Ureteral access sheath facilitates inspection of incision of ureteropelvic junction.

PURPOSE: The Acucise (Applied Medical, Rancho Santa Margarita, California) electrocautery balloon is a highly successful device used in managing congenital and secondary ureteropelvic junction obstruction. Correct orientation of the cutting wire is essential during insertion of the Acucise catheter to avoid injury to crossing vessels. Moreover, confirmation of the lateral ureteropelvic junction incision is typically verified by fluoroscopic identification of extravasated contrast material. We describe a technique of facilitated passage of the Acucise balloon through a ureteral access sheath followed by ureteroscopic visualization of the incision, affording the opportunity to improve the incision with the holmium laser if necessary. MATERIALS AND METHODS: After retrograde pyelography and guidewire placement, a 12/14Fr, 35 cm. ureteral access sheath is fluoroscopically introduced to the proximal ureter. The Acucise balloon is advanced across the ureteropelvic junction and the balloon is partially inflated to confirm proper placement. Following lateral Acucise incision, flexible ureteroscopy allows direct visualization of the ureteropelvic junction, confirming a through-and-through incision. Completion of a partial incision can be performed if needed with a 200 micro holmium laser fiber followed by routine stent placement. RESULTS: During the last 8 months we have used the Acucise device through a ureteral access sheath to treat congenital or secondary ureteropelvic junction obstruction in 8 patients. All incisions demonstrated extravasation of contrast material on retrograde pyelography, and 6 incisions (75%) were noted to be transmural by flexible ureteroscopic inspection. Two patients (25%) with only a partial incision despite contrast extravasation underwent extended incision using the holmium laser. Short-term followup demonstrated patency of the ureteropelvic junction in 7 of the 8 patients (87.5%) with 1 eventually requiring a secondary open pyeloplasty. CONCLUSIONS: The ureteral access sheath greatly facilitates placement of the Acucise device and allows rapid ureteroscopic confirmation of the incision. Insertion and removal of the ureteral access sheath and flexible ureteroscope do not compromise or significantly increase the duration of the procedure. Moreover, flexible ureteroscopic visualization allows confirmation of a complete transmural incision and potentially increases success rates of this minimally invasive approach to ureteropelvic junction obstruction. Continued followup is necessary to confirm the long-term benefits of this procedure.

Neoinfundibulotomy for the management of symptomatic caliceal diverticula.

PURPOSE: Direct percutaneous access provides effective treatment for complex caliceal diverticula. Yet, access into the diverticulum alone is usually tenuous and passage of a guide wire across a stenotic infundibulum is often impossible. An alternative technique is described which creates a "neoinfundibulum" to assist in the management of symptomatic caliceal diverticula. MATERIALS AND METHODS: During a 6-year period 22 patients with symptomatic caliceal diverticula were treated via a percutaneous approach, of whom 21 had calculi within the diverticula. After accessing the diverticulum directly, it was impossible to pass a guide wire through the stenotic infundibulum in 18 (82%) patients, prompting advancement of the access needle through the diverticular wall into the renal pelvis. Once secure access was established, balloon dilation was performed to 30Fr to create the "neoinfundibulum." Percutaneous ultrasonic lithotripsy was performed in the usual fashion. A 22Fr Councill catheter was placed to keep the infundibular tract open for 5 to 7 days to allow complete epithelialization and drainage. Stone-free, symptom-free and complication rates were assessed. RESULTS: Pain, recurrent urinary tract infections and hematuria were the presenting complaints in the subgroup of patients undergoing "neoinfundibulotomy." Average stone burden was 11.7 x 12 mm. and average hospital stay was 2.8 days. Of the patients 94% were symptom-free at 6-week followup, and 80% were stone-free on followup excretory urography. The remaining patients had residual stone fragments less than 3 mm. in diameter. Complications related to access were identified in 2 patients who sustained a pneumothorax after a supra-11th rib access, which was successfully managed with tube thoracostomy. CONCLUSIONS: Percutaneous management of complex caliceal diverticula provides a safe and effective option for symptomatic patients. When the stenotic infundibulum cannot be traversed with a guide wire, creation of a new infundibulum offers a secure alternative for accessing the collecting system, while providing equally effective results.