RU2757530C2 - Method for percutaneous antegrade treatment of recurrent short strictures up to 10 mm of ureteropelvic junction in children with hydronephrosis - Google Patents

Abstract

FIELD: medicine, urology-andrology.

SUBSTANCE: invention relates to medicine, specifically to urology-andrology of childhood. Dissection of ureteropelvic junction stricture is performed in antegrade direction. In this case, core wires are used - one in antegrade and one in retrograde direction, nephroscope is brought to the stricture zone between two core wires, pushing wires into the opposite direction, stretching the ureter paries and increasing its lumen. Dissection of ureteropelvic junction stricture is performed with a holmium laser in "Ablation" mode using 230 nm fiber. Moreover, the dissection is carried out along the lateral side of ureteropelvic junction, longitudinal incisions through all layers to the periureteral adipose tissue. Upon reaching the ureteral lumen under the control of X-ray telescoping the ureteral stent is installed in antegrade direction.

EFFECT: method makes possible to improve visualization of stricture, control the depth of dissection and reduce the risk of such a formidable complication as ureteral perforation, reduce the risk of bleeding and contributes to better visualization of the surgical field.

1 cl, 6 dwg, 1 tbl

Description

The invention relates to medicine, namely urology-andrology of childhood and can be used to treat children with recurrent obstruction of the pyeloureteral segment.

Obstruction of the pelvic-ureteric segment (LMS) leads to the development of hydronephrosis, which is manifested by impaired passage of urine, progressive expansion of the pelvis and calyx, ultimately leading to loss of renal function. The frequency of occurrence of hydronephrosis is 1: 500 - 1: 800 newborns (Vrublevsky S.G., Shmyrov O.S., Vrublevskaya E.N., Lazishvili M.N., Kulaev A.V., Korochkin M.V., Vrublevsky AS Laparoscopic pyeloplasty in children: technique, drainage, complications. Pediatric surgery. 2017. Volume 21. No. 6. S .: 299-302). Obstruction of the pyelourethral segment in boys occurs 2-3 times more often than in girls. The left kidney is most often affected. In 10-25% of cases, the lesion is bilateral (S. Tekgül, HS Dogan, E. Erdem, P. Hoebeke, R. Ko˘cvara, JM Nijman, C. Radmayr, MS Silay, R. Stein, S. Undre. / Guidelines on Paediatric Urology. European Association of Urology. 2015. P. 41 - 44; EAU Guidelines on Paediatric Urology. C. Radmayr, G. Bogaert, HS Dogan, R. Kocˇvara, JM Nijman, R. Stein, S. Tekgül, LA 't Hoen, J. Quaedackers, MS Silay, S. Undre. European Association of Urology 2018. P. 58 - 61). Allocate primary (congenital) hydronephrosis and secondary (acquired). The etiology of acquired stenosis of the pelvic-ureteric segment and secondary hydronephrosis is: scarring of the LMS of unknown origin, fibroepithelial polyps (a rare cause of pyeloureteral segment stenosis) (Adey GS, Vargas SO, Retik AB, et al. Fibroepithelial polyps causing uretero inpelvic children junction obstruction 2003. V. 169. No. 5. P. 1834-1836. Doi: 10.1097 / 01.ju.0000061966.21966.94), malignant neoplasms of the ureter, cicatricial adhesive process in the LMS area after trauma or operations on the upper urinary tract, post-inflammatory periureteritis with scarring of the LMS with nephrolithiasis (prolonged standing of the calculus in the LMS).

Surgical methods of treatment, depending on the access to the kidney and the use of special instruments, are divided into open, minimally invasive endovideosurgical and endoscopic operations.

In open and endoviedosurgical operations, the Anderson-Hynes technique is used, which involves the mobilization of the pelvis and the proximal ureter for 5-7 cm. Cutting off the ureter, above the stenosis zone, from the pelvis in an oblique direction. Longitudinal dissection of the ureter within healthy tissues and resection of the altered pelvic-ureteric segment. With the subsequent formation of ureteropyeloanastomosis. This method of pyeloplasty is used both for primary and recurrent stricture of the pelvic-ureteric segment (Khinman F. Operative urology: Translated from English - M .: GEOTAR-MED, 2001. S. 936 - 940). The Anderson-Hynes method of forming ureteropyeloanastomosis is highly effective and is the gold standard in the treatment of pyeloureteral segment obstruction in children.

However, if the technique described above is performed, a large array of tissues, skin, subcutaneous fat, and lumbar muscles are dissected in an open way. In the postoperative period, episodes of prolonged hematuria often occur, clots are formed in the lumen of the calyx-pelvic system, disrupting the drainage of urine through the internal stent or nephrostomy, which can lead to the development of serious complications and relapse of stricture.

Today, in connection with the development of minimally invasive technologies, a common method of surgical treatment of hydronephrosis is performing the Anderson-Hynes operation by a laparoscopic or retroperitoneoscopic method (Krajewski W, Wojciechowska J, Dembowski J, Zdrojowy R, Szydełko T. : An underestimated problem? Current opinions on the pathogenesis, diagnosis and treatment. Adv Clin Exp Med. 2017. V. 26. No. 5. P. 857-864.doi: 10.17219 / acem / 59509).

However, the known method, although it has a number of advantages over open interventions, such as minimally invasive access, but also has a number of disadvantages inherent in open operations. At the same time, the retroperitoneoscopic approach, in comparison with the laparoscopic approach, has an additional disadvantage - a small working space, which is of great importance especially in young children.

Along with open and endovideosurgical operations, methods of endoscopic treatment of strictures of the pelvic-ureteric segment in children are actively used. These methods include endoscopic balloon dilation and percutaneous antegrade endopyelotomy.

However, it should be borne in mind that the rate of positive results of balloon dilatation is 70-80%, while the effectiveness of percutaneous endopyelotomy is from 65 to 93%. According to the literature, the method of percutaneous antegrade endopyelotomy can be successfully used to treat children with recurrent stricture of the pelvic-ureteric segment, with recurrent hydronephrosis, with careful selection of patients for this procedure (GJ Faerber, ML Ritchey, DA Bloom. Percutaneous endopyelotomy in infants and children after failed open pyeloplasty J Urol 1995 V. 154 No. 4. P. 1495-1497 doi: 10.1016 / s0022-5347 (01) 66912-x; Bodo E Knudsen 1, Anthony J Cook, James D Watterson , Darren T Beiko, Linda Nott, Hassan Razvi, John D Denstedt Percutaneous antegrade endopyelotomy: long-term results from one institution Urology 2004 V. 63 No. 2. P. 230-234 doi: 10.1016 / j.urology .2003.09.049. PMID: 14972459).

The closest is the method of percutaneous antegrade endopyelotomy (Arthur D. Smith. Smith`s Textbook of Endourology. Second edition // London, Hamilton, BC Decker Inc. 2006, p. 167 - 169), which consists in antegrade dissection of the pelvic-ureteric stricture segment with a cold knife, along the postero-lateral surface through the entire thickness, followed by the installation of an internal stent. To perform endopyelotomy, an approach similar to that for removing calculi is used, however, the puncture of the pelvicellular system is performed through the calyx of the middle or upper segment, which facilitates manipulation with a rigid instrument in the area of the pyeloureteral segment. In the classical description of antegrade endopyelotomy, a posterolateral intraluminal incision is used through the entire thickness of the pelvic-ureteric junction with a cold-knife urethrotome under direct control. Before the stage of endopyelotomy, the ureteropelvic junction is expanded with a ureteral balloon if the ureteral lumen is narrow enough for smooth passage of the knife. After expansion, small tears of the mucous membrane are sometimes observed. The endopyelotomy knife is placed over the guidewire under visual control. The incision is made 1 to 2 cm into the renal pelvis and approximately 1 cm distal to the obstruction. Visualization of adipose tissue and retroperitoneal tissue ensures that a full-thickness incision is made in the renal pelvis and ureteral wall. Scarring can make it difficult to determine the required incision depth in cases of secondary obstruction of the pyeloureteral segment.

The disadvantage of this method is increased trauma to the wall of the pelvic-ureteric segment when the zone of obstruction with a balloon expands, which complicates the passage of the ureterotome through the stricture zone, insufficient visualization of the depth of the dissected tissues and the length of the obstruction, especially in the case of recurrent stricture of the pelvic-ureteric segment, increased bleeding in the area of stricture dissection , which may require the use of additional instrumentation for the coagulation of bleeding vessels.

The technical result of the proposed solution is the creation of an effective minimally invasive endoscopic method of surgical treatment of recurrent stricture of the pelvic-ureteric segment, allowing to eliminate obstruction of the pelvic-ureteric segment and minimize the frequency of complications.

The specified technical and therapeutic results in the implementation of the invention are achieved due to the fact that, as in the known method, the stricture of the pelvic-ureteric segment is dissected in the antegrade direction.

A feature of the invention is that to improve the visualization of the stricture zone and control the length and depth of tissue dissection, conductor strings are used - one in the antegrade and one in the retrograde direction, the nephroscope is brought to the stricture zone between the two conductors, the conductors are moved apart in the opposite direction to each other direction, stretching the walls of the ureter, increasing its lumen, dissection of the stricture zone of the pelvic-ureteric segment with a holmium laser, in the "Ablation" mode, using 230 nm fiber, and the dissection is carried out along the lateral side of the segment, with longitudinal cuts through all layers to the periureteral fatty tissue, upon reaching the lumen of the ureter, under the control of fluoroscopy, the installation of the ureteral stent is performed in the antegrade direction, the operation is completed by draining the kidney with nephrostomy drainage.

The use of a holmium laser for stricture dissection minimizes the incidence of hemorrhagic complications due to the fact that tissue dissection and coagulation are performed simultaneously. Also, a feature of this type of laser is a small depth of penetration into tissues of 4-5 mm, which allows a precise incision of tissues to a shallow depth, there is no carbonization and tissue burns, which can significantly affect the outcome of treatment.

The invention is illustrated by a detailed description, clinical examples and illustrations, which depict:

FIG. 1 - retrograde ureteropyelography; in the area of the pelvic-ureteric segment, the stricture is 8 mm.

FIG. 2 - performing percutaneous access by puncture of the pelvic-pelvic system under ultrasound control (the position of the ultrasound device sensor should coincide with the direction of the inserted needle).

FIG. 3 - installation of the nephroscope tube into the dilated fistulous tract.

FIG. 4 - the position of the conductor strings installed in the antegrade and retrograde directions.

FIG. 5 - stage of endopyelotomy with a holmium laser.

FIG. 6 - placement of an endopyelotomy internal stent.

The method is performed as follows.

The main stages of the proposed percutaneous antegrade endopyelotomy correspond to the classical technique, however, they have a number of technical features.

All interventions are performed in an X-ray operating room and under endotracheal anesthesia. The operation begins in the position of the child "on his back", the external genital organs are treated with an antiseptic.

The first step is cystoscopy, in which the location of the ureteral orifices is determined. Next, catheterization of the ureter is carried out and retrograde ureteropyelography is performed (Figure 1), in which the localization and length of the ureteral stricture is determined. Further, in a retrograde manner, under the control of an X-ray telescope, a conductor string is installed through the stricture zone, forming a curl in the pelvis. The cystoscope is removed. The child is transferred to the "on the stomach" position.

After treating the operating field with an antiseptic and covering the lumbar region with a hermetic self-adhesive sterile transparent film that isolates the area of intervention, the percutaneous access to the pelvic-pelvic system is formed.

Under the combined control of ultrasound and X-ray telescope, the puncture of the pelvic-pelvic system is performed through the calyx, which provides the most convenient exit to the area of the pelvic-ureteric segment (Figure 2). A punctured two-component needle with a mark is used, which can be well visualized with ultrasound monitoring of its movement and advancement into the cup. Localization and direction of access is carried out on the basis of preoperative examination: survey and excretory urography, ultrasound, computed tomography with contrast (in older children), as well as on the basis of the obtained intraoperative data.

After the puncture of the calyx-pelvic system, the position of the puncture needle is monitored by X-ray and, if necessary, its position is corrected. The mandrain is removed and the character of the discharge through the needle is assessed. When drops of urine appear, antegrade pyelography is performed to assess the position of the needle. With the correct position of the puncture needle in the calyx-pelvic system, a rigid conductor string with a soft straight end is inserted through the needle so that the string passes into the upper third of the ureter, through the stricture zone of the pelvic-ureteric segment.

At the puncture site, above the needle, a small skin incision is made to facilitate bougienage of the nephrostomy passage. The needle is removed, the nephrostomy course is bougiened with a conical bougie corresponding to the diameter of the tube along the guide string. The bougie is brought into the pelvis. After that, on a bougie, the tube of the nephroscope is started (Fig. 3) and the nephroscope is installed. The collecting system of the child's kidney is examined.

In the case of calculi detected at the preoperative stage of patient examination, the stones are initially lithotripsy using the Auriga XL laser device, in the "Litho" mode. Also, in the lumen of the pelvis, in the area of the previously formed ureteropyeloanastomosis, ligatures can be detected, which are removed with forceps. After the stage of "sanitation" of the cavities, the kidneys move on to the stage of endopyelotomy.

A feature of the endopyelotomy stage from the standard technique is that to improve the visualization of the stricture zone and control the length and depth of tissue dissection, guide strings previously installed in the antegrade and retrograde directions are used (Figure 4). It also eliminates the need for preliminary expansion of the stenosis zone with a balloon, which avoids additional trauma to the ureter (rupture of the mucous membrane) due to a "soft" increase in the lumen of the ureter. This is achieved by bringing the nephroscope to the stricture zone between the two conductors, thereby pushing the conductors apart in the opposite direction to each other. Due to which there is a stretching of the walls of the ureter and an increase in its lumen, which makes it possible to clearly differentiate the tissues under "direct vision".

Dissection of the stricture zone of the pelvic-ureteric segment is performed with a holmium laser, in the "Ablation" mode, using a 230 nm fiber. The dissection is carried out along the lateral side of the segment, with longitudinal cuts through all layers to the periureteral fatty tissue (Fig. 5).

Upon reaching the lumen of the ureter, corresponding to the age of the child, under the control of fluoroscopy, perform the installation of the ureteral stent in the antegrade direction (Fig. 6). At the end of the surgery, the kidney is drained with nephrostomy drainage.

Clinical trials were carried out at the Pediatric Urology Department of the Research Institute of Urology and Interventional Radiology, a branch of the National Medical Research Center of Radiology.

Percutaneous antegrade endopyelotomy was performed in 36 patients aged 2 to 17 years (mean age 6.3 years): 20 boys and 16 girls. Endopyelotomy with the stage of nephrolithotripsy was performed in 14 patients, the rest of the patients underwent endopyelotomy as an independent operation. This method was not used in primary patients with hydronephrosis, since we do not consider it ideal for this group of patients.

The indications for surgery were short ureteral strictures up to 10 mm or fibrous changes (like “spurs”) of the pyeloureteral segment after previously performed plasty of the pelvic-ureteric segment.

The effectiveness of the method was determined on the basis of an assessment of the long-term results of correction of the pyeloureteral segment and was assessed according to the following criteria:

- the degree of dilatation of the calyx-pelvis system;

- functional state of the kidneys according to scintigraphy data;

- relapses of the disease and the need for repeated interventions;

- late postoperative complications.

The duration of the operation varied from 42 to 82 minutes. There were no intraoperative complications. Patients after percutaneous endopyelotomy were observed in the clinic for 2 to 7 days.

In the postoperative period, the following complications were noted: macrohematuria in one patient and hyperthermia up to 38 ° C in one patient. These complications did not require additional interventions. More formidable complications, such as bleeding or perforation of the calyx-pelvic system, ureteral rupture, were not observed.

Clinical examples of the invention.

Example 1.

Patient G. 9 years old was admitted to the department in a planned manner with a diagnosis of hydronephrosis on the left, IV degree, due to recurrent stricture of the pelvic-ureteric segment on the left. ICD: Multiple ligature stones of the pelvic-ureteric segment and stones of the lower calyx on the left. Condition after plasty of the pelvic-ureteric segment from 2010. Polymegacalycosis.

The patient complains of abdominal pain, nausea.

In April 2010, open surgery was performed for hydronephrosis on the left. When carrying out instrumental methods of examination, the following results were obtained.

According to excretory urography and computed tomography with contrast: there is a significant expansion of the pyelocaliceal system: pelvis (anteroposterior size) up to 7.0 cm, calyx up to 3.7 cm, with thinning of the parenchyma of the left kidney up to 8 mm. Concrements are visualized in the pelvis and in the middle group of cups with sizes from 3 mm to 6 mm, with a density of 517 HU.

Ultrasound data of the kidneys also confirmed a significant expansion of the renal pyelocaliceal system with the presence of calculi in it.

The results of dynamic renoscintigraphy indicate a sharp slowdown in the excretory capacity of the left kidney, the renogram curve is obstructive. Scintigraphic signs of hydronephrotic transformation of the left kidney with a sharp slowdown in its excretory capacity.

The patient underwent percutaneous nephrolite extraction on the left, laser ablation of the stricture of the pelvic-ureteric segment on the left, stenting of the left ureter, nephrostomy on the left.

The main stages of the operation.

With the patient in the supine position, cystoscopy was performed, the left ureter was catheterized to perform retrograde ureteropyelography (Figure 1). Next, a conductor string was installed in the retrograde direction, through the stricture zone, into the calyx-pelvis system with the formation of a curl in the pelvis. The patient was turned over to the prone position. Percutaneous access to the kidney was performed by puncture of the calyx-pelvic system under the control of ultrasound (Figure 2) and X-ray telescope, followed by bougienage of the fistulous tract to the size of the tube of the nephroscope. Installed the tube of the nephroscope in the dilated fistulous tract (Figure 3). Ligatures and calculi were removed. A guidewire was installed in the antegrade direction through the stricture zone of the pelvic-ureteric segment. Thus, through the stricture zone of the pyeloureteral segment, two conductor strings are drawn (Fig. 4), in order to control the dissection zone and "soft" dilution of the walls of the ureter. Next, the nephroscope was brought to the stricture zone between the two conductors, thereby separating the conductors in the opposite direction to each other, due to which the walls of the ureter were stretched and its lumen increased, which made it possible to clearly differentiate tissues under "direct vision" and perform the stage of endopyelotomy with holmium laser (Fig. 5) without additional trauma to the ureter. The length of the stricture was 10 mm. The operation was completed with the installation of an internal stent (Fig. 6) and a nephrostomy.

The duration of the operation was 50 minutes. The urethral catheter was removed on the 1st day.

The patient was discharged on the 4th day after surgery with an internal stent and nephrostomy drainage.

One and a half months after the operation, the patient underwent removal of the internal stent and nephrostomy drainage.

During the follow-up examination of the patient within a year and two years after the operation, according to the data of ultrasound examination with lasix load, the patient has a significant decrease in the anteroposterior size of the pelvis, with good compensatory abilities of the pyelocaliceal system, an increase in the thickness of the parenchyma up to 1.1 - 1.5 cm (before surgery 0.4 - 0.7 cm).

After evaluating the results of ultrasound, patient G. 9 years old, with a diuretic load, one hour after the introduction of lasix, the pelvis remains dilated, which is less than 30% of the original size, which testifies in favor of good contractility of the pelvis.

The main criteria for choosing this method of treatment in the patient were unextended stricture of the ureter and a slight decrease in the function of the left kidney.

Example 2.

Patient M., 4 years old, was admitted to the department in a planned manner with a diagnosis of hydronephrosis on the right, postoperative condition dated 06.2016. Recurrent stricture of the pelvic-ureteric segment on the right. Chronic pyelonephritis, remission.

Complaints about changes in urine tests in the form of leukocyturia.

In June 2016, hydronephrosis on the right was revealed, laparoscopic pyeloplasty with stenting of the right ureter was performed. In July 2016, the inner stent was removed. Due to the increase in the expansion of the CLS of the right kidney, the internal stent was reinserted for three months without effect.

When carrying out instrumental survey methods, the following data were obtained.

According to the data of magnetic resonance imaging: the right kidney with dimensions 101 * 46 mm, the pelvis-pelvis system expanded to 32 * 29 mm, the calyx up to 15-26 mm, parenchyma 9-7-12 mm.

According to the data of ultrasound examination with a pharmacological test: The right kidney with dimensions of 9.8x4.5x5.9 cm.Its parenchyma is homogeneous, not changed, not edematous, its thickness is 1.0-1.1 cm. 3.3 cm, cups 2.3-3.2 cm. The right ureter in the upper third is not visualized (Table 1).

Table 1

Ultrasound examination of the kidneys with pharmacological test

The original 30 minutes 60 minutes 90 minutes 120 minutes NS. bud 3.3 3.6 3.6 3.2 3.1 A lion. bud 0 0 0 0 0

Dynamic nephroscintigraphy (03/08/18): The left kidney is normal. The right kidney is hydronephrotic, with a thin parenchyma, reduced concentration against the background of back pressure, obstructive drainage disorder, and significant retention of the proximal collecting system. Nephroscintigraphy revealed obstruction of the right kidney with a decrease in renal function of up to 32%.

The patient underwent surgery: percutaneous antegrade laser ablation of the stricture of the pelvic-ureteric segment on the right, stenting of the right ureter, nephrostomy on the right.

The main stages of the operation:

Urethrocystoscopy was performed under endotracheal anesthesia in an X-ray operating room. At the orifice of the right ureter, a guidewire was inserted, through which an external ureteral catheter No. 6 was passed into the ureter, retrograde ureteropyelography was performed, in which the ureter was freely passable to the level of the ureteropelvic segment, then a stricture 5 mm long. Next, a conductor string was installed in the retrograde direction, through the stricture zone, into the calyx-pelvis system with the formation of a curl in the pelvis. The patient was moved to the "prone" position. In ultrasound examination of the kidney: the collecting system was dilated due to the pelvis up to a maximum of 4 cm and cups, to a maximum of 2 cm. Under ultrasound and X-ray control, a puncture of the pelvic-pelvis system was performed through the middle group of cups. The nephrostomy course was bougienated to 15 Cn, a casing was installed. Examined the area of the pelvic-ureteric segment where the narrowing was determined, the cause of the obstruction was a fold of mucous membrane, like a "spur", which closed the entrance to the ureter. Through the zone of the pelvic-ureteric segment, a guidewire was installed in the antegrade direction. Thus, two guide strings were passed through the stricture zone of the pyeloureteral segment in order to control the dissection zone and "soft" dilution of the ureteral walls. Next, the nephroscope was brought to the stricture zone between the two conductors, thereby separating the conductors in the opposite direction to each other, due to which the walls of the ureter were stretched and its lumen increased, which made it possible to clearly differentiate tissues under "direct vision" and perform the stage of endopyelotomy with holmium laser without additional trauma to the ureter.

An internal stent with a diameter of 6 Cn and a length of 22 cm was installed under X-ray control. The kidney was drained with a Foley catheter No. 14. The urinary bladder was drained with a Foley urethral catheter No. 12.

The duration of the operation was 70 minutes. The urethral catheter was removed on the 1st day. The nephrostomy drainage was removed on the 3rd day. The patient was discharged on the 6th day after surgery with an internal stent.

Two months after the operation, the patient underwent removal of the internal stent.

During the follow-up examination of the patient within 6 months after the operation, according to the ultrasound data, the patient has a reduction in the anteroposterior size of the pelvis to 2 cm (initially to 3.6-4.0 cm), the calyx to 2 cm.

The main criteria for choosing this method of treatment in a patient at the preoperative stage of the examination were unextended ureteral stricture, about 0.5 cm, and a decrease in kidney function to 50%. Intraoperatively, it was revealed that the cause of the obstruction was a fold of mucous membrane, like a "spur", which closed the entrance to the ureter.

Example 3.

Patient G., 2.4 years old, was admitted to the department in a planned manner with a diagnosis of Bilateral hydronephrosis. Condition after plasty of the pelvic-ureteric segment on both sides from 2013. Recurrent stricture of the pelvic-ureteric segment on the right. Nephrostomy on the right.

Complaints from the mother's words about the presence of a nephrostomy on the right.

Bilateral hydronephrosis was diagnosed from birth. 03/07/13. percutaneous puncture nephrostomy on the left. 03/08/13. plasty of the pelvic-ureteric segment according to Andersen on the left. 04.24.13. the nephrostomy on the left was removed. 10/20/13. plasty of the pelvic-ureteric segment on the right according to Andersen, however, patency along the right ureter was not restored, percutaneous puncture nephrostomy was performed on the right.

When carrying out instrumental survey methods, the following data were obtained.

The right kidney measures 5.7x2.6 cm. The parenchyma is 0.7 cm. The calyx-pelvic system is not enlarged. In the pelvis, signals from the nephrostomy. The right ureter is not dilated in the upper third. Loose type of blood supply. The bladder is empty.

According to the data of excretory urography: on the right, the calyceal-pelvic system begins to contrast at 22 minutes. The end of the nephrostomy tube is located in a sharply expanded and deformed pelvis. Calyx irregularly rounded, moderately widened. The ureter on the right is not contrasted.

According to antegrade pyeloureterography, a significant expansion of the pelvis up to 9 cm is determined. The contrast in the ureter is not determined.

According to static nephroscintigraphy: Cleansing deficit on the right 63%, Cleansing deficit on the left 37%.

The patient underwent surgical intervention in the amount of: antegrade, retrograde urethreography. Endopyelotomy on the left. Insertion of the inner stent on the left.

The main stages of the operation:

Cystoscopy was performed under endotracheal anesthesia in an X-ray operating room. A guide string was inserted into the mouth of the right ureter. Next, the left ureter was catheterized with an external ureteral catheter along the guidewire. The latter has been removed. Retrograde ureteropyelography was performed, in which the contrast, with difficulty in the area of the pelvic-ureteric segment, passed through the ureter, filled the calyx-pelvic system, in which nephrostomy drainage was determined. Further, along the external ureteral catheter, a guide string is inserted into the calyx-pelvic system, the proximal end of which is inserted into the apical calyx. The external ureteral catheter was removed. The patient was flipped onto her stomach. Installed earlier, before the operation, the nephrostomy was removed, along the fistula, a nephroscope was installed in the calyx-pelvic system. At nephroscopy, an enlarged pelvicellular system was determined, the stricture of the pelvic-ureteric segment was represented by fibrous changes of the "spur" type. Through the zone of the pelvic-ureteric segment, a guidewire was installed in the antegrade direction. Thus, two guide strings were passed through the stricture zone of the pyeloureteral segment in order to control the dissection zone and "soft" dilution of the ureteral walls. Next, the nephroscope was brought to the stricture zone between the two conductors, thereby separating the conductors in the opposite direction to each other, due to which the walls of the ureter were stretched and its lumen increased, which made it possible to clearly differentiate tissues under "direct vision" and perform the stage of endopyelotomy with holmium laser without additional trauma to the ureter. Antegrade pyeloureterography was performed - the contrast through the ureter freely entered the bladder. An internal stent # 5 and a Foley nephrosome # 10 were installed. The bladder was drained with Foley's urethral catheter # 10. At the end of the operation, hematuria is not significant.

The use of the invention in the clinic made it possible to improve the visualization of the stricture, control the depth of tissue dissection and reduce the risk of such a formidable complication as ureteral perforation, and the use of a laser in the "Ablation" mode at a shallow depth of penetration allows simultaneous dissection and coagulation of blood vessels, which reduces the risk of bleeding and promotes better visualization of the operating field.

Claims (1)

A method of percutaneous antegrade treatment of recurrent short strictures up to 10 mm of the pelvic-ureteric segment in children with hydronephrosis, including dissection of the stricture of the pelvic-ureteric segment in the antegrade direction, characterized in that guide strings are used - one in the antegrade and one in the retrograde direction, nephroscopic to the stricture zone between the two conductors, pushing the conductors in the opposite direction to each other, stretching the walls of the ureter, increasing its lumen, dissecting the stricture zone of the pelvic-ureteric segment with a holmium laser, in the "Ablation" mode, using a 230 nm fiber, and the dissection is carried out along the lateral side of the segment, with longitudinal cuts through all layers to the periureteral fatty tissue, upon reaching the lumen of the ureter, under the control of fluoroscopy, the ureteral stent is installed in the antegrade direction.

Images