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.