Category: Stones: PCNL

Introduction & Objective : Percutaneous nephrolithotomy (PCNL) is a challenging option for renal stones in renal transplanted patients. It is preferable that a single tract PCNL compared to multi tract PCNL because of less probability of complications such as bleeding, renal insufficiency. In recent years, Endoscopic Combined Intrarenal Surgery (ECIRS) has been getting to be a more promising procedure for large or complicated renal stones. ECIRS can allow surgeons to treat complexed renal stones with a single percutaneous renal access and transurethral maneuver. However, upper urinary tract structures of renal transplanted patients are different from healthy one’s so that it may be difficult to indwell a ureteral access sheath to the transplanted patients. We present a novel “Sheath-Connection” technique for cases that have difficulty for indwelling a ureteral sheath to the transplanted patients.

Methods :

A 66 year-old man who had cadaveric renal transplantation 10 years ago was referred to our institution for oliguria and lower abdominal discomfort. CT revealed a 7mm ureteral stone in the renal graft. A double-J stent was indwelled and the patient’s symptoms were relieved. Although transurethral ureterolithotripsy (TUL) was performed for two times, unsuccessful results were obtained due to the difficulty to insert a ureteral access sheath into the ureterovesical anastomosis site that was accordion-like shape.

Results :

ECIRS was performed in the lithotomy position. Single percutaneous renal access was obtained by puncturing the lower-anterior renal calyx and 24Fr nephrostomy sheath (Cook Ultraxx^TM) were placed. Although PCNL for stones in the renal pelvis was performed successfully in conventional fashion, the nephroscope could not reach stones in adjacent renal calyx. A guidewire was inserted into the renal access and sent down the ureter and the bladder. The tip of guidewire was retrieved from the bladder to the urethral meatus under cystoscopy. A ureteral access sheath (Boston Scientific Navigator^TMHD 12/14Fr) was inserted into renal access to the urethral meatus smoothly and the inner dilator was removed. Then, an another ureteral access sheath, disposed such that face each other, was connected to the tip of the other sheath. The joint of each sheaths was proceeded from the ureteral meatus to the bladder, the ureter, and the renal pelvis smoothly. ECIRS was performed successfully. 

Conclusions :

A novel “Sheath-Connection technique” can allow surgeons to perform ECIRS for renal transplanted patients that have difficulty for indwelling a ureteral access sheath. 

Presenting Author(s)

• 

  Keita Nakane

  – Assistant Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan

Author(s)

• KO

  Kaori Ozawa

  – Resident, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• ST

  Shinichi Takeuchi

  – Clinical Fellow, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• KI

  Koji Iinuma

  – Clinical Fellow, Department of Urology, Gifu University Graduate School of Medicine, GIfu, Gifu, Japan
• YM

  Yuka Maekawa

  – Clinical Fellow, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• KH

  Kengo Horie

  – Clinical Fellow, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• YY

  Yoshiteru Yamada

  – Assistant Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• TK

  Taku Kato

  – Assistant Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• KM

  Kosuke Mizutani

  – Assistant Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• TT

  Tomohiro Tsuchiya

  – Associate Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
• MN

  Masahiro Nakano

  – Associate Professor, Department of Urology, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan