- Email: [email protected]
Ureteral Access: Innovations in Guidewire and Balloon Catheter Systems
Accepted 521
522
A CIASSIFIC/l.TION OF AND TErHNIQUES FCR THE MANAGEMENT OF UPPER URINARY TRACT STRICTURES. *John C. Hulbert, Minneapolis, Minnesota. Presentation to be made by Dr. John C. Hulbert.
TRANSURETERAL INTUBATED URETEROTOMY. Joerg Schueller*, Nikolaus Schmeller*, A. Knipper*, Luebeck, FRG (Presentation to be made by Dr. Schueller) To borden the spectrum of endourological manipulations the transuretheral approach offers the possibility for treatment of ureteral stenosis without open surgery. In the time from 8.85 to 8.86 endoscopical ureterotomy was done in 21 cases. The indication fqr ureterotomy was given on the basis of radiological and endoscopic exams. Causes of stenosis were as follows: after surgical procedere 16/21, after ureteral manipulation 1/21, UPJ-obstructions 4/21. The endoscopic ureterotomy was done with a operating ureterotome (R. Wolf). Postoperative splinting was done for 4 to 6 weeks by 10 to 12 F. Double-J-Catheter. The results were excellent in 16/21 cases after minimum of 6 month observationtime. In two cases good results could only be achieved after a second treatment. In 5 cases the postoperative results had not changed in comparison to the previous state. Complications: 2 severe bleedings from an ureteral vessel, that could be treated successfully by endoscopic elcetrocoagulation. In consideration of our results the primary trail of transuretheral ureterotomy for treatment of ureteral stenosis seems to be justified before open reconstructive surgery should be undertaken.
Techniques for establishing safe percutaneous access to the collecting system have becane acoepted in recent years. Initially the stimulus was for the management of stone disease but more recently these techniques have been turned to the management of intrinsic strictures of the upper urinary tract; notably those at the ureteropelvic junction and calyceal infundibulurn. Based on the experience of 21 ureteropelvic and upper ureteral strictures and 11 strictures at the calyceal infundibulurn, a classification system has been devised. Type I, ¼hich are the least difficult, are those through ¼hich the guidewire can successfully be negotiated. Type II are those ¼hich, although demonstrated to be patent radiologically, cannot be negotiated with a guidewire. Type III are those ¼here total obliteration of the lumen has taken place with loss of oontinuity demonstrated radiographically. Detailed descriptions of the techniques used to manage each type are described. The results clearly indicate that success is based on the degree of fibrosis and the longevity of the stricture. All cases were strictures resulting fran prior surgical techniques. Of 21 patients with ureteropelvic strictures, 10 ¼ere returned to normal function. The other 11 ¼Bre oonsidered failures; of those with infundibular stenosis, 6 out of 11 showed improvement following percutaneous management and 5 were not helped. The reasons for failure of this technique and its application to the management of intrarenal strictures are discussed.
523
524
DEVELOPMENT AND CLINICAL EVALUATION OF FLEXIBLE URETEROSCOPES AND ACCESSORIES. ,:,ROBERT U. BREGMAN MD & ARTHUR L, WOLLMAN MD, PHD SAN DIEGO, CA. Presentation by Dr. Bregman.
URETERAL ACCESS: INNOVATIONS IN GUIDEWIRE AND BALLOON CATHETER SYSTEMS Jerry D. Giesy, Matthew W. Hoskins*,
We have been working on this project for 7 years with optical scientists and engineers. Eight prototype and production instruments evolved over the past 4, 5 years in 7, 9 and 10 F sizes with. 020 to. 052" operating channel, 1. 4 to 4, 0 F diameter surgical accessories have been developed and used with these instruments, as well as rigid ureteroscopes, The ureteroscope is introduced into the bladder, ureter and kidney like a ureteral cathether.Since 1982, 90 clinical evaluation reports were prepared on 70 patients. 22 patients had ureteral or renal stones. 4 were rra..nipulated and 10 removed. 23 urologists used the instruments at 11
hospitals.
Diagnosis was established in 30 patients: 8 had
tumors, 12 were normal and there were 10 other diagnoses, 17 to 26F cystoscopes were used. A clear image of normal anatomy was obtained in 58 patients (82%). 12 patients had ureteral dilation, 9 exams were unsatisfactory: 4 due to hematuria, 4 technique and 2 to image bundle deterior~ ation. Patient ages ranged from neonate to 76. Sex distribution was equaL There was no incident of infection or ureteral perforation,, 8 stones were removed under direct vision with the new stone instruments.
At this time, safe, durable 7 and 9Fflexible(fiberoptic) ureteroscopes with high image resolution and 1. 5 to 3. 5F working channels have been developed and tested and are available for urologic diagnosis and treatment.In addition,
surgical accessories from I. 4 to 4. 0 F have also been developed and tested for use with uretero-renoscopy.
Portland, OR; George D. Hermann*, Thomas J. Fogarty*j Palo
Alto, CA.
(Presentation to be made by Dr. Giesy.)
This report describes 3 innovative designs involving guidewires and balloon catheters, which have evolved from our experience in balloon catheter instrumentation since 1982. The first is a catheter system designed to facilitate placement of a guidewire beyond an impacted stone. It con-
sists of a blunt-nosed coaxial balloon catheter with a small lumen attached to the surface of the balloon. The balloon dilates immediately adjacent to the stone while the eccentric lumen enables placement of a guidewire around the impaction, In a mechanical model of an impacted ureteral stone~ this catheter was successful in placing a guidewire around impactions that were otherwise impassable, The second is nn instrument carrier which aids in pl~cement of instruments for visualization and stone extraction,, This design uses a folded flexible membrane to line the ureter, protecting it from the frictional forces encountered by instrument passage. Experience in ex-vivo porcine ureter models clearly shows the elimination of axial frictional forces exerted against the ureter wall during instrument advancement and withdrawal (543 g mean peak force with bare 11.SF scope, 0 g mean peak force with scope within instrument carrier). The third design allows passage of an instrument (stone basket, ureteral catheter, scope) over a guidewire without sacrificing the instrument's through lumen or working channel space, This is achieved by threading the guidewire through an eyebolt-type guide at the tip of the instrument to be passed. The instrument is advanced alongside the guidewire and is kept on course via the guide at the instrument tip. This ensures guidewire access will be maintained throughout the procedure and does not add to the overall bulk of the instrument.
234A
522
A CIASSIFIC/l.TION OF AND TErHNIQUES FCR THE MANAGEMENT OF UPPER URINARY TRACT STRICTURES. *John C. Hulbert, Minneapolis, Minnesota. Presentation to be made by Dr. John C. Hulbert.
TRANSURETERAL INTUBATED URETEROTOMY. Joerg Schueller*, Nikolaus Schmeller*, A. Knipper*, Luebeck, FRG (Presentation to be made by Dr. Schueller) To borden the spectrum of endourological manipulations the transuretheral approach offers the possibility for treatment of ureteral stenosis without open surgery. In the time from 8.85 to 8.86 endoscopical ureterotomy was done in 21 cases. The indication fqr ureterotomy was given on the basis of radiological and endoscopic exams. Causes of stenosis were as follows: after surgical procedere 16/21, after ureteral manipulation 1/21, UPJ-obstructions 4/21. The endoscopic ureterotomy was done with a operating ureterotome (R. Wolf). Postoperative splinting was done for 4 to 6 weeks by 10 to 12 F. Double-J-Catheter. The results were excellent in 16/21 cases after minimum of 6 month observationtime. In two cases good results could only be achieved after a second treatment. In 5 cases the postoperative results had not changed in comparison to the previous state. Complications: 2 severe bleedings from an ureteral vessel, that could be treated successfully by endoscopic elcetrocoagulation. In consideration of our results the primary trail of transuretheral ureterotomy for treatment of ureteral stenosis seems to be justified before open reconstructive surgery should be undertaken.
Techniques for establishing safe percutaneous access to the collecting system have becane acoepted in recent years. Initially the stimulus was for the management of stone disease but more recently these techniques have been turned to the management of intrinsic strictures of the upper urinary tract; notably those at the ureteropelvic junction and calyceal infundibulurn. Based on the experience of 21 ureteropelvic and upper ureteral strictures and 11 strictures at the calyceal infundibulurn, a classification system has been devised. Type I, ¼hich are the least difficult, are those through ¼hich the guidewire can successfully be negotiated. Type II are those ¼hich, although demonstrated to be patent radiologically, cannot be negotiated with a guidewire. Type III are those ¼here total obliteration of the lumen has taken place with loss of oontinuity demonstrated radiographically. Detailed descriptions of the techniques used to manage each type are described. The results clearly indicate that success is based on the degree of fibrosis and the longevity of the stricture. All cases were strictures resulting fran prior surgical techniques. Of 21 patients with ureteropelvic strictures, 10 ¼ere returned to normal function. The other 11 ¼Bre oonsidered failures; of those with infundibular stenosis, 6 out of 11 showed improvement following percutaneous management and 5 were not helped. The reasons for failure of this technique and its application to the management of intrarenal strictures are discussed.
523
524
DEVELOPMENT AND CLINICAL EVALUATION OF FLEXIBLE URETEROSCOPES AND ACCESSORIES. ,:,ROBERT U. BREGMAN MD & ARTHUR L, WOLLMAN MD, PHD SAN DIEGO, CA. Presentation by Dr. Bregman.
URETERAL ACCESS: INNOVATIONS IN GUIDEWIRE AND BALLOON CATHETER SYSTEMS Jerry D. Giesy, Matthew W. Hoskins*,
We have been working on this project for 7 years with optical scientists and engineers. Eight prototype and production instruments evolved over the past 4, 5 years in 7, 9 and 10 F sizes with. 020 to. 052" operating channel, 1. 4 to 4, 0 F diameter surgical accessories have been developed and used with these instruments, as well as rigid ureteroscopes, The ureteroscope is introduced into the bladder, ureter and kidney like a ureteral cathether.Since 1982, 90 clinical evaluation reports were prepared on 70 patients. 22 patients had ureteral or renal stones. 4 were rra..nipulated and 10 removed. 23 urologists used the instruments at 11
hospitals.
Diagnosis was established in 30 patients: 8 had
tumors, 12 were normal and there were 10 other diagnoses, 17 to 26F cystoscopes were used. A clear image of normal anatomy was obtained in 58 patients (82%). 12 patients had ureteral dilation, 9 exams were unsatisfactory: 4 due to hematuria, 4 technique and 2 to image bundle deterior~ ation. Patient ages ranged from neonate to 76. Sex distribution was equaL There was no incident of infection or ureteral perforation,, 8 stones were removed under direct vision with the new stone instruments.
At this time, safe, durable 7 and 9Fflexible(fiberoptic) ureteroscopes with high image resolution and 1. 5 to 3. 5F working channels have been developed and tested and are available for urologic diagnosis and treatment.In addition,
surgical accessories from I. 4 to 4. 0 F have also been developed and tested for use with uretero-renoscopy.
Portland, OR; George D. Hermann*, Thomas J. Fogarty*j Palo
Alto, CA.
(Presentation to be made by Dr. Giesy.)
This report describes 3 innovative designs involving guidewires and balloon catheters, which have evolved from our experience in balloon catheter instrumentation since 1982. The first is a catheter system designed to facilitate placement of a guidewire beyond an impacted stone. It con-
sists of a blunt-nosed coaxial balloon catheter with a small lumen attached to the surface of the balloon. The balloon dilates immediately adjacent to the stone while the eccentric lumen enables placement of a guidewire around the impaction, In a mechanical model of an impacted ureteral stone~ this catheter was successful in placing a guidewire around impactions that were otherwise impassable, The second is nn instrument carrier which aids in pl~cement of instruments for visualization and stone extraction,, This design uses a folded flexible membrane to line the ureter, protecting it from the frictional forces encountered by instrument passage. Experience in ex-vivo porcine ureter models clearly shows the elimination of axial frictional forces exerted against the ureter wall during instrument advancement and withdrawal (543 g mean peak force with bare 11.SF scope, 0 g mean peak force with scope within instrument carrier). The third design allows passage of an instrument (stone basket, ureteral catheter, scope) over a guidewire without sacrificing the instrument's through lumen or working channel space, This is achieved by threading the guidewire through an eyebolt-type guide at the tip of the instrument to be passed. The instrument is advanced alongside the guidewire and is kept on course via the guide at the instrument tip. This ensures guidewire access will be maintained throughout the procedure and does not add to the overall bulk of the instrument.
234A