Bladder calculi in children who perform clean intermittent catheterization

OBJECTIVE

To examine the role of clean intermittent catheterization (CIC) as a possible predisposing risk factor for bladder calculi, assessing risk factors in patients with and without bladder augmentation, and to evaluate management options for bladder calculi in these patients.

PATIENTS AND METHODS

The records of 403 patients who were using a regimen of CIC between January 1981 and March 1998 were reviewed to identify those forming bladder calculi; stones were diagnosed in 28 patients. The patients were categorized as: group 1, patients with no bladder augmentation who catheterized urethrally (227, group 1a) or via a Mitrofanoff conduit (18, group 1b); group 2, patients with augmented bladders who catheterized urethrally (100, group 2a) or via a Mitrofanoff conduit (58, group 2b). The incidence of bladder calculi in each group was determined and compared statistically where applicable. The success of the treatment options for stone management was reviewed.

RESULTS

Bladder calculi developed in 5% of patients in group 1a, 8% in group 2a, 11% in group 1b, and 10% in group 2b; the incidence of calculi was not significantly different among the groups. Of these patients, 18 (64%) were asymptomatic at the time of diagnosis and significant bacteriuria was found in 23 (88%). Difficulty in catheterizing either the Mitrofanoff conduit or the native urethra was reported in 14 (50%) of these patients. Calculi were more often solitary (71%) and typically composed of struvite or apatite. Calculi were managed by open cystolithotomy in 15 patients (54%) and endoscopically in 13 (46%). Stones recurred in nine patients (32%) after treatment, comprising four of six patients treated endoscopically with electrohydraulic lithotripsy and in five of 15 after open cystolithotomy. The mean interval to recurrence was 22.8 months.

CONCLUSION

These results suggest that patients on a regimen of CIC are at risk of developing bladder calculi but the incidence of calculi is not influenced by bladder augmentation. The presence of a Mitrofanoff conduit was associated with a slightly increased incidence of calculus formation. Open cystolithotomy was associated with a lower stone recurrence rate but there were too few patients to draw definitive conclusions.

Experience with the holmium laser as an endoscopic lithotrite

INTRODUCTION

Holmium laser lithotripsy represents an additional option in the management of urinary tract calculi. We report the results of a cohort of patients with ureteric and bladder calculi treated with this modality.

METHODS

Twenty-three patients underwent holmium laser lithotripsy to treat ureteric or bladder calculi. Power settings of 0.5 J to deliver 2.5-4.0 watts were used for the ureteric calculi, and up to 30 watts for the bladder calculi.

RESULTS

The mean ureteric stone size was 7.3 mm (range 4-10 mm). One stone was upper ureteric, seven were mid-ureter and nine were lower-ureter. Eighteen of the 19 patients with ureteric calculi were free of stones 28 days postoperatively. The remaining patient was clear by 12 weeks. All patients with bladder calculi were completely cleared of stones. There were no intraoperative complications.

DISCUSSION

Ureteric stone position can limit the use of extracorporeal shock wave lithotripsy due to imaging difficulties. Ureteric lithotripsy overcomes this problem. The holmium laser has proven to be safe and effective in clearing urinary stone burdens of a variety of sizes, sites and compositions in this cohort of patients.

[Cystolithotripsy for bladder stones: comparison of holmium:YAG laser with Lithoclast as a lithotripsy device]

From March 1995 to March 1999, endoscopic lithotripsy of bladder stones was done for 33 patients. We used Holmium:YAG laser for the initial 23 patients, and the Swiss Lithoclast for the recent 10 patients. We compared the safety and efficacy of the two modalities. Both lithotriptors were safe and effective to fragment the bladder stones. All the patients became stone-free at one session. However, we needed to use the Holmium:YAG laser in one patient to disintegrate the larger fragments after Lithoclast. For a big stone, Holmium:YAG laser is preferable.

The vesical calculus

Bladder calculi account for 5% of urinary calculi and usually occur because of foreign bodies, obstruction, or infection. Males with prostate disease or previous prostate surgery and women who undergo anti-incontinence surgery are at higher risk for developing bladder calculi. Patients with SCI with indwelling Foley catheters are at high risk for developing stones. There appears to be a significant association between bladder calculi and the formation of malignant bladder tumors in these patients. Transplant recipients are not at increased risk for developing vesical calculi in the absence of intravesical suture fragments and other foreign bodies. Patients who undergo bladder-augmentation procedures using a vascularized gastric patch appear to be protected from vesicolithiasis, perhaps by the acidic environment. Ileum and colon tissues, however, are colonized by urease-producing organisms, producing an alkaline pH that promotes stone formation. Children remain at high risk for bladder-stone development in endemic areas. Diet, voiding dysfunction, and uncorrected anatomic abnormalities, such as posterior urethral valves and vesicoureteral reflux, predispose them to bladder-calculus formation. Finally, there are a number of techniques and modalities available to remove bladder stones. Relieving obstruction, eliminating infection, meticulous surgical technique, and accurate diagnosis are essential in their treatment.

Schlieren photography study of energy absorption by uric acid nuclei

Previous studies using microfocus x-ray radiography on concentric laminated uric acid calculi following in vitro extracorporeal shock-wave lithotripsy (ESWL) has demonstrated the enlargement of the matrix layers. The Schlieren technique was used to verify the hypothesis that the incident energy would be concentrated in the matrix layers by total internal reflection. Because of the rough surface of the stone, the ultrasonic beam (4 MHz) was incident at various angles. At the critical Rayleigh angle (45.9 degrees +/- 0.5 degrees ), the reflected beam consisted of a spectacularly reflected lobe and a reradiated leaky Rayleigh wave. Different critical Lamb angles, theta(L), of 30.8 degrees, 38.1 degrees and 50.8 degrees (experimental uncertainty 0.5 degrees ) were also determined. Depending on the angle of incidence on the stone surface, a Rayleigh wave can be produced and/or one or more layers, as a whole, are set into vibration (Lamb excitation), with the result that shell-like fragments consisting of one or more layers, break off the stones at sites of weaker bonding, as has been noted in previous in vitro lithotripsy experiments by our group.

Reduction of urinary stone in children from north-eastern Thailand

Bladder stones in children have decreased now compared with the previous decade. If we promote good nutrition for children, bladder stones will decrease and might be eradicated in the future. A seminar of doctors and health personnel from 19 hospitals in the north-eastern provinces of Thailand was conducted to survey bladder stones in children by weighting and interviewing bladder stone symptoms then giving supplementary diet milk and vitamins and teaching health education about nutrition and urinary stones through referring children with bladder stones to hospitals in north-eastern Thailand for surgery. The findings of the stone patients from October 1995 to June 1996 from hospitals in northern Thailand were: Total number of patients was 6671 of which 287 patients (4.3%) were 10 years old or younger. Of these children there were 135 renal stone operations (2.0%), 29 ureteric stone operations (0.4%), 106 bladder stone operations (1.6%) and 17 urethral stone operations (0.3%). There were 6384 patients aged more than 10 years. (95.7%) The total number of operations was 5373.

Percutaneous suprapubic cystolithotripsy for treatment of large bladder calculi

BACKGROUND AND PURPOSE

The treatment options available for managing bladder calculi include transurethral cystolithotripsy, open cystolithotomy, and shockwave lithotripsy. For larger calculi, transurethral treatment can be time consuming, and the manipulation has the potential to cause urethral injury. Percutaneous suprapubic cystolithotripsy represents another treatment option for bladder calculi which is effective and minimally invasive.

PATIENTS AND METHODS

Fifteen patients had bladder calculi treated with percutaneous cystolithotripsy over a 3-year period. The mean stone size was 39 mm (range 10-64 mm). Stones were single in seven patients and multiple in eight patients. The indications for cystolithotripsy were stone size >3 cm, multiple stones >1 cm, and inability to perform transurethral cystolithotripsy because of patient anatomy. Percutaneous suprapubic cystolithotripsy was done through either a 30F or a 36F cystotomy tract. Fragmentation and removal was performed with a 26F rigid nephroscope and the pneumatic Swiss Lithoclast. Suprapubic and urethral catheters were placed postoperatively in all patients.

RESULTS

Each patient was cleared of the stone burden with a single procedure, and there were no major complications. The mean duration of suprapubic catheterization was 2.6 (range 1-5) days.

CONCLUSION

Percutaneous suprapubic cystolithotripsy is an effective and safe technique for treating large bladder calculi. It is minimally invasive, avoids urethral injury, and, in combination with the pneumatic Swiss Lithoclast, can be used to fragment and remove large and hard bladder calculi.

Percutaneous vesicolithotomy: an alternative to open bladder surgery in patients with an impassable or surgically ablated urethra

PURPOSE

Although vesical calculi are routinely treated transurethrally, open vesicolithotomy is generally performed in patients with an impassable or surgically ablated urethra. We describe a technique of percutaneous vesicolithotomy which we used in patients who had undergone urethral ablation and concomitant continent diversion by appendicovesicostomy.

MATERIALS AND METHODS

Bladder stones were detected in 3 patients with neurogenic bladder who had undergone continent urinary diversion with bladder neck closure and appendicovesicostomy. To treat the stones access to the bladder was achieved percutaneously and the tract was enlarged using a balloon dilator. An Amplatz sheath was slipped over the inflated balloon and after the dilator was removed the sheath provided a working channel through which stones were fragmented and removed using a nephroscope.

RESULTS

Each patient was rendered stone-free and discharged home the same day as the procedure.

CONCLUSIONS

Percutaneous vesicolithotomy provides an alternative approach for bladder stone removal in patients with an impassable urethra with decreased morbidity compared to open procedures.

Holmium:YAG lithotripsy for large renal and bladder calculi: strategies for efficient lithotripsy

Holmium:YAG lithotripsy is effective for all stone compositions, and high success rates may be expected. Large renal and bladder calculi may be treated effectively with Ho:YAG lasertripsy. Using angled optical fibers and increasing power settings may be particularly useful to increase lithotripsy speed.

The management of vesical calculi with combined optical mechanical cystolithotripsy and transurethral prostatectomy: is it safe and effective?

OBJECTIVES

To investigate the effectiveness and reliability of the combination of optical mechanical cystolithotripsy (OMC) and transurethral prostatectomy (TURP) for the treatment of bladder calculi and obstructive benign prostatic enlargement (BPE).

PATIENTS AND METHODS

From December 1990 to December 1996, 61 patients who had bladder stones and BPE or bladder neck contracture were treated with combined OMC and TURP; 32 patients who had bladder stones with no infravesical obstruction were treated with OMC alone. The records of a random selection of 97 patients with obstructive BPE who were treated with TURP only in the same period were used as the control. The operative duration time, the length of hospital stay, the duration of urethral catheterization, outcome and complications of the procedures for each patients were reviewed. The Mann-Whitney U-test and chi-square tests were used for statistical analysis.

RESULTS

The mean duration of surgery, hospital stay and urethral catheterization were significantly longer with combined OMC and TURP than with OMC alone (P<0.05). Stone-free rates were 94% after OMC alone and 93% after combined OMC and TURP. The postoperative mean peak flow rates were 14.3 mL/s after the combined procedure and 15.2 mL/s after TURP alone. The complication rates were 21% for the combined procedure and 13% for OMC alone. The complication rate of TURP was 5%, significantly lower than that for the combined procedure (P<0.05).

CONCLUSION

Bladder stones were associated with infravesical obstruction in two-thirds of patients. Simultaneous treatment with OMC and TURP did not change the effectiveness of these procedures, but caused additional morbidity.

An unusual presentation of a foreign body in the urinary bladder: A migrant intrauterine device

A 35-year-old woman, who had had an intrauterine device inserted 7 years earlier, presented with dysuria, pollakiuria, suprapubic pain and urethral irritation. The intrauterine device was found in the bladder with stone formation and was removed by endoscopy.

Experience with the Dornier lithotriptor MPL 9000-X for the treatment of vesical lithiasis

Between February 1994 and March 1995, 52 patients (48 men and 4 women) with vesical lithiasis were treated by extracorporeal shock wave lithotripsy (ESWL), using the MPL 9000-X Dornier lithotriptor. Twenty-five patients showed bladder outlet obstruction. In 9 patients, there was evidence of associated bladder neuropathy. In 6 patients, calculi presented idiopathically in normal bladders. Two patients had silent migration of ureteral calculi and increase in bladder volume, 8 were high risk and 2 others refused other methods of up to date treatment. Vesical stone sizes ranged from 10 to 22 mm in greatest diameter (mean 15 mm). The treatments were performed without the use of anaesthesia and on an outpatient basis. Complete fragmentation was achieved after a single session in 46 patients and 3 required 2 sessions. Postoperative adjunctive endourological procedures included cystoscopy in 9 patients and urethroscopy in 1 patient for evacuation of stone fragments. The overall stone-free rate was 94.2% (49 out of 52 patients) with ESWL and adjunctive measures as needed. No major complications were noted. We find ESWL with the MPL 9000-X lithotriptor to be a simple, effective and safe modality for the treatment of most patients with vesical lithiasis, especially in high risk patients.

Percutaneous suprapubic cystolithotripsy for vesical calculi in children

BACKGROUND

The majority of vesical calculi in adults can now be treated per-urethrally with the use of ultrasonic or pneumatic lithotripsy. However, the use of these devices is restricted in pediatric patients by the narrow caliber of the urethra. A percutaneous suprapubic approach to the bladder circumvents the problem of urethral caliber in these situations.

PATIENTS AND METHODS

Thirty-eight children presenting with bladder stones underwent percutaneous suprapubic cystolithotripsy (PCCL) between November 1989 and April 1996. The age ranged from 1.5 to 7 years. The stone size ranged from 0.8 to 2.4 cm. Seven of these were recurrent stones, and five of the patients were female. The procedure was done under general anesthesia, and the equipment was the same as for upper tract endourology. The bladder was distended with saline and a suprapubic puncture made. The nephroscope was introduced after tract dilation and the stone removed, intact if small or after fragmentation if >1 cm. The procedure was done without fluoroscopy. A suprapubic catheter was left in for 48 hours.

RESULTS

All patients had an uneventful recovery following stone removal. The average hospital stage was 3 days. Here, the access provided by percutaneous suprapubic cystostomy has been combined with the experience gained in upper-tract endourology to perform procedures that would otherwise require open operation because of nonavailability of urethral access.

CONCLUSION

Extension of endourologic procedures to the lower tract reduces morbidity and hospital stay and thus the cost of treatment. Percutaneous suprapubic cystolithotripsy, in our experience, is a safe and cost-effective alternative to open surgery in children.

Percutaneous cystolithotomy for vesical calculi: a better approach

Vesical calculus is a common problem that is treated traditionally with open cystolithotomy or cystolithalopaxy. Open surgery has the inherent problems of a long scar, prolonged catheterization, extended hospitalization, and risk of infection. Transurethral cystolithalopaxy also requires special instruments that carry a risk of trauma, which could lead to urethral strictures. Thirty-eight patients (15 children and 23 adults) were treated for vesical calculi by percutaneous cystolithotomy (PCCL), a minimally invasive procedure. A fluoroscopic-guided tract was made to the bladder through a small suprapubic puncture (9-10 mm) and a nephroscope was inserted via an Amplatz sheath placed suprapubically. The calculus was fragmented with ultrasound or pneumatic energy before being flushed out. A suprapubic catheter was kept in place for 48 hours postsurgery; no urethral catheter was needed. Urethral instrumentation was kept to a minimum. After 48 hours, the suprapubic catheter was clamped and removed after the patient had two or three normal voids. No significant intraoperative or postoperative complication was encountered. Given that the urethra is spared, percutaneous cystolithotomy is a preferred approach in patients with vesical calculi.

Ballistic shock wave lithotripsy in an 18-year-old thoroughbred gelding

Prolonged postoperative recuperation time and restricted exercise were circumvented by using ballistic shock wave lithotripsy to break up an 8-cm diameter vesical calculus and by flushing out the sand-like residue under epidural anesthesia with the horse standing. Recovery was uneventful.

Ureteroscopy in the treatment of ureteral stones: over 10 years' experience

OBJECTIVE

Rapid development of endourology and the invention of more and more advanced ureteroscopes and other instruments used in ureteral lithotripsy have made the traditional methods of treatment become very rare.

METHODS

We present our experience in ureteral lithotripsy resulting from 1,982 ureteroscopy (URS) procedures, performed because of ureteral stones. Before URS, percutaneous nephrostomy tube (PCNT) was created in 264 (16.7%) cases. We also present our own technique, called the 'Jeromin maneuver', which involves pressing the abdominal wall by the assistant's hand, facilitating URS in difficult cases.

RESULTS

Good results after the first URS procedure of removing ureteral stones were obtained in 1, 364 (86.6%) patients out of 1,575. In the remaining 211 (13.4%) cases, URS was performed two or more times. The overall failure rate was 3.6%. In the vast majority of cases, URS procedures were performed without dilatation of the ureteral orifice and splinting. The most important complications of URS were: perforation of the ureteral wall with periureteral leak which necessitated surgery (4 patients), ureteral stenosis which necessitated endoscopic reparation (4 patients) and stenosis of the ureteral orifice which necessitated endoscopic reparation in 2 patients.

CONCLUSIONS

Routine dilatation of the ureteral orifice before the URS procedure and splinting with a D-J catheter are unnecessary; in case of a narrow ureter and very large prostatic adenoma, URS should not be attempted, because of the high risk of serious damage of the ureter. URS is a safe procedure but requires a highly experienced urologist.

Extracorporeal shock wave lithotripsy for vesical lithiasis

Between 1991 and 1997, 17 male patients with bladder stones underwent extracorporeal shock-wave lithotripsy (ESWL) therapy in our department. One patient required epidural anesthesia and 5 patients were treated under intravenous sedation. Complete fragmentation was achieved after a single session in 9 patients and 4 required 2 sessions. Four patients underwent initial ESWL followed by mechanical cystolithotripsy. No major complications were noted. Fourteen patients were stone-free within 1 week after the procedure. Four patients were treated by transurethral resection of the prostate (TUR-P) on the day after completion ESWL. In conclusion, ESWL therapy is a simple, effective and safe modality for the management of vesical lithiasis.

Bladder calculi in the pediatric augmented bladder

PURPOSE

Bladder augmentation is now a commonly accepted treatment in children with neuropathic bladder and other bladder anomalies. Bladder calculi have been reported in a third to a half of pediatric patients after bladder augmentation. We identify the incidence of bladder calculi and risk factors for stone formation in a large series of pediatric patients after bladder augmentation.

MATERIALS AND METHODS

We reviewed the records of 286 patients who underwent bladder augmentation between 1978 and 1994, assessed the incidence of and risk factors for bladder calculi, and reviewed treatment methods.

RESULTS

Bladder calculi developed in 29 of the 286 patients (10%) who underwent bladder augmentation. The type of bowel used for augmentation did not affect the rate of stone formation except stomach, which did not lead to stone formation in any case. Stones formed more commonly after bladder outlet resistance procedures and in patients with catheterizable abdominal wall stomas. Patients underwent open cystolithotomy or cystolitholapaxy with an overall 44% recurrence rate and no statistically significant difference between treatment methods.

CONCLUSIONS

Bladder calculi are a known complication of bladder augmentation. An increased risk of stone formation is associated with bladder outlet resistance procedures and catheterizable abdominal wall stomas. Daily irrigations to clear mucus and crystals as well as complete emptying of the augmented bladder may have important roles in decreasing stone formation.

[Patient-controlled sedation using propofol for a patient with von Gierke disease]

Patient-controlled sedation (PCS) using propofol under spinal anesthesia in transurethral lithotripsy was carried out in a 44 year old patient with von Gierke disease accompanied with liver dysfunction, chronic renal failure, hypoglycemia and metabolic acidosis. After administering spinal anesthesia PCS was started (0.2 mg.kg-1 intravenous bolus dose of propofol; infusion at 2 mg.kg-1.h-1; a three-minute lockout time interval following an initial doses of 0.4 mg.kg-1). PCS with propofol, throughout the operation, brought about adequate sedation level for this patient with 2 or 3 on Wilson's sedation score, and the sedative effect by propofol diminished quickly within 15 minutes after the end of PCS. In addition, respiratory depression due to this sedation which would be worse in acidotic condition was not seen using PCS during the operation. This patient was much satisfied with this sedation in an interview during the postoperative period. PCS using propofol is a useful method without respiratory depression for a patient with von Gierke disease.

Combination of pneumatic lithotripsy and transurethral prostatectomy in bladder stones with benign prostatic hyperplasia

We present our experience with combined pneumatic lithotripsy and transurethral resection of the prostate (TURP) in 52 patients with bladder stone(s) and benign prostatic hyperplasia (BPH). All stones were fragmented with the pneumatic Swiss Lithoclast. Pneumatic lithotripsy and evacuation caused a mean increase of 16 minutes in operating time. No complications, other than mild hematuria, were observed intraoperatively because of pneumatic lithotripsy. We observed early and long-term complications related to the procedure in 13% of patients. The average hospital stay was 3.2 days. The combination of pneumatic lithotripsy and TURP appears to be an effective, safe, and economical treatment method for patients with bladder stone(s) and BPH.

Laboratory and clinical assessment of pneumatically driven intracorporeal lithotripsy

A pneumatically driven intracorporeal lithotripter (the Swiss Lithoclast) has recently been approved for use in the United States. We compared its performance in vitro with ultrasonic, electrohydraulic and laser lithotripsy devices using a standard plaster-of-Paris stone phantom. The probe sizes and output settings were identical to those used during clinical treatment. The fragmentation efficiency index (measured as the lithotripsy time needed to reduce the stone phantom to particles <2 mm divided by the initial stone weight) ranged from 5.0 to 8.5 min/g of stone mass, with this value increasing from pneumatic to electrohydraulic to laser and to ultrasonic lithotripsy. We also performed an objective study in a swine model, which showed no adverse consequence of pneumatic lithotripsy. Finally, we evaluated our initial 41 patients who had undergone pneumatic stone fragmentation. We treated 8 patients having 11 renal calculi, 30 patients having 37 ureteral calculi, and 3 patients having 6 bladder calculi employing pneumatic probes ranging in size from 0.8 to 2.0 mm. Stone fragmentation was successful in a single session in 95% of the ureteral calculi and 100% of both renal and bladder calculi. Stone analysis in 23 patients revealed 17 (74%) calcium oxalate monohydrate and 1 (4%) cystine calculi. Our clinical and laboratory assessment of this newly developed pneumatic lithotripsy device further validates its efficacy in fragmenting stone of all compositions and its overall safety associated with clinical application.

Endourologic therapy of bladder calculi in simultaneous kidney-pancreas transplant recipients

OBJECTIVES

To identify the incidence and the success of endourologic therapy for symptomatic bladder-related calculi in simultaneous kidney-pancreas (SPK) transplant patients with bladder drainage.

METHODS

A retrospective review of 300 SPK transplant patients with bladder drainage, treated at the University of Wisconsin, Madison from December 1985 to November 1995, is presented. A 3% incidence of bladder calculi was identified. All patients underwent cystolitholapaxy using electrohydraulic lithotripsy and endoscopic suture removal. Follow-up ranged from 15 to 86 months.

RESULTS

A 100% stone-free rate was achieved after cystolitholapaxy and endoscopic suture removal. Two patients (22%) developed postprocedural urinary tract infections. No pancreaticoduodenocystotomy leaks or further complications were identified.

CONCLUSIONS

SPK transplant patients with nonabsorbable sutures used for the duodenocystotomy anastomosis are at an increased risk for bladder calculi. Cystolitholapaxy with electrohydraulic lithotripsy is a safe and effective treatment for these suture-related stones.

Holmium:YAG laser and its use in the treatment of urolithiasis: our first 160 cases

Over the course of 18 months, 160 patients underwent endoscopic holmium:YAG laser surgery at our institution for the treatment of urolithiasis. After appropriate consent had been obtained, 127 patients were treated for ureteral calculi, 18 for renal calculi, and 15 for large bladder stones. All procedures were performed using the VersaPulse combination holmium:YAG/Nd:YAG laser by Coherent Inc., and all were done endoscopically using video guidance. Of the 16 patients treated percutaneously for renal calculi, 5 were rendered stone free (mean stone size 3.5 cm). Two patients with renal calculi were treated in a retrograde fashion. One had a 1-cm stone in an upper-pole calix with a narrow infundibulum, while the other had a stone just proximal to the ureteropelvic junction. Both patients were rendered stone free. Of the 127 patients with ureteral calculi, 46 had stents placed after fragmentation of their stones. To date, 123 patients in this group (97%) are free of stones. All 15 patients with bladder calculi had complete fragmentation of their stones. The Ho:YAG laser is effective and versatile in the treatment of urolithiasis.

[Percutaneous suprapubic bladder lithotripsy]

The authors present a case of multiple bladder stones in a patient with severe ankylosis of the lower extremities, treated via percutaneous suprapubic approach. The suprapubic tract was created with Teflon-coated dilators and an Amplatz tube and the stones were fragmented with the nephroscope and a pneumatic lithotriptor. The simplicity of the procedure and the ease of the manoeuvre accelerated the stone fragmentation process while avoiding unnecessary trauma of the urethra.

Holmium:yttrium-aluminum-garnet laser cystolithotripsy of large bladder calculi

OBJECTIVES

Patients with large bladder calculi (4 cm or larger) have traditionally been managed with open cystolithotomy. Endoscopic management with cystolitholapaxy or electrohydraulic lithotripsy risks complications. In an effort to spare patients the morbidity of open cystolithotomy, the results of holmium:yttrium-aluminum-garnet (YAG) laser cystolithotripsy for bladder calculi 4 cm or larger were reviewed.

METHODS

Consecutive patients with bladder calculi of 4 cm or larger were managed with holmium:YAG laser cystolithotripsy. Laser energy was delivered using either the 365-micron end-firing fiber or the 550-micron side-firing fiber.

RESULTS

Fourteen consecutive patients were managed with holmium:YAG cystolithotripsy. All patients were rendered stone free, regardless of stone composition or size. Median anesthesia time was 57 minutes. Twelve of 14 patients were discharged by the first postoperative day. The procedure times normalized for stone size (mean +/- standard deviation) for the end-firing versus the side-firing fibers were 13 +/- 6 min/cm versus 6 +/- 1 min/cm, respectively; P = 0.04.

CONCLUSIONS

Holmium:YAG laser cystolithotripsy of large bladder calculi is effective, technically facile, and safe. The 550-micron side-firing fiber may be better suited for large bladder calculi compared with the 365-micron end-firing fiber. Holmium:YAG cystolithotripsy may obviate open cystolithotomy in selected patients.

Percutaneous cystolithotomy with endotracheal tube tract dilation after urinary tract reconstruction

PURPOSE

The effectiveness of a percutaneous approach to intact removal of large calculi from the urinary reservoir after urinary tract reconstruction was reviewed.

MATERIALS AND METHODS

The original site of the reservoir drainage tube was used for percutaneous access. After dilation of the tract to 34F a number 10 endotracheal tube was advanced through the tract, and the balloon (diameter up to 43 mm.) was inflated. The rigid nephroscope was then passed through the tract and calculi were removed intact without the need for ultrasonic or electrohydraulic lithotripsy.

RESULTS

Removal of single or multiple reservoir calculi attempted in 4 patients was successful in 3. Patients were discharged home within 2 days.

CONCLUSIONS

The technique of over dilation of the percutaneous tract allows removal of multiple large calculi in select patients without the need for lithotripsy.

Minimally invasive management of the calcified ureteral stent

The double "J" ureter stent has become one of the most basic and valuable tools in urology, but it can cause complications. Stent encrustation is one of its most difficult complications to manage. An evaluation and treatment algorithm that stratifies the treatment based upon the function of the stented kidney and the presence or absence of concomitant ureteral obstruction is presented. Minimally invasive surgery using ESWL and cystolitholapaxy is recommended as the first line of treatment of the extensively encrusted ureteral stent when the kidney has greater than 10% function.

Retained vaginal gauze with unusual complication: a case report

We report a case of a postpartum retained vaginal gauze which migrated to the bladder and presented as a bladder stone. The patient had received numerous clinical evaluations for her chronic abdominal pain, of all which failed to detect or indicate the presence of retained gauze. Retained surgical gauze is a preventable problem but continues to occur periodically. Prevention remains the key to this problem. The gauze packed within the vagina either after transvaginal surgery or delivery should be cared for as in other parts of the body. Though extremely rare, retained surgical gauze should be considered in the differential diagnosis in postpartum patients with chronic abdominal pain, irritable bladder symptoms or pelvic abscess.

Dumbbell stone of prostatic fossa after prostatectomy. A combined ESWL and suprapubic percutaneous treatment

We report our experience with a combined treatment of extracorporeal shock wave lithotripsy and percutaneous suprapubic lithotripsy for a dumbbell-shaped stone of prostatic fossa associated with multiple bladder calculi, in the same operative session. Because of the successful result, we believe the association of the two treatments for this complex calculus to be an easy, effective and minimally invasive method. ESWL should be considered for the primary management of these rare calculi, suprapubic percutaneous endoscopy can be helpful in rapid and complete removal of fragments.

Endoscopic ballistic lithotripsy in the treatment of bladder calculi in patients with neurogenic voiding dysfunction

Bladder stones represent a troublesome complication in patients suffering from neurogenic voiding dysfunction, in whom prompt and effective therapy is required. A variety of endoscopic lithotripsy methods are available; however, current devices can be tedious to use. We have treated 17 patients affected by bladder calculi and spinal cord injury or multiple sclerosis by means of the ballistic lithotripter EMS Swiss Lithoclast. The mean diameter of the stones was 2.7 cm. The mean operative time was 27 minutes. There were five intraoperative complications, including crises of autonomic dysreflexia (three patients) and light hematuria (two patients). There was no malfunction of the lithotripter and no long-term complications. All the patients were stone free at 6 months postoperatively. In conclusion, endoscopic lithotripsy with the ballistic lithotripter proved to be a very effective, rapid, and safe method for treating bladder calculi in patients with neurogenic bladders.

Management of vesical calculi: comparison of lithotripsy devices

Although endoscopic lithotripsy of bladder stones has been well described and is widely practiced, comparison of the main modalities of mechanical, electrohydraulic, and ultrasonic lithotripsy is lacking. The exact role of these and other modalities such as the Swiss Lithoclast and extracorporeal shockwave lithotripsy is not clearly defined. The safety and efficacy of the various lithotripsy modalities available to treat bladder calculi were reviewed retrospectively over an 18-year period. A total of 106 patients were treated with some form of intracorporeal lithotripsy. In general, all devices proved to be effective with a low rate of complications. The addition of transurethral resection of the prostate to bladder stone management under the same anesthetic was also found to be a safe procedure for moderate benign prostatic hyperplasia. In summary, transurethral endoscopic lithotripsy is a safe and effective method of bladder stone management both alone and in combination with transurethral prostatectomy. All modalities of intracorporeal lithotripsy are effective; however, devices such as ultrasound lithotripters or the Swiss Lithoclast that utilize larger, rigid probes may be more efficient for patients with large or particularly hard vesical calculi.

Clinical approach to children with urolithiasis

Urinary stones are being recognized more frequently in children. As a result of major advancements in the urological therapies available to children with obstructed uropathy, infection-related stones no longer dominate the clinical manifestations of pediatric urolithiasis. Clinical manifestations of urolithiasis in children differ somewhat from adults and change during childhood. Causes of urolithiasis in children are remarkably similar to those of adults, although diagnostic criteria frequently vary throughout childhood. Hypercalciuria is the most common metabolic cause of pediatric urolithiasis. This article presents a general overview of urolithiasis in children and a practical approach to the medical evaluation of such children.

Percutaneous vacuum vesicolithotomy under direct vision: a new technique

PURPOSE

The number of vesical calculi is increasing as the number of patients with intestinocystoplasty increases. We describe our technique for easily removing vesical calculi in children via an atraumatic percutaneous endoscopic approach.

MATERIALS AND METHODS

The procedure involves percutaneous suprapubic puncture and direct visualization of the calculi via cystoscopy through the urethra or via a second suprapubic puncture when the bladder neck is closed. The stones are vacuumed up 1 at a time with suction tubing through the suprapubic working sheath in a controlled manner with no urethral trauma. Ten patients 3 to 16 years old (mean age 8) with vesicolithiasis underwent percutaneous vacuum vesicolithotomy under direct vision in 1993 to 1995.

RESULTS

Two to 12 bladder calculi were extracted (mean 7). All calculi less than 1 cm. were removed by this procedure. All bladder calculi between 1 and 1.5 cm. were also removed but they required simultaneous electrohydraulic lithotripsy. There were no complications at a mean 1-year followup. Mean hospitalization was less than 24 hours (range 0 to 3 days).

CONCLUSIONS

Percutaneous vacuum vesicolithotomy is highly successful, easy to perform and safe for extracting vesical calculi. Since the procedure is done through a percutaneous sheath, it is particularly suited to the individual with an absent, small caliber, sensitive or surgically reconstructed urethra.

Experience with the holmium laser as an endoscopic lithotrite

OBJECTIVES

To study, in a clinical series, the safety and efficacy of holmium laser energy applied as an endoscopic lithotrite.

METHODS

Over a 2-year period, patients with urinary tract calculi were treated endoscopically with the holmium laser lithotripter, and data were gathered prospectively. Holmium lasers with maximum outputs of 15, 25, and 60 W were used. Various low water density, quartz fiber delivery systems were developed for specific applications. In addition, various combinations of endoscopes and laser fibers were employed.

RESULTS

A total of 63 patients with 75 calculi were treated. All calculi were cleared endoscopically. Minimal variation in laser efficiency was noted with different stone compositions, including cystine. Thirty-three of 34 ureteral calculi were treated to completion in one sitting (97%). Twenty-nine renal stone burdens were treated with the holmium laser, 26 of which were treated solely in a retrograde fashion. Of the latter, 23 (88.5%) required only a single sitting. Complications from holmium laser energy, including ureteral stricture disease, were not encountered in this series. Patients with complex, large stone burdens were treated to completion without sequelae. The combination of the actively deflectable, flexible ureteroscope and 200-microns fiber facilitated clearance of 18 lower-pole caliceal calculi. Three patients with partial staghorn stone burdens averaging 30 mm in diameter were treated ureteroscopically. Chronic urinary infections that were problematic preoperatively completely resolved after therapy. All 12 patients who had large bladder calculi with a mean diameter of 55.8 mm were treated to completion in one sitting.

CONCLUSIONS

Holmium laser energy is uniquely suited to treat all urinary calculi safely and effectively.

Cystoscopic holmium lithotripsy of large bladder calculi

Patients with large bladder stones are often difficult to treat endoscopically with the current modalities available to the practicing urologist. We present the results of cystolithotripsy of bladder stones larger than 4 cm with the holmium: Yag (Ho:Yag) laser. In our three patients, all patients were rendered stone free without complication using the Ho:Yag laser, with an average anesthesia time of 50 min. Minimal tissue trauma or stone movement were observed. All stones were easily fragmented, even one stone that had previously been refractory to electrohydraulic lithotripsy. Our conclusion is that the Ho:Yag laser is a safe and effective treatment for patients with large bladder stones. Its use may make it possible to eradicate stones endoscopically that otherwise would require open surgery.

Extracorporeal shock wave lithotripsy monotherapy for bladder stones

This report presents our initial experience in 36 patients with bladder stones, treated by extracorporeal shock wave lithotripsy. Minute fragmentation and uncomplicated evacuation occurred in 26 patients (72%). Mean treatment duration was 55 minutes. Mean number of shock waves was 3600 and electrical discharge averaged 24 kV per shock wave. No morbidity, during or after treatment, was encountered in these patients. The treatment was performed without the use of anaesthesia on an outpatient basis.

Long-term catheterization of the bladder: prevalence and morbidity

OBJECTIVE

To estimate the prevalence and morbidity of long-term catheterization (LTC) of the urinary bladder.

PATIENTS AND METHODS

A postal survey was conducted over two successive years from February 1989 to determine the incidence of LTC in three Bristol Health Districts with a total population of 827,595. During the first year the number of patients requiring emergency treatment for complications of LTC was also monitored over a 6-month period. In the second year, 54 patients were selected from the first survey and each was visited by one investigator every 2 weeks for 12 weeks to obtain information on catheter management, the incidence and type of complications, the attitudes of the patients or carers about the catheter and to assess the pH and microbiology of the patient's urine.

RESULTS

The initial surveys identified 457 and 467 patients with long-term catheters during the 2 years, respectively; there were similar numbers of men and women in both years. The survey of catheter complications recorded 506 emergency referrals during the 6 months and the detailed study of 54 patients showed that 48% experienced catheter blockage, 37% reported urine by-passing the catheter and 30% noted haematuria. Patients found the catheter uncomfortable and depended on nursing support. Catheter blockage was associated with bladder stones, a high urinary pH and the presence of Proteus spp in the urine.

CONCLUSION

The prevalence and high morbidity of LTC cause a considerable demand on the available District and Hospital nursing services; most patients with long-term catheters are elderly, disabled or debilitated and more nurses need to be trained in the technique of catheterization and the management of the catheterized patient. Further research is required to reduce the morbidity of LTC by investigating measures to reduce catheter blockage and encrustation at the urine/biomaterial interface.

[Trans-urethral bladder lithotripsy using the Lithoclast in children. Apropos of 7 cases]

We report our experience with a new simple machine for endoscopic disintegration, the "Swiss Lithoclast". The principle of this lithotriptor is based on pneumatic shock waves induced by the central compressed air system of a hospital. This device was used to treat 7 children with bladder stone (5 boys, 2 girls); their age was between 7 and 9 years (average 8.2 years). Endoscopic fragmentation was successful in all patients and all were stone free before leaving the hospital. We have found the Swiss Lithoclast to be a safe, effective and inexpensive means of performing intra-corporeal lithotripsy for bladder stone in children.

Intracorporeal lithotripsy with the Swiss lithoclast

OBJECTIVE

To evaluate the use of the Swiss lithoclast in the management of urinary calculi.

PATIENTS AND METHODS

Between January and November 1993, 60 patients with a total of 61 urinary calculi were treated with the Swiss lithoclast. Forty patients had a ureteric calculus, two had a ureterocele with a calculus, one a steinstrasse, 16 a vesical stone and two a urethral calculus. Eighty per cent of patients were treated on a day-care basis.

RESULTS

Fragmentation of the urinary calculi was successful in 59 of the 60 patients. Both patients with a urethral calculus and 15 of 16 with a vesical calculus were stone-free after the procedure. All those with a ureteric calculus were stone-free at 6 weeks. There were no intra-operative or long-term complications directly related to the use of the Swiss lithoclast.

CONCLUSION

The results of this study show that the Swiss lithoclast is a simple, safe, reliable and economical method of endoscopic lithotripsy for the treatment of urinary tract calculi. Although the lithoclast's use is limited to rigid or semi-rigid endoscopes there is now a suction facility for the immediate removal of small stone fragments.

Endoscopic management of bladder calculi following augmentation cystoplasty

OBJECTIVES

We sought to evaluate the effectiveness and utility of an endoscopic approach to calculi that develop in the bladders of children following augmentation cystoplasty. In addition, we aimed to determine the indications for open vesicolithotomy.

METHODS

We reviewed our experience between 1981 and 1993 with 26 children who formed bladder calculi following augmentation cystoplasty. Data were retrieved retrospectively with respect to management approach and outcome.

RESULTS

Nineteen cases were managed cystoscopically using simple extraction and/or electrohydraulic lithotripsy; 3 cases required open vesicolithotomy and four calculi passed spontaneously. Complete stone extraction was achieved after a single endoscopic treatment in every case approached in this fashion. Every patient resumed preoperative voiding patterns and there were no infections, strictures, or other complications. Calculi reformed in 4 patients and were successfully managed endoscopically.

CONCLUSIONS

An endoscopic approach to bladder calculi is a safe and effective method of managing this increasingly prevalent problem in children following augmentation cystoplasty even in the presence of a reconstructed bladder neck. Open vesicolithotomy should be reserved for the very large stone burden.