002-5347/78/1192-0166$02.00/0 THE
JOURNAL OF UROLOGY
Vol. 119, February Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
OPERATIVE NEPHROSCOPY WITH FIBEROPTIC SCOPE: PRELIMINARY REPORT MAK.OTO MIKI, YOSHIO INABA AND TOYOHEI MACHIDA From the Department of Urology, Jikei University School of Medicine, Tokyo, Japan
ABSTRACT
New fiberoptic scopes, originally designed for biliary tract operations, were used in 23 cases for removal of residual calculi at pyelolithotomy and for examination of the renal pelvis and ureter. The external diameters of the scopes are 6.6 mm. (CHF-Xl) and 4.5 mm. (CHF-X2). Water irrigation and forceps manipulation can be performed simultaneously with the CHF-Xl scope but only irrigation can be done with the CHF-X2 scope. The scopes were reliable and allowed easy endoscopic forceps manipulation. Improvements for an ideal fiberoptic nephroscope are discussed. It would be useful if one could observe the interior of the renal pelvis, remove residual calculi and biopsy small lesions through an endoscope during a renal operation. The usefulness of a lens system scope in performing intrarenal observation and manipulation at operation has been described previously.1-5 We have tried to develop an ideal operative nephroscope: based on our experience with the lens system nephroscope since 1974. Herein we describe clinical urological results that were obtained with special fiberoptic scopes (CHF-Xl and CHF-X2),* originally designed by Yamakawa and associates for biliary tract operations.
Case 2. R. T., 12-1292-3, a 58-year-old man, was seen initially 2 years ago for anuria. The left kidney was not functioning and the right kidney showed signs of obstructive hydronephrosis. A nephrostomy was performed on the right side. Urinary tuberculosis was suspected. A year later the right pyelogram showed a filling defect in the lower calix (fig. 3). The CHF-Xl scope, introduced through the nephrostomy fistula, revealed pyelitis cystica, which was diagnosed histologically by biopsy.
INSTRUMENT AND TECHNIQUE
The CHF-Xl and CHF-X2 scopes are similar in appearance except for the size of the scope end and the shape of the water irrigating nozzle (fig. 1). The over-all length is 600 mm. and the distal third of the scope is flexible in either model. The external diameters are 6.6 mm. and 4.5 mm. in CHF-Xl and CHF-X2, respectively. The viewing angle is 85 degrees in air and 62 degrees in water, and the focus is between 3 and 50 mm. The middle third of the scope is semirigid and the distal third is flexible. Twenty-five mm. of the tip of the scope is designed to be remote-operated up and down by 90 degrees on each side. The operating channel is located at a point on the lower third of the scope through which forceps can be inserted easily. Water irrigation and forceps manipulation can be performed simultaneously with the CHF-Xl scope but only irrigation can be done with the CHF-X2 scope. The Olympus CLS light source was used for taking photographs with automatic exposure in either model. The usual irrigation system for cystoscopy was used as well as a set of intravenous drip infusion. At an open operation the scope was introduced into the renal pelvis through a pyelotomy. Observation of the interior and forceps manipulation could be performed under water flow. Three kinds of forceps were used, including those for stone manipulation, biopsy and coagulation. The nephroscope also was used to observe the interior of the urinary tract and to obtain biopsies through a nephrostomy, ureterocutaneostomy and ileal conduit. CASE REPORTS
Fm. 1. CHF-X2 scope, 4.5 mm. in diameter
Case 3. Y. H., 03-7827-5, a 60-year-old man, had undergone left nephroureterectomy with partial cystectomy in 1972 for a ureteral tumor. Histologic diagnosis was a transitional cell carcinoma. A year later he had a recurrent tumor in the bladder, which was resected transurethrally. The present hospitalization was for a right ureteral tumor, which was suspected by retrograde pyelography (fig. 4). The ureter containing the tumor was resected. The remaining ureter and pelvis were observed with the CHF-X2 scope and were proved to be free of tumor. The ureter was reconstructed by end-to-end anastomosis.
Case 1. Y. W., 24-7362-3, a 75-year-old man, had gross DISCUSSION hematuria and back pain. He had passed urinary calculi on 3 occasions. Examination revealed 3 stones in the renal pelvis From August 1975 to July 1976 the scopes were applied to of the right kidney (fig. 2). After removal of the major stones 23 clinical cases, including the aforementioned 3 (see table). by pyelolithotomy small fragments were picked up with stone Observation took a few minutes and the biopsy or removal of forceps under direct vision with the CHF-Xl scope. residual calculi required 5 to 15 minutes. For irrigation less than 500 ml. of water was sufficient. An angle deflector on Accepted for publication April 1, 1977. * Olympus Optical Co., Ltd. the tip of the scope gave a clear vision of the area for 166
OPERA1'IVE NEPHROSCOPY WITH FIBEROPTIC SCOPE
pelvic interior are shown in figure 5, including the aforeme:n,tioned cases. In 1948 Trattner described the clinical usefulness of the operative nephiroscope that consisted of a rigid straight 24F' sheath and a combination of right angle and foroblique lens system scopes. 1 Leadbetter introduced a 22F right angie scope for obtaining a clearer vision of the renal pelvis with water irrigation. 2 Vatz and associates improved visualization widened viewing angle with a combination of the glass rods and air space of the Hopkins system, and a 15F right endoscope with an irrigating system. 3 Gittes reported on usefulness of the rigid right angle nephroscope and Hertel.'s 5 There stone forceps in 58 cases during a 24-month have been few reports published on a fibe:roptic nephroscope. Tsuchida6 and a few others have papers on the subject at scientific meetings, and a 1n·,~t.,rrnmra,.. loscope was described Takayasu and associates7 in
2 shows filling defect in lower calix and
observation. The instrument allowed safer manipulation than the lens system Of the 4 cases stones 3 were successful but 1 failed because a small calculus was trapped in the minor calix in which there was not enough space for '"'"u'P'"'u,e,,uu and occurred easily. No significant ~v_,,,,,,,,v~•,wu was encountered. The CHF-Xl was used in cases of open renal and the was used mainly for examination a cmm·n"r,.-,Y, or uret,,irc,cu.taneos1corny since the CHF-Xl was too bele(:tect oto~r,-ratpt1s renal
Fm. 4. Retrograde pyelogram of case 3 reveals suspicion of right ureteral tumor.
Uses offiberoptic scope in 23 cases No. Cases
Searching for or removal ofresidual calculi at pyelolithotomy Examination of renal pelvis and ureter during open operation Exploration through nephrostomy Exploration through ureterocutaneostomy Others Total
9 5
4 1 4
23
168
MIKI, INABA AND MACHIDA
Fm. 5. A, residual stone in case 1. B, pyelitis cystica in case 2. C, ureteral tumor in case 3. D to F, pelvic interiors of other cases.
Initially, we used a rigid right angle instrument but it was dangerous to move the tip around close to the renal pedicle and difficult to see some portions of the pelvis or some calices. It was concluded that the fiberoptic scope was better than the lens system scope as an operative nephroscope. The fiberoptic scope is evidently superior to the solid lens system because of its flexibility and it does provide an image resolution sharp enough for observation of the interior of the renal pelvis. However, enlarged pictures are not as sharp with the fiberoptic scope. Not only the major calix but also minor calices were observed satisfactorily and atraumatically with the CHF-X2 scope, which measures 4.5 mm. in diameter, the same size as the scope described by V atz and associates. 3 However, they could not control the tip of the scope for observation and were not familiar with the operation of a fiberoptic scope. When manipulating forceps through the CHF-Xl scope the opened forceps injured the wall of minor calices, a problem that is to be solved in the future. The CHF-Xl and CHF-X2 scopes need several improvements, namely the length and caliber of the scope, and all aspects of operating forceps. The viewing angle, focus, angle deflection and irrigating system are satisfactory. The nephroscope should have a length of at least 35 cm. like the scope used by Vatz and associates. 3 If it is shorter the operator would have ·to be close to the open wound. Conversely, a length of more than 60 cm. would be too long to manipulate. We believe that the best length of the scope is between 40 to
50 cm. With the CHF-X2 scope, which has a 4.5 mm. diameter, minor calices can be examined. Therefore, for 4.5 mm. in diameter, 15F is the proper size. It would be ideal if operating forceps could be used through the CHF-X2 scope but certain details, such as the type, materials and the deflection of the tip of forceps, await further improvement. In our series we obtained various information by using the scope to observe the interior of the urinary tract through a nephrostomy, ureterocutaneostomy and ileal conduit as well as through open renal operation. We hope to improve on the fiberoptic nephroscope based on our experience. REFERENCES
1. Trattner, H. R.: Instrumental visualization of the renal pelvis and its communications: proposal of a new method; preliminary report. J. Urol., 60: 817, 1948. 2. Leadbetter, W. F.: Instrumental visualization of the renal pelvis at operation as an aid to diagnosis. Presentation of a new instrument. J. Urol., 63: 1006, 1950. 3. Vatz, A., Berci, G., Shore, J. M., Kudish, H. and Nemoy, N.: Operative nephroscopy. J. Urol., 107: 355, 1972. 4. Koff, S. A.: Simplified operative nephroscopy. Urology, 7: 260, 1976. 5. Gittes, R. F.: Operative nephroscopy. J. Urol., 116: 148, 1976. 6. Tsuchida, S.: A new operative fiberpyeloscope. J. Urol., 117: 643, 1977. 7. Takayasu, H., Aso, Y., Takagi, T. and Go, T.: Clinical application offiberoptic pyeloureteroscope. Urol. Int., 26: 97, 1971.
JOURNAL OF UROLOGY
Vol. 119, February Printed in U.S.A.
Copyright © 1978 by The Williams & Wilkins Co.
OPERATIVE NEPHROSCOPY WITH FIBEROPTIC SCOPE: PRELIMINARY REPORT MAK.OTO MIKI, YOSHIO INABA AND TOYOHEI MACHIDA From the Department of Urology, Jikei University School of Medicine, Tokyo, Japan
ABSTRACT
New fiberoptic scopes, originally designed for biliary tract operations, were used in 23 cases for removal of residual calculi at pyelolithotomy and for examination of the renal pelvis and ureter. The external diameters of the scopes are 6.6 mm. (CHF-Xl) and 4.5 mm. (CHF-X2). Water irrigation and forceps manipulation can be performed simultaneously with the CHF-Xl scope but only irrigation can be done with the CHF-X2 scope. The scopes were reliable and allowed easy endoscopic forceps manipulation. Improvements for an ideal fiberoptic nephroscope are discussed. It would be useful if one could observe the interior of the renal pelvis, remove residual calculi and biopsy small lesions through an endoscope during a renal operation. The usefulness of a lens system scope in performing intrarenal observation and manipulation at operation has been described previously.1-5 We have tried to develop an ideal operative nephroscope: based on our experience with the lens system nephroscope since 1974. Herein we describe clinical urological results that were obtained with special fiberoptic scopes (CHF-Xl and CHF-X2),* originally designed by Yamakawa and associates for biliary tract operations.
Case 2. R. T., 12-1292-3, a 58-year-old man, was seen initially 2 years ago for anuria. The left kidney was not functioning and the right kidney showed signs of obstructive hydronephrosis. A nephrostomy was performed on the right side. Urinary tuberculosis was suspected. A year later the right pyelogram showed a filling defect in the lower calix (fig. 3). The CHF-Xl scope, introduced through the nephrostomy fistula, revealed pyelitis cystica, which was diagnosed histologically by biopsy.
INSTRUMENT AND TECHNIQUE
The CHF-Xl and CHF-X2 scopes are similar in appearance except for the size of the scope end and the shape of the water irrigating nozzle (fig. 1). The over-all length is 600 mm. and the distal third of the scope is flexible in either model. The external diameters are 6.6 mm. and 4.5 mm. in CHF-Xl and CHF-X2, respectively. The viewing angle is 85 degrees in air and 62 degrees in water, and the focus is between 3 and 50 mm. The middle third of the scope is semirigid and the distal third is flexible. Twenty-five mm. of the tip of the scope is designed to be remote-operated up and down by 90 degrees on each side. The operating channel is located at a point on the lower third of the scope through which forceps can be inserted easily. Water irrigation and forceps manipulation can be performed simultaneously with the CHF-Xl scope but only irrigation can be done with the CHF-X2 scope. The Olympus CLS light source was used for taking photographs with automatic exposure in either model. The usual irrigation system for cystoscopy was used as well as a set of intravenous drip infusion. At an open operation the scope was introduced into the renal pelvis through a pyelotomy. Observation of the interior and forceps manipulation could be performed under water flow. Three kinds of forceps were used, including those for stone manipulation, biopsy and coagulation. The nephroscope also was used to observe the interior of the urinary tract and to obtain biopsies through a nephrostomy, ureterocutaneostomy and ileal conduit. CASE REPORTS
Fm. 1. CHF-X2 scope, 4.5 mm. in diameter
Case 3. Y. H., 03-7827-5, a 60-year-old man, had undergone left nephroureterectomy with partial cystectomy in 1972 for a ureteral tumor. Histologic diagnosis was a transitional cell carcinoma. A year later he had a recurrent tumor in the bladder, which was resected transurethrally. The present hospitalization was for a right ureteral tumor, which was suspected by retrograde pyelography (fig. 4). The ureter containing the tumor was resected. The remaining ureter and pelvis were observed with the CHF-X2 scope and were proved to be free of tumor. The ureter was reconstructed by end-to-end anastomosis.
Case 1. Y. W., 24-7362-3, a 75-year-old man, had gross DISCUSSION hematuria and back pain. He had passed urinary calculi on 3 occasions. Examination revealed 3 stones in the renal pelvis From August 1975 to July 1976 the scopes were applied to of the right kidney (fig. 2). After removal of the major stones 23 clinical cases, including the aforementioned 3 (see table). by pyelolithotomy small fragments were picked up with stone Observation took a few minutes and the biopsy or removal of forceps under direct vision with the CHF-Xl scope. residual calculi required 5 to 15 minutes. For irrigation less than 500 ml. of water was sufficient. An angle deflector on Accepted for publication April 1, 1977. * Olympus Optical Co., Ltd. the tip of the scope gave a clear vision of the area for 166
OPERA1'IVE NEPHROSCOPY WITH FIBEROPTIC SCOPE
pelvic interior are shown in figure 5, including the aforeme:n,tioned cases. In 1948 Trattner described the clinical usefulness of the operative nephiroscope that consisted of a rigid straight 24F' sheath and a combination of right angle and foroblique lens system scopes. 1 Leadbetter introduced a 22F right angie scope for obtaining a clearer vision of the renal pelvis with water irrigation. 2 Vatz and associates improved visualization widened viewing angle with a combination of the glass rods and air space of the Hopkins system, and a 15F right endoscope with an irrigating system. 3 Gittes reported on usefulness of the rigid right angle nephroscope and Hertel.'s 5 There stone forceps in 58 cases during a 24-month have been few reports published on a fibe:roptic nephroscope. Tsuchida6 and a few others have papers on the subject at scientific meetings, and a 1n·,~t.,rrnmra,.. loscope was described Takayasu and associates7 in
2 shows filling defect in lower calix and
observation. The instrument allowed safer manipulation than the lens system Of the 4 cases stones 3 were successful but 1 failed because a small calculus was trapped in the minor calix in which there was not enough space for '"'"u'P'"'u,e,,uu and occurred easily. No significant ~v_,,,,,,,,v~•,wu was encountered. The CHF-Xl was used in cases of open renal and the was used mainly for examination a cmm·n"r,.-,Y, or uret,,irc,cu.taneos1corny since the CHF-Xl was too bele(:tect oto~r,-ratpt1s renal
Fm. 4. Retrograde pyelogram of case 3 reveals suspicion of right ureteral tumor.
Uses offiberoptic scope in 23 cases No. Cases
Searching for or removal ofresidual calculi at pyelolithotomy Examination of renal pelvis and ureter during open operation Exploration through nephrostomy Exploration through ureterocutaneostomy Others Total
9 5
4 1 4
23
168
MIKI, INABA AND MACHIDA
Fm. 5. A, residual stone in case 1. B, pyelitis cystica in case 2. C, ureteral tumor in case 3. D to F, pelvic interiors of other cases.
Initially, we used a rigid right angle instrument but it was dangerous to move the tip around close to the renal pedicle and difficult to see some portions of the pelvis or some calices. It was concluded that the fiberoptic scope was better than the lens system scope as an operative nephroscope. The fiberoptic scope is evidently superior to the solid lens system because of its flexibility and it does provide an image resolution sharp enough for observation of the interior of the renal pelvis. However, enlarged pictures are not as sharp with the fiberoptic scope. Not only the major calix but also minor calices were observed satisfactorily and atraumatically with the CHF-X2 scope, which measures 4.5 mm. in diameter, the same size as the scope described by V atz and associates. 3 However, they could not control the tip of the scope for observation and were not familiar with the operation of a fiberoptic scope. When manipulating forceps through the CHF-Xl scope the opened forceps injured the wall of minor calices, a problem that is to be solved in the future. The CHF-Xl and CHF-X2 scopes need several improvements, namely the length and caliber of the scope, and all aspects of operating forceps. The viewing angle, focus, angle deflection and irrigating system are satisfactory. The nephroscope should have a length of at least 35 cm. like the scope used by Vatz and associates. 3 If it is shorter the operator would have ·to be close to the open wound. Conversely, a length of more than 60 cm. would be too long to manipulate. We believe that the best length of the scope is between 40 to
50 cm. With the CHF-X2 scope, which has a 4.5 mm. diameter, minor calices can be examined. Therefore, for 4.5 mm. in diameter, 15F is the proper size. It would be ideal if operating forceps could be used through the CHF-X2 scope but certain details, such as the type, materials and the deflection of the tip of forceps, await further improvement. In our series we obtained various information by using the scope to observe the interior of the urinary tract through a nephrostomy, ureterocutaneostomy and ileal conduit as well as through open renal operation. We hope to improve on the fiberoptic nephroscope based on our experience. REFERENCES
1. Trattner, H. R.: Instrumental visualization of the renal pelvis and its communications: proposal of a new method; preliminary report. J. Urol., 60: 817, 1948. 2. Leadbetter, W. F.: Instrumental visualization of the renal pelvis at operation as an aid to diagnosis. Presentation of a new instrument. J. Urol., 63: 1006, 1950. 3. Vatz, A., Berci, G., Shore, J. M., Kudish, H. and Nemoy, N.: Operative nephroscopy. J. Urol., 107: 355, 1972. 4. Koff, S. A.: Simplified operative nephroscopy. Urology, 7: 260, 1976. 5. Gittes, R. F.: Operative nephroscopy. J. Urol., 116: 148, 1976. 6. Tsuchida, S.: A new operative fiberpyeloscope. J. Urol., 117: 643, 1977. 7. Takayasu, H., Aso, Y., Takagi, T. and Go, T.: Clinical application offiberoptic pyeloureteroscope. Urol. Int., 26: 97, 1971.
