Antegrade Flexy Ureteroscopy

HISTORY: 79 year old male
Prostate Ca treated with LHRH Agonist and Bicalutamide
PSA 3ng/ml and slowly rising 1.5ng/ml per year.
Lymph node involvement at the time of diagnosis 6years ago.
Lymph node blocks external iliac vessels, common iliac vessels. Left slowly enlarging.
8 months ago left renal colic and hydronephrosis, fever and sepsis.
Multiple stones in kidney and a 2,4cm stone in proximal ureter
He was treated with PCN left due to Pseudomonas sp in blood and urine culture.
Frequent febrile infections ever since, required hospitalization, iv. treatment of multi-resistant Pseudomonas sp.
JJ insertion was not possible with a Retrograde or Antegrade approach
PROCEDURE
Patient in right lateral position with his left flank exposed.
Local anesthetic around the mature PCN track and mild sedation
Contrast injection through PCN
The ureter is not visualized
More contrast though PCN still no ureter visualization.
Pressure contrast injection leads to Pyelo-Venus reflux.
Track dilation up to 12 fr
10/12Fr ureteric introducer sheath into renal pelvis
A dead end for the scope
Probably due to long term PCN the PUJ is closed from scar tissue
Careful evaluation of the PUJ
Laser fragmentation can only work in a tangential approach due to lack of space in proximal ureter
Fragmentation continues until the path to distal ureter if free.

Video by Nikos Bafaloukas.