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FLEXIBLE ENDOSCOPY IN UROLOGY

SAMIR RAI
Dr Prem Rai Hospitals Private Limited, Amritsar.
Constant improvements in the optics and design of endoscopes have made it possible for the urologist to tackle most urological problems endoscopically. While rigid endoscopes have become extremely popular and are in widespread use all across our country, flexible endoscopy is still only in its infancy. This is despite the fact that a flexible endoscope is ideally suited to access almost every part of the GU tract without causing any trauma at all.

Various advantages of flexible endoscopy are as follows

1.Atraumatic

2.No anaesthesia required for most procedures.

3.Does not require any special positions.

4.A flexible endoscope can confidently go where no rigid scope has gone before, e.g. "inaccessible" or "awkwardly placed" calyces or "difficult areas" of the bladder.

Despite these advantages, there are major disadvantages to flexible endoscopy

1.Equipment is expensive.

2.Equipment is fragile and difficult to maintain.

3.Field of vision is small.

4.Limited (and expensive) options in therapeutic accessories.

5.Moire or "Chicken - wire" effect.

The following section describes some common uses of flexible endoscopy in urology :

A) CYSTOURETHROSCOPY

1. Bladder tumour surveillance

A flexible cystoscopy provides an easy, safe and effective means of check cystoscopy in following-up patients of superficial TCC of the Bladder. The flexible cystoscope can provide accurate information about bladder tumours with a specificity of 100 (94-100)% and sensitivity of 96 (80-100)%.[1] Flexible cystoscopy can, therefore, screen out patients and avoid unnecessary anaesthesia and admission. High cost of the equipment (and its maintenance) in India, however, makes this a somewhat cost-ineffective option. Urologists used to the wide field of vision of a rigid endoscope may also find it difficult to adapt to a flexible one even through the flexiscope can access all areas of the bladder mucosa more easily.

2. Ureteric catheterisation / stenting / stent removal

Flexiscopy is very useful for ureteric catheterisation / stenting prior to PCNL / ESWL since positioning is not required, and this can be done while the patient lies flat on the ESWL table. I have found this to be particularly useful in patients requiring dye injection during/prior to ESWL. Flexiscopy also provides greater patient comfort in outpatient removal of DJ stents without anaesthesia.

3. Evaluation of urethral strictures

While retrograde urethroscopy can accurately assess the distal limit of a stricture, I have found Antegrade Flexiscopy through an SPC tract to be invaluable in defining the proximal limit. Antegrade Flexiscopy also helps in passing a guide wire/Ureteric catheter into the correct passage in a patient with false passage(s) and is thus useful in both "core through" as well as open reconstructive procedures. For follow-up of patients after urethral reconstructive surgery, I have been practising regular flexible urethroscopy at 6 weeks, 3 months and 6 months after surgery. Same is true about the follow up in OIU patients. Flexible Urethroscopy has also been effectively used in the management of traumatic posterior urethral disruption immediately after trauma.[2]

B) URETEROSCOPY

A flexible ureteroscope can salvage some pretty sticky situations during ureteroscopy, though cost effectiveness is dubious.

1. Evaluation and treatment of upper tract TCC and "essential" haematuria

Flexible retrograde ureteroscopy has been shown to be effective in diagnosing and treating small tumours hidden away in calyces. Nakada and Clayman[3] diagnosed and treated 17 patients of lateralizing "essential" haematuria and found discrete lesions in 64% and diffuse lesions in 18% patients. Similar results were reported by Puppo et al[4] who were able to find lesions in 22 of 23 patients. More recently, Liatsikos, Kapoor and Smith[5] found the flexible ureteroscope to be the diagnostic tool of choice for the upper urinary tract and collecting system.

2. Calculi

Flexi-Scopic treatment of Ureteric stones, through atraumatic, needs the availability of Laser lithrotripsy which can increase the cost manifold. Hollenbeck et al[6] have demonstrated the efficiency and safety of flexible ureteroscopy in treating small and intermediate-sized lower polar calculi. They found ureteroscopy to be as effective as ESWL in small lower polar stones, and better than ESWL in intermediate sized lower polar stones. However, the main problem with Ureteroscopic access to the lower pole is not just visibility, but the loss of deflection caused by passage of various instruments through the working channel.[5] Thus, often times, the situation resembles that of a dog running after a car. One can see the stone, one can chase after it, but once one catches up with it, one canít do anything to it. Flexible ureteroscopy is also one of the options available for managing calyceal diverticulae and their associated problems.[7]

3. Ureteric strictures

Flexible ureteroscopy, retrograde and/or antegrade, along with Holmium-YAG laser endoureterotomy, offers a minimally invasive and less morbid technique of managing ureteric strictures, especially uretero-intestinal anastomotic strictures even though it is ultimately less successful than open repair.[8]

C) NEPHROSCOPY

1. Calculi

Flexible nephroscopy is of immense value in the antegrade percutaneous removal of urinary stones. Especially in patients with large stone burden and calyceal stones, I always have the flexible nephroscope ready and available. Flexible nephroscopy helps inspect all calyces carefully, and small calculi found therein can either be removed with the flexible forceps/tipless stone basket, or flushed out into the main system for removal. The flexiscope may either be used at the time of PCNL, or as a second look after 48 hours. Baeghler and Lingeman[9] have suggested that the liberal use of flexible nephroscopy during the primary PCNL procedure may increase the stone free rate and decrease the need for additional access tracts. I normally look into the collecting system of all complex stone patients 48 hours after surgery, and many a times have found calyceal calculi even though there were none of the check X-ray. Pearle et al[10] used flexible nephroscopy as the gold standard in detecting residual fragments after PCNL although helical CT was much more cost effective, albeit with a lower specificity (62%).

A flexiscope is also very useful in removing ureteric stones through the PCNL tract and one can go down to almost L5 S4, in selected patients.

CONCLUSION

The final question then, is, should a flexible endoscope be considered an essential part of urological armamentarium? Based on current knowledge and personal experience of the last decade, I would definitely recommend the acquisition of at least the flexible nephrocystoscope. This versatile instrument is not only of great help to any urological department, it can also be shared by colleague involved in biliary surgery as a flexible choledochoscope.

REFERENCES

1. The Nurse Cystoscopist : a feasible option? Gidlow AB et al, BJU Int 2000 April; 85 (6) : 651-4.

2. Evaluation and management of traumatic posterior urethral description with flexible cystourethroscopy. Kielb SJ et al. J Trauma 2001 Jan.; 50 (1) : 36-40.

3. Long-Term outcome of flexible ureteroscopy in the diagnosis and treatment of lateralizing essential hematuria. Nakada SY et al. J Urol 1997; Mar; 157 (3) : 776-9.

4. Exploration of the intra-renal collecting system using flexible fibrescopy Puppo P et al. Arch Esp Urol 1991 Jun.; 44 (5) : 541-5.

5. Transitional-cell carcinoma of the renal pelvis : Ureteroscopic and percutaneous approach. Liatsikos et al. J Endourol 2001 May; 15 (4) : 377-83, discussion 397.

6. Flexible ureteroscopy in conjunction with in situ lithrotripsy for lower pole calculi. Hollenbeck BK et al. Urology 2001 Dec.; 58 (6) : 859-63.

7. Calyceal diverticula. Ureteroscopic management. Chong TW et al. Urol Clin North Am 2000 Nov.; 27 (4) : 647-54.8.

8. Holmium : YAG laser endoureterotomy for treatment of ureteral stricture. Singal RK et al. Urology 1997 Dec.; 50 (6) : 875-80.

9. Expanding role of flexible nephroscopy in the upper urinary tract. Beaghler MA et al. J Endourol 1999 Mar.; 13 (2) : 93-7.

10. Sensitivity of non contrast helical CT and plain film radiology compared to flexible nephroscopy for detecting residual fragments after percutaneous nephrostolithrotomy. Pearls MS et al. J Urol 1999 Jul.; 162 (1) : 23-6.


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