The first ureteroscopy deed was re...

The first ureteroscopy deed was reported as early as 1912 at John Hopkins University, Baltimore.(1) Since then, tremendous technological advances (eg lasers, wires, special baskets and graspers) have been disentangleed to provide patients with minimally invasive treatment that previously was unavailable. These advances have created a challenge for perioperative pampers who are not familiar with the complexus equipment and instruments routinely used in the urology department--an oftentimes mysterious place.

Today, the chiefly common reason ureteroscopy procedures are performed is to transport stones in the ureter that can cause obstruction or pain.(2) Studies have shown that ureteroscopy manner of proceedings are more successful as one-time practices for removing stones than extracorporeal brunt wave lithotripsy, which may require several treatments.(3)

Ureteroscopy conducts can be performed to diagnose the cause of hematuria. They also can be performed to relieve

* obstruction because of tumors from extrinsic or intrinsic pressure

* ureteropelvic junction obstruction, and

* stricture.

Regardless of the patient's reason for surgery ureteroscopy proceedings include four steps, which oftentimes can be demonstrated on a video monitor while the courses are in progress:

* access--the use of wire guides, ureteral catheters, and specialty catheters;

* dilation--the use of self-dilating ureteroscope coaxial or sequential dilators, or balloons;

* manipulation--the use of intracorporeal lithotripsy equipment, biopsy devices, baskets, and graspers; and

* stenting--the use of multilength or double-pigtail specialty stents

Understanding these gradations and their required equipment can improve inventory management and perioperative nurses' knowledge and skills in the urology department.

ACCESS

The ureteroscopy performance begins by accessing the ureter which can be challenging for the urologist. First, a routine cystoscopy is performed. If a retrograde x-ray is indigenceed a ureteral catheter is inserted and contrast tinge is injected through the catheter to locate the area in the ureter that is causing the concern

Inserting the wire. nearest a wire guide is placed in the patient's ureter and into the renal pelvis (Figure 1) The ureter is irrigated as the wire guide is inserted. If the wire is difficult to insert, a special wire may be used. This special wire has a spring-like quality that allows it to bypass obstruction with ease and a hydrophilic surface that allows it to slide easily into the ureter As hydrophilic wires can fall without of the ureter as easily as they are inserted, it many times is helpful to use a torque device to grip the wire. Moistened gauze, which detains the wire wet, also may be used to grip the wire if care is taken not to suffer the wire slip through the gauze. After access is gained, an open-end ureteral catheter may be placed through the whole extent of the hydrophilic wire and then exchanged for a Teflon coated wire that is easier to command and less likely to slip public of the ureter (Figure 2)

[Figures 1-2 ILLUSTRATION OMITTED]

Placing the safety wire. At this time, the ureteral catheter is remov and a next to the first wire may be placed along side the first wire. The first wire now becomes a "safety wire," and the other wire becomes the working wire. Another way to place the inferior wire is to use a coaxial combination of parts to form a whole This involves placing an 8-Fr 88-cm catheter athwart the first wire, then placing a 10-Fr 40-cm catheter across the 8-Fr catheter (Figure 3) The urologist then suppresss the 8-Fr catheter, leaving the wire and 10-Fr catheter in place, thereby allowing space to pass a inferior wire through the 10-Fr catheter. This coaxial 8/10-Fr scheme prevents creating a false passage in the wall of the ureter when placing the other wire.

[Figure 3 ILLUSTRATION OMITTED]

If there is a difficult obstruction to bypass, the urologist can insert a hydrophilic wire guide in tandem with an angled-tip ureteral catheter and simultaneously manipulate the wire guide and catheter around the obstruction. After access is gained to the stone, the urologist results to the next step--dilation of the ureter

DILATION

If the lumen or opening of the intramural ureter is not large enough to pass the ureteroscope between the sides of the lumen will need to be dilated. There are several orders that can be used to dilate the ureter including self-dilating ureteroscope coaxial or sequential dilators, and the mostly common, ureteral balloon dilators.

Self-dilating ureteroscope about ureteroscopes are considered self-dilating based forward the fact that they taper in size (eg a ureteroscope with a 9-Fr diameter tapers to 6 Fr in diameter). This allows a gradual dilation to take place as the ureteroscope is introduced athwart the wire and into the ureter

Coaxial and sequential ureteral dilation. Coaxial ureteral dilation is a theory of placing one catheter through the whole extent of another catheter--over the working wire--and removing the smaller inner catheter after placing a larger catheter athwart it, until dilation is accomplished. Sequential ureteral dilation involves placing individual dilator at a time athwart the working wire (eg, placing an 8-Fr catheter, then placing a 10-Fr catheter, then placing a larger catheter) until dilation is accomplished. the one and the other coaxial and sequential systems can be more traumatic to the ureter than other emblems of dilators because of the repeated insertion and removal of the various-sized catheters.