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Combined endoscopic surgery in the prone-split leg position for successful single-session removal of an encrusted ureteral stent: a case report.

Isero T, Hamamoto S, Koiwa S, Kamiya H, Hashimoto Y, Yasui T, Iwase Y, Kohri K - J Med Case Rep (2014)

Bottom Line: An abdominal radiograph and a noncontrast computed tomography scan showed encrustation along the retained stent with stone burdens in the kidney and ureter.All the stones and the encrusted ureteral stent were successfully removed in a single session.In this case, percutaneous nephrolithomy in addition to flexible ureteroscopy was preferred because severe encrustation of the proximal stent and ureteral stones complicated the therapeutic strategy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, Toyota Kosei Hospital, 500-1 Ibohara, Jyousui-cho, Toyota City, Aichi 470-0396, Japan. hamamo10@med.nagoya-cu.ac.jp.

ABSTRACT

Introduction: Although encrusted stents may lead to some unwanted complications including urinary tract obstruction, urinary sepsis, and potential loss of kidney function, there is currently no consensus on the most efficient method for managing stents that are intentionally left in situ. This is the first report describing the management of an encrusted stent using combined endoscopic surgery in the prone split-leg position in a single session.

Case presentation: A 47-year-old Asian man presented with left flank pain and macrohematuria. The patient had undergone left ureteral stenting three years previously for the treatment of left ureteral stones and hydronephrosis; however, he was lost to follow-up before the treatment for the ureter stones was completed. Therefore, the ureteral stent and stones were not removed. An abdominal radiograph and a noncontrast computed tomography scan showed encrustation along the retained stent with stone burdens in the kidney and ureter. The ureteral stent could not be removed by cystoscopy after shock wave lithotripsy of the left ureteral stones. Therefore, endoscopic lithotripsy combined with flexible ureteroscopy and miniature nephroscopy was performed with the patient in the prone split-leg position. All the stones and the encrusted ureteral stent were successfully removed in a single session.

Conclusions: In this case, percutaneous nephrolithomy in addition to flexible ureteroscopy was preferred because severe encrustation of the proximal stent and ureteral stones complicated the therapeutic strategy. Combined endoscopic techniques in the prone split-leg position can achieve successful and safe management of encrusted stents.

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Patient positioning in the prone split-leg position.
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Figure 2: Patient positioning in the prone split-leg position.

Mentions: One week later, the patient was admitted, and an attempt to remove the stent by cystoscopy after SWL was unsuccessful. One week later, under general anesthesia, stent removal was attempted by combined endoscopic surgery using fURS and mini-PNL. The patient was oriented in the prone split-leg position throughout the operation, allowing both retrograde and antegrade access (Figure 2). The procedure was performed by two urologists working simultaneously to fragment the renal stones; one performed fURS (Figure 3a-d), and the other performed mini-PNL (Figure 3e-h). Flexible cystoscopy was performed to observe the stent encrustation and locate the ureteral orifice. The distal end of the ureteral stent was highly encrusted (Figure 3a). Under fluoroscopic guidance, the ureteral orifice was cannulated with a 0.035-mm guide wire that was passed into the upper urinary tract, and a ureteroscope (Flex X-2™, Karl Storz, Tuttlingen, Germany) was inserted beside the encrusted stent toward the ureteral stones in the upper ureteral tract (Figure 3b). The ureteral stones and the encrustation were fragmented using a Holmium-yttrium aluminum garnet (YAG) laser (a 200-μm fiber 1.5Hz 8H; VersaPulse® 80W, Lumenis Inc, San Jose CA, USA) (Figure 3c). The stent could not be removed successfully after retrograde lithotripsy with fURS, because of severe proximal encrustation of the stent. Renal puncture was achieved using ultrasonography under fluoroscopic guidance. An 18-Fr mini-PNL tract (Karl Storz) was used to dilate the tract and establish working access. To fragment the proximal encrustation and renal stones, lithoclast lithotripsy (Boston Scientific Japan, Tokyo, Japan) was performed using a 12-Fr mini-nephroscope (Karl Storz) (Figure 3d-f). Stones were broken into smaller fragments and washed through the sheath by retrograde irrigation. After fragmentation of both ends of the encrustation, the stent was removed by cystoscopy (Figure 4). The urinary tract was stented with a 4.7-Fr double-J ureteral stent and an 18-Fr nephrostomy tube. The total operation time was 124 minutes. The nephrostomy tube was removed two days after surgery. The ureteral stent was removed one month later. An analysis of the encrusting material showed the presence of calcium-oxalate and calcium-phosphate calculi.


Combined endoscopic surgery in the prone-split leg position for successful single-session removal of an encrusted ureteral stent: a case report.

Isero T, Hamamoto S, Koiwa S, Kamiya H, Hashimoto Y, Yasui T, Iwase Y, Kohri K - J Med Case Rep (2014)

Patient positioning in the prone split-leg position.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4007146&req=5

Figure 2: Patient positioning in the prone split-leg position.
Mentions: One week later, the patient was admitted, and an attempt to remove the stent by cystoscopy after SWL was unsuccessful. One week later, under general anesthesia, stent removal was attempted by combined endoscopic surgery using fURS and mini-PNL. The patient was oriented in the prone split-leg position throughout the operation, allowing both retrograde and antegrade access (Figure 2). The procedure was performed by two urologists working simultaneously to fragment the renal stones; one performed fURS (Figure 3a-d), and the other performed mini-PNL (Figure 3e-h). Flexible cystoscopy was performed to observe the stent encrustation and locate the ureteral orifice. The distal end of the ureteral stent was highly encrusted (Figure 3a). Under fluoroscopic guidance, the ureteral orifice was cannulated with a 0.035-mm guide wire that was passed into the upper urinary tract, and a ureteroscope (Flex X-2™, Karl Storz, Tuttlingen, Germany) was inserted beside the encrusted stent toward the ureteral stones in the upper ureteral tract (Figure 3b). The ureteral stones and the encrustation were fragmented using a Holmium-yttrium aluminum garnet (YAG) laser (a 200-μm fiber 1.5Hz 8H; VersaPulse® 80W, Lumenis Inc, San Jose CA, USA) (Figure 3c). The stent could not be removed successfully after retrograde lithotripsy with fURS, because of severe proximal encrustation of the stent. Renal puncture was achieved using ultrasonography under fluoroscopic guidance. An 18-Fr mini-PNL tract (Karl Storz) was used to dilate the tract and establish working access. To fragment the proximal encrustation and renal stones, lithoclast lithotripsy (Boston Scientific Japan, Tokyo, Japan) was performed using a 12-Fr mini-nephroscope (Karl Storz) (Figure 3d-f). Stones were broken into smaller fragments and washed through the sheath by retrograde irrigation. After fragmentation of both ends of the encrustation, the stent was removed by cystoscopy (Figure 4). The urinary tract was stented with a 4.7-Fr double-J ureteral stent and an 18-Fr nephrostomy tube. The total operation time was 124 minutes. The nephrostomy tube was removed two days after surgery. The ureteral stent was removed one month later. An analysis of the encrusting material showed the presence of calcium-oxalate and calcium-phosphate calculi.

Bottom Line: An abdominal radiograph and a noncontrast computed tomography scan showed encrustation along the retained stent with stone burdens in the kidney and ureter.All the stones and the encrusted ureteral stent were successfully removed in a single session.In this case, percutaneous nephrolithomy in addition to flexible ureteroscopy was preferred because severe encrustation of the proximal stent and ureteral stones complicated the therapeutic strategy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Urology, Toyota Kosei Hospital, 500-1 Ibohara, Jyousui-cho, Toyota City, Aichi 470-0396, Japan. hamamo10@med.nagoya-cu.ac.jp.

ABSTRACT

Introduction: Although encrusted stents may lead to some unwanted complications including urinary tract obstruction, urinary sepsis, and potential loss of kidney function, there is currently no consensus on the most efficient method for managing stents that are intentionally left in situ. This is the first report describing the management of an encrusted stent using combined endoscopic surgery in the prone split-leg position in a single session.

Case presentation: A 47-year-old Asian man presented with left flank pain and macrohematuria. The patient had undergone left ureteral stenting three years previously for the treatment of left ureteral stones and hydronephrosis; however, he was lost to follow-up before the treatment for the ureter stones was completed. Therefore, the ureteral stent and stones were not removed. An abdominal radiograph and a noncontrast computed tomography scan showed encrustation along the retained stent with stone burdens in the kidney and ureter. The ureteral stent could not be removed by cystoscopy after shock wave lithotripsy of the left ureteral stones. Therefore, endoscopic lithotripsy combined with flexible ureteroscopy and miniature nephroscopy was performed with the patient in the prone split-leg position. All the stones and the encrusted ureteral stent were successfully removed in a single session.

Conclusions: In this case, percutaneous nephrolithomy in addition to flexible ureteroscopy was preferred because severe encrustation of the proximal stent and ureteral stones complicated the therapeutic strategy. Combined endoscopic techniques in the prone split-leg position can achieve successful and safe management of encrusted stents.

Show MeSH
Related in: MedlinePlus