Ureteroscopy and Laser Lithotripsy for Ureteral and Renal Stones in a Patient with a Nephrostomy Tube
Zachary Tully, MD; Joseph Y. Clark, MD
Penn State Health Milton S. Hershey Medical Center
Ureteroscopy is a minimally invasive surgical procedure used for the diagnosis and treatment of ureteral and renal pathology, most often urolithiasis. The presence of a percutaneous nephrostomy tube, commonly placed for urgent decompression of an obstructed kidney, often in obstructing stone disease, introduces unique perioperative considerations. Indications for ureteroscopy in this setting involve persistent obstruction with failure of spontaneous stone passage when percutaneous nephrolithotomy is not indicated. Surgical treatment aims to remove obstructing calculi, restore antegrade urinary drainage, and prevent long-term complications such as decline of renal function. Ureteroscopy involves cystoscopic access, ureteroscopic stone fragmentation, and extraction. When coupled with antegrade access as provided by a nephrostomy tract, it enables combined antegrade and retrograde (“rendezvous”) approaches. This video presents a case of a patient with a left-sided distal ureteral stone, nonobstructing renal stones, and an indwelling nephrostomy tube who underwent definitive management with ureteroscopy and laser lithotripsy.
Percutaneous Nephrostolithotomy for Treatment of Impacted Ureteropelvic Junction Calculus
Max S. Yudovich, MD; Joseph Y. Clark, MD
Penn State Health Milton S. Hershey Medical Center
Percutaneous nephrostolithotomy (PCNL) is a minimally invasive urologic procedure used to treat large kidney stones or stones which are not accessible from a retrograde approach. When untreated, these stones can cause chronic pain, infections, and over time, decreased renal function. The indications for PCNL include total renal stone burden greater than 20 mm, lower pole stone burden greater than 10 mm, or any stone burden which cannot be treated with ureteroscopy or extracorporeal shockwave lithotripsy, such as in the setting of a ureteral stricture or ureteropelvic junction obstruction.
During the procedure, the patient is typically positioned prone, and a needle is used to puncture the kidney through the flank. As in the case of our procedure, a pre-existing nephrostomy tube can also be used. After wire access to the kidney is obtained, the tract is dilated and an access sheath is placed to facilitate irrigation and insertion of instruments. Large stones can be removed through ultrasonic lithotripsy, pneumatic (ballistic) lithotripsy, laser lithotripsy (typically holmium:YAG or thulium lasers), and combination devices that integrate ultrasonic and pneumatic mechanisms. Smaller stones, such as in our case, can be extracted using graspers. In this video, we present a left-sided PCNL in which we remove a total of 2.1 cm of renal stone burden. Following stone removal, a ureteral stent and nephrostomy tube were placed to enable maximal drainage of the kidney. Postoperative CT showed complete clearance of stone burden.
Ureteroscopy, Laser Lithotripsy, and Stent Replacement for an Obstructing Left Proximal Ureteral Stone with Forniceal Rupture
Ryan A. Hankins, MD1; John A. Wahl, MS2
1MedStar Georgetown University Hospital
2Georgetown University School of Medicine
The case demonstrates the use of ureteroscopy with laser lithotripsy in the treatment of an obstructed left proximal ureteral stone with forniceal rupture. The patient presented to the emergency department with the signs and symptoms of a ureteral stone and was taken for imaging and a diagnostic ureteroscopy. Following confirmation of the diagnosis, the patient was scheduled for ureteroscopy with laser lithotripsy.
A guidewire was placed, followed by visualization with a retrograde pyelogram and a subsequent flexible ureteroscopy. Laser lithotripsy was performed to fragment the stone. Following fragmentation, the renal pelvis and calyces were visualized to examine for retrograde movement of stone fragments. A confirmatory retrograde pyelogram was then performed, followed by placement of a temporary stent for fluid drainage. The patient was then discharged with opioids for pain medication and prophylactic antibiotics to prevent urinary tract infections and the subsequent risk of urosepsis.
Left Ureteroscopy, Stone Retrieval with Basket, and Stent Replacement
Ahmad N. Alzubaidi, MD; Blake Baer, MD; Tullika Garg, MD, MPH, FACS
Penn State Health Milton S. Hershey Medical Center
Urolithiasis is one of the most common and costly benign urologic conditions in the United States. While there are many options for managing urolithiasis ranging from conservative medical expulsive therapy to shockwave lithotripsy to percutaneous nephrolithotomy, ureteroscopy with laser lithotripsy is one of the most frequently performed minimally invasive urologic surgeries for treatment. In this video, we present a case of a patient with a ureteral stone that was treated with ureteroscopy, laser lithotripsy, and basket stone extraction. As part of the procedure, the patient also underwent a retrograde pyelogram and a ureteral stent exchange.
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