RU2770669C1 - Method for percutaneous antegrade ureterolithotripsy using a ureteral casing - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to operative urology. In the lithotomic position of the patient, the ureteral catheter No. 6-7 Ch is installed under X-ray control by transurethral access. Then a urethral catheter No. 16 Ch is inserted, to which a ureteral catheter is fixed with a ligature. Then, under the control of ultrasound and X-ray equipment, a percutaneous puncture of the calices-pelvis system of the kidney is performed. After antegrade contrast of the calices-pelvis system of the kidney, a guide string is installed through the lumen of the needle into the ureter. Then, a single-stage augmentation of the puncture stroke up to 14 Fr is performed along the string and a ureteral casing 12-14 Fr is installed in the ureter to the standing area of the concrement. After visualizing the concrement and fragmenting it with laser energy, the fragments are removed using litho-extractors and irrigation fluid. After the removal of the concrement, a control ureteronephroscopy is performed.

EFFECT: method makes it possible to use the larger instruments without increasing the traumatism of surgical intervention, improves the visualization of the ureter when accessing the gravel, makes it possible to extract fragments of concretion without the risk of ureter strictures in the postoperative period.

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Description

SUBSTANCE: invention relates to medicine, namely to urology, concerns a technique for percutaneous antegrade ureterolithotripsy using a ureteral sheath, and can be used for fragmentation and removal of ureteral stones.

The problem of urolithiasis (UCD) remains relevant throughout the world, due to the continuing growth of the disease, which is 0.5-5.3% annually [1]. In the Russian Federation, the number of patients with KSD has increased by 17.3% over the past decade [2]. In 70% of patients, KSD is diagnosed at the age of 30-60 years, mainly in men [2]. The question of the method of choosing the surgical treatment of KSD remains a subject of discussion [3, 4]. To date, a large number of techniques are used to treat patients with ureteral calculi: extracorporeal lithotripsy (ESWL), transurethral contact ureterolithotripsy (URLT), laparoscopic and retroperitoneoscopic ureterolithotomy [5].

Over the past decade, URLT has been established as a minimally invasive treatment for ureteral stones [6]. The advent of new endoscopic instruments (small-diameter ureteroscopes, flexible ureteronephroscopes) and laser technology have made URLT the first choice in the treatment of ureteral stones. The use of these tools leads to a reduction in treatment time, reduces the number of intra-postoperative complications, and increases economic efficiency [7].

URLT is an effective treatment for stones located in the middle or lower third of the ureter. At the same time, in some cases (anatomical and physiological features of the ureter, strictures that impede access to the proximal section), URSL cannot be effectively performed. Also, stones larger than one centimeter with a long stay in the lumen, the so-called impacted stones, cause pronounced changes in the ureteral wall and may increase the number of complications [8]. In cases where ESWL is not appropriate (ureter stricture, high calculus density, lack of effect from previous treatment) and the use of URLT is impossible or may lead to complications, percutaneous antegrade ureterolithotripsy becomes an alternative endoscopic treatment.

The most important direction for further development and improvement of the treatment of ureteral stones is to increase the level of complete removal of stones, reduce the risk of damage and detachment of the ureter, and reduce the time of surgical intervention.

The objective of the invention was to create a method for percutaneous antegrade ureterolithotripsy using a ureteral sheath, which has the ability to use larger instruments without increasing the trauma of surgical intervention; improved visualization of the ureter when accessing the stone, the possibility of extracting fragments of the calculus without the risk of formation of ureteral strictures in the postoperative period.

The method is carried out as follows: endotracheal anesthesia is used for surgical intervention, tk. this type of anesthesia is more convenient for kidney puncture and safe for uretero-nephrolithotripsy (possibility to use apnea). Antegrade ureterolithotripsy is performed with the patient supine in the Valdivia Galdakao position. The first stage in the lithotomy position of the patient under X-ray control by transurethral access is the installation of a ureteral catheter No. 6-7 Ch. In the event that it is not possible to pass the conductor above the stone, the ureteral catheter is placed distal to the stone. Then the urethral catheter No. 16 Ch is inserted, to which the ureteral catheter is fixed with a ligature. The second stage, under the control of ultrasound and x-ray equipment, is a percutaneous puncture of the pyelocaliceal system of the kidney (PCS). After antegrade contrasting of the PCLS, a conductor string is inserted through the lumen of the needle. The guide wire must be inserted into the ureter, which allows the ureteral casing to be brought directly to the stone. Further along the string, a simultaneous bougienage of the puncture stroke is performed up to 14 Fr and a ureteral casing 12-14 Fr is installed. This allows to improve the visualization of the calculus due to good irrigation and thereby reduce the operation time, as well as additionally save the resource of the flexible ureteronephroscope. After visualizing the stone and fragmenting it with laser energy, the fragments are removed using lithoextractors and irrigation fluid. After removal of the stone, a control ureteronephroscopy is performed, which makes it possible to decide on the need for antegrade drainage of the PCS. For drainage of PCS, a ureteral stent is used, which is installed in case of pronounced changes in the wall of the ureter in the area where the calculus is standing.

Currently, the proposed method has no analogues.

Example 1

Patient S., 47 years old. was on treatment in the urological department of the hospital from 11/08/2020 to 11/11/20. Clinical diagnosis: Main disease: Urolithiasis. Stone in the middle third of the left ureter. Concomitant diseases: Hypertension II st. Hydronephrosis stage II. Chronic pyelonephritis, latent course.

ICD: N 20.1. ICD. Stone of the middle third of the left ureter

Upon admission, he complained of pain in the lumbar region on the left, frequent urination. He sought medical help on his own. Anamnesis data: he considers himself ill for three months, during which pain in the lumbar region on the left periodically disturbs. On the day of hospitalization, increased pain. Upon admission to the hospital, computed tomography was performed. Conclusion - a stone in the middle third of the left ureter, up to 1.2 cm in size, stone density 1150 HU, pronounced periureteritis in the stone standing area.

The results of the preoperative examination.

I. Clinical blood test (from 08.11.2020)

II. Biochemical blood test (from 08.11.2020)

III. Coagulogram (from 08.11.2020)

IV. Urinalysis (dated 03/08/2020)

V. Results of instrumental studies

VI. Expert advice

Surgical intervention was performed (08.11.2020): antegrade ureterolithotripsy using a ureteral sheath. The course of the operation is described above. Postoperative period: no features.

Conservative treatment: symptomatic and anti-inflammatory therapy, alpha-blockers, preoperative antibacterial prophylaxis (NaCl 0.9% and ceftriaxone - 2.0 intravenously drip once). Compression jersey.

Discharged in a satisfactory condition for 1 day after surgery. Recommended: 1) observation by a urologist at the place of residence; 2) infrared spectroscopy of stone fragments 2) kanefron, 2 tab. 3 times a day for three months; 3) control ultrasound examination of the kidneys after 6 months.

The method of antegrade ureterolithotripsy using a ureteral casing was used by us in 35 patients with ureteral stones. The average time of surgical intervention in patients of the main group from the moment of installation of the ureteral catheter was 47 min ± 12 min, with access without preliminary catheterization of the kidney: 28 min ± 4 min. The level of complete removal of calculi was 97.7%. The average postoperative bed-day was 3 ± 1.3 days. There were no intraoperative complications and no need for blood transfusion. The early postoperative period was uneventful,

Thus, the application of the proposed method in persons with relevant indications allows to obtain the following technical results:

1) reduction of operation time;

2) the possibility of using larger instruments, a wide lumen of the ureter above the level of the stone, a low risk of distal migration of fragments with impacted calculi, the possibility of extracting calculus fragments without; the risk of damage and separation of the ureter;

3) the service life of the flexible ureteronephroscope is preserved.

Based on all of the above, it should be concluded that one of the main advantages of antegrade ureterolithotripsy of ureteral stones is the best endoscopic visibility. In addition, the instrumentation of the operation significantly exceeds the capabilities of any transurethral ureteroscopy. The advantages of antegrade stone fragmentation include: reliable access to the kidney, the possibility of using larger instruments, a wide lumen of the ureter above the level of the stone, a low risk of distal migration of fragments with impacted stones, the possibility of extracting stone fragments without the risk of damage and avulsion of the ureter.

Conclusion: percutaneous antegrade ureterolithotripsy using a ureteral sheath is the preferred method of choice in the treatment of patients with large ureteral calculi who cannot undergo contact and remote ureterolithotripsy with a high level of achievement of complete freedom from calculi and a minimum number of complications.

Information sources

1. Sorokin I, Mamoulakis C, Miyazawa K, Rodgers A, Talati J, Lotan Y. Epidemiology of stone disease across the world. World J Urol. 2017 Sep; 35(9):1301-1320.

2. The incidence of urolithiasis in the Russian Federation (2005-2016) / Apolikhin O.I., Sivkov A.V., Komarova V.A., Prosyannikov M.Yu., Golovanov S.A., Kazachenko A.V. , Nikushina A.A., Shaderkina V.A. // Experimental and Clinical Urology Issue No. 4 for 2018 4-14 pp.

3. Alyaev Yu.G. Modern technologies in the diagnosis and treatment of urolithiasis / Yu.G. Alyaev [i dr.]. - M, 2007. - 144 p.

4. Jonathan Modai, Yuval Avda, Igal Shpunt, Yasmin Abu-Ghanem, Dan Leibovici, Yaniv Shilo Prediction of Surgical Intervention for Distal Ureteral Stones. J Endourol. 2019 Oct; 33(9):750-754.

San S, Selmi V, Ozdemir H,

F. Comparison of semirigid ureteroscopy, flexible ureteroscopy, and shock wave lithotripsy for initial treatment of 11-20 mm proximal ureteral stones. Arch Ital Urol Androl. 2020 Apr 6; 92(1):39-44.5. Kartal I, Baylan B,

San S, Selmi V, Ozdemir H,

F. Comparison of semirigid ureteroscopy, flexible ureteroscopy, and shock wave lithotripsy for initial treatment of 11-20 mm proximal ureteral stones. Arch Ital Urol Androl. 2020 Apr 6; 92(1):39-44.

6. Lai S, Jiao B, Diao T, Seery S, Ni M, Wang M, Hou H, Wang J, Zhang G, Liu M. Optimal management of large proximal ureteral stones (>10 mm): A systematic review and meta -analysis of 12 randomized controlled trials. Int J Surg. 2020 Aug; 80:205-217.

7. Risk factors for complications of contact ureterolithotripsy / E.A. Mamedov, V.V. Dutov, V.V. Bazaev, A.A. Podoinitsyn, S.B. Urenkov, A.E. Ivanov, D.V. Romanov, A.A. Morozov // Urology №4, pp. 60-65.

8. Bhat A, Singh V, Bhat M, Khandelwal N, Bhat A. Comparison of antegrade percutaneous versus retrograde ureteroscopic lithotripsy for upper ureteric calculus for stone clearance, morbidity, and complications. Indian J Urol. 2019 Jan-Mar; 35(1):48-53.

Claims (3)

1. The method of percutaneous antegrade ureterolithotripsy using a ureteral sheath, characterized in that in the lithotomy position of the patient under X-ray control, transurethral access is used to install a ureteral catheter No. 6-7 Ch, then a urethral catheter No. 16 Ch is inserted, to which the ureteral catheter is fixed with a ligature; then, under the control of ultrasound and X-ray equipment, a percutaneous puncture of the pyelocaliceal system of the kidney is performed, after antegrade contrasting of the pyelocaliceal system of the kidney, a guide wire is inserted through the lumen of the needle into the ureter, then a single-stage bougienage of the puncture stroke is performed along the string up to 14 Fr and the ureteral casing is installed 12 -14 Fr into the ureter to the zone of standing stone; after visualization of the stone and its fragmentation using laser energy, the fragments are removed using lithoextractors and irrigation fluid; after removal of the stone, a control ureteronephroscopy is performed. 2. The method according to p. 1, characterized in that the ureteral catheter is installed distal to the stone, if it is not possible to pass the conductor above the stone. 3. The method according to claim 1, characterized in that if there are indications for the need for antegrade drainage of the pelvicalyceal system of the kidney, then a ureteral stent is used, which is installed in case of pronounced changes in the ureteral wall in the area of the calculus.