Open-ended Ureteral Catheter Research Articles

Transvesical Endoscopic Peritoneoscopy: A Novel 5 mm Port for Intra-Abdominal Scarless Surgery

Recently various groups reported successful attempts to perform intra-abdominal surgery through a transgastric pathway. We assessed the feasibility and safety of a novel transvesical endoscopic approach to the peritoneal cavity through a 5 mm port in a porcine model. Transvesical endoscopic peritoneoscopy was performed in 8 anesthetized female pigs, including 3 nonsurvival and 5 survival animals. Under cystoscopic guidance a vesical hole was created on the ventral bladder wall with an open-ended ureteral catheter. An over tube with a luminal diameter of 5.5 mm was placed in the peritoneal cavity, guided by a 0.035-inch guidewire. In all animals we performed peritoneoscopy of the entire abdomen as well as liver biopsy and falciform ligament section. A vesical catheter was placed for 4 days in all survival animals, which were sacrificed by day 15 postoperatively. After a learning curve in the first 3 nonsurvival animals the creation of a vesical hole and placement of the over tube were performed without complication in all survival animals. In these animals we easily introduced an EndoEYEtrade mark into the peritoneal cavity, which provided a view of all intra-abdominal viscera, as well as a 9.8Fr ureteroscope, which allowed simple surgical procedures without complications. In survival experiments all pigs recovered. Necropsy examination revealed complete healing of the vesical hole and no signs of infection or adhesions into the peritoneal cavity. Transvesical endoscopic peritoneoscopy was technically feasible and it could be safely performed in a porcine model. This study provides encouragement for additional preclinical studies of transvesical surgery with or without combinations with other natural orifices approaches to design new intra-abdominal scarless procedures in what seems to be third generation surgery.

Povidone iodine and dextrose solution combination sclerotherapy in chyluria

Objectives To evaluate the effectiveness of combination (povidone iodine and 50% dextrose) renal pelvic instillation sclerotherapy (RPIS) as a minimally invasive therapy for chyluria resistant to conservative treatment. Methods A total of 50 patients with chyluria and hematochyluria (28 men and 22 women) were included in the study. Initially, all were offered conservative antifilarial drug therapy and dietary fat restriction. Intravenous urography was done in all cases to document normal renal functional status. In the patients in whom chyluria persisted after 3 weeks of conservative therapy, cystoscopic lateralization was done and a 5F open-ended ureteral catheter was positioned under local anesthesia. The same was left attached to a 16F Foley catheter for 3 days of RPIS. A solution of 5 mL of 5% povidone iodine and 5 mL of 50% dextrose was instilled twice a day with the patient in the Trendelenburg position for 3 days. In cases of bilateral efflux, the dominant side was treated first. The opposite side was subjected to a similar instillation sclerotherapy schedule after 6 weeks if chyluria persisted. Results Of the 50 patients, only 4 responded to conservative therapy. The remaining 46 patients underwent combination RPIS. The mean follow-up was 24 months. Complete remission of chyluria or hematochyluria occurred in 40 (87%) and persisted in 6 patients (13%). Of the 6 patients in whom symptoms persisted, 2 developed chyluria on the side opposite the one treated with RPIS. Another 2 patients developed recurrence on the same side after remaining asymptomatic for 6 months after RPIS. All four of these patients subsequently underwent chylolymphatic disconnection and nephropexy (two open and two laparoscopic) with a successful outcome. The final 2 patients with persistent symptoms were lost to follow-up. Conclusions Combination sclerotherapy using a 5% povidone iodine and 50% dextrose solution is a safe and cost-effective minimally invasive therapy for chyluria refractory to conservative treatment.

Knot Formation at the Mid Portion of an Indwelling Ureteral Stent

Indwelling ureteral stents are commonly used in the management of upper urinary tract obstruction. A rare complication is the knotting of an indwelling ureteral stent at its proximal coiled end. 13 We report a case in which a complete knot was found in the middle of an indwelling ureteral stent, a finding that to our knowledge has not been described previously. CASE REPORT A 66-year-old female presented with an infected, partially obstructing 8 5 mm. stone at the right ureteropelvic junction. The patient was treated with antibiotics and underwent stent placement to decompress the infected kidney. Physical examination was notable for a large cystocele at the introitus. As a result the ureteral orifices could be identified cystoscopically only after manual transvaginal elevation of the prolapsed bladder. A 6Fr open-ended ureteral catheter was positioned at the right ureteral orifice and a 0.035-inch Bentson guide wire (Cook Urological, Spencer, Indiana) was advanced into the renal pelvis. The stone was dislodged by the advancing guide wire and ultimately settled in the lower pole of the collecting system. A 7Fr 24 cm. Double-J stent (Medical Engineering Corp., New York, New York) was placed over the guide wire. Fluoroscopically the proximal end coiled appropriately in the renal pelvis and the distal end was seen coiled in the bladder under direct cystoscopic examination. The patient quickly improved. Following a 2-week course of antibiotics she underwent extracorporeal shock wave lithotripsy (Lithostar, Siemens Medical Systems, Inc., Iselin, New Jersey), which resulted in excellent stone fragmentation. At the time of lithotripsy the stent was noted to have migrated into the proximal ureter. After lithotripsy the stent was cystoscopically visualized and removed intact without difficulty using endoscopic grasping forceps. Examination of the stent revealed a knot in its mid portion (see figure). DISCUSSION

SUCCESSFULLY TREATED RENAL FUNGAL BALL WITH CONTINUOUS IRRIGATION OF FLUCONAZOLE

A 57-year-old man was referred for gross hematuria and fever 1 month in duration. He had a history of diabetes mellitus for 10 years and was on hemodialysis regularly because of end stage renal disease for 1 year. The patient had been taking oral fluconazole for 1 month because of presumed candidal infection of the bladder diagnosed by repeated positive urine culture for Candida species. At presentation body temperature was 37.5C and daily urine output was about 100 ml. Blood urea nitrogen and creatinine were 52 and 6.1 mg./dl. (normal range 9.1 to 23.3 and 0.5 to 1.4), respectively. Urinalysis showed many red and white blood cells per high power field. Urine culture was positive for 1,000 colonies of Candida species. Cystoscopy revealed bloody efflux from the right ureteral orifice. On retrograde pyelogram a filling defect was seen occupying nearly the entire renal pelvis and calices (fig. 1). Ureterorenoscopy demonstrated whitish friable material filling the renal pelvis and calices nearly totally consistent with a fungal ball. A 5Fr open end ureteral catheter was inserted into the right renal pelvis. The biopsy showed yeasts and pseudohyphae consistent with Candida albicans. While the patient was taking 200 mg. oral fluconazole daily, continuous irrigation was started through the ureteral catheter with 300 mg. fluconazole mixed with 500 ml. 5% dextrose water at the rate of 40 ml.per hour during the day and with normal saline only at night. On day 2 of irrigation whitish debris started gushing out via the Foley catheter, which became clear on day 7. There was no episode of fever or flank pain during treatment. Repeat retrograde pyelogram on day 12 of irrigation showed no filling defect (fig. 2). Irrigation was stopped and the catheter was removed but 100 mg. oral fluconazole were continued daily for 3 weeks. Urine cultures on day 10 and week 4 of treatment showed no growth of Candida species. DISCUSSION

Negotiating ureteral stenoses and kinks with a hydrophilic wire.

Negotiating a tortuous or obstructed ureter with a wire can be time-consuming and sometimes tiring. The principle of using a slippery floppy wire and then replacing it with a stiff wire through a 5-french open-ended ureteral catheter yields a high success rate. The ureteral catheter can be used for a radiocontrast study and allows access for a 0.035 'coaxial wire', which can be used as a guide wire for a single or double J stent.

Morphological and Physiological Changes in the Urinary Tract Associated With Ureteral Dilation and Ureteropyeloscopy: An Experimental Study

The gross and microscopic effects of four common modes of ureteral dilation and ureteroscopy were examined in 26 renoureterai units in 13 minipigs. Acutely, ureters subjected to mechanical (bougie, Teflon, or balloon) ureteral dilation and ureteropyeloscopy (UPS) demonstrated active mucosal bleeding with multiple sites of perforation, whereas ureters subjected to hydraulic dilation and UPS were significantly less traumatized. Two weeks after mechanical ureteral dilation and UPS, 3 of 6 ureters were obstructed radiographically, whereas all 7 hydraulically dilated ureters were unobstructed. By 6 weeks, all radiographic evidence of obstruction had resolved in the mechanically dilated group. While 5 of 6 mechanically dilated ureters showed extensive scarring with muscle loss 4 to 6 weeks after dilation, no scarring was seen in those ureters dilated hydraulically.Renal pelvic pressure (RPP) was measured continuously with a nephrostomy catheter in vivo during (bougie, Teflon, balloon and hydraulic) ureteral dilation and UPS. Renal pelvic pressure during rigid ureteroscopy approximated the resting pelvic pressure plus the irrigant height above the kidney or set pressure on a hydraulic pump, plus a “scope effect” which was characterized by a 20 to 25mm. Hg increase in RPP produced by moving the endoscope in the ureter without flow. The effects on RPP of continuous bladder drainage with a urethral catheter and renal pelvic decompression with an open-ended ureteral catheter passed into the renal pelvis through the ureteroscope working channel were also examined. The maximum RPP was evaluated in vitro in a separate group of 16 freshly harvested pig kidneys of similar weight examined immediately after sacrifice and was found to be 439mm. Hg.We also studied the immediate and long-term effects of low (<120cm. H20 or 90mm. Hg) versus high (>200cm. H20 or 150mm. Hg) RPP on renal histology. Acutely, high pressure caused diffuse denudation and flattening of the caliceal urothelium, submucosal edema and congestion not seen in calyces subjected to low irrigant pressure. Four to six weeks later, there was a higher incidence of columnar metaplasia, subepithelial nests and pericalyceal vasculitis in calyces subjected to high pressure as compared with those subjected to low irrigant pressure. Acutely, renal tubules subjected to high irrigant pressure demonstrated marked vacuolization and degeneration, whereas tubules subjected to low pressure appeared normal. At 4 to 6 weeks, focal scarring was seen in 5 of 7 kidneys subjected to high irrigant pressure, whereas no scarring was noted in all 6 kidneys subjected to low irrigant pressure.In summary, it seems that hydraulic intramural ureteral dilation is less traumatic than mechanical modes of dilation with less potential for ureteral scarring and stricture. Prolonged exposure of the minipig kidney to high RPP (>200cm. H20) during UPS resulted in renal scarring and inflammation not seen following low pressure (<120cm. H20) irrigation. Because the human kidney is anatomically and physiologically similar to the minipig kidney, it may respond to high renal pelvic pressures in a similar fashion.

The Effect of Acute Obstruction on Ureteral Function

In an effort to understand the physiologic processes which contribute to, or hinder the transport of stones through the ureter, we examined the intraluminal ureteral pressures and peristaltic activity above and below the acutely obstructed site. Because of patient differences, variability in stone size, shape and composition, an in vivo animal model was developed to study acute ureteral obstruction.Five adult mongrel dogs were anesthetized. A midline celiotomy was made and an open-ended ureteral catheter was inserted through a distal ureterotomy and advanced up the ureter. An angiographic balloon catheter was inserted through a small nephrotomy and directed down the ureter. The experiment was divided into phases: control, ureteral obstruction (balloon inflation) and release of obstruction (balloon deflation).Compared to control values, peristaltic rate above the obstruction increased significantly (p < 0.05), as well as baseline, peak, and delta (peak minus baseline) pressures. In contrast, the peristaltic rate below the obstructed site remained approximately the same as its control, despite the significant decreases in baseline, peak, and delta (p < 0.05) pressures.Failure of transmission of effective peristalsis across the obstructed site may hinder stone passage; however, this remains to be proven. Moreover, the failure of transmission of the increased rate of peristalsis past the balloon and persistence of peristaltic activity below the site of obstruction despite absence of urine flow suggest segmental forces influence peristaltic activity.