I would primarily suggest narrow caliber urs with holmium laser lithotripsy , if failed immediate open surgery ureterolihotomy

We often face the problem in rural and remote areas where I work. What we have done is to place a DJ stent or guidewire till the place it goes and wait for 2 days when the ureter dilates. then we can use the URS to visualize and break the stone with lithoclast. We have removed renal pelvic and upper and middle calyceal stones with URS.

Ureterorenoscopic removal renal stones: Cost effective patient friendly method in rural areas

J. Gnanaraj, Balaji Prasad Ellapan

(Tropical Doctor April 2011, 41 page 102 )

Consider advancing a fine calibre ureteroscope partially fragment enough to advance a guide wire and leaving a stent for few weeks to allow passive ureteral dilation and competing procedure with say 8 ch URS. Alternate option is to acquire middle or upper pole per cutaneous access advancing a flexible URS and using Laser to fragment. With impacted stones proximal ureter is sufficiently dilated to allow easy access to the stone.

maybe a flexible ureteroscope could help in endoscopic lithotripsy.

if this is not feasable, consider a temporary DJ stent placement...to "enlarge" what's narrow..

Agree with Dr. gnanaraj. place a stent for few days, though you can directly go for Lap ureterolithotomy (or open); which is the only choice if the stent did't work, in case you don't have a flex scope.

Stent and ureteroscopy.

Do not forget shock wave lithotripsy with concomitant stenting.

My choice in order preference.

1. Flexible ureteroscope with laser for fragmentation

2. stenting and then second look in ureteroscopy

3. I will definitely will not hesitate to do open ureterolithotomy.

Impaction is one of the significant independent risk factors for unfavorable results of ureteroscopy. Therefore, I suggest trying to pass a hydrophilic glide wire past the stone, then replace it with an ordinary guide wire. After this ureteroscopy and lithotripsy can be done. If no guide wire can pass the impacted stone, you have two options, the first is to fix a nephrostomy tube to drain the kidney and try URS again after few days. the second is to do laser lithotripsy of one side of the stone unless there is a space to pass a guide wire. Then continue disintegration in the presence of the guide wire. The choice depends on your experience and presence of laser.

It is not an uncommon situation: a narrow lower ureter, a stone at the pelvis or iliac level and the URS that could not be advanced.

First of all, do not try to force the advance of the URS. I do not recommend the acute dilatation of the distal ureter with high pressure balloon or dilators.

It is almost always possible to advance a hydrophilic guide and to place a 6F double J, then to discharge the patient and defer a new URS for two weeks later, where we will find a lengthy and complacent ureter that would readily admit our semi-rigid URS.

I would pass a double J stent and return in a few weeks for ureteroscopy with laser lithotripsy; I would then pass a ureteral access sheath to the stone to make access to the stone easier, to decrease pressures within the ureter and transmitted to the renal pelvis, prevent the bladder from filling with irrigation fluid, and to help irrigate some of the small fragments as you do the lithotripsy.

This was an informative discussion with level 4 evidence and probably can mount to grade 3. Summary:

1- Hydrophilic wire and JJ stent

2- Laser ( this is of course if the URS can get to the stone

3- Flexible is certainly an option if available;

4- Ureterolithotomy is a lone choice

Stent and URSE at a later date.

Dont force for advancing the instrument,Insert a ureteral stent for passive dilation in few days and secind look ureteroscopy if do not have flexible and Laser.

1.flexible ureteroscopy and laser fragmentation

2. Stent and subsequent ureteroscopy

3. Laparoscopic ureterolithotomy if the stone is at upper or middle 1/3 ureter.

With the information provided I say a robotic ureterolithotony.

from our experience is the insertion of JJ stent and later 3-4 weeks ureteroscopy ist the best option in these cases , the later URS will be very easy without any complications

If the other options mentioned before failed

you can use antegrade flexi with laser , the only adverse effect , invasive

Usually we r able to place glide wire, i would prefer to put dj stent without attempting to break stone then come back at least after 15 days.

I think all the presented solutions are reasonable. Neverthless a progression from the less to the more invasive approach should be adopted.

Personally, I suggest a staged procedure:

1) first time : ureteroscopy failure then retrograde stenting (if possible) or nephrostomy (if indicated)

2) second time: if already prestented then semirigid ureteroscopy with thin (6 to 7 Ch) ureteroscope and either laser or balistic stone fragmentation; if nephrostomic tube already placed then antegrade approach with laser and flexible.

If laser and flexible instruments not available open or laparoscopic uretherolithotomy.

Pass a double J stent (passive dilatation) and return after 4-6 weeks with semirigid ureteroscopy and laser.

It depends of the time that the stone was impacted.

If the stone is impacted less than 21 days I will try a flexible ureteroscopy or a semi rrigid ureteroscopy withouth stent placing.

If the stone is impacted more than 21 days or associated with infection (spetially in diabetic or inmunosupressed patients) I prefer to stent and try the ureteroscopic procedure in a second time.

Stent and URS 4-6 weeks later

I thinck we can use 4.5 fr ureteroscope first ,then 6 fr and 8 fr to dilate the distal ureteral narrowing to reach the stone and treat it.

In my experience the best treatment option is Passing a double J stent for ureteral dilatation and trying for flexible or semirigid ureteroscopy 2-4 week later, but if JJ stenting and URS lithotripsy failed , Laparoscopic ureterolithotomy is the best option .

I believe a 6fr ureteroscope with laser fragmentation of the stone is the best option.

For me the really impacted stone means that guide wire and JJ stent can not be passed. In case of large (larger than 1 cm) and dense impacted stone the laparoscopic ureterolithotomy is the first choice in my practice, mostly in the middle part of the ureter.

For me I will dilate the lower ureter with the serial ureteral dilators and then go with the semirigid ureteroscope and crush the stone either with laser or with lithoclast.

Hi there. Since reaching the stone with the scope wasn't possible, I would recommend inserting a double J stent through your safety wire. By doing this not only do you relief the patient's pain, in case there is any, and it will help you when you come 2 weeks later to try a new URS procedure. If you couldn't pass a safety wire because of the obstruction try using a hydrophilic nitinol coated wire to pass the stent under fluoroscopic guidance. If this fails and you still aren't able to pass this kind of wire just put the stent up to the obstruction, leave it there for 2 weeks and come back again for URS. And concerning lithotripsy method, if possible, always use a laser: it's safer, less damaging to the ureter and you can completely dust the stone if you choose to. And at the end of the procedure, as with all ureteric manipulation, leave a double J stent for some days. I hope this helps.

If a wire can be passed proximally, I would stent and return in 3 weeks for a ureteroscopy and laser lithotripsy.

True impaction however would mean, all attempts at guide wire passage was unsuccessful. If that occurs, it might be better to put in a nephrostomy to decompress the system and many a time, relieve oedema.

In a couple of weeks,go back in with a ureteroscope, and then one has the option of trying and negotiating a wire antegrade

Dr. Bassem ....I had such a case and fortunately successfuly done with flexible ureteroscopy, holmium laser fragmentation of the stone and also laser incision of the ureteric stricture (medialy -below level of iliac vessels) and at the end DJ stent for 4 weeks

Another choice is laparoscopic ureterolithotomy, but we shoud discuss with patients first.

Best to try and stent. If not possible, nephrostomy drainage, with antegrade stent placement. With this approach, will help settle hydronephrosis, dilate ureter and allow successful access at next attempt.

Open or lap ureterolithotomy remain as last resorts if failed.

In this situation I prefer laparoscopic ureterolithotomy. Because the option of placing a Dj stent for a secondary procedure, if possible, is usually intolerable to the patient and no one can warranty that the second TUL procedure will be successful.

It depends what technical possibility You have. If you want to get the stone old urologists put the patient into a bed and tried with simple by placing 2 and more ureteral catheters 3-4 french into the distal ureter fixing it on a balloon urethracatheter and made more sessions the same way.until the stone could be seen. Well that was surely not our lifestyle but......

Hello dr basem

Either retrograde flexi and hol. laser on dusting mode

or if there is technical problems canulating the ureter

anegrade PCNL like puncture in a upper or  middle calyx and dilate up to 14 or 16 fr with the wire going down to ureter

then introduce a uretera access sheath down to ureter

then laser it or even basket it

Honourable Collegue Well super Please try puncture of the middle or best reaching calix and take the smallest endosscope to come top -down to the stone and than laser "the rock" All the Best Your Hainz

There is no gold standart. Depends on the patient situation. If you can, urs + hol. Laser will be enough otherwise no need to wait do it laparascopically.

Place a JJ stent for four weeks and then do FURL.Consider a laparoscopic Ureterolithotomy if FURL is not feasible after ureteral dilatation.

You can find the answer at

http://mdcurrent.in/nephrology/managing-ureteric-calculi-obstruction-hydronephrosis-rural-areas/

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Balloon dilation for the narrow lower ureter and proceed with rigid semirigid ureteroscope and laser fragmentation.

Hello it depends to condition of your patient . if it will be possible with use of two guide wire and rail road method we try to crush stone and after then put a jj stent ,but if its not possible to see or crush stone we must drain the system by double j or pcn and after 0ne to 4 week again try for ureteroscopic management .If none of them was successful and patient accept laparoscopic ureterolithotomy with jj insertion is the best option.