Percutaneous Cystolithotomy with Endotracheal Tube Tract Dilation After Urinary Tract Reconstruction

The Whiston Snare Technique for Loop Extraction of Stents (WHISTLES): A novel technique for the intraureteric assembly of a loop snare for the retrograde extraction of a migrated ureteric stent

Background:

While ureteric stent removal remains a frequently performed endourological procedure stent migration either proximally or distally can present the endourologist with a significant intraoperative dilemma. In cases where the stent is of large calibre or impacted into the mucosa of the ureter, retrieval may prove refractory to traditional approaches.

Objective:

To present a further novel procedure: The Whiston Snare Technique for Loop Extraction of Stents (WHISTLES) which allows for intraureteric assembly of a tightening loop through a ureteric catheter thus permitting safe retrieval of a migrated stent.

Methods:

We describe the procedure as it was performed and have recreated the steps in a laboratory environment. This demonstrates an adaptation of existing materials readily found in most urological theatres and is not a prototypical device.

Results:

The procedure was successfully performed to allow extraction of the migrated ureteric stent.

Conclusion:

WHISTLES is a reproducible method for the retrieval of migrated ureteric stents where traditional techniques have failed.

Level of evidence:

5

Paediatric cystolitholapaxy using mini PCNL-kit through the Mitrofanoff stoma

Bladder stones are a common complication after augmentation cystoplasty and urinary diversion. However, the treatment of recurrent cystolithiasis in neuropathic children remains a real challenge for urologists and open procedures may be associated with significant morbidity. Currently, mini-invasive management options are available in the therapeutic armamentarium. Herein, we reported a case of Mitrofanoff cystolitholapaxy using a mini PCNL-kit, in a 14-year-old patient with the history of neurogenic bladder due to myelomeningocele managed by bladder augmentation. This technique has been previously described but we have added a unique modification using Nelaton catheter for carefully dilating the Mitrofanoff stoma before inserting an Amplatz sheeth and we report tips and tricks to guarantee a stone free status with one single procedure. Using high energy Holmium laser, this approach is safe and effective even with large stone burden.

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The treatment of cystolithiasis in neuropathic patients with a bladder-neck closure represents a surgical challenge.

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Open cystolithotomy is a good option to treat large stone burdens or multiple calculi.

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For recurrent stones, endoscopic treatment via a catheterizable channel is an effective option, especially for patients with a closed bladder neck and low-burden stone.

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Dilating the channel is the key step. Using serially Nelaton catheter (10-16Fr) is a good trick to preserve the integrity of the Mitrofanoff stoma.

Anterior vesical hitch--a step to enhance safety of percutaneous access to bladder

PURPOSE

To describe the novel technique of anterior vesical hitch to enhance the efficacy and safety of percutaneous bladder surgery.

MATERIALS AND METHODS

The anterior bladder wall is anchored to the anterior abdominal wall with the help of a prolene suture passed slightly lateral to the midline midway between the pubic symphysis and umbilicus. Percutaneous cystolitholapaxy and antegrade posterior urethral valve ablation were performed after anterior vesical hitch in five pediatric male patients. Data collected included operative parameters and complications related to the technique.

RESULTS

Mean patient age was 2.9 years (range 1.5-6 years). Three patients had bladder stones and two had posterior urethral valves. Mean time to achieve bilateral parietal fixation of the bladder was 7 min 20 s. There was no intraoperative slippage of Amplatz sheath or suture cut through. No bleeding from the puncture site was encountered. No postoperative complication related to the percutaneous access tract was noted in any patient.

CONCLUSIONS

The anterior vesical hitch procedure is safe and easy. It prevents slippage of Amplatz sheath during percutaneous access to the bladder lumen.

Percutaneous cystolithotomy in the pediatric neuropathic bladder with laparoscopic trocar access: a modified approach useful for the augmented and native bladder, and continent urinary reservoir

OBJECTIVE

We present our results of percutaneous cystolithotomy with laparoscopic trocar (PCLT) access in children.

MATERIALS AND METHODS

PCLT was performed in 13 cases. This includes 2 patients who had this performed twice for recurrent stone 12-24 months after initial surgery. Eight patients had a bladder augmentation, 2 had native bladders, and one a continent urinary reservoir. Nine patients had a reconstructed urethra. Cystoscopy was performed in all cases to assess stone burden. Under direct vision, an 18 gauge angiocatheter was placed into bladder and guidewire placed through the angiocatheter. With the bladder distended, a laparoscopic 10 mm trocar was placed under vision next to the guidewire. A 26Fr nephroscope was used via the trocar to extract the stones, utilizing laser or ultrasonic lithotripsy to fragment larger stones. Stone fragments were removed with graspers and/or the vacuum extraction technique.

RESULTS

PCLT was successful in all cases. No complications were noted. Six cases were treated as outpatient, seven discharged home after 12-23 h observation.

CONCLUSIONS

PCLT via laparoscopic trocar access is a facile and safe approach for removing stones in the pediatric neuropathic bladder. Advantages include the ability to distend the bladder with continuous flow and the larger working channel permitting use of the nephroscope to treat and extract stones.

[Multiple stones in atypical heterotopic reservoir in a patient with renal transplant: endourologic resolution]

BACKGROUND

Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity.

INTRODUCTION

Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence.

MATERIALS AND METHODS

We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones.

SURGICAL TECHNIQUE

preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted.

RESULTS

No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported.

CONCLUSIONS

In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Chapitre A-l - Prise en charge chirurgicale des lithiases vésicales sur vessie neurologique

Bladder stones are common in neurological patients. As in other patients, bladder stones may reflect a voiding mode that fails to ensure complete bladder emptying, but they can also be due to more specific accidents, such as a foreign body introduced into the bladder during intermittent catheterization. Due to the frequency of this disease in neurological patients, the first step of treatment consists of correcting any vesico-sphincteric dyssynergia. Bladder stones can usually be easily removed based on a good knowledge of the management of this disease, which has become rare in the general population. This article presents the technical details and results of the various operations proposed in this setting.

Combined use of percutaneous and transurethral instruments in the preadolescent children with intravesical pathologies

The approach for the intravesical suspicious lesions or stones in the preadolescent children especially in boys is still a challenging problem. Open surgery, percutaneous suprapubic endoscopy or transurethral endoscopic approaches are the treatments of choice in children. However, there is a group in children between the ages of 10 and 12 years, which can be named as grey zone population; the length of the instruments is insufficient for transurethral intervention such as endoscopic stone extraction, transurethral bladder tumor resection especially for the lesion at the posterior bladder wall in this group. The aim of this study is to describe a new technique using laparoscopic instruments for percutaneous bladder stone and tumoral lesion and determines the efficacy of this procedure. Satisfactory results have been obtained in patients with these pathologies. In selected cases, operation time, urethral and mucosal damage, hospital stay, and cost can be decreased to a minimum with this simple technique.

Single percutaneous access for endoscopic extraction of lithiasis after intestinocystoplasty

PURPOSE

Bladder-stone formation is a common problem following augmentation cystoplasty. Urological management is controversial. We describe a minimally invasive technique using electrohydraulic vesicolithotripsy via a single percutaneous access.

MATERIAL AND METHODS

Between 1998 and 2004, 10 percutaneous extractions of bladder calculi were performed in seven patients with bladder augmentation. Prior bladder enlargement was performed for neuropathic bladder dysfunction in four cases and bladder exstrophy in three cases. The procedure involved percutaneous placement of a 10- or 12-mm laparoscopic trocar, after which the airtightness valve of the trocar was removed. A rigid nephroscope allowed direct visualization of calculi. Stones were fragmented with electrohydraulic lithotripsy when necessary. Removal of the fragments was by grasping forceps or basket. Vigorous, warmed-saline bladder irrigation eliminated residual fragments.

RESULTS

The technique was successful in all cases, resulting in controlled bladder-stone-free status and no surgical complications. The only complication was hypothermia linked to prolonged operation time, inadequate warmed-saline irrigation and lack of waterproof sheets.

CONCLUSIONS

Percutaneous vesicolithotripsy was highly successful and easy to perform, without being restricted by size and number of calculi. The continence mechanism of a reconstructed urethra or Mitrofanoff conduit should not be compromised. As recurrent stone formation is expected in children with augmented bladder, this technique appears to be suitable for bladder calculi removal during the long-term follow-up of multioperated patients.

Percutaneous cystolithotomy using a laparoscopic entrapment sac

OBJECTIVES

To describe a percutaneous approach that uses laparoscopic techniques and technology to achieve intact removal of bladder stones after augmentation cystoplasty.

METHODS

Percutaneous stone removal using a laparoscopic entrapment sac was performed in 4 patients with augmented bladders. Under endoscopic guidance, a 10-mm laparoscopic trocar was placed percutaneously into the augmented bladder using the previous suprapubic tube site. The stones were then maneuvered into a laparoscopic entrapment sac and extracted intact without lithotripsy.

RESULTS

Percutaneous removal of the entire stone burden (up to seven stones in 1 patient) was achieved in 3 of 4 patients. The total operative time was less than 1 hour in each of these cases. Partial conversion to open cystolithotomy was required in 1 patient, because of tearing of the entrapment sac. Three of 4 cases were performed on an outpatient basis and less than 24 hours of catheter drainage was required in all but 1 patient.

CONCLUSIONS

Percutaneous cystolithotomy using a laparoscopic entrapment sac is a safe, useful, and minimally invasive modification of contemporary percutaneous techniques. In patients with augmented bladders, application of this technique may minimize the risk of residual fragments and obviate the need for adjuvant lithotripsy.

The vesical calculus

Bladder calculi account for 5% of urinary calculi and usually occur because of foreign bodies, obstruction, or infection. Males with prostate disease or previous prostate surgery and women who undergo anti-incontinence surgery are at higher risk for developing bladder calculi. Patients with SCI with indwelling Foley catheters are at high risk for developing stones. There appears to be a significant association between bladder calculi and the formation of malignant bladder tumors in these patients. Transplant recipients are not at increased risk for developing vesical calculi in the absence of intravesical suture fragments and other foreign bodies. Patients who undergo bladder-augmentation procedures using a vascularized gastric patch appear to be protected from vesicolithiasis, perhaps by the acidic environment. Ileum and colon tissues, however, are colonized by urease-producing organisms, producing an alkaline pH that promotes stone formation. Children remain at high risk for bladder-stone development in endemic areas. Diet, voiding dysfunction, and uncorrected anatomic abnormalities, such as posterior urethral valves and vesicoureteral reflux, predispose them to bladder-calculus formation. Finally, there are a number of techniques and modalities available to remove bladder stones. Relieving obstruction, eliminating infection, meticulous surgical technique, and accurate diagnosis are essential in their treatment.

Percutaneous vesicolithotomy: an alternative to open bladder surgery in patients with an impassable or surgically ablated urethra

PURPOSE

Although vesical calculi are routinely treated transurethrally, open vesicolithotomy is generally performed in patients with an impassable or surgically ablated urethra. We describe a technique of percutaneous vesicolithotomy which we used in patients who had undergone urethral ablation and concomitant continent diversion by appendicovesicostomy.

MATERIALS AND METHODS

Bladder stones were detected in 3 patients with neurogenic bladder who had undergone continent urinary diversion with bladder neck closure and appendicovesicostomy. To treat the stones access to the bladder was achieved percutaneously and the tract was enlarged using a balloon dilator. An Amplatz sheath was slipped over the inflated balloon and after the dilator was removed the sheath provided a working channel through which stones were fragmented and removed using a nephroscope.

RESULTS

Each patient was rendered stone-free and discharged home the same day as the procedure.

CONCLUSIONS

Percutaneous vesicolithotomy provides an alternative approach for bladder stone removal in patients with an impassable urethra with decreased morbidity compared to open procedures.