Ureteroscopic stone removal

What is the evidence base for this information?

This leaflet 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 practice in the UK. It is intended to supplement any advice you may already have been given by your urologist or nurse specialist as well as the surgical team at Addenbrookes. Alternative treatments are outlined below and can be discussed in more detail with your urologist or specialist nurse.

What does the procedure involve?

Telescopic removal/ fragmentation of stone(s) in the ureter (pipe connecting kidney to the bladder) 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?

Shock wave therapy, percutaneous surgery 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 may undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made, 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 which may include the consultant, junior urology doctors and your named nurse.

An X-ray may be taken in advance of surgery to confirm the position of your stone(s).

You will be asked not to eat or drink for six hours before surgery. However you can drink clear water until 2 hours before your operation/admission time. Immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.

Please be sure to inform your Urologist 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 prescription for warfarin, aspirin, rivaroxaban, dabigatran, apixaban, edoxaban or clopidogrel, ticagrelor or blood thinning medication
• a previous or current MRSA infection
• high risk of variant CJD (if you have received a corneal transplant, a neurosurgical dural transplant or previous injections of human derived growth hormone)

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 may be left in place, and rarely a bladder catheter will be left in. If a stent is left in, you may notice a little string coming out of your water pipe (urethra). Do not pull this. This allows your stent to be easily removed in clinic a few days after your discharge. If there is no string and a stent has been inserted, this will be removed at a later date usually about 2-3 weeks under local anaesthetic using a small telescope.

What happens immediately after the procedure?

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.

Most patients go home on the same day as their operation.

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.

Please use the check boxes to tick off individual items when you are happy that they have been discussed to your satisfaction:

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

What should I expect when I get home?

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, 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 to 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 seven 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 your GP immediately.

Small blood clots or stone fragments may also pass down the ureter from the kidney, resulting in renal colic; in this event, you should contact your GP 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 in clinic or endoscopy unit under local anaesthetic if no string has been left on, or in the outpatient clinic if there is a string coming out of your water pipe. If there is string we may also discuss removal by yourself at home if you felt able and happy to do this.

You can prevent further stone recurrence by implementing changes to your diet and fluid intake. If you have not already received a written leaflet about this, contact your named nurse, the specialist nurse in outpatients or your consultant.

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 three 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.

Privacy and dignity

Same sex bays and bathrooms are offered in all wards except critical care and theatre recovery areas where the use of high tech equipment and/or specialist one to one care is required.

Hair removal before an operation

For most operations, you do not need to have the hair around the site of the operation removed. However, sometimes the healthcare team need to see or reach your skin and if this is necessary they will use an electric hair clipper with a single-use disposable head, on the day of the surgery. Please do not shave the hair yourself or use a razor to remove hair, as this can increase the risk of infection. Your healthcare team will be happy to discuss this with you.

References

NICE clinical guideline No 74: Surgical site infection (October 2008); Department of Health: High Impact Intervention No 4: Care bundle to preventing surgical site infection (August 2007).

Is there any research being carried out in this field at Addenbrooke’s Hospital?

There is no specific research in this area at the moment but all operative procedures performed in the department are subject to rigorous audit at a monthly audit and clinical governance meeting.

Who can I contact for more help or information?

Oncology nurses

Uro-oncology nurse specialist
01223 586748

Bladder cancer nurse practitioner (haematuria, chemotherapy and BCG)
01223 274608

Prostate cancer nurse practitioner
01223 274608 or 01223 216897

Surgical care practitioner
01223 348590 or 01223 256157

Non-oncology nurses

Urology nurse practitioner (incontinence, urodynamics, catheter patients)
01223 274608

Urology nurse practitioner (stoma care)
01223 349800

Urology nurse practitioner (stone disease)
07860 781828

Patient advice and liaison service (PALS)

Telephone: 01223 216756
PatientLine: *801 (from patient bedside telephones only)
Email PALS

Mail: PALS, Box No 53
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

Chaplaincy and multi faith community

Telephone: 01223 217769
Email the chaplaincy

Mail: The Chaplaincy, Box No 105
Addenbrooke's Hospital
Hills Road, Cambridge, CB2 2QQ

MINICOM System ("type" system for the hard of hearing)

Telephone: 01223 217589

Access office (travel, parking and security information)

Telephone: 01223 596060

What should I do with this leaflet?

Thank you for taking the trouble to read this patient information leaflet. 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 leaflet to be filed in your hospital records for future reference, please let your urologist or specialist nurse know. If you do, however, decide to proceed with the scheduled procedure, you will be asked to sign a separate consent form which will be filed in your hospital notes and you will, in addition, be provided with a copy of the form if you wish. I have read this patient information leaflet and I accept the information it provides.

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