Stone surgery 영역

URS

Level I		Patient positioning (Lithotomy position)
Level II		Cystourethroscope
	II-1	Inspection of urethra
	II-2	Inspection of bladder
	II-3	Insertion of end-hole ureteral catheter with/without guide wire
Level III		Retrograde Pyelogram
	III-1	Injection of contrast medium under fluoroscopic guidance
	III-2	Observation of upper tract anatomy and identification of stone location
Level IV		Ureteroscope Insertion into ureteral orifice
	IV-1	Railroad technique (with dual guide wire)
	IV-2	Scope rotation (with single guide wire)
	IV-3	Balloon dilation of ureteral orifice
Level V		Ureteroscope control
	V-1	Ureteroscope insertion through whole ureter
	V-2	Identification of ureter stone
Level VI		Lithotripsy
	VI-1	Lithotripsy utilizing laser
	VI-2	Lithotripsy utilizing pneumatic lithotripter
Level VII		Stone removal
	VII-1	Stone removal using stone forcep
	VII-2	Stone removal using stone basket
Level VIII		Ureteral stent placement & wrap-up
	VIII-1	Inspection of ureteral injury
	VIII-2	Double J stent placement
	VIII-3	Foley cathter insertion

<youtube width="300" height="180">https://youtu.be/glJRg_KYk5w</youtube>

• Patient position : Lithotomy position

1. Ureteroscopy를 urethra를 거처 bladder내로 진입 시키고 ureteric orifice를 관찰한다.
2. Ureteric orifice로 Safety guide wire를 진입시킨다.
3. Safety guide wire를 따라 ureter내로 ureteroscopy를 진입시킨다.
4. Ureter stone을 확인하고 safety guide wire를 제거한 후 stone basket 이나 stone retrieval devices를 이용해 stone을 고정 시킨다.
5. Holmium YAG laser 나 pneumatic lithotriptor를 이용해 stone을 적절한 크기로 파쇄한다.
6. Stone basket 이나 stone retrieval devices를 이용해 파쇄된 stone을 bladder로 빼낸다.
7. Ureteral stent를 위치시킨다
8. Evacuator를 이용해 bladder내의 파쇄된 stone들을 꺼낸 후 Foley catheter를 넣고 수술을 마친다

Ref) Hinman’s Atlas of Urologic surgery

RIRS

Check list

Level I		Patient positioning (Lithotomy position)
Level II		Cystourethroscope
	II-1	Inspection of urethra
	II-2	Inspection of bladder
	II-3	Insertion of end-hole ureteral catheter with/without guide wire
Level III		Retrograde Ureterogram
	III-1	Injection of contrast medium under fluoroscopic guidance
	III-2	Observation of upper tract anatomy
Level IV		Ureteroscope Insertion into ureteral orifice
	IV-1	Railroad technique (with dual guide wire)
	IV-2	Scope rotation (with single guide wire)
	IV-3	Balloon dilation of ureteral orifice
Level V		Ureteral access sheath Insertion
	V-1	Selection of appropriate size and length
	V-2	Insertion of obturator sheath (under fluoroscope control)
	V-3	Insertion of ureteral access sheath (under fluoroscope control)
Level VI		Flexible ureterorenoscope control
	VI-1	Visualization of pelvocalyx (under fluoroscope control)
	VI-2	Flexible scope control with active deflection
	VI-3	Flexible scope control with passive deflection
	VI-4	Inspection of pelvis and upper/mid/lower calyces
Level VII		Stone control and Lithotripsy
	VII-1	Relocation of renal stone using basket
	VII-2	Performing dusting technique
	VII-3	Performing fragmentation technique
	VII-4	Performing pop-dusting technique
Level VIII		Stone removal
	VIII-1	Stone removal using basket
Level IX		Ureteral stent placement & wrap-up
	IX-1	Retrieval of ureteral access sheath
	IX-2	Inspection of ureteral injury
	IX-3	Double J stent placement
	IX-4	Foley cathter insertion

<youtube width="300" height="180">https://youtu.be/Rc5BpFCg4J4</youtube>

• Patient position : Lithotomy position

1. Rigid cystoscopy를 urethra를 거처 bladder내로 진입 시키고 ureteric orifice를 관찰한다.
2. Ureteric orifice로 Safety guide wire를 진입시킨다.
3. Safety guide wire를 따라 dual-lumen catheter를 넣고 RGP를 찍어 renal pelvis와 calyx의 위치를 확인한다음 dual-lumen catheter를 이용해 PTFE coated stainless steel wire (Amplatz Super Stiff™)를 진입시킨다
4. Safety guide wire와 dual-lumen catheter를 제거하고 super stiff guide wire를 따라 ureteral access sheath (UAS)를 fluoroscopy를 보면서 진입 시킨다.
5. UAS를 통해 flexible ureteroscopy를 신장내로 진입시켜서 upper calyx, mid calyx, lower calyx를 관찰한다.
6. Holmium YAG laser를 이용해 stone을 파쇄하고 술자의 선호도에 따라 stone을 basket을 이용해 꺼내거나 pop-corn technique을 이용해 stone을 잘게 파쇄한다.
7. Lower pole stone의 경우 ureteroscope의 손상위험성이 있으므로 stone basket을 이용해 upper pole이나 renal pelvis 등으로 stone을 위치 시키고 stone을 분쇄한다.
8. Ureteral stent를 위치시키고 Foley catheter를 넣고 수술을 마친다.

Ref) Urolithiasis 2018 Feb;46(1);47-58, Flexible ureteroscopy : technique, tips and tricks (Doizi S, Traxer O)