- Email: [email protected]
Re: Multicenter Experience With Metallic Ureteral Stents for Malignant and Chronic Benign Ureteral Obstruction
UROLITHIASIS/ENDOUROLOGY
185
Use of Inverted Fluoroscope’s C-Arm During Endoscopic Treatment of Urinary Tract Obstruction in Pregnancy: A Practicable Solution to Cut Radiation M. Cocuzza, J. R. Colombo, Jr., R. I. Lopes, A. C. Piovesan, J. L. Borges Mesquita and M. Srougi Department of Urology, University of Sao Paulo (USP), Sao Paulo, Brazil Urology 2010; 75: 1505–1508.
Objectives: To describe the use of pulsed fluoroscopic guidance, to perform endoscopic procedures in pregnant women, by inverting the fluoroscope’s c-arm using a lead thyroid collar to shield the fetus from the direct X-ray beam. The use of radiation during treatment of pregnant patients with urolithiasis remains a recurring dilemma. Methods: Between May 2006 and December 2008, endoscopic treatment due to ureteral stones was attempted in 8 pregnant women. In all cases, we use an inverted fluoroscope’s c-arm during endoscopic treatment associated with 2 lead neck thyroid collars to shield the uterus, protecting the fetus from direct radiation. Indication for treatment was symptomatic ureteral stones unresponsive to medical treatment in 7 and persistent fever in 1. Results: Mean ureteral stone size was 8.1⫹/⫺4.8 mm, located in the left ureter in 5 (62.5%) cases. Three (37.5%) patients had stone located in the upper ureter, 2 (25%) in the middle ureter, and 3 (37.5) in the distal ureter. In 6 cases, ureteral stones were treated using the semi-rigid ureteroscope, whereas in 1 case a flexible ureteroscope was needed. One woman was treated with insertion of a double-J stent due to associated urinary infection. No women has early delivery related to the endoscopic procedure, and all neonates were perfectly normal. Conclusions: We present a technique for endoscopic procedures in pregnant women inverting the fluoroscope’s c-arm and protecting the fetus from the direct X-ray beam. This practical approach should be specially considered when no portable ultrasound and radiologic assistance in available in the operating room. Editorial Comment: Limiting radiation exposure is important, especially in pregnant patients. The approach described seems reasonable. The authors did not measure radiation exposure in this study. One must refrain from having a “lead foot” when using fluoroscopy to limit exposure. However, the use of lead garments and protective eyewear by the operating team is quite important, particularly using this technique, where upward scatter is more prevalent. Dean Assimos, M.D.
Re: Multicenter Experience With Metallic Ureteral Stents for Malignant and Chronic Benign Ureteral Obstruction A. P. Modi, C. R. Ritch, D. Arend, R. M. Walsh, M. Ordonez, J. Landman, M. Gupta and B. E. Knudsen Department of Urology, Ohio State University Medical Center, Columbus, Ohio J Endourol 2010; 24: 1189 –1193.
Background and Purpose: A new coil-based metallic ureteral stent offers greater radial strength with longer indwelling time compared with plastic stents. This multicenter retrospective study reviews the clinical experience with this stent for malignant or benign chronic ureteral obstruction. Patients and Methods: Patients had stent placement in a retrograde fashion. We analyzed preplacement and postplacement renal imaging to determine degree of hydronephrosis. Stent encrustation was determined by either visual inspection at the time of stent change or plain abdominal radiography. Preoperative and follow-up serum creatinine values were compared for each patient. Results: A total of 76 stents in 59 renal units (40 patients) were successfully placed. Creatinine value follow-up on 54 renal units showed 20 (37%) units to have stable, 15 (28%) improved, and 19 (35%) with worsening values. No stent showed encrustation on plain radiography despite it being seen on two during direct visualization. Three stents needed operative removal with either percutaneous nephrolithotomy or
186
UROLITHIASIS/ENDOUROLOGY
cystolitholapaxy. Fifteen of 41 (37%) metallic stents placed because of an obstructed plastic stent also became obstructed. At last follow-up, 6 of 40 patients were kept from nephrostomy tubes because of the metallic stent. Conclusions: Metallic stents are a viable alternative to nephrostomy tubes in patients in whom conventional stents fail because of malignant obstruction, but patients need to be followed closely. Stent encrustation that resulted in retained stents was poorly visualized on plain radiography. Patients still remain at risk for obstruction, urinary tract infections, and lower urinary tract symptoms from the metallic stent. Editorial Comment: The treatment of patients with failed standard ureteral stents is frustrating for patient and physician. This stent may be used in such cases but the failure rate is still high, underscoring the need for careful followup. Nephrostomy tube drainage may ultimately be required in these cases. The search for the perfect stent is still ongoing! Dean Assimos, M.D.
185
Use of Inverted Fluoroscope’s C-Arm During Endoscopic Treatment of Urinary Tract Obstruction in Pregnancy: A Practicable Solution to Cut Radiation M. Cocuzza, J. R. Colombo, Jr., R. I. Lopes, A. C. Piovesan, J. L. Borges Mesquita and M. Srougi Department of Urology, University of Sao Paulo (USP), Sao Paulo, Brazil Urology 2010; 75: 1505–1508.
Objectives: To describe the use of pulsed fluoroscopic guidance, to perform endoscopic procedures in pregnant women, by inverting the fluoroscope’s c-arm using a lead thyroid collar to shield the fetus from the direct X-ray beam. The use of radiation during treatment of pregnant patients with urolithiasis remains a recurring dilemma. Methods: Between May 2006 and December 2008, endoscopic treatment due to ureteral stones was attempted in 8 pregnant women. In all cases, we use an inverted fluoroscope’s c-arm during endoscopic treatment associated with 2 lead neck thyroid collars to shield the uterus, protecting the fetus from direct radiation. Indication for treatment was symptomatic ureteral stones unresponsive to medical treatment in 7 and persistent fever in 1. Results: Mean ureteral stone size was 8.1⫹/⫺4.8 mm, located in the left ureter in 5 (62.5%) cases. Three (37.5%) patients had stone located in the upper ureter, 2 (25%) in the middle ureter, and 3 (37.5) in the distal ureter. In 6 cases, ureteral stones were treated using the semi-rigid ureteroscope, whereas in 1 case a flexible ureteroscope was needed. One woman was treated with insertion of a double-J stent due to associated urinary infection. No women has early delivery related to the endoscopic procedure, and all neonates were perfectly normal. Conclusions: We present a technique for endoscopic procedures in pregnant women inverting the fluoroscope’s c-arm and protecting the fetus from the direct X-ray beam. This practical approach should be specially considered when no portable ultrasound and radiologic assistance in available in the operating room. Editorial Comment: Limiting radiation exposure is important, especially in pregnant patients. The approach described seems reasonable. The authors did not measure radiation exposure in this study. One must refrain from having a “lead foot” when using fluoroscopy to limit exposure. However, the use of lead garments and protective eyewear by the operating team is quite important, particularly using this technique, where upward scatter is more prevalent. Dean Assimos, M.D.
Re: Multicenter Experience With Metallic Ureteral Stents for Malignant and Chronic Benign Ureteral Obstruction A. P. Modi, C. R. Ritch, D. Arend, R. M. Walsh, M. Ordonez, J. Landman, M. Gupta and B. E. Knudsen Department of Urology, Ohio State University Medical Center, Columbus, Ohio J Endourol 2010; 24: 1189 –1193.
Background and Purpose: A new coil-based metallic ureteral stent offers greater radial strength with longer indwelling time compared with plastic stents. This multicenter retrospective study reviews the clinical experience with this stent for malignant or benign chronic ureteral obstruction. Patients and Methods: Patients had stent placement in a retrograde fashion. We analyzed preplacement and postplacement renal imaging to determine degree of hydronephrosis. Stent encrustation was determined by either visual inspection at the time of stent change or plain abdominal radiography. Preoperative and follow-up serum creatinine values were compared for each patient. Results: A total of 76 stents in 59 renal units (40 patients) were successfully placed. Creatinine value follow-up on 54 renal units showed 20 (37%) units to have stable, 15 (28%) improved, and 19 (35%) with worsening values. No stent showed encrustation on plain radiography despite it being seen on two during direct visualization. Three stents needed operative removal with either percutaneous nephrolithotomy or
186
UROLITHIASIS/ENDOUROLOGY
cystolitholapaxy. Fifteen of 41 (37%) metallic stents placed because of an obstructed plastic stent also became obstructed. At last follow-up, 6 of 40 patients were kept from nephrostomy tubes because of the metallic stent. Conclusions: Metallic stents are a viable alternative to nephrostomy tubes in patients in whom conventional stents fail because of malignant obstruction, but patients need to be followed closely. Stent encrustation that resulted in retained stents was poorly visualized on plain radiography. Patients still remain at risk for obstruction, urinary tract infections, and lower urinary tract symptoms from the metallic stent. Editorial Comment: The treatment of patients with failed standard ureteral stents is frustrating for patient and physician. This stent may be used in such cases but the failure rate is still high, underscoring the need for careful followup. Nephrostomy tube drainage may ultimately be required in these cases. The search for the perfect stent is still ongoing! Dean Assimos, M.D.