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E109 The technique of endoscopic combined intrarenal surgery in the prone split-leg position: Prone position is suitable for simultaneous operation of flexible ureteroscopy and mini-percutaneous nephrolithotomy
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thursday 5 september 2013 / european urology supplements 12 (2013) 29–68
performed while looking at three images (the transurethral endoscopic, fluoroscopic and ultrasonic images). The flexible ureteroscope was advanced into the renal pelvis through the ureteral access sheath. Holmium:YAG laser lithotripsy was then performed to carve a channel to allow the ureteroscope to be passed into the desired calyx, which was occupied by the stone, under fluoroscopic vision. The stone in the desired calyx was irradiated and fragmented with the Holmium:YAG laser. At this point, percutaneous antegrade access to the calyx of interest was obtained using a nephrostomy needle under ultrasound guidance with a biopsy attachment. The hyperechoic moving particles over the tip of the ureteroscope provided an excellent ultrasound target during firing of the laser. The needle was safely inserted into the targeted calyx. The puncture of the nephrostomy needle into the collecting system was monitored under direct ureteroscopic vision. PNL and f-TUL were then performed simultaneously while looking at three images (transurethral and percutaneous endoscopic images and the fluoroscopic image). Results: The operating room support staff was able to view images from almost any angle. The operators could efficiently share operative information on the one display to save time without complications. Conclusions: The new Panasonic monitor provided flexible picture-in-picture and picture-by-picture functionality with independent image adjustment, enabling the surgeon to view, toggle or swap a live or saved image. Consolidation of multiple screens eliminated clutter and created additional working space in the operating room. E109 The technique of endoscopic combined intrarenal surgery in the prone split-leg position: Prone position is suitable for simultaneous operation of flexible ureteroscopy and mini-percutaneous nephrolithotomy S. Hamamoto1 , T. Yasui1 , S. Koiwa2 , T. Isero2 , H. Kamiya2 , A. Okada1 , K. Taguchi1 , Y. Hashimoto2 , K. Tozawa1 , Y. Iwase1 , K. Kohri1 . 1 Nagoya City University, Dept. of Nephro-Urology, Nagoya, Japan; 2 Toyota Kosei Hospital, Dept. of Urology, Nagoya, Japan Introduction & Objectives: Endoscopic combined intrarenal surgery (ECIRS) is a versatile procedure for renal calculi using retrograde flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PNL). The modified supine Valdivia position seems beneficial for a bilateral approach during ECIRS. However, use of this position has some disadvantages, including a decreased range of potential access angles and kidney hypermobility, that increase the risk of antegrade renal puncture. We developed a new technique for ECIRS in the prone split-leg position (prone-ECIRS) and evaluated its efficacy. Material & Methods: Between December 2010 and Janyary 2013, 60 patients presenting with large calculi (mean size, 37.2±2.6 mm) underwent prone-ECIRS; 33 had staghorn kidney stones. A laser fiber was used with fURS through a ureteral access sheath, and a lithoclast lithotripsy was performed through a mini-percutaneous tract. Threedimensional computed tomography was used to determine anatomical variations, including a ureteral location and ureteropelvic junction (UPJ) angles, between the prone and supine positions. Results: The mean surgical time for prone-ECIRS was 120.6±6.7 min. The initial stone-free rate was 82%, with a final stone-free rate of 87% after further treatment. One patient required blood transfusions. Computed tomography showed that the ureter between the orifice and the UPJ becomes straight instead of curving and the UPJ angle was significantly smaller in the prone position than in the supine position.
Conclusions: This hybrid therapy, with a simultaneous antero-retrograde approach, afforded better visibility during surgery, allowing effective extraction of small stone fragments. The prone split-leg position was a suitable approach for simultaneous use of fURS and PNL. We believe that proneECIRS is an effective option for the treatment of renal stones, including staghorn calculi. E110 The lesson I have learned from my first 25 ECIRS cases: Notes of technique by a young urologist during his learning-curve A. Bosio, P. Destefanis, E. Alessandria, E. Dalmasso, A. Buffardi, M. Lucci Chiarissi, G. Berta, A. Bisconti, C. Ceruti, D. Fontana, B. Frea. A.O. Citt` a della Salute e della Scienza di Torino – Molinette, Dept. of Urology, Turin, Italy Introduction & Objectives: PCNL learning curve is quite long. The first approach to the technique can be particularly difficult with the increase of indications for RIRS, reserving PCNL for more complex stone cases. On the other hand ECIRS can give more confidence to the operator during his learning curve. We wanted to identify technical aspects that can positively influence the first approach and the learning curve of a young urologist to PCNL. Material & Methods: We retrospectively analyzed the first 25 ECIRS performed by a single young urologist in a highvolume Stone Center where the indications for PCNL were limited to complex and multiple stone cases. We describe the technique that we adopted and progressively refined with the objective to treat complex stones since the learning curve. We considered the capability to gain a correct percutaneous access, to conclude the procedure with satisfying results and to avoid major complications. Results: An ECIRS in Valdivia-Galdakao modified supine position was performed and a single percutaneous access at the inferior posterior calyx was gained in all cases. Percutaneous puncture was performed under direct endoscopic view, radioscopic guidance and US assistance targeting the centre of the papilla. Progressive or balloon dilation was performed. A 17 Fr nephroscope through a 24 Fr Amplatz sheath was used with fluid irrigation at human body temperature and ultrasound and/or pneumatic lithotripsy. Fragments were evacuated by simple irrigation fluid outflow and residuals removed with basket. A final inspection of all calyxes was done with a flexible cystoscope through the Amplatz sheath and with the flexible ureteroscope. Further Olmium laser lithotripsy and fragments removal with basket were performed when needed. A double J ureteral stent and a nephrostomy catheter 12 Fr with distal pig-tail in the renal pelvis were eventually placed and an antegrade pielography performed. In all cases the intervention was concluded in a satisfactory manner without need for surgical conversion and further percutaneous procedures. The nephrostomy was clamped in I-II post-operative day and removed the day after. We had 3 major complications: 1 arteriovenous fistula and 2 septic shock. They all occurred in the first 15 cases of the series and they were successfully treated by selective arterial embolization and by amine support and specific prolonged antibiotic therapy. Conclusions: The standardized ECIRS technique that we reproduced and synthesized in this paper enabled us to treat complex stones also during the beginning of the learning curve, gain a correct access to the collecting system and conclude the procedure with satisfying results in all cases. The refinement of the technique allowed us to reduce peri-operative complications.
thursday 5 september 2013 / european urology supplements 12 (2013) 29–68
performed while looking at three images (the transurethral endoscopic, fluoroscopic and ultrasonic images). The flexible ureteroscope was advanced into the renal pelvis through the ureteral access sheath. Holmium:YAG laser lithotripsy was then performed to carve a channel to allow the ureteroscope to be passed into the desired calyx, which was occupied by the stone, under fluoroscopic vision. The stone in the desired calyx was irradiated and fragmented with the Holmium:YAG laser. At this point, percutaneous antegrade access to the calyx of interest was obtained using a nephrostomy needle under ultrasound guidance with a biopsy attachment. The hyperechoic moving particles over the tip of the ureteroscope provided an excellent ultrasound target during firing of the laser. The needle was safely inserted into the targeted calyx. The puncture of the nephrostomy needle into the collecting system was monitored under direct ureteroscopic vision. PNL and f-TUL were then performed simultaneously while looking at three images (transurethral and percutaneous endoscopic images and the fluoroscopic image). Results: The operating room support staff was able to view images from almost any angle. The operators could efficiently share operative information on the one display to save time without complications. Conclusions: The new Panasonic monitor provided flexible picture-in-picture and picture-by-picture functionality with independent image adjustment, enabling the surgeon to view, toggle or swap a live or saved image. Consolidation of multiple screens eliminated clutter and created additional working space in the operating room. E109 The technique of endoscopic combined intrarenal surgery in the prone split-leg position: Prone position is suitable for simultaneous operation of flexible ureteroscopy and mini-percutaneous nephrolithotomy S. Hamamoto1 , T. Yasui1 , S. Koiwa2 , T. Isero2 , H. Kamiya2 , A. Okada1 , K. Taguchi1 , Y. Hashimoto2 , K. Tozawa1 , Y. Iwase1 , K. Kohri1 . 1 Nagoya City University, Dept. of Nephro-Urology, Nagoya, Japan; 2 Toyota Kosei Hospital, Dept. of Urology, Nagoya, Japan Introduction & Objectives: Endoscopic combined intrarenal surgery (ECIRS) is a versatile procedure for renal calculi using retrograde flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PNL). The modified supine Valdivia position seems beneficial for a bilateral approach during ECIRS. However, use of this position has some disadvantages, including a decreased range of potential access angles and kidney hypermobility, that increase the risk of antegrade renal puncture. We developed a new technique for ECIRS in the prone split-leg position (prone-ECIRS) and evaluated its efficacy. Material & Methods: Between December 2010 and Janyary 2013, 60 patients presenting with large calculi (mean size, 37.2±2.6 mm) underwent prone-ECIRS; 33 had staghorn kidney stones. A laser fiber was used with fURS through a ureteral access sheath, and a lithoclast lithotripsy was performed through a mini-percutaneous tract. Threedimensional computed tomography was used to determine anatomical variations, including a ureteral location and ureteropelvic junction (UPJ) angles, between the prone and supine positions. Results: The mean surgical time for prone-ECIRS was 120.6±6.7 min. The initial stone-free rate was 82%, with a final stone-free rate of 87% after further treatment. One patient required blood transfusions. Computed tomography showed that the ureter between the orifice and the UPJ becomes straight instead of curving and the UPJ angle was significantly smaller in the prone position than in the supine position.
Conclusions: This hybrid therapy, with a simultaneous antero-retrograde approach, afforded better visibility during surgery, allowing effective extraction of small stone fragments. The prone split-leg position was a suitable approach for simultaneous use of fURS and PNL. We believe that proneECIRS is an effective option for the treatment of renal stones, including staghorn calculi. E110 The lesson I have learned from my first 25 ECIRS cases: Notes of technique by a young urologist during his learning-curve A. Bosio, P. Destefanis, E. Alessandria, E. Dalmasso, A. Buffardi, M. Lucci Chiarissi, G. Berta, A. Bisconti, C. Ceruti, D. Fontana, B. Frea. A.O. Citt` a della Salute e della Scienza di Torino – Molinette, Dept. of Urology, Turin, Italy Introduction & Objectives: PCNL learning curve is quite long. The first approach to the technique can be particularly difficult with the increase of indications for RIRS, reserving PCNL for more complex stone cases. On the other hand ECIRS can give more confidence to the operator during his learning curve. We wanted to identify technical aspects that can positively influence the first approach and the learning curve of a young urologist to PCNL. Material & Methods: We retrospectively analyzed the first 25 ECIRS performed by a single young urologist in a highvolume Stone Center where the indications for PCNL were limited to complex and multiple stone cases. We describe the technique that we adopted and progressively refined with the objective to treat complex stones since the learning curve. We considered the capability to gain a correct percutaneous access, to conclude the procedure with satisfying results and to avoid major complications. Results: An ECIRS in Valdivia-Galdakao modified supine position was performed and a single percutaneous access at the inferior posterior calyx was gained in all cases. Percutaneous puncture was performed under direct endoscopic view, radioscopic guidance and US assistance targeting the centre of the papilla. Progressive or balloon dilation was performed. A 17 Fr nephroscope through a 24 Fr Amplatz sheath was used with fluid irrigation at human body temperature and ultrasound and/or pneumatic lithotripsy. Fragments were evacuated by simple irrigation fluid outflow and residuals removed with basket. A final inspection of all calyxes was done with a flexible cystoscope through the Amplatz sheath and with the flexible ureteroscope. Further Olmium laser lithotripsy and fragments removal with basket were performed when needed. A double J ureteral stent and a nephrostomy catheter 12 Fr with distal pig-tail in the renal pelvis were eventually placed and an antegrade pielography performed. In all cases the intervention was concluded in a satisfactory manner without need for surgical conversion and further percutaneous procedures. The nephrostomy was clamped in I-II post-operative day and removed the day after. We had 3 major complications: 1 arteriovenous fistula and 2 septic shock. They all occurred in the first 15 cases of the series and they were successfully treated by selective arterial embolization and by amine support and specific prolonged antibiotic therapy. Conclusions: The standardized ECIRS technique that we reproduced and synthesized in this paper enabled us to treat complex stones also during the beginning of the learning curve, gain a correct access to the collecting system and conclude the procedure with satisfying results in all cases. The refinement of the technique allowed us to reduce peri-operative complications.