Left endoscopic combined intrarenal surgery with electrocoagulation hemostasis and right flexible ureteroscopic lithotripsy for bilateral upper urinary tract stones: a case report

Background

Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large renal stones. However, multi-tract or staged procedures may be necessitated in bilateral or anatomically-complex stones to achieve stone clearance. Endoscopic combined intrarenal surgery (ECIRS) integrates the advantages of PCNL and retrograde intrarenal surgery. In this article, we detail a hybrid surgical technique adopted for the management of complex simultaneous bilateral upper urinary tract stones. In addition, we discuss the advantages and disadvantages of combining a variety of new techniques that may improve post-operative outcomes and patient satisfaction.

Case Description

We report the case of a 36-year-old male with a large left renal pelvis stone, right proximal ureteric stone, and bilateral renal stones. Biochemical results showed raised inflammatory markers but he denied pre-stenting and staged surgery. After receiving 3-day antibiotic prophylaxis, he underwent an elective hybrid procedure. Under split-leg prone position, we performed a hybrid procedure that included left ECIRS with tubeless single-tract mini PCNL and left flexible ureteroscopy, and right flexible ureteroscopic lithotripsy. Hemostasis was achieved by electrocauterization with a novel device. The patient made an uneventful recovery. Follow-up computed tomography (CT) at 1-month revealed complete stone clearance.

Conclusions

Unilateral ECIRS with tubeless single-tract mini PCNL with electrocoagulation hemostasis and adjacent retrograde intrarenal surgery in split-leg prone position is a safe, feasible, and efficient technique to manage large renal stones.

A novel approach in creating nephrostomy using a double-lumen access sheath during endoscopic combined intrarenal surgery

Background

This study aimed to evaluate the safety and efficacy of an inner ureteral access sheath (i-UAS) with a double-lumen channel used in ureteroscopic lithotripsy (URS) as a dilator for the percutaneous tract in endoscopic combined intrarenal surgery (ECIRS).

Methods

This was a single-center cohort study conducted from January 2016 to April 2020. We used an i-UAS as a dilator and a double-lumen catheter to insert a safety guidewire during the creation of the nephrostomy tract in ECIRS. Univariate and multivariate analyses were performed to assess the association between the perioperative parameters and the use of i-UAS. The primary endpoint was perioperative complications, and secondary endpoints were stone-free rate (SFR), operative time, fluoroscopy time, and duration of hospitalization.

Results

In total, 221 patients were enrolled during the study period. Patients were divided into an i-UAS dilation group (n=108) and a one-shot dilation group (n=113). No differences were observed between the two groups in terms of patient history. Univariate analyses indicated that, in the i-UAS dilation group, the operative time was shorter [105.50 (83.75–143.25) vs. 121.00 (90.00–155.00) min; P=0.02] and the modified Valdivia position was more frequently selected. Multivariate analyses showed no significant differences in the frequency of complications, such as urinary injury or postoperative pyelonephritis, but it showed a significantly shorter operative time as well as fewer tract creation troubles in the i-UAS dilation group.

Conclusions

Using an i-UAS as a dilator and a double-lumen catheter to insert a safety guidewire during ECIRS is a convenient and safe technical method for creating a nephrostomy tract that can reduce the operative time.