V9-05: A Simplified Technique for Performance of Fluoroless Ureteroscopy

Video

Introductions and Objectives
Modern radiologic techniques have transformed diagnostic and treatment imaging modalities utilized in urology. Since 1980, effective radiation dose in the United States has increased sixfold. Patients with urolithiasis are at risk for repeated exposure to radiation at diagnosis, treatment, and follow-up. We have adopted the as low as reasonably achievable (ALARA) radiation principle, with the ultimate goal to eliminate unnecessary radiation where possible. In this video, we demonstrate how ureteroscopic laser lithotripsy can be accomplished without the use of any ionizing radiation.

Methods
The steps for performing ureteroscopy without the use of image guidance will be demonstrated in this video. The first step of fluoroless ureteroscopy involves a thorough review of pertinent preoperative imaging. While the use of the C-arm is not anticipated, it is prudent to have the machine and the fluoroscopic technologist present. After cystoscope insertion, wire access to the kidney through the ureteral orifice is achieved under the guidance of visual and tactile cues. A dual lumen catheter is utilized to dilate the ureteral orifice and to allow passage of a safety wire. This wire is secured and the ureteroscope is passed over the working wire. Ureteroscopy and lithotripsy commence under visual guidance. Upon completion of lithotripsy the length of the ureter is measured during ureteroscope removal. Measured ureter length aids in deploying the ureteral stent without fluoroscopy. Observation of distal curl formation via cystoscopy marks procedure completion. Ideal candidates have high-quality pre-operative imaging and a single stone with normal anatomy. Factors which may complicate this technique include infection, impaction, and presence of ureteral stricture.

Results
This video demonstrates successful fluoroless ureteroscopic laser lithotripsy in a morbidly obese 51 year-old female with multiple right renal calculi.

Conclusions
We demonstrate a simple technique that has been developed for fluoroless ureteroscopy. If any concerns arise regarding wire or stent placement, radiation reduction can still be achieved using low-dose fluoroscopy. This technique may be particularly useful in younger or pregnant patients, in whom risk from ionizing radiation is highest. Although this video demonstrates the feasibility of the fluoroless technique, further study and comparison with conventional approaches will be necessary to establish its optimal application.

Funding: None