The ureter is a tube that connects each kidney with your urinary bladder. It is the most common site in which a kidney stone gets caught and by obstructing the flow of urine out of the kidney causes severe pain (renal colic). There are other reasons why a ureter may become blocked. The ureter can also be a site for tumours of the urinary tract. When there is a problem within the ureter, we can usually approach it with a small telescope that is inserted through the urethra (tube through which you urinate), into your bladder, and then into the ureter.
This instrument used to perform a Ureteroscopy is called a ureteroscope. The scope may be rigid or flexible, and can usually be advanced all the way to the inside of the kidney. A ureteroscopy is performed under general anaesthesia so that you do not feel any discomfort, and because it is necessary that you are very still during the procedure.
Once the ureteroscope has been passed into the ureter or kidney, we can break up a stone using a variety of instruments. We can also take biopsies if there is a suspicion that a ureteric obstruction is caused by a tumour. After any of these procedures, it may be necessary to leave a stent (plastic drainage tube) in the ureter for a few days to a few weeks (depending on your particular situation) to allow adequate drainage and resolution of any inflammation caused by the procedure. Alternatively, a catheter can be left in place with a stent attached to the catheter. When the catheter is removed after 24-48hrs, the stent is automatically removed along with it.
It may not be possible to insert a ureteroscope into the ureter safely. This is because the ureter is a narrow and quite fragile structure. In this case, a stent is inserted into the ureter and left in place for a few weeks. This allows the ureter to relax and dilate, making passage of a ureteroscope at a later date easier and safer. Not uncommonly, the stone will pass spontaneously whilst the stent is in place.
Sometimes, we use injection of x-ray contrast up the ureter to help diagnose a problem or to help guide the path of the ureteroscope. This special x-ray is called a retrograde pyelogram. Patients who are allergic to x-ray dye can usually have this procedure because the dye does not enter the bloodstream.
Please refer to the detailed information provided by the rooms. Information is also available on this website.It is very important that you have a urine culture before the ureteroscopy procedure. The procedure cannot be performed if you have an active urinary tract infection due to the risk of precipitating septicaemia.
The actual procedure can take anywhere from 15 minutes to a couple of hours depending on the particulars of the case and the individual’s anatomy. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in stirrups).
First, a scope is inserted into the bladder and the bladder is examined. The ureteric orifice (hole where the ureter enters the bladder) on the side of concern is then identified. Sometimes, one or more wires is/are placed into the ureter to help guide the passage of the scope. Then, the scope is inserted into the ureter and advanced to the area of concern.
Depending on the location, size, and type of stone, we may elect to use one or a combination of instruments to break the stone and remove any significant fragments. These instruments include the Holmium laser and the Swiss Lithoclast (a fine jack-hammer type device).A stent may be placed at the end of the procedure. Alternatively, a temporary ureteric catheter and indwelling bladder catheter may be left in place overnight.
Sometimes, a stone that is in the ureter is pushed back into the kidney by the water current (from the scope) or from the attempt to break it. If it cannot be accessed or adequately broken, a stent may be placed and a different type of procedure might be planned for another day.
It is common and even expected to have some discomfort while urinating. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood may persist as long as a stent is in place. Once the stent is removed, the bleeding stops within a day or two. You may also notice stone fragments in the urine. Because they are small, a patient typically does not feel them as they pass in the urine. As a result of the instrumentation, it is common to have discomfort in the back or groin region much like the pain from the stone. This, too, will gradually disappear.
Although the stent is soft plastic, any degree of sensation from its presence is possible. Some patients have no feeling, while on the other extreme, some have very bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort (like still having a stone), urinary frequency, urgency or burning. The symptoms may last only one day, or persist for the duration of the presence of the stent. Most patients, however, have very mild symptoms that are tolerable.
Possible Complications of the Procedure
The vast majority of patients will not experience any problem after a ureteroscopy. However, any procedure, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. These may include, but are not limited to:
- Urinary Tract Infection or Urosepsis (Bloodstream Infection)
Before this procedure can take place, we must confirm that you do not have an active urinary tract infection. If a urinary tract infection is not present, it is most unlikely that you will suffer sepsis after this procedure. In the rare event that you do, you will be given intravenous and oral antibiotics. This scenario is more common in diabetics, patients on long-term steroids, or in patients with disorders of the immune system.*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest public hospital.
- Blood Clots in the Urine
There is always a small amount of bleeding after removal of a stone. Most commonly, it settles within a few days. If a stent has been left in place, the bleeding may continue until the stent has been removed. If the bleeding is significant, it can cause clots that can block the urine flow. A catheter may need to be inserted to flush out the clots.
- Ureteral Injury
Despite precautionary measures, the ureter may be injured from the scope or from the instruments used to break/remove your stone or take a biopsy. Usually, we will end the procedure, place a stent in the ureter if possible, and allow the tissue to heal itself over the next week or two. A more severe injury (while very rare) may require placement of a nephrostomy tube (different type of tube placed through the back and into the kidney as a temporary means of kidney drainage). A complete ureteral avulsion (separation of the ureter from the bladder or kidney) is an extremely rare occurrence and requires open surgery through an incision to repair.
Please contact the office within 3 days of discharge. You should make an appointment to see Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital.Do not hesitate to call at any time if you have any concerns.