Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.
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The successful execution of ureteroscopy at Liv Hospital relies heavily on a rigorous pre-operative diagnostic phase. This phase is designed not merely to confirm the diagnosis but to construct a detailed anatomical and functional map of the patient’s urinary tract. Ureteroscopy is a precision surgery; the surgeon must know the exact coordinates, density, and size of the target (stone or tumor) before entering the operating room. The diagnostic algorithm transitions from non-invasive imaging to functional assessments, ensuring that the chosen intervention is safe, effective, and indicated.
The diagnostic process typically begins with the patient’s presentation of symptoms but is solidified through advanced radiological and biochemical evaluation.
The undisputed gold standard for diagnosing urolithiasis is the Non-Contrast Computed Tomography (NCCT) of the abdomen and pelvis. Unlike ultrasound or plain X-rays, NCCT provides sub-millimeter cross-sectional detail without the interference of bowel gas or bone.
For patients presenting with hematuria without stones or suspected Upper Tract Urothelial Carcinoma (UTUC), a standard NCCT is insufficient. A CT Urography is performed. This involves a multi-phase scan: a non-contrast phase, a nephrogenic phase (kidney tissue enhancement), and an excretory phase (contrast filling the ureters). The excretory phase creates a “cast” of the internal lining of the ureter and kidney. Filling defects—areas where the contrast cannot flow—often indicate the presence of a tumor. This roadmap guides the ureteroscope directly to the lesion for biopsy.
While CT is the gold standard, Ultrasound plays a vital role as a first-line screening tool, especially in children and pregnant women, to avoid radiation. It is excellent for detecting Hydronephrosis (swelling of the kidney), which indicates the degree of obstruction. A Plain Abdominal Radiograph (KUB) is often used in conjunction to determine if a stone is radio-opaque. This is crucial for follow-up: if a stone is visible on X-ray, follow-up can be performed with X-rays rather than repeated CT scans, reducing radiation exposure.
In cases of chronic obstruction or large staghorn stones, the surgeon must determine whether the kidney remains functional. A Nuclear Renography (DTPA or MAG3 scan) is performed. A radioactive isotope is injected, and a gamma camera measures how well each kidney takes up and drains the tracer. If a kidney is found to contribute less than 10% of total renal function, ureteroscopy for stone removal may be futile, and a nephrectomy (removal of the kidney) might be the better option to prevent future infection and pain.
Before any ureteroscopic intervention, the biological environment must be assessed:
In some complex diagnostic dilemmas—such as “essential hematuria” where bleeding occurs with routine imaging—the procedure itself becomes the final diagnostic test. Diagnostic Ureteroscopy involves systematically inspecting each kidney calyx. If a lesion is found, narrow-band imaging (NBI)—a special light filter on digital scopes—can be used to highlight abnormal vascular patterns characteristic of tumors, guiding accurate biopsy.
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A non-contrast CT scan provides a 3D view with vastly superior resolution compared to a 2D X-ray. Crucially, it can visualize “radiolucent” stones (like uric acid stones) that are entirely invisible on standard X-rays. It also allows measurement of the stone’s density (hardness) in Hounsfield Units, which helps the surgeon predict how the stone will respond to laser energy, something an X-ray cannot.
Hounsfield Units measure the radiodensity of the stone on a CT scan. This directly correlates with the stone’s physical hardness. A low HU (<500) indicates a soft stone that will “dust” quickly into powder. A high HU (>1000) suggests a tough stone (like calcium oxalate monohydrate) that will require high-energy laser fragmentation and basket retrieval. Knowing this allows the surgeon to prepare the correct laser fibers and baskets beforehand.
Ureteroscopy involves irrigating the inside of the kidney with fluid to maintain visibility. This creates elevated pressure within the kidney. If the urine contains bacteria, this pressure can force live bacteria directly into the patient’s bloodstream, causing a severe, life-threatening systemic infection called urosepsis. A negative culture ensures the urine is sterile, minimizing this risk.
Ultrasound is excellent for detecting kidney swelling (hydronephrosis) but is poor at visualizing the ureter itself, especially the mid-section, which is often obscured by bowel gas. It also cannot accurately measure stone size or hardness. Therefore, while useful for screening, it is generally insufficient for the precise surgical planning required for ureteroscopy; a CT is almost always needed for the “roadmap.”
A Nuclear Renogram assesses kidney function, not just its anatomy. If a stone has blocked a kidney for a long time, the kidney tissue may have died. The scan calculates what percentage of the total body work that specific kidney is doing. If the kidney is functioning at less than 10%, repairing it via ureteroscopy might not be worth the risk, and removal of the non-functioning organ might be considered instead.
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