How I Do It Differently Ultrsound-guided ntegrde ccess during lproscopic pyeloplsty in infnts less thn one yer of ge: A point of technique Arvind Gnpule, Amit Bhttu, Shshiknt Mishr, Mhesh R Desi Deprtment of Urology, Muljihi Ptel Urologicl Hospitl, Ndid, Gujrt, Indi Address for correspondence: Dr. Mhesh R Desi, Muljihi Ptel Urologicl Hospitl, Ndid-387001, Gujrt, Indi. E-mil: mrdesi@mpuh.org Astrct BACKGROUND: Access to urethrs nd ureters of infnts my e hzrdous nd injurious through n endoscopic route. Plcement nd removl of stents in infnts requires nesthesi nd ccess through these smll clier urethrs. We descrie our technique of plcing ntegrde splint during lproscopic pyeloplsty in these infnts. MATERIALS AND METHODS: An ultrsound-guided percutneous renl ccess is otined. Telescopic metl two prt needle is pssed into the kidney over guide wire. A second guide wire is pssed through the telescopic metl two prt needle. The trct is dilted with 14 Fr screw diltor. Over one guide wire, 5 Fr ureteric ctheter is pssed nd coiled in the renl pelvis. Over the other wire, 14 Fr mlecot ctheter is plced s nephrostomy. Lproscopic pyeloplsty is then done. During pyelotomy, the ureteric ctheter is pulled nd dvnced through the ureter efore the pyeloplsty is completed. The ureteric ctheter thus cts s splint cross the nstomosis. Ureteric ctheter is removed on the 3 rd post opertive dy nd nephrostomy is clmped. Nephrostomy is removed on 4 th post opertive dy if child is symptomtic. The modified technique ws successfully done in five ptients ged less thn one yer old. All ptients tolerted the procedure well. Post opertive period ws uneventful in ll. CONCLUSION: Ultrsound-guided nte grde nephroureterl ureterl splint for infnt lproscopic Quick Response Code: Access this rticle online Wesite: www.journlofms.com DOI: 10.4103/0972-9941.97602 pyeloplsty is sfe. It voids the need for urethrl instrumenttion for insertion nd removl of stents in these smll ptients. Key words: Pyeloplsty, stent, ureteric splint INTRODUCTION To stent or not to stent is point deted since long time. This ssumes importnce in children nd infnts requiring intervention for ureteropelvic junction ostruction (UPJO). Although literture supports stentless pyeloplsty, in lproscopic pyeloplsty prticulrly, it is common prctice to stent the nstomosis. [1] The dvntges nd disdvntges of oth the pproches re well known. In infnts, the urethr is nrrow nd runs the risk of injury nd susequent strictures with surgicl mnipultions. In ddition, the stent-relted moridities which include dysuri nd infections my mke the postopertive course of the infnt unplesnt. In the dys of open surgery, it ws our policy to employ the technique of open insertion of stent long with nephrostomy, just prior completion of the nstomosis. This served the purpose of nephrostomy cting s sfety vlve prior to removl of splint. In this rticle, we descrie the technique of nte grde ccess of the ureter, thus potentilly voiding the urethrl mnipultions nd the ssocited complictions. MATERIALS AND METHODS Instrumenttion A 7.5MHz (B K Medicl, Denmrk) ultrsound proe with puncture ttchment is used. A peditric proe is used Journl of Miniml Access Surgery July-Septemer 2012 Volume 8 Issue 3 107
for this purpose [Figure 1]. A 18 Guge Echotip disposle two prt trocr needle (Cook Urologicl Inc, Indin, USA) which is ville s two prt needle ws used. A 0.035 Guide wire or lterntively terumo glide wire (Terumo corportion, Tokyo, Jpn)with Alken two prt metllic needle helps simultneously pssing two guide/glide wires [Figure 1]. The dilttion is done with Angiotech one step diltor (PBN medicls, Denmrk), 14 Fr Nephrostomy tue (Devon Innovtions (P) Ltd, Prwnoo, HP, Indi) with 5 Fr open end ureteric ctheter (Devon Innovtions (P) Ltd, Bnglore, Indi) is used. Technique The first step involves positioning the ptient in prone position, lthough the sme cn e done in supine position. [Figure 2] This helps in gining percutneous renl ccess. Figure 1: The rmmentrium () Telescopic metl two prt needle () Peditric ultrsound proe The needle is housed in the needle ttchment of the ultrsound proe nd the posterior clyx identified [Figure 2]. The key for successful ultrsound puncture is tht the needle should e seen throughout the trjectory which includes the skin, sucutneous tissue, cup of the clyx nd the clyx in concern [Figure 3]. An egress of cler fluid suggests entry in the pelviclycel system which cn further e confirmed with contrst study [Figure 3]. Next guide wire is prked in distnt clyx nd the trct dilted up to 14 Fr using screw diltor. An Alken needle, which is two prt needle, helps in pssing second guide wire fter removing the inner stylet [Figure 4]. Once oth guide wires re in plce, one wire is used for pssing ureteric ctheter nd the second one is used for plcing nephrostomy tue [Figure 5]. The ureteric ctheter is coiled in the pelvis. The slient feture of our technique is tht ll steps of percutneous ccess which include ccess nd diltion re done solely using ultrsound guidnce. Figure 2: Line digrm () nd picture () illustrting ultrsound-guided clycel puncture After the ureteric ctheter nd percutneous nephrostomy is in plce, the lproscopic pyeloplsty is performed. Once the pelvis is opened nd the ureter sptulted, the ureteric ctheter which is lredy coiled in the pelvis is pssed under direct vision into the ureter fter the posterior lyer is completed following which the nstomosis is completed [Figure 6]. Ureteric ctheter is removed on the 3 rd post opertive dy nd nephrostomy is clmped. Nephrostomy is removed on 4 th post opertive dy if child is symptomtic. The modified technique ws successfully done in five ptients ged less thn one yer old. All ptients tolerted Figure 3: Technique of ultrsound-guided ccess () An egress of cler fluid suggesting entry in the pelviclycel system () A successful ultrsound puncture - the needle should e seen throughout the trjectory which includes the skin, sucutneous tissue, cup of the clyx nd the clyx in concern 108 Journl of Miniml Access Surgery July-Septemer 2012 Volume 8 Issue 3
the procedure well. Post opertive period ws uneventful in ll cses. DISCUSSION c Figure 4: Antegrde ccess- point of technique () The needle nd guide wire re clerly seen in rel time ultrsound, thus voiding owel injury () (line digrm) nd C (Picture):-Two glide wires pssed into the renl pelvis through the telescopic metl two prt needle fter removing the inner stylet c Figure 5: () Line digrm showing completed nstomosis with nephrostomy nd ureteric ctheter (splint) in situ, () Lproscopic pyeloplsty performed fter the ureteric ctheter nd percutneous nephrostomy is in plce c) Opened up renl pelvis showing presence of oth mlecot ctheter nd ureteric ctheter in pelvis (d) Ultrsound showing flower of mlecot ctheter opened in pelvis d The indictions for stenting re well known, they include pyeloplsty in the presence of solitry functioning kidney, infection, or previous filed procedure. The indictions for plcing stent fter pyeloplsty differ in dults nd children. Plcing stent in retrogrde fshion involves urethrl mnipultion nd the ttendnt complictions; in ddition, this involves n dditionl procedure for removl of the stent. This my e prticulrly chllenging in infnts s young s oneyer or less. The dvntges of stent plcement following pyeloplsty include decresed risk of collection or edem, mintining ureteric lignment Woo et l., in their study on the impct of internl stenting on the surgicl outcome of dismemered pyeloplsty in infnts under the ge of 12 months with the open pproch. They oserved sttisticlly significnt increse in urinry leks, length of hospitl sty nd need for repet pyeloplsty in non stented versus the stented group. [2] A vriety of techniques hve een descried to plce stent or splint ntegrde thus voiding the need for cystoscopy during insertion or removl. Tveres et l descrie technique for inserting n internl-externl nephroureterl ntegrde stent during lproscopic pyeloplsty which cn e removed in clinic s outptient. [3] The dete is ongoing nd the literture is divided nd inconclusive on this suject. The dvntges of the technique we hve descried re the following: 1) The ureterl ccess cn e gined with ultrsound guidnce. This minimizes the risk of owel injury s well rdition in these ptients. 2) The nephrostomy tue cts s sfety vlve nd cn e clmped to confirm the integrity of the nstomosis prior to its removl. 3) If needed, the ureteric ctheter cn ct s conduit to negotite ureterl stent cross the nstomosis. The sme stent cn e removed ntegrde y ttching thred to its til. This voids urethrl mnipultions. Figure 6: Plcement of ureteric splint under vision Once the posterior wll is completed, the ureteric ctheter is pssed into the ureter under vision We cknowledge tht there re few disdvntges with this technique nd the most significnt is the need for dditionl equipment nd expertise for gining percutneous renl ccess. In ddition, t times, repeted ttempts for gining ccess led to extrvstion nd oozing, which might hmper the vision nd the nstomosis. Journl of Miniml Access Surgery July-Septemer 2012 Volume 8 Issue 3 109
CONCLUSION In infnts with pelviureteric junction ostruction when undergoing lproscopic pyeloplsty; ultrsound-guided ntegrde nephroureteric, ureteric ctheter plcement is sfe technique. It voids need for urethrl mnipultion for insertion nd removl of stent, decreses rdition exposure to infnt. Furthermore, nephrostomy tue cts s sfety vlve to confirm the integrity of nstomosis nd ureteric ctheter my ct s conduit to put nother ureteric stent if necessry t lter dte. This technique requires some dditionl equipments nd expertise to get percutneous renl ccess which cn e mstered with prctice. REFERENCES 1. Smith KE, Holmes N, Lie JI, Mndell J, Bskin LS, Kogn BA. Stented versus non stented peditric pyeloplsty: A modern series nd review of literture. J Urol 2002;168:1127-30. 2. Woo HH, Frnsworth RH. Dismemered pyeloplsty in infnts under the ge of 12 months. Br J Urol 1996;77:449-51. 3. Tveres A, Mnorioon N, Lorenzo AJ, Frht WA. Insertion of n internlexternl nephroureterl stent during peditric lproscopic pyeloplsty: Description of the stechnique. Urology 2008;71:1199-202. Cite this rticle s: Gnpule A, Bhttu A, Mishr S, Desi MR. Ultrsoundguided ntegrde ccess during lproscopic pyeloplsty in infnts less thn one yer of ge: A point of technique. J Min Access Surg 2012;8:107-10. Dte of sumission: 22/04/2011, Dte of cceptnce: 25/07/2011 Source of Support: Nil, Conflict of Interest: None declred. 110 Journl of Miniml Access Surgery July-Septemer 2012 Volume 8 Issue 3
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