Advanced APPs perform procedures — and are trained and credentialed to do so through a structured competency pathway (Chapter 1). This chapter is the practical how-to for the core procedures in our scope — setup, technique, pitfalls, and…
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Urology of Indiana
APPs perform procedures — and are trained and credentialed to do so
through a structured competency pathway (Chapter 1). This chapter is
the practical how-to for the core procedures in our scope — setup,
technique, pitfalls, and aftercare. It is a supplement to hands-on
training and direct supervision, not a substitute for either: do not
perform a procedure you have not been signed off on. Every one of
these was taught to you by someone who wanted you to succeed; when
you are unsure mid-procedure, stop and ask.
Universal principles — apply to every
procedure below
Confirm the patient, the
side, the procedure, and the consent. Verify allergies
(especially lidocaine, latex, contrast, and antibiotics).
Sterile urine before
instrumentation. Treat a positive culture first (Chapter 28).
Anesthesia is not optional.
Take the necessary time — a comfortable patient is a still
patient, and a still patient is a safe patient.
If you meet unexpected
resistance, STOP. Force converts a minor problem into a major one
(a false passage, a perforation, a bleed).
Document what you did, what you found, the tolerance, and
the aftercare instructions.
26.1 Flexible cystoscopy
Indications
— hematuria evaluation, bladder-cancer surveillance, LUTS
evaluation, stent removal, recurrent UTI evaluation, foreign body,
and stricture assessment.
Technique
Position
supine (men) or in lithotomy (women). Prep the meatus and drape.
Instill
lidocaine jelly generously INTO the urethra (10–20 mL in men) and
occlude the meatus. Allow approximately 2 minutes before advancing
the scope.
Hold the
penis upright at 90°. Advance the scope gently under direct vision
with continuous irrigation — never advance blind. Follow the
lumen; the lumen is always the darkest point.
At the
membranous urethra/external sphincter, ask the patient to “relax
and breathe out like you are urinating.” Do not push against a
closed sphincter; wait for it to open.
Navigate the
prostatic urethra (note lateral lobes and any median lobe), then
enter the bladder.
Survey the
bladder SYSTEMATICALLY, every time, so you never miss a wall: start
at the air bubble (12 o'clock, your reference point), then sweep the
anterior wall, both lateral walls, the posterior wall, the dome, and
the trigone with both ureteral orifices. Look for the efflux from
each orifice. Retroflex the scope to inspect the bladder neck.
Drain the
bladder and withdraw under vision, inspecting the urethra on the way
out.
Cystoscopy pitfalls
Expect transient dysuria and
hematuria for 24–48 hours; warn the patient or they will call.
Increase fluids.
Do not scope through an
untreated infection.
In a man with a large median
lobe the bladder neck can be hidden — angle up and over it
rather than forcing straight ahead.
If you cannot pass the scope, do not force. Stop, and get
help or a smaller scope.
26.2 Prostate biopsy
Preparation
— confirm the indication (Chapter 8) and review the MRI if there is
one — know your targets before you start. Confirm the
anticoagulation plan (Chapter 28) and give antibiotic prophylaxis.
our practice's APPs perform both transrectal and transperineal biopsies; the
transperineal approach has a markedly lower infection risk and is
increasingly our default.
Technique (fusion/targeted plus systematic)
Position
in left lateral decubitus (transrectal) or lithotomy
(transperineal).
Insert the
ultrasound probe, obtain the gland volume (which you need for PSA
density), and survey for hypoechoic lesions.
Anesthetize
properly. Transrectal: a periprostatic nerve block with lidocaine at
the base bilaterally (the “Mount Everest” sign as the anesthetic
lifts the neurovascular bundle). Transperineal: a generous perineal
skin wheal plus a periprostatic block. Give the anesthetic time to
work.
Take the
TARGETED cores first (MRI-fusion or cognitive) — you do not want
bleeding to obscure your target.
Then take
the SYSTEMATIC cores — typically 12, sampling base, mid, and apex
bilaterally, both lateral and medial. Keep the cores in labeled,
separate containers so the pathology can be mapped.
Confirm
hemostasis before the patient leaves.
Biopsy counseling — say all of this,
every time
Hematuria and hematospermia
are EXPECTED. Hematospermia can persist for weeks to MONTHS and
is alarming but harmless — if you do not warn them, they will
panic.
Mild rectal bleeding
(transrectal) is common and self-limited.
FEVER OR RIGORS IS AN
EMERGENCY. Post-biopsy sepsis can progress to septic shock within
hours. Tell them explicitly: “If you get a fever or the shakes,
go to the emergency room — do not wait to call the office.”
This one sentence saves lives.
Transient worsening of urinary symptoms, and occasionally
retention, can occur — especially in men with large glands.
26.3 Ureteroscopy with laser lithotripsy and
stent placement
Setting —
our ASCs, under general anesthesia. our practice's equipment: thulium fiber
laser, Dornier single-use digital ureteroscopes, and direct in-line
vacuum aspiration (Chapter 7).
Technique
Cystoscopy,
then place a sensor/safety guidewire up the ureter into the renal
pelvis under fluoroscopic guidance. THE SAFETY WIRE IS SACRED — it
is your road back if anything goes wrong. Never lose it.
Perform a
retrograde pyelogram to define the collecting-system anatomy and
confirm the stone position.
Advance the
semirigid ureteroscope for distal/mid-ureteral stones, or place a
ureteral access sheath over a second (working) wire and use the
flexible digital scope for proximal and renal stones. The access
sheath protects the ureter, lowers intrarenal pressure, and allows
repeated passes.
Laser the
stone. Thulium fiber laser settings: low energy/high frequency to
DUST the stone (creating fine particles that pass spontaneously), or
higher energy to fragment it into retrievable pieces. Keep the fiber
in view and against the stone; never fire blind.
Evacuate
fragments with in-line vacuum aspiration and/or a basket. Vacuum
aspiration is a major advantage — it clears dust continuously and
keeps intrarenal pressure low.
Inspect the
entire ureter and collecting system for residual stone, injury, or
perforation.
Place a
ureteral stent over the wire under fluoroscopy — confirm the
proximal curl in the renal pelvis and the distal curl in the
bladder. ALL our practice patients are stented after URS. Decide on and
document a string vs. no-string, and set the removal date.
URS pitfalls
Never lose the safety wire.
Watch intrarenal pressure —
high pressure causes pyelovenous backflow, sepsis, and forniceal
rupture. Use an access sheath and vacuum aspiration, and keep
irrigation modest.
If you cannot pass the scope
past a tight ureter, do NOT force it — stent the patient and
come back in 1–2 weeks after passive dilation. This is a good
decision, not a failure.
A ureteral avulsion is the
catastrophic complication — it comes from pulling a basket with
an impacted stone through a narrow ureter. If a basket will not
come out easily, release the stone.
Document the stent and OWN the removal date. A forgotten
stent encrusts and becomes a disaster.
26.4 Sacral neuromodulation: PNE
(InterStim)
Peripheral nerve evaluation (PNE) — the ASC
test phase
Position
PRONE with a pillow under the pelvis. Prep the sacrum and buttocks.
Expose the feet and the perineum so you can SEE the motor responses.
Identify the
S3 foramen: roughly 9–11 cm above the tip of the coccyx and ~2 cm
lateral to the midline. Use bony landmarks and fluoroscopy.
Anesthetize
the skin and the subcutaneous track (do NOT flood the foramen with
local anesthetic — you will abolish the very motor response you
are looking for).
Advance the
foramen needle at ~60° angle, aiming for S3. Stimulate and watch
for the response.
CONFIRM S3:
the correct responses are a BELLOWS contraction of the perineum (the
levator ani drawing inward/deepening the intergluteal cleft) and
PLANTAR FLEXION OF THE GREAT TOE. If you get a lateral
leg/whole-foot response, you are too lateral or at the wrong level
(S2 gives a clamp-like response and whole-leg rotation; S4 gives a
bellows with NO toe movement).
Note the
SENSORY response as well — the patient should feel it in the
vagina, rectum, or perineum, not in the buttock or leg.
Place the
temporary lead, secure it, and connect the external stimulator. The
patient keeps a voiding diary for 3–7 days. A ≥ 50% improvement
in the target symptom is a positive test and justifies proceeding to
a permanent implant.
PNE pearls
The great-toe plantar
flexion plus bellows response is your proof of S3. Do not accept
anything less — a poorly placed lead gives a false-negative
test and costs the patient a therapy that would have worked.
Do not over-anesthetize; you
need the motor response.
Counsel: no MRI restrictions with modern devices (they are
MRI-conditional), avoid heavy lifting and twisting during the
test, and expect the sensation to change with position.
26.5 Intravesical instillation (BCG and
chemotherapy)
Confirm
the indication and that it is safe to instill TODAY: no active UTI,
no gross hematuria, no traumatic catheterization, and at least ~2
weeks since a TURBT (Chapter 9).
Have the
patient void. Catheterize with a small (e.g., 14 Fr) catheter, using
gentle technique — a traumatic catheterization is a hard STOP for
BCG, because it opens a route to systemic absorption and BCGosis.
Drain the
residual, then instill the agent by gravity. Withdraw the catheter.
The patient
holds it for ~2 hours, repositioning periodically. They then void
SEATED, and (for BCG) disinfect the toilet with bleach for 6 hours.
Counsel on
expected effects: irritative voiding and low-grade flu-like symptoms
for 24–48 hours after BCG.
BCG safety — a hard stop
A traumatic catheterization,
gross hematuria, an active UTI, or a recent TURBT are all
ABSOLUTE reasons to defer the instillation to another day.
Reschedule — do not push through.
A high fever (> 38.5°C),
rigors, or systemic illness after BCG is not “expected side
effects” — it is possible disseminated BCG infection and
needs urgent evaluation and anti-tuberculous therapy. Escalate
immediately.
BCG is a live organism. Handle with appropriate
precautions and do not instill it into a patient who is
immunosuppressed.
26.6 Other core procedures
Procedure
Key points
Urethral catheter placement (difficult)
Lidocaine, patience, coudé tip up. Never force. Escalate to
guidewire/cystoscopic placement or an SPT (Chapter 14)
Suprapubic tube exchange
Confirm a mature tract (≥ 4–6 weeks; the FIRST exchange is
done by the placing physician). Have a spare tube ready and
replace IMMEDIATELY if it comes out — the tract closes within
hours. Confirm urine return before inflating the balloon
Stent removal (on a string)
Simple office pull; warn about transient colic and hematuria.
Confirm the whole stent came out
For anterior stricture. Do not dilate blindly through a false
passage; use a wire. Optilume delivers paclitaxel to reduce
recurrence (Chapter 14)
Cystoscopy with hydrodistension for IC
The ONLY route by which we deliver intravesical therapy for IC —
done in the office or ASC. Diagnostic (Hunner lesions,
glomerulations) and therapeutic; the intravesical agent is
instilled at the same setting, and Hunner lesions are fulgurated
or injected. Avoid prolonged high-pressure distension (bladder
rupture). We do not run standalone office instillation series
(Chapter 27)
Bulkamid urethral bulking
Cystoscopic injection of hydrogel at the mid-urethra, typically
3–4 quadrants, to achieve visible coaptation. Repeatable
(Chapter 15)
Post-void residual / bladder scan
Scan AFTER a natural, comfortable void. A single high value is
not a diagnosis — repeat
Uroflowmetry
Needs a voided volume > 150 mL to be interpretable. Look at
the CURVE, not just the number
Clinical Pathway
Click any node to expand
Advanced APPs perform procedures, trained and credentialed through a structured competency pathway. These are the how-to sequences for the core procedures in our scope — setup, technique, pitfalls, and aftercare. This is a supplement to hands-on training and direct supervision, never a substitute: do not perform a procedure you have not been signed off on, and when you are unsure mid-procedure, stop and ask.
Starts with the universal principles that apply to every procedure in this chapter, then the office flexible cysto sequence.
Select a box to open its teaching details.
Universal principles
Confirm the patient, the side, the procedure, and the consent
Verify allergies — especially lidocaine, latex, contrast, and antibiotics
Sterile urine before instrumentation. Treat a positive culture first (Chapter 28)
Anesthesia is not optional. Take the necessary time — a comfortable patient is a still patient, and a still patient is a safe patient
If you meet unexpected resistance, STOP. Force converts a minor problem into a major one — a false passage, a perforation, a bleed
Document what you did, what you found, the tolerance, and the aftercare instructions
Ch 26 — universal principles
Indications
Hematuria evaluation
Bladder-cancer surveillance
LUTS evaluation
Stent removal
Recurrent UTI evaluation
Foreign body
Stricture assessment
Pitfalls
Do not scope through an untreated infection
Ch 26.1 — indications
Setup
Position supine (men) or in lithotomy (women)
Prep the meatus and drape
Ch 26.1 — technique
Dosing
Lidocaine jelly generously INTO the urethra — 10–20 mL in men
Occlude the meatus
Allow approximately 2 minutes before advancing the scope
Why
This step improves patient comfort.
Ch 26.1 — technique
Technique
Hold the penis upright at 90°
Advance gently under direct vision with continuous irrigation
Never advance blind
Follow the lumen — the lumen is always the darkest point
Ch 26.1 — technique
What to say
Ask the patient to "relax and breathe out like you are urinating"
Pitfalls
Do not push against a closed sphincter — wait for it to open
Ch 26.1 — technique
What to note
Lateral lobes
Any median lobe
Pitfalls
In a man with a large median lobe the bladder neck can be hidden — angle up and over it rather than forcing straight ahead
Ch 26.1 — technique
The sequence
Start at the air bubble (12 o'clock) — your reference point
Sweep the anterior wall
Both lateral walls
The posterior wall
The dome
The trigone with both ureteral orifices — look for efflux from each
Retroflex the scope to inspect the bladder neck
Ch 26.1 — technique
Look for
Papillary tumors
Flat velvety erythema — possible CIS
Trabeculation
Diverticula
Stones
Foreign bodies
Document
Photo-document the findings
Ch 26.1 — technique
Technique
Drain the bladder
Withdraw under vision, inspecting the urethra on the way out
Ch 26.1 — technique
Counsel
Expect transient dysuria and hematuria for 24–48 hours
Increase fluids
Pitfalls
If you cannot pass the scope, do not force. Stop, and get help or a smaller scope
Ch 26.1 — cystoscopy pitfalls
Transrectal and transperineal — Advanced APPs perform both, and transperineal is increasingly our default because the infection risk is markedly lower.
Select a box to open its teaching details.
Preparation
Confirm the indication (Chapter 8)
Review the MRI if there is one — know your targets before you start
Confirm the anticoagulation plan (Chapter 28)
Give antibiotic prophylaxis
Universal principles apply
Patient, side, procedure, consent; allergies; sterile urine before instrumentation
Ch 26.2 — preparation
Local policy
Our protocol
our practice's APPs perform both transrectal and transperineal biopsies
The transperineal approach has a markedly lower infection risk and is increasingly our default
Ch 26.2 — preparation
Positioning
Transrectal — left lateral decubitus
Transperineal — lithotomy
Ch 26.2 — technique
What to obtain
Gland volume — needed for PSA density
Survey for hypoechoic lesions
Ch 26.2 — technique
Transrectal
Periprostatic nerve block with lidocaine at the base bilaterally
Look for the "Mount Everest" sign as the anesthetic lifts the neurovascular bundle
Transperineal
A generous perineal skin wheal PLUS a periprostatic block
Pitfalls
Give the anesthetic time to work — anesthesia is not optional
Ch 26.2 — technique
Technique
Take MRI-fusion or cognitive targeted cores first
Why
You do not want bleeding to obscure your target.
Ch 26.2 — technique
Sampling
Typically 12 cores
Sample base, mid, and apex bilaterally
Both lateral and medial
Handling
Keep the cores in labeled, separate containers so the pathology can be mapped
Ch 26.2 — technique
Before discharge
Confirm hemostasis
Document tolerance and aftercare instructions
Ch 26.2 — technique
Say all of this, every time
Hematuria and hematospermia are EXPECTED
Hematospermia can persist for weeks to MONTHS — alarming but harmless
Mild rectal bleeding (transrectal) is common and self-limited
Transient worsening of urinary symptoms, and occasionally retention — especially in men with large glands
Pitfalls
If you do not warn them about hematospermia, they will panic
Ch 26.2 — biopsy counseling
Time-critical
Say this verbatim
"If you get a fever or the shakes, go to the emergency room — do not wait to call the office." This one sentence saves lives.
Why
Post-biopsy sepsis can progress to septic shock within hours
Transrectal biopsy is the highest-infection-risk procedure we do (Chapter 28)
Ch 26.2 — biopsy counseling
Ureteroscopy with laser lithotripsy and stent placement in our ASCs — thulium fiber laser, single-use digital scopes, and in-line vacuum aspiration.
Select a box to open its teaching details.
Local policy
Our protocol
Setting: our ASCs, under general anesthesia
Thulium fiber laser
Dornier single-use digital ureteroscopes
Direct in-line vacuum aspiration (Chapter 7)
Ch 26.3 — setting
Technique
Cystoscopy, then place a sensor/safety guidewire up the ureter into the renal pelvis under fluoroscopic guidance
Pitfalls
THE SAFETY WIRE IS SACRED — it is your road back if anything goes wrong. Never lose it
Ch 26.3 — technique
What it gives you
The collecting-system anatomy
Confirmation of the stone position
Ch 26.3 — technique
Scope selection
Semirigid ureteroscope for distal/mid-ureteral stones
Ureteral access sheath over a second (working) wire plus the flexible digital scope for proximal and renal stones
What the access sheath does
Protects the ureter
Lowers intrarenal pressure
Allows repeated passes
Ch 26.3 — technique
Thulium fiber laser settings
Low energy / high frequency to DUST the stone — fine particles that pass spontaneously
Higher energy to FRAGMENT it into retrievable pieces
Pitfalls
Keep the fiber in view and against the stone
Never fire blind
Ch 26.3 — technique
Technique
In-line vacuum aspiration and/or a basket
Vacuum aspiration clears dust continuously and keeps intrarenal pressure low — a major advantage
Pitfalls
Ureteral avulsion is the catastrophic complication — it comes from pulling a basket with an impacted stone through a narrow ureter
If a basket will not come out easily, release the stone
Ch 26.3 — technique
How to keep it low
Use an access sheath
Use vacuum aspiration
Keep irrigation modest
Ch 26.3 — URS pitfalls
What you are looking for
Residual stone
Injury
Perforation
Pitfalls
If you cannot pass the scope past a tight ureter, do NOT force it — stent the patient and come back in 1–2 weeks after passive dilation. This is a good decision, not a failure
Ch 26.3 — technique
Local policy
Our protocol
ALL our practice patients are stented after URS
Place the stent over the wire under fluoroscopy
Confirm the proximal curl in the renal pelvis and the distal curl in the bladder
Decide and document
String vs. no-string
Set the removal date
Ch 26.3 — technique
Pitfalls
A forgotten stent encrusts and becomes a disaster
Document the stent, the string decision, and the removal date — and make sure someone owns it
Ch 26.3 — URS pitfalls
Sacral neuromodulation test phase — the ASC PNE step by step and what a true S3 response looks like.
Select a box to open its teaching details.
Local policy
Indications
Refractory OAB / urgency incontinence
Non-obstructive urinary retention, including Fowler's syndrome
Fecal incontinence
Our protocol
PNE is performed in the ASC, not in the office
Ch 26.4 — indications
Setup
Prone with a pillow under the pelvis
Prep the sacrum and buttocks
Expose the feet and the perineum so you can SEE the motor responses
Ch 26.4 — PNE technique
Landmarks
~9–11 cm above the tip of the coccyx
~2 cm lateral to the midline
Confirm with
Bony landmarks and fluoroscopy
Ch 26.4 — PNE technique
Technique
Anesthetize the skin and the subcutaneous track
Pitfalls
Do NOT flood the foramen with local anesthetic — you will abolish the motor response you need to confirm S3
Ch 26.4 — PNE technique
Technique
Advance the foramen needle at a ~60° angle, aiming for S3
Stimulate and watch for the response
Ch 26.4 — PNE technique
The correct S3 responses
BELLOWS contraction of the perineum — the levator ani drawing inward, deepening the intergluteal cleft
PLANTAR FLEXION OF THE GREAT TOE
Wrong-level responses
Lateral leg / whole-foot response — you are too lateral or at the wrong level
S2 — a clamp-like response and whole-leg rotation
S4 — a bellows with NO toe movement
Pitfalls
Do not accept anything less than bellows + great-toe plantar flexion. A poorly placed lead gives a false-negative test and costs the patient a therapy that would have worked
Ch 26.4 — PNE technique
Correct sensory response
The patient should feel it in the vagina, rectum, or perineum
Not in the buttock or leg
Ch 26.4 — PNE technique
Test phase
Place the temporary lead, secure it, connect the external stimulator
The patient keeps a voiding diary for 3–7 days
Ch 26.4 — PNE technique
The threshold
≥ 50% improvement in the target symptom is a positive test
A positive test justifies proceeding to a permanent implant
Ch 26.4 — PNE technique
Counsel
No MRI restrictions with modern devices — they are MRI-conditional
Avoid heavy lifting and twisting during the test
Expect the sensation to change with position
Pitfalls
Do not over-anesthetize at placement — you need the motor response
Ch 26.4 — PNE pearls
BCG and intravesical chemotherapy — including the hard stops that make you reschedule rather than push through.
Select a box to open its teaching details.
All four must be absent
No active UTI
No gross hematuria
No traumatic catheterization
At least ~2 weeks since a TURBT (Chapter 9)
Ch 26.5 — intravesical instillation
Technique
Have the patient void first
Catheterize with a small (e.g., 14 Fr) catheter
Gentle technique
Why gentle matters
A traumatic catheterization is a hard STOP for BCG — it opens a route to systemic absorption and BCGosis.
Ch 26.5 — intravesical instillation
Technique
Drain the residual
Instill the agent by gravity
Withdraw the catheter
Ch 26.5 — intravesical instillation
Dwell and void
Hold for ~2 hours, repositioning periodically
Then void SEATED
For BCG: disinfect the toilet with bleach for 6 hours
Ch 26.5 — intravesical instillation
Expected after BCG
Irritative voiding symptoms
Low-grade flu-like symptoms for 24–48 hours
Ch 26.5 — intravesical instillation
Absolute reasons to defer to another day
A traumatic catheterization
Gross hematuria
An active UTI
A recent TURBT
The rule
Reschedule — do not push through.
Ch 26.5 — BCG safety, a hard stop
Time-critical
Red flags after BCG
Fever > 38.5°C
Rigors
Systemic illness
What it may be
Possible disseminated BCG infection — needs urgent evaluation and anti-tuberculous therapy. Escalate immediately.
Ch 26.5 — BCG safety, a hard stop
Handling
BCG is a live organism — handle with appropriate precautions
Pitfalls
Do not instill BCG into a patient who is immunosuppressed
Ch 26.5 — BCG safety, a hard stop
The rest of the Advanced APP procedural scope — the single highest-yield point for each.
Select a box to open its teaching details.
Key points
Lidocaine, patience, coudé tip up
Never force
Escalate to guidewire or cystoscopic placement, or an SPT (Chapter 14)
Ch 26.6 — other core procedures
Key points
Confirm a mature tract — ≥ 4–6 weeks
The FIRST exchange is done by the placing physician
Have a spare tube ready
Replace IMMEDIATELY if it comes out — the tract closes within hours
Confirm urine return BEFORE inflating the balloon
Pitfalls
Inflating a balloon before confirming urine return
Ch 26.6 — other core procedures
Key points
Simple office pull
Warn about transient colic and hematuria
Confirm the whole stent came out
Ch 26.6 — other core procedures
Key points
Flexible cysto, grasper, gentle steady traction
Confirm complete removal
Ch 26.6 — other core procedures
Key points
For anterior stricture
Do not dilate blindly through a false passage — use a wire
Optilume delivers paclitaxel to reduce recurrence (Chapter 14)
Ch 26.6 — other core procedures
Local policy
Our protocol
The ONLY route by which we deliver intravesical therapy for IC — office or ASC
We do not run standalone office instillation series (Chapter 27)
What it does
Diagnostic — Hunner lesions, glomerulations
Therapeutic — the intravesical agent is instilled at the same setting