Antegrade ureteroscopy for impacted lower ureteral calculus: A salvage procedure for failed retrograde ureteroscopy (original) (raw)
Journal of Endourology, 2005
Purpose: To assess the safety and efficacy of antegrade percutaneous nephrolithotomy (PCNL) of large impacted proximal-ureteral calculi. Patients and Methods: Between July 1998 and October 2003, a total of 66 patients (43 male and 23 female; mean age 37.5 years) underwent PCNL for impacted proximal-ureteral calculi. The inclusion criteria were calculi Ͼ15 mm that were densely impacted and located between the ureteropelvic junction and the lower border of the 4 th lumbar vertebra. The mean drop in hemoglobin, operating time, analgesic requirement, and hospital stay were assessed. Results: Sixty-five patients (98.5%) had complete calculus clearance in a single session through a single tract. The mean operating time and hospital stay were 47 minutes and 46 hours, respectively. The mean analgesic requirement was 65 mg of pethidine (meperidine). The mean follow-up was 14 months. There were no significant postoperative complications. Conclusion: Antegrade PCNL is a safe and effective option for large, impacted proximal-ureteral calculi.
Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi
International Braz J Urol, 2006
Introduction: This work evaluates the results of ureteroscopic treatment of impacted ureteral stones with a pneumatic lithotripter. Materials and Methods: From March 1997 to May 2002, 42 patients with impacted ureteral stones were treated by retrograde ureteroscopic pneumatic lithotripsy. Twenty-eight patients were female and 14 were male. The stone size ranged from 5 to 20 mm. The ureteral sites of the stones were distal in 21, middle in 12 and proximal in 9. Results: Considering stones with distal location in the ureter, 1 patient had ureteral perforation and developed a stricture in the follow-up (4.7%). As for stones in the middle ureter, 2 perforations and 1 stricture were observed (8.3%) and regarding stones located in the proximal ureter, 5 perforations and 4 strictures occurred (44%). In the mid ureter, 1 ureteral avulsion was verified. In 34 patients without ureteral perforation, only 1 developed a stricture (2.9%). Of 8 patients who had perforation, 6 developed strictures. The overall incidence of stricture following treatment of impacted ureteral calculi was 14.2%. Conclusions: Ureteroscopy for impacted ureteral calculi is associated with a higher incidence of ureteral perforation and stricture. Ureteroscopy of proximal ureteral calculi is associated with a high risk of perforation, when compared to mid or distal ureteral calculi. Ureteral perforation at the site of the stone seems to be the primary risk factor for stricture formation in these cases.
The Journal of Urology, 2007
We describe our innovative technique for the treatment of large calculi (greater than 1.5 cm) of the proximal ureter. Materials and Methods: Between 2003 and 2005 we positioned an 8Ch pyelostomy in 25 patients diagnosed with impacted calculi of the proximal ureter greater than 1.5 cm on ultrasound, direct x-ray of the abdomen, and/or computerized tomography and subsequent retrograde pyelography. After 30 days all patients underwent combined treatment in the Valdivia supine position, including positioning a 0.035-inch guidewire through the pyelostomy into the ureter up to above the calculus, pyelostomy removal and insertion onto the guide of a 7Ch balloon occlusion catheter, which was inflated in the ureter immediately above the calculus. Ureteral lithotripsy was done with an 8.5 to 11.5Ch ureteroscope (Wolf, Dudley, Massachusetts) with a 6Ch operating channel and a Calcusplit® ballistic probe, alternating high antegrade pressure by the balloon catheter and retrograde pressure using the ureteroscope, as required. After lithotripsy and fragment dislocation the ureteroscope was retracted with rapid flow antegrade irrigation. At the end of the procedure after antegrade contrast medium followup the balloon catheter was retracted as far as the pelvis as a nephrostomy. We analyzed operative time, the number of postoperative recovery days, the incidence of complications during and after surgery, and the stone-free rate immediately, after 5 days and after 1 month. Results: Average calculus size was 1.7 cm. Ten patients presented with multiple ureteral bending upon diagnosis, which was no longer found at surgery with a consequent lack of difficult ureteroscope feeding. Significant edema downstream of the calculus was present in all cases. High pressure irrigation, a rigid ballistic probe and retrieving forceps enabled the dislocation of even larger fragments from the original calculous site in all cases. Antegrade high pressure irrigation after lithotripsy enabled the complete clearance of calcareous fragments as far as the bladder without the need for ancillary maneuvers. We observed no cases of calcareous fragment push-back. No retroperitoneal extravasation, or pyelolymphatic or pyelovenous backflow was observed. Average procedure time was 33 minutes. The renal-ureteral stone-free rate was 100% at the end of the procedure and all calcareous fragments were in the bladder. We did not observe any ureteral lesions. In no case was there onset of fever. Average postoperative hospitalization was 2 days. Followup with contrast material after 5 days showed a renal-ureteral stone-free rate of 100% and a bladder stone-free rate of 84%. The nephrostomy was removed at an average of 5.5 days. Conclusions: Compared to the techniques described in the medical literature our method appears to have certain advantages, including a mini-invasive approach to the renal pelvis compared to that of percutaneous nephrolithotomy with protection of the renal parenchyma from high pressure, rigid ureteroscope use, which provides a high level of maneuverability and low operating costs, ballistic probe use, which provides lower costs and higher speeds than the laser, and balloon catheter use, which removes the risk of push-back and enables push-down of the fragments without any further ancillary maneuvers. The balloon catheter also enables contrast medium followup and immediate postoperative drainage. The speed of the procedure and the ability to adjust antegrade or retrograde flow with variable pressure and direction make this technique highly suitable for the complete resolution of large, impacted calculi of the proximal ureter.
Site of impaction of ureteric calculi requiring surgical intervention
Abstract Textbooks describe three narrowest anatomic sites in the ureter as the most likely places for ureteral calculi to lodge, these are: the pelvi-ureteric junction (PUJ), the point where the ureters cross over the iliac vessels and the ureterovesical junction (UVJ). The purpose of this study is to determine whether calculi causing ureteric obstruction and requiring surgical treatment are found mostly at these three narrowest anatomic points of the ureter. Three hundred consecutive patients with impacted ureteric calculi who required surgical intervention were studied. The location of the impacted calculus on the day of surgical intervention was categorized according to nine predetermined levels outlined in a designed diagram based on findings on non-contrast CT of kidneys, ureters and bladder. Two peaks in stone distribution in the ureters were encountered; the first was above the ischial spine in the proximal part of the lower third ureter (84 patients, 28 %), while the second was at the level between L3 and L4 lumbar vertebrae (66 patients, 22 %). Overall, the location of impacted calculi was as follows, 53, 34, 10 and 3 % in the lower third ureter, upper third ureter, PUJ and mid ureter, respectively. This study demonstrates two peaks of calculi distribution in the ureter where ureteric calculi become impacted: the upper ureter below the PUJ and a second in the lower ureter, more proximal than the UVJ. There was an absence of the peak in stone location over the iliac vessels, that is, the mid ureter. Keywords Ureter Calculus Anatomic narrowing Impaction sites
Complications of 2735 retrograde semirigid ureteroscopy procedures: a single-center experience
Journal of …, 2006
Purpose: Ureteroscopy is nowadays one of the techniques most widely used for upper urinary-tract pathology. Our goal is to describe its complications in a large series of patients. Patients and Methods: Between June 1994 and February 2005, 2436 patients aged 5 to 87 years underwent retrograde ureteroscopy (2735 procedures) under video and fluoroscopic assistance. We used semirigid ureteroscopes (8/9.8F Wolf, 6.5F Olympus, 8F and 10F Storz) for 384 diagnostic and 2351 therapeutic procedures. Upper urinary-tract lithiasis (2041 cases), ureteropelvic junction stenosis (95 cases), benign ureteral stenosis (29 cases), tumoral extrinsic ureteral stenosis (84 cases), iatrogenic trauma (35 cases), superficial ureteral tumors (16 cases), superficial pelvic tumors (7 cases), and ascending displaced stents (44 cases) were the indications. The mean follow-up period was 56 months (range 4-112 months). Results: The rate of intraoperative incidents was 5.9% (162 cases). Intraoperative incidents consisted of the impossibility of accessing calculi (3.7%), trapped stone extractors (0.7%), equipment damage (0.7%), and double-J stent malpositioning (0.76%). In addition, migration of calculi or stone fragments during lithotripsy was apparent in 116 cases (4.24%). The general rate of intraoperative complications was 3.6% (98 cases). We also saw mucosal injury (abrasion [1.5%] or false passage [1%]), ureteral perforation (0.65%), extraureteral stone migration (0.18%), bleeding (0.1%), and ureteral avulsions (0.11%). Early complications were described in 10.64%: fever or sepsis (1.13%), persistent hematuria (2.04%), renal colic (2.23%), migrated double-J stent (0.66%), and transitory vesicoureteral reflux (4.58%, especially in cases with indwelling double-J stents). We also found late complications such as ureteral stenosis (3 cases) and persistent vesicoureteral reflux (2 cases). Most (87%) of the complications followed ureteroscopic therapy for stones. Three fourths (76%) of the complications occurred in the first 5 years of the series. Conclusions: According to our experience, mastery of ureteroscopic technique allows the urologist to proceed endourologically with minimum morbidity. Despite the new smaller semirigid instruments, this minimally invasive maneuver may sometimes be aggressive, and adequate training is imperative.
Complications Due to Surgical Treatment of Ureteral Calculi
Urological Science, 2010
Ureteral calculi usually induce severe colic pain, hematuria, hydronephrosis, infection and renal function loss, which warrant aggressive surgical management. The incidence of complication seems to decrease with the use of advanced equipment and machines in modern therapy. However, severe complication is still not unusual in our daily practice even as extracorporeal shock wave lithotripsy and endoscopic ureteral lithotripsy have become the most common urologic surgeries. It is important to be familiar with the surgical skills in the management of ureteral calculi as well as in dealing with complications that follow. In this short review, we discuss the complications with respect to the different mode of therapy and the different locations of the ureter, as well as the prevention and management of complications. Special conditions such as ureteral calculi in pregnancy, pediatric ureteral stones, outpatient ureteroscopy surgery, ureteral stents, ureteral dilatation and urinary leakage will also be discussed.
This study was carried out to evaluate laparoscopic retroperitoneal ureterolithotomy (RPUL) as a viable option to open surgical ureterolithotomy, laparoscopic transperitoneal ureterolithotomy (TPUL) & endoscopic urology and to assess its place in the spectrum of alternatives for the surgical treatment of ureteric calculi in a tertiary care centre. This study was conducted on 20 selected patients of single large impacted calculus of size more than 8mm in upper & middle ureter. It was observed that excessive bleeding was present in only one (5%) of the patients, while need for conversion to open ureterolithotomy was seen in 8 (40%) cases. No major peri-operative complications were encountered. From our experience, it can be concluded that this procedure has definitely shown decreased post-operative discomfort, decreased requirement of post-operative analgesia, better cosmesis, early return to work and less morbidity. RPUL can be considered as another well-established armamentarium in the armour of laparoscopic surgeons and is recommended as an effective minimally invasive primary treatment in large, impacted difficult stones in the upper & mid ureter.
The retroperitoneal, inguinal approach to distal part of the ureter
Central European journal of urology, 2014
The inguinal approach to the distal part of the ureter allows the surgeon to perform various types of procedures and is considered to be one of the minimally invasive techniques in pediatric surgery. We aim to describe our initial experience with the surgery of the distal ureter performed through an inguinal mini-incision. Between March 2012 and June 2013, 8 patients were treated using a minimally invasive inguinal technique. The indications for surgical correction were single system primary obstructive megaureter, obstructive megaureter of the upper pole in a duplex kidney and distal ureteral stones. In all patients with single system obstructive megaureter and significant hydronephrosis, ureterocutaneostomy was performed. In one patient with duplex system primary obstructive megaureter and significant hydronephrosis of the upper pole, ureteroureterostomy of the dilated ureter to the normal caliber ureter in the distal part was performed. In the second patient with duplex system pr...
International Surgery Journal
Background: Ureteric calculi are one of the most common cause of abdominal pain in the emergency room. There are several options for the management of ureteric stones. Ureterorenoscopy and lithotripsy is the commonly used modality because it is less morbid and invasive, but the drawback is proximal stone migration which leads to persisting symptoms and increased costs. The aim of this study is to use an anti-retropulsion device to reduce the rate of proximal stone migration.Methods: This description study was conducted in Sree Gokulam Medical college from December 2014 to December 2015, on 75 consecutive patients who had ureteric stones, of ages 20-60 who were willing to give consent. All patients underwent ureteroscopy and lithotripsy and in those patients from who anti-retropulsion device could not be manipulated proximal to the stone lithotripsy alone was done. Both groups were compared for procedure time, post-operative symptoms and stone free rates.Results: The average time tak...