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Methodology for Endoscopic Treatment of Ureteral Calculi
0022-534 7/86/1355-0909$02.00/0 THE JOURNAL OF UROLOGY
Vol. 135, May
Copyright© 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
METHODOLOGY FOR ENDOSCOPIC TREATMENT OF URETERAL CALCULI NELSON RODRIGUES NETTO, JR.,* GUSTAVO CASERTA LEMOS AND JOAQUIM F. A. CLARO From the Division of Urology, Hospital Beneficencia Portuguesa and Hospital Israelita Albert Einstein, Siio Paulo, Brazil
ABSTRACT
The records of 27 patients undergoing endoscopic treatment of ureteral calculi were reviewed. The percutaneous nephrostomy approach was used for calculi located above the iliac vessels, while the transurethral approach was used for those below the iliac vessels. The success rates achieved for these calculi were 82.3 and 90.0 per cent, respectively. Endoscopic treatment has proved to be safe and effective in patients with ureteral stones. Although ureteral calculi occur frequently the treatment remains a major problem to urologists. The concept that only calculi up to 0.8 cm. located below the iliac vessels could be removed by endoscopy has been superseded. 1 In 1912 Young performed the first ureteroscopy and several improvements have been made since then. 2 The new percutaneous techniques for the treatment of renal calculi also have contributed another option for treatment of ureteral calculi.3 Several catheter models with specific characteristics allowed calculi located anywhere in the ureter to be treated with increased effectiveness and safety. 4 The methodology of the techniques used in the endoscopic removal of ureteral stones is discussed.
MATERIAL AND METHODS
From September 1983 to January 1985, 27 patients with ureteral calculi were studied. The patients were assigned to 1 of 2 groups according to calculi location. Group 1 included 10 men and 7 women between 19 and 63 years old (average age 40 years), with calculi above the iliac vessels removed via percutaneous nephrostomy. The calculi were in the upper ureter in 13 patients and in the mid ureter in 4. The length of the calculi ranged from 0.8 to 1.2 cm. (median 1.0 cm.) and the width ranged from 0.5 to 1.0 cm. (median 0.8 cm.). Group 2 included 3 men and 7 women between 25 and 47 years old (average age 32 years), with calculi below the iliac vessels removed by the transurethral approach. The length of the calculi ranged from 0.6 to 1.5 cm. (median 1.2 cm.), and the width ranged from 0.3 to 0.6 cm. (median 0.6 cm.). Group 1. One day preoperatively the patient underwent continuous peridural anesthesia with the catheter left in place. A double lumen 7F catheter was introduced in the ureter via a transurethral approach. One lumen was used to introduce the fluid in the ureter and the other was used to inflate a 1 cc balloon placed at the tip of the catheter. The balloon was kept inflated for 24 hours and was placed about 5 cm. below the calculus. The aim was to occlude the ureteral segment below the calculus (fig. 1). The next day the patient was anesthetized through the peridural catheter, which was left in place, and percutaneous nephrostomy was done. The renal approach was performed via puncture of the lower pole calix, usually the posteroinferior calix. In special cases, to make the endoscopic manipulation easier in the ureter, the middle pole calix was used. After access of the guide wire to the collecting system had been performed under fluoroscopic control, the nephrocutaneous tract was dilated to 24F with the aid of a facial dilator and the nephroscope Accepted for publication January 15, 1986. * Requests for reprints: Rua Augusta, 2347-3.Q Andar, 01413 Sao Paulo, Brazil. 909
FIG. 1. Balloon placed below calculus transurethrally
was inserted. The ureteral ostium was found by direct visualization with the nephroscope, and a safety wire was inserted up to the balloon placed below the calculus and was kept in place during the entire procedure. A second guide wire, a working wire, was introduced in the ureter beyond the stone. A 7F polyethylene catheter was passed over the wire and was placed at the ureteral calculus. Two types of manipulation were used. The most frequent method was removal of the working wire and introduction of a Dormia stone basket through the polyethylene catheter, which should bypass the calculus. The Dormia stone basket was
910
NETTO, LEMOS AND CLARO
A
I\
\ 1,
FIG. 2. A, Dormia sheath bypassing calculus over guide wire. B, Dormia stone basket in place to engage calculus. SW, safety guide wire. PC, polyethylene catheter. DB, Dormia basket. WW, working guide wire.
opened under fluoroscopic control and the calculus was engaged. When the stone could not be engaged with the Dormia stone basket the second operative manipulation was used. The working wire was inserted, again bypassing the calculus. The sheath of the Dormia catheter was placed over the working wire without its basket (fig. 2, A). In this manner the sheath then could traverse the stone. At this point the working wire was withdrawn from the tract. The basket was inserted through the sheath and the stone was grasped, repeating the manipulation described so that the stone was engaged in the basket (fig. 2, B). The Dormia stone basket, calculus and polyethylene catheter were removed carefully and slowly. Then, the balloon catheter was removed. A 7F multifenestrated angiographic catheter was inserted via the nephrostomy and was placed close to the bladder to drain the ureter. The kidney was drained through a 24F Foley catheter. The ureteral splint was left in place for an average of 2 days and the nephrostomy tube was left for 3 days. The catheters were removed under fluoroscopic control, with contrast medium used to examine the ureteral permeability and whether there was any bleeding in the kidney. The ureteral splint was removed first and the nephrostomy tube was occluded for about 8 hours. When there was effective ureteral drainage with no pain or high temperature, the nephrostomy tube was withdrawn. The patient was discharged from the hospital on day 4. Group 2. The transurethral approach was used in these patients. A safety guide wire was introduced up to the renal pelvis. The intramural portion of the ureter was dilated to 12F with dilating catheters. A second guide wire, a working wire, was introduced to the level of the renal pelvis. The lens of the cystoscope was removed and the sheath was left in place to allow introduction of larger caliber catheters. Dilation continued through the cystoscope sheath up to 16F; the dilators always were guided by the guide wire under fluoroscopic control (fig. 3, A). A 7F polyethylene catheter was passed over the
guide wire and was inserted up to the ureteral calculus. The same manipulation used for group 1 was repeated. First, attempts to bypass the calculus with a stone basket through the polyethylene catheter were made. When these attempts were not successful the working wire was reintroduced and passed beyond the stone. Only the sheath of the Dormia catheter was inserted. The sheath guided by the working wire then managed to traverse the stone. The working wire was removed and the Dormia stone basket was inserted through the sheath (fig. 3, B). The calculus was engaged under fluoroscopic control and was pulled out towards the bladder. After the stone was removed, a 7F polyethylene multifenestrated ureteral catheter was inserted over the safety wire and was left in place for 24 to 48 hours. The bladder was'drained through a 20F Foley catheter for the same interval. RESULTS
The results were considered to be successful or unsuccessful according to the outcome of stone removal. The procedure was successful in 14 of 17 patients (82.3 per cent) in group 1. The calculus could not be removed in 3 patients. The ureter below the calculus had not been dilated in these patients and the stone basket could not be opened completely to engage the stone. In 2 patients an attempt to introduce the nephroscope in the upper dilated ureter caused disruption of the ureteropelvic junction. The patients underwent an open operation after the calculus with withdrawn and the ureter was sutured. An Escherichia coli urinary tract infection was present in 3 patients. Urine cultures performed 30 days postoperatively were sterile. There was no extravasation or bleeding following balloon dilation or stone extraction. Hospitalization ranged from 3 to 6 days, with a median of 5 days. The success rate was 90.0 per cent (9 of 10 patients) in group 2. The patient who failed underwent ureterolithotomy during the same operation. Urinary infection was present preoperatively in 2 patients and was absent at followup 30 days later.
Bll
FIG. 3. A, dilator catheter introduced transurethrally over guide wire. WW, working guide wire. SW, safety guide wire. DC, dilator catheter. B, Dormia stone basket bypassing calculus. SW, safety guide wire. PC, polyethylene catheter. DB, Dormia basket.
Hospitalization ranged from 1 to 4 days, with a median of 2 days. Complete recovery with return to normal activities was considered to be the recovery period. In group l the recovery period ranged from 6 to 14 days, with a median of 7 days. Operative time averaged 45 minutes, with a range of 15 to 90 minutes. In group 2 the recovery period ranged from 3 to 7 days, with a median of 5 days, and operative time averaged 35 minutes, with a range of 10 to 105 minutes. Excretory urography 3 months later failed to show any stricture formation in the meter in both groups. DISCUSSION
The damage caused by impacted ureteral calculi is variable. General and local symptoms with a range of severity result. The indication for an .~~.,~n~,r.~ will be based upon the analysis of these factors. In several cases "'"v,.,,uvv,nu must be to remove a small stone, which seems to be too aggressive a procedure to the physician and patient. '"""'"'""'"' the recovery although variable, is an important factor tO be auan' £<:'U. Endoscopic treatment of ureteral calculi has proved to be a preferable option in severnl cases. However, there were some restrictions as to the size and site of the stone, as well as concerns about infection. In our study the use of percutaneous and transurethral approaches for calculi above and below the iliac vessels, respectively, was intended to remove all of the stones and to reduce the risks of ureteral trauma. To date, with the great acceptance of percutaneous techniques, the indication for this method has included ureteral stones. However, the results are not as favorable as those achieved with renal calculi. 5 Therefore, changes in technique were introduced to attempt to increase the success rate. The use of a balloon catheter to dilate the ureter below the calculus is an important addition. Patients whose upper ureteral calculi were not removed did not have the ureter dilated with the balloon catheter. The dismountable Dormia stone basket is
another useful improvement that allows introduction of the sheath over the guide wire and introduction of the basket after the wire has been withdrawn. In regard to lower meteral calculi some precautions must be taken. Dilation of the intravesical ureter is compulsory. The use of safety and working wires allows dilation of the ureter up to 16F. Clinical and experimental studies show that dilation does not damage the ureter. 6 Despite use of the rigid ureteroscope 1• 7 we believe that calculous manipulation through dilating catheters and stone baskets should be the first option because of its simplicity and potentially lower incidence of ureteral damage. All of the endoscopic procedures used to treat ureteral stones must be performed in the hospital setting with radiological and fluoroscopic equipment available. The success rates of 82.3 and 90.0 per cent for the ,:,11uu,-,u,µ.,.c treatment of calculi in the mid to ureter, and in the ureter, re~;oect1vel!v encourage use of enctosci)p1tc surgery for ureteral REFERENCES i
V. and 1..,astane,aa-·£unu,a. W. R.: Techniques in a Guide to the Percutaneous Removal of Renal and Calculi. Minneapolis, Minnesota, 1984. 2. Ford, T. F., Parkinson, M. C. and Wickham, J.E. A.: Clinical and experimental evaluation ofureteric dilatation. Brit. J. Urol., 56: 460, 1984. 3. Huffman, J. L., Bagley, D. H., Schoenberg, H. W. and Lyon, E. S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J. Urol., 130: 31, 1983. 4. Perez-Castro Ellendt, E. and Martinez-Pineiro, J. A.: La ureterorrenoscopia transuretral. Un actual proceder urologico. Arch. Esp. Urol., 33: 445, 1980. 5. Segura, J. W., Patterson, D. E., LeRoy, A. J., McGough, P. F. and Barrett, D. M.: Percutaneous removal of kidney stones: preliminary report. Mayo Clin. Proc., 57: 615, 1982. 6. Rutner, A. B.: Ureteral balloon dilatation and stone basketing. Urology, suppl. 5, 23: 44, 1984. 7. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urology, suppl. 5, 23: 37, 1984. L
Vol. 135, May
Copyright© 1986 by The Williams & Wilkins Co.
Printed in U.S.A.
METHODOLOGY FOR ENDOSCOPIC TREATMENT OF URETERAL CALCULI NELSON RODRIGUES NETTO, JR.,* GUSTAVO CASERTA LEMOS AND JOAQUIM F. A. CLARO From the Division of Urology, Hospital Beneficencia Portuguesa and Hospital Israelita Albert Einstein, Siio Paulo, Brazil
ABSTRACT
The records of 27 patients undergoing endoscopic treatment of ureteral calculi were reviewed. The percutaneous nephrostomy approach was used for calculi located above the iliac vessels, while the transurethral approach was used for those below the iliac vessels. The success rates achieved for these calculi were 82.3 and 90.0 per cent, respectively. Endoscopic treatment has proved to be safe and effective in patients with ureteral stones. Although ureteral calculi occur frequently the treatment remains a major problem to urologists. The concept that only calculi up to 0.8 cm. located below the iliac vessels could be removed by endoscopy has been superseded. 1 In 1912 Young performed the first ureteroscopy and several improvements have been made since then. 2 The new percutaneous techniques for the treatment of renal calculi also have contributed another option for treatment of ureteral calculi.3 Several catheter models with specific characteristics allowed calculi located anywhere in the ureter to be treated with increased effectiveness and safety. 4 The methodology of the techniques used in the endoscopic removal of ureteral stones is discussed.
MATERIAL AND METHODS
From September 1983 to January 1985, 27 patients with ureteral calculi were studied. The patients were assigned to 1 of 2 groups according to calculi location. Group 1 included 10 men and 7 women between 19 and 63 years old (average age 40 years), with calculi above the iliac vessels removed via percutaneous nephrostomy. The calculi were in the upper ureter in 13 patients and in the mid ureter in 4. The length of the calculi ranged from 0.8 to 1.2 cm. (median 1.0 cm.) and the width ranged from 0.5 to 1.0 cm. (median 0.8 cm.). Group 2 included 3 men and 7 women between 25 and 47 years old (average age 32 years), with calculi below the iliac vessels removed by the transurethral approach. The length of the calculi ranged from 0.6 to 1.5 cm. (median 1.2 cm.), and the width ranged from 0.3 to 0.6 cm. (median 0.6 cm.). Group 1. One day preoperatively the patient underwent continuous peridural anesthesia with the catheter left in place. A double lumen 7F catheter was introduced in the ureter via a transurethral approach. One lumen was used to introduce the fluid in the ureter and the other was used to inflate a 1 cc balloon placed at the tip of the catheter. The balloon was kept inflated for 24 hours and was placed about 5 cm. below the calculus. The aim was to occlude the ureteral segment below the calculus (fig. 1). The next day the patient was anesthetized through the peridural catheter, which was left in place, and percutaneous nephrostomy was done. The renal approach was performed via puncture of the lower pole calix, usually the posteroinferior calix. In special cases, to make the endoscopic manipulation easier in the ureter, the middle pole calix was used. After access of the guide wire to the collecting system had been performed under fluoroscopic control, the nephrocutaneous tract was dilated to 24F with the aid of a facial dilator and the nephroscope Accepted for publication January 15, 1986. * Requests for reprints: Rua Augusta, 2347-3.Q Andar, 01413 Sao Paulo, Brazil. 909
FIG. 1. Balloon placed below calculus transurethrally
was inserted. The ureteral ostium was found by direct visualization with the nephroscope, and a safety wire was inserted up to the balloon placed below the calculus and was kept in place during the entire procedure. A second guide wire, a working wire, was introduced in the ureter beyond the stone. A 7F polyethylene catheter was passed over the wire and was placed at the ureteral calculus. Two types of manipulation were used. The most frequent method was removal of the working wire and introduction of a Dormia stone basket through the polyethylene catheter, which should bypass the calculus. The Dormia stone basket was
910
NETTO, LEMOS AND CLARO
A
I\
\ 1,
FIG. 2. A, Dormia sheath bypassing calculus over guide wire. B, Dormia stone basket in place to engage calculus. SW, safety guide wire. PC, polyethylene catheter. DB, Dormia basket. WW, working guide wire.
opened under fluoroscopic control and the calculus was engaged. When the stone could not be engaged with the Dormia stone basket the second operative manipulation was used. The working wire was inserted, again bypassing the calculus. The sheath of the Dormia catheter was placed over the working wire without its basket (fig. 2, A). In this manner the sheath then could traverse the stone. At this point the working wire was withdrawn from the tract. The basket was inserted through the sheath and the stone was grasped, repeating the manipulation described so that the stone was engaged in the basket (fig. 2, B). The Dormia stone basket, calculus and polyethylene catheter were removed carefully and slowly. Then, the balloon catheter was removed. A 7F multifenestrated angiographic catheter was inserted via the nephrostomy and was placed close to the bladder to drain the ureter. The kidney was drained through a 24F Foley catheter. The ureteral splint was left in place for an average of 2 days and the nephrostomy tube was left for 3 days. The catheters were removed under fluoroscopic control, with contrast medium used to examine the ureteral permeability and whether there was any bleeding in the kidney. The ureteral splint was removed first and the nephrostomy tube was occluded for about 8 hours. When there was effective ureteral drainage with no pain or high temperature, the nephrostomy tube was withdrawn. The patient was discharged from the hospital on day 4. Group 2. The transurethral approach was used in these patients. A safety guide wire was introduced up to the renal pelvis. The intramural portion of the ureter was dilated to 12F with dilating catheters. A second guide wire, a working wire, was introduced to the level of the renal pelvis. The lens of the cystoscope was removed and the sheath was left in place to allow introduction of larger caliber catheters. Dilation continued through the cystoscope sheath up to 16F; the dilators always were guided by the guide wire under fluoroscopic control (fig. 3, A). A 7F polyethylene catheter was passed over the
guide wire and was inserted up to the ureteral calculus. The same manipulation used for group 1 was repeated. First, attempts to bypass the calculus with a stone basket through the polyethylene catheter were made. When these attempts were not successful the working wire was reintroduced and passed beyond the stone. Only the sheath of the Dormia catheter was inserted. The sheath guided by the working wire then managed to traverse the stone. The working wire was removed and the Dormia stone basket was inserted through the sheath (fig. 3, B). The calculus was engaged under fluoroscopic control and was pulled out towards the bladder. After the stone was removed, a 7F polyethylene multifenestrated ureteral catheter was inserted over the safety wire and was left in place for 24 to 48 hours. The bladder was'drained through a 20F Foley catheter for the same interval. RESULTS
The results were considered to be successful or unsuccessful according to the outcome of stone removal. The procedure was successful in 14 of 17 patients (82.3 per cent) in group 1. The calculus could not be removed in 3 patients. The ureter below the calculus had not been dilated in these patients and the stone basket could not be opened completely to engage the stone. In 2 patients an attempt to introduce the nephroscope in the upper dilated ureter caused disruption of the ureteropelvic junction. The patients underwent an open operation after the calculus with withdrawn and the ureter was sutured. An Escherichia coli urinary tract infection was present in 3 patients. Urine cultures performed 30 days postoperatively were sterile. There was no extravasation or bleeding following balloon dilation or stone extraction. Hospitalization ranged from 3 to 6 days, with a median of 5 days. The success rate was 90.0 per cent (9 of 10 patients) in group 2. The patient who failed underwent ureterolithotomy during the same operation. Urinary infection was present preoperatively in 2 patients and was absent at followup 30 days later.
Bll
FIG. 3. A, dilator catheter introduced transurethrally over guide wire. WW, working guide wire. SW, safety guide wire. DC, dilator catheter. B, Dormia stone basket bypassing calculus. SW, safety guide wire. PC, polyethylene catheter. DB, Dormia basket.
Hospitalization ranged from 1 to 4 days, with a median of 2 days. Complete recovery with return to normal activities was considered to be the recovery period. In group l the recovery period ranged from 6 to 14 days, with a median of 7 days. Operative time averaged 45 minutes, with a range of 15 to 90 minutes. In group 2 the recovery period ranged from 3 to 7 days, with a median of 5 days, and operative time averaged 35 minutes, with a range of 10 to 105 minutes. Excretory urography 3 months later failed to show any stricture formation in the meter in both groups. DISCUSSION
The damage caused by impacted ureteral calculi is variable. General and local symptoms with a range of severity result. The indication for an .~~.,~n~,r.~ will be based upon the analysis of these factors. In several cases "'"v,.,,uvv,nu must be to remove a small stone, which seems to be too aggressive a procedure to the physician and patient. '"""'"'""'"' the recovery although variable, is an important factor tO be auan' £<:'U. Endoscopic treatment of ureteral calculi has proved to be a preferable option in severnl cases. However, there were some restrictions as to the size and site of the stone, as well as concerns about infection. In our study the use of percutaneous and transurethral approaches for calculi above and below the iliac vessels, respectively, was intended to remove all of the stones and to reduce the risks of ureteral trauma. To date, with the great acceptance of percutaneous techniques, the indication for this method has included ureteral stones. However, the results are not as favorable as those achieved with renal calculi. 5 Therefore, changes in technique were introduced to attempt to increase the success rate. The use of a balloon catheter to dilate the ureter below the calculus is an important addition. Patients whose upper ureteral calculi were not removed did not have the ureter dilated with the balloon catheter. The dismountable Dormia stone basket is
another useful improvement that allows introduction of the sheath over the guide wire and introduction of the basket after the wire has been withdrawn. In regard to lower meteral calculi some precautions must be taken. Dilation of the intravesical ureter is compulsory. The use of safety and working wires allows dilation of the ureter up to 16F. Clinical and experimental studies show that dilation does not damage the ureter. 6 Despite use of the rigid ureteroscope 1• 7 we believe that calculous manipulation through dilating catheters and stone baskets should be the first option because of its simplicity and potentially lower incidence of ureteral damage. All of the endoscopic procedures used to treat ureteral stones must be performed in the hospital setting with radiological and fluoroscopic equipment available. The success rates of 82.3 and 90.0 per cent for the ,:,11uu,-,u,µ.,.c treatment of calculi in the mid to ureter, and in the ureter, re~;oect1vel!v encourage use of enctosci)p1tc surgery for ureteral REFERENCES i
V. and 1..,astane,aa-·£unu,a. W. R.: Techniques in a Guide to the Percutaneous Removal of Renal and Calculi. Minneapolis, Minnesota, 1984. 2. Ford, T. F., Parkinson, M. C. and Wickham, J.E. A.: Clinical and experimental evaluation ofureteric dilatation. Brit. J. Urol., 56: 460, 1984. 3. Huffman, J. L., Bagley, D. H., Schoenberg, H. W. and Lyon, E. S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J. Urol., 130: 31, 1983. 4. Perez-Castro Ellendt, E. and Martinez-Pineiro, J. A.: La ureterorrenoscopia transuretral. Un actual proceder urologico. Arch. Esp. Urol., 33: 445, 1980. 5. Segura, J. W., Patterson, D. E., LeRoy, A. J., McGough, P. F. and Barrett, D. M.: Percutaneous removal of kidney stones: preliminary report. Mayo Clin. Proc., 57: 615, 1982. 6. Rutner, A. B.: Ureteral balloon dilatation and stone basketing. Urology, suppl. 5, 23: 44, 1984. 7. Smith, A. D.: Percutaneous ureteral surgery and stenting. Urology, suppl. 5, 23: 37, 1984. L