l’ureteroscopie souple peut elle remplacer la nlpc?
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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 !
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