Percutaneous Nephrostolithotomy for Treatment of Impacted Ureteropelvic Junction Calculus

CHAPTER 1

Hi, I am Dr. Joseph Clark, professor of urology here at the Penn State Health Milton S. Hershey Medical Center. Today we are going to demonstrate a surgery called a percutaneous nephrostolithotomy. This patient has a fairly large stone in the left renal pelvis, and she had obstruction from that stone. A percutaneous nephrostomy tube had been placed to divert the urine, and now she presents to take care of that stone through that nephrostomy tube tract. During the procedure, you will first see that she'll be put under anesthesia. Then we'll place a Foley catheter. And once the catheter is in place, she will be placed in a special position, it's the prone position. And you will see that the anesthesiologists have a special mask to put over her face, and then we're gonna basically flip her from her back onto her abdomen. And this is so that we can actually access the area where the percutaneous nephrostomy tube exits. Once she's in that position, we will prep the area, and we'll put in the special drape that allows irrigation fluid to go down into a pouch. Once that is done, you will see that we bring in the C-arm so we can see the area under fluoroscopy. We will put dye in through the nephrostomy tube. We'll try to pass a wire through the existing nephrostomy tube. We usually try to get that wire down into the ureter. And once that's done, we take out the nephrostomy tube, we dilate up a tract and put a large sheath. Through this sheath we put in a nephroscope. And through the nephroscope, we can either remove the large stones intact, sometimes we have to use a lithotripsy device to break and suck up those pieces. Once that's done, we will either replace the nephrostomy tube to let everything heal, and/or we will put an internal ureteral stent.

CHAPTER 2

Once we flip her over, we're gonna put her arms out like this with the with arm board. All right, just wait until they get all set up to flip.

CHAPTER 3

Go in towards you. All right. Spot. So now take these... So you're gonna try a sensor wire to get the... Spot. So right now we're trying to get wire access into the renal pelvis through the nephrostomy tube. Spot. Can you move the C-arm just a little bit closer toward the midline so it's curling up in the upper infundibulum or upper calyx? There there is one thing that's like going down. Yeah, you can keep on trying. That's a straight? Yeah. Yes. All right, can we get an angle sensor? One thing I could do is straighten out the... Yeah, we could. So since you already cut it, it's pretty much free. Should be. I think it's just hitting up against the stone. All right. I mean you can also, there's enough room to try an angle tip, it might go. So let's try that. So it's hitting the stone, and it's just turning. So I think what we can do is, as long as we we have multiple curls... Yeah. We can try to dilate the tract. So just make sure there's multiple curls. This one that you're holding is very curled. I'm gonna get scissors. Yeah, so we're gonna cut the nephrostomy tube suture, and we're gonna leave the two wires in place. Do you have a 10 French dual lumen catheter? I do. Got it. Slide that off. All right, so we can just snap one of these and just, you can use a dual lumen and you can also shoot a retrograde or antegrade. All right, may I have some contrast, so we can actually, once we... Absolutely. I'll shoot a little contrast. You can... So where do you think you are right now with the... I think I'm in the upper pole here. All right, I'm gonna shoot some dye. Spot. Spot. All right, so if you dilate, it'll kind of go like that, right? Yep. So you can... All right. It should be okay. Yeah, I mean we could... The other thing we can do is we can also put a stiffer wire. Yeah. Since we have access, so... So I was thinking we could put a super stiff through this and use the super stiff as a - to dilate through. Yep. I'll give you this. And then we have the NephroMax? Yep. Spot. All right. Spot. Let's see both wires. Okay. Got both? All right. So let me have the sheath, so I can - I just want to - 'cause we have to cut the skin. So hold on to the super stiff one. I'm just gonna secure this one as like a second safety. Yep. Just 'cause this one is pretty adequately curled. All right, so you know about how big to cut the skin? Yep. And fascia. So now we can put this thing back. Was there a light handle that came with this set? We didn't open any, but we can. Okay. It's just, I think he can see it well enough. All right, so what we're doing right now is we're passing the balloon to dilate up the tract. We actually cut the skin with a scalpel Spot. Alright, so I'm trying to... The tip of the balloon is right in the upper pole there. Right. Maybe you can put it in just a little bit more again, the balloon, yeah, good. Spot. All right. That should be good. Yeah, yeah. So let's blow up the balloon with the LeVeen. So we blow this up to 20. Up to 20. Not 20? 15, 18? Those two lines, 12 to 13. And we can monitor the progress of this balloon dilation. Spot. All right, so we can see that there's actually a waste. So keep on... Keep going. Yep, keep on cranking. Keep going. 18. Spot. All right. Keep going? This one's going away. Yep, so keep on going. Ah. 20. Okay. Oh, okay. It just gave... It stopped. Which means that that way is probably broke. Spot. Okay. A little back up. Spot. So what we can do is we can leave that, and let's just get the nephroscope ready. So we'll let it stretch, tamponade, whatever. It may bleed. And we can just get the nephroscope set up. So put this in here. So, but again, get this and the light cord and all that for the nephroscope. You have a snap? Give Linda the nephroscope, and you can put the light cord and give you additional slack. And then the irrigation fluid, which is hooked up to our level one, just so that once we get access we'll be ready. All right, I want you to take your hand away. We'll do one more spot. Spot. So now what we're gonna do is, I guess we're gonna have all these safety wires. And we have three wires, and you're gonna kind of twist and kind of see if we can get into... So I'm gonna try to hold this so that we we're not pushing that in as you twist. Can you irrigate my hands a little bit? Sure. So I'm gonna, if I can just kind of hold it like this. Spot. All right, so we're slowly putting... Just kind of screw it. Oh good. I just... Spot. Lean in a little bit more. All right, oh, I'm gonna, so the balloon got pushed back a little bit. I'm gonna pull back just a tad, all right. Spot. Yep. So I think the edge is about like three-quarters of the way in. Yeah. Spot. All right. Are we there? I think almost, I think maybe like a centimeter more. All right. Spot. Yep, good. Thank you. I think that should be okay. All right. Well again, so we have to put it in just a tad more. Yeah. All right. So that means we're gonna now deflate the balloon. Do a spot. I think that's right in the upper pole. All right. We're gonna have to torque it down to get to the renal pelvis. All right, so we're gonna push, pull and get the NephroMax balloon out. Okay. All right, you got the wire? All right. We can put that in the pouch I think, 'cause it's no biggie if we lose the access to that. Spot. It's going. All right.

CHAPTER 4

All right, so let's see what we got. So we're now putting the nephroscope down in through the tract. All right, good. Got multiple curls. All right, do you mind bringing the C-arm out please? Yeah. Is that enough or more? Yeah, that's perfect. Yeah. And actually do do one spot. Okay, that's fine. All right. There's the problem. All right, so can I get the three-pronged grasper please? Yes. So that stone looks like it's lodged right at the ureteropelvic junction. And that's why we were not able to get a wire. And we might be able to pluck it out. Can I get the Neptune on please?

CHAPTER 5

Oh yeah. Are we not sucking? All right, so... Amazing. All right, now this is gonna fit through the access sheath like I was hoping. All right, Linda, can you hold the access sheath for me so it doesn't get dislodged? I'm holding it. I'm holding it. And hold the wire as well. Holding both or... I'm holding this wire. I'm holding the other ones. All right. There we go. That was the big stone now. Weigh it? So now we're gonna get the lower... We're gonna just inspect the renal pelvis to see what other fragments are left over. But that was the stone we just plucked out intact through the sheath. All right, so we'll probably send that for stone analysis. Okay. At some point. I'll put it right there. Yeah, it looks like there's a little defect. I dunno if there's a stone piece in there, but you can take a look and see. Yep. You don't need me to hold on to these anymore? Nope. All right, so we're inside the renal pelvis and, oh yeah, there are little stone pieces. Holy crap. There's like 10 of them. Okay, and then I'll hold onto the wire. That's the stone piece we just plucked out of the renal pelvis. It was an additional fragment. So we'll put that in there. Nice, definite clunk. I think this is the UPJ. And it's like chronically impacted, fibrotic and stuff. Yeah, so we can try to put something in there. Maybe we should try to put a stent antegrade, I don't know. Yeah, I think so.

CHAPTER 6

Now she also had like a non-obstructing stone mass. Yeah. We may have to put a flexed scope. And also, are there little fragments that we can get out? Yeah, that's what I'm looking for... Because right at the UPJ... Do you mind bringing the C-arm either out or like toward the feet so I can get a little bit of room to work? Yeah. Thank you. All right, so look around. And, again, if there's like pieces of stone at the UPJ, we can also try to use a basket or something to get those out, and then we can try to put a stent down. Try this, see? Yeah. Yep, we can just... That is the... This is the three-prong for the u-scope. Yeah, just keep that at on hold. We may ask for it depending on... All right, so... Yeah, it is kind of embedded in there. All right, so we have a smaller three three-prong as well. But I'm just thinking if we are able to get the stone fragments and some of the clots out of the way, we would be able to see where the opening is. And again, we can also pass a flexible uterus or cystoscope down and try to get access. I don't really see anything else that I can grab. How about down over here? Wasn't there? All right, well then maybe we can just, I mean you can try make one more attempt at putting a wire down. In fact, this time we can just try a dual lumen. I mean I think that's definitely UPJ. There's more stone there. Oh, spot. Oh, yeah, we got it. Probably, sometimes you get lucky. There's just a bunch of stone down there. Can you come on down just a little bit. I just make sure the wire. If we think we're we're good, we can actually pass this over and maybe shoot a gentle retrograde. Yeah. Or antegrade. Yeah. Yeah, do a spot. All right, I think, so pass it down just a little bit. Take some contrast agent. Okay. Okay. Do a spot. All right, it's going down. So again, what we can do is we can place a antegrade stent, just to let that heal. Yep. 'Cause again, it looks like it's so impacted. Is there anything around there stone-wise that we need to... I think there is. So I was going to, we could put a ureteroscope down and... All right, so we have wire access. Now actually, just go all the way down to the bladder. We just wanna see a curl in the bladder. Yep. Yep, that's in the bladder. All right. So I guess we can push/pull. Yep. All right. so we just confirm wire access into the bladder. And maybe we can just keep that wire in place and then just look around, try to get that non-obstructing stone that was seen on CT scan, and then we can try to stent antegrade. I'll hold this. You hook that up. We'll get the light. All right, and then this goes to this. All right, there you go. All right, so what we're doing now is we're actually passing a flexible nephroscope. It's actually a cystoscope, but we're calling it a nephroscope since we're putting it into the kidney. It's flexible, and we're just looking for any other stone pieces. That's the UPJ. I'm gonna focus just a little bit and just let's see. Hold on, let's see. All right, I think, is that better? Irrigating. Can you come up to the kidney and take a spot right here? Sure, a contrast. I want a full load of contrast. I wanna stick it through the, yeah, so once... We've got some like parenchymal stuff, like if there's little Randalls. All right, so look around, and what I'm gonna do is I'm gonna irrigate with the - a contrast agent so we have an outline of the system. I think that is the lower pole. Okay. And then we're in the upper pole. Because I think it was a lower pole non-obstructing stone that was seen on CT scan. Yeah. Right, I think that's it. But if we look, and we don't find anything, then it's just probably a Randall's plaque or a calcified papilla tip. I don't see anything. Is that the lower pole? 'Cause again, what I can do is I can squirt. Yeah, you can squirt. All right, so stay right there and just... All right, so we're gonna do, all right, spot. So you can look around. Yep. Spot. Looks like a mid-pole calyx. Yeah, the contrast isn't going down to the ureter too well, so... Spot. So that's like the lowest low pole. Okay. And there's like this parenchymal... Yeah. I think that's what we were seeing on CT. There's like nothing floating around or anything. All right. Is that worth getting? I mean I don't think we can even reach it. All right, so we saw a little calcifications of maybe it's a calcified... Yeah. Is that Randall's plaque maybe? All right. All right, so we're gonna be passing an antegrade stent. And then I don't know if there's a calyx like up here behind the sheath. Yeah, we can look on the way out. On the way out. But I think we should just put a... Yeah, so should we do an antegrade ureteroscopy now alongside the wire? I'm not sure if we should even do an antegrade 'cause we're gonna get a CT scan post-op. Sure. And it was so impacted, I don't think any stone could have gone down. Okay. So I think we should probably just put a... Let's see, should we do a 626? Yeah, let's do a 6-French. All right, open up a 626 stent for us. So are we gonna put it through the nephroscope, or are you gonna do it on fluoro? I think you can probably do it. We could do it over the scope. Okay. Usually I leave a short dangler, but it's gonna be an extremely short dangler. Do you want any suture for the back? Yeah, maybe it's some kind of nylon. Okay. Okay. That's an extremely small dangler. You wanted a council tip? Yeah, have a council tip Foley catheter as a nephrostomy tube. Are we back loading? Yeah. So this is the stent. Can we get the nephroscope? So why do you have the irrigation fluid going through the sheath? So that there's no clot formation. Oh, okay, gotcha. So you're gonna back load? And then you wanna hold this irrigation? So back load the nephroscope. Just go through the... Yep. Yep. So he's got the wire. So we can pull this out, leaving the wire in place. Get this thing a little bit closer. Here's your irrigation. All right, I think it's in. Yep.

CHAPTER 7

All right, let's take the stent. You have the wire? Mm-hm. All right, can you move the C-arm toward the bladder please? A shot or just get out of the way. Get out the way for a second. But like center it over the bladder. 'cause her next shot's gonna be... Actually, I'll let you do it. You have better eyes. And tiny, tiny fingers. That's parked right at the UPJ. It's basically like doing a cysto. Yeah, it's a short dangler. We probably don't need it, but if in case... This is like doing the cysto stent. Yeah. But just in reverse. All right, can we have that pusher? Okay, stent's going through the UPJ fairly easily. Mm-hm. All right, you can just hold onto the wire for him. All right, so we're now putting the stent antegrade. We're using the pusher to push the stent down. So that's, was that two? So that's 10 centimeters, 15 centimeters, 20 centimeters. Spot. And let's see, I don't, do you see where the stent end is? I see the wire? All right, I would just keep on pushing until you, you know, kind of just like on the... Yeah. Okay, so that's the end Spot. Spot. I see it. It's like crossing midline. Yeah, all right. So pull the wire back like three inches. Okay. Spot. Pull back more. More, okay. More, more, more, more, more, more, spot. We have a curl in the bladder. Yep. And then I wanna make sure we disengage the proximal curl in the renal pelvis. So I'd rather have it a little bit long in the bladder. Yep. So keep on pushing. All right, ooh. Pull back a little bit and then burn the wire. Burning wire. All right, so now we have a curl at the UPJ. Okay, can we do the red phone, 'cause I think we'll be done soon? All right, so we have, how... Can you pull it back a little bit? Oh yeah, if you want we can do it with some graspers. Yep, can I get a three-prong grasper here? And let's just do a spot. I wanna see exactly where that... It's like crossing midline. Yeah, yeah, we can pull back a little bit. I don't know if it'll probably fall back, you know... Oh, there's a little stone piece. Maybe we should also get that, because I don't know if it'll pass through the tight UPJ. Yeah, do you see that small stone piece? All right, so we have the 20-French council tip. All right, let's open that up and then we will prep that.

CHAPTER 8

Excellent. And then, let's see, that's water. I'm gonna just get, this is contrast? So this is already half and half. Oh okay. That's fine. I just wanna see where the balloon is when we put this in. I'll get rid of this and just, actually we're supposed to put water in, right? Yeah, I got water. We got everything out? Yep. So we have so many safety wires. I just, actually just this one. So this wire is where? Spot. So that wire is in the sheath. It is... Because I think what we can do is, I mean we can... It's like curled at the UPJ. Yeah so just put it through here. Yep. Can we have some contrast in a catheter tip syringe? -So we're gonna shoot a nephrostogram through the Foley catheter to confirm placement. On the right. Up. Yeah, it'll leak a little bit. Yep, it did look different. Spot. All right, so that's probably, actually, I don't know where the balloon's gonna blow up. So I would push it in just a little bit more. Spot. Okay, that's pull back just a little bit. You want like three ccs or something? Wait, wait, there's contrast in there. That's just to see where we are. I wanna put water in there but you can do a spot with a little bit in there. Just so that you... With this? Yeah, yeah. You can see where the balloon is with the contrast. Spot. I don't know, maybe... I think it's still in the sheath. Spot. Yeah, there's the balloon, right? Yeah. So it's just outside the sheath, I think, right? Yeah, but we're gonna put... This is half and half. Okay, so I'll shoot a... It'll leak a little bit because of the wire. Are you ready to do a, okay, I'll just, spot. All right. Help me. It'll dissipate in in just a sec. Maybe I can suck. I didn't think it would be that much contrast. Do one more spot. All right, so where that balloon was, I think you could put it in just a little bit more, right? Mm-hm. A little bit deeper. So I'm gonna give you this. Can we have just water now? We'll put water in the balloon so that when she gets a CT scan they don't call it a stone or I'm just gonna kind of rinse this. Oh, 25... Probably just three ccs is good enough. This was to five? Yeah, I put it to five. So, I dunno if it'll show up as a filling defect on that or not. Spot. Okay? Yep. And then so when we remove the nephrostomy tube, we're not gonna pull the stent out, right? Correct. I I think we can also pull it back a little bit. So I think at this point, we can, yeah, take out that wire. And you can pull that out and cut the sleeve, and then we'll sew it in. This, Linda, this sensor wire is the last thing to go. Okay. This safety wire. All right, so you said we have a like a 2-0 nylon? What kind? Yep. 2-0 nylon, and we got dressings. What do you prefer for dressings? What do we normally do, like have big wads of...? Kerlix? We could do Ker... I mean I think we're gonna be taking this out tomorrow, I think. Four by fours? Yeah four by fours and tape. Okay. We have the left kidney stones. Yeah, left kidney stones for stone analysis. For stone analysis, yep. You wanna shoot another spot? Just do a spot, 'cause I think there's still a lot of contrast in the system. Oh, actually, it came out. If you want, you can shoot another antegrade nephrostogram. Actually, I think we can do it with this, because there's no wire in there so you can just... Spot. Looks good. All right, yeah, but again, the contrast doesn't go down, so I'm thinking if she may actually even have UPJ obstruction. She does, for sure. All right, so let's sew that in place. There's a 2-0 nylon here. All right, so what we're gonna do now is we're just gonna secure that catheter in place. It's actually a type of Foley catheter called a council tip catheter as a hole at the end. So we can put it over a wire. And we're using it as a nephrostomy tube. It'll be temporary. What we're gonna do tomorrow is get a CT scan in the morning. Scissors. Make sure that we did not miss any stones. And then we will probably clamp the tube to make sure that urine is able to go down the stent. And then we'll probably remove the tube in her back, the nephrostomy tube, tomorrow. She'll probably leak a little bit of urine through her back, and eventually it'll seal. Dr. Clark, would you like a purse-string suture? It doesn't really really matter. My plan is that she's likely gonna just have that removed tomorrow. So just make it easier so that we can just snip the suture to pull it out. Can we do one final spot? Yep. I'll let you press the button. Yeah, I'll press the button. I'll press the button.

CHAPTER 9

You can see that during the case, we first capped the nephrostomy tube 'cause it was connected to a bag drainage. And then once it's capped, we prep the area and place that special drape. Now before we actually do any of the dilation, we want to have through and through access. So we had a wire that we try to pass through the nephrostomy tube down into the ureter, but you will see that we actually had some difficulty trying to get that wire down the ureter. So what we did was we made the decision to put lots of curls into the renal pelvis, and then we dilated it up the tract. Once the sheath was in, and we put the nephroscope in, we could actually see why we were unable to get that wire. Because that large stone was impacted right at the UPJ or the ureteropelvic junction, and that was causing blockage. And we weren't able to access the ureter, despite us trying a lot of different types of wires, angle tip sensor wires, things like that. But again, we were able to remove the stone, and you can see that in that area it looked inflamed. That stone was impacted, there was a lot of inflammation. Eventually, you will see that we actually were able to get a wire down into the ureter and into the bladder. And after we got access, we then placed an internal ureteral stent to allow that area to heal, because there's some concern that with that inflammation that as it heals it will heal as a scar. So we kept that internal stent in place so that it could allow drainage of urine down into the bladder and to give it a chance to heal. So at the end of the case, what we did was we want maximal drainage. And so we did put that internal stent in. She already had the existing Foley catheter. And instead of putting the standard nephrostomy tube back in, what I did was I actually used a type of Foley catheter. It's called a council tip catheter. And it's a regular Foley catheter, but it has a hole at the end, and we passed it over a wire. And we blew up the balloon in the renal pelvis. Again, that will allow maximal drainage. If there's any extravasation of fluid, it'll allow everything to heal. And what we're planning to do is in the morning to get a CT scan to make sure we got all the stones. And then what we'll probably do is take out that nephrostomy tube. So once we take out that nephrostomy tube, she'll probably leak some urine through her back, but it should eventually seal, especially since she has that internal ureteral stent and a Foley catheter. So hopefully urine will preferentially drain down the ureter into the bladder, allowing that nephrostomy tube tract to heal. Hopefully the patient will be able to be discharged tomorrow after we take out the nephrostomy tube and after taking out the Foley catheter. She would then have this internal stent to allow everything to heal. And I plan to bring her back approximately one month after the procedure, and we'll do a quick procedure under local anesthesia. We'll pass a scope into her bladder, grab the distal curl of the internal ureteral stent and remove it. She will have to be monitored closely for future obstruction, because that inflammatory area where the stone was impacted could heal as a scar and she could have a blocked kidney.