EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of...
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Transcript of EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES Pandey S, Shroff S. Department of...
EVOLVING ENDOSCOPIC ALGORITHMS FOR MULTIPLE UROLOGICAL PATHOLOGIES
Pandey S, Shroff S. Department of Urology & Renal Transplantation,
Sri Ramachandra Medical College and Research Institute, Chennai, India
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INTRODUCTION
No known incidence of such presentations Not much literature available on how to tackle these multiple pathologies No set rules laid out for approaching these multiple pathologies endoscopically in one sitting
Multiple Urological pathologies at presentation are not unusual on the same patient especially in the developing countries
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Problems in Developing Countries
Presentation is relatively late
Economic considerations of the patient population plays a pivotal role in this delayed presentation
“cure all one sitting” Pressure on clinicians more in following situation:
Women Children Old PeopleSole earning member Poor or lower middle class people Patient coming from a distance for treatment
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ANALYSIS OF MULTIPLE ENDO- PROCEDURES
Study Group - SRMC – Urology Unit 1
Period - 1996 to 2002 Exclusions
- Local Anaesthesia cases- Diagnostic procedures
- open with endoscopic - E.g Hernias with TURP
Incidence of multiple procedures at presentation Various combinations of these Pathologies at presentation Endourological algorithms devised where applicable to tackle these problems effectively
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INCIDENCE
Total number of endourological procedures since 1996 – 2002 2176
Multiple pathologies at presentations 239 Incidence of presentations 11.1
%
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MOST COMMON MULTIPLE PATHOLOGIES239 (11.1 %)
Bilateral Ureteral calculus - 81 Vesical calculus + BPH - 54 Vesical calculus + Ureteral calculus - 41 BPH + Ureteral calculus - 39 BPH + Bladder tumour - 06 Stricture Urethra with bladder and ureteral
calculus - 05
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Endoscopic Clearance of easier / less demanding pathologies first
Lower tract to be cleared first before proceeding to upper tract
Completely clear one entity first - exceptions to rule - may need TUIP for a large median lobe to proceed for URS, followed by TURP
EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES
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Lower tract stone disease before upper tract Stone disease
Chronological order of Intervention helps in maintaining vision till the end of such multiple procedures
Litholapaxy-> Lithotripsy> Incisions> Resections
EVOLVING ENDOSCOPIC PROCEDURE ‘GUIDELINES’ FOR TACKLING MULTIPLE URO - PATHOLOGIES
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ALGORITHMS
Simple “common sense” Algorithms
Complex Endourologic
Algorithms
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COMMOM SENSE ALGORITHMS
BNI TURP TUIP
INTERNAL URETHROTOMY
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BILATERAL URS- HIGHLIGHTS - WHICH SIDE FIRST!!
Lower Ureteric Calculus first Lesser Impacted calculus first Bilateral safety guide wires first Side needing stents only first.
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CYSTOLITHOLAPAXY/TRIPSY+TURP/TUIP
Cystolithotripsy -36
Using 27fr nephroscope, 2 mm Swiss Litho probe
Cystolitholapaxy -18 Using 25Fr Sheath
&Mechanical Lithotrite
Extra operative times-10-45 min
Morbidity-nil Few patients had
increased Irritative LUTS
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CYSTHOLAPAXY/TRIPSY+TURP CALCULUS FIRST !
Advantages Bladder free of fragments of the calculus Good vision still being maintained-Preventing
inadvertent bladder injury Any untoward incident forcing abandonment of
surgery-May end up with a resected lobe and calculus free status!!
Preventing Absorption/Extravasation of irrigant when calculus is dealt before
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VESICAL CALCULUS+ URETERAL CALCULUS
Combination-41 Majority of vesical
calculus were 2-2.5 cm Majority of ureteral
calculus were in the lower ureter -26
WHICH FIRST!! OPTIONS------ 1.Placing guide wire-
cystolithotrripsy-URS 2.Cystolithotripsy-URS+
DJ Stenting
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VESICAL+URETERAL CALCULUS Advantageous to complete the ureteral calculus
first Exceptions- large bladder calculus fragments of ureteral calculus and vesical calculus
can be evacuated at the same time from the bladder
less chances of ureteric orifice injury preventing upper tract intervention -
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TURP +TURBT
Total number of cases-6
Maurmayer et al- 7%
Blandy et al -5.2%
TURP FIRST !
Advantages-1.Resection of Bladder tumour in inaccesible locations facilitated in empty prostatic fossa
2.Easy instrumentation.
TURBT FIRST!
Advantages-1.Resection occurs in clearer access
2.Preventing massive absorption of irrigant as can happen from prostatic fossa.
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BPH + URETERAL CALCULUS
NUMBER OF CASES- 31 Ureteral calculus first!! ( Exceptions-Large median lobe
preventing upper tract access TUIP and proceed) Advantages-1. prevents ureteric orifice injury 2.
TURP first !! ( with guide wire in situ to keep the vision of Ureteric orifice )
Advantages – Allows ease of instrumentation of the upper tract
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BPH WITH VESICAL & URETERAL CALCULUS
19 cases Large median lobe-4, B/L ureteral calculi-1
Calculi first ! !
May need TUIP for larger prostates
lesser extravasation/absorption
Ureteral first ! ! Advantage- Prevents oedema/injury to ureteral orifice
- Easier access with best vision
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PREREQUISITES FOR “CURE ALL” ENDOSCOPIC APPROACH Use of Endovision camera Services of Experienced Operator Perceive limitations of Combination procedures Preference for general anaesthesia over regional Patients to be well counselled and appreciate
combinations Warm Irrigant fluids to avoid hypothermia
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Aim towards minimal morbidity- keeping the patients stable haemorrhage and extravasation
Candidates must be relatively ‘fit’ for extended procedures
Presence of experienced assistant desirable
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TURP + HERNIORRAPHY / HERNIOPLASTY (guidelines ) TURP F IRST ! Avoid liberal TUIP / BNI Avoid mesh Repair in presence of Infected Urine Postpone herniorraphy in case of gross
Extravasation Avoid Bilateral herniorraphy with TURP / TUIP
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AVOID …… TURP & PCNL -- both accompanied with
considerable haemorrhage - !! B/L Upper tract procedure if-
1.First side is difficult / prolonged procedure
2.Pus seen on clearing calculus on one side
REMEMBER ………
THERE IS ALWAYS
A SECOND CHANCE !!!