Ureteroscopic Stone Removal

This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence-based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Alternative treatments are outlined below and can be discussed in more detail with your Urologist.

What does the procedure involve?

It involves telescopic removal of stones in the ureter or kidney with possible placement of a soft plastic tube or stent between the kidney and the bladder. This procedure also includes cystoscopy and x-ray screening

What are the alternatives to this procedure?

Open surgery, shock wave therapy or observation to allow spontaneous passage

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. You will normally receive an appointment for pre-assessment to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team. An X-ray or limited CT scan may be performed before your surgery to confirm the position of your stone(s).

You will be asked not to eat or drink for 6 hours before surgery. Please be sure to inform your surgeon in advance of your surgery if you have any of the following:

• An artificial heart valve a coronary artery stent a heart pacemaker or defibrillator an artificial joint
• An artificial blood vessel graft
• A neurosurgical shunt
• Any other implanted foreign body
• A regular prescription for Warfarin, Aspirin or Clopidogrel (Plavix®)
• A previous or current MRSA infection
• A high risk of variant-CJD (if you have received a corneal transplant, aneurosurgical dural transplant or previous injections of human-derived growth hormone)

At some stage during the admission process, you will be asked to sign the second part of the consent form giving permission for your operation to take place, showing you understand what is to be done and confirming that you wish to proceed. Make sure that you are given the opportunity to discuss any concerns and to ask any questions you may still have before signing the form.

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure.

You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

A telescope is inserted into the bladder through the water pipe (urethra). Under X- ray screening, a flexible guidewire is inserted into the affected ureter up to the kidney. A longer telescope (either rigid or flexible) is then inserted into the ureter and passed up to the kidney. The stone is disintegrated using a mechanical probe or laser and the fragments extracted with special retrieval devices. A ureteric stent is normally left in place, together with a bladder catheter, after the procedure.

What happens immediately after the procedure?

In general terms, you should expect to be told how the procedure went and you should:

• Ask if what was planned to be done was achieved
• Let the medical staff know if you are in any discomfort
• Ask what you can and cannot do
• Feel free to ask any questions or discuss any concerns with the ward staff and members of the surgical team
• Ensure that you are clear about what has been done and what is the next move

If a bladder catheter has been inserted, this is usually removed on the day after surgery. You will be able to go home once you are passing urine normally.

The average hospital stay is 1 day.

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

Common (greater than 1 in 10)

• Mild burning or bleeding on passing urine for short period after operation
• Temporary insertion of a bladder catheter
• Insertion of a stent with a further procedure to remove it
• The stent may cause pain, frequency and bleeding in the urine

Occasional (between 1 in 10 and 1 in 50)

• Inability to retrieve the stone or movement of the stone back into kidney where it is not retrievable
• Kidney damage or infection needing further treatment
• Failure to pass the telescope if the ureter is narrow
• Recurrence of stones

Rare (less than 1 in 50)

• Damage to the ureter with need for open operation or tube placed into kidney directly from back to allow any leak to heal
• Very rarely, scarring or stricture of the ureter requiring further procedures

Hospital-acquired infection

• Colonisation with MRSA (0.9% – 1 in 110)
• Clostridium difficile bowel infection (0.01% – 1 in 10,000)
• MRSA bloodstream infection (0.02% – 1 in 5000)

The rates for hospital-acquired infection may be greater in high-risk patients e.g. with long-term drainage tubes, after removal of the bladder for cancer, after previous infections, after prolonged hospitalisation or after multiple admissions.

What should I expect when I get home?

By the time of your discharge from hospital, you should:

• Be given advice about your recovery at home
• Ask when to resume normal activities such as work, exercise, driving, housework and sexual intimacy
• Ask for a contact number if you have any concerns once you return home
• Ask when your follow-up will be and who will do this (the hospital or your GP)
• Ensure that you know when you will be told the results of any tests done on tissues or organs which have been removed

When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

When you get home, you should drink twice as much fluid as you would normally to flush your system through and minimise any bleeding.

You may experience pain in the kidney over the first 24-72 hours, due to the swelling caused by insertion of the instrument or by the presence of a stent. Anti- inflammatory painkillers will help this pain which normally settles after 72 hours.

It will take at least 10 days to recover fully from the operation. You should not expect to return to work within 7 days.

What else should I look out for?

If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact the hospital or your Consultant immediately. Small blood clots or stone fragments may also pass down the ureter from the kidney, resulting in renal colic; if pain is severe, you should contact the hospital or your Consultant immediately.

Are there any other important points?

If a stent has been inserted, you will be informed before your discharge when the stent needs to be removed. Ureteric stents are usually removed under local anaesthetic.

You can prevent further stone recurrence by implementing changes to your diet and fluid intake.

Driving after surgery

It is your responsibility to ensure that you are fit to drive following your surgery. You do not normally need to notify the DVLA unless you have a medical condition that will last for longer than 3 months after your surgery and may affect your ability to drive. You should, however, check with your insurance company before returning to driving. Your doctors will be happy to provide you with advice on request.

What should I do with this information?

Thank you for taking the trouble to read this publication. If you wish to sign it and retain a copy for your own records, please do so below.

If you would like a copy of this publication to be filed in your hospital records for future reference, please let your Urologist or Specialist Nurse know. However, if you do agree to proceed with the scheduled procedure, you will be asked to sign a separate consent form that will be filed in your hospital. You will, if you wish, be provided with a copy of the consent form.

Disclaimer

While every effort has been made to ensure the accuracy of the information contained in this publication, no guarantee can be given that all errors and omissions have been excluded. No responsibility for loss occasioned by any person acting or refraining from action as a result of the material in this publication can be accepted.