Sheathless and fluoroscopy-free retrograde intrarenal surgery: An attractive way of renal stone management in high-volume stone centers.

OBJECTIVE: To evaluate the efficacy and safety of sheathless and fluoroscopy-free flexible ureterorenoscopic laser lithotripsy (FURSL) for treating renal stones. METHODS: Between May 2015 and May 2017, 135 patients with renal stones treated with sheathless and fluoroscopy-free FURSL were prospectively evaluated. Our technique involved a semi-rigid ureteroscopic assessment of the ureter, and the guidewire was left in situ to railroad the flexible ureteroscope. A holmium laser was used to fragment and dust the stones; fragments were neither grasped nor collected. RESULTS: The study population consisted of 135 patients including 85 males (62.96%) and 50 females (37.04%) with a mean age of 40.65 years (range: 3-70 years) were evaluated. The mean stone size was 17.23 mm (range: 8-41 mm). Complete stone-free status was achieved in 122 (90.37%) patients and clinically insignificant residual fragments (CIRF) in two (1.48%), while residual stones were still present in 11 (8.15%) patients. Postoperative complications occurred in 23 (17.4%) cases and were mostly minor, including fever in 17 (12.6%), pyelonephritis in four (3.0%), subcapsular hematoma in one (0.7%) and steinstrasse in one (0.7%). These complications were Clavien I-II, GI in 17 (12.6%) patients, GII in five (3.7%), and Clavien IIIb in one (0.7%). No major complications were observed. Stone size ≥2 cm, operative time ≥30 min, and lasing time ≥20 min were significantly associated with a higher rate of complications and lower stone-free rates upon univariate analysis (p<0.05). CONCLUSION: Sheathless and fluoroscopy-free FURSL are effective and safe for renal stone management, especially for stones under 2 cm in diameter. This process is a feasible option for avoiding sheath complications, which can protect surgeons from the negative effects of radiation.

Impacted ureteric stone causing iliofemoral vein thrombosis: The first reported case.

INTRODUCTION: Extrinsic compression with resulting obstruction of the iliac veins is recognized as a crucial cause of deep vein thrombosis (DVT). We report a case of impacted ureteric stone causing DVT. CASE REPORT: A 65-year-old man presented with left lower limb swelling that diagnosed and treated as extensive DVT. Further evaluation revealed incidental left severe hydroureteronephrosis and impacted ureteric stone compressing iliac vessels. Immediate percutaneous nephrostomy done followed by left ureterolithotripsy 6 weeks later. DISCUSSION: several iliofemoral venous thromboses have been reported due to extrinsic compression by various pathologies, but to best of our knowledge, this is the 1st report of the impacted ureteric stone causing life-threatening proximal DVT. CONCLUSION: Isolated unilateral iliofemoral DVT may raise the suspicion of pelvic pathology including ureteric stone.

Endourologic Management of a 15-Year-Old Neglected, Fragmented, and Encrusted Ureteral Stent.

Background: Ureteral stents (Double-J stents) have been widely used in urology to prevent or relieve ureteral obstruction and have become an integral part of urologic practice. However, if ureteral stents are kept for a prolonged period or neglected, they can cause significant morbidity because of complications such as stent migration, encrustation, occlusion, stone formation, and fragmentation. Therefore, it is crucial to remove stents as soon as possible after they have served their purpose, to prevent complications and morbidity. Case Presentation: In this study, we present a case of a 28-year-old man who presented with broken extensively encrusted Double-J stent, with bulky stones at both ends of the stents that had been inserted 15 years ago, after an open right pyelolithotomy, and that was lost to follow-up. Cystolithotripsy, ureteroscopic laser lithotripsy, and two consecutive mini-percutaneous nephrolithotomies were necessary to extract the stent and the patient became stone free. Conclusion: Forgotten Double-J stents for long times with extensive encrustation and stone formation can be managed safely with a combined endourologic approach with minimal morbidity.

Renal Vein Injury During Percutaneous Nephrolithotomy Procedure.

Background: Percutaneous nephrostolithotomy is an important approach for removing kidney stones. Puncturing and dilatation are two mandatory steps in percutaneous nephrolithotomy (PCNL). Uncommonly, during dilatation, the dilators can cause direct injury to the main renal vein or to their tributaries. Case Presentation: A 75-year-old female underwent PCNL for partial staghorn stone in the left kidney. During puncturing and dilatation, renal vein tributary was injured, and the nephroscope entered the renal vein and inferior vena cava, which was clearly recognized. Injection of contrast material through the nephroscope confirms the false pathway to the great veins (renal vein and inferior vena cava). Bleeding was controlled intraoperatively by applying Amplatz sheath over the abnormal tract, the procedure was continued and stones were removed. At the end of the procedure, a Foley catheter was used as a nephrostomy tube and its balloon was inflated inside the renal pelvis and pulled back with light pressure to the lower calix, which was the site of injury to the renal vein tributaries, then the nephrostomy tube was closed; by this we effectively controlled the bleeding. The patient remained hemodynamically stable; antegrade pyelography was done on the second postoperative day, there was distally patent ureter with no extravasation, neither contrast leak to renal vein, and was discharged home at third postoperative day. After 2 weeks, the nephrostomy tube was gradually removed in the operative room, without bleeding, on the next day, Double-J stent was removed. Conclusion: Direct injury and false tract to the renal vein tributaries during PCNL can result in massive hemorrhage, and can be treated conservatively in hemodynamically stable patients, using a nephrostomy catheter as a tamponade.