rigid endoscopes should be used unless there is a specific indication or need for flexible instruments.
flexible endoscopes should be used in most cases to prevent urethral trauma.
the largest endoscope the urethra can accept should be used.
the smallest scope that permits performance of the anticipated procedure should be used.
the endoscope that provides the best irrigation should be used.
The rod-lens systems in rigid cystoscopes offer superior imaging quality compared with fiberoptic flexible cystoscopes.
There are more patient positioning options when performing flexible cystoscopy compared with rigid cystoscopy.
Flexible cystoscopes generally have a larger working channel compared with rigid cystoscopes, allowing passage of a wider variety of instruments.
The larger internal lumen of a rigid cystoscope provides improved irrigant flow and thus visualization compared with flexible cystoscopes.
Endoscope passage over an elevated bladder neck/median lobe may be easier with a flexible cystoscope compared with a rigid cystoscope.
When antimicrobial prophylaxis is indicated, the antimicrobials of choice are the fluoroquinolones and trimethoprim-sulfamethoxazole.
Preoperative antimicrobial prophylaxis is not indicated before simple cystourethroscopy unless specific patient risk factors are present.
It is important to ensure the patient does not have a urinary tract infection before the procedure because mechanical manipulation and bladder distention may exacerbate the infection.
Informed consent should be obtained, explaining the risks and benefits of the procedure.
Preoperative intraurethral injection of a water-soluble lubricant-anesthetic has been shown in most randomized studies to improve patient comfort during flexible cystoscopy.
Simple filling and diagnostic procedures may be performed via the catheterizable channel, but percutaneous access should be performed if ancillary procedures are indicated.
The Mitrofanoff and tapered/imbricated ileal continence mechanisms are quite sturdy and will permit aggressive manipulation.
Afferent limbs are best evaluated with flexible endoscopes because they are well suited to navigate limb folding, kinking, and tortuosity.
Visualization may be impaired by mucus, debris, bowel peristalsis, and tortuous afferent limbs.
Detailed understanding of the diversion type and construction may facilitate successful cystoscopy.
The optical system in most currently available semirigid ureteroscopes is the rod-lens system.
The proximal ureter is routinely accessed with the semirigid ureteroscope in male patients.
In males a longer urethra, relatively fixed prostate, and larger psoas muscles rarely prevent semirigid ureteroscopy above the iliac vessels.
Compared with flexible ureteroscopes they have smaller irrigation channels, reduced irrigant flow and visualization, and a smaller field of vision.
Semirigid ureteroscopy is typically utilized for diagnosis and treatment of a pathologic process below the iliac vessels.
Ureterovesical junction dilation is indicated before routine ureteroscopy.
Ureteral dilation is most commonly required at the ureteropelvic junction.
Ureteral dilation is most commonly required in the mid ureter.
Ureteral dilation should be performed only when ureteroscope passage is impaired.
Ureteral dilation is least commonly required at the ureterovesical junction.
UASs increase the risk of ureteral strictures.
UASs reduce operative time and cost when utilized during ureteroscopy.
UASs significantly reduce renal pressures during ureteroscopy.
UASs reduce ureteroscope damage and increase the time between instrument servicing.
UASs facilitate ureteroscope insertion, simple reentry, and calculi retrieval.
The primary disadvantage of EHL lithotripsy is poor probe flexibility that limits access to the lower pole.
Ballistic lithotripsy utilizes electrical energy to generate a spark that leads to the formation of cavitation bubbles.
The primary disadvantage of ballistic lithotripsy is the low safety margin relating to heat generated at the probe tip.
Holmium laser lithotripsy occurs primarily through a photothermal mechanism resulting in calculus vaporization.
Electrohydraulic lithotripsy (EHL) utilizes pneumatic or electrokinetic energy to drive a projectile body against a probe tip, creating a “jackhammer” effect.
Energy from the holmium:YAG laser propagates 0.5 to 1.0 cm, providing a high margin of safety.
The holmium:YAG laser effectively fragments all stone types except cystine stones.
Maintaining a pulse energy ≥1.0 J and varying pulse frequency facilitates efficient lithotripsy.
Holmium:YAG laser lithotripsy causes less calculus retropulsion compared with other lithotriptors.
Fragments produced by holmium:YAG laser lithotripsy are slightly larger compared with other intracorporeal lithotriptors.
Ureteroscopy may be performed in the supine, flank, or prone positions.
When indicated, the prophylactic antimicrobials of choice are the fluoroquinolones and trimethoprim-sulfamethoxazole.
Preoperative antimicrobial prophylaxis is not recommended before diagnostic ureteroscopy.
Both Trendelenburg and reverse-Trendelenburg positioning may facilitate laser lithotripsy.
Anesthetic options include local anesthesia with or without intravenous sedation, regional anesthesia, and general anesthesia.
Pass a guidewire through the working channel of the ureteroscope and advance the scope between the two “railroad” wires.
Dilate the distal ureter with a 6/10-Fr coaxial dilator over a guidewire.
Dilate the distal ureter with a 10-mm radially expanding balloon dilator.
Rotate the beak of the ureteroscope while providing adequate irrigation.
Place an indwelling ureteral stent and allow passive dilation for 2 weeks.
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