Operative Fiberoptic Nephroureteroscopy: Removal of Upper Ureteral and Renal Calculi

0022-534 7/87 /137 4-D629$02.00/C THE JOURNAL OF UROLOGY

Copyright© 1987 by The Vhlliams & Wilkins Co.

OPERATIVE FIBEROPTIC NEPHROURETEROSCOPY: REMOVAL OF UPPER URETERAL AND RENAL CALCULI YOSHIO ASO, YOSHIHISA OHTAWARA, KEN FUKUTA, HIROSHI SUDOKO, MASARU NAKANO, TOMOMI USHIYAMA, NOBUTAKA OHTA, KAZUO SUZUKI AND ATSUSHI TAJIMA From the Department of Urology, Hamamatsu University School of Medicine, Hamamatsu-shi, Japan

ABSTRACT

We tested 2 prototypes of an operating fiberoptic nephroureteroscope, measuring 3.5 and 4.5 mm. in diameter, that have an adequate working channel for auxiliary instruments and irrigation. Difficulty in passing the fiberscope through the ureteral orifice was overcome by dilation with balloon and polytetrafluoroethylene (Teflon) dilators. Our initial trial for stone retrieval under fiberscopic control was performed on 21 patients with upper ureteral and renal calculi. A stone was removed successfully in 15 of the 21 patients (71 per cent). After electrohydraulic Hthotripsy calculi were extracted successfully in 9 of 11 patients (82 per cent). Three patients suffered ureteral perforation. The fiberscope was especially helpful when an upper ureteral stone moved back to the kidney during stone manipulation. Since Takayasu and associates reported on a fiberoptic pyeloureteroscope in 1971,1 remarkable progress has been made in endoscopy of the upper urinary tract. Percutaneous endoscopy of the upper urinary tract has developed since the end of the 1970s. 2- 5 In 1980 Perez-Castro and Martinez-Pineiro introduced a rigid ureterorenoscope that has been used widely in the diagnosis and treatment of upper urinary tract lesions. 6 Percutaneous endoscopy and rigid ureterorenoscopy have been used primarily for the removal of calculi. On the other hand, the flexible instruments were applied clinically primarily for examination and diagnosis, 7 • 8 although Bush9 and Bagley 10• 11 and their associates reported on the successful removal of ureteral calculi. It appeared to be impossible to insert into the ureter a large fiberscope with a working channel that accommodated auxiliary operative instruments, such as a basket catheter, grasping forceps, laser probe, electrohydraulic lithotriptor and so forth. Therefore, urologists tended to disregard the clinical application of the fiberscope in the upper urinary tract. However, percutaneous techniques and rigid ureterorenoscopy are used with enthusiasm. In addition to the progress made with these innovative procedures, ureteral dilation techniques also have improved. We developed an operative fiberoptic nephroureteroscope* for use in the upper urinary tract. These new fiberscopes are described and their results in the removal of upper ureteral and renal calculi are v»r"""""'"'

ytetrafluoroethylene dilator consists of a thin outer sheath and stylet that slips over a guide wire. With the operative fiberoptic nephroureteroscope extraction was attempted in a patient with a renal staghorn calculus, 8 with renal pelvic calculi and 12 with upper ureteral calculi above the pelvic brim (table 2). The indications for fiberscopic manipulation were stones 6 mm. or more in diameter without satisfactory progression toward spontaneous passage, unrelenting pain, persistent obstruction or infection. RESULTS

Insertion of the nephroureteroscope into the ureter. Either type of fiberscope was introduced into the ureter after ureteral dilation. In our earlier cases (patients 1 to 8) the ureter was dilated with either an olive tip dilator, balloon dilator or Fogarty catheter. Among these patients the larger fiberscope (XURF2.0) could be passed only in 2 (patients 5 and 6), since the

MATER!ALS AND METHODS

The new fiberoptic nephroureteroscope (fig. 1) is similar in appearance to the old pyeloureteroscope. 1 The specifications of both types of the nephroureteroscope are summarized in table 1. Both devices have a working portion with a larger diameter to encase a large working channel used for irrigation and for insertion of various auxiliary operative instruments. One instrument (XURF-2.0) has a working portion that measures 4.5 mm. in diameter with a 2 mm. in diameter working channel. The other instmment (XURF-3Cl0) has a 3.5 mm. in diameter working portion with a 0.9 mm. working channel that accommodates only a 3F basket catheter. The XURF-2.0 device can accommodate various basket catheters, 3-pronged forceps and grasping or biopsy forceps through the working channel. To insert the operative nephroureteroscope the ureter must be dilated with an olive tip dilator, balloon dilator, Fogarty catheter and/or polytetrafluoroethylene dilator (fig. 2). A polAccepted for publication November 4, 1986. * Olympus Optical, Co., 1-22-2 Nishishinjuku shinjuka-ku, Tokyo, Japan. 629

FIG. L Prototype of operative nephroureteroscope TABLE

L Device specifications

Angle of field (degrees) Diameter (mmJF) Angulation (degrees): Up Down Diameter of working channel (mmJF) Full length (mm.)

XURF-2.0

XURF-3C10

75 4.5/13.5

75 3.5/10.5

160 100 2/6 1,015

160 100

1.2/3.6 1,115

630

ASO AND ASSOCIATES

method of ureteral dilation was not established to secure the passage of the nephroureteroscope. In subsequent cases (patients 9 to 21) balloon and polytetrafluoroethylene dilators were applied, which allowed for easy passage of the larger nephroureteroscope. Calculi were visualized well in all cases, since the nephroureteroscope was guided close to the stone. Removal of calculi. A stone was removed in 15 of the 21

A

B

patients (71 per cent) (table 2). Of the 8 renal pelvic calculi 3 (patients 13, 17 and 19) initially had been located in the upper third of the ureter and were moved to the renal pelvis during manipulation. Patients 11 to 18, 20 and 21 underwent electrohydraulic lithotripsy and the success rate for stone extraction improved to 9 of 11 (82 per cent). In patients 1 to 10 only basket catheters and grasping forceps were used to extract the stones. Consequently, the success rate was 6 of 10 patients (60 per cent). Figure 3 demonstrates a renal pelvic stone caught by a basket catheter in patient 6. Complications. Ureteral perforation occurred in 3 patients and required surgical repair to secure complete wound healing, although the ureter might have been stented. Fever and flank pain did not last longer than a few days in all patients. DISCUSSION

C Fm. 2. A, balloon dilator. B, stylet of polytetrafluoroethylene dilator. C, sheath of polytetrafluoroethylene dilator.

There have been many reports on transurethral endoscopic manipulation of ureteral calculi with a rigid ureteroscope or ureteropyeloscope. 9- 21 The reported success rates range from 89 to 98 per cent15• 21 • 22 and from 48 to 55 per cent14• 21 for stones below and above the pelvic brim, respectively. Therefore, rigid ureteroscopy is highly recommended for transurethral retrieval of lower ureteral calculi. However, the low success rate for extraction of upper ureteral stones is a disadvantage of the

TABLE 2. Results in 21 patients Pt.-Pt.-Age-Sex No.

(mm.)

l-MT-26-M 2-AM-34-F 3-TK-28-M 4-JB-62-M 5-MH-26-F 6-SK-57-M 7-TM-58-M 8-YY-24-M 9-HU-24-F

10 X 6 12 X 6 10 X 7 8X5 8X6 12 X 10* 12 X 10* 15 X 10 8X6

Size

10-Yl-58-M

13 X 12*

11-HK-27-M

18 X 8 9X8

12-KK-38-F

15 X 10

13-1\11-29----'l'/i

14 X 7-1:

14-HK-50-M

9X6

15-M0-51-M

lOX 4

16-SK-55-M

13 X 8

17-TM-54-F

20 X 20*

18-SY-27-M

8 X 8*

19-YS-49-M

8 X 5*

20-MY-52-M

16 X 15*

21-HS-57-F

Staghorn

Patients 10. 11 and 14 suffered ureteral perforation. * Renal pelvis.

Extracting Devices

Dilator

Fiberscope

Olive tip Balloon Balloon Balloon Balloon Balloon, Fogarty Balloon Balloon Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene Balloon, polytetrafluoroethylene

XURF-3Cl0 XURF-3Cl0 XURF-3Cl0 XURF-3Cl0 XURF-2.0 XURF-2.0 XURF-3Cl0 XURF-3Cl0 XURF-2.0

Basket Basket Basket Basket Basket Basket Basket Forceps, basket Forceps

Success Failure Success Success Failure Success Failure Failure Success

XURF-2.0

Forceps, basket

Success

XURF-2.0

Forceps, basket, electrohydraulie lithotripsy Forceps, basket, electrohydraulie lithotripsy Electrohydiimlic lithotripsy, forceps Basket, forceps, electrohydraulie lithotripsy Basket, forceps, electrohydraulie lithotripsy Electrohydraulic lithotripsy

Failure

XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0 XURF-2.0

Result

Failure Success Success Success Success

Electrohydraulic lithotripsy, basket Electro hydraulic lithotripsy, basket Basket

Success

Electrohydraulic lithotripsy, basket Electrohydraulic lithotripsy, basket

Success

Success Success

Success

FH:lEROPTIC NEPHROURETEROSCOPIC REMOVAL OF CALCULI

rigid ureteroscope. In awun1ux1, a instrument becomes useless once a stone in the upper ureter is pushed up into the renal pelvis. The disadvantages of the rigid ureteroscope appear to be compensated for by the excellent results with percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL). 22 - 25 Therefore, the value of percutaneous nephrolithotomy and ESWL has been recognized widely. However, they also have a few shortcomings, including the high cost of the instruments and devices (especially for ESWL), formation of an artificial tract, the occasional necessity to insert an occlusion catheter to prevent outflow of stone fragments and frequent necessity of staged procedures in percutaneous nephrolithotomy, ureteral impaction with stone fragments and only fluoroscopic observation of stone disintegration in ESWL, and the possibility of renal parenchymal damage with repetition of both procedures. To overcome these shortcomings ureteropyeloscopy with flexible instruments is recommended. The cost of the instruments is reasonable and they can be passed through the natural path (urethra to bladder to ureter) up to the renal

I

FIG. 3. X-ray in patient 6 shows pelvic calculus in basket (arrow)

ureter

guide wire

631

pelvis and calices without damaging the renal parenchyma. Stone retrieval usually is a 1-stage procedure with no residual stones. A stone can be removed from the upper ureter even if it is pushed up into the intrarenal cavities. The low success rate of upper ureteral stone retrieval via a rigid ureteroscope is partly owing to the inability to remove a stone that has moved back to the renal pelvis during manipulation. Stones that had moved into the kidney were extracted successfully in patients 13, 17, and 19. In regard to ureteral dilation, the ureter cannot be dilated enough to pass the larger (XURF-2.0) nephroureteroscope with the use of an olive tip or balloon dilator. Recently, we developed a new method to introduce the nephroureteroscope into the ureter with a combination of balloon and polytetrafluoroethylene dilators to achieve satisfactory dilation. The principle of this method is the same as the guide wire method for introduction of a pyeloureteroscope into the ureter. 26 A guide wire is introduced first into the ureter (fig. 4, A). Then a balloon dilator is slipped over the guide wire in the ureteral orifice (fig. 4, B). The balloon dilator is kept inflated for 5 minutes. After the balloon catheter is withdrawn an 18F polytetrafluoroethylene dilator is introduced a few centimeters above the level of the pelvic brim under fluoroscopic control (fig. 4, C). The stylet of the polytetrafluoroethylene dilator is replaced with the fiberoptic nephroureteroscope (fig. 4, D), which is guided up to a stone through the outer sheath of the dilator while the ureter is kept dilated with irrigating solution. With this method the larger XURF -2.0 nephroureteroscope can be passed easily into the ureter and the stone can be observed clearly. Generally, a ureteral stone that requires removal often is impacted in the ureter. Even if we succeed in barely passing a basket catheter above the stone the open basket usually is compressed between the ureteral wall and the stone when it is pulled. Grasping forceps are too small to catch a stone and they usually grasp only a part of it. An electrohydraulic lithotriptor is effective in disintegrating a stone. In our series electrohydraulic lithotripsy was effective in patients 11 to 21. However, sometimes it is hard to guide the tip of the probe to the center of the stone surface without touching the surrounding mucosa, especially in cases of upper ureteral calculi. Therefore, the main difficulty in removing a stone with the fiberoptic nephroureteroscope is the lack of proper auxiliary instruments to extract or disintegrate the stone. In the 6 patients in whom stone extraction failed we were almost at the point of removing the stone. In the future stone extractors and disintegrators must be improved to obtain a better treatment

ureter

guide wire

Fm. 4. A, to introduce nephroureteroscope guide wire is inserted into ureter. B, balloon dilator is inserted into ureter over guide wire. Balloon is kept dilated for 5 minutes. C, after balloon dilator is withdrawn polytetrafluoroethylene dilator is inserted into dilated ureter. D, nephroureteroscope is passed freely into ureter through sheath of polytetrafluoroethylene dilator after stylet is removed.

632

ASO AND ASSOCIATES

result without complications. In this respect laser fragmentation might be of help, as noted by Dretler and associates. 27 At the beginning of our study the indication to use the nephroureteroscope was a less than 10 mm. stone in the renal calices, pelvis and upper ureter when an electrohydraulic lithotriptor was not available. After we realized the effect of electrohydraulic lithotripsy for stone disintegration, the indication for the nephroureteroscope was widened to include all stones in the kidney and upper ureter. Various degrees of ureteral injury might occur during stone dislodgement and disintegration. 28 When an electro hydraulic lithotripsy probe is used great care must be taken to avoid ureteral injury. A stone larger than 10 mm. in diameter is difficult to remove without breaking it apart, since extraction of a large stone without fragmentation can cause serious injury to the ureteral mucosa. REFERENCES

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