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FLEXIBLE URETEROSCOPY LASER TREATMENT
Category: Urology
Abstract : Kidney stone treatment: flexible ureteroscopy and laser treatment The development of small-calibre ureteroscopes with active deflecting mechanisms and instrument channels, in combination with the development of laser technology, small-diameter laser fibres, and stone baskets and graspers, has opened the way for intracorporeal, endoscopic treatment of kidney stones. Access to virtually the entir
Kidney stone treatment: flexible ureteroscopy and laser treatment
The development of small-calibre ureteroscopes with active deflecting mechanisms and instrument channels, in combination with the development of laser technology, small-diameter laser fibres, and stone baskets and graspers, has opened the way for intracorporeal, endoscopic treatment of kidney stones.
Access to virtually the entire collecting system is possible with modern instruments. The holmium: YAG laser has a minimal effect on tissues at distances of 2 - 3mm from the laser tip and so colateral tissue damage is minimal with this laser type.
Flexible ureteroscopy and laser fragmentation offers a more effective treatment option compared with ESWL, with a lower morbidity than PCNL, but usually requires a general anaesthetic (some patients will tolerate it with sedation alone). It can also allow access to areas of the kidney where ESWL is less efficient or where PCNL cannot reach. It is most suited to stones <2cm in diameter.
Indications for flexible ureteroscopic kidney stone treatment
- ESWL failure.
- Lower pole stone (reduces likelihood of stone passage post ESWL fragments have to pass uphill ).
- Cystine stones.
- Obesity such that PCNL access is technically difficult or impossible (nephroscopes may not be long enough to reach stone).
- Obesity such that ESWL is technically difficult or impossible. BMI >28 is associated with lower ESWL success rates. Treatment distance may exceed focal length of lithotriptor.
- Musculoskeletal deformities such that stone access by PCNL or ESWL is difficult or impossible (e.g. kyphoscoliosis).
- Stone in a calyceal diverticulum (accessing stones in small diverticulae in upper and anterior calyces is difficult and carries significant risks).
- Stenosis of a calcyceal infundibulum or tight angle between renal pelvis and infundibulum. The flexible ureteroscope can negotiate acute angles and the laser can be used to divide obstructions.
- Bleeding diathesis where reversal of this diathesis is potentially dangerous or difficult.
- Horseshoe or pelvic kidney. ESWL fragmentation rates are only 50% in such cases15 due to difficulties of shock-wave transmission through overlying organs (bowel). PCNL for such kidneys is difficult because of bowel proximity and variable blood supply (blood supply derived from multiple sources).
- Patient preference.
Disadvantages
Efficacy diminishes as stone burden increases it simply takes a long time to paint the surface of the stone with laser energy, so destroying it. A dust-cloud is produced as the stone fragments and this temporarily
obscures the view, until it has been washed away by irrigation. Stone fragmentation rates for those expert in flexible ureteroscopy are ~70 - 80% for stones <2cm in diameter and 50% for those >2cm in diameter16 and ~10% of patients will require 2 or more treatment sessions.
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