0007-1 33 l/90/oO65~137/$l0.oO
British Journalof Urolo y(1990), 65,137-140
0 1990 British lournakof Urology
Antegrade Ureterolitholapaxy in the Treatment of Obstructing or Incarcerated Proximal Ureteric Stones G. ANSELMO, E. BASSI, A. FANDELLA, F. MERLO, E. FELlCl and L. MACCATROZZO Department of Urology, Regional Hospital, Treviso, Italy
Summary-Extracorporeal shockwave lithotripsy (ESWL) and retrograde ureterorenoscopy (RU) have transformed the management of ureteric calculi. Nevertheless, patients with obstructing proximal ureteric calculi are not suitable for ESWL or RU. From January 1986 to September 1988, 17 patients with fixed upper ureteric stones underwent antegrade renoureteroscopyand percutaneous surgery. The technique was effective in removing incarcerated proximal ureteric calculi: all patients were stone-free at follow-up 3 months later.
Proximal ureteric stone disease remains a problem with no simple solution despite the recent advances in extracorporeal shockwave lithotripsy and the use of sophisticated endourological instruments. In the case of a stone which is obstructing, or remains blocked for over a month in the ureteric wall, ESWL is not a viable procedure because of the lack of space necessary for stone disintegration (Gumpiger et a/., 1985). Even retrograde ureterorenoscopy does not usually achieve total clearance of calculi, since difficulties in manipulation may lead to damage (Fuchs et al., 1986). The percutaneous approach, using the ureteroscope via an antegrade access, seems a better solution in the treatment of obstructing or incarcerated proximal (down to the iliac crest) ureteric stones.
years) had had a fixed proximal ureteric stone without evidence of progression for more than 1 month. After an unsuccessful attempt to push the stone into the renal cavity, patients underwent antegrade ureterolitholapaxy (Figs. 1-3). The ureteric calculi varied in size from 0.9 to 2.2 cm. We performed 15 punctures in the middle calix and 2 in the lower posterior calices; in 7 patients it was necessary to proceed by intercostal access and in 10 cases access was subcostal. The operations were performed under local anaesthesia by regional infiltration (mepivacaine 2%, 20-40 ml, with the support of a narcotic and atropine) and sedation with flunitrazepam continuous i.v. infusion (Anselmo et al., 1987). The upper urinary tract was visualised and dilated (when possible) by a contrast medium injected through a ureteric catheter ( 6 8 F) previously positioned by transurethral access close to the stone, in order to perform the puncture under fluoroscopic control, Patients and Methods coaxial with the most appropriate calix. During Between January 1986 and December 1988, 157 lithotripsy the ureteric catheter also prevents patients (102 men and 55 women, mean age 44 fragments from falling down the ureter. Before the operation 8 patients, 3 of whom had years) were subjected to percutaneous lithotripsy; 17 of them (10 men and 7 women, mean age 38 pyonephrosis, were subjected to repositioning of a percutaneous nephrostomy left in place for 15-30 days (Fig. 4). In the case of intercostal access an echograph is essential in order to avoid pleuroAccepted for publication 7 March 1989 pulmonary, hepatic or splenic lesions. 137
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BRITISH JOURNAL OF UROLOGY
Fig. 1 (A) Plain film. (B) Intravenous urogram.
angiographic catheter can be pushed along the ureter in order to make manipulation easier. In all cases we applied ultrasonic lithotripsy using grasp forceps to remove the resulting fragments. After removal of the stone, a 24F nephrostomy is left in place until X-ray evidence confirms complete clearance of fragments. If there remains any suspicion of lesions or perforations, a ureteric catheter is positioned as far as the bladder and left in situ for 7 days.
Results
Fig. 2 Antegrade ureterolitholapaxy.
Dilatation is performed up to 26F by Alken telescopic dilators. A rigid 11F ureteroscope is inserted through the nephroscope sheath, pushing it under direct vision into the ureter to reach the stone (Fig. 5 ) . Either a Seldinger guide or a small
No significant bleeding occurred during the procedure and no major complications were encountered ; 16 patients were completely cleared of stones in a single session. In 1 patient the procedure had to be interrupted because of a small ureteric perforation which was treated by positioning a ureteric stent, left in place for 7 days, and also leaving a nephroscopic drain in the percutaneous tract ; this was used later to extract residual stone fragments. After 3 months all patients were screened by Xray; none had residual fragments or dilatation of the axis treated.
Discussion In the last few years, treatment of proximal ureteric
ANTEGRADE URETEROLITHOLAPAXY AND PROXIMAL URETERIC STONES
Fig. 3 Post-treatment nephrostography.
stone disease has undergone remarkable changes following the development of extracorporeal lithotriptors and other sophisticated endourological instruments (Goodfriend, 1984). The choice of treatment depends mainly on the position and size of the stone and on its relationship with the ureter (Sanseverino et al., 1988). A large proximal ureteric stone, blocked for over a month in the urinary tract, cannot be treated by
139
retrograde access. Extracorporeal shockwaves are unsuitable owing to the lack of room for expansion. Retrograde ureterorenoscopy is therefore inadequate if applied to the proximal ureter because the distance covered by the instrument makes manipulation of the stone difficult and there is a high risk of perforating the urinary tract. Moreover, the ureteric section under the stone either maintains its normal diameter or becomes stenotic because of inflammation or spasm. Anatomical conditions thus prevent sufficient water cooling during ultrasonic treatment and abnormal heat could damage the ureter. It is also possible that during manipulation some calcareous fragments might enter the excretory cavities. This method, therefore, when applied to blocked and obstructing proximal ureteric calculi, is invasive and has a high morbidity rate. In patients with abnormal dilatation or dysfunction of the upper urinary tract, or affected by hydropyonephrosis, any intervention should be preceded, in our opinion, by the repositioning of a translumbar percutaneous nephrostomy in order to ease any obstruction and to obtain “nephrological reanimation” of the relevant axis; renal function should be assessed later. The application of antegrade ureteroscopy makes it possible to avoid or reduce to a minimum any damages to the ureter, bearing in mind that the excretory axis above the stone is dilated and thus facilitates progression of the instrument. Heat lesions are also avoided while using ultrasound as a result of the irrigation related to the anatomical conditions and to the water exchange afforded by the nephroscope sheath, which actsas an Amplatzsheath. The short duration of the procedure reduces to a minimum any discomfort to the patients. The procedure should always be preceded by an attempt to push the stone into the renal pelvis; if successful it is possible to apply less invasive methods for stone clearance. In the present series this manoeuvre failed because of ureteric oedema or total incarceration of the stones. We believe, as do Gumpinger et al. (1985), that proximal ureteric obstructing stones which are blocked for over a month should be treated by antegrade ureterolitholapaxy as the method of first choice, this being the best alternative to ureterolithotomy.
Acknowledgement The authors thank L. Faggiano and P. Checchin for their help.
BRITISH JOURNAL OF UROLOGY
140
Fig. 4 (A) Plain film. (B) Pre-operative nephrostography. (C) Post-operative nephrostography.
References Anselmo, C., Bassi, E., Rizzotti, A. ef ol. (1987). Accessi e
chirurgia percutanea per calcolosi renale in anestesia locale: nostra esperienza. Acta Urol. Ital.. 4,224249. Fuchs, G . J., Lupu, A. N. and Chaussy, C. C. (1986). Treatment of ureteric stones: controversies and current differential indications. In Proceedings of Fourth World Congress on Endourology and ES WL, Madrid. Goodfriend, R. (1984). Ultrasonic and electrohydraulic lithotripsy of ureteric calculi. Urology, 23.5-8. Cumpinger, R., Miller, K., Fuchs, C ef d (1985). Anterograde ureteroscopy for stone removal. Eur. Urol.. 11, 199-202. Sanseverino, R.,Canton, F., Salas, G . ef ol. (1988). Treatment of upper ureteric stones. Eur. Urol., 14, I 1 1-1 14.
The Authors G. Anselmo, MD, Professor, Post-graduate Medical School, Padua University; Chief of Urology Division, Treviso. E. Bassi, MD, Assistant Urologist. A. Fandella, MD, Assistant Urologist. F. Merlo, MD, Assistant Urologist. E. Felici, MD, Assistant Urologist. L. Maccatrozzo, MD, Assistant Urologist.
Fig. 5 Antegrade ureterolitholapaxy.
Requests for reprints to: G. Anselmo, Department of Urology, Regional Hospital, Treviso 31 100, Italy.
British Journalof Urolo y(1990), 65,137-140
0 1990 British lournakof Urology
Antegrade Ureterolitholapaxy in the Treatment of Obstructing or Incarcerated Proximal Ureteric Stones G. ANSELMO, E. BASSI, A. FANDELLA, F. MERLO, E. FELlCl and L. MACCATROZZO Department of Urology, Regional Hospital, Treviso, Italy
Summary-Extracorporeal shockwave lithotripsy (ESWL) and retrograde ureterorenoscopy (RU) have transformed the management of ureteric calculi. Nevertheless, patients with obstructing proximal ureteric calculi are not suitable for ESWL or RU. From January 1986 to September 1988, 17 patients with fixed upper ureteric stones underwent antegrade renoureteroscopyand percutaneous surgery. The technique was effective in removing incarcerated proximal ureteric calculi: all patients were stone-free at follow-up 3 months later.
Proximal ureteric stone disease remains a problem with no simple solution despite the recent advances in extracorporeal shockwave lithotripsy and the use of sophisticated endourological instruments. In the case of a stone which is obstructing, or remains blocked for over a month in the ureteric wall, ESWL is not a viable procedure because of the lack of space necessary for stone disintegration (Gumpiger et a/., 1985). Even retrograde ureterorenoscopy does not usually achieve total clearance of calculi, since difficulties in manipulation may lead to damage (Fuchs et al., 1986). The percutaneous approach, using the ureteroscope via an antegrade access, seems a better solution in the treatment of obstructing or incarcerated proximal (down to the iliac crest) ureteric stones.
years) had had a fixed proximal ureteric stone without evidence of progression for more than 1 month. After an unsuccessful attempt to push the stone into the renal cavity, patients underwent antegrade ureterolitholapaxy (Figs. 1-3). The ureteric calculi varied in size from 0.9 to 2.2 cm. We performed 15 punctures in the middle calix and 2 in the lower posterior calices; in 7 patients it was necessary to proceed by intercostal access and in 10 cases access was subcostal. The operations were performed under local anaesthesia by regional infiltration (mepivacaine 2%, 20-40 ml, with the support of a narcotic and atropine) and sedation with flunitrazepam continuous i.v. infusion (Anselmo et al., 1987). The upper urinary tract was visualised and dilated (when possible) by a contrast medium injected through a ureteric catheter ( 6 8 F) previously positioned by transurethral access close to the stone, in order to perform the puncture under fluoroscopic control, Patients and Methods coaxial with the most appropriate calix. During Between January 1986 and December 1988, 157 lithotripsy the ureteric catheter also prevents patients (102 men and 55 women, mean age 44 fragments from falling down the ureter. Before the operation 8 patients, 3 of whom had years) were subjected to percutaneous lithotripsy; 17 of them (10 men and 7 women, mean age 38 pyonephrosis, were subjected to repositioning of a percutaneous nephrostomy left in place for 15-30 days (Fig. 4). In the case of intercostal access an echograph is essential in order to avoid pleuroAccepted for publication 7 March 1989 pulmonary, hepatic or splenic lesions. 137
138
BRITISH JOURNAL OF UROLOGY
Fig. 1 (A) Plain film. (B) Intravenous urogram.
angiographic catheter can be pushed along the ureter in order to make manipulation easier. In all cases we applied ultrasonic lithotripsy using grasp forceps to remove the resulting fragments. After removal of the stone, a 24F nephrostomy is left in place until X-ray evidence confirms complete clearance of fragments. If there remains any suspicion of lesions or perforations, a ureteric catheter is positioned as far as the bladder and left in situ for 7 days.
Results
Fig. 2 Antegrade ureterolitholapaxy.
Dilatation is performed up to 26F by Alken telescopic dilators. A rigid 11F ureteroscope is inserted through the nephroscope sheath, pushing it under direct vision into the ureter to reach the stone (Fig. 5 ) . Either a Seldinger guide or a small
No significant bleeding occurred during the procedure and no major complications were encountered ; 16 patients were completely cleared of stones in a single session. In 1 patient the procedure had to be interrupted because of a small ureteric perforation which was treated by positioning a ureteric stent, left in place for 7 days, and also leaving a nephroscopic drain in the percutaneous tract ; this was used later to extract residual stone fragments. After 3 months all patients were screened by Xray; none had residual fragments or dilatation of the axis treated.
Discussion In the last few years, treatment of proximal ureteric
ANTEGRADE URETEROLITHOLAPAXY AND PROXIMAL URETERIC STONES
Fig. 3 Post-treatment nephrostography.
stone disease has undergone remarkable changes following the development of extracorporeal lithotriptors and other sophisticated endourological instruments (Goodfriend, 1984). The choice of treatment depends mainly on the position and size of the stone and on its relationship with the ureter (Sanseverino et al., 1988). A large proximal ureteric stone, blocked for over a month in the urinary tract, cannot be treated by
139
retrograde access. Extracorporeal shockwaves are unsuitable owing to the lack of room for expansion. Retrograde ureterorenoscopy is therefore inadequate if applied to the proximal ureter because the distance covered by the instrument makes manipulation of the stone difficult and there is a high risk of perforating the urinary tract. Moreover, the ureteric section under the stone either maintains its normal diameter or becomes stenotic because of inflammation or spasm. Anatomical conditions thus prevent sufficient water cooling during ultrasonic treatment and abnormal heat could damage the ureter. It is also possible that during manipulation some calcareous fragments might enter the excretory cavities. This method, therefore, when applied to blocked and obstructing proximal ureteric calculi, is invasive and has a high morbidity rate. In patients with abnormal dilatation or dysfunction of the upper urinary tract, or affected by hydropyonephrosis, any intervention should be preceded, in our opinion, by the repositioning of a translumbar percutaneous nephrostomy in order to ease any obstruction and to obtain “nephrological reanimation” of the relevant axis; renal function should be assessed later. The application of antegrade ureteroscopy makes it possible to avoid or reduce to a minimum any damages to the ureter, bearing in mind that the excretory axis above the stone is dilated and thus facilitates progression of the instrument. Heat lesions are also avoided while using ultrasound as a result of the irrigation related to the anatomical conditions and to the water exchange afforded by the nephroscope sheath, which actsas an Amplatzsheath. The short duration of the procedure reduces to a minimum any discomfort to the patients. The procedure should always be preceded by an attempt to push the stone into the renal pelvis; if successful it is possible to apply less invasive methods for stone clearance. In the present series this manoeuvre failed because of ureteric oedema or total incarceration of the stones. We believe, as do Gumpinger et al. (1985), that proximal ureteric obstructing stones which are blocked for over a month should be treated by antegrade ureterolitholapaxy as the method of first choice, this being the best alternative to ureterolithotomy.
Acknowledgement The authors thank L. Faggiano and P. Checchin for their help.
BRITISH JOURNAL OF UROLOGY
140
Fig. 4 (A) Plain film. (B) Pre-operative nephrostography. (C) Post-operative nephrostography.
References Anselmo, C., Bassi, E., Rizzotti, A. ef ol. (1987). Accessi e
chirurgia percutanea per calcolosi renale in anestesia locale: nostra esperienza. Acta Urol. Ital.. 4,224249. Fuchs, G . J., Lupu, A. N. and Chaussy, C. C. (1986). Treatment of ureteric stones: controversies and current differential indications. In Proceedings of Fourth World Congress on Endourology and ES WL, Madrid. Goodfriend, R. (1984). Ultrasonic and electrohydraulic lithotripsy of ureteric calculi. Urology, 23.5-8. Cumpinger, R., Miller, K., Fuchs, C ef d (1985). Anterograde ureteroscopy for stone removal. Eur. Urol.. 11, 199-202. Sanseverino, R.,Canton, F., Salas, G . ef ol. (1988). Treatment of upper ureteric stones. Eur. Urol., 14, I 1 1-1 14.
The Authors G. Anselmo, MD, Professor, Post-graduate Medical School, Padua University; Chief of Urology Division, Treviso. E. Bassi, MD, Assistant Urologist. A. Fandella, MD, Assistant Urologist. F. Merlo, MD, Assistant Urologist. E. Felici, MD, Assistant Urologist. L. Maccatrozzo, MD, Assistant Urologist.
Fig. 5 Antegrade ureterolitholapaxy.
Requests for reprints to: G. Anselmo, Department of Urology, Regional Hospital, Treviso 31 100, Italy.
