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Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement

DOI: 10.1097/JU.0000000000001299
Reference: JU-20-1119

Contexto del Tema: La ureteroscopía flexible (URSf) ha sido el procedimiento endourológico que más se ha desarrollado en los últimos años (1). Esto tiene que ver con el acceso masivo a ureteroscopios descartables y por sus mejores resultados comparados con la litotripsia extracorpórea. Con el aumento de URSf, y por lo tanto, un aumento del uso de vainas de acceso ureterales, comenzamos a ver complicaciones que no eran frecuente en nuestra práctica clínica. Las estenosis de uréter post ureteroscopía están ampliamente descritas en la literatura llegando a ser hasta el 4 % (2). Este tipo de complicaciones son graves, ya que su resolución, dependiendo en que segmento del uréter ocurran, implica un desafío quirúrgico importante. La comunidad urológica, comenzó a mirar con detención este fenómeno cuando Traxer el año 2012 publica su clasificación de daño a la pared ureteral (Grado 0 al Grado 4) e insinúa el tratamiento a realizar en cada caso. Múltiples otras publicaciones dan cuenta que al existir lesiones ureterales de alto grado por el uso de vainas de acceso, la posibilidad de estenosis ureteral tardía es mayor.  ¿Cómo podemos prevenir o intuir este tipo de daño? El trabajo a revisar del grupo de la Cleveland Clinic trata de una manera sencilla e inteligente, de definir factores de riesgo en pacientes que se les realizará una URFf con uso de vaina de acceso y de esta manera planificar de mejor manera la cirugía, incluso indicando la instalación previa de un catéter doble jota, para prevenir la eventual estenosis de uréter.

Resumen: Se trata de un trabajo prospectivo desarrollado en un año. Se enrolaron 68 pacientes a los que se les realizaría una URSf por litiasis renal y por lo tanto contaban con uréteres sin previa dilatación. Solo en 64 pacientes se logró instalar vaina de acceso, esto nos deja un primer dato importante; la necesidad de un catéter ureteral previo a una URSf en casi un 10% de los casos. De los 64 pacientes con uso de vaina de acceso 12/14 fr., 70% (46 pacientes) presentaron algún grado de lesión ureteral. Pacientes con lesiones grado 4 no fueron consignados, sin embargo, hubo 12 pacientes (25%) que presentaron lesiones grado 3, consideradas de alto grado y que eventualmente podrían desarrollar una estenosis ureteral tardía. La mayoría de las lesiones de alto grado fueron en uréter proximal (80 %); segundo mensaje relevante; las lesiones de uréter al usar vaina de acceso son más frecuentes de lo creemos y en un porcentaje no menor pueden ser graves. A todos los pacientes enrolados en el estudio se les solicitó una tomografía axial computarizada sin contraste días previos a la cirugía y siguiendo un estricto protocolo se midió el ancho del uréter a nivel proximal, medio y distal. Existen varios hallazgos a destacar, principalmente si nos concentramos en las lesiones de alto grado. La mayoría de las lesiones de alto grado se producen en uréter proximal y en género masculino. Un diámetro de uréter proximal menor, se relaciona directamente con la posibilidad de tener una lesión ureteral proximal de alto grado, en este trabajo el diámetro promedio de uréteres proximales que tuvieron lesiones de alto grado fue de 3,29 mm. (Tabla 1).

Valoración Personal

Puntos Fuertes

  • Trabajo muy bien realizado, de una manera simple e inteligente.
  • Muestra que al menos en un 10% de los pacientes no se lograra la instalación de vaina de acceso ureteral, lo cual debe ser conocido por el paciente, previo a la cirugía.
  • Nos entrega herramientas para prevenir el daño ureteral al usar vainas de acceso en URSf, permitiéndonos planificar previo a la cirugía el uso de una vaina de acceso más corta, o simplemente no usarla.

Puntos Débiles

  • Podría existir cierta subjetividad en las mediciones del diámetro ureteral y del grado de daño ureteral posterior a la cirugía, porque son operadores dependientes.

Dr. Fernando Marchant G.
Prof. Asociado Universidad de Chile
Unidad de Endourología Hospital Clínico
Universidad de Chile

Bibliography

  1. Trends in Upper Tract Stone Disease in England: Evidence from the Hospital Episodes Statistics (HES) Database. Rukin N, Siddiqui Z, Chedgy E, Somani BK. Urol Int. 2017; 98:391–396. 
  2. The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: A long-term study at two academic centres. El-Abd AS, Suliman MG, Abo Farha MO, Ramadan AR, El-Tatawy HH, El-Gamal OM, et al. Arab J Urol. 2014;12:168–72
  3. Prospective evaluation and classification of ureteral wall injuries resulting from insertion of a ureteral access sheath during retrograde intrarenal surgery. Olivier Traxer 1, Alexandre Thomas. J Urol  2013 Feb;189(2):580-4

129 replies on “Ureteral Diameter as Predictor of Ureteral Injury during Ureteral Access Sheath Placement”

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