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@#A forgotten and encrusted ureteral stent poses as a management dilemma especially when the encrustations are so severe that they involve the entire length of the ureteral stent. These can lead to staghorn formation, high volume ureterolithiasis and giant cystolithiasis which are all encasing the ureteral stent, This may lead to significant morbidity and mortality as a result of chronic urinary obstruction, recurrent urinary tract infection, and renal dysfunction and renal failure. During the acute phase of the pandemic, a 31-year-old pregnant female, with 9 weeks age of gestation, underwent insertion of an indwelling ureteral stent for an obstructing renal pelvic calculus. She was lost to follow-up only to return two years later, with right flank and lower abdominal pains. Non-contrast CT showed encasement of the ureteral stent with a staghorn calculus on the proximal coil, extensive encrustations on the upper and middle segments, and a giant cystolithiasis at the distal coil of the ureteral stent. She underwent a supine endoscopically-combined intrarenal surgery (ECIRS), allowing retrograde retrieval of the ureteral stent after all the encrustations had been removed. There was minimal blood loss and no intraoperative and postoperative complications.Encrusted ureteral stents with large stone burden may be treated effectively and safely with an endoscopically-combined intrarenal surgery. This combined antegrade and retrograde approaches to the urinary tract allows synchronous treatment of all calcifications around the forgotten ureteral stent, without resorting to open surgery.
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Objective:To compare the efficacy of ultrasound combined with endoscopy and ultrasound combined with X-ray guided percutaneous nephrolithotomy(PCNL) in the treatment of complex renal calculi.Methods:The clinical data of 119 patients with complex kidney stones treated by ultrasound combined with endoscopy or ultrasound combined with X-ray guided PCNL in the Second Affiliated Hospital of Anhui Medical University from March 2019 to February 2022 were analyzed retrospectively. According to different guidance methods, they were divided into ultrasound combined with endoscopic guidance group and ultrasound combined with X-ray guidance group.There was no significant difference in age [(53.9±14.2) years vs. (55.6±13.5) years], gender (male/female: 38/21 vs. 30/30), body mass index [(25.0±3.7) kg/m 2 vs. (24.8±3.8)kg/m 2], stone location (left/right: 34/25 vs. 31/29), maximum diameter of renal stones [(31.9±8.3)mm vs. (33.9±13.5)mm], kidney stones maximum cross-sectional area [(601.5±242.5)mm 2 vs. (632.6±278.9)mm 2], number of renal calices involved (3.5±0.9 vs. 3.6±1.3), S. T.O.N.E. scores (9.4±1.0 vs. 9.7±1.4), Guy's grade(Ⅲ/Ⅳ: 45/14 vs. 41/19), preoperative hemoglobin [(125.2±21.5)g/L vs. (125.6±18.4)g/L], serum creatinine[(89.1±33.8) μmol/L vs. (81.9±27.1) μmol/L], urinary tract infection (43/59 vs. 47/60)and positive urinary bacterial culture (12/59 vs.11/60) between the two groups(all P>0.05). The patients in the ultrasound combined with endoscopic guidance group were placed in the modified prone split-leg position. Flexible ureteroscope retrograde into the renal pelvis, combined with ultrasound to determine the best puncture calices. The channels were established and stones were removed under the guidance of ultrasound and endoscopy. In the ultrasound combined with X-ray guidance group, the F5 ureteral catheter was placed retrogradely into the operative side ureter under the lithotomy position. Then the patient changed to prone position and the target calices were punctured under the guidance of ultrasound and X-ray. Through anterograde or retrograde injection of contrast medium, the puncture position was determined to enter in the center of the calicean dome, and the channel establishment process and stone removal are monitored. The operative results and postoperative data were recorded. Results:The average operation time in the ultrasound combined with endoscopic guidance group was significantly shorter than that in the ultrasound combined with X-ray guidance group [(90.2 ± 34.5) min vs. (129.4 ± 43.0) min, P < 0.001]. There was no significant difference in the success rates of initial channel establishment [94.0% (63/67) vs. 87.7% (107/122), P = 0.167], the time of single channel establishment [(7.7 ± 1.9) min vs. (7.7 ± 1.4) min, P =0.765], serum creatinine on the first day after operation[ (89.3±33.6) μmol/L vs. (82.9±27.0) μmol/L, P=0.257] and postoperative hospital stay[(5.3±1.6) d vs.(5.4±1.7) d, P=0.883]. In contrast, patients in ultrasound combined with X-ray guidance group had higher stone free rate [93.3% (56/60) vs. 81.4% (48/59), P=0.049] and lower reoperation rate [3.3% (2/60) vs. 15.3% (9/59), P=0.025]. The mean hemoglobin decrease value of ultrasound combined with endoscopic guidance group was significantly lower than ultrasound combined with X-ray guidance group on the first day after operation [(8.7±6.3) g/L vs. (16.8±6.9) g/L, P<0.001]. The complication rate of ultrasound combined with endoscopic guidance group was significantly lower than that of ultrasound combined with X-ray guidance group [5.1% (3/59) vs. 16.7% (10/60), P = 0.043]. Conclusions:Ultrasound combined with endoscopic guidance PCNL does not need to change body position during operation and has fewer puncture channels, thus saving operation time and reducing complications. It is more suitable for patients with isolated kidney or easy bleeding. Ultrasound combined with X-ray guidance is conducive to the establishment of multi-channel, the stone clearance rate is high and the reoperation rate is low, which is suitable for patients with good health and more renal calices involved with stones.
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Objective:Objectives The aim of the study is to evaluate the mechanical performance, safety and efficacy of the novel robotic-assistant flexible ureteroscopy system (Ra-fURS) under in vitro and in vivo environments.Methods:Combing with commercial flexible ureteroscopes, the novel Ra-fURS was used for the in vitro test and animal model operation in October 2020. The study included three sections. ①Basic mechanical performance assessment: including endoscope motion control (dual deflection, axial rotation and forward/backward distance), reaction time and fiber regulation. ②Simulated surgery in ex-vivo 3D-printing renal collecting system model: including completion rate and time of calyxes exploration, directional movement and laser fragmentation [gypsum models (0.5×0.5×0.5 cm) were used to stimulate kidney stones]. ③Intrarenal surgeries in animal models (two 5-month female Yorkshire white pigs). In total, 32 surgeries was performed (8 surgeons × 2 pigs × 2 kidneys/pig). In vivo assessments were carried out including: ①consuming time for Ra-fURS installation and offloading; ②completion rate and time of calyxes exploration; ③comfort score (ranging from 0-10) as compared to the manual f-URS, which was corresponding to each Ra-fURS surgery. In simulated surgery and animal surgery sections, 8 surgeons were enrolled in the study (group A 4 without flexible ureteroscopy experience; group B: 4 highly experienced), and results were compared between two groups.Results:Under the Ra-fURS control, the flexible ureteroscope movement in three degrees of freedom (forward / backward: + 11 to -11 cm, axial rotation + 225°to -225°; active duel-flection: + 270°to -270°, as well as the laser fiber regulation + 2.5 to -2.5 cm). In simulated surgery tests, both groups achieved 100% completion rate of calyxes exploration, and there were no statistical differences in the time of the calyxes exploration between group A and group B (116.0±8.0)s vs.(110.3±15.4)s( P>0.05). Time-consumption for laser fragmentation of group B was shorter than that of group A (525.8±58.5)s vs. (780.5±141.2)s( P<0.01). In animal surgery, the installation time of Ra-fURS gradually shortened within the first 7 cases was(234.0±43.0)s, and became comparable in the later 8-32 cases was(149.3±8.0)s. The average uninstall time was (43.9 ±5.9)s and was relatively stable. There were 51 renal calyxes in two pigs. It was higher for the completion rate of calyxes exploration in group B than in group A [(95.5±9.1)% vs. (59.1±9.1)%, P<0.05], and the exploration time was also statistically variant between the two groups group A and group B[(274.8±34.6)s vs.(127.3±18.2)s, P<0.05]. For all the operators, the comfort scores were favorable to the Ra-fURS as compared to the manual f-URS (8.9±0.3 vs. 5.9±1.1, P<0.05). Conclusions:This preliminary study demonstrated that the novel Ra-fURS was capable of controlling flexible ureteroscope to perform retrograde intrarenal surgery and fragmenting stones with laser. Besides, other features, including easy installation, stable performance and comfortable manipulating environment, made it easy to use in clinical application.
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OBJECTIVE@#To compare the outcomes of endoscopic combined ultrasound-guided access (EUGA) with the conventional ultrasound-guided access (UGA) to achieve percutaneous renal access in endoscopic combined intrarenal surgery (ECIRS).@*METHODS@#A retrospective review of 53 patients undergoing ECIRS to treat upper urinary tract calculi between January 2017 and October 2019 was con-ducted. All of the cases were of complex upper urinary tract stones larger than 2 cm in diameter. The com-plex stone situations, such as multiple renal calyces calculi or staghorn calculi necessitated ECIRS. Under general anesthesia, the patients were placed in the galdakao-modified supine valdivia (GMSV) position, thus allowing both antegrade and retrograde accesss. The patients were divided to UGA and EUGA groups according to the protocol of achieving percutaneous renal access. In 28 cases, endoscopic combined ultrasound-guided accesss were obtained. Puncture and dilation were performed under direct flexible ureteroscopic visualization, while percutaneous renal access of 25 cases were performed with the conventional technique employing ultrasound guidance. Demographic and perioperative information, such as stone burden, presence of hydronephrosis and number of calyces involved was compared. Primary outcomes included total operative time, renal access time, repeat puncture, hemoglobin level, perioperative complications, and stone-free rate.@*RESULTS@#No major intra-operative complication was recorded in all the 53 ECRIS. No significant difference was observed between the groups in age and gender. There was no significant difference in body mass index[BMI (29.21±3.14) kg/m2 vs.(28.53±2.56) kg/m2], stone burden (37.68±6.89) mm vs. (35.53±6.52) mm, number of calyces involved 2.72±0.68 vs. 2.86±0.71, presence of hydronephrosis (56.0% vs. 46.4%), total operative time (93.0±12.2) min vs. (96.8±14.2) min, hemoglobin level reduction (6.56±2.16) g/L vs. 97.54±2.64) g/L, stone-free rate (92.0% vs. 92.8%), hospital stay (5.52±0.59) d vs. (5.64±0.62) d, perioperative complication rate (8.0% vs. 7.2%). Two patients in EUGA group experienced perioperative complications (one urinary tract infection and one hematuria) while two patients in UGA group experienced perioperative urinary tract infection. None in both groups received blood transfusion. The patients undergoing EUGA had shorter renal access time [(4.0±0.7) min vs. (6.8±2.6) min, P < 0.01] and less repeat puncture (0 vs. 4 cases, P < 0.05).@*CONCLUSION@#EUGA is an optimal technique to establish percutaneous renal access in ECIRS, which minimizes access time and repeated procedures.