病例報告:以順向螢光透視技術移除逆行性技術移除失敗的輸尿管導管

陳鐸文、林威宇、陳志碩、何東儒、黃雲慶、林健煇、黃國財、劉昱良

嘉義長庚紀念醫院 外科部 泌尿科

Case report: a fluoroscopic guidance antegrade management to remove ureteral stents after failure of retrograde management

Duo-Wun Chen, Wei-Yu Lin, Chih-Shou Chen, Dong-Ru Ho, Yun-Ching Huang, Jian-Hui Lin, Kuo-Tsai Huang, Yu-Liang Liu

Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan

Introduction: Double J ureteral stent is a common treatment for several urological problem. Commonly, the stents are retrieved by retrograde approach via cystoscopy with forceps. However, in some situations, the retrograde way to remove or exchange stent might be difficult or even failure. Therefore, antegrade management may be able to become alternative way to solve this problem, and the fluoroscopic technique is possible a usable way to operate this management safely and  effectively.

Case presentation: We report a case of failure of retrograde way to remove double J stent and successfully exchange by antegrade approach with fluoroscopic guidance technique. In our case, we present a patient who had received several steps to remove the ureteral double stent. At first, due to failure of the exchange ureteral stent by the radiologist who suspected ureter stenosis, they had done the percutaneous nephrostomy first. After that, we arrange retrograde cystoscopy to exchange the stent. During operation, we found a bladder stone which had blocked the orifice, so we removed it by lithotripsy but still failure to retrieved the stent. Finally, we created the left nephrostomy access via the sonography guidance and enlarged by balloon dilater. Then, a 30 Fr. of nephoscopy sheath was inserted into collecting system and guidewire into the lower ureter smoothly under fluoroscopy. After confirm the location of guidewire, we remove the previous stent by nephrostomy forceps and insert a new 6.0 Fr. 26cm double J stent via the guidewire. At last, the contrast media was injected to check if there any abnormal finding from ureter to neo-bladder. The final fluoroscopy showed no ureter stenosis or urine leakage so we remove the nephrostomy and insert a foley for monitoring urinary status. Till the post 10 days after surgery, the patient was under stable condition without foley insertion and any obvious complication or uncomfortable feeling noted.

Discussion: Ureteral double J stent removal or exchange by retrograde cystoscopy was more prefered by operators because its less invasive and more safety. However, it is still other ways that can exchange the stent feasibility and effectively. According to antegrade approach, there are several conditions indicated the most common one is preexisting nephrostomy route. In previous study, the antegrade technical success rate is ranged from 95%-100%, and multiple tools include forceps or snare can be used. After procedure, we found there was rare major compilation reported in studies, and minor complications was more often included hematoma, hematuria, laceration or tract leakage of the pelvicalyceal system, but these often do not need any further treatment and can spontaneously resolve in the follow-up period