陳浩瑋¹、陳妤甄¹、黃琮懿¹、李經家¹

高雄醫學大學附設醫院 泌尿部¹

Hao-Wei Chen¹, Yu-Chen Chen¹, Tsung-Yi Huang¹, Ching-Chia Li¹

Divisions of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan ¹

 

Large ureteral stone with severe ureteral tortuosity is challenging and always prevent successful retrograde ureteral access in rigid ureteroscopic lithotripsy (URSL). A flexible ureteroscope (fURS) is considered a new trend. However, fURS is not commonly available worldwide due to its high cost, skill-dependence, and long operative time. Therefore, our study is to share our experiences of a modified procedure in which the antegrade guidewire from percutaneous nephrostomy (PCN) tract was pulled out of the urethra by cystoscopy to straighten the tortuous ureter, following by the simultaneous supine PCNL and URSL for treating ureter stones with severe ureteral tortuosity.

 

This study retrospectively reported patients with large impacted ureter stone (>15mm) with severe tortuosity who failed with URSL and underwent this modified procedure at Kaohsiung Medical University Hospital between January 2017 to September 2017. All the patients received abdominal computed tomography to define total stone burden and the position of tortuosity. The patient was placed in the Galdakao-modified supine valdivia (GMSV) position. A hydrophilic guidewire (Radifocus® Glidewire®) from PCN was inserted antegradely along the ureter under fluroscopically guided to the bladder. The distal end of the guidewire was pulled out of the urethra by the cystoscopy. We straightened the guidewire from both ends with tension to against the tortuous ureter. After “straightening” the ureter, ureteroscopy was available to approach the ureter stones, which was disintegrated by holmium:YAG laser till the diameter of fragments small than 1cm. We pushed the fragments back by ureteroscopy retrogradely and removed antegradely by forceps under renoscopy through an Amplatz sheath. The post-operative complication was classified with modified Clavien grading system. Stone clearance was defined as a single fragment ≤ 4 mm on standard radiography at the 3-month follow-up.

 

A total of 5 patients underwent this modified procedure for large impacted upper ureter stone (>15mm) with severe tortuosity were included. The average of patient’s age, stone size, operation time, postoperative hospital stay were 62.2 years (range, 45-76 years), 22.8 mm (range, 17.4-30.4 mm), 86 minutes (range, 60–105) and 3.4 days (range, 2-7 days) respectively. All patients were treated with ureteral stents without a nephrostomy tube, and all patients achieved stone-free status. 2 patients with grade 1 (hematuria) and 1 patient with grade 2 complication (fever with antibiotic treatment) were observed. Noticeably, no blood transfusions or urine leakage was observed in this series

 

Our preliminary data showed that our modified procedure is safety and validity for ureteral stones with ureteral tortuosity, which cannot be treated with URSL. Large-scale studies should be conducted to better examine technique efficacy; however, our current results regarding the additional endourological maneuver seem promising.