Antegrade flexible ureteroscopic lithotripsy with suctioning ureteral access sheath for large distal ureteral stones in neobladder patients: A case report

Abstract

The use of suctioning ureteral access sheaths (sUAS) in endoscopic stone surgery provides significant advantages for retrograde procedures, including enhancing stone-free outcomes, shortening hospitalization stay, and lowering the incidence of infection. Nevertheless, in specific instances where an antegrade approach is necessary for lithotripsy, the application of these sheaths is not well established. We present the case of a patient with a neobladder and a significant ureteral calculus who was effectively treated via an antegrade approach using a flexible ureteroscope with a sUAS. This intervention enabled complete stone removal, leading to the patient's full recovery without complications.

1. Introduction

Currently, radical cystectomy remains the standard surgical treatment for muscle-invasive bladder cancer, as well as for recurrent high-risk non-muscle-invasive bladder cancer unresponsive to adjuvant intravesical therapy. This procedure necessitates the creation of a urinary diversion, which may include Bricker ileal conduits, catheterizable pouches, orthotopic neobladders, or ureterosigmoidostomies.^1,2 Postoperative complications are frequently observed following radical cystectomy with abdominal urinary diversion. During the first 90 days postoperatively, up to two-thirds of patients may experience complications, with approximately 20 % classified as high-grade.³ Additionally, patients are at increased risk of developing urolithiasis in the upper urinary tract, urinary reservoir, or conduit. This elevated risk is multifactorial, involving metabolic alterations, urinary tract infections or colonization, and anatomical features inherent to the type of urinary diversion.⁴ Despite the availability of treatment options such as percutaneous nephrolithotomy (PCNL), extracorporeal shockwave lithotripsy (ESWL), and ureteroscopy, there remains no clear consensus on the optimal approach for stone management in these complex cases.

To enhance the safety and efficacy of retrograde intrarenal surgery (RIRS), a novel device—the suctioning ureteral access sheath (S-UAS) with a bendable tip—has been developed. This device offers enhanced flexibility, allowing the tip to bend passively in synchrony with a flexible ureteroscope, and can be connected to a suction system to facilitate stone fragment evacuation.⁵ While the S-UAS has demonstrated utility in standard retrograde procedures, its application in antegrade lithotripsy remains underexplored.

This report presents what is, to the authors’ knowledge, the first documented clinical case utilizing a suctioning ureteral access sheath during antegrade flexible ureteroscopic lithotripsy for the management of a large ureteral stone in a patient with a neobladder.

2. Case report

We present the case of a 67-year-old male with underlying hypertension, who previously underwent open radical cystectomy and ileal Studer neobladder reconstruction for muscle-invasive bladder cancer. The patient presented with recurrent urinary tract infections and persistent symptoms of urinary urgency. Prior management with ESWL for a distal ureteral calculus had been attempted twice at an external facility without success.

Initial evaluation revealed a serum creatinine level of 1.0 mg/dL. Non-contrast computed tomography (CT) imaging demonstrated a calculus measuring 10 × 11 × 15 mm, with a density of 1250 Hounsfield Units (HU), located in the distal left ureter and associated moderate hydronephrosis (Fig. 1A). Following multidisciplinary consultation and patient-centered discussion regarding available treatment modalities, antegrade flexible ureteroscopic lithotripsy utilizing a suctioning ureteral access sheath (S-UAS) with the patient positioned prone was determined to be the optimal therapeutic approach.

Fig. 1.

A, Computerized tomography scan illustrating a left distal ureteric calculus.; B, Fluoroscopic image of antegrade suction ureteric sheath placement.

Under general anesthesia, prophylactic intravenous cefuroxime was administered, and the patient was placed in the prone position. Percutaneous renal access was obtained via ultrasound-guided puncture of the mid-pole calyx using an 18-gauge, 20 cm needle, followed by dilation of the access tract to 15 Fr using a one-step metal dilator over a guidewire. A 10/12 Fr Clear Petra disposable suctioning ureteral access sheath (Well Lead Medical Co), integrated with a stylet, was then introduced under fluoroscopic guidance and positioned immediately proximal to the ureteral calculus (Fig. 1B). An 8.4 Fr flexible ureteroscope (fURS; Scivita Medical, Suzhou, China) was inserted through the sheath (Fig. 2). Continuous irrigation was maintained at a pressure of 80 mmHg using a pressure-controlled double-roller pump. Lithotripsy was performed employing a dusting technique with a 120W Holmium:YAG laser (Lumenis, San Jose, CA) equipped with a 200 μm laser fiber at energy settings of 0.5 J and 30 Hz. Concurrently, stone fragments, dust, and irrigation fluid were continuously evacuated through the suction sheath. Upon complete lithotripsy, a 6 Fr, 26 cm double-J (DJ) stent was antegradely placed across the ureteroenteric anastomosis under fluoroscopic visualization.

Fig. 2.

Antegrade suction ureteric sheath within Mini-PCNL metallic sheath.

The total operative time was 60 minutes, including 20 minutes of laser application. Postoperative abdominal radiography confirmed complete stone clearance, with both the 6 Fr DJ stent and the 12 Fr nephrostomy tube positioned correctly (Fig. 3). The postoperative recovery was uneventful, and the patient was discharged without complications. The nephrostomy tube was removed three days postoperatively, and the DJ stent was subsequently removed via cystoscopy three weeks after hospital discharge. Analysis of stone composition was not performed due to patient financial constraints.

Fig. 3.

Postoperative abdominal radiography.

3. Discussion

Patients presenting with upper urinary tract calculi following urinary diversion exhibit clinical features similar to those observed in the general population, most commonly loin pain and recurrent urinary tract infections. Current therapeutic modalities for managing upper tract stones in diverted urinary systems encompass ESWL, PCNL, antegrade or retrograde ureteroscopy (URS), and, in selected instances, open or laparoscopic surgery. The choice of optimal treatment is influenced by several factors, including stone characteristics (size, location, composition), anatomical modifications of the urinary tract, patient comorbidities, and the surgical expertise available.⁶ Selecting an effective, minimally invasive technique is crucial to achieve a high stone-free rate with minimal morbidity, particularly in patients previously subjected to major reconstructive surgeries, such as radical cystectomy with urinary diversion, who are also prone to recurrent stone formation.

Establishing access to the upper urinary tract poses the most significant technical challenge in endourological management of calculi post-urinary diversion. Retrograde ureteral access is frequently not feasible in non-refluxing ureteroenteric anastomoses due to difficulties in locating the neo-ureteral orifice, anastomotic strictures, or alterations in ureteral anatomy.⁷ In patients with refluxing ureteroenteric anastomoses, contrast instillation through the ileal conduit allows fluoroscopic visualization of the upper urinary tract, facilitating antegrade puncture. In our practice, we have successfully employed ultrasound-guided percutaneous renal access to navigate these challenges effectively, especially in the presence of hydronephrosis.

Over the past 25 years, significant advancements have occurred not only in surgical instrumentation, artificial intelligence, and virtual reality technologies, but also in the refinement and evolution of endourological techniques.8, 9, 10, 11 Miniature percutaneous nephrolithotomy was developed through the miniaturization of equipment and advancements in PCNL systems, aiming to achieve a stone clearance rate comparable to standard PCNL while potentially reducing complication rates and postoperative pain through the use of smaller tract sizes.12, 13, 14, 15 Moreover, the incorporation of intraoperative suction systems has notably enhanced stone fragment clearance and, in many cases, obviated the need for manual retrieval with baskets.16, 17, 18 More recently, its application has expanded to RIRS, where it offers numerous benefits, including improved fragment evacuation, enhanced visualization, and better control of intrarenal pressure and temperature. The integration of suction systems helps maintain intrarenal pressure at approximately 20 mmHg—a level that reduces postoperative complications, improves endoscopic visibility, and shortens operative time (¹⁹,²⁰). Despite these advantages, the application of suction systems in the management of distal ureteral stones has been largely unexplored. To the best of our knowledge, this report presents the first case utilizing a combination of innovative techniques for the treatment of distal ureteric calculi in a patient with a neobladder.

4. Conclusion

We successfully managed a large distal ureteral calculus in a neobladder patient using antegrade flexible ureteroscopic lithotripsy with a suctioning ureteral access sheath. This integrative approach facilitates effective stone clearance, reduces operative time, and minimizes procedure-related complications. Our experience highlights the feasibility and potential advantages of incorporating suction-assisted technology in the antegrade management of complex ureteral stones in anatomically altered urinary tracts.

CRediT authorship contribution statement

Thanakorn Pattamawalai: Writing – original draft, Project administration, Formal analysis, Data curation, Conceptualization. Kun Sirisopana: Methodology, Investigation. Surawach Piyawannarat: Methodology, Investigation. Premsant Sangkum: Validation, Supervision. Wisoot Kongchareonsombat: Validation, Supervision, Conceptualization. Chinnakhet Ketsuwan: Writing – review & editing.

Ethical approval

This case report was conducted in accordance with the ethical standards of the institution and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The ethical approval number is COA No. MURA2024/263. Informed consent was obtained from the patient included in this case report.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no conflicts of interest.