as low as 10%.

people with a history of bladder cancer.

anatomical relationships to the spine.

anatomical relationships to the spine.

Ureteroscopy overall Flexible ureteroscopy

**Distal ureter:**

Ureteroscopy overall Rigid ureteroscopy

the first episode [25].

esses of the lumbar verterbrae and focus of the lithotripsy beam is more difficult due to the anatomical relationships to the spine.


**Table 5.** Mid Ureter; stone clearance comparison between Ureteroscopy and ESWL.

The reduced success for stone free rates using ESWL in the mid ureter is likely explained by the anatomical changes at this site. The mid-ureter is closely related to the transverse proc‐ esses of the lumbar verterbrae and focus of the lithotripsy beam is more difficult due to the anatomical relationships to the spine.

#### **Distal ureter:**

teroscopic procedures rose from 86% to 96%. In addition, they observed an overall decrease in complications (20% to 12%) in ureteroscopy and 6.6% to 1.5% in ureteroscopic laser litho‐ tripsy [21]. Partly, this was thought to be due to greater surgeon experience and that this is significantly correlated to higher success and lower complication rates in ureteroscopic laser

The success rates (stone free or insignificant fragments) reported with PCNL are greater than 90% for renal stones >2cm. However, major complications during or after PCNL occur at reported rates of 0.03 % to 10% [22]. The success rates of retrograde intra-renal surgery have been reported as 75-95% for intra-renal stones >2cm after the first or second treatment, whereas the major or minor complications vary from 1.5 % to 12% [23].This is less frequent than rates in PCNL procedures. Major complications in ureteroscopy such as ureteric perfo‐

One study of a two year experience, highlighted that the success rates following ESWL were heavily influenced by stone size.The overall stone free success rate was 74.7% with one ses‐ sion. However, as the size of the stone increased, the success rate reduced. For stones <1cm the success ratewas 83.6%and when the stone size > 1cm the success rate reduced to 42.1%. The stone free rates also varied according to the site of the stone - 72.4% (proximal), 70%

In ureteroscopy, an overall stone –free rate of 87.8% was obtained irrespective of the size of the stone (88.9% for <1cm and 86.6% for >1cm). The success rates did slightly vary in relation to the stone site. The stone-free rates were 75% (proximal), 94.6% (mid ureter) and 84.6%

The American Urological Association recent 2012 guidelines have published stone free rates for Shock Wave lithotripsy and ureteroscopy for the treatment of ureteric calculi and these

> 80% 84%

The reduced success for stone free rates using ESWL in the mid ureter is likely explained by the anatomical changes at this site. The mid-ureter is closely related to the transverse proc‐

79%

**Treatment Overall Stone size < 10mm Stone size >10mm**

ESWL 82% 90% 68%

**Table 4.** Proximal Ureter; stone clearance comparison between Ureteroscopy and ESWL.

81% 89%

lithotripsy with holmium laser [21].

ration or avulsion are extremely rare.

(mid ureter), and 82% (distal) after a single session [14-15].

**Renal Calculi**

376 Endoscopy

**Ureteric Calculi**

(distal) [24].

**Proximal ureter:**

Ureteroscopy overall Flexible ureteroscopy

**Mid Ureter:**

are outlined in the tables below:


**Table 6.** Distal Ureter; stone clearance comparison between Ureteroscopy and ESWL.

The use of holmium laser lithotripsy via ureteroscopy is safe and effective in urinary stone management, particularly for larger calculi. It is associated with success rates of more than 90% and with complication rates as low as 10%.

In a study which described 300 procedures of ureteric stone lithotripsy with holmium la‐ ser, there was an overall complication rate of 10%. Their overall success rates were 90% and after the first episode, 86% were stone free [21]. In another series of 598 patients, the overall complication rate was 4%, with an overall the success rate of 97% and 94% after the first episode [25].

### **5. Upper tract Transitional Cell Carcinoma (TCC) / malignancy**

Upper tract TCC accounts for approximately 10% of all renal tumors and 5% of all urothelial tumors. It is found to be more common in Caucasian, occurs more often in the sixth to sev‐ enth decade of life [26]. Worryingly there is evidence to suggest that the incidence of upper tract TCC is increasing [27]. The presentation is usually with haematuria and approximately 30% will have "ureteric colic" secondary to blood clot [28]. They occur more commonly in people with a history of bladder cancer.

CT Urography is the standard diagnostic tool. However non-visualisation of lesions has been reported in 20% of renal pelvis and 40% of ureteric tumors. Ureteroscopy (semi-rigid or flexible) has been used to improve this accuracy as well as provide histological confirma‐ tion (figure 11). Williams et al have shown that ureteroscopic biopsy accurately predicts fi‐ nal histology at Nephro-ureterectomy in 75% of cases and further increases accuracy when combined with exfoliative cytology (brushing the lesion with a brush passed endoscopical‐ ly) [29]. Ureteroscopic technique is as outlined before with the exception of use of a safety wire. While a wire is used, it should be placed in the ureter under direct ureteroscopic vi‐ sion. This is because wire related urothelial trauma can mimic TCC and such trauma does make cytological analysis more difficult.

appearance with negative cytology [32]. From the point of view of laser choice the Holmium

Modern Upper Urinary Tract Endoscopy http://dx.doi.org/10.5772/52750 379

PUJ obstruction is a functional blockage to antegrade flow of urine to the bladder from the upper tract due to a narrowing at the PUJ. Its classically treated by an open (or laterally lap‐ aroscopic) procedure by the name of Pyeloplasty. Retrograde endopyelotomy is a minimally invasive option.This is performed using a large calibre rigid ureterorenoresectoscope or us‐ ing a Holmium laser. The laser procedure is more common and usually linked with subse‐ quent balloon dilatation of the incised area. The incision is made laterally at the PUJ to minimise vascular injury. The incision is deepened until peri-ureteric fat is seen. Balloon di‐ latation up to 24 F is then performed and a special stent inserted (Tapered with greater di‐ ameter at the top end) for six weeks. Longterm success rates of up to 77% have been reported. Failure usually requires either open or laparoscopic pyeloplasty. A split function

Ureteric strictures can also be treated with laser incision. For distal strictures the success rates are of the order of 75% with an average follow-up of 3 years. Failures tend to occur early [33]. Similar results are reported for mid-ureteric and proximal ureteric strictures. The technique for ureteroscopic surgery is again incision to peri-ureteric fat but also includes in‐

An alternative form of endo-urological stricture management is to use a combined balloon dilator and Monopolar electrode. Identification of the stricture is radiological as once the balloon is inflated with contrast, the stricture will be identified as an indentation on the bal‐ loon ie "waisting". As the procedure is not visualised an adequate incision is identified as

There are now production models of video ureterorenoscopes. Their advantage is that they are smaller, more manoeuvrable with a better picture and fluid flow rate. These instruments use distal chip technology where the incoming light energy impacts on a digital chip. This energy transfer results in a charge which is transmitted along a single fibre to a processor which converts it into a usuable image.The better visual image is primarily due to less trans‐ mission loss. Energy (light) loss in fibreoptic ureteroscopes is multi-factorial but involves cladding damage, damage to the fibre-optic bundles, light lead / connection damage and camera head. It is primarily in the treatment of upper tract TCC where the improved imag‐ ing will be of most use. The increased magnification and resolution of the images together with technology such as Narrow Band Imaging should expand the place of ureteroscopy in

is best for resection and Neodymium YAG is best for fulgaration.

**6. Ureteric stricture / Pelvi-Ureteric Junction (PUJ) obstruction**

of less than 20% and redundant renal pelvis are factors predictive of failure.

cision into normal tissue either side of the stricture.

the management of low grade upper tract TCC.

contrast extravasation.

**7. The future**

**Figure 11.** Bigopty ®(Cook Medical) forceps removing a superficial TCC from the ureter.

Radical nephroureterectomy with an ipsi-lateral bladder cuff is still the gold standard treat‐ ment for upper tract TCC. Endourological management was initially introduced for those in whom such radical procedure was not possible or who would have required dialysis post operatively. However, the indications for endourological management increased with in‐ creased experience [30]. Now endourological management can be considered as potentially curative for all bar those with high-grade or bulky lesions [31].

Because the indications for endoscopic management of upper tract TCC have expanded so rapidly it is difficult to evaluate its efficacy. Potential markers of success are the subsequent recurrence rate and the need for Nephro-ureterectomy.For tumors of the renal pelvis the re‐ currence rate is quite stable at 40%. This is not that dissimilar to bladder recurrences follow‐ ing endoscopic treatment of bladder TCC.However when looking at recurrences following treatment of ureteric tumors the rates have increased from 14 up to 25% with a correspond‐ ing rise in rates of nephro-ureterectomy from 4 up to 14%. It is unclear whether this reflects poor technique or the increasing expansion in use of ureteoscopy for upper tract TCC. As alluded to above the best tumors are those of low grade, solitary and small with a papillary appearance with negative cytology [32]. From the point of view of laser choice the Holmium is best for resection and Neodymium YAG is best for fulgaration.

### **6. Ureteric stricture / Pelvi-Ureteric Junction (PUJ) obstruction**

PUJ obstruction is a functional blockage to antegrade flow of urine to the bladder from the upper tract due to a narrowing at the PUJ. Its classically treated by an open (or laterally lap‐ aroscopic) procedure by the name of Pyeloplasty. Retrograde endopyelotomy is a minimally invasive option.This is performed using a large calibre rigid ureterorenoresectoscope or us‐ ing a Holmium laser. The laser procedure is more common and usually linked with subse‐ quent balloon dilatation of the incised area. The incision is made laterally at the PUJ to minimise vascular injury. The incision is deepened until peri-ureteric fat is seen. Balloon di‐ latation up to 24 F is then performed and a special stent inserted (Tapered with greater di‐ ameter at the top end) for six weeks. Longterm success rates of up to 77% have been reported. Failure usually requires either open or laparoscopic pyeloplasty. A split function of less than 20% and redundant renal pelvis are factors predictive of failure.

Ureteric strictures can also be treated with laser incision. For distal strictures the success rates are of the order of 75% with an average follow-up of 3 years. Failures tend to occur early [33]. Similar results are reported for mid-ureteric and proximal ureteric strictures. The technique for ureteroscopic surgery is again incision to peri-ureteric fat but also includes in‐ cision into normal tissue either side of the stricture.

An alternative form of endo-urological stricture management is to use a combined balloon dilator and Monopolar electrode. Identification of the stricture is radiological as once the balloon is inflated with contrast, the stricture will be identified as an indentation on the bal‐ loon ie "waisting". As the procedure is not visualised an adequate incision is identified as contrast extravasation.

### **7. The future**

CT Urography is the standard diagnostic tool. However non-visualisation of lesions has been reported in 20% of renal pelvis and 40% of ureteric tumors. Ureteroscopy (semi-rigid or flexible) has been used to improve this accuracy as well as provide histological confirma‐ tion (figure 11). Williams et al have shown that ureteroscopic biopsy accurately predicts fi‐ nal histology at Nephro-ureterectomy in 75% of cases and further increases accuracy when combined with exfoliative cytology (brushing the lesion with a brush passed endoscopical‐ ly) [29]. Ureteroscopic technique is as outlined before with the exception of use of a safety wire. While a wire is used, it should be placed in the ureter under direct ureteroscopic vi‐ sion. This is because wire related urothelial trauma can mimic TCC and such trauma does

make cytological analysis more difficult.

378 Endoscopy

**Figure 11.** Bigopty ®(Cook Medical) forceps removing a superficial TCC from the ureter.

curative for all bar those with high-grade or bulky lesions [31].

Radical nephroureterectomy with an ipsi-lateral bladder cuff is still the gold standard treat‐ ment for upper tract TCC. Endourological management was initially introduced for those in whom such radical procedure was not possible or who would have required dialysis post operatively. However, the indications for endourological management increased with in‐ creased experience [30]. Now endourological management can be considered as potentially

Because the indications for endoscopic management of upper tract TCC have expanded so rapidly it is difficult to evaluate its efficacy. Potential markers of success are the subsequent recurrence rate and the need for Nephro-ureterectomy.For tumors of the renal pelvis the re‐ currence rate is quite stable at 40%. This is not that dissimilar to bladder recurrences follow‐ ing endoscopic treatment of bladder TCC.However when looking at recurrences following treatment of ureteric tumors the rates have increased from 14 up to 25% with a correspond‐ ing rise in rates of nephro-ureterectomy from 4 up to 14%. It is unclear whether this reflects poor technique or the increasing expansion in use of ureteoscopy for upper tract TCC. As alluded to above the best tumors are those of low grade, solitary and small with a papillary

There are now production models of video ureterorenoscopes. Their advantage is that they are smaller, more manoeuvrable with a better picture and fluid flow rate. These instruments use distal chip technology where the incoming light energy impacts on a digital chip. This energy transfer results in a charge which is transmitted along a single fibre to a processor which converts it into a usuable image.The better visual image is primarily due to less trans‐ mission loss. Energy (light) loss in fibreoptic ureteroscopes is multi-factorial but involves cladding damage, damage to the fibre-optic bundles, light lead / connection damage and camera head. It is primarily in the treatment of upper tract TCC where the improved imag‐ ing will be of most use. The increased magnification and resolution of the images together with technology such as Narrow Band Imaging should expand the place of ureteroscopy in the management of low grade upper tract TCC.

### **8. Conclusion**

The use of endo-urological techniques in day to day urological practice is increasing. This is fuelled by many factors but amongst them is better technology, a greater number of trained individuals and a desire to improve patient experience while maintaining outcomes. The fu‐ ture will be even better as better image definition becomes more readily available as videoureteroscopes become more durable.

[10] Lingeman JE, Matlaga BR, Evan AP. Surgical management of upper urinary tract cal‐ culi. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA eds. Campbell

Modern Upper Urinary Tract Endoscopy http://dx.doi.org/10.5772/52750 381

[11] Chan KF, Vasser GJ, Pfefer TJ, Teichman JM, Glickman RD, Weintraub ST, Welch AJ. Holmium: YAG laser lithotripsy. A dominant photothermal ablative mechanism with chemical decomposition of urinary calculi. Lasers Surg Med 1999; 25:22-37

[12] Santa-Cruz RW, Leveille RJ, Krongrad A. Ex vivo comparison of four lithotriptors commonly used in the ureter: what does it take to perforate? J Endourol 1998;

[13] Knopf HJ, Graff HJ, Schulze H. Perioperative antibiotic prophylaxis in ureteroscopic

[14] Turk F, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. European Urology association guidelines on urolithiasis. http://www.uroweb.org/guidelines accessed 1st August

[15] AUA / EAU guidelines 2007, Ureteral calculi. http://auanet.org/content/clinical-prac‐

[17] Gerber Glenn S. Acharya Sujeet S. Management of ureteral calculi. Journal of endour‐

[18] Bach C, Buchholz N. Shock wave lithotripsy for renal and ureteric stones.European

[19] Atis Gokhan, Gurbuz Cenk, Arikan Ozgur, Canat Lutfi, Kiic Mert, Caskurlu Turhan. Ureteroscopic Management with Laser Lithotripsy of renal Pelvic Stones. Journal of

[20] Bryniarski P, Paradysz A, Zyczkowski M et al. A randomised control study to ana‐ lyze the safety and efficacy of percutaneous nephrolithotripsy and retrograde intra‐ renal surgery in the management of stones more than 2cm in diameter. Journal of

[21] Leijte Joost AP, Odeens Jorg R, Lock Tycho MTW. Holmiun laser lithotripsy for ure‐ teric calculi: Predictive factors for complications and success. Journal of endourology.

[22] Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy.

[23] Breda A, Ogunyemi O, leppert JT, et al. Flexible ureteroscopy and laser lithotripsy for single intra-renal stones 2cm or greater – is this the new frontier? Journal of Urol‐

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2012.

### **Author details**

Puru Naidu, Jessica Packer, Maheshi Samaraweera and John G. Calleary

\*Address all correspondence to: johngcall@aol.com.

Department of Urology, Morth Manchester General Hospital, UK

### **References**


[10] Lingeman JE, Matlaga BR, Evan AP. Surgical management of upper urinary tract cal‐ culi. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA eds. Campbell Walsh Urology, 9th ed Philadelphia: WB Saunders 2007, 1431-1506.

**8. Conclusion**

380 Endoscopy

**Author details**

**References**

ureteroscopes become more durable.

The use of endo-urological techniques in day to day urological practice is increasing. This is fuelled by many factors but amongst them is better technology, a greater number of trained individuals and a desire to improve patient experience while maintaining outcomes. The fu‐ ture will be even better as better image definition becomes more readily available as video-

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Puru Naidu, Jessica Packer, Maheshi Samaraweera and John G. Calleary

Department of Urology, Morth Manchester General Hospital, UK

\*Address all correspondence to: johngcall@aol.com.

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382 Endoscopy

## *Edited by Somchai Amornyotin*

Endoscopy has had a major impact in the development of modern medicine and other medical specialties. The field of endoscopic procedure has developed over the last decade. By using different data it provided a better understanding of pathogenic mechanisms, described new entities and used for early detection, diagnostic procedures and therapeutic procedures. The advantages of many technical advances and modern endoscopic equipments, endoscopy has had a developed spectacularly. Consequently, endoscopy has surpassed its function as an examination tool and it became a rapid and efficient therapeutic tool of various organs including gastrointestinal tract, head and neck, respiratory tract and others. The efficacy and usefulness of endoscopy has yet been established.

Endoscopy

Endoscopy

*Edited by Somchai Amornyotin*

Photo by zilli / iStock