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A New Technique for Retrograde Stone Displacement in the Tortuous Ureter before Extracorporeal Shock Wave Lithotripsy
0022-534 7/89/1423-0778$02.00/0 Vol. 142, September Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
A NEW TECHNIQUE FOR RETROGRADE STONE DISPLACEMENT IN THE TORTUOUS URETER BEFORE EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY JON L. PRYOR
AND
JAY Y. GILLENWATER
From the Department of Urology, University of Virginia Medical Center, Charlottesville, Virginia
ABSTRACT
A tortuous ureter can prevent a ureteral calculus from being manipulated into the kidney before extracorporeal shock wave lithotripsy. We describe a technique using a floppy-tip guide wire and a double channel cystoscope to manipulate a stone from a tortuous ureter into the kidney. (J. Urol., 142: 778-779, 1989) Extracorporeal shock wave lithotripsy (ESWL*) has become the mainstay of treatment for urinary calculi. Techniques have improved so that stones in the entire ureter can be treated with ESWL. Although upper ureteral calculi can be treated in situ, recent evidence suggests better pulverization if the stones are manipulated into the kidney before lithotripsy. 1 • 2 Management of lower ureteral calculi is less straightforward. Our preferred treatment of lower ureteral calculi is basket extraction, or laser or ultrasonic lithotripsy. Lower ureteral calculi also can be treated in situ by ESWL. Alternatively, lower ureteral calculi can be manipulated into the kidney before lithotripsy to increase the wet surface area and assist in fragmentation. A tortuous ureter may cause occasional difficulty in manipulating upper and lower ureteral calculi. We describe an endourological maneuver using a floppy-tip guide wire and a double channel cystoscope to assist in manipulating a stone from a tortuous ureter into the kidney.
floppy-tip Bentson guide wire was passed up the ureter and as it passed the stone the ureter sprang back to a gentle S configuration. The 6F whistle-tip catheter was passed via the second port along the guide wire. The catheter then was in direct contact with the stone, which was easily manipulated into the
TECHNIQUE
Cystoscopy and attempted manipulation of a ureteral stone with a ureteral catheter are done in the usual fashion. With fluoroscopic guidance the stone may not appear to be moving and the ureteral catheter may not be in contact with the stone, suggesting a tortuous ureter (part A of figure). A tortuous ureter also may be diagnosed by a retrograde ureterogram or a previous excretory urogram. If the stone is not moving and a tortuous ureter is suspected, the ureteral catheter is removed and the bridge is changed to a double channel bridge on the cystoscope. A floppy-tip guide wire is placed through a channel, and maneuvered past the stone and up into the kidney (part B of figure). This should straighten the ureter. The ureteral catheter is reinserted into the second channel and the catheter is passed into the ureter adjacent to the guide wire (part C of figure). The force of the catheter is directed against the stone and in line with the ureter, and this usually allows for manipulation of the stone into the kidney (part D of figure).
A
B
CASE REPORTS
Case 1. W. L., a 65-year-old man, presented with a 10 X 7 mm. distal left ureteral calculus. Before ESWL, cystoscopy was performed and a 6F whistle-tip ureteral catheter was used in an attempt to manipulate the stone into the left kidney under fluoroscopic control. The catheter was not in direct contact with the stone and it appeared that the ureter would move when the catheter was pushed, which implied a tortuous ureter. The stone did not move despite repeated attempts at retrograde flushing with saline. The catheter was removed and a double channel bridge was placed on the cystoscope. A 0.038-inch Accepted for publication March 8, 1989. * Dornier Medical Systems, Inc., Marietta, Georgia.
A, calculus in tortuous ureter. Ureteral catheter is not in contact with stone. In addition, force of catheter (arrow 1) is not in line with ureter above stone (arrow 2). B, floppy-tip guide wire (arrow) straightens tortuous ureter. C, ureteral catheter is replaced in double channel cystoscope and is pushing stone in direction of ureter (arrow). D, calculus is manipulated into kidney (arrow).
778
NEW TECHNIQUE FOR RETROGRADE STONE D1SPLACEMENT l:N TORTUOUS URETER
kidney. ESWL with 2,000 shocks in the 18 to 22 kv. range was done. A plain abdominal film the next day demonstrated the stone to be well fragmented in the renal pelvis. Case 2. C. P., a 46-year-old man, had a 3 X 15 mm. stone in the right mid ureter. Multiple attempts were made to push the stone up into the renal pelvis before ESWL but the ureter, not the stone, appeared to be moving. The patient was believed to have a tortuous ureter. Therefore, we changed to a double channel bridge and used a floppy-tip guide wire to straighten the ureter as described previously. A 6F ureteral catheter was passed alongside the guide wire and the stone was pushed easily up into the renal pelvis. The patient then underwent ESWL, with the renal stone receiving 1,500 shocks in the 18 to 20 kv. range. A plain abdominal film the next day revealed only sand in the right kidney.
DISCUSSION
As mentioned previously, there is controversy over how to treat ureteral calculi. The decision on the mode of therapy often is individual. When a decision is made to treat a ureteral stone by ESWL, recent evidence suggests that manipulating the stone back into the kidney or placing a ureteral catheter past the stone may help to disintegrate it. It is believed that space for the fragments to fall apart allows for transmission of shock wave energy. 2 A tortuous ureter may prevent a stone from being
779
manipulated into the kidney. Traditional techniques at retrograde displacement of a calculus in a tortuous ureter include placing the patient in the Trendelenburg position to straighten the ureter followed by pushing the calculus with a ureteral catheter or flushing with saline. When these techniques fail an alternative method is described using a floppy-tip guide wire to straighten the tortuous ureter. Then, a catheter placed adjacent to the guide wire is used to direct force to the stone in the direction of the ureter. With a guide wire passed and the ureter straightened, there still is a potential for perforation if the stone is impacted severely. The calculus should be manipulated gently and if it cannot be displaced in a retrograde manner other techniques, such as treatment in situ or antegrade manipulation, should be used. Our 2 cases document the safety and success of this method. This maneuver generally is successful only when the ureter is tortuous and it does not work well for other causes of failure to manipulate a stone into the kidney. REFERENCES
1. Lingeman, J. E., Shirrell, W. L., Newman, D. M., Mosbaugh, P.
G., Steele, R. E. and Woods, J. R.: Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J. Urol., 138: 720, 1987. 2. Mueller, S. C., Wilbert, D., Thueroff, J. W. and Alken, P.: Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J. Urol., 135: 831, 1986.
THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
A NEW TECHNIQUE FOR RETROGRADE STONE DISPLACEMENT IN THE TORTUOUS URETER BEFORE EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY JON L. PRYOR
AND
JAY Y. GILLENWATER
From the Department of Urology, University of Virginia Medical Center, Charlottesville, Virginia
ABSTRACT
A tortuous ureter can prevent a ureteral calculus from being manipulated into the kidney before extracorporeal shock wave lithotripsy. We describe a technique using a floppy-tip guide wire and a double channel cystoscope to manipulate a stone from a tortuous ureter into the kidney. (J. Urol., 142: 778-779, 1989) Extracorporeal shock wave lithotripsy (ESWL*) has become the mainstay of treatment for urinary calculi. Techniques have improved so that stones in the entire ureter can be treated with ESWL. Although upper ureteral calculi can be treated in situ, recent evidence suggests better pulverization if the stones are manipulated into the kidney before lithotripsy. 1 • 2 Management of lower ureteral calculi is less straightforward. Our preferred treatment of lower ureteral calculi is basket extraction, or laser or ultrasonic lithotripsy. Lower ureteral calculi also can be treated in situ by ESWL. Alternatively, lower ureteral calculi can be manipulated into the kidney before lithotripsy to increase the wet surface area and assist in fragmentation. A tortuous ureter may cause occasional difficulty in manipulating upper and lower ureteral calculi. We describe an endourological maneuver using a floppy-tip guide wire and a double channel cystoscope to assist in manipulating a stone from a tortuous ureter into the kidney.
floppy-tip Bentson guide wire was passed up the ureter and as it passed the stone the ureter sprang back to a gentle S configuration. The 6F whistle-tip catheter was passed via the second port along the guide wire. The catheter then was in direct contact with the stone, which was easily manipulated into the
TECHNIQUE
Cystoscopy and attempted manipulation of a ureteral stone with a ureteral catheter are done in the usual fashion. With fluoroscopic guidance the stone may not appear to be moving and the ureteral catheter may not be in contact with the stone, suggesting a tortuous ureter (part A of figure). A tortuous ureter also may be diagnosed by a retrograde ureterogram or a previous excretory urogram. If the stone is not moving and a tortuous ureter is suspected, the ureteral catheter is removed and the bridge is changed to a double channel bridge on the cystoscope. A floppy-tip guide wire is placed through a channel, and maneuvered past the stone and up into the kidney (part B of figure). This should straighten the ureter. The ureteral catheter is reinserted into the second channel and the catheter is passed into the ureter adjacent to the guide wire (part C of figure). The force of the catheter is directed against the stone and in line with the ureter, and this usually allows for manipulation of the stone into the kidney (part D of figure).
A
B
CASE REPORTS
Case 1. W. L., a 65-year-old man, presented with a 10 X 7 mm. distal left ureteral calculus. Before ESWL, cystoscopy was performed and a 6F whistle-tip ureteral catheter was used in an attempt to manipulate the stone into the left kidney under fluoroscopic control. The catheter was not in direct contact with the stone and it appeared that the ureter would move when the catheter was pushed, which implied a tortuous ureter. The stone did not move despite repeated attempts at retrograde flushing with saline. The catheter was removed and a double channel bridge was placed on the cystoscope. A 0.038-inch Accepted for publication March 8, 1989. * Dornier Medical Systems, Inc., Marietta, Georgia.
A, calculus in tortuous ureter. Ureteral catheter is not in contact with stone. In addition, force of catheter (arrow 1) is not in line with ureter above stone (arrow 2). B, floppy-tip guide wire (arrow) straightens tortuous ureter. C, ureteral catheter is replaced in double channel cystoscope and is pushing stone in direction of ureter (arrow). D, calculus is manipulated into kidney (arrow).
778
NEW TECHNIQUE FOR RETROGRADE STONE D1SPLACEMENT l:N TORTUOUS URETER
kidney. ESWL with 2,000 shocks in the 18 to 22 kv. range was done. A plain abdominal film the next day demonstrated the stone to be well fragmented in the renal pelvis. Case 2. C. P., a 46-year-old man, had a 3 X 15 mm. stone in the right mid ureter. Multiple attempts were made to push the stone up into the renal pelvis before ESWL but the ureter, not the stone, appeared to be moving. The patient was believed to have a tortuous ureter. Therefore, we changed to a double channel bridge and used a floppy-tip guide wire to straighten the ureter as described previously. A 6F ureteral catheter was passed alongside the guide wire and the stone was pushed easily up into the renal pelvis. The patient then underwent ESWL, with the renal stone receiving 1,500 shocks in the 18 to 20 kv. range. A plain abdominal film the next day revealed only sand in the right kidney.
DISCUSSION
As mentioned previously, there is controversy over how to treat ureteral calculi. The decision on the mode of therapy often is individual. When a decision is made to treat a ureteral stone by ESWL, recent evidence suggests that manipulating the stone back into the kidney or placing a ureteral catheter past the stone may help to disintegrate it. It is believed that space for the fragments to fall apart allows for transmission of shock wave energy. 2 A tortuous ureter may prevent a stone from being
779
manipulated into the kidney. Traditional techniques at retrograde displacement of a calculus in a tortuous ureter include placing the patient in the Trendelenburg position to straighten the ureter followed by pushing the calculus with a ureteral catheter or flushing with saline. When these techniques fail an alternative method is described using a floppy-tip guide wire to straighten the tortuous ureter. Then, a catheter placed adjacent to the guide wire is used to direct force to the stone in the direction of the ureter. With a guide wire passed and the ureter straightened, there still is a potential for perforation if the stone is impacted severely. The calculus should be manipulated gently and if it cannot be displaced in a retrograde manner other techniques, such as treatment in situ or antegrade manipulation, should be used. Our 2 cases document the safety and success of this method. This maneuver generally is successful only when the ureter is tortuous and it does not work well for other causes of failure to manipulate a stone into the kidney. REFERENCES
1. Lingeman, J. E., Shirrell, W. L., Newman, D. M., Mosbaugh, P.
G., Steele, R. E. and Woods, J. R.: Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J. Urol., 138: 720, 1987. 2. Mueller, S. C., Wilbert, D., Thueroff, J. W. and Alken, P.: Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J. Urol., 135: 831, 1986.