Casing Sharing | Holmium Laser Lithotripsy
2023-10-18 11:29:57
Professor Xi Qilin

M.D., Associate Professor, M.S. Supervisor

Chief Physician and Medical Group Leader of the Department of Urology at the First Affiliated Hospital of Soochow University

Leader of the Urolithiasis Group, Urology Branch of Suzhou Medical Association

Deputy Leader of the Urolithiasis Group, Urology Branch of Jiangsu Medical Association

National Member of the Basic Research Group, Urology Branch of Chinese Medical Association

National Member of the Urolithiasis Group, Urology Branch of Chinese Association of Integrative Medicine

National Member of the Urolithiasis Group, Urology Branch of Chinese Medical Doctor Association

 

Case Overview

Incision of the renal calyx diverticulum for use of flexible ureteroscope on the left side 

+ holmium laser lithotripsy

 

Basic information

• 30-year-old female

• Main complaint: Continuous low back pain lasting more than 2 months

• Past medical history: Denied history of hypertension, diabetes, coronary heart disease, chronic bronchitis, and cerebral infarction. Denied history of surgery, trauma, and blood transfusion.

• Current medical history: Over 2 months ago, the patient developed unexplained lower back pain characterized by severe, sharp pain. There were no symptoms such as fever, chills, nausea, or heartburn. The patient denied experiencing hematuria, frequent urination, urgency, incomplete emptying, and painful urination. Subsequently, the patient sought care at our hospital. The CT scan indicated: 1. The presence of a stone in the upper segment of the left ureter and left kidney, along with enlargement of the left renal pelvis and ureter resulting in accumulation of fluid in the area. 2. Possibility of a cyst in the right lobe of the liver After receiving conservative treatment during the hospitalization in our department, a follow-up CT scan revealed that the left ureteral stone had been passed. On August 2, 2022, the patient experienced recurrent lower back pain. A subsequent CT scan indicated: A left kidney stone. On August 4,2022, we performed left ureteral stent placement (level 2) + urinary catheter insertion (level 1). The patient's recovery after the procedures was satisfactory. Currently, the patient continues to have intermittent lumbar and back discomfort and has been admitted to our hospital for the treatment of the left kidney stone. The patient is doing well overall, experiencing occasional left lower abdominal pain with lower backache. No fever, chills, nausea, or heartburn. No signs of hematuria, frequent urination, urgency, incomplete emptying, or painful urination. Sleep and weight are normal.

• CT: Left kidney stone

 

 

 

Treatment Process

• Surgical plan: Incision of the renal calyx diverticulum for use of flexible ureteroscope on the left side + holmium laser lithotripsy

• Surgical process:

1. Once the patient was anesthetized, the lithotomy position was adopted, and standard disinfection measures are applied with draping.

2. The F8.5 rigid ureteroscope was inserted into the bladder, the left ureteral stent was removed, and congestion and edema of the bladder mucosa with follicular hyperplasia were observed. With continuous water injection and guidewire assistance, the ureteroscope was successfully advanced into the left ureter and reached the left renal pelvis. The guide wire was left in position, and the ureteroscope was then retracted.

 

 

3. An F11 ureteral access sheath (UAS) was inserted along the guidewire, then the flexible ureteroscope was inserted into the left renal pelvis along the UAS; next, the mucosa was incised based on the location of the stone according to the CT scan, and the stone was found after repeated careful identification; the patient was diagnosed with a stone in the calyceal diverticulum on the left side, with complete obstruction of the diverticular neck.

 

 

 

4. A 10-mm incision was made with a holmium laser fiber. A pale yellow stone measuring approximately 2 cm was observed, and the stone was further fragmented using an 18W power setting until it was reduced to below 2 mm in size.

 

 

5. Large stone fragments were taken out with a four-wire mesh basket. Inspection of all renal pelvises and calyces revealed no apparent stones or signs of bleeding.

 

 

 

6. The guidewire was retained, and the flexible ureteroscope was withdrawn and replaced with a rigid ureteroscope; then, under direct visualization, an F6 ureteral stent was inserted into the left ureter along the zebra guidewire; next, the rigid ureteroscope was withdrawn, an indwelling urinary catheter was retained, and surgery was completed.

 

Surgical Summary

Diagnosis: A stone in the calyceal diverticulum on the left side, with complete obstruction of the diverticular neck

① Firstly, the mucosa was incised based on the location of the stone according to the CT scan, and the stone was found after repeated careful identification.

② Secondly, the stone was quite large, reaching 2 cm in size. During the procedure with the k8凯发国际官网入口's single-use ureteroscope, the imaging was clear, and the camera could move in different directions (up to 285 degrees), making it easier to find the stone quickly and accurately.