Ureteroscopy and Laser Lithotripsy for Ureteral and Renal Stones in a Patient with a Nephrostomy Tube

CHAPTER 1

I am Dr. Joseph Clark, professor of urology here in the department of urology at Penn State Health Milton S. Hershey Medical Center. Today we're going to see a surgery that I'm going to perform with our residents. This is a ureteroscopy case to take care of stones. It's a little bit different because this patient has a nephrostomy tube which drains urine. So usually when patients present with an obstructing kidney stone, they're in a lot of pain. And the pain is caused by blockage. And I think most urologists will place a ureteral stent. So this is a hollow tube that goes from the kidney down to the bladder to allow urine to flow freely, bypassing that obstruction. And then after that is placed, the patient's pain will be much improved and then they later come back for the definitive surgery, which is to take care of that obstructing stone. In this patient's case, when she had presented, the decision was made to place a nephrostomy tube, so that is a tube that goes through the skin in the back and this tube goes directly into the renal pelvis. And so that will drain urine and bypass the obstruction. So she has a tube, it's connected to a bag and it's draining urine through her left kidney. So to treat her stone, what we performed was ureteroscopy. Patients who have very large stones sometimes purposely get a nephrostomy tube so that we can use that as a tract going through the back to dilate up a large tract to put in a big instrument, a nephroscope, and we can use ultrasound energy to break and aspirate those stone pieces. In this patient's case, she didn't have a large stone burden, and so I had decided to perform ureteroscopy on her. You will see first of all, that because she already has a nephrostomy tube, I left that tube open so that while we're doing the case, irrigation fluid can come out through that nephrostomy tube. I will anticipate that we're going to be successful in ablating the stone. So eventually she'll be able to have her nephrostomy tube removed. So actually I cut the suture and took that dressing from around the nephrostomy tube site so that we could more easily remove the nephrostomy tube at the end of the procedure. You will see that we will pass a scope into the bladder. We'll pass a wire and we'll pass a scope to the distal stone. So she had a six-millimeter stone in the distal ureter. We'll ablate the stone either with laser energy or we may basket the stone intact. And then she also has smaller, non-obstructing stones in the kidney and so we'll plan to pass the scope all the way up into the kidney where you will see the curl of that nephrostomy tube. We'll ablate the smaller, non-obstructing stones and ultimately plan to remove that nephrostomy tube. She will be left with an indwelling ureteral stent because after passing the scope up the tube, there'll be some swelling which itself can cause obstruction.

CHAPTER 2

So this patient, when she presented, had a left renal colic. She had a distal left ureteral stone as well as some kind of smaller non-obstructing stone in the left kidney. But at that time to treat her obstruction and pain, she had a nephrostomy tube. So that is a tube that goes from the skin through the tissues directly into the renal pelvis to drain the urine. So pain is caused by obstruction, so that is one way of unobstructing the kidney to treat the pain. So this is the nephrostomy tube. It's hooked up to a bag. It's draining urine. And this tube is going directly into her back right there. So that is a left percutaneous nephrostomy tube. I've already taken off the bandages because I anticipate that we're gonna actually remove this nephrostomy tube as soon as we're done treating the stone. So I want all the bandages off. I've already clipped the suture and we'll remove this as soon as we're done. The advantage to having this nephrostomy tube when we do ureteroscopy is that the pressure within the system will be low. If she has high pressure and there's bacteria in there, then she could become very sick. So as we're running irrigation fluid up through the ureter into the kidney, this will fill up. And again, this will help dissipate the pressure. We may actually have to empty this during the case if this fills, but again, this is a percutaneous nephrostomy tube. Sometimes we'll use this, the tract to the kidney if they have very large stones, but she doesn't have very large stones. So we're just gonna do standard ureteroscopy to get the stones and then we'll take this out at the end.

CHAPTER 3

So these are axial CT images of the patient, and here is the nephrostomy tube going through the skin directly into the kidney. And that's the curl in the kidney. Now she has these non-obstructing stones in the kidney, here. And so again, urine drains through her back into the nephrostomy tube. I am going to go up to, there's the top of her kidney, there's nothing there. Okay, there's these small, non-obstructing stones that we're gonna try to take care of. And then I'm gonna go down to her ureter. She has a distal stone. Let's see if I can find it. Yeah, so this is the distal stone that we're gonna treat via ureteroscopy. The plan is to pass a semi-ridge ureteroscope to take care of the stone. Then we'll go all the way up back up to the kidney through that tube. And we'll pass a flexible scope up here and we'll take care of these non-obstructing stones. And then we'll put an internal ureteral stent and take out this nephrostomy tube. So that's the plan. I will show you the axial images. Lemme see if I can show you the axial, or the coronal reformatted images. So these are slices through the front of the patient. And we can see here is her nephrostomy tube with the non-obstructing stones. And let me see if I can get to where her distal left ureteral stone is right there. All right.

CHAPTER 4

We're just doing cystoscopy right now? All right, do a spot. Yeah. I'm almost done. Do a spot. All right, nephrostomy tube is in place. I'm gonna inject some dye. So this is called an antegrade nephrostogram. Do a spot. All right, so you can see clearly the tube and you get a good outline of the kidney and we've saved that image? All right, I'm just gonna inject a little bit more dye so that it'll help them out to see the outline. Spot one more time. All right, and if you could save that image and come down. Let's see, try it, all right, there's no shower cap. Yeah, do a spot. All right, so there's the ureter and then the ureteral stone will be down here. Can we lower her leg 'cause I don't think the excursion of the C-arm is gonna go... Yeah, yeah, you can do that and maybe come down just a tad. I'm not sure where the stone is. It's probably somewhere here, but let me just inject a little more contrast and then do a spot. So can you go down, this needs to go down just a tad lower. And there's probably a stone right here because the tube is dilated and it stops right here. So what I'm gonna do now is I'm just gonna let this nephrostomy tube stay open, so that as they run irrigation, it'll fill up the bag.

CHAPTER 5

What's that? Foley, you have a catheter? Foley catheter at the end. It can be regular latex. Do you want a whole kit then? Yeah, we can have a whole kit. And we're gonna take some Siltape because we're gonna tape the dangler string of the stent to the Foley catheter. All right, so right now from the bladder has passed a wire up to the renal pelvis and we have a semi-rigid ureteroscope, which we're gonna try to pass alongside that wire. And in the distal ureter, we should see the stone. We may be able to basket it intact, or we may have to use a laser to break it up into small pieces. So our laser is on and we have a 200 fiber, 240, yes. All right, so we're in the bladder yet, right? Yes. So Linda, we talked about abducting the opposite leg if you're doing semi-rigid ureteroscopy, because again, you have to kind of torque the scope to the opposite leg. All right, so there's the wire and the ureteral orifice. The other thing you could do is you could pass a wire. Oh no, you're there, okay, there's a stone. I'm thinking about the laser. All right, looks like we're gonna laser the stone to small bits.

CHAPTER 6

Wait, wait, yeah, yeah, so unfurl or take out the fiber out of that. Like this, what you would have done. Like a lasso, no no of course, I wouldn't expect you to know. Like a lasso. Yeah, unless you, you know, have done these, you know, it's, yeah... If you just said like hold it out and lasso me, I'd just be like, who are you? Let me see. Five and five. Let's do, what's the lowest it will go? Can you go go point? 0.1. 0.1, put 0.2 in like 20. I just want dust it, yeah. And again, we can always change these based on... I just wanna see if the nephrostomy tube bag is filling up or not like, eh, yes. All right, it is not filling up, so we're okay. All right, so that's the stone. It looks kind of yellowish, but I think once it's outta the body, it'll look black. Our chief resident is passing a laser fiber through the semi-rigid ureteroscope. Laser ready. Laser ready. Actually, I don't see the fiber yet. Oh it's there, it's just like kind of off... The other thing you can do is sometimes you can try to push it up higher where it's a little bit more dilated and you have more room. Yes. All right, so you can see the laser fiber coming out at the 5-o'clock position. And here's a laser, yep, we're drilling a hole. All right. All right, yeah just slow and steady. I think we can, hold on, why don't you stop? Why don't you increase the energy to 0.4? Hold on, 0.4. All right, let's see what, yep. Yep, let's see what it looks like. Okay, now we're excavating the stone. Not much room to move around. All right, again, you can still push it up a little bit higher. Yeah, my hope is, fracture down here, then we could like... Yeah, maybe you could basket out the fragments. Irrigate them out. Yep. We have a flexible ureteroscope, correct? It's on your field. Oh, is it, all right. All right, so we're still up here, right? Do one spot. And then, let's see, are you able to go down any lower where they're lasering the stone? All right, and then do a spot there, okay. Even lower and save that image, and... All right, and this, okay. You still have the ureteroscope in the ureter? Yes, I don't see the ureteroscope, so go... Are you able to go just a tad lower? All right, yep and then do a spot. All right, so there's the ureteroscope and again, the stone is just distal to that, that he's lasering right now. And let me see what how much this is filling up. Okay, so the bag is filling up as the irrigation fluid is going up the ureter and as this fills, we'll have to empty it. All right, so it looks like you did push up the stone a little bit, that's fine. Can you do a spot, I just wanna see how high he is. All right, so you can see that he's higher. As the stone was fragmented, the irrigation fluid pushed the fragment up, and that's where it is right now. Can you do another spot? All right, so he's even higher. Can you go up and chase the stone and do a spot? Excellent, all right, so we're now in the mid ureter. You find there's a sweet spot where it's like... If the stone is like far enough away, then just pop it. The other thing you could do is just laser that fragment to bits and it'll pass. Yeah, it's up in the kidney. All right, then maybe it's time for the flexible U-scope. So he's gonna be passing a ureteroscope all the way up to the kidney, and actually then we can see that curl of the nephrostomy tube from the inside. And again, we're still keeping the nephrostomy tube open so that it will decrease the intrapelvic pressures. I think because we have the nephrostomy tube, so she doesn't need the decompression from the nephrostomy tube. That's one of the benefits of having the nephrostomy tube. Yep, or you could try to freehand the flex ureteroscope. All right, we're gonna freehand that flexible ureteroscope alongside that single wire. And once we're in the kidney, we'll see the nephrostomy tube from the inside. She has some non-obstructing stones that we're gonna treat while we're here. All right, how are we doing? About to laser. All right, let see how much is filled up. It's starting to fill in. Hey, was that last patient when you brought to the recovery room, was the urine fairly clear or was it red? Yeah, it was like clear like very light pink open so I told Mike to check on it and he said he would. All right. His contractions slowed down. All right, so let's see. We're up in the kidney now? Yeah. All right, so can you come up and do a spot where the kidney is? All right, so here we can see the nephrostomy tube, the wire, and the tip of the flexible ureteroscope. And again, as he looks around, we'll see the curl of that nephrostomy tube. Let me see if I can find it. All right, she's got some stones. Laser ready. So you can see using the wire as, for comparison, or the laser fiber that these stones are relatively small, that laser fiber is about a quarter of a millimeter. Yeah, I can actually clamp it, but don't irrigate real hard. Yeah, we can undo it every minute or so. Yeah, so... See if I can get in there, and... Okay, I'm gonna clamp the nephrostomy tube, so it should fill up now. So he's having difficulty with the ureteroscopy because the renal pelvis is collapsing on him and that's because the irrigation fluid is going through the nephrostomy tube. So I just clamped it temporarily so that it could distend the renal pelvis and he could actually laser the stone. Wait. Oh, excuse me. Thanks. All right, how are we working on? Okay, that's all very, very small stone. She'll pass those around the stent. Or once the stent is removed, she will pass these extremely small fragments. Did you see any of those non-obstructing stones? Yeah, that's what those were. Okay, so you, that's what you laser, all right. Yeah, it was a big one... Again, just irrigate just so that he's got enough to see, because again, I clamped off the nephrostomy tube, so the pressures will be relatively high. Let's open up a 26-centimeter stent, 6-26. All right, so he's still in the kidney, so we're still in the kidney. Why don't you do a spot? All right, so again he's, we have the safety wire, we have the nephrostomy tube, we have the ureteroscope, the flexible ureteroscope, and he has a laser fiber going through the ureteroscope, which we can't see the fiber because it's so small. And he's just lasering those small non-obstructing stone. And you can see that there being, you know, fragmented to dust. Again, that laser fiber diameter is about a quarter of one millimeter. And if we're successful, the plan will be to take out the nephrostomy tube because no one wants to have a tube in their back. And we'll put up an internal ureteral stent. This is one of the non-obstructing stones. This is where stones typically form in the calyces. And he's just dusting the stone. I specifically asked for a large room, but with all the equipment, it seems like a small room. All right, so we have a Foley catheter, we have a 6-26. Let's see, no, the contour is fine. We got both. Yep. This is really just really standard ureteroscopy, laser lithotripsy, and the only thing that's a little bit uncommon is that she has a nephrostomy tube and again, if she had a large stone like, you know, a centimeter, two centimeters, we could actually put her on her abdomen and do nephrostolithotomy, pass a wire through that nephrostomy tube tract, dilate up a tract, put a big sheath, put a nephroscope, and with the bigger access sheath into the renal pelvis and the big nephroscope, we can break and suck up the pieces. But since she has relatively small stones, we're just using the nephrostomy tube as a pop off valve to decrease the pressures as Dr. Bramwell does this procedure. Almost there. You can irrigate a little bit more than that for a second. All right. So we see that the tube on the right, that is the nephrostomy tube. It is currently clamped, so the irrigation fluid is not going through that. Can you go down to... All right, so that's all just dust. There's a larger chunk still. All right just chase it and dust it. So this patient won't need anything. I had previously written for oxycodone, and she is on Bactrim prophylaxis. She will take out her Foley catheter in maybe we can say six days. I put instructions on how to remove your Foley catheter. And why Foley for her? Because we're gonna take out the nephrostomy tube. Oh, okay. Oh yeah, stent, nephrostomy tube, gotcha. All right. And we're gonna secure the dangler string of the stent to the Foley catheter. Okay. Doing everything by feel. All right, it is open. So I don't know if it'll decompress. In fact maybe some of the stone fragments may come out through the nephrostomy tube. You can irrigate hard now because again the nephrostomy tube is open. laser standby. laser on standby. You can either shoot dye through the ureteroscope, I can shoot dye from the nephrostomy tube and put up the stent. And then again, I think we'll take out the nephrostomy tube on fluoro so that we don't hook up the ureteral stent. Oh, I saw some, yeah, there's something in there. Yeah, all right, we're gonna take care of that. Look at it, do a spot, I just wanna see exactly where that is. All right, so that's a lower pole stone. So we can see now, I'll just point out here. So he has the ureteroscope flexed downward and looking at the stone. And so this is a lower pole calyceal stone that he's gonna laser. You want me to clamp the nephrostomy tube? I think it seems okay. You're okay? Laser ready. Ready. Let me see what happens if I clamp the nephrostomy tube, it'll fill out a little bit better. All right, tube is clamped. Actually that's pretty full. So, do you have, actually, can we have half the lights on and let me have some container, it doesn't have to be sterile. Yeah, I'm just gonna empty out the nephrostomy bag since it's getting full. All right. All right, nephrostomy bag is emptied. I'm just gonna dump this. So the clamping the nephrostomy tube helped visualize a little. Push the calyx away. When you're ready for the stent, I can just do an antegrade nephrostogram, because I kept the contrast connected to the nephrostomy tube. So I can just squirt the dye down. Where's the stone? Oh, all right. All right, I see it. Oh, there it is. Can you do a spot, just wanna see where you are. Oh, all right, so that's still the lower pole of the kidney. The stone's like going into the tract. Yeah, yeah, that's fine. I think we can just leave it. It's pretty small. So you can actually see that he's right up against the nephrostomy tube that's entering the kidney on the endoscopic images. I think that's actually 0.2 and whatever it was, 0.2 and 50. Yeah. So you can also see in this image, this video clip, she's got these white plaques on the papilla. Those are called Randall's plaques. These are where stones start to form and sometimes they will calcify, and the stone will flick off the calyx and it will cause obstruction of the ureter and cause renal colic. Sometimes the calyx will calcify and the calyx will fall off, which will also then cause blockage and cause renal colic. All right, I think those are like sub-millimeter stones. Yeah, looks like it's five or six.

CHAPTER 7

All right, you gonna pull out or...? All right. All right, so we're pulling the ureter scope down, and you can just prepare the stent 'cause I'll just shoot dye down. So this is the ureter. We see the safety wire off to the side. All right, we're out of the ureter. And you wanna just put the stent over? The female style. Female, all right, you let me know and I'm gonna shoot the dye. Can we have the lights up? See we're still in the kidney, so do a spot right now. All right, so right now we just see the nephrostomy tube and the safety wire. Just to give him an outline of the renal pelvis, I'm gonna inject contrast agent through this nephrostomy tube. So we get an outline, and he's gonna place the internal ureteral stent. So female style, about really... All that, I get my fingers... All the way there. Can I do another spot? Spot. All right, so let me shoot the dye, spot again. Oh, I guess the dye did not, I didn't have that much dye, lemme just... Go live for a second. Lemme just, oh, get... Stop. And spot. I think it's there. I mean, you can tell based on the nephrostomy tube that it's in the right position. Yeah. Let me just squirt some dye. I'm trying to get it to curl. All right, spot. All right, so there, oh, now you can't see anything. So the wire, is that where the wire is? I pulled the wire, yeah. I can suck some of this contrast back. Here it's almost... There. Spot. There, it's turning into a curl. All right, so you wanna just make sure there's a curl 'cause I also wanna remove this so that we don't pull on this. Do you wanna pull that under fluoro? Why don't you go ahead and do that? Yeah, I can do that. So luckily, actually, is there a hemostat that I could have? All right, I'm gonna, I'd say do a spot. Spot. All right, spot, all right, nephrostomy tube is out. Happy with that proximal curl? Yep. All right, and one more there. Great, and then if you can come down to bladder. This is the nephrostomy tube that was in her renal pelvis. We just took that out under fluoroscopic guidance.

CHAPTER 8

All right, let's dump this. All right, I'm gonna put this here, it's contaminated. Don't touch that corner. Okay. We need some gauze as a dressing for her back where I removed the nephrostomy tube and we need some Siltape. Okay. I have a three inch. Yeah, yeah, I think this is fine. And then a boat of galls. Yeah, I think... All right, great. All right, so dry the catheter and we're gonna secure the string of the dangler. So again, seat the catheter and make sure the string won't come out. There's a stat lock in that set, right? So in six days, she's gonna remove her own Foley catheter. The string of the dangler or this dangler string will be, is connected to that stent that was placed and the stent will also come out when she takes out her Foley catheter. But the balloon is against the bladder neck. And then I'll give you that and again, I can kinda do a mesentery of some sort. Do like just, can we wrap it around or just say single? I can just do that, we can, I just wanna do it enough so that the tape isn't gonna irritate her meatus. Again, I can put another piece of tape. All right, is there another place I can just...? Redo that spot. All right, I think that should be far enough away, and then we'll just get our legs down and then we'll probably have to bring her up and then we will get rid of this. I have to put a dressing over her back where we removed the nephrostomy tube.

CHAPTER 9

So at the beginning of the case, you can see that we removed the dressings from around the nephrostomy tube site. I actually cut the suture so that it'd be a lot easier to remove once the procedure was done. You saw that I actually injected some contrast agent through the nephrostomy tube to give us an outline and that's seen on the fluoroscopic images obtained using the C-arm. That helped us to get an idea of exactly where the curl of the nephrostomy tube is. And we got an outline of the ureter. You will see that we actually used a semi-rigid ureteroscope to access the distal ureter where the six-millimeter stone was lodged. We then used a laser to break up that stone into very small pieces. And then we went up the tube, I think up to the middle of the ureter to make sure that there were no other stones. Now she does have known smaller non-obstructing stones and so we passed the flexible ureteroscope all the way up to the kidney and lasered the stone into small pieces. Now during the case I had the nephrostomy tube open so all the irrigation fluid that we were using will go out through the nephrostomy tube. Now this is important because if there is bacteria in the system, all that irrigation fluid can push the bacteria into the bloodstream. So that nephrostomy tube kind of acts as a pop-off valve to keep the pressures within the renal pelvis low and also helps with the irrigation so we can kind of see a little bit better. You will see that the nephrostomy tube kind of fills up during the case and we actually had to empty it at one point in time. We also clamped the nephrostomy tube because when all the irrigation fluid goes out through the nephrostomy tube, the system kind of collapses and it's a little bit harder to see and target the stone. So again, the nephrostomy tube was helpful. We opened it up to decrease pressures within the kidney and sometimes we closed it to kind of distend the system so that we can see the stone a little better. Again at the end we were successful in laser lithotripsying in the stones, we basically lithotripsied the stones to dust. She'll pass those very small fragments. And because we went up and down the ureter, we did pass an internal double-J stent. And then under fluoroscopic control, we did remove that nephrostomy tube. This is important because sometimes the curls of the nephrostomy tube and the stent will overlap and sometimes we can pull the ureteral stent with the nephrostomy tube. But again, that did not happen and the procedure was done successfully. The drain site where the nephrostomy tube was, was just dressed with some gauze and tape and we also did put in a Foley catheter to completely drain the bladder because if we did not leave that Foley catheter, when she urinates, the urine can reflux up the ureter into the kidney and could perpetuate urine leak through the back through where the nephrostomy tube had been.