Left Ureteroscopy, Stone Retrieval with Basket, and Stent Replacement

CHAPTER 1

Hi. I'm Tullika Garg. I'm an associate professor of urology at Penn State Health in Hershey, Pennsylvania. And today we're going to do a case of a patient, who came in with a kidney stone, a few weeks ago and, had some infection going on as well. And we placed a stent to relieve the pain from her kidney stone obstruction. She now returns to have her kidney stone treated. It's a five-millimeter stone that is located in the proximal ureter on the left side. And the key steps of this operation are first to enter the bladder with the cystoscope, then to retrieve the existing stent that is present and gain access to the ureter and the kidney by placing a wire up to the kidney. The next step is to place a second wire in order to have a safety wire in case there are any issues with access to the kidney. And then the third step is to drive the ureteroscope up into the ureter and identify the stone and then break it up or retrieve the stone with a basket. The final step of the operation is to place a new stent at the end in order to allow the ureter to heal.

CHAPTER 2

Alright. So we have entered the bladder now. And we're just gonna empty it out and and just take a quick look around. Everybody covered? Come down a little bit more. Okay. So there's our stent. It's emanating from the left ureteral orifice. And now we're going to place our grasper in through the scope to grab the stent. There's the grasper. And, so we're gonna grab it right at the end of the stent. And you can see there's a little bit of encrustation on that stent. So we're gonna try to place a wire through it. If that doesn't work, then we'll consider putting a wire alongside the stent.

CHAPTER 3

And then this will give us access to the kidney and the ureter. Is that wire going in okay? It's not through all the way there. Don't pull your stent until wire's all the way through. Take another spot there. Let me take a peek. It's not - it's not going through. Yeah, not yet. Okay. I just need to pull this stem back a little bit. Let's take a peek here. So this stent has been in there for about two months. Yeah. She basically refused any sooner surgeries. It's pretty crunchy. Yeah. I think we just put it alongside, and then we'll just pull the stent.

CHAPTER 4

Can we please open a 5 French open ended. So this stent is pretty encrusted, so it's not easy to get the wire through the stent. So we are going to instead put the cystoscope back in alongside the stent. 5 French open ended. And we're... Yep. Thank you. And we're going to put a wire alongside the stent up to the kidney so we don't lose access to it. I offered her multiple sooner surgery dates, and she refused all of them. Okay. Yep. So there's the ureteral orifice again, and you're going to see the five French open ended catheter come in. And here's your wire. And we're just going to place that wire alongside. Yep. You wanna get right under it and kinda yep. You might wanna push that - yeah, there you go. There. Oh, that's going up. And come back and just keep an eye on your stent because sometimes you can push your stent up too. Yeah. Keep going to the kidney. There you go. Okay. Good. So now the wire is all the way up to the kidney. Yep. That's good. Yep. And now you can just take your scope out of the bladder.

CHAPTER 5

Alright, so push... Yeah. And now you can just pull the stent. And just keep keep the a hold of the wire while you pull a stent out. Just be careful how much fluoro you're using. Okay? I don't like, I would not use that much fluoro. Alright.

CHAPTER 6

So now we're going to put a second wire up. I always do your ureteroscopy with a safety wire. Do we have that flexible ureteroscope? Right here. Okay. Ready to take it? Yeah. So now we're going to use a dual lumen catheter, which is going to go over the wire and help us introduce our second wire. Alright. Let me just cut this. You should see your second wire first. Yeah. Confirm the other one. Okay. Alright. There you go. Do you need...? Is that what you need? No. I use the ThermoDex. I have - I always use the ThermoDex. Do you want - yeah. Can we get... So, I usually just put this in over fluoro, over the wire directly all the way up to the kidney, under fluoro. And then I pull the working wire and leave the safety in. Here we go. Thank you.

CHAPTER 7

Is she doing okay? She's what? Okay. Yeah. So you're gonna hold... Yeah, you, yeah. You hold actually, you hold back here. And then, Blake, you use your hands to feed over the wire and, fluoro live all the way up to the kidney. Okay. That's good. And you have the Gateway up there? Yeah. Oh, here. Gateway's there. Okay. I can take care of that for you. And then, can we increase our fluids to 150, please? 150? Yep. And you're probably gonna need to switch to ureteroscopy. Is your scope still up there in the kidney? It is, yeah. Okay. So I typically snap it on the same side as this stone is because you're - otherwise, you're working against it. So put it on the same side. And it's not on her skin. Right? You need your camera set up properly? Okay. Focus. When you focus, you want this notch to be sharp. There you go. Yep. Just take this thing off. Yeah. Alright. So, let's find a stone. So here, we're probably looking at the - that's just a stone in training. So we're here in the upper pole of the kidney, most likely. And looking around at the calyces, it's a little cloudy just from this patient having a stent in for a couple months. That's the wire sitting in the upper pole. Yep. That's probably a midpole calyx there. You can see the papilla of the kidney. That might be maybe lower pole. And so we systematically look at all of the calyces of the kidney to check for whether the stone maybe got pushed up there, and also to check for other stones. Okay. Thanks. Okay. Yeah. You wanna kinda try to stay in the middle there so that you don't schmutz your camera too much. So there's it looks like some little stone material there. See, is that lower pole? Yes, that looks lower pole to me. That's lower pole. Yeah. Yeah. Yeah. So all these... So that might be like a little compound calyx there. Got all the air bubbles. Oh, careful. Yeah. There it is. Alright. What do you wanna do with it?

CHAPTER 8

Do you feel comfortable lasering in the ureter? Or do you wanna try to basket it and move it up into the... Oh yeah, I think it's fine in the ureter. Yeah. It's five mm - that's what I'm wondering because her ureter looks pretty wide open. Yeah. And there's some fragments around the stone, so it's less than what we've seen on the scan. Yeah. We can certainly try to basket it. We'll see if her ureter dilated enough. Can we get a basket, please? So this stone looks like it might be able to be basketed and removed, in its entirety from the ureter just given its size and the caliber of the ureter. So, we'll try to bring it down from the kidney. So we're going to use a stone basket. Thank you. So now we're inserting the stone basket into the ureteroscope. The stone looks a little impacted in the ureter, but we will see if it can be dislodged with the basket. Are you still running your fluid? Just kinda drive your scope past the stone a little bit. Yeah. And then come on back. Why do we have so many bubbles? Okay. Yeah. Come on back to the stone now. Is that basket closed all the way? Okay. There you go. Yep. Advance it past - yeah. It's a little - there, yeah. Now the bubbles are going away. Yeah. So we're just kinda dislodging the stone from the ureteral wall. No. Just it's it's a captive audience right now, so you should try to - yeah. I would come the other side, but oh, okay. Well... I think you - I think you have it. Oh, there. Okay. You've captured the stone now. There. Yep. And now we're slowly pulling the stone through the ureter, and it's kind of a fine balance between keeping it far enough away to keep an eye on it and also, you know, bringing it along in the ureter with us. I'm not sure that's gonna - oh, yeah. Maybe it'll come. Just take it slow and stay in the middle. Is your fluid running at full blast? It is, yes. Okay. Yep. If you feel any catching, then you don't want to pull. Okay? Yeah. It looks like it's coming along. We're just sliding the stone out of the ureter. Now the the tricky part's gonna be the UO, and we'll see if it will if the ureteral orifice will accommodate the stone. Looks like are you in the bladder - there? You got it. Can we get a specimen cup, please? You just take it out of the bottle? Yep. And so - wow. That's a pretty big size stone. So that's our ureteral stone. Thank you. So we'll be sending this off as a specimen to be analyzed to try to figure out what kind of stones this patient is forming. And that will help us to make recommendations to try to help prevent her from having stones again in the future.

CHAPTER 9

So now we're going back up to the kidney to just take another quick look around and make sure that there aren't any other stones. There's two 0.8 stones. What was that? There's two 0.8 stones that we left behind. Yeah. Gentle on that ureter. Keep it in the middle. Me? Oh, no. Yeah. Just get up to the kidney there. We're driving back up to the kidney. That's the area where her stone was before. I think that stone was reasonably impacted. It was still mobile, but... Careful. Don't don't push it. I - that - oh, there's more there. So there's a little bit more stone fragment there. So we're going to grab it with the stone basket again. It's a pretty decent-sized fragment. I would try to get it the long way so that it'll come down the ureter. Oh, here's our stone basket again. Yep. Now we're opening the stone basket and then sliding it back. So you wanna just slide the - just the - you wanna keep your scope in the same spot and just yeah. Slide your basket. Yeah. Okay. Yeah. I think that's fine. We already have our specimen, so it's it's fine. Yeah. Yeah. That's the way you wanna go. Yep. Your instinct is right. You can empty it if you want. I mean, it's not too tough. Now we're trying to freehand go in to go into the ureteral orifice, and... Which is a lot easier to do in a a patient who's been prestented like this one. So we're traveling back up the ureter here. As the bladder gets fuller, it becomes more challenging to freehand in because the opening becomes more narrow from pressure from the fluid in the bladder. Oh, cloudy. Yep. Make sure you see the lumen. Just kind of fighting with the wire right now. Yeah. That happens. Oh, yep. There you go. Come on back. If you follow the wire, you'll always find your path. Come on back. Yep. Find your lumen. Find your wire. And, of course, they always get these little clots that try to get in your way. Is your flow good? Is the flow good, or do we need to change...? It looks good. Yeah. Just come on back a little bit. Always - you can always recalibrate. You know, just come on back. Come back to the - keep coming back towards the bladder. Get away from that clot. I don't love that view. Yeah. Oh, your basket was still in? There you go. No wonder. Yeah. I would not drive up the ureter with the basket still in. When you're - especially when you're trying to freehand because it's not... The flow is not there. The flow, yeah. You're - you don't wanna damage anything. Her ureter already looks kinda, like, with the impaction and everything. Is this the other portion of this? Oh, that's a really tiny fragment. So look up in over that stuff. Is is there a little something? There's some stone, like, right in there. You might wanna grab that. Are you still running your fluid? Okay. Oh, yeah. Because it'll squirt in your face otherwise. There it is. Alright. So now we've grabbed another large fragment of the stone. And, we're gonna bring this down from the ureter. Ahhh! We'll grab that other piece. So some - this stone looks like it's pretty soft, and it's just kinda... It can just kinda break up even from gentle pressure. Now we're bringing it back down to the bladder. And now we're in the bladder and releasing it. It's kind of sticking to the basket because it's kind of a soft stone, and there's some clots. You can just take the basket out, I think, and take that out. It's just clots. And you're gonna need to take it out anyways to get back up into the ureter. Find your wire. Yep. Oh, really nice. Really nice here. You're almost there. You can kinda bounce off the wall. There you go. Yep. And then just think about where that fragment fell off because we wanna try to go after that fragment. Yeah. It might have gotten blown up, which is fine. Yep. There's a piece there. There's some more of the stone. Actually, kind of a larger stone. I think it's been impacted in the wall for a little while. So now we're getting our basket back in to grab the stone. There it is. Plus air bubble. There you go. Yeah. Careful there. Yeah. I think you might have - I think you have something. Just pull the basket out so you can get that clot out. It's not actually a bad thing to get the clot out because it's not helping you right now. Yeah. You can just kinda rinse it in the - that's contrast. Yeah. There you go. Run your fluid in there a little, Blake, first. Yeah. So you can see your lumen there. Yep. There you go. There's your stone material. Yeah. Good. Some of this is this is pretty, like, soft stone. Yeah. Try again. Yep. You just kinda jiggle it a little bit. Pull back your scope a little bit so you can see. Yeah. Looks like you got some stuff there. Yeah. Yep. I'm seeing the peristalsis of the ureter there. Okay. You wanna pull your basket back again. Do you wanna empty your out at all? There you go. Or we're just gonna empty the bladder. We have to be careful that the bladder doesn't get too distended. And we're just emptying out the bladder now. Now we're gonna go back up into the ureter again. And now that the bladder is decompressed, we're trying to find our wire again. So we'll follow that up into the ureter. It's always a little bit more challenging after the bladder is decompressed to find the wire, but it makes it a little easier to go up. There you go. Look up. Yep. Are you on in full blast? Okay. Good. It's been, but not too much. There you go. Yep. And this patient will definitely need a stent for about a week after the procedure because of how impacted the stone was and multiple passes to get it all out. I don't know why my vision is so poor. I think you have some schmutz on your lens. That's a technical term. You know? Schmutz. That ureter looks rough in that area. I kind of - I'm not sure how much more manipulation I wanna do there just given, you know, how ratty it looks in there. I guess. I think the stone was in I think so too. I think there is. I think you should grab that. And - and then I think, you know, if that's all of it, then I think we should stent it, and... I think if we dislodge that stone totally off the wall, is that it? I think that's it. Yeah. Yeah. And it's actually kinda nice that they're like stuck in that clot because you can - because this stone is very soft. So that's why it just kinda keeps breaking up. So how much of the units on this stone is about six hundred? That's always the downside of putting in your basket. It, you know, makes your view a little tougher, but we could also increase our pressure. Yeah. Can we, just increase our pressure to two hundred, please? Two hundred? You got it. Yeah. Just to help, Blake see there. So we're just going to increase our fluid pressure to two hundred to help us. Two hundred. Thank you. To help us to see a little bit better. I think it's in that, isn't it? Yeah. Why don't you take a quick look up, yeah. And follow that up just in case we push the stone up with our fluid. That's really small. Yeah. Yep. So really small. Yeah. I think so too. Sure. Thanks. Yeah. It's a little cloudy up there, isn't it? I would say if we're gonna go after that, I probably wanna put a sheath up at this point. Can I ask, have you guys been running your fluid a lot? Yeah. It would it's - it's a very small caliber scope. So how much? We've only used five hundred milliliters. Oh. Yeah. I mean, we've been - okay. Yeah. I think that sounds about right. Yeah. I don't I don't think I would put - I think that's gonna sit there. She had some stones that looked a little intraparenchymal on her CT as well. Alright. Let's - let's also get - oh, is that a little something in there? That just looks like clot fragment. Yeah. Let's get a retrograde.

CHAPTER 10

Why don't you bring your scope back down a little bit distal to the area where the stone was impacted. Yeah. About there, I think. And let's, yeah. So we're just going to shoot a retrograde pyelogram now through the scope, and this will help us to see, the renal anatomy. And, basically, it will give us a landmark for where our stent is gonna go. Everybody covered? Okay. Okay. That looks good. Okay. So we just wanna see the renal anatomy so that so we know where the proximal curl of our stent is going to go.

CHAPTER 11

And, we're gonna need a 6 by 24. So we're just gonna get a good look at the ureter on our way out. 6 by 24. 6 by 24, double J, please. 6 by 24, French. Expiration's April 17th, 2026. Okay. Great. Can you decrease the pressure on our fluids to 60? 60.

CHAPTER 12

Alright. You're at 60. Thank you. Where are scissors? Scissors. That's okay. I got it. Let's do this. Oh, sorry. Pop over this way. So now we're going to place our cycstoscope. Hold the wire at the urethra. Oh, I see, here. Yep. And then we'll pull the pusher out. So we use the pusher to backload the wire into the cystoscope. We always make sure to reduce the pressure on our fluids before we start cystoscopy again. And - now we'll drive the scope into the bladder over the wire. Did this lady have a stent already? She did. Did we take one out? Yes, we did. What do we call this specimen? Left ureteral stone. So now you can see the wire coming out of the ureteral orifice, and we are threading the stent over the wire. The stents are very slippery. Do you want that specimen sent for chemical analysis or pathology? I think it's chemical analysis. You might wanna empty out a little bit. Yeah. The outflow and a little inflow so you can see a little better. Yeah. You're - yes. Just try to empty a little bit and put some fresh fluid in there because it's really - I just I don't want you to push the stent up the ureter. Okay. Now you can try this. If you can see a little bit better. I think your camera is probably actually a little cloudy too. Okay. So now the stent is going up slowly, slowly. No. I don't fluoro yet. I keep going to the solid line. And then come on back to the bladder neck. And push until you see the orange. Don't come out of the bladder though. Woah. Woah. Woah. Woah. Woah. Okay. Good. Now spot. Okay. Now pull the wire. Okay. Okay. And another spot. Okay. Good. Alright. Alright. So now we have the stent in.

CHAPTER 13

Let's go ahead and empty her out. And let's make sure that there aren't any stone fragments left in the bladder. We're gonna be done here shortly. Okay. Thank you. So we're just gonna take one more quick look in the bladder here to get rid of any stone fragments that we had pulled out. There you go. And this one. Yep. Look right at it and then disconnect and flush it out. I don't think I got it with that one. You did? I don't think I did. Okay. It's still there. It's still knocking. Yeah. And now drop your hands. Yeah. I think you got it. Got something. Okay. Terrific. It'll probably still be in here. Should I get that clot out? Yeah. I don't I'm not sure that that's - yeah. It's still there. Yeah. You sort of scoop it up and and then you drop your hands. Yeah. Alright. Oh, I think you've got - it's still there. It's gonna be fine. Yes. Alright. It'll be fine. Yeah. Just empty her out and alright.

CHAPTER 14

So now we're done with the procedure and we were able to retrieve the stone and render this patient stone free. I thought the operation went pretty well, and we pretty much accomplished all the same steps that I described earlier. Some key decision points: first, we found that the stent was a little bit encrusted, and so it would not accept a wire through it to gain access to the kidney. And in order to maintain access to the kidney and not lose our opportunity to take care of the stone, we instead decided to place the wire alongside the stent because it just wasn't passing because of the encrustation. And so that's a way that you can maintain access to the kidney if the stent is encrusted. I think the second key decision point was that when we encountered the stone, what to do about it. So the stone, there's several things that we could have done. One was to use a laser to break it up and then the second option was to move it up to the kidney to break it up and a third option which is the one that we chose was to introduce a basket into the ureter and grab the stone and slide it out. Given that the patient had had a stent before, their ureter was quite dilated and so that size of the stone was easily retrievable with a basket and so we did not need to use the laser and we were able to pull it out in its entirety. And another thing about that stone is that it was a little softer and so it did break up a little bit while we were basketing it. So we did have to go back in a couple times to make sure that we got all of the pieces out. The other key decision point was deciding how long of a stent to place, and the patient had had some discomfort with the prior stent which maybe it was a little bit too long or it wasn't quite fitting right in her ureter, and so we made some adjustments to the size. We opted for a shorter stent in order to improve her comfort. And then I think another decision point is whether to leave the stent on a string or not. Usually if we're just leaving the stent in for a couple days, we can have the patient remove the stent on their own by leaving a little pull out string that comes out of the urethra. But for this patient, because it looked like the stone was a little bit impacted, we wanted to leave the stent a little longer in order to allow that area to heal. And so in that case, we took off the pull out string and plan to bring her back for another procedure in the outpatient setting to remove the stent.