MANAGEMENT  OF  LARGE  VOLUMES  URETERAL  LITHIASIS:  DESCRIPTION  OF  A  NEW   SURGICAL  TECHNIQUE.  

Navarro  Medina,  P.;  Mejia  Chavarria  D.;  Armas  Serrano,  F.M.;  Henrríquez  Hernández,  L.A.;  Armas  Molina  J.;ArMles   Hernández,  J.L.  

 

 

Complejo  Hospitalario  Universitario  Insular  Materno  InfanMl.  Las  Palmas  de  Gran  Canaria,  Spain.  

INTRODUCTION  

There   is   no   doubt   that   the   URS   is   the   minimally   invasive   technique   of   choice   for   most   of   ureteral   stones.   Handling   larger   lithiasic     are   subject  of  controversy.  

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PURPOSE  

Reduce   the   need   for   reoperaMon,   ureteral   stenosis   and   prolong   the   life   of   the   flexible   instrumental   in   treaMng   large   volumes   lithiasic,   defined   as   greater   than   1   cm   single   stones   or   mulMple   stones,   without   significant  increase  in  cost.  

DESCRIPTION  OF  THE  TECHNIQUE  

In   the   operaMng   room   under   general   anesthesia   in   the   lithotomy   posiMon,   rigid   ureteroscopy   is   performed   according   to   standard   technique   unMl   lithiasic   level.   Subsequently   introduced   by   fluoroscopy   guidance  on  which  ureteral  access  sheath  (Flexor  14Ch  COOK®)  (  Fig  1)   is  introduced.  The  handle  of  the  outer  sheath  is  cut  to  allow  to  adapt   the   length   (Figure   2)   of   semirigid   ureterorenoscopy   (FibroFighters   according   Bichler   compact   with   lateral   viewfinder   Richard   Wolf®,   6.5   Fr   at   distal   end)   (Figure   3).   We   use   pneumaMc   lithotripsy   as   fragmentaMon   method,   extracMon   of   fragments   with   niMnol   basket   (NGage   Cook®)   and   finally   extracMon   sheath   aeer   introducMon   of   safety   under   fluoroscopy   guidance   and   placement   of   double-­‐J   catheter  .  

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CONCLUSION  

The  advantages  of  the  technique  were  evident  from  the  first  moment  of  its  realizaMon.  The   extracMon   of   fragments   was   less   traumaMc   and   faster,   vision   permanently   maintained   adequate  and  constant  flow  of  water  through  the  system,  avoiding  extreme  pressure  in  the   upper  urinary  tract,  leading  to  less  upward  migraMon  of  residual  fragments,  as  well  as  access   to  the  more  proximal  porMon  of  non-­‐fragmented  calculi  without  drawbacks.  And  the  ability  to   access,   in   the   case   of   migrated   fragments   with   flexible   ureterorrenoscopy   to   renal   caviMes   without  performing  new  surgical  handling.