L’Ureteroscopie Souple !Peut elle Remplacer la NLPC? !

H.KOUICEM, Algérie

September 25-27, 2014 Hilton Habtoor Hotel Beirut, Lebanon

En Pratique l’ureteroscopie souple est…

A.  Souvent pratiquer? B.  Peu pratiquer? C.  Pas pratiquer?

LES STARS…

Ureteroscopy

PCNL

Laparoscopy

Davancci Robot

Ureteroscopy

Open Surgery

ESWL

PCNL

Roboflex Avicenna 2014

MET

Armada Thérapeutique 2014

�  1941: 1ère nephroscopie (Ruppel & brown)

�  1955: ponction du système collecteur (Willard Goodwing)

�  1978:

ü  Technique d’extraction des calculs du rein sous control radiologique (Fernstrom & Johansson)

ü  “Endourology”: closed, controlled, manipulation of genitourinary tract (Arthur Smith )

ü  Kurth Amplatz (interventional and medical inventor)

NLPC: Une Histoire, des Dates…

1980s’ ..Francisco Sampho’s (accès au système collecteur)

2014… NLPC…UMP

Janak DESAI (IN,2012)

Noor BUKHOLZ (UK, 2013)

Et le flexible arrive…

�  1911: Sussmann flexible gastroscope (George Wolf)

�  1912: 1ère procédure ureteroscopique (Hugh Hampton Young)

�  1950: développement de l’otique médicale (Harold Hopkins & Karl Storz)

�  1957: 1ère fibre optique endoscopique (Basil Hirschowitz & Larry Curtiss)

�  1960: Fibroscope flexible de 3mm ( Marshall )

�  1968:1er flexible + canal opérateur ( Takayasu & Aso)

�  1977: 1ère “rod-lens ureteroscopy”explore l’uretere distatal /cystoscope pediatrique 11 fr ( Lyon)

�  1979: ureteroscope original ( Richard Wolf medical instruments)

�  1980: 1er Uretroscope Rigide pratique

�  1995: 1er article flexible

Enrique Perez-Castro

Michael Grasso

Futur…

Digital, Roboflex Avicenna

RECOMMANDATIONS AFU

Prog Urol,2004,1095

EAU Guidelines

2011 2012

March 2013

April 2014

EAU Urolithiasis April 2014

Special indications for RIRS ü Morbid obesity (there are no fat ureters!) ü Co-existent ureteral stone ü Co-existent intra renal stricture ü Bleeding diathesis (inherent or drugs) ü Renal anomalies (form or position) ü Solitary kidney or compromised renal reserve ü Anatomical (previous nephrectomy, agenesis, upj) ü Functional (systemic diseases) ü Salvage after failed first treatment (SWL – URS – PCNL

- open surgery) ü Calcified retained stent ü Multiple previous PCNL / Open Surgery ü Medullary sponge kidney ü Stone in transplant or pelvic kidney

PCNL Ureteroscopy

Choisir la NLPC…

SUPINE POSITION ü  Shorter operating time ü  Possibility of simultaneous retrograde

manipulation ü  More convenient position for the

operation ü  Easier anesthesia

ü CI General Anesthesia ü Anticoagulant ü Other important contraindications include

§  untreated UTI; §  atypical bowel interposition; §  tumour in the presumptive access tract area; §  potential malignant kidney tumour; §  pregnancy.

Recommendation LE GR

Ho:YAG laser lithotripsy is the preferred method for (flexible) URS, 3 B

EAU Urolithiasis April 2014

Complications

Transfusions

Embolisation Urinoma Fever Sepsis Thoracic Complication

Organ injury

Death LE

(Range) (0-20%) (0-1,5%) (0-1%) (0-32,1%) (0,3-1,1%) (0-11,6%) (0-1,7%) (0-0,3%) 1a

N= 11,929

7% 0,4% 02% 10,8% 0,5% 1,5% 0,4%

Complications Following NLPC

Complications of URS Rate % Intraoperative Complications 3.6

Mucosal injury 1.5

Ureteral perforation 1.7

Significant bleeding 0.1

Ureteral avulsion 0.1

Early Complications 6.0

Fever or urosepsis 1.1

Persistent haematuria 2.0

Renal colic 2.2

Late Complications 0.2

Ureteral stricture 0.

Persistent vesicoureteral reflux 0.1 From Geavlete, et al. (55)

Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm:

a multi-institutional experience Hyams ES, Munver RBird ,VGUberoi ,JShah O,New York, USA.

ü 120 patients ü  Indications for URS/laser lithotripsy vs PCNL included patient preference (57):

§  technical or anatomic factors (24), §  patient comorbidities (17), §  failed shockwave lithotripsy (9) §  patient body habitus (3), §  solitary kidney (3), §  chronic renal insufficiency (3), §  strict anticoagulation (2).

ü 31 (26%) patients had stent placement pre-procedure, ü Ureteral access sheath was used in 67%. ü 101 (84%) patients underwent single-stage procedures. ü Complications: 01 ureteral perforation, 08 minor postoperative complications (6.7%). ü The reoperation rate through the mean 18-month follow-up was 3/120 or 2.5%. ü 76 (63%) patients had residual stone burden of 0 to 2 mm, and ü 100 (83%) patients had residual burden of <4 mm.  

 [J  Endourol]  2010  Oct;  Vol.  24  (10),  pp.  1583-­‐8.  

Urétéroscopie  souple  dans  le  traitement  des  calculs  du  rein  de  2  à  3  cm  

   M.A.  Ben  Saddik,  S.  Al-­‐Qahtani  Sejiny,  M.  Ndoye,  S.  Gil-­‐diez-­‐de-­‐Medina,  B.  Merlet,  A.  

Thomas,  F.  Haab,  O.  Traxer      

   ü étude  prospective  de  101  patients    ü succès  de  63,1  %.  (1ère  séance)  ü 34  %  sans-­‐fragments,  ü 29,1  %  avec  des  fragments  résiduels  de  moins  de  3mm    ü 36,9  %  des  patients  ont  gardé  des  fragments  de  plus  de  3mm.    ü succès  :  89,3  %  (  2ème  séance);    97,1  %  (  3ème  séance  )                    

                                                     Progrés  en  Urologie  :    [2011,  21(5):327-­‐332]          

 

Ureteroscopic versus percutaneous treatment for medium-size (1-2-cm) renal calculi.

Chung BI; Stevan B. Streem , Cleveland, Ohio, USA.

ü 27 patients : PCNL (N = 15) or URS (N = 12) ü successful in all 27 patients( one session) ü operative time (79.0 minutes v 68.5 minutes) ü complications (2 v 0).( No required blood transfusion) ü stone-free rate was 87% for PCNL and 67% for URS (P = 0.36).  

                                                                                                   

[J  Endourol]  2008  Feb;  Vol.  22(2),  pp.  343-­‐6.  

Competing Techniques Micro-perc vs RIRS

BJU Int. 2013 Aug; 112(3): 355-61.

Micro-perc

ü  Micro-perc: 4,85 f (16 gauge needle) ü  250 micron fibre

§  97,1% SF §  Stent 20% §  Greater

Ø  Analgesia requirements Ø  Fever Ø  Fall Hgb

RIRS

ü  Flexible URS 7,9 Fr ü  272 micron fibre

§  94,1% SF §  Stent 62,8%

HARNSTEINTHERAPIE UNIVERSITATSKLINK MANNHEIM

+ - ü  Chirurgie non agressive: voies naturelles ü  Non hémorragique ü  Position standard sur table

opératoire ü  Abord endoscopique facile

(sujet obèse) ü  Patients sous anticoagulant ü  URS: + 2 cm (0.Traxer) ü  UMP: ≤ 2 cm (Desai) ü  Complications: exceptionnelles

ü  Rétrécissement urétérale ü  coût

Choisir le Flexible…

Message…

“given the complexity of the treatment of renal stones, one may consider a centralized renal stone treatment in dedicated stone centres. It is most likely that in these c e n t r e s , t h e c o m b i n e d expertise is present to perform a successful Flexible URS and PCNL” (Editorial comment, la Rosette,

Eurpean Urol 2008; 54:1400)

Verdict !