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.