Prognosis of ureteral dilatation during procedures using a ureteral access sheath in patients with urolithiasis

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Дәйексөз келтіру

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Рұқсат жабық Рұқсат ақылы немесе тек жазылушылар үшін

Аннотация

Aim. To improve the results of treatment of patients with urolithiasis who underwent endoscopic interventions using a ureteral access sheath (UAS) by developing a predictive model of ureteral dilatation without pre-stenting.

Materials and methods. A total of 180 patients with kidney stones up to 20 mm were included in the study. They were divided into two groups: in the group 1 (n=79) UAS of 12/14 Ch was used, while in group II (n=101) UAS of 10/12 Ch was inserted. In group I, 48 (60.8%) patients underwent micropercutaneous nephrolithotomy and in 31 (39.2%) retrograde intrarenal surgery was done, compared to 42 (41.6%) and 59 (58, 4%) of patients in group 2. A non-inclusion criterion was a history of ureteral stenting. At the stage of preoperative diagnosis, 60 minutes before the X-ray examination, the patient took a single dose of 80 mg of furosemide per os to improve visualization of the upper urinary tract. After digital processing of computed tomography data and 3D-reconstruction of the upper urinary tract using the DICOM image processing program “RadiAnt DICOM Viewer,” a visual assessment of the ureter was carried out to exclude significant deviations and strictures. The ureteral width was measured at three points: pyeloureteral segment, the level of the iliac bifurcation and intramural part.

The number of cases of successful insertion of UAS and the rate of damage to the ureteral wall according to the classification proposed by O. Traxer and A. Thomas (2012) were analyzed. The prediction of successful insertion of a UAS was carried out using ROC analysis.

Results. In group 1, successful insertion of UAS was observed in 37 (46.8%) patients compared to 84 (83.2%) patients in group 2. In the remaining 42 (53.2%) and 17 (16.8%) cases, respectively, placement of UAS was not possible due to significant tissue resistance and high risk of traumatic injury. The average ureteral diameter at the points of physiological narrowing in patients with successful insertion of 12/14 Ch UAS were 2.0±0.1 mm, compared to 1.2±0.4 mm in those with failed insertion (p<0.05). In the group 2, similar indicators were 1.6±0.1 mm and 1.2±0.5 mm, respectively (p<0.05). According to ROC analysis, the diagnostic efficiency of the predictive model when using 12/14 Ch and 10/12 Ch UAS was confirmed by high AUC values (0.925 [95% CI 0.871-0.98] and 0.944 [95% CI 0.89=0.97], respectively). The total number of patients with ureteral injuries was 35 (44.3%) and 40 (39.6%) in groups with 12/14 Ch and 10/12 Ch UAS, respectively. At the same time, complications of the I degree were observed in 24 (30.4%) patients of the group 1 and in 31 (30.7%) patients of the group 2, while injuries of II degree were detected in 10 (12.7%) and 9 (8.9%) cases, respectively (p>0.05). Only in 1 (1.3%) patient, when 12/14 Ch UAS was inserted, grade III damage to the ureteral wall was determined.

Conclusion. The proposed technique for measuring the cross-section of the ureter allows to predict the successful insertion of UAS at the preoperative stage. The probability of successful passage of UAS of 10/12 and 12/14 Ch in patients with ureteral diameter in physiological narrowings of more than 1.6 mm and 2 mm, respectively, is 95%. An insertion of UAS is a safe procedure, and most complications are classified as grades I or II.

Толық мәтін

Рұқсат жабық

Авторлар туралы

V. Protoshchak

FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Email: protoshakurology@mail.ru
SPIN-код: 6289-4250

Ph.D., MD, professor, Head of the Department of Urology of FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Ресей, Saint Petersburg

D. Orlov

FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Хат алмасуға жауапты Автор.
Email: d.n.orlov@mail.ru
SPIN-код: 4014-6818

urologist at the Urologic Clinic of FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Ресей, Saint Petersburg

M. Paronnikov

FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Email: paronnikov@mail.ru
SPIN-код: 6147-7357

Ph.D., MD, Head of the Department of Urology Clinic of FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Ресей, Saint Petersburg

E. Karpushchenko

FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Email: z_karpushe@mail.ru
SPIN-код: 3753-4990

Ph.D., senior lecturer of the Department of urology of FGBVOU VO S.M. Kirov Military Medical Academy of the Ministry of Defense of Russian Federation

Ресей, Saint Petersburg

Әдебиет тізімі

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2. Fig. 1. Three-dimensional model of computed tomogram of the upper urinary tract (red arrows indicate the levels of ureter diameter measurement in physiologic ureteral constrictions)

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3. Fig. 2. ROC curves of dM scores for predicting the feasibility of ureteral shroud placement (A. for group I; B. for group II)

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4. Fig. 3. Threshold value of the "cutoff point" at different ureter diameter in physiologic constrictions (A - for group I; B - for group II)

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5. Fig. 4. Dependence of the success rate of ureteral shroud placement on the ureteral diameter (A - for group I; B - for group II)

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