Simultaneous antegrade and retrograde and approach for upper ureteric and renal stones in modified supine valdivia position: initial experience

Abstract

Background: Management of large impacted proximal ureteric stone remains controversial. Stone free rate for ESWL is decreased in stones > 2 cm. URSL to impacted upper ureteric stones causes a back-pressure effect which flushes stone fragments to the kidney. Percutaneous antegrade ureteroscopy is an acceptable first-line treatment for (i) large impacted upper ureteric stones(ii) in combination with renal stone removal or (iii) in failure of retrograde access to the stone. Both approaches risk migration of stones to either the more distal ureter or into renal pelvis, resulting in residual stones that are difficult to be retrieved. Simultaneous antegrade and retrograde approach for upper ureteric stone and renal stone theoretically brings about the advantages of both approaches, while minimizing the risk of stone migration and residual stones. However, there is paucity of literature on simultaneous and retrograde approach for impacted upper tract stones. Purpose: To present early experience in management of complex upper ureteric and renal stones using a combined percutaneous and ureteroscopic approach in the supine position under local anaesthesia. Materials and methods: 10 patients who underwent simultaneous antegrade and retrograde approach for complex upper urinary tract stones from June 2009 to March 2010 were entered into the study. Demographics, stone characteristics, perioperative parameters, stone clearance rate were prospectively collected. Data was entered into a database, and analyzed. Results: 10 patients (M:F=7:3) underwent simultaneous antegrade and retrograde approach to upper urinary tract stones under local anaesthesia with sedoanalgesia. The mean age was 63 (range: 50 – 80 y.o.) 6 patients had impacted upper ureteric stones, of which two had previously failed URSL. 2 patients had obstructing PUJ stone. 1 patient had large lower pole stone. 1 patient had obstructing lower ureteric stone with multiple stones in upper, mid and lower poles. Mean stone size (maximum diameter) was 23.3 mm (range: 12 - 54 mm). 6 patients had PCN inserted pre-operatively due to sepsis, acute renal failure or pyonephrosis. 9 patients had hydronephrosis documented on pre-op imaging. Sheathless PCNL with Fr 16 nephroscope was performed in 3 patients with well-formed tract. 7 patients required the use of amplatz sheath, ranging from 18 – 30 Fr. All procedures were performed in the modified supine Valdivia position. 50% had ‘tubeless PCNL’with double J catheter inserted. OT time ranged from 64 to 125 min (mean 93.4 min). 7 patients achieved complete stone clearance on postop AP and KUB film. 1 patient with 8 mm residual stone underwent 2nd look PCNL, and was stone-free thereafter. 2 patients had residual stone of 2mm & 4 mm respectively, and preferred conservative management. Mean blood loss was 39ml and hemoglobin drop was 0.6 g. No patients required blood transfusion. Length of stay ranged from 0.5 days to 5 days (mean 2.65 days). 2 patients developed morbidities – post-op fever and hematuria, and were treated as urinary tract infection. Conclusion: Simultaneous antegrade and retrograde approach for complex upper ureteric stones and renal stones is feasible, with high stone-free rates and low morbidity.