V03-10: Percutaneous endoscopic puncture of the proximal ureter for recanalization of the ureteropelvic junction
we present a video of the feasibility study of a new fluoroscopic endoscopic technique for the recanalization of the complete obstruction of the Uretero-pelvic junction (UPJ), using a puncture of the proximal ureter through the renal-pelvic wall, via the Amplatz sheath.
3 patients (median 42 years-old) with a history of open pyelolithotomy, presented large hydronephrosis. Retrograde pyelography showed complete UPJ obstruction. In 2 patients the stenosis was about 2 cm, and 1 patient had a stenosis of few millimeters. The institution Ethical Committee had approved the technique. The patients are placed in the split-leg modified lateral position. An attempt to force the obstruction with a stiff guidewire failed. After, calyx puncture and dilation, a 24 F Amplatz sheath is placed. A ureteral catheter is placed in the ureter and contrast media is injected. Under fluoroscopy, the Amplatz sheath is placed in front of the tip of the ureter. The proximal ureteral tip is punctured through the renal pelvis wall, with an 18-Gauge needle, via the Amplatz sheath. A hydrophilic guidewire is advanced down the ureter. Endopyelotomy is performed with an electrode through the nephroscope, following the guidewire. In the long strictures, A 3.5 needle-holder is inserted via the nephroscope and using a 13-mm needle suture, sutures are placed between the pelvic and the ureteral wall. Then, a J-stent is placed. Follow up is performed with retrograde pyelography and/or ureteroscopy. If the UPJ is wide open the J-stent is removed. If the UPJ patency is equivocal, balloon dilation is performed and a J stent is placed.
Puncture of the ureteral end through the renal-pelvic wall was rapidly and easily performed. It had allowed guidewire insertion into the ureter, and had oriented the endopyelotomy. The suturing was difficult due to fibrosis and the tissue edges were fixed far apart. The mean operative time was 154 minutes for the 2 sutured cases, and 35 minutes for the other case. The mean postoperative hospital stay was 3 days. Control in 1 patient with the long stenosis showed a medium patent UPJ, and a new JJ-stent was placed, with a follow up of 52 months. For the other patients, the JJ-sent was removed at 3 months and 40 months, and the kidney is not dilated with a follow up of 20 and 46 months respectively.
The puncture of the ureteral end through the renal-pelvic wall was possible, and it was easily performed. It had allowed insertion of at least of replaceable double-J-stent in complete stenosis, where all the other endoscopic techniques had failed, especially, in long UPJ stenosis.