Urology

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Endoscopic ureteral surgery

What does this procedure entail?

Examination of the ureter by sight, with the possibility of removing stones, mucosal tumours, cutting a narrowed area (stricture) or ensuring the outflow of urine by inserting a stent (plastic tube between the kidney and bladder).

What are the alternatives to this procedure?

Observation – monitoring, suitable if spontaneous adjustment can be expected or if the condition is not necessary or cannot be resolved
In the case of urinary stones, their crushing with extracorporeal shock wave
Open surgery – access via an incision through the abdominal wall
In case of strictures, permanent drainage with a ureteral stent (with regular replacements)

What should I expect before this procedure?

If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.

At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.

You will be asked not to eat or drink for at least 6 hours before the surgery!

In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.

Remember to inform your physician about the following possible facts before the surgery:

artificial heart valve
coronary artery stent
pacemaker
artificial joint
artificial vascular graft
neurosurgical bypass
other implanted foreign body
use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton  Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
drug and other allergies
any abnormalities or eventualities

It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.

What will happen during the surgery?

You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.
The procedure is performed exclusively under general anaesthesia.
The surgery is started with cystoscopy (examination of the bladder with a telescopic instrument inserted into the urethra), followed by the examination of the ureter using a thin rod-shaped instrument connected to a camera, followed by the eventual management of a detected problem:
The detected stones or their fragments are removed completely or after crushing them using an ultrasonic wave, medical pneumatic hammer or laser.
Removal of a tumour of ureteral mucosa via endoresection (cutting with an electric loop), possibly with sampling (biopsy) to clarify the diagnosis.
Urethral stricture transection using a knife or electrode.
This procedure takes between 30-60 minutes. The procedure usually uses an X-ray emitter.
Depending on the course of the procedure and the local finding before the end of the procedure, kidney drainage through the ureter is sometimes introduced via a ureteral catheter (usually for up to 24 hours) or a ureteral stent (a special tube between the bladder and kidney – for 6-8 weeks). After cutting the urethral stricture, a special stent is always inserted for 6-8 weeks.
In unfavourable conditions prohibiting a definitive solution of the problem, the actual procedure is sometimes postponed and a temporary stent is inserted.

What will happen immediately after the procedure?

You will wake up at the intensive care unit equipped for the continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.
Kidney/ureteral bleeding may occur after the surgery. Blood in the urine usually disappears within 24-48 hours. If blood loss is more significant, you will be given a blood transfusion. Revision (surgical control) may be considered in case of massive or persistent bleeding. If a ureteral catheter (plastic tube inserted in the ureter) has been inserted into the kidney during the procedure to ensure free urine outflow, you must not get up from the bed or sit on the bed until it has been removed. After the procedure, you will have a permanent catheter inserted into your bladder for 2-3 days.
The average general hospitalisation is 4-5 days.

Once you are fully conscious, you should:

ask if the planned outcome was achieved
inform the medical staff about any problems
ask what you can and cannot do
ask all the questions you have for the healthcare professionals and members of the medical team.
remember (and understand) why the surgery was performed, how it turned out, and what will follow

What are the postoperative risks or complications?

Common (10% of procedures of this type)

Mild burning when urinating or the presence of blood in the urine shortly after the surgery (hours up to a day)
Necessity of temporary urinary tract drainage using a permanent catheter (day to several days)
Stent introduction is usually a temporary solution and another procedure will be necessary – resolution of the finding and removal of the stent (sometimes necessary or possible only during the next, third procedure)

Occasional (2-10% of procedures of this type)

Urinary tract infections
Injuries to the examined organs – bladder, ureter, kidneys (insignificant, without the need for a surgical management)
Repeated formation of stones
Anatomical conditions preventing the successful completion of the procedure at that moment – e.g. tender or meandering ureter
Ureter or its immediate surroundings altered by previous treatment (e.g. after surgery, irradiation)
The stone cannot be reached or removed
The tumour is not radically manageable in this way

Rare (may occur in 2% of procedures of this type)

Significant injury to the ureter, kidney or other organs requiring temporary drainage of the kidney via nephrostomy drain (plastic tube inserted into the kidney through the back muscles) or open surgery with possible need to remove the injured organ.
Scarring of the ureter with the formation of strictures (narrowed areas of the ureter preventing free outflow of urine from the kidney), requiring a further intervention.
Kidney infection with subsequent deterioration of general health condition, rarely with the development of sepsis ("blood poisoning") and the need for intensive treatment with prolonged hospitalisation.
TUR syndrome caused by the absorption of a larger amount of lavage fluid into the bloodstream. It leads to increased blood pressure and heart rate, shortness of breath, headache with nausea or vomiting. Severe events can lead to unconsciousness or renal failure requiring dialysis.

Hospital infections

MRSA colonisation (0.9% – 1 of 110)
Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
MRSA blood infection (0.02% – 1 of 5,000)

Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.

What should I expect when I return home?

When you are discharged from the hospital, you should:

get recommendations on recovery at home
ask when you can return to normal activities such as work, exercise, driving, housework
get a contact number for further questions after returning home or in case of trouble
ask about the date of the following check-ups and the place where you should come (hospital or your attending physician)
make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs.

At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.

What else should I watch out for?

If you experience more frequent problems, burning or difficulty urinating, or have unusual bleeding, consult your attending physician.
However, these problems, including the presence of blood in the urine, are relatively common with an inserted stent.

Any important information?

Most patients need 2-4 weeks of rest at home before they are able to handle a full workload. Before returning to work, we recommend a 3-4-week-long rest period, especially if you have a physically strenuous occupation. You should avoid lifting heavy loads at this time.