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By: Noreen A Hynes, M.D., M.P.H.

• Director, Geographic Medicine Center of the Division of Infectious Diseases
• Associate Professor of Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0010761/noreen-hynes

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Interestingly, the endoscopic cohort had fewer patients presenting with hydronephrosis compared to the standard group (12% vs 27%, P =. No difference was seen for intraoperative or perioperative issues, embolization charges, narcotic utilization, or change in glomerular filtration rate. The endoscopic group had a barely longer operative time in comparison with our normal group (227 min vs 208 min, P =. Finally, stone-free charges have been comparable between the endoscopic and standard groups (35% vs 46%; P =. Obtaining renal entry from a superior renal calyx provides essentially the most direct access to the renal pelvis, superior, middle, and decrease calyces, and facilitates complete stone clearance utilizing a single tract in most sufferers. Our expertise demonstrates the reduced pulmonary morbidity of this system when utilized for a primarily upper pole calyx entry. Retrograde endoscopic-assisted percutaneous renal entry: a novel "lasso" approach to obtain fast secure entry to Chapter 15 Endoscopic Guidance for Percutaneous Renal Access 205 the collecting system. Endoscopy-guided percutaneous nephrostolithotomy: Benefits of ureteroscopic access and therapy. Ganpule Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India Introduction and indications for ultrasound-guided renal entry Percutaneous renal entry may be achieved either with ultrasound or fluoroscopy steerage. The unwanted effects of intensive radiation throughout therapeutic procedures are well-known, which is the principle disadvantage of fluoroscopy [1]. It has no radiation and supplies guidance for entry in multiple, transverse, longitudinal, and oblique planes. Its best benefit is use for realtime monitoring of the needle tip, which guides proper placement of the needle and avoidance of essential viscera. An added advantage is that it can be used at the aspect of Doppler to keep away from essential vascular structures mendacity alongside the needle path. Percutaneous ultrasound-guided access is the best and most direct method to drain a hydronephrotic accumulating system. It is most frequently utilized to place a brief lived urinary diversion because of an obstructing stone or pyonephrosis. It has also been used successfully to relieve higher tract obstruction secondary to malignancy. Ultrasound-guided nephrostomy puncture is preferred for sufferers in whom retrograde ureteral access is unsuccessful. Allergies to topical or injectable local anesthetic and coagulopathy are the only relative contraindications to ultrasound-guided renal access [2]. The ultrasound-guided strategy has confirmed to be protected and efficacious in the pediatric inhabitants [3], renal stones in transplanted kidneys [4], and pelvic renal ectopia [5]. Contemporary issues concerning ultrasound as a way to information entry are: � Who ought to obtain access � urologists or radiologists We also describe our technique of attaining percutaneous renal entry with ultrasound. Ultrasound entry requires a devoted transducer with an ultrasound frequency starting from 3. The monitor used for intervention should ideally be equipped with an digital dotted line which shows the needle path. The 18G needle tip can also be readily identifiable with realtime ultrasonography guidance. Another variant of the needle has a Teflon sheath which permits instillation of distinction and a guidewire. Convex probes these probes produce rectangular scans and are most commonly used for gaining percutaneous renal entry. Linear array probes: these probes are mostly used for scanning the breast and thyroid. Access needles Using an 18G needle to access the renal accumulating system helps with the introduction of a zero. The most common purpose for nonvisualization of the needle tip is nonalignment of the needle tip and transducer. A "bobbing" or "in�out jiggling" motion of the tissue within the superficial airplane helps determine the path of the needle. This motion additionally helps push the delicate tissue away from the needle path and clear visualization of the needle. A few other ways during which the needle could be higher visualized are by rising the reflectivity utilizing massive caliber needles, scoring the needle tip (see above), and maintaining the bevel of the needle going through upwards. We contemplate that with the affected person in the prone position and bolsters in these positions, the bowels and viscera tend to drop down, thus minimizing the possibility of bowel injury. Ultrasound scanning commences posteriorly and proceeds until the posterior axiliary line. The site of needle entry is marked and the puncture carried out with an 18G echo tip (Cook Medical Incorporated) needle. The key level at this important step is that there must be minimal respiratory and ultrasound probe motion. In order to guarantee an accurate puncture, the needle tip must be seen along the electronic dotted line all through its course. The position of the needle in the desired calyx is confirmed with return of clear fluid. Ultrasound-guided access with a needle guide this is the strategy of selection for ultrasound-guided access at our middle. Ultrasound-guided puncture with a Doppler guide is of assist in irregular renal anatomy, similar to horseshoe kidney and malrotated kidneys. Ultrasound-guided punctures are also of worth in emergency situations, corresponding to percutaneous nephrostomies in obstructive uropathy in pregnancy [8, 10]. This helps in identification of gasoline within the sigmoid colon, which helps establish the bowel and prevents potential damage. Pressure on the ultrasound probe helps to displace the intervening bowel loops between the puncture line and targeted calyx. Similarly, contralateral stress utilized by the assistant helps displace the kidney close to the belly wall. With the patient in a left-sided oblique position with a bolster under the ipsilateral hip, the bowel is displaced and a puncture in to the superior calyx offers quick access to the ureteropelvic junction and stone within the pelvis [4]. Preceptorship and mentoring Competence in ultrasound-guided renal entry requires a studying curve to be overcome. We consider this method shortens the learning curve by giving the trainee perception in to the intricacy of aligning the needle with the transducers. Preoperatively the side-to-side mobility and skill to displace the kidney in relation to the abdominal wall is assessed. A supine oblique Chapter 12 Percutaneous Renal Access Under Ultrasound Control 177 mannequin utilizing a hen carcass and contemporary ex vivo porcine kidney.

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As in ultrasonic lithotripsy, the mechanism of action in pneumatic lithotripsy raises concern over the potential for accumulating system damage, specifically perforation. On histologic examination, the lithoclast resulted in only partial abrasion of the epithelium and edema of deeper layers [8]. Additional animal research have additional documented the safety of the Swiss Lithoclast; notably Santa-Cruz et al. One of the constraints of pneumatic over ultrasonic lithotripsy is the solid design of the probe, and subsequently the shortage of a suction channel. The improvement of a suction channel by way of which pneumatic lithotripsy is commenced and suction is utilized alleviated this concern. In addition, the appliance of suction during pneumatic lithotripsy can counteract one other major disadvantage of direct contact lithotripsy, retropulsion of stone fragments [33]. Pneumatic lithotripsy ends in profitable stone fragmentation in 73�100% of circumstances [9, 20, 33�37]. Its 272 Section 2 Percutaneous Renal Surgery: Stone Removal pedal and allows the surgeon to use either of the lithotriptors individually or in combination. Stone fragmentation was profitable in all 15 sufferers with renal and bladder stones. Since that point numerous in vitro research have examined the efficacy of the combined lithotriptor [43� 46]. The combination pneumatic/ ultrasonic unit was found to be considerably more environment friendly in completely fragmenting and clearing the stone mannequin compared to either pneumatic or ultrasonic lithotripsy alone (7. The clinical utility of the combined lithotriptor has been evaluated in a number of research [47�49]. In the largest of those studies, 68 sufferers had been handled for staghorn calculi over a 2-year interval. The combination gadget required significantly much less time for full stone clearance (21. Further studies are required to adequately define the position of the mixed ultrasonic and pneumatic lithotriptor amongst the at present obtainable intracorporeal lithotriptors. The rigid nature of the probes also limits the ability to use the Swiss Lithoclast with ureteroscopy. Despite the added ability to use the Lithoclast with a versatile ureteroscope, a big lower in tip displacement and velocity, and therefore effectiveness, is famous because the scope is deflected [40]. Technically, using pneumatic lithotripsy is facilitated by means of a nondeflected working channel. Direct imaginative and prescient ought to always be employed to ensure safety in addition to to facilitate enough fixation of the calculus in opposition to the urothelium. When the smaller probe was used, nonetheless, a slower price of impact (6 vs 12 Hz) was found to be more effective [41]. Combined ultrasonic and pneumatic lithotripsy Ultrasonic lithotripsy supplies the surgeon with a really effective methodology for stone elimination. The included suction channel functions to decrease the effects of stone retropulsion and further assists with the removing of fragments less than 2 mm in diameter. Unfortunately, ultrasonic lithotripsy has limitations, especially in phrases of the destruction of very dense or onerous stone compositions (calcium oxalate monohydrate). Pneumatic lithotripsy has beforehand been demonstrated to be a very efficient endoscopic lithotriptor, particularly when treating exhausting or very massive stones [38, 39]. Unfortunately, this system leads to the formation of comparatively giant stone fragments and the shortage of a suction channel further interferes with stone elimination. In an attempt to combine the benefits of these two technologies, the Lithoclast Ultra was developed. This system uses a combination of ultrasonic and pneumatic lithotripsy to accomplish calculus fragmentation and evacuation. A single management unit is activated via a foot Laser lithotripsy Light amplification by stimulated emission of radiation (laser) is both a mnemonic in addition to a descriptive Chapter 24 Percutaneous Lithotripsy and Stone Extraction 273 assertion. Laser is a mechanism for emitting electromagnetic radiation through stimulated emission of photons. When an atom is stimulated by an exterior vitality source, electrons turn into metastable and alter their orbit. There are three variations between laser gentle and natural gentle: laser light is coherent (all photons are in phase), collimated (photons journey parallel to one another), and monochromatic (photons have the identical wavelength) [50]. It is these characteristics that enable lasers to transmit excessive energy in a concentrated fashion. In 1966 Parsons was the primary to use laser technology in urology when he experimented with the pulsed-ruby laser in canine bladders [52]. Since the initial ruby laser, several lasers have been developed and carried out in intracorporeal lithotripsy. Plasma, a gas in which a portion of the particles are ionized, is shaped, and expands on the tip of the laser fiber. The fast growth and collapse of the resultant plasma bubble generates an acoustic shock wave that fragments the stone [54]. It features by way of a main photothermal that ends in stone vaporization [55, 56]. Despite the fact that the HoL is the most lately developed laser expertise, it has turn out to be the most extensively clinically utilized laser and is the laser on which our discussion will focus. Given that human tissues are chiefly composed of water, the vitality of the HoL is absorbed superficially. In an ex vivo comparability of 4 completely different lithotriptors in a porcine ureteral model, the HoL was unable to induce perforation at a distance of two mm, even at very high power settings [31]. In one study, the HoL was reported to perforate the ureter after solely 2 s of direct contact activation [8, 31]. Throughout the literature HoL lithotripsy has been demonstrated to be very effective, with success rates of 91�100% and stone-free charges after ureterorenoscopy of 87�100% [58�64]. Calculus location within the accumulating system has been proven to affect HoL lithotripsy success. When the procedures have been stratified by stone location (renal, proximal ureter, center ureter, and distal ureter), stone-free rates have been 84%, 97%, 100 percent, and 98%, respectively [64]. At the start of the procedure a 5�7F ureteral catheter was placed in a retrograde style to the level of the uteropelvic junction. This catheter was utilized to stop stone migration, facilitate renal puncture, and for the instillation of forceful retrograde irrigant (normal saline) throughout the procedure. Since its inception, HoL lithotripsy has been extensively accepted as an intracorporeal lithotriptor. In fact, the latest version of Campbell�Walsh Urology states, "the holmium laser has become the mainstay of ureterorenoscopic lithotripsy" [11]. Both the 200 m and 365 m fibers can be used with each semi-rigid and flexible ureteroscopes, and their flexible nature allows for preservation of flexion capabilities during ureteroscopy, a major advantage. The HoL, specifically, has proven to be an extraordinarily versatile weapon inside our arsenal of remedy modalities for urolithiasis. Their efficiency permits an skilled surgeon to deal with massive stone burdens with optimal operative occasions and low complication charges. We have discovered the combination of ultrasonic and pneumatic lithotripsy to be superior and therefore we employ the Lithoclast Ultra.

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While the thoracic complication price is reportedly decrease with a subcostal approach, sufferers with complex stones are more probably to profit from improved stone clearance associated with a supracostal strategy. The incidence of thoracic issues additionally will increase when a more cephalad intercostal area is used for entry. Of these sufferers, entry was obtained within the tenth intercostal area in 26 patients and in the 11th intercostal area in seventy two sufferers. Thoracic issues occurred after eight procedures, of which seven have been via a supracostal access. Of these seven thoracic problems, six occurred in the tenth intercostal area group and one within the 11th intercostal space group. The authors concluded that access by way of the 10th intercostal area is related to a 16-fold larger thoracic complication rate when in comparability with the eleventh intercostal house, and a 46-fold higher price when compared to subcostal access. Both of those problems occurred in sufferers with tenth intercostal area entry. Based on these findings, the authors really helpful that access above the eleventh rib ought to be carried out solely by those with vital experience and only when the benefits of this entry outweigh the risks. Intraoperative technical elements may enhance the danger of thoracic problems. A working sheath had not been used during this procedure, and the authors advised that use of a working sheath could have prevented this complication. In abstract, a extra cephalad entry site increases the danger for thoracic complications. Renal access above the eleventh rib is related to a marked increase in complication rates. Technical factors can also contribute to the event of problems, corresponding to avoiding use of a working sheath. The sheath ought to be advanced in to the renal amassing system to decrease efflux of irrigation in to the retroperitoneum and pleural house. In this case, fluoroscopy can be used to examine the costophrenic angle to consider for hydrothorax. Diagnosis the analysis of pleural harm is ideally made intraoperatively, at which time it could be handled expeditiously and with minimal patient discomfort. Alterations in ventilatory parameters might point out pleural violation and should prompt fluoroscopic evaluation to search for a pneumothorax or hydrothorax. Even in the absence of ventilatory modifications, fluoroscopic evaluation of the lung and costophrenic angle should be carried out at the end of the process. This complication can additionally be diagnosed within the postoperative interval either primarily based on routine chest imaging or the development of indicators and symptoms. Another intraoperative indication of a thoracic complication is critical bleeding by way of the nephrostomy tract. While this may happen from a renal vascular injury, the surgeon should be suspicious of an intercostal artery damage in instances using a supracostal method. Left display exhibits cephalad angulation of nephroscope; right display screen exhibits the obscured view because of bleeding. Of the 104 percutaneous renal accesses performed in the examine, 58% had been supracostal. An intervention for hydropneumothorax was necessary in seven patients, all of whom had undergone a supracostal access. Note fluid layering in the proper hemithorax (photograph courtesy of Dr Glenn Preminger). Complaints could include shortness of breath or chest pain, with objective findings including increasing oxygen requirement and decreased breath sounds over the affected lung area. Four sufferers were recognized intraoperatively before extubation, three had been recognized in the restoration room based on oxygen desaturations, and three developed shortness of breath and tachypnea a number of hours later after transfer to the surgical flooring [5]. Nephropleural fistula is a unique complication, often presenting later in the postoperative course after nephrostomy tube removing. Four sufferers were diagnosed with nephropleural fistula after nephrostomy removing, two of which introduced immediately. In instances of persistent drainage from a chest tube placed for hydrothorax, a nephropleural fistula should be thought-about. Persistent drainage suggests the potential of distal ureteral obstruction, which can be assessed with a retrograde ureteropyelogram. At the beginning of the procedure, fluoroscopic evaluation can assist in figuring out the inferior pleural margin. Biplanar fluoroscopy may provide superior visualization of the anatomic relationship between the kidney and pleural area, and decrease the chance of problems [9]. Supracostal access should be performed lateral to the midscapular line to decrease harm to the pleura. The needle ought to be advanced alongside the higher margin of the rib during shallow breathing or through the expiratory part. Needle passage along the inferior margin of the rib dangers damage to the intercostal neurovascular bundle, which may result in significant bleeding. Some authors have recommended calyceal entry throughout inspiration to displace the kidney caudally [27]. If the targeted calyx is above the 11th rib, the authors place an additional access site in to a mid�posterior calyx to help displace the kidney caudally. A similar advice, using either saline or carbon dioxide, was described by Romero et al. The injection of saline or carbon dioxide displaced the kidney caudally away from the diaphragm. Displacing the kidney on this manner also minimizes diaphragmatic irritation from extravasated blood merchandise. Once entry has been obtained and the tract dilated, an entry sheath must be utilized to minimize extravasation of irrigant in to the retroperitoneum and pleural space. In the event that the parietal pleura is traversed by the needle, using an access sheath can typically forestall this from evolving in to a thoracic complication. The amount of irrigant used in the course of the process should be monitored, though a precise measurement is troublesome. If the influx of irrigant is considerably more than the measured outflow, the potential for extravasation in to the pleural area should be thought of, and the chest fluoroscopically evaluated. Postoperative renal drainage after percutaneous nephrolithotomy is based on the positioning of access, quantity of stone burden, degree of amassing system trauma, plan for a second-look process, and surgeon desire. Blood clots or stone fragments that will cross in to the ureter can cause ureteral obstruction, probably leading to a nephropleural fistula. In many patients, a nephrostomy tube is left in place for no less than 24 h following the process.

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However, throughout the following 5 years, there was an increase within the recurrence of ureteral tumors (43%) with renal pelvic tumors steady at 37%. Thus, it could be speculated that the distinction is expounded to the ureteroscopic treatment of bigger and more proximal ureteral lesions in the later years. We have discovered that most of the recurrent lesions are small and could be handled endoscopically. Only when there are intensive and speedy recurrences does nephroureterectomy turn out to be essential (Table forty one. These collection are also characterised by excessive diseasespecific survival, with the two notable exceptions of the series reported from the Mayo Clinic of sufferers presenting initially with bladder tumors, and in those in whom crucial indications such as a solitary kidney prompted their endoscopic remedy. It is notable that in most of the patients, biopsy affirmation was not available and high-grade recurrences developed [86, 88, 89]. Some of those traits are similar for to those for danger of recurrence for bladder tumors. There is also the next threat of recurrence for high-grade tumors treated either ureteroscopically or by open surgery. There is proof that constructive urinary cytology at the time of remedy is a poor prognostic sign. The impact of the location of the primary tumor, whether in the intrarenal collecting system or ureter, has been inconsistent, with some sequence reporting a better rate for intrarenal neoplasms and others finding no difference or extra frequent recurrence after ureteral primaries. However, multifocal lesions have consistently been seen to be associated with extra frequent recurrences, each within the higher tract and in the bladder. Tumor location Bladder tumors There is important risk of latest bladder tumors developing in sufferers with higher tract neoplasms. In a abstract of several collection reporting laparoscopic and open neph- roureterectomy, the following bladder tumor rate was 31. However, there was a variety in each group: 10�55% within the laparoscopic group and 15�45% in the open surgical group [90]. Additionally, one sequence compared bladder recurrences after retroperitoneoscopic or open nephroureterectomy without discovering any difference [91]. Among patients with upper tract tumors treated ureteroscopically, the average subsequent bladder tumor incidence price was 38. In two series of patients with out earlier bladder tumors, the rate was 34% and 33%, respectively (Table 41. Some series have famous that the bladder tumor price is said to the grade of the primary tumor, whereas the effect of grade was not thought-about in others. One report 446 Section 3 Ureteroscopy: General Principles high-grade upper tract neoplasm. There is some proof that high-grade lesions will recur extra incessantly, however long-term successes have also been reported [77]. The affected person must be informed of the risks of resection and be succesful of take part in subsequent endoscopic surveillance. A survey of endourologists showed that 77% favored a distal ureterectomy for a large distal ureteral tumor. Only 21% thought that ureteroscopic ablation for such a lesion would be the primary selection [43]. Based on the success of this expertise, ureteroscopic remedy has been extended to sufferers with a traditional contralateral kidney. The feasibility of this strategy was demonstrated in studies trying specifically at patients who had two kidneys. More recently, patients with two normal kidneys are generally included in reported series. There was a 46% recurrence price among thirteen ureteral tumors and only 12% (one of eight) for renal pelvic tumors. There was, however, a excessive mortality fee with eleven of 20 patients dying of unrelated causes, with one dying from invasive bladder cancer. There had been no deaths related to the endoscopic tumor therapy or the upper tract neoplasm. The high unrelated mortality rates suggest that these sufferers are typically at excessive risk. In a series by Chen and Bagley, 23 patients with two useful kidneys were treated ureteroscopically [93]. The patients had several recurrences, however there was no significant grade improve and no affected person developed metastatic disease. At the time of their follow-up, 17% had an ipsilateral recurrence and 5% (one patient) had developed a brand new contralateral neoplasm. An inverse relationship between tumor measurement and pathologic stage on subsequent improvement of bladder cancer was additionally noted [92]. Large tumors Large neoplasms of the higher tract can be handled successfully ureteroscopically in some patients. If visibility deteriorates with bleeding or tumor particles, it could be unimaginable to distinguish the margin of the tumor. Some tumors that regrow too rapidly or are too large to be handled ureteroscopically may require a percutaneous nephroscopic process and even nephroureterectomy. Almost each paper reviewing experience with this treatment has cautioned that endoscopic surveillance is critical. Cystoscopy has been well-established as the standard approach to consider for new bladder neoplasms after surgical treatment of upper tract neoplasms. After endoscopic therapy, surveillance of the bladder must also be maintained with cystoscopy. Evaluation of the upper tracts for model spanking new or recurrent tumors must be maintained with different methods. Ureteroscopy is probably the most delicate method to consider the upper tract and must be used routinely in follow-up surveillance. In another series, urinalysis, voided cytology, retrograde ureteropyelography, and ureteroscopic biopsy were compared in sufferers with ureteroscopically visualized and handled tumors [94]. There was a excessive specificity of bladder urine cytology and urinalysis, which do assist their use. Some authors recommend excretory urography or retrograde ureteropyelography at intervals of 3�6 months, with ureteroscopy used only when particularly indicated. However, the greater sensitivity of direct endoscopic inspection should be recommended as a significant approach for surveillance. Ureteroscopy is continued at intervals of three months until the upper tract is obvious, at which time the affected person is examined ureteroscopically at 6-month intervals. Cystoscopy and cytology with urinalysis are continued at intervals of three months during the first 2 years (Table forty one. Evaluation of the contralateral amassing system with retrograde pyelography ought to be carried out a minimal of yearly and possibly at 6-month intervals. Complications Complications can occur with any ureteroscopic procedure but there are some that seem to be particular to ureteroscopic tumor treatment. A evaluation of issues from published series of ureteroscopic therapy of upper tract tumors indicates a ureteral stricture price of 13%, which is considerably larger than the rate of less than 1% seen for stone treatment [95].

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The orientation of those neurons in the cortex creates a sensory homunculus, which is actually a map of the body on the mind. For example, in tabes dorsalis, a late-stage manifestation of syphilis, neurons in the dorsal root ganglia are destroyed, which in turn causes degeneration of the myelinated afferent fibers within the dorsal columns. Note that the face, palms, and fingers-areas where precise localization is critical-represent the most important areas of the homunculus. Anterolateral system (spinothalamic tract) � the spinothalamic tract processes the sensory modalities of pain, temperature, and crude touch. Thalamus � Sensory "relay station" between lower-order afferents and the cortex Clinical note: Thalamic (pain) syndrome is a uncommon situation by which destruction or ischemia of the thalamus ends in hypersensitivity to a wide selection of stimuli. Most usually these stimuli, which can be as benign as contact, chilly or warmth, or emotional anxiety, can end result in significant pain and paresthesias on one aspect of the body. Pain receptors are free nerve endings which would possibly be positioned in the pores and skin, muscle, and viscera and are answerable for the detection and perception of pain (nociception). The ache is normally experienced within the dermatome equipped by the spinal nerve that enters the spinal twine on the similar degree because the visceral nerve (Table 2-12). They comprise imaginative and prescient, hearing (audition), equilibrium (the vestibular system), olfaction, and style. The retina is composed of a sheet of photoreceptors on the posterior facet of the orbit. They are responsible for low-acuity imaginative and prescient at evening, when the light provide is poor. Their photosensitive element is rhodopsin, which consists of 11-cisretinal and scotopsin. They are much less numerous than rods and are concentrated within the fovea centralis of the macula. Horizontal cells transmit indicators horizontally within the outer layer from the photoreceptors to the bipolar cells. Rods and cones Horizontal cell Bipolar cells Amacrine cell Ganglion cells To optic nerve Light Pupillary light reflex: regulates intensity of sunshine entering the eye by controlling pupil diameter Shining light in one eye: normal response is constriction of each pupils Direct response: constriction of pupil in eye exposed to light Consensual response: constriction of pupil in eye not exposed to mild a. Constriction of the pupil the sunshine is directed at is termed the direct response, and constriction of the other eye is termed the consensual response. Bilateral pupil constriction occurs because � Impulses from the retina of the eye in to which the sunshine is shone cross through the optic nerve to the pretectal area of the midbrain. When a distant object is brought close to the eyes, the focus is initially behind the retina, resulting in a blurred image. Optic tract (Ieft) Right hemianopia 4 5 Lateral geniculate nucleus 6 7 Optic radiation to lingual gyrus Optic radiation to cuneus Visual cortex area 17 6. Both divisions Right hemianopia with macular sparing 7 2-22: the visible pathways, displaying the consequences of lesions at numerous points. In the lodging reflex, parasympathetic outflow from the EdingerWestphal nuclei causes contraction of the ciliary muscle, resulting in much less tension in the suspensory ligaments. Parasympathetic outflow additionally contracts the radial fibers of the iris (sphincter pupillae), lowering the quantity of light that enters the pupil; this ends in better focusing of the sunshine and less scattering. There is simultaneous contraction of the medial recti, which ends up in convergence of the eyes on to the near object. A collection of ducts known as the membranous labyrinth � Fluid is positioned both inside the ducts (endolymph) and out of doors the ducts (perilymph). They synapse with dendrites of unmyelinated neurons, axons of which comprise 10% of the cochlear nerve. The waves journey until they attain the air-filled middle ear, the place they trigger the tympanic membrane to vibrate. Common causes are cerumen impaction (obstruction), otitis media, and otosclerosis. Clinical notice: Cerebellopontine angle tumors are typically benign schwannomas known as acoustic, or more correctly, vestibular neuromas. Vestibular neuromas could trigger ipsilateral sensorineural hearing loss or deafness, vertigo, and tinnitus. High-frequency sounds: stimulate hair cells at base of basilar membrane to vibrate Low-frequency sounds: stimulate hair cells at apex of basilar membrane to vibrate � Sound encoding a. Low frequencies trigger hair cells on the apex of the basilar membrane, close to the helicotrema, to vibrate. The base of a vibrating tuning fork is positioned on the mastoid course of until the patient can not hear the bone-conducted vibration; at this point, the vibrating end of the fork is repositioned about 1 cm from the external Normally and in sensorineural deafness, air conduction is best than bone conduction in both ears; in conduction deafness, bone conduction is healthier (Table 2-13). Clinical notice: Weber take a look at is performed by placing a vibrating tuning fork on the vertex of the skull and asking the patient whether or not the sound is identical in both ears. The vestibular system (vestibular organ) � the vestibular system maintains posture and equilibrium (balance) and coordinates head and eye actions. Semicircular canals Utricle Endolymph duct Ampulla of semicircular canals Vestibule Saccule Oval window Round window Cochlea If the stereocilia bend toward the kinocilium, the hair cell is depolarized and excited. If the stereocilia bend away from the kinocilium, the hair cell is hyperpolarized and inhibited. Vestibular-ocular reflexes � these reflexes stabilize visual images by compensating for head motion. It is characterized by an alternating easy pursuit in a single path and quick saccadic movement within the different direction. Vestibular-ocular reflexes: stabilize visible images by compensating for head movement Nystagmus: might point out vestibulocerebellar damage Vestibular (horizontal) nystagmus � Resets eye position throughout sustained rotation of the head � the quick part of nystagmus is within the path of rotation. Surface of tongue Pore Stratified squamous epithelium Microvilli Taste receptor cells Binding of odoriferous molecules to cilia on olfactory cells: in the end leads to motion potential era and transduction of sign to olfactory cortex Taste buds on anterior two thirds of tongue: detect candy and salty tastes; transmit by way of lingual nerve to facial nerve Basal cell Nerve fibers Subendothelium connective tissue To facial, glossopharyngeal, or vagus nerves, relying on location of the taste bud on the tongue Second-order neurons depart the solitary nucleus and project ipsilaterally to the ventral posterior medial nucleus of the thalamus. Neurons from the thalamus project to the taste cortex positioned within the primary somatosensory cortex. Intermediate long-term reminiscences final for days to weeks but then are forgotten; they outcome from momentary chemical and/or structural changes. The major area for language comprehension is Wernicke area, positioned behind the first auditory cortex in the posterior part of the superior gyrus of the temporal lobe. Both the depth and sample of electrical activity are determined by the level of excitation of the brain throughout sleep and wakefulness or in illness states corresponding to epilepsy. This cycle is driven by the suprachiasmatic nucleus of the hypothalamus, which receives enter from the retina. The anterior cerebral arteries provide blood to the inferior frontal lobes, the medial surfaces of the frontal and parietal lobes, and the anterior corpus callosum. Small penetrating branches supply the limbic structures, the pinnacle of the caudate, and the anterior limb of the internal capsule. Middle cerebral artery Internal carotid system Internal carotid arteries Posterior cerebral artery Cerebellar arteries Basilar artery Circle of Willis Vertebral artery Posterior inferior cerebellar artery Vertebrobasilar system Through the circle of Willis, the vertebrobasilar system anastomoses with the anterior portion of the circle of Willis provided by the carotid arteries. Clinical notice: Thrombosis of the basilar artery may outcome in the locked-in syndrome.

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These photographs help create a mental threedimensional (3D) image of the calyceal anatomy, and can be referred to during the process. A three-way valve is hooked up and related to a ten mL syringe and intravenous tubing leading to a bottle of distinction. This allows aspiration and infusion of further distinction as needed in the course of the case. Second, the constant strain of contrast within the renal amassing system ensures a persistent pyelogram, facilitating calyx identification when the patient is repositioned inclined. Third, circulate of contrast underneath gravity distends the accumulating system, providing a bigger goal for entry. Fourth, free return of contrast out via the needle permits the surgeon to quickly confirm successful puncture of the chosen calyx. Our anesthesiologists use generous padding of the eyes to stop corneal abrasions and have varied head helps on the ready with cut-out holes for the endotracheal tube. To forestall brachial plexus damage, the shoulders must be situated beneath the chest and are each externally rotated at the shoulder and flexed at the elbow. In the susceptible position, the pure, anterior lordosis of the backbone is exaggerated. This complicates access by compressing the working area and results in instrument conflicts with the buttocks. In one latest multicentered randomized study examin- ing the issue of surgical website infections following clean-contaminated surgical procedure, it was found that pores and skin preparation with chlorhexidine�alcohol was superior to povidone�iodine within the perioperative period [13]. To prevent hypothermia, all irrigation fluid is heated to 42� C in a warming cupboard. We favor a traditional "bullseye" technique for performing renal puncture in the prone position; nevertheless, a "triangulation" method may also be used (described below). Note additionally that prone�flexed positioning decreases obstruction from the buttocks with decrease pole access. With the C-arm rotated 30� from the vertical, towards the operator, the posterior calyces move away, and shorten. This needle lacks a beveled edge and as such, resists deflection away from the axis of puncture. Once the calyx is entered, and a free move of distinction obtained, an Amplatz extra-stiff or super-stiff guidewire is handed down the needle in to the accumulating system. A small depth gauge ring on the needle is adjusted to pores and skin degree to mark the depth between the skin and the accumulating system. Knowledge of this measurement reduces radiation exposure during insertion of the fascial dilators and nephrostomy tract dilating balloon. Initially, skinny fascial dilators are used to dilate the tract to a short 10F, after which a security guidewire may be inserted utilizing a 10F dual-lumen catheter. The tract is then further dilated to 30F with a nephrostomy tract dilating balloon over which an Amplatz sheath with a 30F inner diameter is handed. Although completely different methods of tract dilation exist, together with balloons, Amplatz serial dilators, and the Alken telescopic dilator amongst others, we favor balloon dilation. We have found this to be each fast and atraumatic, though this comes at elevated value. Its benefits include the power to control the degree of flexion required in addition to to use adjustable contour pads that permit free of charge excursion of the stomach, preventing respiratory compromise. The major limitation to its use is the reduction in depth, preventing C-arm motion, instrument manipulation, with fluoroscopic guidance. By commencing the process with the patient within the inclined position instantly following induction of common anesthesia, the affected person will nonetheless require repositioning, but is only draped once [17]. A split-leg modification can facilitate access to the exterior genitalia, for simultaneous antegrade and retrograde approaches [7, 8]. In the inclined position it may be troublesome to access the anteriorly displaced ureteric orifices for the retrograde study, however with apply this can become routine. Additionally, if the process is started prone, identification of the posterior calyces, particularly in obstructed systems, could also be difficult, or unimaginable, as the presence of pure urine throughout the collecting system might float on top of the radiographic contrast and render them invisible. Although nonetheless possible in the supine position, higher pole access is significantly simpler when the affected person is inclined. An upper pole puncture has many benefits, together with the power to work down the renal axis, with minimal torque, because the more cell lower pole rotates to align with the nephroscope. Selection of an upper pole calyx is indicated in obese patients, because the upper pole is closer to the posterior abdominal wall than the lower pole. It can be indicated in sufferers with staghorn calculi, or stones in a horseshoe kidney, and facilitates entry to multiple decrease pole calyces, with a single tract. The "Montreal mattress" is a preshaped surgical bolster that can be used as an adjunct for the support of prone patients [14]. The advantage of this device is the central cavity which permits for free motion of the stomach. The lateral�flexed position is familiar to any urologist who performs open and laparoscopic renal surgery. This position considerably widens the area between the 12th from the operator throughout dilation and kink the guidewire. Despite these benefits, many authors still choose a lower pole puncture with the reassurance that this strategy will keep away from thoracic issues. The prone�flexed modification that we describe provides several extra benefits over the standard method. This effect is most pronounced with the left kidney, which is decrease than the proper kidney in greater than 90% of cases. Also, due to this modification, a supra-11th rib access may be transformed to a supra-12th rib, or a supra-12th to an infracostal entry. Finally, the flank is considerably flattened, eliminating interference from the buttock during inflexible nephroscopy through a lower pole tract [10]. Note that the pannus falls away from the affected person, preventing respiratory compromise. The elevated distance between the 12th rib and iliac crest, produced by this flexion, is much more pronounced than the increase produced by flexion with the patient 159 A inclined. One drawback to flank positioning is that percutaneous entry often requires either ultrasound guidance or use of "triangulation" using the C-arm picture intensifier, as opposed to the "bullseye" method. This is partly due to the restricted arc of rotation of most C-arms, but in addition as a outcome of the metal aspect rails of most radiolucent tables prevent enough visualization of the amassing system when the C-arm is rotated to an exaggerated place. Percutaneous nephrolithotomy in the lateral and lateral�flexed positions (see Video eleven. An axillary roll or padded wedge with a groove to accommodate the dependent arm have to be positioned to adequately help the chest and prevent positioningrelated damage. Extra padding should even be positioned under the dependent knee and ankle to forestall pressurerelated problems. In this demonstration, the target is an higher pole, posterior calyx, viewed from immediately above.

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Neobladders Unique challenges have been recognized with this type of urinary diversion. Often a retrograde approach to the implanted ureteral orifice is fraught with problem. Nonuniformity of the orifice location mixed with mucosal folds often make identification of the ureteral orifices time-consuming, if not inconceivable. In a Kock pouch diversion, using a versatile ureteroscope is strongly recommended, because the extreme torque required for a inflexible endoscope to reach via an afferent nipple has the potential to injure the sphincter [31]. With a proper colon pouch diversion, the fragile continence mechanism may be compromised using a normal cystoscope to determine the ureteral orifice. In many orthotopic neobladder strategies, both one or each ureters are implanted in to an afferent limb of bowel that extends from the reservoir. In such cases, identification of both the limb and related ureters is crucial [32]. Direct visualization of the ureteral orifice requires versatile cystoscopy as entry usually requires a "retroflexion maneuver. Again, the vital thing point in all these circumstances is placement of an antegrade guidewire by way of the collecting system down in to the reservoir; it serves as a security wire and a landmark when performing retrograde ureteroscopy. Renal transplantation Ureteral reimplantation during renal transplant results in an ectopic and anterior ureteral orifice, making its identification difficult [20]. Nevertheless, retrograde ureteroscopy of a transplanted ureter may be successful with method modifications [41, 42]. In addition, a versatile cystoscope as well as angled catheters (Kumpe or cobra) and angled hydrophilic glidewires may be useful for negotiating both the acutely angled transplanted ureteral orifice, in addition to the frequently tortuous and redundant transplanted ureter [20]. Summary and conclusions Whether the ureter has a classical or an uncommon appearance, one ought to be acquainted with both the normal and potential irregular anatomy, on account of congenital anomalies or previous surgical procedures. The anatomy of the ureter ought to never be ignored when contemplating any type of endoscopic manipulation. Appropriate preoperative analysis and intraoperative endourologic methods ought to ensure correct, clean, and often profitable endoscopic procedures. Reports of ureteroscopy carried out on a reimplanted ureter have started to emerge as this pediatric population has entered maturity, with an increased incidence of urolithiasis. Crossing vessels on the ureteropelvic junction: do they influence endopyelotomy consequence Holmium laser ureteroscopic remedy of varied pathologic options in pediatrics. Successful administration of lower-pole moiety ureteropelvic junction obstruction in a partially duplicated accumulating system using minimally invasive retrograde endoscopic strategies. Endourological management of a giant distal ureteral calculus in a affected person with ureterosigmoidostomy diversion. Combined antegrade and retrograde endoscopic method for the management of urinary diversion-associated pathology. Management of nephrolithiasis after Cohen cross-trigonal and Glenn-Anderson advancement ureteroneocystostomy. Percutaneous transvesical ureteroscopy for removal of distal ureteral stone in reimplanted ureter. Strategies for ureteral catheterization after antireflux surgical procedure by the Cohen technique of transverse advancement. From the common-or-garden beginnings where Young performed the primary recorded ureteroscopy in 1912 using a 9. The introduction of fiberoptics paralleled by the progression of instrument expertise has led to smaller, more maneuverable scopes with more acceptable ergonomic layouts. The latest technology of ureteroscopes now offers high-definition digital pictures of the ureter and intrarenal collecting system, allowing procedures to be carried out safely, with high success charges and minimal morbidity in adults and children. To appreciate how ureteroscopes have evolved in to their present day guise, this chapter begins with a abstract of key technical developments, starting with the first acknowledgment of the endoscope, the impact of modifications in instrumentation, and progressing via to the newest digital know-how. A breakdown of key features of ureteroscopes is then given, discussing their similarities and variations earlier than transferring on to contemplate ureteroscopes presently obtainable and potential future tendencies for their additional improvement. Rigid and semi-rigid ureteroscopes Rigid ureteroscopes Historical perspective the historical past of the endoscope is properly documented [2�4] and its consideration units the scene for the progression to present day ureteroscopes (Table 34. The traditional elements required to carry out a inflexible endoscopic process are the telescope with working channels for irrigation and instrumentation, a lightweight source, optics to convey the picture, and a digicam system to seize the image. The digital period is here and can ultimately condemn the fiberoptic association to the historic archives. The forerunner of the endoscope can be traced back to 1806 with the development of the light-guiding instrument or "Lichtleiter" by Phillip Bozzini for direct inspection of inner organs [5]. This scope was primary in design, consisting of a direct-vision hollow tube via which candlelight was transmitted by a mirror. Gustave Trouv� further upgraded oblique illumination by candlelight to electrical illumination using glowing heated platinum wires at the tip of the instrument in 1873 [5]. Year 1806 1853 1873 1879 1960s 1960s Pioneer Phillip Bozzini Antoine Jean Desormeaux Gustave Trouv� Maximilian Nitze and Joseph Leiter Several contributors Harold Hopkins Rigid endoscope and technologic advances German physician who introduced the ""Lichtleiter" or light guiding instrument French surgeon who first launched the "endoscope". The NitzeLeiter cystoscope, a rudimentary version of the trendy cystoscope, was constructed in 1879, incorporating a easy lens system in to the viewing tube [5]. The introduction of fiberoptic lighting within the 1960s replaced the incandescent bulb, revolutionizing the manufacture of inflexible endoscopes. The design was based mostly on the precept of total inside reflection; when gentle travels in a transparent medium similar to glass, inside reflection of the sunshine occurs at the interface between the medium and its environment, as demonstrated by John Tyndall in 1854 [6]. This bodily property of inside reflection allows the "bending" of sunshine within versatile glass. Thus, mild travelling inside a small-diameter versatile glass fiber surrounded by cladding of lower refractory index could be transmitted over a long distance with minimal degradation. The profit of recent fiberoptic lighting is larger illumination by cooler mild, finally making it safer. An further profit is that the scopes could be made with a smaller-profile shaft, allowing extra room throughout the shaft for the addition of an irrigation and instrument channel. The fiberoptic cable is often attached by way of a light-weight publish to the endoscope, but might alternatively be inbuilt to the design of the scope. The progressive work of the British physicist Harold Hopkins led to the subsequent major breakthrough in rigid endoscopic design with the introduction of the rod�lens system within the Sixties [7]. Until then, the shaft of the scope consisted of a hole tube with a collection of skinny relay lenses separated by long air areas. The relay lenses needed to stay in precise alignment and any displacement of the lens resulted in a major loss of picture transmission. Hopkins replaced the thin relay lenses inside the shaft of the endoscope with lengthy, contoured glass rods performing because the transmission medium, whilst the thin pockets interspersed between the glass rods acted as lenses. With the telescope primarily being Chapter 34 Rigid and Flexible Ureteroscopes: Technical Features 367 made of glass, which has the next refractive index than air, light transmission could probably be elevated ninefold over previous lens methods, with the additional good thing about decreased picture distortion and a wider viewing angle.

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C Ureterorenoscopy with a rigid scope nonetheless had inherent problems with the rod�lens optics as a result of the tortuous nature of the ureter and the caliber and working length of the instrument, which gave impaired vision. With the growing demand for rigid ureteroscopes in the 1980s, the additional use of fiberoptic know-how would enable further miniaturization of the shaft diameter along with reduction in dimension of the working channels. The "miniscope" or semi-rigid ureteroscope combined smaller working channels and fiberoptics, allowing both illumination and picture incorporated in to a metal sheath. The optical system was gotten smaller in contrast with the rod�lens design, resulting in its major benefit, an total discount in the outside diameter of the scope, but not on the expense of lowering the dimensions of the working channels. Although the inflexible rod�lens system provided glorious optical quality, a further benefit of the miniscope was that the fiberoptic bundles inside the metallic shaft could presumably be flexed considerably without distortion of the picture and the looks of a dark crescent-shaped area that may occur with extreme torque applied to the rod�lens telescope. Such flexibility allows simpler passage of the scope via the intramural ureter after which anteriorly over the iliac vessels with nice maneuverability to negotiate narrowed or strictured ureters. Other benefits of the miniscope included simpler access, decreased requirement for ureteric dilation, and decreased ureteric damage. It was the primary to incorporate two impartial working channels, one for an adjunct and one for circulate, every of two. The last distal form was decided by enclosing the smallest dimension optical system the engineers might conceive at the time, along with the two separate throughput channels in a triangular-shaped outer tube, giving a 6. Over the previous decade, miniureterosopes or semi-rigid ureteroscopes have been refined when it comes to materials, ergonomic layout, fiberoptics, and camera methods, though there has been no actually vital steps ahead in scope evolution. General properties Optics and eyepiece In follow, the rod�lens ureteroscope, although offering high quality photographs, permits solely limited vertical deviation on development and is suited to ureteral sorties the place the scope undergoes minimal change in path. The introduction of fiberoptic bundles inside a inflexible shaft has enabled navigation through the more difficult tortuous ureter with out resulting in optical malfunction. Newer fiber-packing strategies and advanced camera systems have led to further enchancment. Fiberoptic methods now present light and picture transmission via most present semi-rigid ureteroscopes. As discussed earlier, offset eyepieces grew to become needed when rigid ultrasound probes have been developed for ureteroscopic lithotripsy. These probes, as nicely as larger extra inflexible working instruments, required a straight working channel for passage via the scope. Instrument producers have made attempts to scale back the trauma of insertion by modifying shaft design and manufacture. The miniureteroscope shaft has a graduated stepless design, beginning with a distal tip diameter as small as 6. This ensures maximal proximal strength of the scope while providing a gradual dilation of the ureter because the scope is superior. The continued discount in ureteroscope diameter has led to a reduction within the variety of ureteral strictures seen and an increased success rate for the process [17]. Most of the currently out there miniureteroscopes are beveled for simpler development and have a round or oval tip design; however, scopes with smooth triangular tips have just lately turn out to be available. A "brief" ureteroscope of simply over 30 cm can be used to entry as much as the extent of the mid ureter in males and renal pelvis in females. To reach the renal pelvis in a male requires a "lengthy" ureteroscope of 40 cm or extra. A bigger single channel permits the use of bigger devices and attainable removal of small stone fragments or biopsy specimens through the sheath, and twin instrumentation depending on the bounds of each channel port. Two separate channels enable the operator to work through one channel without impeding irrigation circulate through the opposite. The channels are either triangular or oval in cross-section, which permits irrigation to continue across the sides despite the location of an accessory instrument. These facilitate both straightforward insertion under direct vision with the (A) normal design, as nicely as the ability to use the straight inflexible equipment in consolation with the (B) lateral and (C) oblique offset designs (courtesy of Richard Wolf). The introduction of holmium laser lithotripsy for the treatment of higher urinary tract stone disease in 1996 [18] was an enormous step ahead in endoscopic stone remedy, and is now the bedrock of contact lithotripsy in most departments. With fiber diameter measuring solely 200 and 365 m, this has just about abolished the requirement for anything bigger than a three. The slim lasers also enable them to be used simultaneously with one other accessory down a working channel, whereas nonetheless maintaining some flow. Camera and video techniques Image transmission has developed according to changes seen with the semi-rigid ureteroscopes. The high-resolution picture output has additionally lowered the discrepancy between the higher images obtained with the larger endoscopes in contrast with those previously seen with the ureteroscope. Analog pictures produced by transmission down fiberoptic bundles proceed to be the primary pathway to ship views of the subject matter to the camera in the majority of semi-rigid ureteroscopes. The drive to engineer semi-rigid ureteroscopes with digital distal sensor 372 Section three Ureteroscopy: General Principles exist which require no enter from the endoscopist. Current ureteroscopes Rigid ureteroscopes can be found in many of the designs previously described. The characteristics of the newest designs of currently available semi-rigid ureteroscopes are given in Table 34. Care, upkeep, and technical failure An important consideration when weighing up the purchase of a new ureteroscope is its longevity and often a stability is sought between optimal length of scope life and its efficacy. Although much less of an issue with the semi-rigid ureteroscope in comparison with its flexible counterpart, applying excessive torque causing deflections over 5 cm can lead to vital picture distortion and scope failure. The majority of ureteroscopic failures are attributed to iatrogenic causes, together with improper handling at the time of instrumentation and issues during the sterilizing course of [21]. Regardless of the type and make of ureteroscope, the frequency of restore will increase with decreasing ureteroscope diameter and increasing length of instrument [22]. Previously, with stepped shaft design of the inflexible ureteroscope, bend stress was concentrated at solder factors. Newer tapered shafts were produced to reduce this drawback, making them extra sturdy and less traumatic. Other notable danger factors for predicting the number of uses expected from a ureteroscope are its age and whether the ureteroscope has undergone comprehensive restore because of prior harm [21]. This is partly because of the excessive density of fiberoptic bundles that could be incorporated in to the semi-rigid ureteroscope, that are extra immune to image degradation when compared to these found in the flexible ureterorenoscope. Irrigation An effective irrigation system is important to optimize the chance of access in to the ureteric orifice and supply good visibility during both inflexible or flexible ureteroscopy. The easiest association entails gravity irrigation, which has to contend with the small diameter and long size of the ureteroscope causing a reduction in circulate. Other configurations can be found that generate a greater pressure and therefore flow, with the pneumatic sleeve applied across the bag of fluid being the commonest semi-automated set-up. Devices requiring operator/assistant enter to supply elevated circulate on demand include attaching two 60 mL syringes through a Y-connector to inject irrigation as needed, and the Peditrol irrigation system that delivers a bolus by way of a foot pedal [19]. Automated infusion techniques providing continuous saline irrigation, such as the Ureteromat, also Flexible ureteroscopes Flexible ureteroscope versus rigid ureteroscope Flexible ureterorenoscopy has developed rapidly over the previous 30 years as technologic enhancements have been made in both instrument size and design. Advances in fiberoptic expertise, improved deflecting mechanisms, and a greater range of working instruments, have all elevated the utility of the flexible ureterorenoscope in the analysis of upper tract disorders. This has led to ever-increasing indications for minimally invasive diagnostic and therapeutic interventions. Over the same timeframe, the variety of ureteric complications Chapter 34 Rigid and Flexible Ureteroscopes: Technical Features 373 Table 34.

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Physical characteristics of next-generation ureteral entry sheaths: Buckling and kinking. Ex vivo comparability of four lithotriptors commonly used in the ureter: what does it take to perforate Experimental utilization of the holmium laser in a mannequin of ureteroscopic lithotripsy: vitality analysis. Flexible endoscope deflectability: modifications using quite lots of working instruments and laser fibers. The Dretler stone cone: a tool to stop ureteral stone migration � the initial scientific expertise. Assessment of novel ureteral occlusion gadget and comparison with stone cone in prevention of stone fragment migration during lithotripsy. Assessment of a brand new tipless nitinol stone basket and comparison with an current flat-wire basket. Use of the Escape nitinol stone retrieval basket facilitates fragmentation and extraction of ureteral and renal calculi: a pilot study. J Endourol Part B 394 Section three Ureteroscopy: General Principles month failure and repair experience. In vitro comparability of a disposable versatile ureteroscope and traditional flexible ureteroscopes. Improving the efficiency ff stone fragment removal: use of iron-oxide microparticles to permit stone extraction with novel magnetic tools. Endoluminal isoproterenol inhibits the stress improve to perfusion during semirigid ureterorenoscopy. Effects and unwanted facet effects of endoluminal isoproterenol perfusion in a porcine mannequin. Comparison of flexible ureteroscopes: deflection, irrigant circulate and optical traits. Flexible ureteroscopes: a single center analysis of the sturdiness and performance of the model new endoscopes smaller than 9Fr. Durability of the next-generation flexible fiberoptic ureteroscopes: a randomized potential multi-institutional medical trial. Conventional fiberoptic versatile ureteroscope versus fourth generation digital flexible ureteroscope: a critical comparison. Indications for distal ureteroscopy the ureter is split in to proximal, mid, and distal segments. The distal ureter is defined because the phase distal to the pelvic brim and iliac vessels. Its intramural portion is fixed and slender, and must be manipulated with care to keep away from iatrogenic insults. A semi-rigid endoscope normally grants quick access in to the distal ureter and on occasions it can be used above the iliac vessels, particularly in females or skinny males with out giant psoas muscle tissue. However, the endoscopic surgeon needs to turn out to be conversant in the tactile feedback in order to avoid iatrogenic injury or scope injury. Ureteroscopy is expanding its frontiers and now may be becoming extra widely accepted as first-line remedy after failed conservative administration of urolithiasis in prepubertal children and pregnancy, urolithiasis in sufferers with urinary diversions, morbid weight problems, and renal ectopia or fusion abnormalities [2�9]. Preoperative analysis and patient positioning Preoperative evaluation requires cautious history taking pertinent to the urologic disease being handled, but also geared toward identifying pathology which will affect or compromise the graceful circulate of surgery. Prior urologic procedures, pelvic radiation, or orthopedic conditions that will preclude enough affected person positioning need to be elicited. Lenses of 12o and 70o, and a cystoscopic sheath larger than 17F to accommodate a ureteral catheter are wanted if inflexible cystoscopy is contemplated. Of all preoperative laboratory research, a unfavorable urine culture is of paramount significance. The American Urological Association recommends 24-h antimicrobial prophylaxis for all upper tract instrumentation. Alternative antibiotics embrace an aminoglycoside with or with out ampicillin, a first- or second-generation cephalosporin or amoxicillin/clavulanate. In sufferers with renal insufficiency, aminoglycosides may be substituted for aztreonam [11]. Guidewires Guidewires are key to a profitable endoscopic process because they allow fixed access in to the higher tract. Access is especially necessary throughout difficult cases because it enables the surgeon to negotiate a difficult spot either to find back the ureter and continue with the ureteroscopy or to deploy a stent and return at a later date. Wires are also used to monorail ureteral dilators, sheaths, and versatile endoscopes in to the higher tracts, and as such are made of different supplies that enhance the aim for which they were designed. In basic, guidewires have two elements: an internal core that determines the stiffness of the guidewire shaft and the flexibility of the tip, and an outer coating that determines guidewire lubricity. In distinction, the more expensive nitinol wires consist of a nitinol core with a polyurethane jacket and a hydrophilic polymer coating. The hydrophilic coating of the nitinol-type wires have to be saved moist, because it becomes tacky if it dries out [12]. Hydrophilic (nitinol) wires with straight or angled suggestions absorb water to turn into very slippery and atraumatic, and are purposely designed to acquire upper tract entry in the setting of an obstructing stone or ureteral kink or obstruction. Super-stiff wires are more kink resistant than the opposite varieties, and are subsequently finest used for proximal deployment of ureteral dilators (balloon, sheaths, or coaxial) and to "straighten"` a tortuous ureter. Hybrid or combination wires mix a versatile hydrophilic-coated floppy tip, which facilitates entry, with a kink-resistant core that allows for working devices to be delivered over them, thus avoiding the use of multiple other wires. Equipment for ureteroscopic access Ideally, ureteroscopy takes place in a lead-shielded endourology-dedicated working room, which consists of a exhausting and fast urology-specific endoscopy desk with fluoroscopic capabilities and at least two monitors that obtain fluoroscopic and endoscopic feed. Operating room personnel should put on sufficient protecting gear, including lead aprons and thyroid shields. Lead glasses are especially beneficial for endoscopic surgeons because of their proximity to the radiation source and chronic publicity. Ureteral dilators Ureteral orifice dilation is seldom necessary when using the newer and smaller semirigid ureteroscopes. Balloon dilators have a deflated shaft diameter of 5F, balloon lengths between four and 10 cm, and an inflated profile of 12�30F. They are positioned over a super-stiff or hybrid wire straddling the realm of interest and inflated up to 20 atm of pressure with diluted contrast with a specifically designed syringe. They produce radial dilation which is believed to result in much less ureteral trauma than the shearing forces of ureteral dilators. Semi-rigid ureteroscopes are most popular over their flexible counterparts every time potential, and especially within the distal ureter because of their bigger working channels, quicker irrigation, higher and bigger image high quality, and sturdiness. Moreover, flexible ureteroscopes are tough to use in the distal ureter due to their lack of "purchase" of this ureteral section. This design obviates the want to connect a camera to the eyepiece, resulting in a neater set-up and a lighter hand piece. When in comparability with normal semi-rigid ureteroscopes, the image of videoendoscopes is larger and with out the honeycomb effect because of the absence of image-carrying fiberoptic bundles.

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Occasionally, it might be of worth to loosen the impaction by instillation of a lubricant jelly via a ureteral catheter and to place a stent afterwards if the steinstrasse may be passed with a guidewire. To counteract such problems, the routine administration of diclofenac twice daily for 5�7 days is beneficial [56]. In addition, alpha-receptor antagonists or calcium channel blockers may be useful to facilitate fragment passage [3, 57]. Data from the literature up to 1993 showed stone-free rates between 44% and 90% in 3231 sufferers treated with electrohydraulic lithotripters [61]. With electromagnetically generated shock waves in sixteen 307 sufferers, the stone-free fee ranged between 52% and one hundred pc, with a imply stone-free price of 67. With the piezoelectric approach utilized in approximately 2000 patients, between 51% and 75% grew to become stone free. Such treatment choices should be considered in patients with lowered renal perform and in those in whom repeated sessions can be foreseen. Chapter fifty one Shock-Wave Treatment of Renal Calculi 585 62�69], the average stone-free fee was 68. Nevertheless, the retreatment rate for the electrohydraulic systems varied between 6% and 46%, and for the electromagnetic techniques between 7% and 32%. It is of observe, and never shocking, that the retreatment rates were highest with the piezoelectric system, ranging between 14% and 51% and averaging 27%. Determinants of therapy outcome Treatment results, want for retreatment and auxiliary procedures, as well as profile of issues are depending on the sort of lithotripter used, its physical properties and disintegration capability. Why massive stones, albeit satisfactorily disintegrated, are related to considerably extra residual fragments is less simple to understand. Such an consequence possibly may be explained by disturbed contraction forces of the calyceal system brought on by massive stones residing in the kidney for a long period of time [71]. Collecting system anatomy Anatomic abnormalities might prevent fragment elimination from the kidney in several ways and the effect has to be judged in every individual case. Many of these patients could greatest be treated with alternative strategies, as discussed elsewhere on this guide. The rules are much like these for adults with the exception that stents seldom are needed even when giant stones are treated [77]. It is especially essential to use low vitality levels and a restricted number of shock waves in kids. Stone-free fee is lowest for stones originally situated in the decrease calyx, but the variations in mean stone-free charges are comparatively small. Although as many as 79% of the residuals were found within the decrease calyces, in 34% of the sufferers the treated stone had not been situated within the lower calyx. A massive variety of reports have dealt with the geometric features of the decrease calyceal system and a quantity of other determinants have been advised to predict stone clearance [97�102]. The inclusion of each an absolute and a share change in creatinine permits for variations associated to age, gender and physique mass index. Postrenal failure is consequent to mechanical obstruction within the collecting system. Leakage of glomerular filtrate back in to the circulation throughout the broken tubular epithelium and tubular obstruction from impaction of Table sixteen. While early phases are quickly reversible by infusion of fluids, extended or extreme ischemia could result in acute tubular necrosis. Nephrotoxic agents trigger uniform epithelial injury, especially within the proximal tubules, without disruption of tubular basement membrane. Clinical Features In acute tubular necrosis, examination could also be normal aside from dehydration. The oliguric section lasts about 3-10 days, throughout which period the biochemical and clinical abnormalities progressively worsen, more quickly if an infection, trauma and bleeding are associated. A diuretic part could also be noticed, often lasting for per week, during which large quantities of water and electrolytes, particularly potassium may be misplaced. A historical past of diarrhea, vomiting, fluid or blood loss is taken and evaluation of fluid consumption within the earlier 24 hr made. In patients with nephrotoxicity or intravascular hemolysis, urine output is commonly not diminished (nonoliguric renal failure). In prerenal azotemia, the renal tubular perform is intact and reabsorption of water and sodium is increased. Impaired tubular function in intrinsic renal failure ends in elevated sodium excretion and failure to focus urine. Determination of urine sodium and osmolality and fractional excretion of sodium assist in differentiating useful oliguria (prerenal) from established (intrinsic) renal failure. Patients with severe azotemia might require dialysis prior to biopsy to scale back the risk of bleeding. Occasionally a patient with undetected persistent kidney disease could current for the first time with acute onset of oliguria. The presence of the next suggests the potential of continual kidney disease: (i) retarded physical development, (ii) severe anemia, (iii) hypertensive retinopathy, (iv) hypocalcemia, hyperphosphatemia and high para thormone, (v) radiologic options of mineral bone illness and (vi) small kidneys on imaging. Management contains remedy of life-threatening issues, maintenance of fluid and electrolyte stability and dietary support. Evaluation for compli cations consists of measurement of blood strain, seek for signs of congestive heart failure, fluid overload, acidosis and anemia. Complications corresponding to dehydration or fluid overload, hypertension, coronary heart failure, extreme anemia, hyperkalemia and acidosis require urgent remedy. Intake-output monitoring, daily weight, physical exami nation and serum sodium guide fluid administration. A speedy weight reduction and rising sodium counsel insufficient fluid substitute, whereas absence of weight reduction and low serum sodium point out fluid excess. Adequate dietary help with maximization of caloric consumption should be achieved as early as attainable. Drugs that enhance severity of renal harm, delay recovery of renal perform or cut back renal perfusion. Standard charts are used for modifying the dose and dosing interval of antibiotics, depending on the severity of renal harm. Their utility is limited to settings the place high urine circulate is required to forestall intratubular precipitation, similar to with intravascular hemolysis, hyperuricemia and myoglobinuria. Dopamine at low doses causes renal vasodilatation and will induce a modest natriuresis and diuresis. The position of other medications, together with fenoldopam, atrial natriuretic peptide, calcium channel blockers and different medications is investigational. Severe acidosis is treated by administration of sodium bicarbonate, and, if persistent, dialysis. Factors that worsen hyperkalemia are acidosis, which causes potassium to shift from the intracellular compart ment, an infection, hemolysis and tissue damage. Symptoms of hypertensive encephalopathy are associated to the rapidity of rise somewhat than the absolute worth of blood strain.

References

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