In order to explore the minimally invasive treatment of embedded stones in the upper ureter, a total of 182 cases were treated by minimally invasive percutaneous ureteroscopic lithotomy (mini-PCNL) and transurethral ureteroscopic lithotomy (URL) from August 2002 to December 2004 in our department, and the clinical results of the two treatments were compared.
I. Clinical data and methods
1.Clinical data
The criteria for the use of upper ureteral stones were: stones larger than 1,0 cm, irregular shape, moderate to severe hydronephrosis by B-ultrasound, or intravenous urography (IVU) without kidney visualization; some of them had a history of 1~3 times extracorporeal shock wave lithotripsy (ESWL) treatment, but there was no significant change of stones or only very little discharge. There were 95 cases in the percutaneous ureteroscopy (mini-PCNL) group, 74 males and 21 females; age 16-65 years, maximum stones 2,0×3,5 cm; 87 cases in the transurethral ureteroscopy (URL) group, 59 males and 28 females; age 25-73 years, maximum stones 1,2×2,6 cm.
2. Treatment method
mini-PCNL group: After epidural anesthesia, the patient was placed in the lithotomy position, and the F5 ureteral catheter was inserted under the ureteroscope on the affected side to the bottom of the stone or across the stone pelvis (more difficult to succeed); the patient was placed in the prone position with a small pillow on the abdomen, and the ureteral catheter was injected with 38% pantothenic glucosamine and the puncture point was located with the cooperation of the C-arm machine, usually between the scapular line and the posterior axillary line, and the needle was inserted in the 11th intercostal space or under the 12th inlet rib. After successful insertion of the guidewire, the puncture channel is dilated with F8 fascial dilator along the guidewire to F16, and then the F16 peel-away sheath is left in place. With the hydraulic pump flushing, the F8/9,8 ureteroscope enters the upper ureter and finds the stone, and the stone is crushed, flushed and removed with pneumatic ballast or holmium laser lithotripter. The F7 double “J” tube and F14 nephrostomy tube were left in place.
URL group: After epidural anesthesia, the patient was placed in the lithotomy position, Wolf F8/9,8 or F7/8,5 ureteroscope was used to enter the ureter through the urethra and bladder along the guidewire to the bottom of the stone, and the stone was crushed to less than 0,3 cm by pneumatic ballast or holmium laser lithotripter, and the polyp was clamped or ablated, and the larger stone could be removed (if the ureteral lumen was small, it was not forced to enter and exit), and finally F5-7 double “J” tubes were left in place. 7 double “J” tube.
II. Results
In the mini-PCNL group, three cases failed to enter the microscope due to ureteral adhesions (one case was converted to open surgery, and two cases were successfully treated by transurethral ureteroscopy); one case was cured by ESWL after nephrostomy due to a stone wandering into one calyx, and the success rate was 98% (93M95). Two cases with postoperative hyperthermia and severe hematuria were cured by conservative symptomatic treatment. One case of renal pelvis cancer was found intraoperatively and was treated with conventional surgery after pathological confirmation. The incidence of complications was 4,2% (4M95), and the rate of stone clearing was 100% on ultrasound or X-ray after 1 month.
In the URL group, there were 24 cases of large lithotripsy reflux into the kidney, which were cured by ESWL, 2 cases of ureteral perforation were converted to open surgery, and 3 cases of severe tortuous ureteroscopy could not be performed by mini-PCNL, and the success rate of surgery was 94% (82M87). The incidence of complications was 5 and 7% (5M87) The 1-month stone clearance rate was 92%. Tables 1 and 2 show the treatment history, efficacy and postoperative complications in both groups.
Table 1 Comparison of results between mini-PCNL group and URL group
Group Number of cases Stone wandering Change to open surgery PCN, URL Mutual change Postoperative ESWL Treatment of ipsilateral kidney stones 1-month stone clearance rate
PCN 95 1 1 2 2 1 8 100%
URL 87 24 2 3 24 0 92%
Table 2 Comparison of surgical complications between mini-PCNL group and URL group
Group Number of cases Renal colic Severe hematuria Hyperthermia Ureteral perforation Renal pelvic tumor found
PCN 95 0 2 2 0 1
URL 87 1 1 1 1 2 0
III. Discussion
ESWL, PCN and URL have been widely used to eliminate open surgery in more than 95% of ureteral stone patients, but most of the embedded stones in the upper ureter often have polyps or strictures, so ESWL is often less effective, with a success rate of less than 40%. Compared with PCN, URL is more minimally invasive and easily accepted by patients, but its main disadvantage is that stones are easily displaced when performing pneumatic ballistic or holmium laser lithotripsy, and stones may reflux to the renal pelvis and lower renal calyces, and the impact is often more likely to cause stone reflux than pneumatic ballistic or holmium laser lithotripsy; due to the large mobility and tortuosity of the upper ureter, it may not be possible to go up to the stone location during the operation, and it may not be possible to retrieve the stone and deal with it. The repeated entry and exit of polyps into and out of the ureter are prone to complications such as edema, bleeding, injury, perforation, tearing, fracture and exfoliation, and it is difficult to completely remove the stones remaining in the attached wall, so the stone clearance rate is low; there are more cases of ESWL supplemental treatment after surgery, reaching 27,6% (24M87) in our group. Compared with transurethral ureteroscopy, the Lisson mini-PCN technique has the following superiority in the treatment of embedded stones in the upper ureter, and we have the following experience.
1. Renal puncture and establishment of operational access are easier. Since all patients in this group have different degrees of hydronephrosis, renal puncture becomes easy and successful, and skilled patients can achieve the effect of “seeing urine with one needle”.
2. Good stone clearing effect and effective treatment of ipsilateral kidney stones. The F16 skinning sheath is used to enter the scope in a prograde manner, and the renal fistula channel is wide and the operation angle is large, which reduces ureteral injury. The pressure perfusion pump has good control of water flow, clear vision, and more thorough treatment of stones with wall adhesions. It can also deal with stones in all parts of the kidney at the same time and reduce the residual stones as much as possible, and the stone clearance rate can reach 100%.
3. Less complications. Renal puncture microstomy is less traumatic, with smooth drainage and fewer complications such as intraoperative bleeding, colic and fever, which can usually be cured by conservative therapy.
PCN can examine ureter, renal pelvis and renal calyces intraoperatively.
In conclusion, the technique of minimally invasive percutaneous ureteroscopy for the treatment of embedded stones in the upper ureter has the advantages of less trauma, simpler operation, fewer complications, and faster patient recovery, especially for patients with combined ipsilateral renal stones, mini-PCNL can be the first choice of treatment.