Accessory instruments in URS & PCNL

1. Accessory instruments in URS & PCNL Dr. S. B. Patil Professor & HOD Department of Urology, B.L.D.E.U.’s Shri B. M. Patil Medical College, Hospital & Research Centre, Bijapur, Karnataka.

3. Ureteral dilators • Metal dilator • Balloon dilator • Nottingham single-step dilator • Stenting

4. Ureteral metal dilator 10 F Length – 60 cms

5. Ureteric balloon dilator • Length – 70 cms ( 3F ) • Balloon length – 4 cms • Dilatation upto15 F ( 5mm ) • Pressure – max 15 atm Advantages • Balloon dilator dilates to 100% of the expected diameter regardless of any amount of radial constrictive force Disadvantage • Recurring cost • Always needs C-ARM

7. Nottingham one step dilator • One step dilatation of intramural portion of ureter • Used to inject contrast mediumto determine Sub mucosal tunneling or anesthetic jellyto aid in dislodging ureteral stones • Used over 0.038 guide wire • Overall length – 60 cms • Taper length – 4 cms

8. Nottingham one step dilator

10. PCNL dilators • Alken metal dilators • Balloon dilators • Amplatz dilators • Radially Expanding Single step Dilator system • Screw dilators

11. Alken metal dilator ( co-axial dilatation system )

12. Alken metal dilator ( co-axial dilatation system ) • Hollow guide – rod - 8F • Co-axial dilatation – each increasing in size by 4F • Tract dilatationupto26F Advantage • Rigidity of the system • Dilatation of dense scar tissue Disadvantage • Iatrogenic injury – due to difficulty in controlling pressure during dilatation • Stabilisation of guide-rod

13. PCNL balloon dilator • Creation of tracts in a rapid, single step eliminating the need for serial dilation • Expandable balloon – 10 atm = 10 mm ( 30 F ) • Working sheath – 30 F • length – 15 cms

15. Advantages- • Tract is created by lateral forces rather than angular, shearing forces ( less traumatic, less chance of large vessel injury & therefore less haemorrhage) • saves operating time • If more than one tract in the same setting is required then same balloon can be used Disadvantage – • Higher cost • Designed for single use only • Inability to dilate through dense scar tissue • Risk of Baro trauma

16. Amplatz dilators • Plastic (polyurethane dilators) • Introducer catheter acts as a guide for dilators 12F – 30F • Introducer catheter sheath allows safety wire placement • Length - 30 cms • The dilators are passed one after the other, not coaxially like the rigid metal dilators Advantages • Radio opaque dilators & sheath • Short tapered tips, smooth surface – decrease trauma Disadvantage • Haemorrhage can occur each time the dilator is withdrawn • More expensive , disposable

18. RESN ( Radially Expanding Single step Nephrostomy dilator system ) Advantages • Use of lateral force – decreased trauma • Advantageous in dilatation of heavily scarred tissue Disadvantages • Use of manual force & manual counterbalancing

19. RESN dilator system

20. Screw dilator Allows dilatation upto14F by using only 1 dilator Advantage • Can dilate dense scar tissue • Minimal patient discomfort • Blunt dissection • Minimises risk of guide wire dislocation • Radiographic / fluoroscopicvisualisation

22. Ureteral access sheaths (UAS) • Diameter of UAS – 9.5/12F 11/13F 12/14F 13/15F 14/16F • Length – 25 – 55cms

23. 2 parts – • Inner part with tip to dilate ureteral orifice (dilator) • Outer part ( hydrophillic ) made from enforced material to avoid any buckling ( sheath) Size of sheath chosen depends on particular situation of the patient • Commonly used – 9.5/12F • Double-J stent insitu/female patient – 14 / 16F • Larger stone burden – larger access sheath

24. Ureteral access sheath

26. Advantages • Allows easy re-entry of the calyceal system • Allows multiple passages for removal of stone fragments • Pressure of irrigant in the calyceal system is kept lowFebrile infections occur very rarely • Decrease cost & operative time • Decreased need for emptying of the bladder duringprotracted procedure • Maintains intrapelvic pressure < 20 cms water • Proper visualisation

27. Balloon dilatation is necessary if UAS cannot be placed through ureteric orifice • Stenting is recommended after the procedure using UAS Disadvantages • Needs pre-stenting in some patients • Ureteric injury • Uretericstricture

28. Stone Retrieval Baskets • Stainless steel • Nitinol

29. Helical Segura

30. Advantage of stainless steel baskets • Cheaper • Can be dismantled Drawbacks of stainless steel baskets • Increased tendency for ureteral perforation • Decreased flexibility - limits their use in flexible ureteroscopes

31. Nitinol baskets • Nickel Titanium Naval Ordinance Labarotary (NITINOL) Advantages • Flexible &kink resistant & permit a tipless basket design • Tipless design - less traumatic during use in the ureter & kidney compared with tipped baskets, especially when retrieving or repositioning calyceal stones . • The flexibility of nitinol baskets is superior to that of their stainless steel counterparts, allowing for consistent retrieval from lower pole calyces .

32. Zero Tip Nitinol Nitinol

33. Basket for flexible URS • Sizes – 1.2F, 1.8F, 1.9F, 2.2F • 1.2F = miniature basket – enhance irrigation flow in flexible URS

34. Smaller baskets (≤1.5 Fr) improve irrigant flow • May permit passage of a laser alongside it in the ureteroscope working channel • This is a distinct advantage when multiple exchanges between the basket & intracorporeal lithotripter are anticipated or when calculi are entrapped in the basket

35. Complications of ureteroscopicbasketing • Ureteralavulsion • Intussusception • Abrasion • Perforation • Postoperativestricture formation • Basket breakage or entrapment

36. PCNL Basket • Size – 7F , 12F • Length – 37 cms • Detachable basket • Nitinol Wire Tipless basket

37. Forceps • Forceps are important accessories required during URS & PCNL • Preferred due to their reversible grasp & re-usability Advantages • Provide stone fragments for stone analysis • Patient satisfaction • Better clearance • Shorterns time of surgery Disadvantages • Injury • avulsion

38. Various forceps used in URS • Biprong • Triprong

39. URS Alligator Forceps

40. URS Tripronge Forceps

41. URS Bipronge Forceps

42. Semi-rigid ureteroscopes

43. Biopsy forceps Flexible Biopsy Forceps(Cup Biopsy)

44. Forceps for PCNL • PCNL Alligator Forceps • PCNL Peanut Forceps • PCNL Tripronge Forceps • PCNL U-Handle Tripronge Forceps • PCNL Bipronge Forceps

45. PCNL Forceps PCNL Alligator Forceps

46. PCNL Peanut Forceps

47. PCNL Tripronge Forceps

48. PCNL U-Handle Tripronge Forceps

49. PCNL Bipronge Forceps

50. Nephroscope – 26F • Channel – 12F