De Fazio Adam Michael, Borofsky Michael Seth
Department of Urology, University of Minnesota, Minneapolis, Minnesota.
J Endourol Case Rep. 2020 Mar 11;6(1):10-12. doi: 10.1089/cren.2019.0047. eCollection 2020.
Published case reports on the management of ureteral stones in patients with prior ureterosigmoidostomy have described the challenges of direct retrograde access to the ureter using standard endourologic instruments. In light of these challenges, reported effective techniques have involved either (1) direct retrograde access utilizing sigmoid endoscopy with air insufflation or (2) percutaneous antegrade access. We report the first experience of effective retrograde ureteroscopy utilizing traditional endourologic instruments in a patient without percutaneous access. The patient is a 70-year-old man born with bladder exstrophy who underwent end colostomy and ureterosigmoidostomy as a child. He presented with a symptomatic 6 mm stone at the right ureterosigmoid junction. A trial of spontaneous passage failed because of persistent pain. Treatment options were limited by the patient's recent history of coronary stent placement, requiring uninterrupted antiplatelet therapy with clopidogrel. As such, we attempted retrograde ureteroscopy through a transrectal approach. Anticipating some difficulty in the identification of the ureteral orifices, we administered methylene blue at the time of induction. After placing the patient in lithotomy position, we advanced a flexible cystoscope to the rectosigmoid junction where we identified a ureteral orifice. Guidewire access was obtained and we confirmed right-sided laterality with fluoroscopic imaging. A semirigid ureteroscope was passed to the ureterosigmoid junction where the stone was encountered and retrieved intact using a basket. A 6 × 26 Double-J stent was placed with a string to facilitate removal 5 days later. The postoperative course was unremarkable. Despite the previously reported challenges of the approach, retrograde ureteroscopy without percutaneous access represents a viable treatment option for ureteral stones in patients with ureterosigmoidostomy.
已发表的关于既往有输尿管乙状结肠吻合术患者输尿管结石处理的病例报告描述了使用标准腔内泌尿外科器械直接逆行进入输尿管的挑战。鉴于这些挑战，已报道的有效技术包括：（1）利用乙状结肠镜检查并注入空气进行直接逆行进入；或（2）经皮顺行进入。我们报告了首例在无经皮进入途径的患者中使用传统腔内泌尿外科器械进行有效逆行输尿管镜检查的经验。患者为一名70岁男性，出生时患有膀胱外翻，儿童时期接受了结肠造口术和输尿管乙状结肠吻合术。他在右侧输尿管乙状结肠交界处出现了一枚有症状的6毫米结石。由于持续疼痛，自行排石试验失败。由于患者近期有冠状动脉支架置入史，需要不间断地使用氯吡格雷进行抗血小板治疗，治疗选择受到限制。因此，我们尝试经直肠途径进行逆行输尿管镜检查。鉴于在识别输尿管口时可能会遇到一些困难，我们在诱导时给予了亚甲蓝。将患者置于截石位后，我们将软性膀胱镜推进至直肠乙状结肠交界处，在那里识别出一个输尿管口。获得导丝通路后，我们通过荧光透视成像确认了右侧。将半硬性输尿管镜插入至输尿管乙状结肠交界处，在那里遇到结石并用网篮完整取出。放置了一根6×26的双J支架，并系上一根线以便于5天后取出。术后过程顺利。尽管此前报道了该方法存在挑战，但对于有输尿管乙状结肠吻合术的患者，无经皮进入途径的逆行输尿管镜检查仍是输尿管结石的一种可行治疗选择。
