Ureteroscopy

Surgical approach

Endoscopic access via urethra → bladder → ureteric orifice using semi-rigid or flexible ureteroscope
- Often performed for ureteric stones; flexible ureteroscopy (RIRS) for renal stones
Ureteric dilatation and/or ureteric access sheath may be used
- Reduces intrarenal pressure and improves irrigation outflow but can cause ureteric trauma
Irrigation used continuously to maintain vision; laser lithotripsy (Holmium:YAG or Thulium fibre) fragments stone
- Stone extraction with baskets; fragments may be left to pass
Ureteric stent (JJ stent) may be inserted at end (planned or if oedema/trauma/obstruction)
- May be left on a string for outpatient removal
Position: lithotomy; fluoroscopy may be used
- Risk of nerve injury/compartment syndrome if prolonged lithotomy

Anaesthetic management

Type of anaesthesia: usually GA; spinal anaesthesia is possible for distal ureteroscopy but less common for flexible/RIRS
- GA preferred for immobility, airway control, and tolerance of irrigation/longer duration
Airway: SGA often suitable for short uncomplicated cases; ETT if longer case, obese/OSA, aspiration risk, significant comorbidity, or need for controlled ventilation
- ETT favoured if steep Trendelenburg anticipated (more common in other pelvic endoscopy) or if high airway pressures expected
Duration: typically 30–90 min; can be 2–3 h for large stone burden, bilateral procedures, complex anatomy, or flexible ureteroscopy/RIRS
- Plan for overrun: analgesia, temperature, fluids, and positioning checks
How painful: moderate; pain often from ureteric spasm, stent discomfort, bladder irritation; renal colic may persist post-op
- Multimodal analgesia; consider NSAID unless contraindicated (renal impairment, bleeding risk, asthma history, etc.)
Key intra-op aims: immobility, stable haemodynamics, antiemesis, temperature maintenance, and safe lithotomy positioning
- Antibiotics usually given (often already started) due to risk of urosepsis

Indications and patient factors

Indications: ureteric calculi (especially distal/mid), renal calculi via flexible ureteroscopy (RIRS), diagnostic ureteroscopy for suspected urothelial pathology, management of strictures
Common comorbidities: CKD, recurrent UTIs, diabetes, obesity/OSA, anticoagulation, pregnancy (selected cases), solitary kidney
Pre-op symptoms: renal colic, vomiting/dehydration, haematuria, dysuria; may have stent in situ already

Pre-operative assessment and optimisation

Sepsis screening is critical: fever, rigors, tachycardia, hypotension, confusion; review obs, lactate, CRP/WCC, cultures
- Infected obstructed system is an emergency: priority is drainage (stent/nephrostomy), not definitive stone treatment
Renal function and electrolytes: U&E/eGFR; consider hyperkalaemia in obstruction/CKD; correct dehydration
Anticoagulation/antiplatelets: follow local urology guidance; ureteroscopy generally lower bleeding risk than PCNL but mucosal bleeding can occur
- Clarify if laser lithotripsy planned and whether stent insertion only (lower risk) vs extensive manipulation
Infection prophylaxis: ensure urine culture/urinalysis reviewed; treat bacteriuria; peri-op antibiotics as per policy
Aspiration risk: pain/opioids, vomiting, emergency cases; consider RSI if indicated

Intra-operative anaesthetic technique (GA)

Induction: standard IV induction; consider RSI if non-fasted/active vomiting/obstruction-related ileus
Maintenance: volatile or TIVA; ensure immobility (small doses of NMBD may help if laser work and movement problematic)
- Avoid excessive coughing/bucking at critical moments (risk of ureteric injury)
Ventilation: usually controlled ventilation; mild hyperventilation not required; maintain normocapnia
Monitoring: standard; consider arterial line only if septic/unstable or significant comorbidity
Fluids: aim euvolaemia; treat pre-op dehydration; avoid overload (especially CKD/elderly); urine output not a reliable intra-op endpoint due to irrigation
Temperature: active warming; irrigation can contribute to heat loss (less than TURP but still relevant in long cases)

Regional/neuraxial options

Spinal anaesthesia can be used for distal ureteroscopy (T10–S4 coverage) but may be less suitable for prolonged flexible ureteroscopy/RIRS
- Advantages: reduced PONV, avoids airway instrumentation; Disadvantages: patient movement, discomfort from lithotomy, limited duration, hypotension
Local infiltration not applicable; peripheral nerve blocks generally not helpful

Analgesia and antiemesis

Multimodal: paracetamol + NSAID (if appropriate) + small opioid doses; consider intra-op ketamine (low dose) if opioid-tolerant
Ureteric spasm/colic: NSAIDs reduce ureteric smooth muscle tone and prostaglandin-mediated pain; consider antispasmodics per local practice
PONV: high risk due to opioids, pain, and urological surgery; use dual/triple prophylaxis (e.g., dexamethasone + ondansetron ± droperidol)

Specific complications and anaesthetic implications

Urosepsis/septic shock: can occur intra- or post-op due to instrumentation and raised intrarenal pressure with infected urine
- Features: sudden hypotension, tachycardia, pyrexia, rising airway pressures (less common), metabolic acidosis; treat as sepsis (O2, cultures, broad-spectrum antibiotics, fluids, vasopressors, source control)
Bleeding/haematuria: usually minor; significant bleeding rare but consider anticoagulation status and mucosal trauma
Ureteric injury/perforation/avulsion: rare but serious; may present with pain, bleeding, prolonged procedure; may require stent or open conversion
Extravasation and fluid absorption: irrigation fluid is typically isotonic saline; systemic absorption usually limited but can contribute to volume overload in long/high-pressure cases
- TURP syndrome is not expected with saline irrigation, but fluid overload/hypothermia can still occur
Lithotomy complications: common peroneal nerve palsy, femoral neuropathy, compartment syndrome, back/hip pain, pressure injuries
- Prevent: padding, avoid extreme hip flexion/abduction, limit duration, document checks
Laser hazards: eye injury, airway fire risk is extremely low (no airway laser), but theatre laser safety protocols apply

Post-operative care

Common issues: pain/colic, dysuria, frequency/urgency (stent), haematuria, PONV
Discharge advice (day case common): hydration, analgesia plan, expected haematuria, when to seek help (fever/rigors, worsening pain, urinary retention, heavy bleeding)
Sepsis can present after discharge: ensure clear instructions and low threshold for review

You are anaesthetising a patient for ureteroscopy and laser lithotripsy. Talk through your anaesthetic plan.

Structure: pre-op assessment → technique → intra-op priorities → analgesia/PONV → post-op.

Check indication, urgency, fasting status, vomiting/aspiration risk, and whether infection/obstruction present
Review renal function, electrolytes, Hb, coagulation/anticoagulants, urine culture and antibiotic plan
GA usually: induction ± RSI; airway SGA for short low-risk cases vs ETT for longer/OSA/aspiration risk
Maintenance: volatile/TIVA; ensure immobility; consider small NMBD boluses; active warming
Analgesia: paracetamol + NSAID if appropriate + opioid titration; consider antispasmodic strategies; plan for stent discomfort
PONV prophylaxis: dual/triple therapy; minimise opioids where possible
Positioning: lithotomy checks, padding, limit duration; document
Post-op: monitor for sepsis, haematuria, urinary retention; provide safety-net advice

What are the key anaesthetic concerns specific to ureteroscopy?

Urosepsis risk from instrumentation, especially with infected obstruction or positive cultures
Renal impairment and fluid management (dehydration pre-op; avoid overload intra-op)
Lithotomy positioning injuries (nerve palsies, compartment syndrome if prolonged)
Need for immobility during ureteroscope manipulation/laser lithotripsy
Post-op pain/colic and high PONV incidence

A patient has an obstructed infected kidney and is listed for emergency ureteroscopy. What is the priority and how does it change your anaesthetic approach?

This is a time-critical sepsis/source control scenario.

Priority is drainage of the infected obstructed system (ureteric stent or percutaneous nephrostomy), not definitive stone clearance
Treat as sepsis: early antibiotics, cultures, lactate, fluid resuscitation, vasopressors if needed, consider HDU/ICU post-op
Anaesthesia: GA with secured airway often appropriate; consider invasive monitoring if unstable; cautious induction (vasopressor ready)
Post-op: high risk of deterioration; plan critical care escalation and ongoing source control

How would you manage sudden hypotension and pyrexia during ureteroscopy?

Assume urosepsis until proven otherwise while excluding common anaesthetic causes.

Immediate actions: call for help, 100% O2, check pulse/ECG, confirm BP, assess depth of anaesthesia, check bleeding, check anaphylaxis signs
Treat likely sepsis: obtain cultures (blood/urine if possible), give broad-spectrum antibiotics, fluid bolus, start vasopressor (metaraminol/phenylephrine; consider noradrenaline infusion if persistent)
Ask surgeon to reduce irrigation pressure, consider stopping procedure and placing stent for drainage
Check ABG/lactate, temperature management, consider arterial line and ICU referral

Discuss fluid and irrigation issues in ureteroscopy compared with TURP.

Ureteroscopy typically uses isotonic saline irrigation; electrolyte disturbance from hypotonic absorption (classic TURP syndrome) is not expected
However, systemic absorption/extravasation can still cause volume overload, especially with prolonged high-pressure irrigation and impaired renal function
Irrigation contributes to hypothermia in longer cases; use active warming
Urine output is difficult to interpret due to irrigation; assess volume status clinically and with haemodynamics

What are the causes of pain after ureteroscopy and how would you treat it?

Ureteric spasm/colic from manipulation and oedema; treat with NSAIDs (if safe), opioids titrated, hydration as appropriate
Stent-related symptoms: frequency, urgency, suprapubic discomfort, flank pain; treat with simple analgesics ± alpha-blocker/anticholinergic per urology plan
Bladder irritation from instrumentation; consider antimuscarinic if prescribed; exclude retention
Red flag: severe pain with fever/rigors suggests infection/obstruction—needs urgent review

How does chronic kidney disease change your anaesthetic management for ureteroscopy?

Drug handling: adjust doses/avoid accumulation (opioids, sedatives); consider short-acting agents
Avoid nephrotoxins where possible: NSAIDs may be contraindicated; ensure appropriate antibiotic choice/dose
Fluid balance: treat dehydration but avoid overload; consider invasive monitoring if severe CKD with cardiovascular disease
Electrolytes: check potassium and acid-base status; manage hyperkalaemia pre-op

Lithotomy position: what complications are you worried about and how do you prevent them?

Nerve injuries: common peroneal (fibular head pressure), femoral (hip flexion), sciatic; also obturator stretch
Compartment syndrome/rhabdomyolysis in prolonged lithotomy, especially obese patients
Prevention: padding, avoid extreme positions, keep legs level/symmetric, limit duration, periodic checks, careful transfer

A common FRCA theme is ‘day-case suitability’. What factors determine whether ureteroscopy can be day case and what are your discharge criteria?

Suitable if: stable comorbidities, uncomplicated procedure, pain and PONV controlled, able to pass urine (or clear plan with catheter), no sepsis concerns
Discharge criteria: observations stable, mobilising, tolerating oral intake, adequate analgesia, understands haematuria expectations and red flags, escort and follow-up (stent removal plan)

What peri-operative antibiotics issues are relevant to ureteroscopy?

Instrumentation of urinary tract carries bacteraemia/urosepsis risk; prophylaxis guided by urine culture and local resistance patterns
If positive culture or prior resistant organisms: ensure targeted therapy and consider postponing definitive stone treatment if infection not controlled
In suspected sepsis: take cultures early but do not delay antibiotics

Discuss the anaesthetic management of a patient undergoing ureteroscopy for ureteric stone disease.

A common FRCA long viva/short answer theme: provide a structured peri-operative plan and highlight sepsis and positioning.

Pre-op: assess severity (pain/vomiting), fasting, aspiration risk; screen for sepsis and infected obstruction; review renal function and electrolytes; check anticoagulants; confirm antibiotic plan
- If infected obstruction suspected: prioritise drainage and resuscitation; anticipate ICU
Technique: GA usually; SGA for short low-risk cases; ETT/RSI if aspiration risk, obesity/OSA, longer case, or instability
Intra-op: standard monitoring; maintain immobility; manage fluids (correct dehydration, avoid overload); active warming; lithotomy positioning checks
Analgesia: paracetamol + NSAID if appropriate + opioid titration; consider that stent discomfort may dominate post-op symptoms
PONV: prophylaxis (at least dual); minimise opioids; consider TIVA in high-risk patients
Complications: urosepsis, ureteric injury, bleeding, hypothermia, lithotomy nerve injury; have escalation plan
Post-op: monitor for sepsis, urinary retention, uncontrolled pain; day-case criteria and safety-net advice including stent plan

A patient becomes hypotensive during ureteroscopy. Give a differential diagnosis and immediate management.

FRCA expects a broad differential plus decisive initial actions and sepsis awareness.

Differential: sepsis/bacteraemia, anaphylaxis (antibiotic/latex), haemorrhage (rare), deep anaesthesia, myocardial ischaemia/arrhythmia, hypovolaemia (dehydration), PE (rare)
Immediate management: A-E, 100% O2, confirm BP, check ECG, capnography, depth, bleeding; give vasopressor boluses and fluids as appropriate
If sepsis likely: cultures, broad-spectrum antibiotics, lactate/ABG, start vasopressor infusion early; ask surgeon to stop/reduce irrigation pressure and consider stenting only
If anaphylaxis suspected: stop trigger, call for help, adrenaline, fluids, antihistamine/steroid, tryptase, ICU

Outline the complications of ureteroscopy and how they present peri-operatively.

Infective: urosepsis (hypotension, tachycardia, fever, raised lactate) intra- or post-op
Traumatic: ureteric perforation/avulsion (bleeding, prolonged procedure, post-op pain, urinoma); may require stent/open repair
Bleeding: haematuria common; significant bleeding uncommon
Functional: post-op colic/spasm, urinary retention, stent discomfort
Position-related: nerve injury/compartment syndrome from lithotomy
Anaesthetic: PONV, aspiration (vomiting/urgent cases), hypothermia in prolonged cases