Bedside flexible cystoscopy: an approach to the critically ill patient

Live Renal Ultrasonography Facilitates Double-J Ureteral Stent Insertion at the Bedside: A Pilot Study for the COVID-19 Era

Objectives: To investigate the feasibility and efficacy of live renal ultrasonography to guide Double-J ureteral stent placement at the bedside. Patients and Methods: Between April 12 and June 5, 2020, patients presenting with acute ureteral obstruction requiring decompression were prospectively selected for ultrasound-guided bedside ureteral stent placement. During stent placement, upper tract access confirmed using ultrasound with or without retrograde injection of ultrasound contrast before Double-J stent insertion. A postprocedural abdominal X-ray was obtained for stent position confirmation. Results: Eight patients (four men and four women) were offered bedside ultrasound-guided ureteral stent placement, and all eight consented to proceed. Stents were placed in seven of eight patients. One patient had an impacted ureterovesical junction stone and stricture requiring ureteroscopy and laser lithotripsy in the operating room. All patients tolerated procedures without immediate complications. Conclusion: Live renal ultrasonography can facilitate a high success rate for bedside ureteral stent placement outside the operating room. This approach is an attractive alternative to fluoroscopy-guided stent placement in the operating room and is of particular value in the COVID-19 era when judicious use of these resources is salient.

Expert and Crowdsourced Evaluation of Image Quality From a Novel Endoscopy Phone Light Adapter

OBJECTIVE

To evaluate the image quality of cystourethroscopy using a novel 3D printed phone light adapter with subject expert and crowdsourced evaluators.

METHODS

A simple 3D printed light adaptor for a flexible cystoscopy was developed and made open source. Two videos were then recorded of a simulated cystourethroscopy, one using the novel adapter and the other using a traditional endoscopy light source. Expert evaluators (urology trainees and attendings) were then asked to evaluate the video quality using a double stimulus impairment scale. They were also asked to rate their level of confidence in using the novel adapter in clinical scenarios. Using Amazon's Mechanical Turk marketplace, 100 crowdsourced evaluators viewed the same videos and completed the same rating scale. The Mann-Whitney U test was then used to compare the expert and crowdsourced ratings.

RESULTS

Expert and crowdsourced evaluators saw minimal degradation of video quality for the simulated urethroscopy (P= .66). However, while expert evaluators did identify degradation in the cystoscopy video, the crowdsourced evaluators did not (P = .012). 96% of the expert evaluators would either "often" or "always" use the novel adapter for difficult Foley placements and removal of ureteric stents.

CONCLUSION

The novel light adapter caused minimal degradation in image quality for urethroscopy as compared to a traditional endoscopy light source, with vast majority of raters believing it would be adequate to perform common bedside cystoscopy procedures.

Safety and Efficacy of Ureteral Stent Placement at the Bedside Using Local Anesthesia

PURPOSE

Ureteral stent placement for decompressing renal units obstructed by calculi is safe and can be potentially lifesaving in the prompt resolution of the sequelae of renal obstruction, infection and an obstructing stone. At many institutions there can be prolonged delay in getting patients to the operating room for stent placement. We hypothesized that it is safe and efficacious to attempt ureteral stent placement using local anesthesia at the bedside without live fluoroscopic guidance.

MATERIALS AND METHODS

Patients presenting with symptomatic, obstructing ureteral calculi were given the option of bedside ureteral stent placement. Viscous lidocaine was placed into the urethra before flexible cystoscopic examination. A 260 cm Glidewire® was used as initial access with only 1 attempt at passage. All stent placements were confirmed with immediate post-procedure radiograph. Prospectively collected data were retrospectively analyzed for all patients who underwent attempted bedside ureteral stent placement.

RESULTS

A total of 42 patients underwent attempted bedside stent placement under local anesthesia without fluoroscopic guidance. Mean stone size was 8.3 mm and 71% of stones were in the proximal ureter. Ureteral stent placement was pursued in 14% of patients for infection and in 59% for intractable pain. Ureteral stent placement was successful in 30 patients (71%). Statistical analysis did not reveal any significant predictors of successful stent placement in this cohort of patients.

CONCLUSIONS

In our cohort bedside ureteral stent placement was well tolerated, safe and efficacious, thus expediting upper tract decompression in the setting of obstructed renal units in more than 70% of patients.

Bedside ureteral stenting for the critically ill patient: technical considerations

Bedside ureteral stenting, although a challenging technique, can be achieved with frequent success by using some simple endoscopic maneuvers. By understanding the relationship of the working port to the lens and light source, surgeons can supinate or pronate their wrist to cannulate the ureteral orifices with greater success.

Imaging of the lower urinary tract in adults

Imaging of the lower urinary tract is an integral part of everyday urologic practice. Clinical application of less commonly used techniques is discussed to expand their usefulness in an ambulatory setting.

Inability to pass a urethral catheter: the bedside role of the flexible cystoscope

An all too common cause of urologic consultation is the inability to place a urethral catheter. Often other health care providers have unsuccessfully attempted catheter placement. Urethral false passages, perforations, and edema are common sequelae. Diseases such as urethral strictures, bladder neck contractures, and prostate cancer are often the underlying etiologies for failed catheterization. Traditionally, the use of filiforms and followers or the placement of a suprapubic tube is required to drain the lower urinary tract. Bedside flexible endoscopy was performed in this series not only to define the area and etiology of urethral obstruction, but also to facilitate catheter placement. Fifty-four patients were studied prospectively. Initial endoscopic assessment was based on bedside flexible cystoscopy. Most procedures were performed under topical lidocaine anesthetic. Under direct vision a 0.038 inch standard guide wire was directed through the area or areas of obstruction. Strictures, fibrosis, and false passages were dilated using a series of graduated Nottingham dilators over the guide wire. A Council-tipped urethral catheter was then placed over the guide wire to assure bladder drainage. In 52 of the 54 patients urethral obstructions were dilated and drainage catheters were placed into the bladder. No complications were encountered. This technique is simple, it avoids suprapubic puncture, and it minimizes unneeded trips to the operating room.

Actively deflectable, flexible cystoscopes: no longer solely a diagnostic instrument

The recent evolution of actively deflectable, flexible endoscopes has included the flexible cystoscope. Improvements in optics, deflectability, and the size of the outer sheath and working channel have been accomplished. A superior flexible cystoscope is one with an outer sheath of 16F or less and working channel large enough to admit standard endoscopic instruments (> or = 6F). The 180 degrees two-way thumb-directed deflection and a removable light bundle are significant improvement. We present 55 patients with either urethral, bladder, or upper urinary tract lesions who were treated at the bedside using the flexible cystoscope in many settings. Local anesthesia alone was usually used. Flexible cystoscopy was also used for emergency intraoperative consultation requiring endoscopy. A treatment cart was constructed consisting of a light source, endoscopic instruments, irrigating supplies, and the endoscope. Urethral strictures, perforation, and bladder neck contractures were treated. Ureteral catheters were placed under direct vision. Removal of ureteral stents and foreign bodies, treatment of small bladder tumors with the Nd:YAG laser, and fragmentation of bladder calculi with the pulsed-dye laser were also therapeutic applications. Explanations of each treatment type and the instruments used concurrently with this endoscope are provided.

Flexible cystoscopy as an adjunct to extracorporeal shockwave lithotripsy

Ancillary procedures associated with extracorporeal shockwave lithotripsy (ESWL) include placement and subsequent removal of double pigtail ureteric stents. A simple new technique has been developed for the insertion of these stents. Using the flexible cystoscope, the procedure is performed on an out-patient basis under local anaesthesia. Placement of the stents was successful in 30/34 patients and removal was successful in 14/14 patients.

Flexible cystoscopy and retrograde catheterization in renal transplant patients

Catheterizing the ureteral orifice of a renal transplant patient can be difficult using traditional rigid instruments. This report describes our experience with 4 patients who underwent cystoscopy and attempted retrograde catheterization of a transplanted ureter. In all cases attempted catheterization using rigid instruments was unsuccessful, while in 3 of the 4 patients, successful cannulation was accomplished using the flexible cystoscope. These results are attributed to the expanded range of motion achieved with the tip of the flexible cystoscope. The increased mobility afforded by this instrument facilitates access to the ureteral orifice, which is often positioned on the distensible portion of the bladder.

Prone flexible cystoscopy: an adjunct to percutaneous stone removal

Percutaneous removal of renal calculi is completed most often in the United States after initial placement of a retrograde ureteral catheter. Catheterization usually is accomplished with a rigid cystoscope with the patient in a dorsal lithotomy position, following which the patient must be turned to a prone position for percutaneous puncture and stone removal. We report our experience with the use of a flexible cystoscope with the patient in a prone position for placement of a retrograde catheter. In male patients this approach was difficult secondary to urethral length and angulation. Currently, in male patients we prefer a supine approach with the flexible cystoscope. In female patients the prone approach was performed easily. Among female patients prone cystoscopy for retrograde ureteral catheterization resulted in decreased operating room time, less manipulation of the anesthetized patient and creation of a 2-tiered field to maintain the sterility of the retrograde ureteral catheter. We found the prone approach to be feasible and effective in female patients.