Ureteroscopy and Laser Lithotripsy
Kidney stones affect 1 in 500 Americans each year, causing significant pain and healthcare expense.
Surgical options for patients with symptomatic kidney stones include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, and percutaneous nephrolithotomy (PCNL). Your renal anatomy, stone composition, and body habitus all play major roles in determining outcomes and operative approach.
The role of ureteroscopy over the last ten years has undergone a dramatic evolution, due to improvements in the ureteroscope size and deflection capabilities, video-imaging, miniature baskets and instruments, and in lithotripsy (stone breakage) with the advent of holmium laser. Over 25% of all kidney stone surgeries are now done using small ureteroscope technology.
Vincent G. Bird, MD
Department of Urology
Residency: University of Miami School of Medicine, Miami, FL
Fellowship: Endourology & Laparoscopy University of Iowa Hospitals & Clinics, Iowa City, Iowa
Clinical Interests: Urinary Stone Disease, Renal Obstruction and Renal Cancer
Benjamin K. Canales, MD, MPH
Department of Urology
Residency: University of Minnesota Medical School, Minneapolis, MN
Fellowship: Laparoscopy and Endourology, University of Minnesota, Minneapolis, MN
Clinical Interests: Urologic Stone Disease, Endourology and Laparoscopy
Brandon J. Otto, MD
Department of Urology
Residency: Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY
Fellowship: Endourology and Minimally Invasive Surgery, University of Florida Department of Urology, College of Medicine, Gainesville, FL
Clinical Interests: Endourology, Robotic and laparoscopic surgery, Kidney Stones, Prostate and Kidney cancer
To schedule an appointment with one of our surgeons, please contact the UF & Shands Medical Plaza Urology Clinic at 352-265-8240. For more information, directions to the Medical Plaza and local accommodations please visit: Maps and Locations & Appointments.
Prior to Procedure
What to expect during your initial consultation: It is important that prior to your initial clinic consultation that all Xray films and their reports (e.g. CT scans, intravenous pyelogram or IVP, sonogram, or MRI) are compiled and brought to your appointment for careful review by your surgeon. These films can be requested along with the radiology report from the facility that performed the Xray. A review of your medical history and a physical examination will be performed along with blood and urine tests if needed. If your surgeon determines that you are a candidate for ureteroscopy, you will then meet with a Surgery Scheduling Coordinator to arrange for the date of your procedure.
What to expect prior to surgery: Once your surgery date is secured by one of our Surgery Scheduling Coordinators, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery. These will be performed through a preoperative anesthesia consultation at the Presurgical Center at UF & Shands that will be arranged for you at your initial visit. During this consultation you will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks/benefits.
- Physical exam
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood chemistry profile)
Preparation for surgery
Medications to Avoid Prior to Surgery: Ureteroscopy is the only minimally-invasive, stone surgery that can be performed while on active anti-coagulation. Even with this option, it is most preferable to discontinue all blood thinners prior to surgery, if medically possible. Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. The following is a list of medications to avoid at least 7-10 days prior to surgery. Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during or after surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.
- Aspirin, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix
- A formal list of these medications and others will be provided to you by our Surgery Scheduling Coordinators.
There is no bowel preparation needed for ureteroscopy, and most patients are asked to be NPO (“nothing by mouth”) after midnight of the night prior to surgery.
Once you are asleep, the surgeon passes a small lighted tube (ureteroscope), through the urethra and bladder and into the ureter to the point where the stone is located. If the stone is small, it may be snared with a basket device and removed whole from the ureter. If the stone is large and/or if the diameter of the ureter is narrow, the stone will need to be fragmented, which is usually accomplished with a laser. Once the stone is broken into tiny pieces, these pieces are usually removed from the ureter. In most cases, to ensure that the kidney drains urine well after surgery, a ureteral stent is left in place (see FAQs).
Ureteroscopy can also be performed for stones located within the kidney. Similar to ureteral stones, kidney stones can be fragmented and removed with baskets. Occasionally, a kidney stone will fragment with a laser into very small pieces (grains of sand), too small to be basketed. The urologist will usually leave a stent and allow these pieces to clear by themselves over time. Lastly, if the ureter is too small to advance the ureteroscope, the urologist will usually leave a stent, allowing the ureter to “dilate” around the stent, and reschedule the procedure for 2-3 weeks later. Ureteroscopy is usually performed as an outpatient procedure. Some patients, however, may require an overnight hospital stay if the procedure proves lengthy or difficult.
Potential Risks and Complications
As with any major surgery, complications, although rare, may occur with ureteroscopy. Potential risks and complications with this operation include but are not limited to the following:
Stent pain: About 50% of patients who undergo ureteroscopy and have a stent will have “stent pain,” and this is by far the most common risk/complaint following ureteroscopy. A stent is a soft plastic tube (about half the size of IV tubing) that allows the kidney to drain to the bladder regardless of edema or obstruction. Not only can the stent “rub” on the inside of the bladder, causing a feeling of needing to urinate/overactive bladder, but also the stent allows urine to pass up from the bladder to the kidney during urination – causing symptoms from a warm, tingling sensation to intense pain in the affected flank. Ask your surgeon about the risks/benefits of a ureteral stent following surgery.
Stone fragments: Residual stones within the kidney or ureter may be present up to 40% of the time following ureteroscopy, depending on the original stone size and location. These stone fragments will be seen and addressed on follow-up imaging. Ask your urologist to give you some idea of success rates for your particular stone size and location.
Ureteral injury: Injury to the ureter is the most common intra-operative complication during ureteroscopy. The reported risk of perforation ranges greatly, depending on whether it is defined as a complete perforation (0.1-0.7% — think of this as a hole through the entire ureter), a partial perforation (1.6% — a hole nearly through the entire ureter), or mucosal tear/scrape (5% — these are similar to a sore on the inside of the mouth). Almost 100% of these will heal with prolonged stenting (anywhere between 2 – 4 weeks). Should a large perforation occur, your urologist may chose to stop the procedure and return on another day when the ureter has had time to heal. Should your urologist not be able to place a stent after a perforation, a tube called a “nephrostomy tube” will be placed through the skin of your back into the kidney. This tube temporarily diverts the urine away from the hole and out into a bag until healing can occur and the hole close.
Ureteral stricture and avulsion: Ureteral strictures (scar tissue within the ureter) and ureteral avulsion (complete dissociation of the ureter from the kidney) are the most feared complication of ureteroscopy. Fortunately, due to the advent of small ureteroscopes and heightened surgeon awareness, the risk of avulsion (0.05%, 1/2000) or stricture (0.2%, 1/500) is rare.
Hematuria and infection: Bleeding and infection are certainly possible following ureteroscopy (5%), but most of these are self-limiting and resolve with hydration and antibiotics, respectively.
What to Expect After Surgery
Immediate post-operative period: After the surgery you will be taken to the recovery room. If a urinary catheter (foley) was placed during surgery, this may be removed by your nurse once you are awake, alert, and moving comfortably. Once your pain is controlled and you are able to urinate, you may be discharged from the recovery room to home. Expect blood in the urine with almost every urination. With time and hydration, the urine should slowly turn from a watermelon red color to pink to clear. You may have stent pain or bladder spasms (see complications of ureteroscopy above) that can be helped by overactive bladder medications or by an indwelling foley catheter. Due to instrumentation, most patients will receive 4-5 days of oral antibiotics to prevent a urinary tract infection.
Postoperative Pain: Most patients after ureteroscopy experience mild to moderate pain in the flank and/or bladder area. This is generally well controlled by use of oral narcotics (pain medication) such as Percocet or Vicodin. As you get further out from your ureteroscopy, you may be able to decrease the strength of the medication to Extra Strength Tylenol or Motrin, as narcotics may cause constipation and sedation.
Ureteral Stent: Almost always after ureteroscopy, a small tube called a ureteral stent will be placed. The stent serves to facilitate drainage of urine down to the bladder. At a later date, the stent will be removed in the office by your surgeon. You may experience bladder spasms related to the ureteral stent that was placed at the end of your procedure (see FAQs).
Nausea: Nausea is fairly common following any surgery especially related to general anesthesia. This is usually transient and is self-limiting. Should you have excessive nausea and vomiting, you should contact your surgeon for advice.
Showering: Patients can shower immediately upon discharge from the hospital
Activity: Patients may begin driving once they are off all narcotic pain medication. Most patients are able to perform normal, daily activities within 5-7 days after ureteroscopy. However, many patients describe more fatigue and discomfort with a ureteral stent in the bladder. This may limit the amount of activities that you can perform.
Diet: Most patients only desire clear liquids for the first 24 hours following ureteroscopy, as your intestinal function may be sluggish due to the effects of surgery and general anesthesia. Following this period, Patients may resume a regular diet as tolerated.
Fatigue: Fatigue is quite common following surgery and should subside in several days following surgery.
Constipation/Gas Cramps: You may experience sluggish bowels for several days following your ureteroscopy as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
Follow-up Appointment: Patients should make a follow-up appointment with their surgeon by contacting the Shands Medical Plaza Urology Clinic at 352-265-8240. Your surgeon will let you know the timing and schedule of clinic visits following surgery.
Frequently Asked Questions (FAQs)
What are the advantages of ureteroscopy compared to other stone treatments?
- Provided that the kidney stones are an appropriate size and location, an advantage of flexible ureteroscopy is that it allows entry into all parts of the kidney. As long as the ureter is large enough to allow the ureteroscope to pass, there is a good chance that the stone can be broken and removed with one surgery.
- Compared to SWL, a kidney or ureteral stone can be seen under direct vision by the ureteroscope, allowing lithotripsy with lasers followed by basketting and removal. With shock wave lithotripsy, patients are asked to pass stone fragments themselves, causing potential additional pain or obstruction. Additionally, shock wave lithotripsy may not break up very dense, hard stones (termed SWL resistant stones). Ureteroscopy with a contact holmium laser can break up any stone, as long as the stone itself is accessible to the ureteroscope. Additionally, ureteroscopy allows the treatment of stones are invisible on plain x-ray (“acid” stones).
- Compared to percutaneous procedures, the ureteroscope is passed through natural body orifices and involve no skin incisions. It is an outpatient procedure, where PCNL requires at least an overnight hospital stay. Certain patient groups who cannot be treated with ESWL or PCNL (such as patients on blood thinners, women who are pregnant, the morbidly obese, and airline pilots/astronauts) can be treated safely and effectively by ureteroscopy.
Who is not a good candidate for ureteroscopy?
Patients with large stones: Because ureteroscopy requires active removal of all or most stone fragments, the treatment of very large stones (>2 cm) may yield so many fragments that complete removal becomes impractical or impossible.
Patients with a history of urinary tract reconstruction: The anatomy of patients who have undergone ureteral or bladder reconstruction may not allow for passage of a ureteroscope.
Patients who are intolerant of stents: As stents are usually almost routinely following ureteroscopy, patients with a history of stent intolerance may be more comfortable with other stone approaches.
What are the success rates of ureteroscopy?
- Depending on stone size, location, and number, success rates vary anywhere from 50% – 90%. Ask your surgeon to discuss success rates tailored to your particular stone disease.
How long will my stent stay in place?
- The length of time the stent remains in your ureter is variable. Your doctor will probably request it to be removed somewhere between 5- 10 days after your procedure. About 50% of patients feel flank fullness (usually during voiding) and urgency as a result of the stent. These symptoms often improve over time. It is critical that you return to have your stent removed (as instructed), as a prolonged indwelling ureteral stent can result in encrustation, chronic infections, chronic kidney obstruction, and eventual loss of kidney function.
What is a ureteral stent?
- The ureter is the natural tube that transmits urine from the kidney to the bladder. A ureteral stent is a specially designed hollow tube, made of a soft, plastic material that is placed inside the lumen of the ureter. This tube facilitate urine passage until the obstruction has resolved. Stent size and lengths vary according to patient characteristics.
What’s the reason for having a stent placed?
- The placement of a ureteral stent allows urine to flow from the kidney to the bladder, even when the ureter is obstructed (stones, edema, external compression, tumors, clots, etc). Because of the stent, the kidney can continue to function properly while avoiding the pain that can occur when the kidney is obstructed. Additionally, ureteral stents allow the kidney to clear bacterial infections associated with obstruction.
- Following ureteral or kidney surgery, the stent protects the ureter and allows the ureter to heal even when damaged. If a stent is not placed following surgery, occasionally, the ureteral lumen can heal with what is called a stricture. Stents are thought to prevent this from occuring, as they allow for healing in the shape of a tube.
- Occasionally, a stent is placed in order to allow the ureter to dilate over a period of time. This can be important when access through the ureter is needed to pass instruments or remove stones. Clinically, this is seen when the diameter of the ureter is too small to allow for passage of instruments or when a ureteral stone has narrowed the lumen of the ureter due to edema or inflammation. Inserting a stent allows the ureter to passively dilate, in the hope of making later attempts to get up the ureter successful.
What are the disadvantages of having a ureteral stent?
- About 50% of patients will have some type of side-effect associated with their stent. It is not possible to predict who will have stent-associated difficulties or when the stent symptoms will resolve. Some patients have stent symptoms for just a few days, while others find their symptoms persist throughout their entire stent duration. Ureteral stent symptoms may include:
- Hematuria: Stents can cause blood to appear in the urine at various times. Usually, physical activity of one kind or other results in movement of the stent inside the body. This can give rise to blood in the urine. Pain may be felt in the back (loin), bladder area, groin, penis in men or urethra in women, and sometimes the testicles. The discomfort or pain may be more noticeable after physical activities and after passing urine.
- Bladder spasms: The stent can rub and irritate the lining of the bladder, making it necessary to pass urine more frequently during the day and at night. These symptoms can occasionally be improved by medication.
- Incontinence: Rarely, a stent may cause such bladder spasms leading to urinary leakage. This can usually be controlled with oral medications or with stent removal.
- Stent migration: Stents may move from their intended positions to other parts of the urinary tract, causing pain or incontinence.
- Infection: As stents are foreign bodies, bacteria can attach to their surface and become protected by a layer of slime known as a “biofilm.” These bacteria may then be released into the urine, causing infection and fever. These infections may temporarily be cleared with antibiotics, but usually recur 2-3 weeks after antibiotics as the antibiotics are unable to penetrate the biofilm.
- Encrustation: Stents may be forgotten by patients and their care-givers. Over time, they can become coated with urinary salts and minerals and eventually become one very large calcified stone. This may lead to chronic obstruction, pain, chronic infections, or even complete atrophy (death) of that kidney. Typically, 2-3 procedures are necessary to remove these calcified stents.
How is a stent inserted?
- A stent is inserted usually under a general anesthesia, often in combination with other procedures (depending on the reason for the stent). A telescope called a cystoscope is passed through the urethra and into the bladder. The stent is then passed through the cystoscope and into the ureter with the use of a guide wire, and its position is confirmed using x-rays.
How is a stent removed?
- Under local anesthesia in the urology clinic, a special flexible telescope (cystoscope) is passed through the urethra into the bladder. The ureteral stent is picked up with a grasper and removed.
How does a stent interfere with daily life?
- Most patients are able to perform normal, daily activities with a stent in place. However, many patients describe more fatigue and discomfort during the day, limiting the amount of activities that can perform. Additionally, as some patients have bladder spasms that require using a toilet more frequently, travel may be more tedious or difficult. Ureteral stents do not limit sexual activity, although there may be less enjoyment as a result of the side-effects described above.
What additional care is necessary when a stent is in place?
- No particular cares are necessary. Drink at least 1½ to 2 liters of fluids a day is encouraged to help to dilute the urine. Discuss with your doctor or nurse if you have troublesome side-effects.
Following stent placement, when might it be necessary to call a doctor?
- You should contact your urologist if the stent is causing you constant, unrelenting pain, if you have symptoms of a urinary tract infection (fever, rigours, feeling unwell and pain passing urine), or if the stent falls out.
What alternatives are there to a ureteral stent?
- It may be reasonable not to leave a ureteral stent if obstruction is likely to be transient. Your surgeon decides at the time of the procedure whether or not your circumstance warrants “stent free.” Occasionally, it may be possible to place a tube externally that drains the kidney. This tube is placed directly through the skin, through the kidney, and into the urinary space, called a ‘nephrostomy’ tube. This is placed under ultrasound or fluoroscopic Xray guidance. As the tube remains outside the body, it is slightly more inconvenient, has higher infection rates, and can sometimes get pulled out by accident. The advantage of a nephrostomy tube is better drainage, ability to place contrast into the kidney to evaluate for obstruction or leakage, and removal that does not require a cystoscopic procedure.