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Clinical History:
52 yo female patient. The patient was taking topiramate to prevent migraines. No other relevant past medical history besides urolithiasis with previous right ureteroscopy and SWL. After ureteroscopy performed in May 2021, during follow-up the patient continued taking the topiramate (a known cause of urolithiasis) and was diagnosed with a new 1.5 cm stone in the right renal pelvis causing obstruction. It was decided to perform a flexible ureteroscopy with previous stenting.
Technique description:
After putting the patient under general anesthesia, the patient is placed in a lithotomy position, sterilized and draped.
A table is set below the patients left leg, the monitors are set at the patients left side and the C arm in the patients right side.
On the table, we place dry gauzes and wet gauzes in a surgical dish.
Also in the dish, we open the guidewire, a syringe and scissors.
Setting the irrigation bag 40 cm above the patient the surgery begins with the small, 9.5 fr semirigid ureteroscope to perform the initial cystoscopy, and placement of a guide wire in the renal cavities, keeping it as a safety wire. Then a semirigid ureteroscopy is performed to check the ureter for stones and for passive dilation. A second guidewire is placed in the kidney.
Then the ureteral access sheath is passed through one of the wires (working wire) keeping the second as a safety wire. The access sheath should be inserted gently without forcing the entry.
Then the flexible ureteroscopy with a single use scope (Lithovue) is performed with systematic renal inspection. Once the stone is identified the laser (Lumenis Pulse Moses 2.0) is set, a small 200 micron laser fiber is placed and for dusting, low energy, long pulse and high frequency settings are used.
The stone is dusted from the periphery. If breathing movements are intense, episodes of apnea can help stabilize the kidney. After completing the dusting, the basket is inserted, preferring small 1.9 fr baskets to remove a fragment for further analysis. Final stone dusting is performed with the popcorn technique until complete dust is achieved.
The access sheath is removed and a ureteral inspection is done at the end of the procedure. A double J stent is placed finally with a bladder catheter.
Procedure steps:
Cystoscopy.
Guidewire placement in the renal cavities and keeping it as a safety wire.
Semirigid ureteroscopy and placement of second guidewire.
Ureteral access sheath placement.
Flexible ureteroscopy with renal inspection.
Dusting of the stone until small fragments are achieved.
Stone removal with basket.
Final stone dusting with popcorn technique.
Access sheath removal and ureteral inspection.
Double J and bladder catheter placement.
Trainings Objectives:
Be systematic on the procedure, patient placement and setting.
Never force the entry of the instruments.
Always plan ahead for possible complications and make choices based on what you could resolve.
-Plan the fragmentation technique in order to accomplish a stone free status.
Extract a stone fragment for analysis.
