Endourology Courses

 Rationale:

The trend in medicine has been toward non-operative or "minimally invasive" surgical procedures. This trend has been apparent in urology. Often minimally invasive endoscopic procedures replace surgical procedures. As part of this trend toward non-operative therapy, there has been a steady increase in the number of endoscopic procedures performed within the urinary tract both for diagnostic and therapeutic purposes.

Endoscopic procedures have many advantages it has been associated with less minor complications, shorter hospital stay, short convalescence when compared to open surgery. Also, the use of endoscopic procedure in urology could have implications in reducing the financial burden on health care systems and at the same time will improve the well-being of patients. Before embarking on endourologic procedure, each urologist should develop a safe technique firstly  for the basic skills followed  by advanced skills..

Goal:

There is a core group of knowledge common to all endourologic procedures concerning selection, and care of endoscopic sets.  Mastering basic skills is mandatory before selection of ideal candidate for endoscopic procedure  .

 Upon completion of this course, the participant will be able to know the basics of diagnostic and therapeutic procedures in the field of endourology. 

  Objectives:

This course will focus on the basic principles and skills of both diagnostic and therapeutic procedures in endourology. The participant will be able to:-

1-          Select the endoscopic instruments needed for each endourologic procedures.

2-          Apply the basic principles of sterilization and care of endourologic sets.

3-          Recognize the indications and potential complications of every endourologic procedure.

4-          Recognize special considerations in auxiliary   instruments, guide wire and type of  irrigant fluid used.

5-          Learn some procedure on simulators, Vido-tape and CD.

6-          Ultimately learn these procedures in the operating room under the supervision of skilled endourologists.

 History of evolution:

-         Endourologic instruments have been advanced to deal with urinary system for both diagnostic and therapeutic purposes.

-         The Greatest single advance in minimally invasive surgery was the development of the endoscope.

-         The first endoscope was that developed by Phillipe Bozzini of Frankfurt between 1803-1808.  It is consisted of silver tube illuminated by light from candle reflected by mirror.

-         1853, Desormeaux improved illumination by replacing candle with a lamp powered by turpentine and achohol with limited field of view.

-         In 1879 Nitze-Lieter endoscope was the first endscope to resemble a modern rigid cystoscope with distal illumination by platinum wire, lens system and an instrument channel.

-         Numerous modifications occurred after Edison bulb invention in 1891 including prism to correct image inversion and to achieve angled field.

-         In 1951 professor Harold Hopkins introduced the first glass fiber since then the fiberoptics has progressed rapidly, where the light was transmitted to the tip of instrument.

-         In 1956 Hopkins transformed the optics on rigid telescopes by introducing a rod lens system.

 Rigid enoscopes:

The main components of rigid endoscopes are:

1- Rod lens system.

2- Fiberoptic bundle.

3- Irrigant channel.

 Rod lens system:

This is the optical system of telescope, and composed of:

-         Objective lens.

-         Series of rod lenses to relay image on eyepiece.

-         Eye piece lens produces magnified virtual non inverted image.

-          Most telescopes contain reflecting prisms to deviate the optical axis to desired direction of view either 0, 30, 70 or 120.

 Cleaning and sterilization of instruments

·        Tap-water.

·        Soap

·        Brush.

·        Gluteraldehyde 2% (Cidex) for 20  minutes

·        Antimony compound (Micro 10) for  15  minutes

·        Draying by cotton piece and compressed dry air.

Basic endourologic course for Postgraduates :

1- URETHRO-CYSTOCOPY

 Instruments:

1- Cystescope sheath.

2- Bridge.

3- Telescope (0-30-70).

4-  Light source and light cable

 Indications:

1- Cystitis.

2- Haematuria.

3- Echognic bladder growth in U/S.

4- Filling defect in cystogram

5- Difficulty.

6- Follow up after TURT.

7- Preliminary step in ureteroscopy.

8- Insertion of ureteric catheter or JJ stent..

9- Removal of JJ stent.

10- Evacuation of clot retention.

 Procedure of urethrocystoscopy:

1- General anesthesia.

2- Position: lithotomy

3- Sterilization

4- Ttowling

5- Introduction of cystoscope under vision from till the bladder

6- Inspection of bladder neck, ureteric orifices, bladder lesion, remaining bladder mucosa.

 2- VISUAL INTERNAL URETHEROTOMY (VIU)

Instruments:

- Uretherotome sheath.

- Telescope 0.

- Working element of uretherotomy.

- Cold, Knife.

Indications:

- In treatment of stricture urethera which has the following criteria:       

- Short.

- Mucosal.

- Passable.

- On alignment.

- Not complicated.

 Procedure of visual internal urethrotomy

1.     General anesthesia (perferrable).

2.     Position: lithotomy

3.     Sterilization

4.     Towling

5.     Introduction of the urethrotome under vision till the strictuer area

6.     Passing a guide wire till the bladder

7.     Cut through the stricture along the guide wire

8.     Insertion of uretheral catheter

 Complications:

1- Failure.

2- Bleeding.

3- False passage (extravasations).

4- Infection.

5- Recurrence.

 3- LITHOLAPAXY

 Instruments:

- Visual lithotrite.

- Telescope 70.

- Ellik's evacuator.

 Indications:

- Stone bladder in adult without contraindications.

 Contraindications:

a. Absolute:

1- Children.

2- Contracted bladder.

3- Bilateral VUR.

 b. Relative

1- Hard stone.

2- Soft stone.

3- Large sized > 2.5 cm.

4- stricture urethra.

5- BPH (Benign prostatic hyperplasia).

6- BNO (Bladder outlet destruction).

7- Stone in diverticulum.

 Litholapaxy procedure:

1- General or regional anesthesia.

2- Lithotomy position.

3- Urethrocystoscopy and leave the bladder smifilled.

4- Introduction of lithotite with 70 telescope.

5- Under vision, open the jaws of lithotrte, catch and crush the stone to small fragment.

6- Evacuate the fragment by ellik's evacuator.

7- Cystoscopy to ensure mucosal integrity.

8- Fixation of foley's catheler for 24 hours.

 Complications:

1- Failure of introduction.

2- Bleeding.

3- False passage.

4- Failure of disintegration.

5- Bladder injury.

6- Failure of extraction.

7- UTI.

 4- Transurethral resection

Instruments:

1- Resectoscope sheath.

2- Working element of resectoscope.

3- Telescope 30 degree.

4- Loop and high frequency cable.

5- Under water electro-cautary system.

6- Ellik's evacuator.

7- Three way's Foley's catheter.

 Indications:

1- Transurethral resection of prostate.

2- Transurethral resection of bladder tumour.

3- TUR biopsy.

4- TUR meatotomy.

5- TUR ulcer bladder.

6- TUR granuloma.

7- TUR of BOO.

 Steps of  TURP

1- General or regional anaesthesia.

2- Position: lithotomy

3- Sterilization

4- Towling

5- Uethrocustoscopy

6- Insertion of resectoscope under vision and visualize the land marks: urethral orifices proximal and verumontanum and external Sphicks distal.

7- Start resection  with median lobe then the lateral lobes then the anterior

    lobe

8- Evacuation resected chips by Ellik's evacuator.

9- Ensure haemostasis and trimming of edges

10- Insertion of three way uretheral catheter

11- Traction

Complications:

1- Bleeding.

2- TUR syndrome.

3- Perforation.

4- Incomplete resection.

5- Incontinence.

6- Retrograde ejaculation.

7- Stricture urethra.

 5- URETEROSCOPY

Instruments

1- Ureteroscope (semirigid – flexible).

2- Ureteral dilators (Balloon-Teflon).

3- Dormia – disintegrators.

4- Guide-wire (Floppy)

 Procedure of ureteroscopy

1.     General or regional anaesthesia.

2.     Position: lithotomy

3.     Sterilization

4.     Towling

5.     Uethrocustoscopy

6.     Visulalization of the ureteric orifice

7.     insertion of the guide wire

8.     ureteral dilatation

9.     introduction of the uretroscope

10. dealing with the pathology ( stone – stricture)

11. stenting of the ureter

 Indications:

1- Ureteral stone.

2- Ureteral stricture.

3- Upper tract hematuira.

4- Upper tract filling defect.

 Complications:

1- Failure of visuculization of ureteric orifice.

2- Failure of passage of guidwire.

3- False passage of guidwire.

4- Perforation.

5- Failure of stone disintegration or extraction.

6- Ascending infection.

7- Stricture (ureteral and/or urethral).

 6- NEPHROSCOPY

Instruments:

1- Nephroscope.

2- Disintegrators.

3- Dilator system.

4- Forceps.

5- Guid wire (J-tip wire)

 Indications:

1- PCNL.

2- Endopylotomy.

3- Tumour ablation.

4- Stricture upper ureter.

PCNL procedure:

1- General or regional anesthesia.

2- Lithotomy position for fixation of ureteral catheter.

3- Turm the pateitn to prone position.

4- Puncture the target calyx through the center of it's formix under x-ray or ultrasound guidance.

5- Dilatation of tract under fluoroscopic control.

6- Introudction of nephroscopy.

7- Extraction or disintegration of stone.

8- Inspection for residual stone and for any musosal injury.

9- Injection of contrast to exclude extravasation.

10- Leave the nephrostomy tuble till urine clearance.

Complications:

1- Perforation and extravasations.

2- Bleeding.

3- Injury of adjacent organs.

 Practical training  

The practical training will  consist of training with  help of lectures, DVD video and simulators  which are effective simple and affordable teaching method in  endourology .

 Needs Assessment:

AUCEST will continue to assess the needs of endourologic programs both  in term  of training and overall  program needs. Safe techniques for basic skills are an essential part of all procedures . Perioperative care and good anesthetic management can  make  a significant difference in the outcome for patients undergoing  endoscopic procedure . Last but not the least there is no  substitute for thorough training and the urologist's discretion regarding the case he chooses to operate.

 Done Courses:

1.    1^st basic Course of Endourology :

            · 17-18 Jun 2006.

· 11 Trainees. (8 Form Assiut University Hospitals, 3 from MOH).

2.    2^nd basic Course of Endourology:

· 19-20 Jun 2006.

·  11 Trainees. (8 Form Assiut University Hospitals, 3 from MOH).

    3.     3^rd  basic Course of Endourology:

·  25-26  November 2006.

·  14 Trainees.

    Photo Gallary

  4.     4^th basic Course of Endourology

.   11 – 12 June 2007 

·  11 Trainees.  

Photo Gallary