Abstract
Whereas a retrograde attempt to insert an indwelling stent is performed in lithotomy position, usually renal access is gained in a prone position. To overcome the time loss of patient repositioning, a renal puncture can be performed in a modified lithotomy position with torqued truncus and slightly elevated flank. There is a two-fold advantage of this position: transurethral and transrenal access can be obtained using a combined approach. In the present study, this simple technique is used to position a floppy guide wire through a modified needle directly through the renal pelvis into the ureter. The kidney is punctured in the modified lithotomy position under sonographic control using an initial three-part puncture needle. A floppy tip guide-wire is inserted into the collecting system via the needle after retrieving the stylet. The retracted needle is bent at the tip while the guide-wire is secured in the needle and the collecting system. The use of the floppy tip guide-wire helps to insert the curved needle back into the kidney pelvis, which becomes the precise guidance for the now steerable wire. The desired steerable stent is positioned under radiographic control in a retrograde fashion over the endoscopically harbored tip of the guide-wire. Two patient cohorts (newly described method and conventional method) were compared. The presented steering procedure saves 16.5 mean minutes compared to the conventional antegrade stenting and 79.5 Euros compared to the control group. The described combined antegrade-retrograde stent placement through a bent three-part puncture needle results in both clinical superiority (OR time, success rate) and financial benefits.
Highlights
Whereas a retrograde attempt to insert an indwelling stent is normally done in the lithotomy position, usually renal access is gained in the prone position
This study demonstrates a simple technique by using only the puncture needle and a floppy guidewire to pass the guide-wire into the pyeloureteral junction
A retrospective chart review was performed on consecutive patients receiving an indwelling ureteral stent using the presented technique, which were compared to the following consecutive patients, who received the stent in the conventional technique with the additional nephrostomy tube
Summary
Retrograde ureteral stenting is a daily routine in endourologic procedures. Large prostatic glands, transitional cell carcinoma of the bladder, impacted ureteral stones, kidney transplants and orthotopic as well as incontinent diversions belong to those challenging cases, where a successful retrograde stenting is not always possible; especially if the ureteral orifice is involved in a pathological process, antegrade access is sometimes preferable. Three critical steps are necessary to be successful: 1) access of the collecting system, 2) introduction of a guide-wire into the ureter and 3) passage of the ureteral segment that could not be passed in a retrograde fashion. A major advantage of this position is the combined approach transurethral and transrenal access [1]. This position, in particular, is the easiest way to gain a safe access below the 12th rib, in the lower or middle calyx, resulting in an unfavorable angle to the pyeloureteral junction. This study demonstrates a simple technique by using only the puncture needle and a floppy guidewire to pass the guide-wire into the pyeloureteral junction
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