Endoscopic Retrograde Treatment Research Articles

Original articleAbdominal pelvic radiotherapy prolongs surgical time of retrograde endoscopic treatment of upper urinary tract stones

Objective: the main objective is to assess whether urolithiasis diagnosed in patients with previous APRT need more endoscopic procedures to reach stone-free status and if these procedures are longer. The secondary objective is to find out if these patients have more complications resulting from endourologic procedures. Design and methodology: we designed a case-control unicentric study including patients with upper urinary tract lithiasis treated with retrograde ureterorenoscopy (URS) between 2006 and 2022. Case patients have previous history of APRT, while controls are patients without this history. We collected epidemiological, lithiasis and treatment related information in both groups. Results: we identified 18 upper urinary tract stones in cases that underwent endoscopic retrograde treatment. We linked these urinary stones with 18 urolithiasis diagnosed in control patients. The average age in patients and the diameter of the stones diagnosed were very similar in both groups, as well as the stones’ location. Longer surgical time was found for lithiasis treatment in case patients (129.6 versus 80.2 minutes in controls, p = 0.025). No significant differences were found regarding the rest of variables. Limitations: this is a retrospective and observational study, and the sample size is small, so we need to expand to a multicentric study. Originality and value: to our best knowledge this is the first study to provide data on how APRT may affect the effectiveness of endourological treatment of urolithiasis. Conclusion: endourological procedures for treatment of upper urinary tract stones in patients with previous APRT are longer than in patients without this background.

Retrograde endoscopic treatment of stones in horseshoe kidney

Retrograde endoscopic treatment of stones in horseshoe kidney

Prevention value of endoscopic retrograde appendicitis treatment for postoperative infection of patients with appendicitis

Objective To analyze the prevention value of endoscopic retrograde appendicitis treatment (ERAT) for postoperative infection of patients with appendicitis. Methods A total of 71 patients with acute appendicitis were selected and divided into two groups, 35 patients in the observation group were treated with ERAT, and 36 patients of the control group underwent laparoscopic appendectomy. The operation indicators, postoperative adverse events, pain scores, and levels of serum inflammatory factors were compared between the two groups. Results The observation group got a longer operation time, less bleeding, shorter in-bed and hospital stay, and lower hospital cost (all P 0.05). Twelve hours after treatment, the pain score of the observation group was lower than that of the control group (P<0.05). The post-operational serum levers of hypersensitivity C reactive protein, interleukin 1β, interleukin 6, and tumor necrosis factor α decreased in both groups, while the serum levers of interleukin 4 and interleukin 10 increased, especially in the observation group (all P<0.05). Conclusion ERAT is more conducive to balance serum inflammatory factors and stabilize immune function compared with laparoscopic appendectomy, which can effectively prevent postoperative infection. Key words: Appendicitis, acute; Endoscopic retrograde appendicitis treatment; Appendectomy, laparoscopic; Postoperative infection; Inflammatory factor

Simultaneous antegrade and retrograde endoscopic treatment of non-malignant ureterointestinal anastomotic strictures following urinary diversion

BackgroundThe ureterointestinal anastomosis stricture (UAS) is a common complication of urinary diversion after radical cystectomy. For decades, open anastomotic revision remained the gold standard for the treatment of UAS. However, with the advancement in endoscopic technology, mini-invasive therapeutic approaches have been used in its management. Here, we report our experience with and long-term results of combined simultaneous antegrade and retrograde endoscopy (SARE) in the treatment of non-malignant UASs after urinary diversion in a consecutive series of patients.MethodsFrom March 2012 to January 2015, there were 32 consecutive patients with 32 non-malignant UASs following radical cystectomy and urinary diversion. Twenty-nine patients were treated with SARE technique and comprised the study group. Using simultaneous antegrade flexible ureteroscope combined with retrograde semi-rigid ureteroscope or nephroscope, partial or complete strictures were managed with laser incision and balloon dilation under direct visualization. A 7/12 Fr graded endopyelotomy stent was left for 3–6 months after the procedure. Success was defined as symptomatic improvement and radiographic resolution of obstruction.ResultsWith a median followup of 22 months (6–36), the overall success rate for SARE was 69.0%. Twenty patients with partial stricture had a success rate of 85%, and 9 patients with complete stricture had a success rate of 33.3%. Renal function, hydronephrosis grade, stricture type, and stricture length were significant influences on the outcome (P < 0.05). No complication was observed.ConclusionsThe SARE is a safe and effective treatment for UAS, and may be the only endoscopic treatment approach for complete UAS. While success rate for complete strictures is low compared to open revision, it should be considered as an initial approach given its low overall morbidity. For partial strictures, prudent patient selection results in higher success rates that are nearly comparable to open revision.

Flexible ureterorenoscopy versus miniaturized PNL for solitary renal calculi of 10–30 mm size

The value of flexible ureterorenoscopy (fURS) and miniaturized PNL (mPNL) for larger renal calculi is under discussion. This non-randomized prospective study aimed to evaluate fURS and mPNL for solitary renal stones of 10-30 mm size. fURS was carried out in 21 patients with last generation 7.5F endoscopes. Ureteral access sheaths were used in 19 patients. For mPNL, an 18F modified Amplatz sheath with a 14F nephroscope were used (n = 25). The procedure was performed either tubeless with an antegrade stent or a nephrostomy. Outcome and complications of both procedures were assessed. Patients' demographics and stone sizes were comparable (18 ± 5 vs. 19 ± 4 mm, P = 0.08). Patients in the fURS group had a higher mean BMI (31 vs. 27, P < 0.05). Total OR time was significantly longer for fURS (106 ± 51 vs. 59 ± 19 min., P < 0.001). More patients were stone-free after one single percutaneous treatment, while 2nd-stage treatments with fURS were common (total procedures 1.04 vs. 1.52, P < 0.001; immediate stone-free rate (SFR) 96% vs. 71.5%, P < 0.001). SFR after 4 weeks was 100% (mPNL) and 85.8% (fURS) (P < 0.01). Minor complications as classified by Clavien I or II occurred in 16 and 23.8%, mPNL and fURS, respectively, P = 0.13). No major complications (Clavien III-V) occured in both groups. Our series supports both the concept of either percutaneous or retrograde endoscopic treatment for renal calculi with both modalities offering excellent safety. However, while for fURS, a significantly higher rate of 2nd-stage procedures was necessary, and mPNL led to faster and higher SFR without increasing complication rate.

Conservative Endoscopic Retrograde Treatment of Upper Urinary Tract Tumors: Retrospective Analysis of the Last 105 Cases

Modern flexible ureterorenoscopy allows a retrograde approach to urothelial tumors in the upper urinary tract (UUTT) of small dimensions (<1.5 cm), of low grade and non-invasive. The percutaneous renal approach, although more invasive, provides an alternative treatment in case of larger dimension neoplasia or difficult retrograde access. The key to the success of endoscopic treatment of UUTT is an accurate patient selection. We will bring our experience in the treatment of UUTT by conservative endoscopic retrograde treatment. Treatment through endoscopic retrograde approach with rigid or flexible ureterorenoscopy has been applied to 105 patients; lesions were treated with electrocution or lasers using thin laser fibers type Ho:YAG. We evaluated the recurrence rate and the intra- and perioperative complications. The recurrence rate was equal to 30.4%. In no case was it necessary to recur to blood transfusion; 15% of wall perforations treated in a conservative manner occurred without following complications. Technological innovations, miniaturization and the increase of energy sources, such as fiber laser Holmium, have improved the management of endoscopic instruments for upper urinary tract tumors. The endoscopic retrograde conservative treatment is considered a valid alternative approach in the case of low-stage tumors, low-grading and small in dimensions.

Evaluation of pneumatic versus holmium:YAG laser lithotripsy for impacted ureteral stones

We prospectively analyzed and compared the effectiveness and complications of pneumatic lithotripter with a holmium:yttrium-aluminum-garnet (Ho:YAG) laser for the ureterorenoscopic management of impacted ureteral stones. From January 2006 to January 2008, we performed retrograde endoscopic treatment in 288 patients with ureteral stones in our clinic. The patients with impacted stones were randomized into two groups according to the lithotripter used to fragment the stone: pneumatic (n = 40) and laser (n = 40). The preoperative, operative, and post-operative follow-up findings were analyzed and compared. The average stone size was similar in both groups (118.8 ± 58.3 mm(2) vs. 110.7 ± 54.4 mm(2)). The calculi were located in the distal ureter in most of the patients in both groups (65% in pneumatic group and 52.5% in laser group). The operation time was significantly diminished in the laser group (P = 0.001). The stone-free rates after a single ureteroscopic procedure were 80 and 97.5% in the pneumatic and laser groups, respectively (P = 0.03). Auxiliary treatments were needed in seven patients in the pneumatic group, while only one patient in the laser group (P = 0.05) needed this treatment. After the additional procedures, a 100% success rate was achieved in both groups. The rate of double J stent insertion was significantly higher in the pneumatic group (P = 0.01). In the pneumatic group, four cases of stone up-migration and one case of post-operative stricture were seen, whereas only one case of stone up-migration was noted in the laser group. Our comparative study has shown that the use of Ho:YAG as an intracorporeal lithotripter during ureteroscopic management of impacted ureteral stones is highly efficient with high success rates, regardless of the stone location.

Su1433 Retrograde Endoscopic Treatment of External and Internal Pancreatic Fistulas: Stenting Starts and Wins

Treatment of pancreatic fistulas (PF) is one of the most difficult and urgent problems of modern abdominal surgery. Retrograde endoscopic procedures on the main pancreatic duct (MPD) has become an alternative for surgical treatment of PF. From January 1998 to November 2010, 6364 endoscopic retrograde interventions have been performed in our clinic. Stenting of MPD has been performed in 182 cases as a method of treatment for various pathologies. In 33 cases out of 182 PF were the reason for the pancreatic stenting. This group consisted of 28 men and 5 women, whose average age was 40,1+11,9 yrs. We observed external PF in 21 cases (63.6%), internal PF in 10 cases (30.3%) - which included 3 cases of pancreatopleural fistulas, and 7 cases of pancreatoabdominal fistulas - and mixed PF in 2 (6%) cases. Complex diagnostic program revealed that the defect of the wall of the pancreatic duct system was localized in the projection of the pancreas' body in 10 cases, in the neck in 10, in the head in 8 cases and in the tail in 5 cases. In all 33 cases, upon the completion of ERCP, we attempted to perform pancreatic stenting, and succeeded in 21 cases (63.6%). In 12 cases (36.4%), stenting was not possible. Occlusions and deformations of MPD as well as the full rupture of the Wirsung's or Santoriniev's ducts were the causes of failure. In 2 (6%) cases there were complications in endoscopic interventions: acute pancreatitis (1) and empyema of pansreatic tail pseudocyst (1). There were no lethal outcomes. In all the cases, in the period of 2 to 30 days after successful pancreatic stenting, complete closing of both external and internal PF was ascertained. It was confirmed clinically and by performing control ERCP after removal of stents in the period of 1 to 7 months after the initial intervention. Thus, after successful pancreatic stenting the closing of pancreatic fistulas was observed in all cases (100%). In 11 patients, the surgical interventions were utilized to treat PF. There were complications in 2 (18.2%) of them, and the lethality constituted 1 (9.1 %) due to anastomotic leak. Successful endoscopic pancreatic stenting as a means of PF treatment was possible in 64.3% of the cases. After the stenting of MPD, the closing of PF was observed in 100 % of both external and internal PF. Endoscopic retrograde correction has low level of complications (6%).

Retrograde endoscopic management of ureteral stones more than 2 cm in size

Objectives To verify the safety and efficacy of retrograde endoscopic lithotripsy as the treatment modality for large ureteral stones. Methods From July 1996 to May 2005, we performed retrograde endoscopic treatment in 54 patients with large ureteral stones more than 2 cm in size, using a small-caliber ureteroscope and a holmium:yttrium-aluminum-garnet laser lithotriptor. Although the mean maximal stone diameter was 2.4 cm, 6 patients had stones measuring larger than 3 cm. Of the 54 patients, 11 had stones that could not be effectively fragmented by shock wave lithotripsy previously. Results Of the 54 patients, 48 were treated solely using retrograde ureteroscopy. In 47 patients (87%), the stones were fragmented completely by a single endoscopic procedure. Additional shock wave lithotripsy was performed after endoscopic debulking in 2 patients, and any stones remaining in the ureter were easily treated by shock wave lithotripsy. Pyelonephritis resulting from obstruction caused by ureteral stones was observed in 4 patients, 3 of whom required percutaneous nephrostomy and 1 of whom required stent insertion before the endoscopic procedure. These patients then underwent retrograde endoscopic lithotripsy, which completely cleared the calculi in one session. No intraoperative complications occurred. The only postoperative complication was found in 1 patient presenting with a ureteral stricture. One month after the final treatment, no patients had evidence of residual stones. Conclusions With use of a small-caliber ureteroscope and a holmium:yttrium-aluminum-garnet laser lithotriptor, retrograde endoscopic lithotripsy seems to be an effective first-line therapy for large ureteral stones measuring more than 2 cm in size.

Broadening experience with the retrograde endoscopic management of upper urinary tract urothelial malignancies

OBJECTIVETo evaluate the results of the retrograde endoscopic treatment of upper urinary tract urothelial malignancies (UUTUM) in an attempt to preserve renal function while also obtaining an acceptable oncological result.PATIENTS AND METHODSSince 1995, 63 patients who were referred for retrograde endoscopic management of UUTUM were evaluated and treated. All patients had an initial diagnostic ureteroscopy and biopsy to obtain histopathological grading. Additional imaging studies were obtained to exclude metastatic disease. The treatment was directed by tumour grade at presentation and medical comorbidity. Tumour volume and multifocality did not exclude patients from vigorous endoscopic treatment. Tumours were resected with electrocautery, holmium‐YAG and Nd:YAG laser. Follow‐up endoscopic surveillance was initially at 3‐month intervals, with increasing intervals in patients with repeatedly negative findings.RESULTSThe tumour grade at presentation was high in 14 (22%), moderate in six (10%), low in 35 (55%) and carcinoma in situ in eight (13%), with 13 (20%) presenting with or subsequently developing bilateral disease. Twenty patients had a nephroureterectomy as they were not amenable to endoscopic treatment. Medical comorbidities necessitated palliative endoscopic therapy of high‐grade tumour in six patients; the remaining 35 had low‐grade tumour and were managed with retrograde endoscopic therapy. Recurrent low‐grade disease was identified in 24 with a mean (range) time to recurrence of 15 (3–63) months. There was concurrent low‐grade bladder cancer in 21 (60%) of the patients. The mean (range) follow‐up was 32 (3–84) months. No patient with low‐grade tumour progressed in grade or stage, and all but one who presented with high‐grade tumour progressed.CONCLUSIONThe retrograde endoscopic management of UTTUMs is particularly useful for patients who present with low‐grade lesions, providing good oncological control and preserving renal function. These patients require a careful and consistent follow‐up, as many will develop recurrent disease. Treatment of higher‐grade lesions is at best palliative.

Endoscopic Features of Impacted Ureteral Stones

We retrospectively evaluated endoscopic findings in 165 patients with impacted ureteral stones to determine the incidence of associated ureteral lesions and predisposing factors for such lesions. From July 1993 to March 2003 we performed retrograde endoscopic treatment in 165 patients with ureteral stones that had been impacted for more than 2 months. Average maximum stone diameter was 15.0 mm and the mean duration of impaction was 17.6 months. Treatment was done with small caliber ureteroscopes and a laser lithotriptor. We analyzed the endoscopic findings and determined the outcome by reviewing the clinical records and radiographic studies. Endoscopic observation revealed inflammatory ureteral polyps associated with calculi in 51 patients (30.9%). Endoscopic biopsy of 5 polyps was performed. Histological examination showed no malignancy and only chronic granulomatous inflammation of the ureter. Endoscopic observation also detected ureteral stricture in 28 patients (17.0%). Patients with polyps and strictures had long-term impaction (median 12 and 24 months, respectively), which was significantly longer than in patients without ureteral lesions (4 months). Endoscopic observation revealed that long-term impacted stones were frequently associated with ureteral polyps and strictures. Although concurrent ureteral lesions can make it more difficult to approach the calculus in patients with impacted stones, we found that a small caliber flexible endoscope was effective and laser fragmentation could be achieved easily.

ENDOSCOPIC MANAGEMENT OF IMPACTED URETERAL STONES USING A SMALL CALIBER URETEROSCOPE AND A LASER LITHOTRIPTOR

We reviewed our experience with retrograde endoscopy using a small caliber ureteroscope and a laser lithotriptor in 104 consecutive patients with impacted ureteral stones and also analyzed the associated endoscopic findings. From July 1993 to October 1999 we performed retrograde endoscopic treatment in 104 patients with impacted ureteral stones. Average maximum stone diameter was 15.2 mm. (range 2 to 110), and 9 patients had stones larger than 3 cm. Mean duration of impaction was more than 14 months and the longest was 10 years. We used 6.9Fr rigid or 6.9 to 7.5Fr flexible ureteroscopes and a pulsed dye laser or holmium:YAG laser lithotriptor. Of the 104 ureteral stones 100 (96.2%) were completely fragmented by a single endoscopic procedure. Although 1 uric acid stone could not be disintegrated by either the pulsed dye laser or electrohydraulic lithotripsy early in this series, it was discharged spontaneously 2 weeks after the procedure. Additional extracorporeal shock wave lithotripsy (ESWL*) was required in 3 patients who initially had stones larger than 3 cm. A month after treatment no patient had evidence of residual stones. Using adjuvant ESWL a 100% success rate was attained with minimal morbidity. Endoscopic observation revealed inflammatory polyps of the ureter in 22 patients (21.2%), and stricture adjacent to the stone in 16 (15. 4%). There were no significant complications. Using a small caliber ureteroscope and a laser lithotriptor we could treat the target stone in all 104 patients with adjuvant ESWL in 3 cases. Endoscopic lithotripsy seems to be effective first line therapy for chronically impacted stones which are frequently associated with chronic inflammation, polyps and strictures, and avoids the futile repetition of ESWL and problems related to the prolonged passage of stone fragments.

Endoscopic management of upper urinary tract disease using a 200-μm holmium laser fiber: initial experience in japan

Objectives. To study the clinical effectiveness of the 200-μm holmium laser fiber for endoscopic management of upper urinary tract lesions. Methods. From January 1997 to March 1998, we performed retrograde endoscopic treatment in 25 patients with urinary tract lesions using a 200-μm holmium laser fiber. Nineteen patients had 20 stones (16 ureteral, 3 lower calyx, and 1 middle calyx), 4 had bleeding lesions in the lower calyx, 1 had transitional cell carcinoma involving the renal pelvis and upper calyx, and 1 had a ureteral stricture associated with an impacted ureteral stone. We used a 7.5F flexible ureterorenoscope for renal and upper ureteral lesions, and a 6.9F rigid ureteroscope for mid and lower ureteral lesions. For treatment, we used a holmium:yttrium-aluminum-garnet laser generator and a 200-μm flexible quartz fiber. Results. All stones were successfully fragmented, including three lower caliceal stones. Lower caliceal bleeding spots were successfully cauterized for hemostasis in all 4 patients, and the pelvic tumor was successfully vaporized and ablated. In 1 patient, we had previously failed to treat a ureteral stricture with a 365-μm fiber because of inadequate visualization, but it was successfully incised using the 200-μm fiber. There were no significant complications such as ureteral obstruction or stenosis. Conclusions. The improved flexibility of the new 200-μm holmium laser fiber facilitates treatment of stones, tumors, strictures, and lesions in the lower calyx, where access is difficult when using the previously available 365-μm fiber.

Applications of the KTP laser in the treatment of posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient.

We describes our experience using the potassium titanyl phosphate (KTP)-532 laser in treating posterior urethral valves, ureteroceles, and urethral strictures in the pediatric patient. A retrospective chart review was performed from 1987 to 1997 on a total of 33 pediatric patients who underwent retrograde endoscopic treatment for posterior urethral valves (PUV), ureteroceles (UC), and urethral strictures using a KTP-532 laser. Overall, our success rate was excellent in the treatment of valves and ureteroceles. With a mean follow-up of three years in the PUV group, no urethral strictures of micturation abnormalities were seen. The majority of ureteroceles were decompressed and only half of our patients required and additional procedure. Our experience with urethral strictures, however, was not as promising. All of these patients ultimately required open urethral reconstruction. The desirable thermal characteristics of the KTP laser, along with minimal complications and the availability of delicate pediatric endoscopic instruments have made this operation optimally suited for treating posterior urethral valves and ureteroceles in infants. However, the advantages for treating urethral strictures in children with the laser still remains to be established.