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Complete Guide to Urology Surgical Instruments - Exam Ready

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PART 1: ENDOSCOPIC INSTRUMENTS (Most Exam-Important)

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1. CYSTOSCOPE

• Telescope has a rod-lens (Hopkins lens) system that transmits magnified image
• Light transmitted through fiber-optic bundles running alongside the telescope
• Irrigation channels allow continuous inflow/outflow to distend bladder and clear blood/debris
• Available in different telescope angles: 0° (forward), 12°, 30°, 70° (most common for bladder), 120° (retrograde view)
• French size (Fr) = outer diameter in mm x 3; standard diagnostic cystoscope is 17-21 Fr

• Rigid cystoscope - metal sheath, better optics, used in OR
• Flexible cystoscope - fiber optic or digital chip-tip, office-based, better for anterior wall visualization, more patient comfort
• Continuous flow cystoscope - two-channel: irrigant in one, out the other simultaneously

• Hematuria evaluation, bladder tumor diagnosis/surveillance, ureteral catheterization, foreign body removal, urodynamics

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2. RESECTOSCOPE

• The working element has a spring-return mechanism - the loop is pushed forward into tissue by the surgeon's thumb, then snaps back automatically
• Monopolar resectoscope: Uses non-ionic irrigant (glycine 1.5%, sorbitol/mannitol) because saline disperses monopolar current. Risk of TUR syndrome (dilutional hyponatraemia, water intoxication from glycine absorption)
• Bipolar resectoscope: Active and return electrodes are both on the same loop - current flows between them only through the tissue at the tip. Can use normal saline as irrigant. Eliminates TUR syndrome. This is the modern preferred approach.

• Monopolar TURP: glycine irrigant, risk of TUR syndrome
• Bipolar TURP: saline irrigant, safer, especially in large prostates
• Loop is advanced UNDER vision, cutting on withdrawal (not on forward movement)
• Verumontanum is the anatomical landmark to avoid distal sphincter injury

• TURP (Transurethral Resection of Prostate)
• TURBT (Transurethral Resection of Bladder Tumour)
• TUIP (Transurethral Incision of Prostate)
• Transurethral resection of ureterocele
• Urethral stricture (internal urethrotomy variant)

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3. URETEROSCOPE

• Eyepiece/camera port at proximal end
• Handle with deflection lever (active deflection of tip)
• Irrigation port (inflow)
• Working channel (2.4-3.6 Fr) - for laser fibers, baskets, biopsy forceps
• Long insertion tube (40-45 cm)
• Distal tip with lens and light

• Active deflection via a pull-wire mechanism (Bowden cable): pulling the lever bends the distal tip
• Fiber-optic bundles transmit light and image (or digital chip transmits image directly)
• Access sheath (ureteral access sheath, UAS) used to facilitate repeated insertion/removal, reduces intrarenal pressure
• Holmium:YAG laser fiber passed through working channel for lithotripsy

• Ureterorenoscopy (URS) for ureteral/renal stones - laser lithotripsy
• Upper tract urothelial carcinoma - biopsy, fulguration
• Ureteral stricture assessment/management

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4. NEPHROSCOPE

• Short rigid shaft (15-20 cm)
• Wide working channel (3-4 mm) for large stone forceps, EHL/laser probes, ultrasonic probes
• Offset eyepiece (to allow instruments to be passed in a straight line while viewing obliquely)
• Irrigation in/out ports

• Introduced through a percutaneous tract dilated in the flank/back
• Alligator stone forceps, three-prong graspers passed through working channel
• Ultrasonic lithotripter: hollow probe that transmits ultrasound vibrations to fragment stone, suction through center removes fragments
• Electrohydraulic lithotripsy (EHL): spark-gap probe creates shock waves
• Pneumatic lithotripter: compressed air fires a probe to fragment stone mechanically

• PCNL for large (>2 cm) or complex renal stones
• Calyceal diverticulum access
• Endopyelotomy

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PART 2: DILATORS

5. URETHRAL DILATORS

A. Van Buren Sounds (Metal Sounds)

• Solid, curved, metal instruments in graduated sizes (8-34 Fr)
• S-shaped curve follows the male urethra (penile + perineal + prostatic)
• Used for: urethral stricture dilation, assessment of urethral calibre
• Passed by "sounding" - following the urethral curve with gentle forward pressure

B. Clutton Sounds

• Longer, more gently curved than Van Buren
• Used in females (shorter, straighter urethra - no need for S-curve)

C. Filiform Bougies + Followers

• Filiforms: Very fine (1-5 Fr), flexible, with a screw-tip; used when urethra is nearly completely obstructed and a sound cannot pass
• Followers: Hollow dilators that screw onto the filiform to gradually dilate over the guidewire
• Mechanics: Pass filiform past stricture, screw on progressively larger followers

D. Hegar Dilators

• Straight, solid dilators
• Used primarily for cervical/urethral dilation in females, also used in paediatric urethral dilation

E. Balloon Dilators

• Angioplasty-type catheter with an inflatable balloon at the tip
• Used for ureteral strictures, urethral strictures, ureteropelvic junction (UPJ) obstruction
• Mechanics: Placed over a guidewire, inflated to a preset pressure (ATM) to dilate stricture radially without shear force

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PART 3: CATHETERS

6. FOLEY CATHETER

• Self-retaining urethral catheter with an inflatable balloon (5-30 mL)
• Drainage eye at tip, balloon inflation port, drainage port
• Standard sizes: 12-24 Fr
• Three-way Foley: Has a third channel for continuous irrigation (used post-TURP)

7. COUNCIL CATHETER

• Has a through-and-through lumen from tip to balloon port
• Passed over a guidewire (wire exits through the tip)
• Used when the urethra is difficult/traumatised

8. COUDE CATHETER

• Has a slightly bent (elbow) tip
• Helps navigate the curved male urethra / enlarged prostate / bladder neck obstruction
• Named from French "coude" = elbow

9. SUPRAPUBIC CATHETER (SPC)

• Introduced percutaneously through the abdominal wall into the bladder
• Used when urethral catheterization is impossible/contraindicated
• Placed using a trocar/cannula system under ultrasound guidance

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PART 4: STONE INSTRUMENTS (Intracorporeal Lithotripsy)

10. STONE BASKETS / DORMIA BASKET

• Wire basket (3-4 wires) opened around a stone and then withdrawn to trap/extract it
• Available in: flat wire (rigid), nitinol (flexible, shape-memory for flexible ureteroscopy), tip-deflecting
• Mechanics: Passed beyond stone in collapsed state, opened to surround stone, withdrawn with stone trapped

11. ELLIK EVACUATOR

• A glass or plastic bulb device with two channels
• Mechanics: Creates a Venturi effect - squeezing the bulb forces irrigant into bladder, releasing it creates suction that draws chips/clots into the bulb's lower reservoir
• Used after TURP, TURBT: evacuates prostatic chips and blood clots from bladder
• Quoted directly from Hinman's Atlas: "the Ellik evacuator produces a Venturi effect, allowing chips of prostate tissue to settle to the bottom of the bulb"

12. RANDALL STONE FORCEPS

• Four curved forceps of progressively increasing angulation (one straight + three curved)
• Key distinguishing feature: no locking ratchet mechanism (unlike hemostatic clamps)
• Used to retrieve stone fragments from renal calyces through a nephroscope
• The progressive angles allow access to differently oriented calyces

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PART 5: OPEN/LAPAROSCOPIC INSTRUMENTS

13. VASCULAR CLAMPS (Urological)

14. KIDNEY PEDICLE CLAMPS

• Extra-long (30+ cm), right-angled or curved
• Designed to control the renal hilum en masse during nephrectomy
• Examples: Herrick kidney pedicle clamp

15. RETRACTORS

16. CIRCUMCISION CLAMPS

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PART 6: SPECIAL/NOVEL INSTRUMENTS

17. HOLMIUM:YAG LASER SYSTEM (HoLEP / RIRS)

• Wavelength 2140 nm (absorbed by water)
• Equipment (from Hinman's Atlas): Holmium laser (minimum 100 W), 550 μm end-firing quartz fiber, fiber-stabilizing catheter
• Used in HoLEP (Holmium Laser Enucleation of Prostate): the laser precisely enucleates the prostate adenoma in anatomical planes
• Also used for lithotripsy in flexible ureteroscopy (RIRS - Retrograde Intrarenal Surgery)
• Thulium fiber laser (TFL): Newer, wavelength 1940 nm, superior absorption by water, finer dust fragmentation (dusting mode), being rapidly adopted

18. TISSUE MORCELLATOR

• Used after HoLEP to fragment the enucleated prostate lobe inside the bladder
• Introduced through an offset nephroscope working channel
• Reciprocating blades macerate tissue, fragments aspirated through suction
• Allows retrieval of large enucleated prostatic lobes that cannot exit through the urethra
• Quoted from Hinman's Atlas: "A standard tissue morcellator with reciprocating blades is introduced through the working channel of an offset nephroscope"

19. SINGLE-USE DIGITAL FLEXIBLE URETEROSCOPE

• Examples: LithoVue (Boston Scientific), Uscope PU3022 (Pusen)
• Chip-on-tip digital sensor eliminates optical fiber degradation
• Single-use eliminates repair costs, sterilization issues, cross-infection
• Enhanced deflection (up to 270°) and irrigation compared to reusable scopes

20. ROBOTIC SURGICAL SYSTEM (da Vinci)

• EndoWrist instruments: 7 degrees of freedom (more than human wrist)
• Tremor filtration, motion scaling
• Used for: Robot-assisted radical prostatectomy (RARP), robot-assisted radical cystectomy (RARC), robot-assisted partial nephrectomy (RAPN), robotic pyeloplasty
• Currently considered standard of care for radical prostatectomy in high-volume centers

21. URETERAL ACCESS SHEATH (UAS)

• Two-component (inner dilator + outer sheath) hollow tube placed in the ureter (10-16 Fr outer diameter)
• Allows repeated passage of flexible ureteroscope without repeated ureteral dilation
• Reduces intrarenal pressure during flexible ureteroscopy (prevents pyelovenous backflow/sepsis)
• Examples: Cook Navigator, Bard Optitip UAS

22. DOUBLE-J (DJ) STENT / URETERAL STENT

• Polyurethane or silicone tube with coiled (pigtail) ends - one in renal pelvis, one in bladder
• The coils prevent migration
• Used for: ureteric obstruction relief, post-ureteroscopy drainage, post-pyeloplasty splinting
• Retrieval string or flexible cystoscopy + grasping forceps used for removal

23. NEPHROSTOMY TUBE

• Placed percutaneously into renal pelvis under ultrasound/fluoroscopic guidance
• Drains obstructed kidney directly externally
• Also serves as access for PCNL (later upsized)

24. OPTICAL URETHROTOME (Sachse)

• Cold knife (or laser) attached to cystoscope working channel
• The cold knife is a guarded, forward-cutting blade
• Used for internal urethrotomy (Otis/Sachse urethrotomy) of urethral strictures
• Mechanics: Blade deployed under direct vision, incision made at 12 o'clock position through the stricture

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PART 7: QUICK EXAM REVISION TABLE

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PART 8: MNEMONICS FOR THE EXAM

• Sheath (outer)
• Telescope (30° lens)
• Obturator (blind/visual)
• Loop electrode (cutting/coagulation)
• Element (working element with spring return)

• 0° = forward view (urethra, bladder neck)
• 30° = slightly forward (most diagnostic use)
• 70° = lateral/upward (bladder dome, lateral walls, ureteral orifices)
• 120° = retrograde (bladder neck from inside)

• Too much glycine absorption → dilutional hyponatraemia
• Treat: IV hypertonic saline (3%) if symptomatic, furosemide

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