LECTURE № 1

1-Introduction to Endourology
2-History of Endourology
3-Cystourethroscope
4-Trans Urethral Resection of the Bladder (TURBT)
5-Transurethral Cystolithotripsy
6-Upper Urinary Tract Endoscope
INTRODUCTION TO ENDOUROLOGY
The history of endourology is as old as the specialty of urology itself. However,
modern day endourology came into its own during the late 1970s with several path-
breaking discoveries. These included percutaneous and ureteroscopic approaches to
the upper tract, which following the arrival of extra-corporeal shock-wave lithotripsy
(ESWL) in early 1980s, completely revolutionized the management of urinary stone
disease, rendering open stone surgery nearly obsolete.
The subsequent years have seen steady refinements and improvement in the
armamentarium and technique of endourological procedures to make them more
efficient, safe and cost-effective. The addition of flexible instrumentation and lasers
has improved the reach and versatility of endourological approach. There has been
widespread adoption and spread of this new technology to every corner of the world.
To our satisfaction, India has been right in the forefront of this revolution. There are
many centers in the country performing extensive endourological work both in
qualitative and quantitative terms, with increasing international recognition.
The Birth of Endourology In 1978, Arthur Smith, described the first antegrade stent
placement when he introduced a Gibbons stent through a percutaneous nephrostomy in
a patient with a reimplanted ureter with a urine leak to allow the urinary leak to seal.

Endourology refers to a subspecialty in urology where minimally invasive techniques

are used to inspect the urinary tract and perform surgery or laparoscopy surgery. A
surgeon with special training feeds tiny cameras and surgical tools through a thin,
flexible tube called an endoscope.
Endourology, for example, can be used to locate and remove small kidney stones.
Stones may be taken out or fragmented using tiny instruments inserted into the body
through such areas as the urethra, bladder, ureter, and kidney. In addition to
treatment, doctors can help determine what is causing the kidney stones and help
identify ways to prevent further stones from forming. Thin, flexible instruments
including lasers, graspers, miniature stone retrieval baskets, special scalpels, and
cautery, can be used to perform surgery without creating any incisions at all. Nearly all
endoscopic procedures can be done on an outpatient basis.
Urology is a surgical specialty which deals with diseases of the male and female
urinary tract and the male reproductive organs. Urology includes: Oncology;
Urolithiasis/Stones and Andrology. Although urology technically is a "surgical
specialty," an Urologist must be knowledgeable in other areas including internal
medicine, pediatrics, and gynecology because of the wide variety of clinical problems
that a urologist deals with. The seven urological subspecialty areas are:
-Pediatric Urology
-Urologic Oncology (Benignant tumor-adenoma) and malignant tumor ( cancer)
-Renal Transplantation
-Andrology-Male Infertility, Erectile Dysfunction or Sexual impotence, Ejaculatory
disorders).
-Urolithiasis (urinary tract stones)
-UroGynecology (Urinary Tract Infections, Urinary Incontinence and pelvic outlet
relaxation disorders, Ureterocele).
-NeuroUrology (voiding disorders, urodynamic evaluation of patients, Nerves)

Endourological Procedures Include:

-Urethroscopy : used to treat strictures or blockages of the urethra.
-Cystoscopy: used to treat bladder stones and tumors. Obstructing prostate tissue can
be removed with this approach as well (a procedure called “TURP”). Flexible plastic
tubes called stents can be passed up the ureter using cystoscopy and x-rays to relieve
blockage of the ureter.
-Ureteroscope: used to treat stones and tumors of the ureter.
-Nephroscope: used to treat stones and tumors of the kidney lining.

Flexible Cystoscope
Fine glass fibres are flexible. If made of completely clear optical glass, the light
entering one end will undergo total internal refraction and leave from the other. A
fibre‐optic cable comprises a large number of these fibres and when fitted to an
appropriate lens and deflecting mechanism can be introduced into any orifice of
the body and manipulated within the body to investigate disease and will transmit
an image in a series of tiny dots like ground glass .
The modern flexible cystoscope has channels for irrigation, for light and for
passing flexible instruments such as biopsy forceps, laser fibres or a diathermy
electrode. Passing the cystoscope is uncomfortable but usually painless.
Flexible Cystoscope is a routine examination of the bladder which is carried out
using a flexible telescope (cystoscope). It is passed along the water pipe (urethra) and
into the bladder.

Rigid Cystoscope A rigid cystoscopy is a procedure to check for any problems in the
bladder using a rigid telescope (cystoscope). Sometimes certain problems with the
bladder and urinary tubes can be treated at the same time.

Rigid Cystoscope
The image seen through the rigid cystoscope is much clearer than that of the
flexible instrument, and the instrument channel allows a large variety of
instruments to be used inside the bladder Biopsies can be taken, tumor
resected, stones crushed and ureters catheterized and examined. It is less
comfortable for the patient than the flexible cystoscopy, and general anesthetic is
required. The patient is placed in the lithotomy position. Technological
advances are continuously ongoing to improve the characteristics of the
instruments to achieve superior visualization. There has been an introduction
of improved camera system with 3D system for improved vision. Using the
camera allows projection of the view on large screens, which is valuable in
teaching members of staff. It also allows photography.
 Cystourethroscope is a procedure that allows your provider to visually examine the
inside of your bladder and urethra. This is done using either a rigid or flexible tube
(cystoscope), which is inserted through the urethra and into the bladder. Sterile
water runs through the cystoscope to allow for a more comfortable and more
complete examination. (Cystourethroscope)

Cystourethroscope is a procedure used to examine the inside of the bladder and

urethra.

Some Indications for Cystourethroscope:

 Rule out bladder perforations during sling procedures
 Confirm ureteral patency after vaginal vault suspensions, hysterectomies, and complex
pelvic surgical cases
 Undiagnosed hematuria (blood in the urine)
 Refractory urge urinary incontinence (especially if it develops after a previous surgery)
 Rule our a foreign body
 Recurrent Urinary Tract Infections
 Rule out Interstitial Cystitis
 Evaluation for vesicovaginal fistula
 Examination for stones or tumors inside the bladder
 Evaluation for bladder/urethral diverticulum

Preparation for a Cystourethroscopy Procedure

 Generally, there is not much preparation needed for a routine, in-office cystoscopy.
Simply follow instructions given to you before your procedure, which can be
found here. Cystourethroscopy is generally well-tolerated. We ask our patients to take
ibuprofen before arriving for their appointment, and we administer lidocaine gel into
the urethra a few minutes before the procedure. This is usually enough to keep the
majority of patients pain free until the procedure is completed. Afterwards, to avoid
dysuria, or burning, we will give our patients a couple of tablets of a medicine called
Uribel.
If your cystoscope is scheduled as an “operative cystoscope,” this will typically mean
that the procedure will be performed in the operating room under general anesthesia. If
that is the case, the preparation changes a bit, as you will not be allowed to eat or drink
anything after midnight in the hours leading up to you exam. While most people can
usually drive themselves home after an in-office exam, you will need someone to drive
you home if you have an operative cystoscope or any cystoscopic exam that requires
general anesthesia.

In-office cystourethroscopy usually takes no more than 5 minutes to complete, while

times for operative cystoscopies vary depending on the reason for the exam.

After Cystourethroscopy Procedure

Generally, people experience little to no problems following these exams. However,

you should call your physician immediately if you experience any of the following:

 Fever
 Hematuria (or blood in the urine)
 Inability to urinate
 Burning or pain during urination

Cystoscopy is performed with a cystoscope, a specialized endoscope (a small telescope

with a camera on the end) and typically takes between 5 and 20 minutes. The urethra (the
tube that empties the bladder) is cleansed and local anesthetic jelly is applied. The
cystoscope is then inserted through the urethra into the bladder. Sterile water flows
through the cystoscope and the bladder is gently filled, much like a balloon, which allows
examination of the entire bladder wall.
 Transurethral Resection of Bladder Tumor (TURBT)
TURB is the procedure done to diagnose and to treat early stage bladder cancer at the
same time. The initials stand for transurethral resection of a bladder tumor. This
procedure is the first-line diagnostic test and treatment for bladder cancer. Men are
almost four times more likely than women to be diagnosed with this type of cancer.
The majority of people have bladder cancer that hasn’t invaded the muscle wall when
first diagnosed. Almost everyone diagnosed with bladder cancer will undergo bladder
tumor biopsy and resection.
A biopsy is a procedure in which a doctor takes a tissue sample from the area where
cancer may exist. During the biopsy procedure, the doctor also will try to remove the
cancerous growth. This is called resectioning. The entire procedure for bladder tumor
biopsy and resection is known as transurethral resection of bladder tumor (TURB).
TRANSURETHRAL RESECTION OF A BLADDER TUMOR

TREATMENT OF BLADDER CANCER BLADDER CANCER

PROCEDURE DETAILS
Preparation For a TURBT
Normally, you have to stop eating and drinking the night before any procedure that
requires anesthesia. Make sure your provider knows about all of the medications that
you take, including over-the-counter medicines and supplements.
Your healthcare provider will tell you if you need to avoid taking any of your
medication — for instance, blood thinners — and when you should stop. Don’t just stop
taking medication without discussing it with your provider.
If you’re allowed to take medications in the morning before the TURB, make sure you
only take a sip or two of water.
Take a bath or shower before you go in for the procedure. Don’t use any kind of lotions
or perfumes or deodorants after your shower. Dress comfortably the day of the
procedure. Bring identification, but leave your money, credit cards and jewelry at home.
Bring someone who can drive you home. Between anesthesia and pain medication, it
won’t be safe for you to drive yourself.
Performance of Bladder Tumor Biopsy and Resection.
You may have general anesthesia for this procedure, which means you’ll be asleep for
it. Some providers might use regional (or spinal) anesthesia, which means you’ll be
awake. However, you won’t feel any pain. Bladder tumor biopsy and resection is
performed when a doctor inserts a rigid instrument called a resectoscope into the
bladder through the urethra. (This is the meaning of the word transurethral.) Inserting
the resectoscope in this way means that no incisions are necessary.
Your provider will use the resectoscope to remove the tumor, which will be sent to a
pathology lab for testing. Once the tumor is removed, your doctor will attempt to
destroy any remaining cancer cells by burning the area using electric current by a
process called fulguration or cauterization.
Your provider may decide to insert some type of chemotherapy medicine into the
bladder using the scope. This is called intravesical chemotherapy. Your provider might
suggest that you have maintenance intravesical chemotherapy for a period of time,
meaning that you'll have regular treatments.

The Risks of Bladder Tumor Biopsy and Resection

Bladder tumor biopsy and resection is a very safe procedure. However, like any
surgery, it has some risks. These include:
 Risks related to anesthesia.
 Urinary tract infections.
  Excessive or prolonged bleeding.
 Perforation (or a hole) in the bladder.
If you have any symptoms such as fever, feeling cold and shivery, or heavy
bleeding following bladder tumor biopsy and resection, you should seek medical
help right away.
Transurethral Cystolithotripsy:

Transurethral cystolithotripsy with Holmium laser is an effective and safe

procedure with large bladder stones. This procedure can be easily performed as a
day care procedure.

Bladder stones constitute around 5% of bladder stones in the developed countries.

Holmium laser lithotripsy has revolutionized the treatment of urinary lithiasis.
Aim
The aim of this technique is to report the outcome of transurethral cystolithotripsy
with Holmium Laser under Local Anaesthesia (LA) as a day care procedure in
patients with bladder stones.

Materials and Methods

Patients with bladder stone greater than 1.5cm attending urology Outpatient
Department underwent transurethral cystolithotripsy with Holmium Laser under
LA as day care procedure.

Complications of Lithotripsy may Include, but are not limited to

 Bleeding around the kidney.
 Infection.
 Obstruction of the urinary tract by stone fragments.
 Stone fragments left that may require more lithotripsies.
Upper Urinary Tract Endoscopy

Upper urinary tract endoscopy has come a long way from the first endoscopic
examination performed in 1912 by Young and McKay. They used a 9.5 F rigid
cystoscope in a patient with a very dilated ureter. Current semi-rigid and flexible
instruments are purposely designed to allow diagnostic and effective therapeutic
interventions with minimal associated morbidity. The timeline of this evolution is
perfectly described elsewhere. This chapter summarizes the instrumentation
available to the modern urologist, the basic principles behind their use and the
major clinical outcomes now expected from their use.

The semi-rigid ureteroscope is the workhorse of endoscopic ureteric surgery. It

was developed from the larger rigid ureteroscope primarily because of concerns
about the inability of the rigid scope to access the upper ureter without causing
significant damage to the urothelium. The “flexibility” and reduced size are
primarily due to the introduction of fibre-optics. The fibre-optic bundles (clad for
image transmission, unclad for light transmission) are fixed at both ends which
permits movement without loss of picture quality.
Semi-rigid ureteroscopes are very durable instruments. The biggest reason for
failure is improper use or maintenance. Factors associated with failure are age,
shaft design (tapered < stepped) length (long > short) and diameter (narrow >
wider). While the instruments flexibility has increased its therapeutic potential, it
also increases its susceptibility to breakage and deflections above 5cm are said to
be particularly damaging to the instruments.
Flexible Ureteroscopy is used less as a first line treatment for stones > 1.5cm in
size. However, with ongoing improvements in newer generation flexible
ureteroscopes, there is an increasing trend toward ureteroscopy and laser lithotripsy
for intr-renal calculi of all sizes and compositions. In the available literature, there
are very few reported studies on the use of semi rigid ureteroscopy to treat renal
stones. A prospective analysis performed by Bryniarski and co-workers assessed
the safety of PNCL and retrograde intrarenal surgery use semi rigid ureteroscopy
for the management of renal stones of >2cm in size. Although stone free rates were
superior in the PCNL group, the semi rigid ureteroscopy provides advantages for
operating times, haemoglobin loss, post-operative visual analogue scoring by
patients and reduced hospital stay. The situation is slightly more complex in lower
pole stones as the following table shows.
Urolithiasis, Stone, Calculi, Nephrolithiasis
Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are hard deposits
made of minerals and salts that form inside the kidneys. Diet, excess body weight, some
medical conditions, and certain supplements and medications are among the many causes
of kidney stones.