針對輸尿管扭結患者使用輸尿管鞘輔助輸尿管校直技巧之軟式輸尿管鏡經驗
陳鴻毅、吳俊德、林政鋒、陳文祥、林承家
基隆長庚醫院 外科部 泌尿科
Ureteral access sheath assisted straightening technique for kinking ureter during flexible ureteroscopy
Hung-Yi Chen, Chun-Te Wu, Cheng-Feng Lin, Wen-Hsiang Chen, Cheng-chia Lin
Divisions of Urology, Department of Surgery, Chang Gung Memorial Hospital, Keelung
Purpose:
Upper tract ureteral stone related kinking ureter with difficult ureteroscopy approach is always a troubled condition. We present our experience of using a novel ureteral access sheath (UAS) assisted ureter straightening technique for successfully approach while performing flexible ureteroscopy (fURS).
Materials and Methods
Between Jan 2017 and Feb 2019, a total of 632 consecutive patients underwent fURS by a single experienced surgeon at our institute for upper tract urolithiasis. After excluded pre-existing ureteral stricture or intrinsic ureteric-pelvic junction obstruction cases, failure of initial fURS approach was encountered in 22 patients since kinking ureter. We described a novel UAS assisted straightening technique as followed: UAS placement under fluoroscopy guidance as proximal as possible first, then we drew back UAS with hydrophilic guidewire or fURS advanced simultaneously. Ureteral straightening and successfully approach are achieved through the above manipulation because of the force of static friction between UAS and ureter. Ureteral injury after surgery was assessed visually while withdrawing UAS and JJ stent placement in all patients. Preoperative, intraoperative, postoperative variables were retrospectively analyzed.
Result
The mean stone size was 16.7 ± 6mm, stone was located at upper ureter (14/22, 63.6%); kidney (8/22, 36.4%), ureter kinking location: upper ureter (19/22, 86.4%); middle ureter (3/22, 13.6%), Overall successful approach rate was 81.8% (18/22); two of the failure approach patients due to difficult guidewire advanced which approach through antegrade route smoothly; another 2 patients experienced endoscopic classification high-grade ureteral injury during procedure (grade II: 1; grade III: 1), JJ stent placement and staged fURS were arranged thereafter. All the successfully approach patients achieved stone free at 1-mo follow up, the overall primary stone-free rate was 81.8%. High grade (> grade II) ureteral injury was observed in 4 patients (18.2%). Complications were reported in 3 patients (13.6%) overall, with Clavien grade 2 in 1 patients (4.5%), grade 3 in 2 patients (9.1%).
Conclusion
We described a UAS assisted ureter straightening technique during fURS which is an effective approach for kinking ureter with the low complicated rate.