From the Guidelines
The next step in management when intussuscepted mucosa is attached to the basket and semi-rigid ureteroscope during midureteral stone extraction, with no guidewire access and inability to cannulate the ureteral orifice, is to perform a percutaneous nephrostomy (PCNT) to divert the urine flow and prevent further complications. This approach is based on the guidelines for managing ureteral injuries, which recommend percutaneous nephrostomy tube placement when ureteral stent placement is not possible or has failed 1. The presence of intussuscepted mucosa attached to the basket and semi-rigid ureteroscope indicates a significant ureteral injury that cannot be managed endoscopically without guidewire access.
Key Considerations
- The inability to cannulate the ureteral orifice and the lack of guidewire access make endoscopic management challenging.
- Attempting to forcefully remove the basket could lead to complete ureteral avulsion, while leaving the basket in place risks ongoing obstruction and infection.
- Percutaneous nephrostomy (PCNT) is a recommended approach for managing ureteral injuries when stent placement is not possible, as it allows for diversion of urine flow and prevention of further complications 1.
- The use of broad-spectrum antibiotics, such as a fluoroquinolone or cephalosporin, is essential to prevent infection and promote healing.
Management Approach
- Perform percutaneous nephrostomy (PCNT) to divert urine flow and prevent further complications.
- Administer broad-spectrum antibiotics perioperatively to prevent infection and promote healing.
- Consider delayed ureteral reconstruction, such as ureteroureterostomy or ureteral re-implantation, once the acute injury has been managed and the patient's condition has stabilized 1.
From the Research
Management of Intussuscepted Mucosa During Basket Extraction of a Midureteral Stone
- The situation described involves intussuscepted mucosa attached to the basket and semi-rigid ureteroscope during the extraction of a midureteral stone, with no guidewire access and an inability to cannulate the ureteral orifice.
- In such complex scenarios, the primary goal is to ensure the patient's safety and prevent further complications.
Consideration of Percutaneous Nephrostomy (PCN)
- PCN is a procedure that involves the insertion of a catheter into the kidney to drain urine directly from the kidney [ 2 ].
- It is often used in cases of urinary obstruction, including those caused by stones, and can be performed under ultrasound and/or fluoroscopic guidance.
- The success rate of PCN is high, with more than 90% of procedures being successful [ 2 ].
Antegrade Nephroureteral Stent Placement
- Antegrade nephroureteral stent placement involves the insertion of a stent into the ureter through a percutaneous approach [ 3 ].
- This procedure can be used when retrograde ureteral stenting is not possible, such as in the case described.
- The study by [ 3 ] compared the first-hand approach and the nephrostomy route for antegrade double-J ureteral stent placement, finding both approaches to have high technical success rates.
Decision Making
- Given the complexity of the situation and the inability to access the ureteral orifice, percutaneous approaches such as PCN or antegrade nephroureteral stent placement may be considered [ 2 , 3 ].
- The choice between these options would depend on various factors, including the patient's overall condition, the presence of any infection, and the availability of expertise and equipment.
Other Options
- Primary ureteroureterostomy, ureteroneocystostomy with Boari flap, and ileal interposition are surgical procedures that may be considered in certain cases of ureteral obstruction or injury [ 4 , 5 , 6 ].
- However, these procedures are typically more invasive and may not be the immediate next step in managing the situation described.