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Keywords:

  • Ureteroscopy;
  • URS;
  • Lawson Catheter;
  • retrograde nephrostomy;
  • PCNL

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

Retrograde nephrostomy was first developed by Lawson et al. in 1983, and Hunter et al. reported 30 cases of retrograde nephrostomy in 1987. This procedure uses less radiation exposure and has a shorter duration compared with the previous percutaneous nephrostomy techniques. Retrograde nephrostomy using Lawson's procedure was reported in the late 1980s by several authors. But since then, few studies have been reported about this procedure due to the development of ultrasonography assisted percutaneous nephrostomy. With the arrival and development of the flexible ureteroscope (URS) both observation and manipulation in the renal pelvis are now easily achieved.

The present procedure provides less radiation exposure, less bleeding, and a shorter procedure than previous percutaneous nephrostomy techniques. Using this procedure, after the needle has exited through the skin, no further steps are required in preparation for dilatation. In the present study, we continuously visualised from puncture to inserting the nephron-access sheath with the URS.

OBJECTIVE

  • • 
    To describe a technique for ureteroscopy assisted retrograde nephrostomy.

PATIENTS AND METHODS

  • • 
    Under general and epidural anaesthesia, the patient is placed in a modified-Valdivia position. Flexible ureteroscopy is carried out, and a Lawson retrograde nephrostomy puncture wire is placed in the ureteroscope (URS).
  • • 
    After the needle has exited through the skin, no further steps are required in preparation for dilatation.

RESULTS

  • • 
    After informed consent was obtained, two patients (a 43-year-old man with left renal stones and a 57-year-old woman with right renal stones) underwent this procedure.
  • • 
    The URS was positioned in the middle posterior calyx and punctured toward the skin.

CONCLUSIONS

  • • 
    This procedure involves less radiation exposure and shorter surgery than the previous percutaneous nephrostomy technique.
  • • 
    Our technique represents another new option for percutaneous nephrolithotomy in patients with a non-dilated intrarenal collecting system.

Abbreviations
US

ultrasonography

URS

ureteroscope

PCNL

percutaneous nephrolithotomy.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Retrograde nephrostomy was first developed by Lawson et al. [1] in 1983, and Hunter et al. [2] reported 30 cases of retrograde nephrostomy in 1987. A Lawson retrograde nephrostomy wire puncture set (COOK Urological, USA) is now easily obtained. This procedure uses less radiation exposure and the procedure is quicker compared with the previous percutaneous nephrostomy technique. After the needle exits through the skin, no further steps are required in preparation for dilatation [2,3]. Retrograde nephrostomy using Lawson's procedure was reported in the late 1980s by several authors [1–4]. But since then, few studies have been reported about this procedure due to the development of ultrasonography (US)-assisted percutaneous nephrostomy [5].

At that time, a nephrostomy was usually made with US and/or fluoroscopic guidance transcutaneously. With the arrival and development of the flexible ureteroscope (URS), both observation and manipulation in the renal pelvis are now easily achieved.

We herein report our experience with retrograde nephrostomy with URS guidance.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

Under general and epidural anaesthesia, the patient is placed in a modified-Valdivia position (Galdakao modified Valdivia position) [6–9]. A flexible URS (Flex-X2, Karl Storz, Germany) insertion is carried out with an inserted ureteric access sheath (Flexor® 12Fr 35 cm, COOK Urological, USA) to the ureter, after checking to ensure that the rigid URS (Uretero-Renoscope, Karl Storz, Germany) does not encounter either ureteric stenosis or ureteric stones. We carefully observe the target calculi and define the appropriate renal calyx to puncture. Thereafter, a Lawson retrograde nephrostomy puncture wire is carefully placed into the flexible URS [1]. The URS approaches the desired renal calyx again and the route from the renal calyx to the exit skin is then confirmed using fluoroscopy (Figs 1 and 2).

image

Figure 1. The Lawson puncture wire was advanced from the middle posterior calyx to the skin through the flexible URS. (A) Puncture wire was set in the URS. (B) Advancing the puncture wire. (C) Catheter dilatation. (D) Balloon dilatation.

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image

Figure 2. The Lawson puncture wire exiting through the retro-penetrated skin at the posterior auxiliary line.

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To avoid injuries to the spleen, liver, intestines, and pleural cavity, the puncture is then performed using US. The puncture wire passes through the muscle easily and ‘tents’ the skin at the posterior axially line. The skin is incised, and the needle is then delivered. Next, the dilator is placed by the puncture wire, which is advanced through the skin, subcutaneous fat, abdominal wall musculature, and perinephric fat until it reaches the renal parenchyma. A 24 F percutaneous nephro-access sheath (X-Force®N30 Nephrostomy Balloon Dilation Catheter, BARD, USA) is passed over the balloon into the calyx using ureteroscopic and fluoroscopic guidance, and then the balloon is removed. The stone is then removed with a holmium : yttrium-aluminum-garnet laser (VersaPulse 30W, LUMENIS surgical, USA).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

After informed consent was obtained, two patients, a 43 year-old man with left renal stones and a 57 year-old woman with right renal stones, underwent this procedure. The URS was positioned in the middle posterior calyx and punctured toward the skin. The total duration of the operations was 160 and 135 min, including 48 and 37 min for constructing retrograde nephrostomy, respectively.

We successfully removed the renal stones. There was no significant decrease in the haematocrit levels, and there were no complications either during or after the operation.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES

The present cases are the first cases of URS-assisted retrograde nephrostomy. During surgeries for renal staghorn calculi with no hydronephrosis, percutaneous nephrostomy is sometimes very difficult, even if a balloon occlusion catheter is used to dilate the intrarenal collecting systems [10]. The present procedure provides less radiation exposure, less bleeding, and a shorter duration than the previous percutaneous nephrostomy technique. With this procedure, after the needle has exited through the skin, no further steps are required in preparation for dilatation [2,3].

In 1964, Marshall [11] first reported the use of a flexible URS. Subsequently, in 1971, Takagi et al. [12] reported passively deflectable flexible ureteroscopy. In recent years, there have been major advances that have made the observation of the renal pelvis easier and it is therefore now possible to perform a wide variety of intrarenal procedures using the URS [13]. Thus, it is easier to approach the desired renal calyx using a flexible URS than was possible using the previous fluoroscopic approach.

The present cases were done in the modified-Valdivia position (Galdakao modified Valdivia position). In 1987, Valdivia Uria et al. [6] described a percutaneous nephrolithotomy (PCNL) with the patient in the supine position, with a 3-L serum bag below the flank. In that position, both surgical and anaesthesiological advantages were described. Thereafter, Ibarluzea Gonzalez et al. [14] reported a Galdakao modified-Valdivia position in 2001. The supine position is the same in this position, but the leg of the target side is extended, while the contralateral one is well abducted. This position has the advantages of allowing simultaneous percutaneous and retrograde access [15]. In the present study, we continuously visualised the motion of the URS easily using US, and were able to detect the ‘tent’ sign easily.

In the present cases, two plans for the URS-assisted retrograde nephrostomy were considered. One was that the puncture wire is in the URS (as was selected for this case), and the other is that the puncture wire is outside the URS. The latter requires an additional polyurethane catheter and flexible tip, which are also included in the Lawson retrograde nephrostomy wire puncture set. The former has the advantage of providing continuous visibility, but the puncture wire is so stiff that the URS cannot reach all the way to the strongly bent lower calyx. Therefore, for puncturing the lower calyx, it is more suitable to place the puncture wire outside of the URS.

Hunter et al. [2] reported six complications in 30 patients including two pneumothorax, two haemorrhage, and two cases of severe narcosis. Regarding haemorrhage, this also occurs after percutaneous nephrostomy [16]. The retrograde nephrostomy puncture usually requires a single movement, and as the needle passes from a posteriorly located calyx through the retroperitoneum, the possibility of damage to intra-/extrarenal vessels is less likely [3]. A potential disadvantage of the procedure is the danger of exiting the kidney in a cranial direction, with possible injury to the spleen, liver, or pleural cavity. In the ventral direction, possible injury to the intestines may occur [3]. We made the puncture using US and fluoroscopic guidance to avoid injuries to the surrounding organs. US provided excellent visibility from the renal parenchyma to the skin (also in the puncture line route), and was also useful to avoid injury, especially to the intestines.

Further cases are needed to confirm the safety and efficacy of this procedure.

In conclusion, we herein provided the first reported cases of URS-assisted retrograde percutaneous nephrostomy. Our technique represents a new option for PCNL.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONFLICT OF INTEREST
  8. REFERENCES