Maldonado Jonathan, Belay Ruth E, Keheila Mohamed, Amasyali Akin, Groegler Jason, Baldwin D Duane, Hajiha Mohammad
Department of Urology, Loma Linda University Health, Loma Linda, CA.
Department of Urology, Loma Linda University Health, Loma Linda, CA.
Urology. 2020 Nov;145:299-300. doi: 10.1016/j.urology.2020.07.022. Epub 2020 Jul 25.
Calculi encountered in the lower urinary tract typically reside within the bladder, less often in the urethra. In this video, we present a minimally invasive endoscopic approach for removal of the largest total stone volume in the lower urinary tract reported in the literature to date.
A 25-year-old male (body mass index 61 kg/m) with neurogenic bladder presented with urosepsis and acute kidney injury secondary to obstructive uropathy. Computerized tomography (CT) of the abdomen and pelvis demonstrated bilateral severe hydroureteronephrosis, a 4.2-cm bladder stone, and 3 urethral stones, including a 7.7-cm prostatic urethral stone and 2 membranous urethral stones (Fig. 1). Urgent bilateral percutaneous nephrostomy tubes were placed. The patient elected for endoscopic management.
The patient was placed in the supine lithotomy position. His buried penis and narrow urethra only accommodated a 16-French flexible cystoscope. Multiple stones were encountered in the membranous urethra. A 60-W SuperPulse Thulium Fiber laser at 2 J and 30 Hz was utilized to dust the urethral stones efficiently. Simultaneous ultrasound-guided percutaneous access into the bladder was obtained and ultrasonic lithotripsy via shockpulse was used to clear the bladder stone and prostatic stone from above. Total stone treatment time was 240 minutes. Suprapubic and urethral catheters were placed at the conclusion. Postoperative day 1 CT scan confirmed stone-free status and he was discharged postoperative day 2. Outpatient nephrostogram demonstrated patency of bilateral ureters and nephrostomy tubes were removed.
Higher morbidity procedures including open or laparoscopic approaches have been described for management of large lower urinary tract stones. In this video, we demonstrate a minimally invasive approach of combined simultaneous antegrade and retrograde lithotripsy to achieve a stone-free status in this morbidly obese and complicated patient.
下尿路结石通常位于膀胱内，位于尿道的情况较少见。在本视频中，我们展示了一种微创内镜手术方法，用于取出迄今为止文献报道的下尿路中最大总体积结石。
一名25岁男性（体重指数61kg/m），患有神经源性膀胱，因梗阻性尿路病继发尿脓毒症和急性肾损伤。腹部和骨盆的计算机断层扫描（CT）显示双侧严重肾盂输尿管积水、一枚4.2厘米膀胱结石以及3枚尿道结石，包括一枚7.7厘米前列腺部尿道结石和2枚膜部尿道结石（图1）。紧急置入双侧经皮肾造瘘管。患者选择接受内镜治疗。
患者取仰卧位膀胱截石位。其隐匿阴茎和狭窄尿道仅能容纳一根16法式的可弯曲膀胱镜。在膜部尿道发现多枚结石。使用一台60瓦的超脉冲铥光纤激光，能量为2焦耳，频率为30赫兹，有效粉碎尿道结石。同时在超声引导下经皮进入膀胱，并通过冲击脉冲进行超声碎石，从上方清除膀胱结石和前列腺结石。结石总治疗时间为240分钟。最后留置耻骨上导尿管和尿道导尿管。术后第1天的CT扫描证实结石清除，患者于术后第2天出院。门诊肾造影显示双侧输尿管通畅，肾造瘘管拔除。
对于大型下尿路结石的处理，已有包括开放或腹腔镜手术等更高发病率的手术方法报道。在本视频中，我们展示了一种微创方法，即同时进行顺行和逆行联合碎石术，使这位病态肥胖且病情复杂的患者达到结石清除状态。
