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Combinde antegrade and retrograde ureterorenoscpoy for treatment of multipel ureteric stones post cystectomy and Ileal-conduit
Dr. Wadah Ceifo, Department Urology, Al-Jahra Hospital, Ministry of health in Kuwait,e-mail:wceifo@yahoo.de
Dr. Addel al-Tawhyed Department of Surgery and Urology,al-Jahra Hospital, , Ministry of health in Kuwait,e-mail:adeltawhyed@yahoo.com
Contact at :wceifo@yahoo.de
ABSTRACT
Objective:
Urinary tract calculi occur in 4-30% of patients who have undergone ileal conduit diversion1 about half of these stones are not voided spontaneously and further management is necessary. It was mentioned previously in literature about different methods for treatment of ureteric stone post incontinent urinary diversion2-5 . The objective of our case presentation is to describe the technique and results of Combinde antegrade and retrograde ureterorenoscpoy for treatment of multipel ureteric stones post cystectomy and Ileal-conduit.
Materials and Methods:
A 65 years old lady admitted in our ward with sever left loin pain, heigh fever and leukocytosis. Ph/o: radical cystectomy and ileal conduit 7 years ago by of Cancer-Bladder heigh grade TCC, (T3b,N0,M0).Ph/o:Chronic Kidney disease, diabetes mellitus, hypertension, Bronchial asthma. Left percutaneous nephrostomy catheter (10french) was fixed and urinary tract infection was reated with antibiotics. Plain CT(abdomen,pelvis) revealed multiple left ureteric stones. The general Condition was improved three weeks later and the left antegrade nephrostogram showed complete obstructed left lower ureter, the loopogram revealed reflux of contrast material only into right ureter. Procedure: Under general anesthesia , in supine and modified left lateral position, we started our operation with diagnostic loopscopy using flexible cystoscpe ( Olympus CYF-V2/VA2) which showed no evidence of recurrent tumor, but both ureteric orifices couldn’t be identified even post ante grade injection of methylene blue thru the left nephrostomy catheter. The nephrostomy tract was dilated with balloon-dilator (NephroMax™ High Pressure Nephrostomy Balloon Catheter) to 30 french over standard guide- wire (0.038 inch) and using the 26 french semi rigid nephroscope (Karl Storz), a second hydrophilic glide-wires ( Terumo) were inserted into the ileal-conduit which extracted outside the stoma using flexible cystoscope. The flexible nephroscope (Wolf Flexible Fibre nephroscope) was introduced into the left upper ureter and the upper ureteric stones were fragmented using Holmium-laser(8 watt,200 micron laser-fiber) and extracted by zero-tip endo-basket and using semi rigid forceps. From the stoma side, the flexibe ureterorenoscpe (FLEX-X2 Ureteroscope, Karl storz) is introduced over the guide-wire into the left lower ureter and the residual stones were fragmented and extracted using a zero-tip endo-basket. At the end of the operation we fixed a (6 french,70 cm) ureteric catheter and 18 french silicon nephrostomy catheter .
Results :
technical success was achieved ,there were no intra-or postprocedural complications. The average operating time was 150 min,the average intraoperative blood loss was 300 ml , Post operation the patient was asymptomatic, afebrile with improvement in her renal function tests,the postoperative intestinal function recovery time was 2 days ,and the average hospitalization time was 15 days .Post operative X-ray (abdomen, pelvis) ,and left ant grade nephrostogram revealed no residual stones, the left ureteric catheter was removed 10 days later, and the nephrostomy catheter removed after 2 weeks. The patient was discharged in a very well general condition for follow-up in our outpatient urologic clinic
Conclusion:
The combinde antegrade and retrograde ureterorenoscpoy for treatment of multipel ureteric stones post cystectomy and Ileal-conduit is a viable method to treat ureteroileal obstruction after incontinent urinary diversion in patients who require minimally invasive alternatives to open intervention . Its safe and effective in minimizing the patient discomfort.