Article Text
PDF
Abstract
A standard surgical treatment of distal ureteric defects is represented by the ureteroneocystostomy-ureteric reimplantation. However, the procedure involves an anatomical alteration of the ureterovesical (neo)junction that often hinders the retrograde catheterisation of the reimplanted ureter.
We describe a case of antegrade ureterolithotripsy (AULT) in a psoas-hitch reimplanted ureter. A woman with severe left hydronephrosis supported by a subcentimetric proximal ureteral stone in a psoas-hitch reimplanted ureter was referred to our unit. Retrograde ureteroscopy was unsuccessful due to impossibility in incannulating the ureteral neo-orifice. Following the placement of a percutaneous nephrostomy, percutaneous AULT through ureteral sheath was successfully performed with complete treatment of the stone.
AULT may represent a viable alternative in the management of ureteral stones when the upper urinary tract is not amenable to retrograde ureteroscopy. In experienced hands, the procedure is straightforward and may avoid the adoption of transabdominal approaches.
- Urinary tract infections
- Urology
Statistics from Altmetric.com
Background
Definitive surgical management of patients with distal ureteral pathologies may involve ureteroneocystostomy (UNC), which is the reimplantation of the ureter into the bladder.1 Because a tension-free anastomosis between the ureter and the bladder is critical for a successful UNC, patients with ureteral strictures that are extensive or involve more proximal segments of the distal ureter are typically managed with a concomitant psoas hitch or Boari flap or both during UNC.2
Following ureteral reimplantation, achieving ureteric access for retrograde diagnostic and therapeutic manoeuvres (such as, for example, in cases of urolithiasis, urothelial cancer or ureteral stenosis) may be challenging or even impossible. In fact, the location and shape of the ureteral neo-orifice, as well as the characteristics of the intravesical tunnel (in antireflux techniques), may be at the basis of anatomical alterations of the ureterovesical neojunction that hinder retrograde manoeuvres.3 In these cases, antegrade ureteroscopy may represent an intermediate step before proceeding to more invasive, transabdominal approaches.4
The purpose of our study is to describe an approach of antegrade ureterolithotripsy (AULT) for the treatment of an impacted stone in a left psoas-hitch reimplanted ureter not amenable to retrograde treatment.
Case presentation
We experienced a case involving a woman with a medical history of type II diabetes mellitus, autoimmune hepatitis in immunosuppressive therapy and recent episodes of acute respiratory failure due to severe haemoptysis treated with bronchial artery selective embolisation. During hysterectomy for human papillomavirus infection (2009), an iatrogenic lesion of the left ureter was encountered and treated in first line with ureteral stent placement and subsequently, due to persistence of severe stenosis, with ureteral extravesical reimplantation (Lich-Gregoir) and psoas hitch.
Following recurrent episodes of left flank pain, the patient underwent kidney ultrasound and CT evaluation that documented severe left hydronephrosis supported by a proximal subcentimetric ureteral stone (1200 Hounsfield units). An 8 Fr percutaneous nephrostomy was placed in emergency through a middle calyx to decompress the upper urinary tract. The descending (antegrade) pyelography detected a complete ureteral stop near the stone in the proximal ureter, without any contrast progression, as for impacted stone. Although the renal cortex was thinned, both the nephrostomy output and the MAG3 clearance of the left kidney (44 mL/min) suggested against a left nephrectomy.
Thus, the patient was listed for retrograde ureterolithotripsy. The attempts to gain retrograde access in the reimplanted ureter were unsuccessful due to the location of the meatus and the difficult angle of the ureterovesical junction that hindered the placement of the guidewire. A transabdominal ureterolithotomy versus AULT was planned and the patient was discharged. An abdominal CT scan performed confirmed the absence of left hydronephrosis, correct placement of the percutaneous ipsilateral nephrostomy and the presence of a stone of 10 mm in the proximal ureteral midsection.
Three months after, the patient consented for AULT. Following antibiotic prophylaxis with cefazolin 2 g, general anaesthesia was induced, and the patient was placed in the Valdivia position. A percutaneous antegrade pyelography was performed and a 0.035-inch hydrophilic-coated straight-tip guidewire was inserted through the nephrostomy and advanced under radioscopic control until the stone, but it did not advance into the bladder. The nephrostomy tube was removed, and the percutaneous placement of a ureteral sheath was attempted; however, the manoeuvre was unsuccessful due to increased fascial resistance of the abdominal wall. For this reason, a Uromax ultra balloon dilation catheter (18 Fr) was used, in order to allow for a radial dilatation of the transparietal nephrostomy tract. Following dilation at 19 atm, the Navigator (13/15 Fr) ureteral access sheath was easily inserted and advanced over the guidewire until the proximal ureter, allowing us to pass the endoscope. A flexible ureteroscope was inserted, the stone was identified and holmium laser lithotripsy with the dusting effect was performed with complete stone disintegration. At the end of the lithotripsy, the guidewire was passed in the bladder; the final antegrade ureteroscopy did not document any stenotic segments of the distal ureter. A 28 cm double J ureteral stent was finally placed in an antegrade fashion. The main steps of the procedure are summarised in figure 1.
The descending (antegrade) pyelography detected a complete ureteral stop near the stone in the proximal ureter, without any contrast progression, as for impacted stone (A). Following the dusting of the stone, both the final antegrade ureteroscopy (B) and ureterography (C) did not document any residual fragments or significant stenosis of the distal ureter. A 28 Fr double J ureteral stent was finally placed in an antegrade fashion (D).
The nephrostomy (NFS) tube was left in place as a security access. The absence of fever and renal colic pain allowed us to remove the NFS 24 hours postoperatively.
The total operating time was 100 min.
Figure 2 summarises the steps of the procedure performed and reasons for declining the available treatments in the current case.
Algorithm for approaching ureteral stones in patients with reimplanted ureter. Reasons for declining the available treatments in the current case. HU, Hounsfield unit; URS, ureteroscopy; ESWL, extracorporeal shock wave lithotripsy.
Outcome and follow-up
The patient had no postoperative complications, and she was discharged in postoperative day 2. The stent was removed 2 weeks after surgery. The subsequent ultrasound evaluation, performed at 1 and 6 months following the stent removal, documented complete resolution of the left hydronephrosis.
Discussion
When shock wave lithotripsy is not indicated or has failed, and when the upper urinary tract is not amenable to retrograde ureteroscopy (URS) such as in cases of urinary derivations, or ureteral reimplantation with or without psoas hitch/Boari flap, the percutaneous antegrade removal of ureteral stones may represent a valid alternative before considering surgical approaches to the ureter characterised by higher morbidity, such as the transabdominal ones (ie, ureterolithotomy).
Antegrade access is relatively easy and quick to obtain when there is dilation of the upper urinary tract. Following the placement of the percutaneous nephrostomy, a guidewire is inserted; in cases where the guidewire bends or additional force is required on its tip, a ureteral open-end catheter can be used similarly to standard URS. If the guidewire passes into the bladder through the target stones, then it could be even used to perform a retrograde ureterolithotripsy. However, this was not the case in our patient.
AULT in experienced hands is quick and safe, however is not devoid of difficulties. One of these is the creation of the percutaneous tract; in our case, a balloon dilation was used that allowed us to dilate the fascia. Another difficulty is the usually steep angle between renal calyxes (particularly the inferior one) and ureter. These two issues, combined with the necessity of inserting a laser fibre into the working channel with slight deflection of the ureteroscope, confer a considerable risk of damaging the instrument. Thus, single-use ureteroscopes may be preferred in these approaches.
The antegrade approach to the stone confers no risk of regression of it. The pressurised irrigator aids in achieving better visualisation and helps the leaching of fragments. Several authors underline the safety and effectiveness of the AULT for the management of impacted upper ureteral stones, with success rates that frequently overcome the ones of the standard retrograde approach.4
Patient’s perspective
I had a gynaecological surgery. During the surgery and due to a lesion of my left ureter I had my ureter reimplanted. After 3 years, a ureteral stone was discovered in the reimplanted ureter. I had frequent episodes of flank pain not responsive to antalgic therapy. After 2 weeks, I was submitted to an unsuccessful attempt to remove the stone because it was not possible for the surgeons to negotiate the ureter with the classical approach. I decided to refer to the urologists of the hospital San Donato, that managed to treat the stone successfully accessing it endoscopically passing through my kidney. The care I have had was faultless-it really has been fantastic. I am grateful to the treating doctors that helped me to avoid a major open surgery!
Learning points
Antegrade ureterolithotripsy may represent a viable option when:
The shock wave lithotripsy is not indicated.
The retrograde approach is challenging or impossible (such as in cases of ureteral reimplantations that may alter the anatomical axis of the ureter and the ureterovesical neojunction).
The morbidity of the ureterolithotomy needs to be avoided.
Ethics statements
Patient consent for publication
Footnotes
Contributors GC and AA provided substantial contribution to the conception and design of the work as well as analysis and interpretation of data and drafting of the manuscript. GC, AA, FA and SK have revised the work critically for important intellectual content and provided final approval of the version to be published. They agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. FA has been also involved in the patient’s care. All authors contributed to the article and approved the submitted version. FA and SK were the surgeons in charge of the case and they were involved in management of the patient.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.