Category: Clinical Stones: PCNL

MP12-22 - Ureteroscopic Holmium Laser-Assisted Retrograde Nephrostomy Access: A Novel Approach to Percutaneous Stone Removal

Fri, Sep 21
2:00 PM - 4:00 PM

Introduction & Objective :

Percutaneous nephrolithotomy remains a challenging procedure primarily due to difficulties obtaining access. Indeed, few urologists obtain their own access due to difficulties using a fluoroscopic or ultrasonic based antegrade puncture technique. Herein we report the first experience using holmium laser energy to obtain access in a retrograde fashion.

Methods :

After a pretreatment week of tamsulosin 0.4 mg/day (one center only) and following a documented sterile urine, a total of 10 patients underwent retrograde holmium laser-assisted endoscopic-guided nephrostomy access in a prone split leg position.

Results :

In 9 of 10 patients, ureteroscopic guided, holmium laser access via an upper pole posterior calyx was achieved. In one patient the laser tract could not be safely dilated and antegrade endoscopic and fluoroscopic guided access was performed. The mean operative time was 202 minutes; the mean fluoroscopy time was 32 seconds (6/9 cases). The mean pre-operative stone volume was 14420 mm3. CT imaging on post-operative day 1 revealed 6/6 patients had residual stone fragments with total mean volume of 250 mm3 (96% reduction); there were no residual fragments in 3 patients who were evaluated with non-CT radiographic imaging (KUB). There was a single complication requiring angioembolization due to: a subcapsular hematoma with associated secondary tearing of an inter-polar vessel remote from the nephrostomy site.

Conclusions :

Holmium laser-assisted endoscopic-guided retrograde access in a prone split-leg position was successfully performed at two institutions.  The accuracy of nephrostomy placement and lessening of fluoroscopy time are two potential benefits of this approach.

Kamaljot S. Kaler

Clinical Assistant Professor
University of California, Irvine; University of Calgary
Orange, California

Egor Parkhomenko

Boston Medical Center
Boston, Massachusetts

Zhamshid Okhunov

University of California, Irvine, Department of Urology
Orange, California

Roshan M. Patel

Assistant Clinical Professor
University of California, Irvine, Department of Urology
Orange, California

Jaime Landman

Professor and Chair
Department of Urology, University of California, Irvine, Orange, CA
Orange, California

Professor Landman completed his medical training at Columbia University. He then completed his Urology residency at Mt. Sinai Hospital in New York before moving to St. Louis to complete his minimally invasive urology training at Washington University under the guidance of Dr. Ralph Clayman. Dr. Landman’s fellowship training focused on the minimally invasive treatment of renal diseases.

Prof. Landman focuses on developing new clinical approaches to minimally invasive and more effective treatments for surgical renal diseases such as renal cell carcinoma, urolithiasis and ureteropelvic junction obstruction. For the past decade, his clinical practice has been focused almost exclusively on the minimally invasive management of kidney disease with a focus on renal oncology and urolithiasis.

Since 2002 Dr. Landman has directed an active minimally invasive urology laboratory. His laboratory has focused largely on innovative minimally invasive solutions in the diagnosis and treatment of urologic malignancies, kidney stones and the development of minimally invasive surgical technologies.

A major focus of Dr. Landman’s efforts has been the didactic and technical training of students, residents and fellows. Dr. Landman has had an active role in medical student and resident education since 2001. Since 2002 Dr. Landman has been actively directing the Endourology sanctioned clinical and research fellowship, and he was until recently the program director for the UC Irvine Urology residency. Dr. Landman engendered and currently directs the LIFT (Leadership Innovation Fellowship Training) program at UC Irvine and has focused on helping medical students become academic leaders in Urology.

A current focus of Dr. Landman’s research remains didactic and technical training for students, residents and fellows. His research team continues to develop novel strategies for surgical education.

Ralph V. Clayman

University of California, Irvine, Department of Urology
Orange, California

Carlos A. Uribe

Department of Urology, Hospital Pablo Tobon Uribe (HPTU), Medellin, Columbia
Medellín, Antioquia, Colombia