- Email: [email protected]
URETEROSCOPIC RETRIEVAL OF MIGRATED STENTS UNDER LOCAL ANAESTHESIA
341 CONGENITAL RENAL ARTERIOVENOUS DIAGNOSTIC CLUES AND METHODS
MALFORMATION:
P21 ENDOUROLOGY FOR STONES Thursday, 6 April, 12.15-13.45, Room 242 / Level 2 PREDICTORS OF PAIN DURING OUTPATIENT CYSTOSCOPY
342 FLEXIBLE
Kommu S.S.1, Surange R.S.2, Gupta M.2, Chowdhury S.D.2, Sharma N.K.2
Lee D.G.1, Huh J.S.2, Jeon S.H.1, Lee S.J.1
1
1 Kyunghee Medical Centre, Urology, Seoul, South Korea, 2Cheju University, Urology, Cheju, South Korea
INTRODUCTION & OBJECTIVES: Congenital renal arteriovenous malformation (AVM) is very rare abnormal communications between arteries and veins. AVM are rarer than renal arteriovenous fistulas that were occurred secondarily or iatrogenically. AVM are also difficulty to diagnosis used by conventional methods because of its rarity. Therefore we investigated the effective diagnostic clues and methods of AVM. MATERIAL & METHODS: We analysed the clinical features, diagnostic modalities, and the treatments of 9 patients who were diagnosed as AVM used by renal angiography from 1986 to 2004. All patients were female and mean age was 38.1 years (range 19 to 54 years). RESULTS: All patients complained of gross hematuria. 6 patients had experienced recurrent gross hematuria and spontaneous resolution. 2 patients were developed symptoms after child delivery, and 1 patient had being pregnant. In angiographically finding, 6 patients showed circoid type and 3 patients were aneurysmal (idiopathic) type. In 5 patients who were performed computed tomography (CT), only 2 patients (aneurismal type) were detected mass like vascular lesion. In 4 patients who performed renal duplex Doppler, all patients showed a focal vascular lesion with posterior colour spots. A total of 9 patients underwent transarterial embolisation (TAE), and only one patient received nephrectomy because of sustained bleeding and hypovolemic shock after TAE. CONCLUSIONS: The mid aged female who were presented recurrent gross hematuria that were not diagnosed used by usually method (especially had the experiences of recent delivery or pregnancy) should be doubted of possibilities of AVM. Renal duplex Doppler is effective methods for diagnosis of AVM. Therefore, if ultrasonography was not detected bleeding cause, renal duplex doppler should be performed immediately. And TAE is effective treatment for hemodynamically stable patients.
The Institute of Cancer Research and The Royal Marsden Hospitals NHS Foundation Trust, Urology, London, United Kingdom, 2The Royal Oldham Hospital. The Pennine Acute Hospitals NHS Trust., Urology, Oldham, United Kingdom INTRODUCTION & OBJECTIVES: Flexible cystoscopy (FC) is an established mode of investigating urethral and bladder conditions and is the most common endourological procedure performed. Despite the use of analgesics and lubricants, a considerable number of patients still report significant discomfort and pain during the procedure. The aim of this study was to identify the predictors of discomfort and pain during outpatient FC. MATERIAL & METHODS: Patients scheduled for FC were prospectively studied. Indications for FC were placed into one of six categories. Patients who had more than one of the symptoms and/or indications were excluded. The categories were (1) lower urinary tract symptoms (LUTS), (2) haematuria, (3) bladder tumours, (4) strictures, (5) recurrent urinary tract infections and (6) incontinence. All males had 2% lidocaine gel instillation per urethra with gauze and clip occlusion of the distal urethra for approximately 5 minutes before the procedure. All women were scoped with 2% lidocaine gel over the scope. A 100-point visual analogue pain score (VAS) was recorded during the procedure in both genders at a time just prior to removing the scope (per procedural score-PERP). A VAS was again performed after the first void (after void score-AV) at the end of the FC. Patients were then interviewed before discharge. RESULTS: A total of 373 patients [176 males (M) and 197 females (F)] were studied. The average PERP for M=18.1 (range: 2.2-31.2) vs. F=13.7 (range: 2.6-22.5). The mean AV for M=16.9 (range: 0.7-35.0) vs. F=12.3 (range: 1.1-24.3). Women had overall lower pain scores both during and after the FC. The highest pain score for both males and females was in those with LUTS (PERP=31.2 and AV=35.0) vs. (PERP=22.5 and AV=24.3) respectively. The lowest pain score for both males and females was in those with bladder tumours for follow-up (PERP=2.2 and AV=0.7) vs. (PERP=2.6 and AV=1.1) respectively. First time FC patients, regardless of gender, experienced pain scores of at least 17% more than those who had FC at least twice. The ratio of PERP/AV was an independent predictor of pain. The ratio was greater than 1.0 in all groups except for LUTS in which a ratio of less than 1.0 was noted in both genders (M: PERP/AV=0.8 vs. F: PERP/AV=0.9). A PERP/AV ratio of less than 1.0 at first cystoscopy indicated a high chance of pain score at second cystoscopy and was able to predict a VAS score of > 30 in 100% of 15 patients (M=10 and F=5) subsequently rescored at second cystoscopy. No correlation was found between age and pain. CONCLUSIONS: The quadrad of male gender, LUTS, a (PERP/AV) ratio of <1.0 and first FC renders the highest pain scores at FC. Females who have repeat check cystoscopy for bladder tumours and who have a (PERP/AV) ratio of >1.0 are likely to have the least pain scores. This knowledge can lead to targeting patients at risk of high pain scores at FC with additional analgesia and preprocedural counselling.
343
344
A PROSPECTIVE AUDIT OF FLEXIBLE URETERORENOSCOPY
URETEROSCOPIC RETRIEVAL OF MIGRATED STENTS UNDER LOCAL ANAESTHESIA
AND HOLMIUM LASER LITHOTRIPSY FOR THE TREATMENT OF INTRARENAL CALCULI Henderson J., Ajayi L., Thomas K., Dasgupta P., Tiptaft R., Glass J. Guy’s Hospital, Urology, London, United Kingdom INTRODUCTION & OBJECTIVES: We report our experience with flexible ureterorenoscopy for intrarenal calculi over a 3-month period. MATERIAL & METHODS: A prospective audit of flexible ureterorenoscopies was performed over a 3month period. During that time 82 flexible ureterorenoscopies were performed on 77 patients for stone disease. 64 patients had intrarenal calculi and this cohort is reported here. The patients treated had a mean age of 51(range 15-83). 42% of patients had failed prev ESWL. 71% of the stones treated were less than 1cm. Holmium:YAG laser lithotripter was used in all cases. Success was defined as complete clearance or stone fragmentation to 2 mm or less. RESULTS: The overall success rate was 83%. This increased to 90% with repeated treatment. The mean operative time was 33 mins (range 5-95mins). The targeted stone was fragmented in 92% of cases. In 5 cases the stones could not be accessed. This was due to several reasons including calyceal diverticulum’s, and horseshoe kidney. There were no intraoperative complications, 2 urinary tract infections were documented post operatively. CONCLUSIONS: Retrograde intrarenal lithotripsy is an effective and safe treatment option for intrarenal stones. Our results compare favourably to published series. We demonstrate a significantly shorter operating time compared to other centres. Eur Urol Suppl 2006;5(2):108
Livadas K.1, Skolarikos A.2, Varkarakis I.2, Chalikopoulos D.2, Karagiotis E.2, Alivizatos G.2, Bisas A.2 1
Sismanoglio Hospital, Dept. of Urology, Athens, Greece, 2Athens Medical School, 2nd Department of Urology, Athens, Greece INTRODUCTION & OBJECTIVES: The aim of this study was to evaluate the feasibility of using local anaesthesia or no anaesthesia at all for ureteroscopic removal of distally migrated stents. MATERIAL & METHODS: Minor upward ureteral stent migration was diagnosed during the regular follow-up of 26 patients (18 females and 8 males; mean age 45-years old), who had previously been treated with SWL and stent placement. This migration occurred in the distal ureter and was diagnosed either by a KUB film or during scheduled cystoscopic stent removal. Ten minutes after the intraurethral application of a local aesthetic (15 ml lidocaine jell 2%) in males, and without any anaesthesia in females, a 10Fr semi-rigid ureteroscope with a 5Fr grasping forceps were used to remove the double-J. Antibiotic coverage was used in all cases. Per-procedural pain was evaluated using a 5-scale visual analogue questionnaire. RESULTS: The stent was successfully removed in 23 of 26 patients (88.5%). Mean procedural time was 3 minutes (range 2-3). Ureteroscopic stent removal was unsuccessful due to a large median prostatic lobe in 2 males and due to excessive oedema of the ureteral orifice in one female. All the procedures were uncomplicated and no patient presented with postoperative urinary retention, infection or ureteral colic. Mean visual analogue pain score was 2.1 (range 1 to 3). Non-steroidal antiinflammatory drugs were required in 5 patients postoperatively. Narcotic analgesia was not required. CONCLUSIONS: Ureteroscopic retrieval of migrated stents in the distal ureter, under local anaesthesia or under no anaesthesia, is a feasible and safe procedure.
MALFORMATION:
P21 ENDOUROLOGY FOR STONES Thursday, 6 April, 12.15-13.45, Room 242 / Level 2 PREDICTORS OF PAIN DURING OUTPATIENT CYSTOSCOPY
342 FLEXIBLE
Kommu S.S.1, Surange R.S.2, Gupta M.2, Chowdhury S.D.2, Sharma N.K.2
Lee D.G.1, Huh J.S.2, Jeon S.H.1, Lee S.J.1
1
1 Kyunghee Medical Centre, Urology, Seoul, South Korea, 2Cheju University, Urology, Cheju, South Korea
INTRODUCTION & OBJECTIVES: Congenital renal arteriovenous malformation (AVM) is very rare abnormal communications between arteries and veins. AVM are rarer than renal arteriovenous fistulas that were occurred secondarily or iatrogenically. AVM are also difficulty to diagnosis used by conventional methods because of its rarity. Therefore we investigated the effective diagnostic clues and methods of AVM. MATERIAL & METHODS: We analysed the clinical features, diagnostic modalities, and the treatments of 9 patients who were diagnosed as AVM used by renal angiography from 1986 to 2004. All patients were female and mean age was 38.1 years (range 19 to 54 years). RESULTS: All patients complained of gross hematuria. 6 patients had experienced recurrent gross hematuria and spontaneous resolution. 2 patients were developed symptoms after child delivery, and 1 patient had being pregnant. In angiographically finding, 6 patients showed circoid type and 3 patients were aneurysmal (idiopathic) type. In 5 patients who were performed computed tomography (CT), only 2 patients (aneurismal type) were detected mass like vascular lesion. In 4 patients who performed renal duplex Doppler, all patients showed a focal vascular lesion with posterior colour spots. A total of 9 patients underwent transarterial embolisation (TAE), and only one patient received nephrectomy because of sustained bleeding and hypovolemic shock after TAE. CONCLUSIONS: The mid aged female who were presented recurrent gross hematuria that were not diagnosed used by usually method (especially had the experiences of recent delivery or pregnancy) should be doubted of possibilities of AVM. Renal duplex Doppler is effective methods for diagnosis of AVM. Therefore, if ultrasonography was not detected bleeding cause, renal duplex doppler should be performed immediately. And TAE is effective treatment for hemodynamically stable patients.
The Institute of Cancer Research and The Royal Marsden Hospitals NHS Foundation Trust, Urology, London, United Kingdom, 2The Royal Oldham Hospital. The Pennine Acute Hospitals NHS Trust., Urology, Oldham, United Kingdom INTRODUCTION & OBJECTIVES: Flexible cystoscopy (FC) is an established mode of investigating urethral and bladder conditions and is the most common endourological procedure performed. Despite the use of analgesics and lubricants, a considerable number of patients still report significant discomfort and pain during the procedure. The aim of this study was to identify the predictors of discomfort and pain during outpatient FC. MATERIAL & METHODS: Patients scheduled for FC were prospectively studied. Indications for FC were placed into one of six categories. Patients who had more than one of the symptoms and/or indications were excluded. The categories were (1) lower urinary tract symptoms (LUTS), (2) haematuria, (3) bladder tumours, (4) strictures, (5) recurrent urinary tract infections and (6) incontinence. All males had 2% lidocaine gel instillation per urethra with gauze and clip occlusion of the distal urethra for approximately 5 minutes before the procedure. All women were scoped with 2% lidocaine gel over the scope. A 100-point visual analogue pain score (VAS) was recorded during the procedure in both genders at a time just prior to removing the scope (per procedural score-PERP). A VAS was again performed after the first void (after void score-AV) at the end of the FC. Patients were then interviewed before discharge. RESULTS: A total of 373 patients [176 males (M) and 197 females (F)] were studied. The average PERP for M=18.1 (range: 2.2-31.2) vs. F=13.7 (range: 2.6-22.5). The mean AV for M=16.9 (range: 0.7-35.0) vs. F=12.3 (range: 1.1-24.3). Women had overall lower pain scores both during and after the FC. The highest pain score for both males and females was in those with LUTS (PERP=31.2 and AV=35.0) vs. (PERP=22.5 and AV=24.3) respectively. The lowest pain score for both males and females was in those with bladder tumours for follow-up (PERP=2.2 and AV=0.7) vs. (PERP=2.6 and AV=1.1) respectively. First time FC patients, regardless of gender, experienced pain scores of at least 17% more than those who had FC at least twice. The ratio of PERP/AV was an independent predictor of pain. The ratio was greater than 1.0 in all groups except for LUTS in which a ratio of less than 1.0 was noted in both genders (M: PERP/AV=0.8 vs. F: PERP/AV=0.9). A PERP/AV ratio of less than 1.0 at first cystoscopy indicated a high chance of pain score at second cystoscopy and was able to predict a VAS score of > 30 in 100% of 15 patients (M=10 and F=5) subsequently rescored at second cystoscopy. No correlation was found between age and pain. CONCLUSIONS: The quadrad of male gender, LUTS, a (PERP/AV) ratio of <1.0 and first FC renders the highest pain scores at FC. Females who have repeat check cystoscopy for bladder tumours and who have a (PERP/AV) ratio of >1.0 are likely to have the least pain scores. This knowledge can lead to targeting patients at risk of high pain scores at FC with additional analgesia and preprocedural counselling.
343
344
A PROSPECTIVE AUDIT OF FLEXIBLE URETERORENOSCOPY
URETEROSCOPIC RETRIEVAL OF MIGRATED STENTS UNDER LOCAL ANAESTHESIA
AND HOLMIUM LASER LITHOTRIPSY FOR THE TREATMENT OF INTRARENAL CALCULI Henderson J., Ajayi L., Thomas K., Dasgupta P., Tiptaft R., Glass J. Guy’s Hospital, Urology, London, United Kingdom INTRODUCTION & OBJECTIVES: We report our experience with flexible ureterorenoscopy for intrarenal calculi over a 3-month period. MATERIAL & METHODS: A prospective audit of flexible ureterorenoscopies was performed over a 3month period. During that time 82 flexible ureterorenoscopies were performed on 77 patients for stone disease. 64 patients had intrarenal calculi and this cohort is reported here. The patients treated had a mean age of 51(range 15-83). 42% of patients had failed prev ESWL. 71% of the stones treated were less than 1cm. Holmium:YAG laser lithotripter was used in all cases. Success was defined as complete clearance or stone fragmentation to 2 mm or less. RESULTS: The overall success rate was 83%. This increased to 90% with repeated treatment. The mean operative time was 33 mins (range 5-95mins). The targeted stone was fragmented in 92% of cases. In 5 cases the stones could not be accessed. This was due to several reasons including calyceal diverticulum’s, and horseshoe kidney. There were no intraoperative complications, 2 urinary tract infections were documented post operatively. CONCLUSIONS: Retrograde intrarenal lithotripsy is an effective and safe treatment option for intrarenal stones. Our results compare favourably to published series. We demonstrate a significantly shorter operating time compared to other centres. Eur Urol Suppl 2006;5(2):108
Livadas K.1, Skolarikos A.2, Varkarakis I.2, Chalikopoulos D.2, Karagiotis E.2, Alivizatos G.2, Bisas A.2 1
Sismanoglio Hospital, Dept. of Urology, Athens, Greece, 2Athens Medical School, 2nd Department of Urology, Athens, Greece INTRODUCTION & OBJECTIVES: The aim of this study was to evaluate the feasibility of using local anaesthesia or no anaesthesia at all for ureteroscopic removal of distally migrated stents. MATERIAL & METHODS: Minor upward ureteral stent migration was diagnosed during the regular follow-up of 26 patients (18 females and 8 males; mean age 45-years old), who had previously been treated with SWL and stent placement. This migration occurred in the distal ureter and was diagnosed either by a KUB film or during scheduled cystoscopic stent removal. Ten minutes after the intraurethral application of a local aesthetic (15 ml lidocaine jell 2%) in males, and without any anaesthesia in females, a 10Fr semi-rigid ureteroscope with a 5Fr grasping forceps were used to remove the double-J. Antibiotic coverage was used in all cases. Per-procedural pain was evaluated using a 5-scale visual analogue questionnaire. RESULTS: The stent was successfully removed in 23 of 26 patients (88.5%). Mean procedural time was 3 minutes (range 2-3). Ureteroscopic stent removal was unsuccessful due to a large median prostatic lobe in 2 males and due to excessive oedema of the ureteral orifice in one female. All the procedures were uncomplicated and no patient presented with postoperative urinary retention, infection or ureteral colic. Mean visual analogue pain score was 2.1 (range 1 to 3). Non-steroidal antiinflammatory drugs were required in 5 patients postoperatively. Narcotic analgesia was not required. CONCLUSIONS: Ureteroscopic retrieval of migrated stents in the distal ureter, under local anaesthesia or under no anaesthesia, is a feasible and safe procedure.