Clinical Papers © 1990 S. Karger AG, Basel 0302-2838/90/0173-0193Î2.75/0
Eur Urol 1990;17:193-199
Flexible Antegrade and Retrograde Nephroscopy: Review of 50 Cases P. Puppo, P. Bottino, F. Germinale, C. Caviglia, G. Ricciotti, L. Giuliani Department of Urology, University of Genoa, Italy 1608037
Key Words. Flexible scopes ■ Tumors • Stones • Upper urinary tract Abstract. 50 cases of flexible instrumentation of the intrarenal collecting system are reviewed. 28 were performed by retrograde flexible ureterorenoscopy. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. 22 cases were performed through a percutaneous route. The indications were both diagnostic (filling defects and/or hematuria) and therapeutic (caliceal stone and/or fragments). The success rate was high in the diagnostic cases (20 of 24), but lower in the therapeutic cases ( 13 of 26). The complication rate was extremely low and the postoperative course was always uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system. Both transureteral and percutaneous flexible nephroscopies are feasible and effective procedures. A laser can be used well in this area.
Material and Methods 50 patients aged between 25 and 73 underwent flexible instru mentation of the intrarenal collecting system from January 1986 to December 1988. 32 patients were males and 18 females. The indi cation for flexible instrumentation was the evaluation of filling defects in 10 cases (group A), the evaluation of undiagnosed hema-
tuna in 14 cases (group B), and the treatment of caliceal stones or fragments in 26 cases (group C). 14 of 26 patients in group C had undergone percutaneous debulking and repeated ESWL sessions for complete staghorn stones. Flexible nephroscopy was planned to treat caliceal stones resistant to ESWL and to wash the fragments out of the peripheral calices. 6 of 26 patients had had surgical removal of branched stones and flexible nephroscopy was planned to reach residual caliceal stones. 6 patients had had repeated unsuc cessful ESWL sessions for caliceal stones. The infundibulum was narrow but present in all 6 cases. The procedure was always carried out under general anesthesia. The access, transureteral or percutaneous, was chosen according to the presence of local factors facilitating one of the procedures. The percutaneous route was essentially chosen when a nephrostomy tube (percutaneously or surgically placed) was already present ( 19 cases) and when there was severe stenosis of the ureter (3 cases). A retrograde flexible nephroscopy was performed in 8 of 10 group-A patients, in all group-B patients and in 6 of 26 group-C patients. Technical Details A 10.8-french flexible ureterorenoscope (Olympus) was always used, with 160 and 90° of deflection and a 1,2-mm working channel. Hydraulic dilation in combination with a working sheath was used in 21 of 28 cases. A 13-french rigid ureterorenoscope (Olympus) was prepared by placing a Teflon sheath (15 french inner diameter, 18 french outer diameter) around it, long enough to ensure the commu nication between the ureter and the external urethral meatus (fig. 1). Irrigation through the working channel was ensured by the same Ureteromat pump [7], Ureteral tortuosity was passed by deflecting the tip of the instrument to remain within the lumen. Owing to the Downloaded by: University of Exeter 144.173.6.94 - 6/7/2020 5:15:20 AM
The intrarenal collecting system is spatially arranged in such a way that it is impossible to explore it entirely with a rigid scope whatever form of entry is used [1]. The natural diagnostic and operative endoscopy of the intra renal collecting system is flexible fiberoscopy. Flexible ureteropyeloscopy was reported by Takayasu and Aso [2] in the 1970s. Flexible percutaneous nephroscopy was envisaged in the early 1980s [3] soon after the introduc tion of percutaneous lithotripsy. However, the extreme difficulty in irrigating and working through the instru ments limited the application of flexible fiberoscopy to specialized centers and to selected cases. The continuing progress in instrumentation and the increase in endourological skills have made it possible in recent years to col lect significant series [4-6]. We review our first 50 cases of flexible nephroscopy, carried out via the ureter (28 cases) or via percutaneous puncture (22 cases).
Puppo/Bottino/Germinale/Caviglia/Ricciotti/Giuliani
194
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Fig. 1. a A rigid ureteroscope with a working Teflon sheath is pre viously inserted with hydraulic dila tion over a rigid scope, b Through the working sheath the flexible 10french ureteroscope can easily be in serted.
Antegrade Flexible Fiberoscopy A 14.5- or 16-french flexible nephroscope (Olympus) was used, with 160 and 100° of deflection and a 2-mm working channel. When a nephrostomy tube over 16 french was already present, the flexible nephroscope was simply inserted through the néphros tomie track under visual and fluoroscopic control. In the 3 cases where percutaneous puncture was needed, dilation was carried out to 27 french and a 24-french rigid nephroscope was first inserted to explore the pelvis. The flexible scope was inserted through the Amplatz sheath without any rubber diaphragm. In the last 12 cases, irrigation was carried out through a peristaltic pump as for the ureterorenoscope. For orientation we used the same technique pre viously described for ureterorenoscopy. For stone disintegration we used 5-french electrohydraulic probes. Grasping forceps and baskets were also used to remove fragments. After the procedure had been completed, a nephrostomy tube was left in place for 48-72 h.
Results
In all 10 patients of group A (filling defects), the pro cedure was successful, that is, the whole intrarenal col lecting system was satisfactorily explored. In 3 of 10
patients, balloon dilation of the ureter was necessary to reach the pelvis. In 4 cases no pathology was found and the radiological filling defect was interpreted as a false image. In 4 cases a tumor was detected and biopsied. 3 of 4 cases were operated on by a nephroureterectomy. 1 case of solitary kidney was percutaneously treated by dilating the track used for antegrade flexible nephroscopy and inserting a 27-french resectoscope. The patient is free of tumor 2 years after the procedure. In 2 cases radiolucent stones were found. They were successfully treated by ureteral double-j stenting and urine alkalinization. In 4 of 14 patients of group B the procedure was unsuccessful. In 1 case the meatus could not be passed and dilated. In 1 patient the ureter was perforated at the lumbar level and a double-j stent was placed. In 2 patients brisk bleeding into the pelvis made satisfactory exploration impossible. In 10 of 14 patients exploration of the intrarenal collecting system was fully accom plished. In 3 cases no pathology could be found. In 3 patients radiolucent stones were detected and disinte grated by electrohydraulic discharges. Stenting and urine alkalinization completed the treatment. In 3 patients a small tumor (less than 0.5 mm in diameter) was detected and biopsied (Go in all cases). In 1 case papillary necrosis in a sponge kidney was diagnosed (fig. 4). In 13 of 26 patients of group C complete disintegra tion of the stone was achieved. In 10 of 26 patients bleeding forced us to stop the procedure before it could be completed. In 3 cases of retrograde nephroscopy the calix could not be entered and a percutaneous calicoscopy with a rigid 17-french instrument was planned. In 2 cases the infundibulum was dilated through a balloon Downloaded by: University of Exeter 144.173.6.94 - 6/7/2020 5:15:20 AM
sometimes difficult orientation within the kidney, control injection of diluted contrast medium proved to be very useful. Biplane fluoroscopic control was also very useful (fig. 2) in order to distinguish between anterior and posterior calices. A radiography was taken for each calix explored in order to compare them with the position of the scope and to avoid repeated explorations. Biopsy was taken when a tumor was seen or suspected. When disintegration of caliceal stones was wanted, it was accomplished by a 3-french electrohydraulic probe (Waltz) or by laser fiber (Candela). When the caliceal infundibulum was narrow, we tried to dilate it with a balloon catheter (fig. 3) before entering it and disintegrating the stones. After the procedure was completed, a polyethylene 10french soft catheter was inserted through the sheath and left for 24 h. Antibiotics were always given for at least 4 days.
195
Flexible Nephroscopy
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Eur Urol 1990;17:193-199
Flexible Antegrade and Retrograde Nephroscopy: Review of 50 Cases P. Puppo, P. Bottino, F. Germinale, C. Caviglia, G. Ricciotti, L. Giuliani Department of Urology, University of Genoa, Italy 1608037
Key Words. Flexible scopes ■ Tumors • Stones • Upper urinary tract Abstract. 50 cases of flexible instrumentation of the intrarenal collecting system are reviewed. 28 were performed by retrograde flexible ureterorenoscopy. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. 22 cases were performed through a percutaneous route. The indications were both diagnostic (filling defects and/or hematuria) and therapeutic (caliceal stone and/or fragments). The success rate was high in the diagnostic cases (20 of 24), but lower in the therapeutic cases ( 13 of 26). The complication rate was extremely low and the postoperative course was always uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system. Both transureteral and percutaneous flexible nephroscopies are feasible and effective procedures. A laser can be used well in this area.
Material and Methods 50 patients aged between 25 and 73 underwent flexible instru mentation of the intrarenal collecting system from January 1986 to December 1988. 32 patients were males and 18 females. The indi cation for flexible instrumentation was the evaluation of filling defects in 10 cases (group A), the evaluation of undiagnosed hema-
tuna in 14 cases (group B), and the treatment of caliceal stones or fragments in 26 cases (group C). 14 of 26 patients in group C had undergone percutaneous debulking and repeated ESWL sessions for complete staghorn stones. Flexible nephroscopy was planned to treat caliceal stones resistant to ESWL and to wash the fragments out of the peripheral calices. 6 of 26 patients had had surgical removal of branched stones and flexible nephroscopy was planned to reach residual caliceal stones. 6 patients had had repeated unsuc cessful ESWL sessions for caliceal stones. The infundibulum was narrow but present in all 6 cases. The procedure was always carried out under general anesthesia. The access, transureteral or percutaneous, was chosen according to the presence of local factors facilitating one of the procedures. The percutaneous route was essentially chosen when a nephrostomy tube (percutaneously or surgically placed) was already present ( 19 cases) and when there was severe stenosis of the ureter (3 cases). A retrograde flexible nephroscopy was performed in 8 of 10 group-A patients, in all group-B patients and in 6 of 26 group-C patients. Technical Details A 10.8-french flexible ureterorenoscope (Olympus) was always used, with 160 and 90° of deflection and a 1,2-mm working channel. Hydraulic dilation in combination with a working sheath was used in 21 of 28 cases. A 13-french rigid ureterorenoscope (Olympus) was prepared by placing a Teflon sheath (15 french inner diameter, 18 french outer diameter) around it, long enough to ensure the commu nication between the ureter and the external urethral meatus (fig. 1). Irrigation through the working channel was ensured by the same Ureteromat pump [7], Ureteral tortuosity was passed by deflecting the tip of the instrument to remain within the lumen. Owing to the Downloaded by: University of Exeter 144.173.6.94 - 6/7/2020 5:15:20 AM
The intrarenal collecting system is spatially arranged in such a way that it is impossible to explore it entirely with a rigid scope whatever form of entry is used [1]. The natural diagnostic and operative endoscopy of the intra renal collecting system is flexible fiberoscopy. Flexible ureteropyeloscopy was reported by Takayasu and Aso [2] in the 1970s. Flexible percutaneous nephroscopy was envisaged in the early 1980s [3] soon after the introduc tion of percutaneous lithotripsy. However, the extreme difficulty in irrigating and working through the instru ments limited the application of flexible fiberoscopy to specialized centers and to selected cases. The continuing progress in instrumentation and the increase in endourological skills have made it possible in recent years to col lect significant series [4-6]. We review our first 50 cases of flexible nephroscopy, carried out via the ureter (28 cases) or via percutaneous puncture (22 cases).
Puppo/Bottino/Germinale/Caviglia/Ricciotti/Giuliani
194
b
a
■» w ft
*
...... *
* •Ì,
;
I y'
■' ^
Fig. 1. a A rigid ureteroscope with a working Teflon sheath is pre viously inserted with hydraulic dila tion over a rigid scope, b Through the working sheath the flexible 10french ureteroscope can easily be in serted.
Antegrade Flexible Fiberoscopy A 14.5- or 16-french flexible nephroscope (Olympus) was used, with 160 and 100° of deflection and a 2-mm working channel. When a nephrostomy tube over 16 french was already present, the flexible nephroscope was simply inserted through the néphros tomie track under visual and fluoroscopic control. In the 3 cases where percutaneous puncture was needed, dilation was carried out to 27 french and a 24-french rigid nephroscope was first inserted to explore the pelvis. The flexible scope was inserted through the Amplatz sheath without any rubber diaphragm. In the last 12 cases, irrigation was carried out through a peristaltic pump as for the ureterorenoscope. For orientation we used the same technique pre viously described for ureterorenoscopy. For stone disintegration we used 5-french electrohydraulic probes. Grasping forceps and baskets were also used to remove fragments. After the procedure had been completed, a nephrostomy tube was left in place for 48-72 h.
Results
In all 10 patients of group A (filling defects), the pro cedure was successful, that is, the whole intrarenal col lecting system was satisfactorily explored. In 3 of 10
patients, balloon dilation of the ureter was necessary to reach the pelvis. In 4 cases no pathology was found and the radiological filling defect was interpreted as a false image. In 4 cases a tumor was detected and biopsied. 3 of 4 cases were operated on by a nephroureterectomy. 1 case of solitary kidney was percutaneously treated by dilating the track used for antegrade flexible nephroscopy and inserting a 27-french resectoscope. The patient is free of tumor 2 years after the procedure. In 2 cases radiolucent stones were found. They were successfully treated by ureteral double-j stenting and urine alkalinization. In 4 of 14 patients of group B the procedure was unsuccessful. In 1 case the meatus could not be passed and dilated. In 1 patient the ureter was perforated at the lumbar level and a double-j stent was placed. In 2 patients brisk bleeding into the pelvis made satisfactory exploration impossible. In 10 of 14 patients exploration of the intrarenal collecting system was fully accom plished. In 3 cases no pathology could be found. In 3 patients radiolucent stones were detected and disinte grated by electrohydraulic discharges. Stenting and urine alkalinization completed the treatment. In 3 patients a small tumor (less than 0.5 mm in diameter) was detected and biopsied (Go in all cases). In 1 case papillary necrosis in a sponge kidney was diagnosed (fig. 4). In 13 of 26 patients of group C complete disintegra tion of the stone was achieved. In 10 of 26 patients bleeding forced us to stop the procedure before it could be completed. In 3 cases of retrograde nephroscopy the calix could not be entered and a percutaneous calicoscopy with a rigid 17-french instrument was planned. In 2 cases the infundibulum was dilated through a balloon Downloaded by: University of Exeter 144.173.6.94 - 6/7/2020 5:15:20 AM
sometimes difficult orientation within the kidney, control injection of diluted contrast medium proved to be very useful. Biplane fluoroscopic control was also very useful (fig. 2) in order to distinguish between anterior and posterior calices. A radiography was taken for each calix explored in order to compare them with the position of the scope and to avoid repeated explorations. Biopsy was taken when a tumor was seen or suspected. When disintegration of caliceal stones was wanted, it was accomplished by a 3-french electrohydraulic probe (Waltz) or by laser fiber (Candela). When the caliceal infundibulum was narrow, we tried to dilate it with a balloon catheter (fig. 3) before entering it and disintegrating the stones. After the procedure was completed, a polyethylene 10french soft catheter was inserted through the sheath and left for 24 h. Antibiotics were always given for at least 4 days.
195
Flexible Nephroscopy
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