Retrograde Endoscopic Techniques Research Articles

Safety and efficacy of combined antegrade and retrograde endoscopic dilation for complete esophageal obstruction: a systematic review and meta-analysis.

BackgroundComplete esophageal obstruction (CEO) due to occlusive proximal stricture occurs after chemoradiation for head and neck cancers. A combined antegrade and retrograde endoscopic technique with controlled recanalization and dilation (CARD) has been shown to be an effective and safe method for regaining and maintaining esophageal luminal patency in the short term.MethodsWe conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception through November 2018), to identify studies that reported the outcomes of CARD. The primary outcomes were the pooled rates of technical and clinical success, specifically improvement in dysphagia and independence from percutaneous endoscopic gastrostomy (PEG)-tube feeds. The secondary outcomes were the need for repeat dilations and the risks of complications, such as pneumomediastinum, perforation, and death.ResultsFrom a total of 19 studies (229 cases and 251 procedures) the calculated technical success rate was 88.9% (95% confidence interval [CI] 83.9-92.5, I2=0). The rates of improvement in dysphagia and being PEG-tube free were 58.4% (95%CI 50-66.3, I2=12.6) and 43.5% (95%CI 34.1-53.4, I2=30.6), respectively. The pooled rate of repeat dilatations was 78.9% (95%CI 69.7-85.8, I2=15.2). The risks of pneumomediastinum, perforation and death were 9.9% (95%CI 6.2-15.6, I2=0), 8% (95%CI 4.8-13, I2=0), and 6.8% (95%CI 3.4-13.1, I2=0), respectively. Minimal heterogeneity was noted in the analysis.ConclusionsThe CARD procedure for CEO has a high technical success rate, but also a high rate of repeat dilations. Given its complexity and associated adverse events, this procedure should be restricted to centers with a high level of expertise.

Stone management in children

Children constitute only a small number of the total patients with urolithiasis. Nevertheless, pediatric stone disease is an important health care problem because of its high recurrence rate. In recent years, the incidence of pediatric stone disease has increased several-fold, mostly owing to hypercalciuria and hypocitraturia. Chang Kit and colleagues’1 article highlights the pattern of nephrolithiasis in developed countries and depicts the major differences in presentation, predisposing factors and treatment options in children presenting with urinary stones. Children can present with a wide range of symptoms varying from flank pain and hematuria to nonspecific symptoms such as irritability and nausea. Ultrasonography and plain radiography play a role in diagnosis and follow-up. As shown by Chang Kit and colleagues, the most common diagnostic radiological methods used were abdominal ultrasonography (74%) and (or) abdominal plain film radiography (56%). Approaching pediatric urolithiasis requires a thorough metabolic and environmental evaluation of all patients on an individual basis, and as shown by Chang Kit and coworkers, 41% (28/69) had a metabolic abnormality. In addition, since there is a high recurrence rate, metabolic evaluation of every child with a urinary stone should be undertaken, medical treatment should be given when indicated and children should be followed closely to avoid stone recurrence. The medical treatment is based on the chemical composition of the stone and the biochemical abnormalities causing its formation; hence, chemical analysis of the stone, urine and blood is of paramount importance and should be done when the first stone is detected. The nonpharmacological means to address stone disease include high fluid intake and, frequently, modification of nutritional habits. Urine volume increases in parallel with body mass index, and medical therapeutic agents that increase urine citrate levels should be encouraged. Limiting salt in the diet and drinking plenty of water are the best ways to prevent the most common types of kidney stones or to slow their growth, but the ease in applying these dietary guidelines in children is not known. Furthermore, obstructive pathologies such as ureteropelvic junction obstruction have to be corrected concomitantly when present, and apparent metabolic abnormalities should also be treated adequately. The goal of medical treatment is not only to decrease recurrence but also to decrease the expansion of existing stones. It is thought that children have elastic ureters, allowing them to pass stones easily. In Chang Kit and colleagues’ study, 47% of patients spontaneously passed their stones even when they were as big as 11 mm. Nevertheless, more than one-half of the patients needed surgical intervention. With recent advances in technology, stone management has changed from an open surgical approach to less-invasive approaches such as extracorporeal shock wave lithotripsy and endoscopic techniques. In children, clearance of stones after extracorporeal shock wave lithotripsy especially in the presence of metabolic abnormality is necessary because residual fragments are clinically significant in children and increase the chance of adverse clinical outcomes.2 Thus these patients, particularly those with identifiable predisposing disorders, require close follow-up. Traditionally, upper urinary tract calculi that are too large to treat with extracorporeal shock wave lithotripsy are most commonly cleared with percutaneous endoscopic techniques. Recently, improved ureteroscopic access to stones throughout the pediatric urinary tract and stone-free rates that are comparable to the adult population have led to the adoption of ureteroscopy as first-line therapy in children at our institution.3 In a select group of patients who are poor candidates for percutaneous nephrostolithotomy, retrograde endoscopic lithotripsy is becoming an attractive option. Thus with miniaturization and advances in technology, large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques. For instance, ureteroscopy achieves reasonable results with minimal complications in pediatric patients with renal pelvic calculi. On the other hand, polar stones require multiple sessions for complete clearance, and staghorn calculi may not be amenable to ureteroscopy. In their article, Chang Kit and colleagues do not report the number of procedures performed that lead to full success for each surgical approach, nor do they report the complications that occurred when they approached the patients surgically.

Fragmented Pigtail Percutaneous Nephrostomy Tubes: Etiology and Management

PurposeTo review our experience with the management of fragmented and retained pigtail percutaneous nephrostomy (PCN) tubes and to explore the reasons for the fragmentation.Materials and MethodsWe retrospectively reviewed our institute database from January 2006 to December 2011 for patients who had undergone retrieval of fragmented PCN tubes. We assessed the preoperative factors, operative technique, and post-operative outcomes.ResultsA total of seven patients (4 males and 3 females) had been diagnosed with fragmented PCN tubes. The mean age of the patients was 41.5 years. Of the seven patients, five required antegrade instrumentation by way of a percutaneous tract to remove the foreign body, mostly along with stone retrieval. One patient underwent ureterorenoscopy and pneumolithotripsy for a ureteric stone along with ureteroscopic removal of the PCN fragment. Another patient underwent nephrectomy of the kidney containing the PCN fragment because it had become nonfunctioning. All patients were free of stones and symptoms on follow-up.ConclusionsA prolonged waiting period for definitive surgery, urinary infection, and associated stone disease are significant factors causing fragmentation of PCN tubes. Proper insertion techniques, regular timed changes of the PCN tube, appropriate care of the PCN tube, and early surgery for underlying stone disease are required to avoid this complication. Patients with retained PCN tubes can be managed effectively with antegrade or retrograde endoscopic techniques while definitive management of the primary pathology is carried out, without any additional morbidity.

Treatment of Upper Urinary Lithiasis in Patients Who Have Undergone Urinary Diversion

Patients undergoing urinary diversion are at high risk for developing stone disease due to the metabolic and structural features intrinsic to the creation of a urinary reservoir. The utilization of shockwave lithotripsy as well as antegrade and retrograde endoscopic techniques in appropriately selected patients affords a relatively safe and effective means of stone removal. This review focuses on the etiology of stone formation in patients with urinary diversion and examines the most relevant and current reports on expulsive techniques and their associated outcomes for patients within this population who develop upper urinary tract calculi.

RETROGRADE URETEROPYELOSCOPIC TREATMENT OF 2 CM. OR GREATER UPPER URINARY TRACT AND MINOR STAGHORN CALCULI

Purpose Upper urinary tract calculi that are too large to treat with extracorporeal shock wave lithotripsy are most commonly cleared with percutaneous endoscopic techniques. In a select group of patients who were poor candidates for percutaneous nephrostolithotomy we used retrograde endoscopic lithotripsy, and define the safety and efficacy of this modality in treating large, noninfectious stone burdens (2 cm. or greater). Materials and Methods A total of 51 patients with 66 large (2 cm. or greater) upper urinary tract stones were chosen for retrograde ureteroscopic surgery. Many of these patients had co-morbid conditions that precluded or complicated standard percutaneous treatment. Lithotripsy was based on the application of small diameter fiberoptic ureteroscopes and the holmium laser lithotriptor. Specifically, the 200 micro. laser fiber was used when lower pole renal access was required. Successful therapy was defined as total fragmentation of a stone burden with creation of fine sand and 2 mm. or smaller debris. Second look endoscopy was commonly performed in select patients with large branched calculi or stone burdens in excess of 3 cm. to rule out and treat large residual fragments. Results Of 51 patients 48 were treated solely in a retrograde ureteroscopic manner and in 3 either failure of lower pole access or infectious material encountered on initial endoscopy led to conversion to more standard percutaneous techniques. In 34 of 45 renal (76%), and 20 of 21 ureteral (95%) complete ureteroscopic fragmentation of the respective stone burden was accomplished after a single session. Second look endoscopy defined significant residual fragments requiring additional endoscopic lithotripsy in 8 of 15 large renal (53%) and 1 of 3 complex ureteral stone burdens. Success, that is complete pulverization of the stone burden to fine dust and small 2 mm. fragments, increased to 41 of 45 renal (91%) and all 21 ureteral calculi after these second look procedures. One patient required a third session to treat completely an exceptionally large (6 cm.) renal stone burden composed of pure cystine, thus increasing the overall success rate for renal calculi to 93%. Six-month followup data were available for 25 patients with large calculi treated ureteroscopically, of whom 15 (60%) had completely clear imaging, 6 (24%) had small lower pole debris that was decreasing on serial imaging and 4 (16%) had new stone growth which was, in part, related either to uncorrectable metabolic disorders or chronic renal scarring and urinary stasis. There were no intraoperative complications. Three postoperative complications included pyelonephritis in 1 patient, prostatic bleeding in 1 on anticoagulant therapy and a cerebral vascular accident 24 hours after the procedure in 1 with severe vascular disease. Conclusions Large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.

Endoscopic Management of the Symptomatic Caliceal Diverticular Calculus

Caliceal diverticular calculi are most often asymptomatic and of little clinical significance. In certain cases they may be associated with flank pain, pyuria and chronic urinary tract infections. Treatment has evolved from open surgical techniques to a purely endoscopic approach. Percutaneous techniques are frequently used to address the diverticular stone burden and to dilate the diverticular neck, improving drainage. Small volume caliceal diverticular calculi and those in the anterior portion of the collecting system represent a greater technical challenge to the endoscopist. We describe a purely retrograde endoscopic technique for treating small stone burdens trapped in caliceal diverticula. Flexible ureteroscopy combined with 3F dilating balloons passed through the endoscopic working channel facilitated treatment. This retrograde technique was combined with a simultaneous primary percutaneous puncture into the diverticulum to treat larger stone burdens and calculi within long-necked diverticula. This combination facilitated prompt, through and through access of a percutaneously placed guide wire, increasing the overall efficiency of treatment. In conclusion, a retrograde endoscopic technique using the actively deflectable, flexible ureteroscope can successfully treat certain caliceal diverticular calculi. By combining this technique with a simultaneous percutaneous puncture, caliceal diverticular calculi throughout the collecting system may be cleared expeditiously.