Ureteroscopy and Holmium Laser Lithotripsy

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Dr. Nimeh is proud to offer the latest, most minimally invasive options for management of stones within the kidney and ureter (the tube connecting the kidney and bladder) with ureteroscopy.

Using the latest generation, high-definition, fiberoptic, and digital technology, we are able to locate and use small lasers and baskets to remove kidney and ureteral stones.

Once upon a time, this required major surgery or incisions. The latest technology allows us to usually perform these cases in one hour or less on an outpatient basis.

URETEROsCOPY

Dr. Nimeh passes a very small telescope, called an ureteroscope, into the bladder, up the ureter and into the kidney. Rigid telescopes are used for stones in the lower part of the ureter near the bladder. Flexible telescopes are used to treat stones in the upper ureter and kidney.

The ureteroscope lets the urologist see the stone without making an incision (cuts). General anesthesia keeps you comfortable during the URS procedure. Once the urologist sees the stone with the ureteroscope, a small, basket-like device grabs smaller stones and removes them. If a stone is too large to remove in one piece, it can be broken into smaller pieces with a laser or other stone-breaking tools.

Once the stone has been removed whole or in pieces, the health care provider may place a temporary stent in the ureter. A stent is a tiny, rigid plastic tube that helps hold the ureter open so that urine can drain from the kidney into the bladder. Unlike a catheter or PCNL drain tube, this tube is completely within the body and does not require an external bag to collect urine.

You may go home the same day as the URS and can begin normal activities in two to three days. If your urologist places a stent, he or she will remove it four to 10 days later. Sometimes a string is left on the end of the stent so you can remove it on your own. It is very important that the stent is removed when your health care provider tells you. Leaving the stent in for long periods can cause an infection and loss of kidney function.

Pre-Procedure

Some of our patients come via the emergency room in severe pain. Usually, these stones are lodged in the tube connecting the kidney and bladder. The resulting blockage causes dilation, or backup of urine in the kidney, causing pain. The ureter, which is a muscular tube, contracts, as it is trying to move the stone towards the bladder. This results in waves of pain followed by relatively pain-free episodes.

For other patients, who are a bit luckier, we are able to locate the stone before it begins its journey down the ureter. Most patients can pass a stone less than 4mm on their own. Any bigger than that, however, and the stone is likely to get lodged, causing trouble.

When appropriate, we will give pain medicine, including Toradol, which also relaxes the ureter and decreases pain. We also use medications called alpha-blockers such as Uroxatral, Flomax, and Rapaflo, which can potentially dilate the ureter, allowing urine to pass by the stone, reducing pain. In some lucky cases, the ureter dilates enough to pass the stone spontaneously. This means no surgery!

For those with larger stones, complex anatomy, or other factors such as urinary infection or more severe pain, ureteroscopy will be necessary to remove the stone.

 

Procedure

The good part is that no incisions are involved! Ureteroscopy is performed under general anesthesia in the hospital or outpatient surgery center. Dr Nimeh uses a thin, fiber-optic or digital scope that is gently introduced via the urethra into the bladder. They then guide the scope with a high-definition camera up to the stone.

When possible, the stone is broken down with a laser. Stone fragments can be basketed. The remaining stone is blasted to sandlike particles washed out in surgery. Remaining sandy pieces will pass in the next few days with urination.

For people with more obstruction, or complex situations like larger stones, urinary infection, and other situations, temporary placement of a stent is necessary. The ureter is about the size of a soda straw. In complex ureteroscopy, the straw can temporarily swell shut after surgery, much like a swollen eye. This can result in pain, urinary infection, and failure to pass the stone fragments from surgery.

In these situations, a temporary plastic tube is placed internally that goes from the kidney to the bladder. This stent is about as wide as coffee stirrer straw, and helps to keep the ureter from closing shut after surgery. The stent relieves obstruction and allows kidney stone fragments to pass. Most patients tolerate the stent just fine, although some may have discomfort between the kidney and bladder, or an urge to urinate frequently, because of the stent. Luckily, the stent is temporary, usually just a few days, and is removed in a 30-second procedure with numbing jelly.

 

Post-procedure

After the procedure, patients may have a variety of minor issues. Although many patients do fine, some patients may experience temporary problems such as burning with urination, frequent urination, small clots, pink/red urine, or occasional discomfort that radiates from the kidney to the bladder. Again, these usually tend to be minor issues, and resolve within one to two days after the procedure.

Advice After Ureteroscopy

Definitely rest up for a day or two after ureteroscopy. Drink at least six to eight glasses of water to wash out your system. Adding lemon to your water will help dissolve the stones!

For pain, Advil, Motrin or prescription Toradol work great as inflammatories, and are also non-narcotic, so you won’t get sleepy or constipated, or have other issues. Take them on a regular basis the first two to three days after the procedure. For pain not relieved by these medications, use the prescription Tylenol with codeine or Vicodin that was prescribed for you.

Follow-up

Usually, Dr Nimeh or his staff will recommend a good followup time frame. Call the office the day after the procedure to verify a time to see us in the office. Usually, if there are stone fragments, we will have a stone analysis performed. We will also want to check an X-ray of the abdomen to make sure all stones were removed.

Finally, Dr Nimeh prides themselves on keeping their patients out of the OR and to reduce the chance of further kidney stones. This includes review of a diet to reduce kidney stones, 24-hour in-depth urine studies, and blood panels to find out the cause and source of stones. For most people, dietary and lifestyle changes will drastically reduce the chance of stones, while others may need the addition of medicines to help reduce stone formation.


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