I. Basic Principals: Prostate Anatomy

ANATOMY OF THE PROSTATE

Detailed understanding of prostatic anatomy is essential for every
urologist.

Figure 1: Prostate Anatomy

PS=pubic symphisis AFS=anterior fibromuscular stroma SV=seminal
vesicle CZ, TZ, PZ=zones of prostate (see text)

• In a young adult, prostate weights ~20g and measures ~3 by 4 by
  2 cm
• Apex = inferior portion of prostate, continuous with striated sphincter.
  Base = superior portion and continuous with bladder neck.
• Prostatic urethra
  • Covered by transitional epithelium
  • Hugs anterior portion of gland
  • Makes a ~30 degree bend in its mid portion (degree of angulation can
    vary from 0 to 90 degrees)
  • Verumontanum
    • just distal to urethral angulation
    • ejaculatory ducts (union of seminal vesicles and each vas deferens)
      drain to each side of prostatic utricle (vestigial Mullerian duct
      structure)
• Zones of Prostate (Figure 1)
  • Central zone (CZ)
    • Cone shaped region that surround the ejaculatory ducts (extends
      from bladder base to the veru)
    • Likely stems from Wolffian ducts
    • 25% of glandular tissue in young adults
    • Only 1-5% of prostate cancer from this region (likely because
      of Wolffian duct embryologic origin)
  • Peripheral zone (PZ)
    • Posteriolateral prostate
    • Mesodermal in origin
    • Majority of prostatic glandular tissue
    • Origin of up to 70% of prostate adenocarcinoma
  • Transitional zone (TZ)
    • Surrounds the prostatic urethra proximal to the veru (aka preprostatic
      urethra)
    • Endodermal in origin
    • In young men, accounts for only 5-10% of prostatic glandular tissue.
    • Only ~20% of prostate cancer arise from TZ
    • Gives rise to BPH
• "Lobes" of the prostate
  • Enlargement of periuthral tissue in the TZ results in hyperplasia
    of "lateral lobes" (Figure 2).
  • In some men, hyperplasia of periurethral glands of the TZ at the bladder
    neck produces a "median lobe" -- tissue mass that can
    ball-valve into the outlet (Figure 3)

Figure 2: Cystoscopic view of lateral lobes.

Edge of the verumontanum is seen at 6 o'clock.

Figure 3: Cystoscopic view of a large median lobe.

The ball-valve obstruction created by a median lobe in some men is clearly
appreciated from this image.

Grades and Boards

Grades

You needed good grades to get into college and good grades to get into medical school--getting into residency is no different. Grades in the first two years are important, but residency directors care much more about clinical clerkship performance. Strong grades in Core Surgery and Core Medicine clerkships are very desirable. A high grade in your Urology sub-intership(s) is extremely helpful. Beyond these specific clerkships, it is your overall pattern of grades that will stand out. What's most coveted, not surprisingly, is AOA, as this gives the residency admission committee the best evidence that you are among the top of your class. You can absolutely still match without being AOA, but it will be more difficult to match at top programs. Some top medical schools do not have AOA chapters, and ERAS allows you to select "No AOA Chapter At My School" option on the application. Bottom line: if you think your grades are marginal, you should find a good advisor to council you on where you stand.

Board Scores

Board scores are extremely important. They provide the most objective comparison of applicants and play a significant role in the selection of candidates for interviews. You will find that once you have made it to the interview round, these scores begin to carry significantly less weight. Here is a rough breakdown of scores:

< 215 - seek advice on whether you have a reasonable chance at matching; people do match with these scores, but only with a very solid application.

215-230 - your score may hurt you in the eyes of many programs, but many people match every year with these scores.

230-240 - these are solid scores and you should certainly do fine. If you are aiming for top-tier programs, however, this is hopefully not the strongest part of your application. 

240-250 - you are in great shape.

>250 - your board score is outstanding and will stand out.

Having USMLE Step 2 on your application is not at all necessary, but if you believe that your score on Step 1 is marginal, doing well on Step 2 can be a very strong move. The best advice is to take Step 2 after you submitted your ERAS application and all the schools have downloaded your USMLE score report (early November is perfect). Be sure that you do NOT select "automatic score reporting" when filling out the application. This way, if your Step 2 scores are high, you can instruct ERAS to release them to the residency programs in time to help you. If you do no better on Step 2 than on Step 1, do not release your scores and no one finds out. Every year we see applicants who apply with excellent Step 1 scores and poor Step 2 scores--these students have completely unnecessarily severely damaged their application.   Note, recently the UCSF program (see details) has announced a requirement that students must have Step 2 scores submitted prior to being ranked.

 

 

II. Basic Principals: Benign Prostatic Hyperplasia (BPH) and Its Treatment

Benign Prostatic Hyperplasia (BPH) and Its Treatment

Pathophysiology

Evaluation

Treatment

Watchful waiting

Medical Therapy

Surgical Therapy (Thermal therapy, Laser prostatectomy , TURP , Open Prostatectomy)

• Pathogenesis of BPH is more complex than the simplistic notation of "large prostate = obstruction"
  
  
  
  • Complex interaction of anatomic and physiologic processes result in increased resistance of prostatic urethra.
    
    
    
    • Glandular enlargment
      
      
      
      • Hyperplastic process in the glandular tissues of the transitional zone and periurethral tissues (Figure 1 and 2, see prostate anatomy page for full description of prostate anatomy).
        
      • Presence of prostatic capsule results in compressive forces on prostatic urethra (BPH in dogs, for example, does not cause bladder outlet obstruction, since there is no prostatic capsule).
      
      
    • Increased prostatic smooth muscle tone - mediated by the alpha-1a receptors.
      
    • Decreased prostatic compliance.
      
    • Changes in prostatic urethral geometry.
  
  
  
  
  • Important to note that pathology unrelated to the prostate can result in identical lower urinary tract symptoms (LUTS) -- e.g.: urethral stricture disease, bladder neck dysfunction, bladder pathology.
  
  

   

  
  
  
  
• Figure 1: Cystoscopic view of lateral lobes.
  Edge of the verumontanum is seen at 6 o'clock. Rollover image with mouse to see position of scope in in prostatic urethra.

• Figure 2: Cystoscopic view of a large median lobe.
  The ball-valve obstruction created by a median lobe in some men is clearly appreciated from this image.
  Rollover image with mouse to see position of scope in prostatic urethra.

• History
  
  
  
  • Be sure to elicit history of conditions that contribute to bladder dysfunction and polyuria
    
  • Include family history of BPH and prostate cancer
    
  • Assess symptoms with Americal Urologic Association Symptom Index (AUA-SI) -- identical to International Prostate Symptom Score

• Physical examination should include digital rectal exam (DRE) t
  
  
  
  • Assess prostate size -- DRE shown to underestimate prostate size, but glands that feel large on exam usually are indeed hyperplastic.
    
  • Assess presence of localized prostate cancer -- a possible cause of LUTS in elderly men.
  
  
• Urinalysis -- to screen for bladder calculi, UTIs, and bladder cancer as cause of LUTS.
  
  
  
  • Consider voided urine cytology for those men with predominantly irritative symptoms or a significant history of smoking.
  
  
• Discussion of PSA screening is appropriate in men with LUTS.
  
• Other tests at initial visit for LUTS include:
  
  
  
  • Flow/PVR -- but be aware that there are no established guidelines for acceptable Qmax or PVR in men with LUTS.
    
  • Creatinine -- shown to be unnecessary as men with BPH have same rate of renal insufficiency (<1%) as general population.

• Watchful waiting
  
  
  
  • Men with AUA-SI equal or <7.
    
  • Men with AUA-SI >7 and are:
    
    
    
    • reluctant to undergo invasive treatments or are unwilling to initiate life-long medical therapy
      
    • do not have BPH complications such as UTIs, retention, bladder stones, or renal insufficiency
    
    
  • Reevaluate patients at least annually.
  
  
• Medical therapy
  
  
  
  • alpha-Adrenergic blockade
    
    
    
    • reduces AUA-SI by an average of 4-6 points within weeks of therapy initiation
      
    • alfuzosin, doxazosin, tamsulosin and terazosin are therapeutically equivalent
      
      
      
      • costs and side-effects differ
        
      • overall side effects are mild and include dizziness, headache, fatigue, postural hypotension, nasal congestion, edema, and retrograde ejaculation
      
      
    • first-line agents for LUTS treatment
    
    
  • 5-alpha-reductase inhibitors
    
    
    
    • block production of dihydrotestosterone (DHT) in the prostate, while serum testosterone levels remain within normal limits
      
    • AUA-SI reduced by 3 points (less than alpha-blockers) and are ineffective in men with normal-sized prostates
      
    • 5-alpha-reductase enzyme
      
      
      
      • Type I - liver, sebaceous glands, skin, and most hair follicles
        
      • Type II - face/scalp/gentialia hair follicles, prostate
      
      
    • Finasteride
      
      
      
      • competitive inhibitor of Type II isoenzyme
        
      • 60-70% reduction in serum and 85%-90% reduction in prostatic DHT levels
        
      • prostatic glandular epithelium atrophies; prostate size decreases by 15-30% within several months
      
      
    • Dutasteride
      
      
      
      • competitive inhibition of both Type I and Type II isoenzymes
        
      • more global suppression of DHT than finasteride
        
      • no head to head trial of finasteride to dutasteride, but the two drugs appear clinically to be simial (dutasteride may have quicker onset of action)
      
      
    • Well-tolerated -- small risk of libido reduction and erectile dysfunction.
    
    
  • Combination therapy
    
    
    
    • Based on assumption that drugs that work by different mechanisms will have synergistic or at least additive action
      
    • Initial trials that enrolled men with small glands showed no benefit to adding 5-alpha reductase inhibitors.
      
    • MTOPS trial
      
      
      
      • randomized, double-blind, placebo-controlled trial: 3047 men randomized to placebo, doxazosin, finasteride, or combination with mean follow up of 4.5 years
        
      • mean prostate volume 35.3 cm^3 and AUA-SI 8 to 30 (mean 16.9).
        
      • disease progression defined as at least 4 point rise in AUA-SI, acute urinary retention, urinary incontinence, renal insufficiency, recurrent UTIs
        
      • placebo group - 17% progression; doxazosin group - 10% progression (39% reduction); finasteride group - 34% reduction; combination therapy only 5% progression (66% reduction, p<0.001).
      
      
    • Combination therapy currently used in men with LUTS and documented prostatic enlargement (if gland is small use alpha blockade monotherapy)
      
    • Recently some have advocated addition of anticholinergic agents and even PDE-5 inhibitors to alpha blockade in treating men with LUTS.
  
  
• Surgical therapy
  
  
  
  • Thermal therapy
    
    
    
    • RF Therapy
      
      
      
      • Employs heat to produce coagulation necrosis in the lateral lobes of the prostate
        
      • Heating is achieved with two radiofrequency energy-emitting needles
  
  
  
  
  
  
  • Transurethral microwave thermotherapy (TUMT)
    
    
    
    • Produces coagulation necrosis of prostatic tissues through heat produced by a microwave-emitting coil.
      
    • Several companies produce devices that work in similar fashion and most employ a water-cooling balloon coupled with a high-energy source.
      
    • Complications include prolonged urinary retention and prolonged irritative voiding symptoms.s, Urology
  
  
  • Laser prostatectomy -- offers decreased blood loss and shorter catheterization as compared to TURP
    
    
    
    • HoLEP
      
      
      
      • Enucleation of tissue using front-firing laser fiber of a HYAG laser (2097 nm)
        
      • Prostatic tissue is pushed into bladder and extracted using an evacuator or morcillator
      
      
    • HoLAP
      
      
      
      • Side-firing HYAG laser (2097 nm) used for tissue vaporization
      
      
    • Photoselective Vaporization of the Prostate (PVP)
      
      
      
      • Side-firing KTP laser (532 nm)
    
    
  • Transurethral Resection of the Prostate (TURP)
    
    
    
    • Said to be the hallmark of the urologist and is the "Gold Standard" BPH treatment
      
    • Prostatic adenoma resected transurethrally using electrocautery loop (Figure 4)
      
    • Spinal anesthesia is preferred to monitor patient's mental status in face of potential hyponatremia (TURP syndrome)
      
    • Up to 90% of patient see improvement in symptoms -- upto 9.6 AUA-SI points and in some studies up to 80% reduction in AUA-SI score.
      
    • Complications
      
      
      
      • TURP syndrome
        
        
        
        • 2% of patients
          
        • Vision disturbances, changes in mental status, wide complex tachycardia
          
        • Glycine is used as irrigation -- does NOT prevent hyponatremia but limits hemolysis
        
        
      • Incontinence -- patients should be warned regarding this rare yet devastating side-effect
        
      • Erectile dysfunction -- prospective data does not support retrospective reports suggesting that men following TURP are at risk for new erectile dysfunction.
  Figure 4: Resection with electrocautery loop during TURP.
  
  
  
  • Open prostatectomy
    
    
    
    • Enucleation of periurethral prostatic tissues, leaving prostatic capsule intact
      
    • Retropubic - make lower abdominal incision, gain access to adenoma through incision in anterior prostate (Figure 3).
      
    • Suprapubic (aka transvesical) - access to adenoma through incision in anterior bladder wall; better for patients with large median lobes and large bladder calculi.
      
    • Procedure currently reserved for patients with glans greater than 100 grams and is performed in <1% of patients with BPH, but must keep in mind that reoperation rate is very low and morbidity is comparable to TURP.
    
    

    
    

    Figure 3: Delivery of enucleated lateral and median lobes during an open prostatectomy in a patient with a ~250 g gland. Another lateral lobe is yet to be enucleated.

III. Basic Principals: Laparoscopic Fundamentals from the AUA

The link below will open a document in a new window:
Laparoscopic Fundamentals from the AUA

IV. Basic Principals: GU Pathology from the AUA

Click the link below to open AUAnet.org document in a new window.

GU Pathology from the AUA

V. Surgical Procedures: Lithalopaxy

Bladder Stone Treatment

I will not cut for stone, even for patients in whom the disease is manifest;
I will leave this operation to be performed by practitioners.
-Hippocratic Oath

Before the advent of modern surgical techniques, treatment of bladder stones was a very risky venture. The most common approach to removing bladder stones, known as lithotomy, involved removal of the stone through a perineal incision in an awake patient after a metal sound was placed through the urethra to secure the stone's position in the inferior portion of bladder. Indeed, Hippocrates considered the procedure so risky that in his oath he advised that only the skilled professional attempt the feat. Some believe that Hippocrates' recommendation is the first designation of a surgical subspecialty.

Urinary stasis (whether from bladder outlet obstruction or neurogenic dysfunction), infection, and presence of a foreign body are the primary culprits for bladder stone formation.

Classic "jack" stone in an elderly patient with bladder outlet obstruction (click to watch video)

Modern surgical armamentarium for treatment of bladder stones includes open surgery (suprapubic approach), manual cystoscopic lithalopaxy (crushing of stone with forecepts), ultrasonic lithotripsy, pneumatic lithotripsy, electrodydralulic lithotripsy (EHL), holmium:YAG laser, and rarely extracorporeal shock wave lithotripsy.

Surgical Tips:

• Pre-Operative considerations:
  • Does the patient need concominant bladder outlet obstruction procedure?
  • If bladder outlet reduction is required, decide between benign suprapubic prostatectomy with bladder stone removal vs cystoscopic lithalopaxy combined with TURP.
  • Large portion of bladder stones have infectious components, pre-operative broad-specturm antiobiotic prophylaxis is a must.
  • Screen for upper tract urolithiasis.
• Intra-Operative considerations:
  • It is quite easy to stir up major bleeding during a lithalopaxy procedure
    • Keep the lithotripsy device away from the prostate and bladder walls
    • Continuous flow is your friend -- use a resectoscope with an adapter for a bridge to introduce instruments
    • Poor visualization can easily lead to bladder perforation -- be careful.
  • When treating hard stones with a lithotripsy probe, it is sometimes useful to trap the stone in a fold of a partially deflated bladder (however, take care not to damage the bladder wall).
  • Always treat lithalopaxy forecepts with respect -- this is a deadly weapon. When using lithalopaxy forecepts, it is best to crush the stone in the middle of a fully filled bladder after the stone is grasped. This greatly reduces the chance of damaging the bladder.
• Post-Operative considerations:
  • Monitor patients for bleeding and infection.
  • Prophylactic antibiosis is advisable.

VI. Surgical Procedures: Orchiectomy - radical/simple

Radical Orchiectomy

 Pre-Operative considerations:

1. Verify side of tumor - have imaging in the room

2. Make sure tumor markers have been drawn

3. Examine patient thoroughly prior to making incision -- this will help develop your testicular exam skills and verify side of tumor
*When performing testicular examination (in any setting), convince yourself that you are able to palpate (1) testicle proper, (2) epididymis, and (3) cord

4. A single dose of a second generation cephalosporin is appropriate prior to making incision. 

Intra-Operative considerations

1.       In supine position, lower abdomen, genitalia, and perineum are shaved, prepped, and draped

2.       Incision is made over the inguinal ligament similar to an inguinal herniorrhaphy. Landmarks are the anterior superior iliac spine and the pubic symphisis (marked on image below)

3.       Electrocautery is used to divide the subcutaneous fat and expose the external oblique fascia

4.      The fat is bluntly cleaned off the fascia for better exposure, typically using a sponge and/or retractors (spreading down to fascia with two band retractors works very well)

5.       Using a scalpel, a small incision is made in the external oblique fascia in line with the muscle fibers

6.      Metzenbaum scissors are used to extend the fascial incision all the way to the external ring as well as in the opposite direction (toward internal ring)

a.       Care is taken to first spread open the scissors underneath the fascia to clear off the ilioinguinal nerve

b.       The nerve can often now be identified and set aside by placing a hemostat on the lateral edge of the fascia with the nerve lateral to the hemostat

c.       Some may find tagging the medial and lateral fascial edges with suture useful to expedite closure later

d.       It is important to open the external ring completely, dividing all of the fascial fibers -- this will faciliate delivery of the testis later

7.       Grasping the edges of the fascia, the cord is bluntly dissected free

8.     The cord is then encircled, often first with a finger (tease the cord off the pubic symphisis with thumb and finger) and then a Penrose drain is pulled through to fully retract the cord.

9.       The Penrose drain is then wrapped a second time around the cord and clamped to completely constrict the cord

a.       The theoretical goal is to prevent hematogenous micrometastases from being sent into the circulation during tumor manipulation   

10.  The testis is then delivered into the wound by pulling on the cord and pushing on the testis (it you find this step difficult, you did not divide all the necessary fibers of the external ring). Fascial attachments preventing delivery of the testis into the wound may need to be freed. One must be very careful not to violate scrotal skin. Blunt dissection with a surgical sponge to peel off the testicle from scrotal skin is very useful here (image below).

11.    The gubernaculums is then clamped, divided and ligated. Again be absolutely sure you are not button-holing the scrotal skin (note how the scrotal skin in inverted into the wound on the image below -- if you violate the scrotal skin, you upstage the tumor and may change post-operative management!)

12.    Attention is then turned to the superior portion of the cord and vas, which are separately clamped and divided as high as possible above where the Penrose was placed.

a.       Ligation is typically performed with 2-0 silk or proline free ties and a suture ligature. Leave one suture long, so you can find it at RPLND.

b.       It is important to drop the cord into the internal ring/retroperitoneum in order to faciliate cord removal at RPLND.

c.       Be sure your ligation is secure -- bleeding into the retroperitoneum from a poorly secured testicular artery can be life-threatening.

13.    Electrocautery is used to obtain hemostasis, careful attention needs to be paid to the scrotum to prevent hematoma formation

14.    The external oblique fascia is then closed followed by the subcutaneous fat and the skin

15.    A sterile dressing as well as fluffs and a scrotal support are then typically applied.

Post-Operative considerations

1. Monitor patient for scrotal hematoma and retroperitoneal bleeding

2. Markers must be rechecked during a post-operative visit in ~ 4 weeks (remember T1/2 for AFP = ~5 days and for HCG = ~48 hours)

Simple Orchiectomy

1)       In supine position, lower abdomen, genitalia, and perineum are prepped and draped

2)       If bilateral orchiectomy, median raphe incision is made. If unilateral, can perform either median raphe or transverse hemiscrotal incision.

a.       Skin traction is important when making scrotal incisions due to tissue laxity

3)       Electrocautery is used to dissect through the dartos muscle and cremasteric fibers in order to expose the tunica vaginalis

4)       A sponge is used to push the fibers off of the tunica vaginalis and fully deliver the testis/tunica vaginalis through the wound

5)       Continue to use a sponge to clean off the tunica vaginalis such that it is fully exposed

6)       Incise the tunica and expose the testis

7)       With traction on the testis to expose the cord, bluntly dissect the cord into 2 or 3 segments. The vas is typically isolated in its own segment. Clamp, cut, and ligate each segment, typically with 2-0 silk. A suture ligature is often used due to risk of bleeding from the cord and the fact that it will quickly retract up into the pelvis once it is released.

8)       Irrigate the wound and liberally electrocoagulate possible bleeders due to risk of scrotal hematoma

9)       Close the dartos in a running layer and then the skin.

10)    The wound is typically dressed with bacitracin, fluffs, and scrotal support.

VII. Surgical Procedures: Sacral Nerve Stimulation

Medtronic InterStim^® Therapy for Urinary Control

Medtronic InterStim Therapy for urinary control has been shown to successfully treat certain bladder control problems in patients for whom more conservative treatments were unsuccessful. InterStim Therapy addresses the nerve component of bladder control problems by sending mild electrical pulses to the sacral nerve which influences the bladder and surrounding muscles that manage urinary function.

InterStim Therapy for is indicated for the treatment of non-obstructive urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments. It is not indicated for mechanical obstruction such as benign prostatic hypertrophy, cancer, or urethral stricture.

Patients must undergo a trial assessment period, known as Peripheral Nerve Evaluation (PNE). Through a simple, in-office procedure, the physician places a temporary lead that is connected to a small external test stimulator. The trial assessment allows the patient to experience the effects of the therapy for approximately 3-7 days to help the patient and physician determine if long-term therapy will be beneficial. 

Peripheral Nerve Evaluation Procedure

• Minimally-invasive, office-based procedure done under local anesthetic
• Can be performed with or without fluoroscopy
• Lead placement procedure typically takes 30-60 minutes
• Allows patient to experience the effects of the stimulation to determine whether the therapy is beneficial
• Helps physician and patient make an informed choice regarding the long-term therapeutic value
• Safe and fully reversible

Note: Complications can occur with the trial assessment, including movement of the wire, technical problems with the device, and some temporary pain.

If the PNE test is inconclusive or unsuccessful, a chronic lead test is recommended. This test utilizes a tined (chronic) lead, to reduce migration. Placement of the tined lead is performed through an outpatient procedure and is connected to the same external stimulator. With conclusive test results, this lead can remain in place and the implantable neurostimulator (INS) and lead extension would then be implanted.

Placement of the Permanent InterStim Tined Lead and Implantable Neurostimulator (INS)
Patient-reported results will allow the physician and the patient to make an informed choice regarding the long-term therapeutic success of the therapy. Permanent implantation of the InterStim tined lead and INS is performed after a successful PNE or chronic lead test.

Physician training is required prior to implantation of InterStim components and the product technical manual must be reviewed for detailed, step-by-step instructions of the implant procedure. A summary of the InterStim II device implant procedure is presented below:

For additional information on InterStim Therapy and educational opportunities, visit http://professional.medtronic.com/sns

InterStim^® Therapy for Urinary Control is indicated for the treatment of urinary retention and the symptoms of overactive bladder, including urinary urge incontinence and significant symptoms of urgency-frequency alone or in combination, in patients who have failed or could not tolerate more conservative treatments.

VIII. Surgical Procedures: Ureteroscopy

Flexible Ureteroscopy

Principles:

1. Ureteroscope technology continues to improve. The key components are the diameter of the scope (now down as low as 7.5Fr), the lumen of the working port (around 3.5 Fr), and the diameter of the working element (eg. laser fiber or basket). Water flow decreases as the diameter of the working element approaches the diameter of the port making visualization more difficult.
   
2. "Safety wire": Always have an extra wire fully up the ureter and set securely aside when performing ureteroscopy. The rationale is that if there is any significant trouble during the procedure (eg. ureteral perforation or "red-out"), the ureteroscope can be removed and a stent can be placed over the safety wire.
   
3. Patients with pre-existing urinary infections, or, particularly, an infected stone, can become quickly septic with significant ureteral manipulation. Ureteroscopy should be avoided in these patients.

Ureteroscopic view of an 8 mm proximal ureteral stone. A safety wire is seen at 10 o'clock
(follow link to watch video)

Wire review:
There are numerous different types of wires which are used in Urologic procedures reflecting the many different ways in which wires are utilized. Their most common functions are to: a) gain access to the ureter, and b) act as the inner component of a coaxial system allowing stents, catheters, and other working devices to be safely passed into the collecting system. The basic characteristics of interest which differ among wires are flexibility, lubricity, and shaft stiffness. Wire diameters typically range from 0.018 to 0.038 inches, with 0.035 and 0.038 wires used most frequently. The tips are often made flexible in order to minimize ureteral trauma.Here, we review the most commonly used wires.

1. Guide or "House" wire: Standard all-purpose wire with moderate stiffness. It is the most commonly employed wire and is often used for placement of ureteral stents and/or initial access to a ureter.
   
2. Hydrophilic or "Glide" wire: Very slippery and flexible. Comes in both angled-tip and straight-tip varieties. Utilized to gain access where access is difficult. Examples include ureteral orifices which will not pass a ureteral catheter, ureters with a stone or stricture blocking passage of a wire, or urethras which will not allow a Foley catheter to pass. Note: difficult to handle due to slipperiness, therefore needs to be exchanged for another wire once access is achieved.
   
3. Super-stiff: These very rigid wires provide secure access to a ureter and are used to pass sheaths, stents, or other working devices such as balloon dilators.
   
4. Double flexible tip: These wires with moderate shaft stiffness are primarily utilized for passing the flexible ureteroscope. The advantage of the 2nd flexible tip is that it decreases trauma to the (expensive) ureteroscope as it is passed over the wire.

Ureteral access and pyeloscopy:

• Cystoscopy to gain access to the bladder
  
• A 5 Fr open-ended ureteral catheter is typically used to gain access to the ureteral orifice, though the ureter can also be directly cannulated with a wire
  
• A retrograde pyelogram may be performed through the ureteral catheter to delineate the anatomy of the collecting system
  
• Using fluoroscopic guidance, a wire is then passed through the ureteral catheter and up the ureter into the renal pelvis. This is often a double floppy tip wire which will be used to pass the ureteroscope.
  
  
  
  • a. If there is any difficulty passing the wire (eg. due to a ureteral stone), a hydrophilic (glide) wire is passed into the renal pelvis. The open-ended catheter is passed over the wire into the renal pelvis and the glide wire is replaced with another, more sturdy wire.
  
  
• The open-ended catheter is then removed
  
• A second wire-the "safety wire"-is then passed by any of a variety of means. Steps 2-4 may be repeated, or devices such as a ureteral access sheath or a dual lumen ureteral access catheter may be employed.
  
  
  
  • The access sheath or catheter have the advantage of both allowing quick passage of a second wire and dilating the distal ureter. This facilitates passage of the ureteroscope and may save then need for further ureteral dilation such as with a balloon dilator.
    
  • The dual lumen catheter is inserted over a wire, through the cystoscope sheath, and under fluoroscopic guidance. The second wire (typically a Guide or Super-stiff wire) is passed through the second port and the dual lumen cather is removed
    
  • The ureteral access sheath is passed directly over a wire without using the cystoscope. It provides continuous, direct access to the ureter which can be useful when the ureteroscope has to be passed in and out repeatedly (eg. when basketing small stones or obtaining ureteral biopsies).
  
  
• With two wires in place, the safety wire is secured well to the drapes and set aside

The double floppy tip wire is used to pass the ureteroscope. The flexible ureteroscope is passed under fluoroscopic guidance over the wire all the way up to the renal pelvis (unless there is a ureteral stone or stricture blocking its path)

• If the scope cannot pass through the ureteral orifice-typically the most common hang-up-it may help to ensure the bladder is empty (by passing the cystoscope). Otherwise, it may be necessary to pass a balloon dilator over the wire and dilate the orifice.
  
• The scope is easiest to pass without any attachments (ie. camera, light cord), then hook the scope up to everything after it is in place
  
• Fluid is attached to the ureteroscope. This is typically pressurized normal saline.
  
• Pyeloscopy is then performed. Contrast can be first injected through the ureteroscope to delineate the calyceal system. The calyces are then systematically visualized with the ureteroscope.
  
• Further procedures such as laser lithotripsy, stone basketting, ureteral biopsy, etc. . . can now be performed
  
• When complete, the ureteroscope is gradually removed with visualization of the entire ureter
  
• The safety wire is still in place and can now be used for placement of a stent if necessary. Otherwise, the wire can be removed.

Ureteroscopic lithotripsy with Ho:YAG laser of an 8mm proximal ureteral stone
(follow link to watch video)

Laser lithotripsy:

1. Holmium:YAG (Yttrium Aluminium Garnet, Y3Al5O12) laser  (light amplification by stimulated emission of radiation)  is most commonly used
   
2. Light energy of 2150 nm
   
3. The laser is delivered using flexible quartz fibers which come in different diameters, typically approximately 200, 365, and 550 microns. Larger fibers deliver more energy faster, however the flexibility decreases with increased diameter - Energy settings for the laser range from 0.5-2.0 Joules, with 0.5 J being a common starting level. The initial frequency is usually 5-8 Hz. Energy and frequency settings are altered during lithototripsy depending on stone break-up and damage to urothelium
   
4. Key concept: maintain contact with stone in order to fragment it while avoiding contact with urothelium. The urothelium will bleed with trauma, making visualization difficult.
   
5. The two main techniques employed for lithotripsy are to
   
   
   
   1. fracture the stone into multiple tiny fragments which will pass on their own or may be basketted, or
      
   2. gradually "dust" each stone, a tedious process but with the goal of clearing the entire upper tract by the end of the procedure

Post-op management:

1. Patients are typically discharged the same day as the procedure. Some practices admit the patient overnight for drainage with an external ureteral catheter.
   
2. Patient should expect renal colic post-op, and, if stent placed, may have intermittent flank and lower abd pain while stent is in place.
   
3. There is a significant risk of UTI post-op. Patients should receive single-dose IV abx (fluoroquinolone or cefazolin) pre-op. Patients may be sent home with up to 3 days of oral antibiotics for UTI prophylaxis although there is minimal evidence to support this practice.
   
4. Patients undergoing ureteroscopic manipulation of a solitary kidney are at high-risk for post-obstructive diuresis. These patients usually need to be admitted and their fluid balance and electrolytes need to be closely monitored.

IX. Surgical Procedures: Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma (UTUC)

  I. Introduction

         Transitional cell carcinoma of the upper urinary tract (ureter and/or renal pelvis) accounts for approximately 2-5% of all urothelial carcinomas.  Traditionally, management of these lesions has consisted of open or laparoscopic nephroureterectomy with a bladder cuff or, if the lesion is distal, a distal ureterectomy with a bladder cuff and ureteral reimplantation.  This surgical approach to UTUC yielded a 45-90% cancer-specific survival at 5 years; 10-30% of these patients developed metastatic disease.  With the introduction of ureteroscopes and percutaneous techniques in the early 1980s and their continued technological improvements, direct visualization and treatment of an upper urinary tract urothelial tumor is now possible and efficient.  Historically, endoscopic management of UTUC was reserved for patients with bilateral disease, a solitary kidney, chronic kidney disease (CKD), or significant co-morbidities that would preclude a major abdominal operation (Note:  These indications are almost identical for the widespread adoption of partial nephrectomy for renal tumors).  Rendering a patient functionally or anatomically anephric is fraught with significant health risks, thus endoscopic management was employed.  One study cites the 5-year overall survival range for patients aged 55-84 with end-stage renal disease as 10-32%. 

As endoscopic management for UTUCs have became technically feasible for patients with absolute indications, data began to mature that showed equivalent 5-year cancer-specific and overall survival between patients treated with endoscopic, nephron-sparing approaches versus traditional extirpative management.  Table 1 is a synopsis of the most recent studies comparing open versus endoscopic management of UTUC.  In sum, these studies show that endoscopic management of UTUC has equivalent overall, cancer-specific, and metastatic-free survivals to traditional management for low-grade and low-stage UTUC tumors.  Patients who undergo endoscopic management do have a higher local recurrence rate (20-85%) and are subject to more procedures for long-term surveillance.  Most practioners are unwilling to subject patients with high-grade UTUC to endoscopic management unless absolute indications exist; as of yet, there is no data to support the use of endoscopic management for high-grade disease.

 Table 1.  Comparison of series employing endoscopic treatment of UTTCC as primary management strategy

 II.Technique

        Diagnostic ureteroscopy is employed as the first-line treatment for evaluation of a filling defect seen on CT urography, intravenous urography, or retrograde ureteropyelography.  A distal lesion can be accessed with a semi-rigid ureteroscope while a lesion in the proximal ureter or renal collecting system is best approached with a flexible ureteroscope.  The method for ureteral access is similar to the technique employed for ureteroscopy for stone disease (see Surgical Procedures Atlas VIII).

A brief step-wise approach to ureteroscopic evaluation and management of upper urinary tract urothelial carcinomas is presented below:

1.   A wire is placed into the desired kidney under fluoroscopic and cystoscopic guidance (Fig1).  The choice of wire is at the discretion of the operating urologist; we use a 0.038 Guidewire.  (See review of wires under ureteroscopy Atlas.)  During this portion of the procedure, take care to perform a thorough cystoscopic examination of the bladder as a bladder lesion will develop in 23-75% of patients with an UTUC.

 

 

 

 

 

 Figure 1: Placement of initial wire

 

2.    We then insert a dual-lumen access catheter over the existing wire (Fig 2) into the ureter for two reasons: the dual-lumen catheter passively dilates the distal ureter and we can obtain a selective cytology from the interested side and then place a second wire (0.038 Guidewire) without losing access to the kidney (Fig 3). 

 Figure 2: Placement of 2nd wire

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7.  Figure 3: Insertion of dual-lumen access catheter

3.  Once we have cytology, we then perform another retrograde pyelogram to outline the collecting system (Fig 4).

 Figure 4: Retrograde Pyelogram (make sure cytology
 has been obtained prior to injection of dye)

4.  For renal pelvic and/or calyceal lesions, we then advance the flexible ureteroscope under fluoroscopic guidance up into the renal pelvis over one of the Guidewires (Fig 5).  Once the ureteroscope is in good position, the Guidewire is removed and the second wire is used as a safety wire.

 Figure 5: Advancement of ureteroscope under
 fluoroscopic guidance.

4a. Sometimes you may have trouble traversing the distal ureter with the flexible ureteroscope.  Rather than using a balloon dilator to dilate the distal ureter, we have found that leaving the cystoscopic sheath in the bladder and using it to provide backing as you try to navigate the distal ureter is a helpful means to circumnavigate this potential impediment.  If you are ever in doubt or cannot bypass the distal ureter, simply leave a JJ stent and return for your diagnostic ureteroscopy in 1-2 weeks.

 5.  Once you have the ureteroscope in the renal pelvis (Fig 6), you can perform a thorough upper tract endoscopic examination, using fluoroscopy as an aid in accessing difficult calyces.

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10.  Figure 6: Assessment of calyx with ureteroscope.
     Fuoroscopy is used to help direct the ureteroscope
     into appropriate anatomic location.  

6.  If you find a papillary lesion, obtain a repeat cytology with the ureteroscope directed at the lesion.  Then obtain multiple biopsies of the lesion with either a flat-wire basket or a 3 Fr. ureteroscopic biopsy forceps.

7.  Remember, grade correlates with stage.  In multiple series, low-grade tumors correlated with Ta or T1 disease in 86.6-100.0% of cases.  Similarly, high-grade tumors correlated with invasive TCC in 66.7-96.0% of cases.  Thus, a low-grade lesion is going to be superficial and should be treated endoscopically.  This may require multiple endoscopic treatments, however this is preferable in light of renal preservation.

8.  Once you have sufficient biopsies, the tumor then can be treated with either the Nd:YAG and/or Ho:YAG laser or a ureteroscopic Bugbee.  See Surgical Atlas VIII for a brief review of lasers.  In brief, Nd:YAG laser has a greater depth of penetration (4-6 mm) and can be used to coagulate the tumor.  The Nd:YAG laser does not need to touch the tumor for effect.  The Ho:YAG laser has a shallower depth of penetration (less than 0.5 mm) and can be used to ablate the tumor deeper.

9.  These are the recommended fibers and settings for each laser:

       a. 200 um or 365 um fiber

       b. Nd:YAG:  30W

       c. Ho:YAG:  1J and 10Hz

10.  In general, it is best to use the Nd:YAG laser first to coagulate the superficial portion of the tumor.  This laser’s depth of penetration is not as precise as the Ho:YAG, so care must be taken when treating the deeper portions of the tumor.  The Nd:YAG laser can perforate the ureter or the renal pelvis.  When ablating large lesions, it is helpful to begin ablation at the more proximal portion of the tissue and then work distally.  This hopefully helps to avoid advancing the fiber into the mucosa or wall of the ureter or renal pelvis.

11.  The Ho:YAG laser can then be used to ablate the deeper aspects of the tumor and detach the tumor from the underlying parenchyma/urothelium.  The Ho:YAG laser must be in direct or close contact of the tumor in order to treat the lesion.

12.    For difficult to access calyceal tumors, a 2 Fr. Bugbee electrocautery probe can be used to fulgurate a lesion.  The smaller probe allows for more ureteroscopic deflection in order to treat the difficult to access lesion.  When using the Bugbee electrocautery, fulgurate on the cutting mode.  This theoretically reduces the chance of an ureteral stricture or infundibular stenosis.

13.  Once tumor treatment is complete, the decision to leave a temporary ureteral stent is left to the treating urologist.  Nevertheless, there are few disadvantages to inserting a JJ stent in this setting.

14.  Percutaneous resection of UTUC is generally reserved for tumors larger than 1.5 cm or bulky proximal ureteral tumors.  The technique for this approach is very similar to a percutaneous approach for stone management (PCNL).  Once intrarenal access has been obtained, a cystoscopic resectoscope can be used to remove the tumor followed by deep laser ablation.

III. Complications

              The most common technical complications associated with endoscopic management of UTUC are similar to those seen with any upper tract endoscopic intervention:  ureteral perforation and ureteral stricture.  Reported rates of ureteral perforation and ureteral stricture are 1-4% and 9-12%.  Not all ureteral strictures are due to technical considerations and biopsy of the stricture must be performed to rule out recurrent disease.

IV. Recommended Readings

1.Bagley DH and Grasso M.  Ureteroscopic laser treatment of upper urinary tract neoplasms.  World Journal of Urology.  28: 143-9, 2010. 

2. Soderdahl DW et al.  Endoscopic treatment of upper tract transitional cell carcinoma.  Urologic Oncology.  23:  114-22, 2010.

This page was written for UrologyMatch.com by Daniel J. Canter, MD

Dr. Canter  is a graduate of the University of Pennsylvania Urology Residency Program.
He is currently a Society of Urologic Oncology Fellow at Fox Chase Cancer Center.