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International Journal of Urology (2014) 21, 1076–1084

doi: 10.1111/iju.12582

Review Article

Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014? Petrisor Geavlete, Razvan Multescu and Bogdan Geavlete Department of Urology, Saint John Emergency Clinical Hospital, Bucharest, Romania

Abbreviations & Acronyms EAU = European Association of Urology Ho:YAG = holmium yttrium aluminium garnet laser NBI = narrow band imaging PCNL = percutaneous nephrolithotomy SWL = shockwave lithotripsy UUTC = upper urinary tract urothelial carcinoma Correspondence: Petrisor Geavlete M.D., Ph.D., Department of Urology, Saint John Emergency Clinical Hospital, Vitan Barzesti 13, 042122 Bucharest, Romania. Email: [email protected] Received 6 May 2014; accepted 22 June 2014. Online publication 1 August 2014

Abstract: Flexible uretero-renoscopy witnessed dramatic technological improvements, ultimately translating in more diverse indications, better instrument durability, procedural efficacy and safety. Diagnostic exploration of the upper urinary tract, treatment of selected cases of ureteral and especially pyelocaliceal stones, caliceal diverticulum and infundibular stenosis, treatment, and follow-up of upper urinary tract tumors are the main indications for this approach. We review the technique, results and complications of retrograde flexible ureteroscopy, with an emphasis on the latest developments of the method. Key words: diagnosis, flexible ureteroscopy, holmium laser, urolithiasis, urothelial tumors.

Introduction Flexible uretero-renoscopy is probably one of the most dynamic fields of endourology. During the past two decades, it witnessed dramatic technological improvements, ultimately translating into more diverse indications, better instrument durability, procedural efficacy and safety. The complex architecture of the upper urinary tract made its entire retrograde approach using only rigid instruments virtually impossible. For this reason, the development of flexible ureteroscopes was absolutely necessary in order to continuously decrease the invasivity of endourological procedures. The first flexible approach of the upper urinary tract was carried out by Marshall in 1964 who used a 9-Fr endoscope for diagnosis purposes only.1 The development of modern flexible ureteroscopes started in the 1980s with Bagley, Huffman and Lyon, who added three essential characteristics: the working channel, irrigation system and active deflection.2

Indications Initially, the possibility to inspect the entire upper urinary tract made flexible ureteroscopes, despite their fragility, valuable diagnostic tools. Their utility proved essential in identifying the upper urinary tract pathology, especially when imaging techniques offered equivocal data. In this regard, the main indications for diagnostic flexible ureteroscopy are represented by the investigation of upper urinary tract filling defects, obstruction or hematuria, as well as searching for the source of abnormal cytology in patients with normal cystoscopy. It can provide a clear diagnosis in patients in which other less invasive diagnostic methods failed to do so, thus allowing the quick management of patients with potentially severe pathology.3,4 It can be also used in the follow-up protocol of patients with conservatively treated upper urinary tract tumors while taking into consideration their high potential of recurrence.4,5 Technological progress allowed the development of more durable and efficient flexible ureteroscopes, and consequently expanded the indications of therapeutic flexible ureterorenoscopy. Nowadays, this type of procedure can be used in the treatment of selected cases of ureteral or pyelocaliceal lithiasis, upper urinary tract tumors, pyelocaliceal diverticulum or infundibular stenosis. The therapeutic use of flexible ureteroscopes is strongly linked with the development of holmium laser, with its capabilities of lithotripsy, incision and tissue ablation. Flexible ureteroscopes are useful in the treatment of ureteral pathology in cases in which the semirigid retrograde approach is difficult or impossible, such as patients with urinary diversions, anatomic abnormalities of upper urinary tract, musculo-skeletal deformities etc. Flexible ureteroscopy with intrarenal lithotripsy is already included in the guidelines as an alternative for proximal ureteral or pyelocaliceal stone treatment, by comparison with the older recommendations, which only included SWL, PCNL and, in extreme cases, open surgery.6 The

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© 2014 The Japanese Urological Association

Retrograde flexible ureteroscopy

Table 1

Technical characteristics of flexible ureteroscopes (data from manufacturers)

Manufacturer

Model

Tip diameter (tip/maximal)

Optical system

Deflection (down/up)

Olympus

URF-V URF-V2 URF-P5 URF-P6 Viper Cobra Flex-X2 Flex-Xc

8.5/9.9-Fr 8.4/8.5-Fr 5.3/8.4-Fr 4.9/7.95-Fr 6/8.8-Fr 6/9.9-Fr 7.5/8.4-Fr 7.8/8.5-Fr

Digital Digital Fiberoptic Fiberoptic Fiberoptic Fiberoptic Fiberoptic Digital

275o/180o 275o/275o 275o/180o 275o/275o 270o/270o 270o/270o 270o/270o 270o/270o

Richard Wolf Karl Storz Endoskope

Fig. 1

Different configurations of the flexible ureteroscopes tip: (a) Storz Flex-Xc, (b) Wolf Cobra and (c) Olympus Urf-V.

introduction of more durable flexible ureteroscopes, their increasing efficacy, combined with increased PCNL morbidity and disappointing evolution of SWL devices, made flexible ureteroscopy a viable and quite valuable option in the treatment of upper urinary tract lithiasis. The use of flexible ureteroscopes combined with holmium laser also offers minimally-invasive solutions in the management of cases with stones associated with intrarenal obstruction, such as pyelocaliceal diverticulum or infundibular stenosis.7 UUTC constitute approximately 5–6% of all urothelial malignancies. Ureteral tumors represent approximately 25% of UUTC. They are found in the distal ureter in 70% of cases, and in the middle ureter in 25% of cases, whereas the remaining 5% are discovered in the proximal ureter. Bilateral disease appears in 2–4% of cases, whereas a bladder lesion develops in 30–75% of patients.8 According to the EAU Guidelines, the indications for conservative surgery are represented by all imperative cases (renal insufficiency, solitary kidney, bilateral tumors, severe comorbidities) or, eventually, in low-risk patients (low-grade ureteroscopic biopsy, low-grade cytology, tumor size

Retrograde flexible ureteroscopic approach of upper urinary tract pathology: What is the status in 2014?

Flexible uretero-renoscopy witnessed dramatic technological improvements, ultimately translating in more diverse indications, better instrument durabi...
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