Removal of ureteral stones with extracorporeal shock wave lithotripsy and ureteroscopic procedures. What can we learn from the literature in terms of results and treatment efforts?

The Effect of Shock Wave Lithotripsy on Male and Female Sexual Dysfunction in Patients with Proximal Ureteral Stones

INTRODUCTION

This study aims to investigate the effects of shock wave lithotripsy (SWL) treatment for proximal ureteral stones on the sexual functions of patients of both genders.

METHODS

In this prospective study, 30 female and 72 male patients who had received SWL treatment for proximal ureteral stones in our clinic between August 2019 and October 2020 were evaluated. CT, creatinine, urinary analysis, and culture were performed during the initial consultation for all patients. Information regarding the age, BMI, and stone burden of the patients was recorded. Male patients answered the International Index of Erectile Function-5 (IIEF-5) questionnaire, and female participants answered the Female Sexual Function Index (FSFI) 3 times: pre-procedural and post-procedural first and third month. CT was repeated on the first month, and any residues were noted.

RESULTS

The mean IIEF-5 scores of the male patients were 23.11 ± 8.11 prior to surgery, and it decreased to 19.74 ± 7.65 in the first month and 23.88 ± 9.23 in the third, p = 0.001. The mean FSFI scores of female patients were 18.2 ± 9.9, which decreased to 12.8 ± 6.12 in the first month and 17.8 ± 8.66 in the third, p = 0.001. Univariate analysis revealed that the patients' age (male: p = 0.004 and female: p = 0.008) and BMI (male: p = 0.044 and female: p = 0.027) were related to the poorer scores for both genders. However, there were not any significant findings regarding stone burden (male: p = 0.054 and female: p = 0.078).

CONCLUSIONS

The possibility of developing temporary sexual dysfunction should be taken into account for patients who are candidates for SWL treatment. As the patient's age and BMI increase, SWL-related sexual dysfunction becomes more severe.

Successful single-stage transperitoneal laparoscopic ureterolithotomy in a solitary functioning renal unit with multiple large ureteric calculi along its entire length

Background

Laparoscopic ureterolithotomy bridges the gap between open and endourologic procedures as it is minimally invasive and overcomes a few of the disadvantages of open ureterolithotomy. We report a case of a solitary functioning renal unit with at least 12 large ureteric calculi coursing along the entire length of the ureter and involving the renal pelvis presenting with obstructive uropathy which was subsequently successfully managed with laparoscopic ureterolithotomy.

Case presentation

A 50-year-old male patient presented with obstructive uropathy with CT suggestive of solitary functioning right kidney with right ureter showing at least 13 large ureteric calculi and large renal pelvic calculi. Right transperitoneal laparoscopic ureterolithotomy was performed. All the renal and ureteric calculi were successfully removed.

Conclusion

Thus, laparoscopic ureterolithotomy with only three ports can be used to remove any burden of calculi along the course of the entire urinary tract being successful in a single stage with minimal morbidity.

Extracorporeal shock wave therapy for treatment of vulvodynia: a prospective, randomized, double-blind, placebo-controlled study

BACKGROUND

Currently, there are no effective therapy strategies for idiopathic, non-organic vulvodynia in women. ESWT (extracorporeal shock wave therapy) is a nonsurgical/noninvasive technique widely used to treat musculoskeletal diseases, muscle spasticity and hypertonia, renal and biliary calculi and urological disorders.

AIM

We examined the effects of ESWT on vulvodynia in women.

DESIGN

A prospective, randomized, double-blind, placebo-controlled study was conducted between 2015 and 2018 following a feasibility study.

SETTING

Obstetrics and Gynecology Hospital departments.

POPULATION

The study included 62 women with vulvodynia for at least 3 months.

METHODS

The women were randomly assigned to either a treatment group (N.=31) or a placebo group (N.=31). The patients in the treatment group received perineally applied ESWT weekly (3000 pulses each for four consecutive weeks). The energy flux density was 0.25 mJ/mm2, frequency 4 Hz, focus zone 0-30 mm, therapeutic efficacy 0-90 mm, stand-off II. The device used was a standard electromagnetic shock wave unit with a focused shock wave handpiece. The position of the shock wave transducer was changed six times after every 500 pulses. Patients in the placebo group underwent the same treatment procedure, but the handpiece was provided with a placebo stand-off that disabled energy transmission. Subjective pain was self-evaluated by each patient using two tools before and after treatment: a 10 cm linear visual analogue scale (VAS, 0-10) and a cotton-swab test (CST, Goetsch scale 0-4). Follow-ups were done 1, 4, and 12 weeks post-ESWT.

RESULTS

In all, 61 women completed the study. We tested for differences in the VAS and CST within and between the treatment and placebo groups. The testing was between before treatment and particular follow-up. We found significant changes in the treatment group. Reductions in VAS (P<0.01) and CST (P<0.01) were observed at all three follow-ups. At all assessments, pain reduction was always >30%. In the placebo group there were no statistically significant changes between before and after treatment. There were no differences between the treatment and placebo groups before treatment but statistically significant differences at all three follow-ups (VAS P<0.01); CST P<0.01).

CONCLUSIONS

ESWT seems to reduce pain perception in our treatment group. Thus, we are encouraged to explore this technique further.

CLINICAL REHABILITATION IMPACT

The method is easily replicable, inexpensive, and without known side effects.

Factors predictive of shockwave lithotripsy failure for ureteral stones: why we need to hurry

BACKGROUND

The aims of this study are to evaluate the prognostic factors of extracorporeal shockwave lithotripsy in patients with ureteric stones, and to identify which patients might directly benefit of an endoscopic treatment.

METHODS

We performed a prospective study from January 2013 and July 2016 on patients with single ureteric stone and undergoing extracorporeal shockwave lithotripsy (SWL). We divided patients into two groups: first group (success group) included cases resolved with SWL only, and a second group (failure group) including patients with stone not resolved by SWL and requiring an endoscopic treatment. We evaluated age, weight, height, body mass index, stone size, hydronephrosis, laterality, location, days elapsed from onset of symptoms to SWL and stone density when computed tomography was performed. In case of stone fragments >4 mm, the procedure was repeated up to a maximum of three times. SWL was considered as failed if patients had a residual stone of any size after a follow-up of 3 months or if a complication occurred.

RESULTS

274 patients completed follow-up and were enrolled in the study. Mean age was 53.22 years (standard deviation: 13.98). SWL overall success rate was 84.3% (231 patients successfully treated with shockwaves) and failure rate was 15.7% (43 patients underwent auxiliary endoscopic procedure). At the univariate analysis, we observed a statistically significant difference for hydronephrosis (P=0.006), time elapsed from symptoms onset (P=0.013), patients' age (P=0.06) and mean stone density (0.023). In the multivariate logistic regression, patients' age (OR: 1.517), and time elapsed from obstruction to SWL (OR: 3.005) were independent predictive factors for SWL failure. Furthermore, moderate and severe hydronephrosis seemed to be independent predictive factors for SWL failure, presenting an OR of 2.451 and 4.207 respectively. High stone density resulted to be a predictive factor for SWL failure (OR: 2.293 if density was higher than 1100 Hounsfield Units).

CONCLUSIONS

We report a large series of patients undergone primary SWL for ureteric stones. Our data demonstrated the role of hydronephrosis, time elapsed from obstruction onset to treatment and stone density as independent predictive factors of SWL failure.

Ureteroscopic lithotripsy in the Trendelenburg position for extracting obstructive upper ureteral obstruction stones: a prospective, randomized, comparative trial

OBJECTIVE

To introduce a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi.

MATERIALS AND METHODS

Between June 2014 and May 2017, 192 patients were enrolled in this study. Patients were randomly assigned to one of two groups: group A, ureteroscopic lithotripsy (URSL) in the Trendelenburg position; or group B, URSL in the standard position. Baseline information, including gender, age, body mass index (BMI), stone side, stone size and hydronephrosis grade, was collected and determined preoperatively. Stone-free rate (SFR) was evaluated 3 weeks after surgery and was defined by the absence of residual stones or the presence of residual stones <2 mm in diameter. Operation time, hospital stay, stone migration, operative complications and SFR were assessed and compared between the two groups.

RESULTS

There were no statistically significant differences in gender, age, BMI, stone side, stone size, serum creatinine or hydronephrosis grade between the two groups (all p > 0.05). There were no significant differences in the postoperative hospital stay or postoperative complications between the two groups (all p > 0.05), but the differences in operative time, stone migration and SFR between the two groups were statistically significant (p < 0.05).

CONCLUSION

This study introduced a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi. The Trendelenburg position can improve the SFR and may provide an optional surgical method for treating upper ureteral calculi.

Management of upper ureteral stones exceeding 15 mm in diameter: Shock wave lithotripsy versus semirigid ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy

Objectives:

We conducted a retrospective study to evaluate the efficacy and outcome of shock wave lithotripsy versus semirigid ureteroscopy in the management of the proximal ureteral stones of diameter exceeding 15 mm.

Methods:

During the 2009−2014 study period, 147 patients presenting with the proximal ureteral stones exceeding 15 mm in diameter were treated. Both shock wave lithotripsy and ureteroscopy with laser lithotripsy were offered for our patients. A 6/8.9 Fr semirigid ureteroscope was used in conjunction with a holmium:yttrium–aluminum–garnet laser. The stone-free rate was assessed at 2 weeks and 3 months post-treatment. All patients were evaluated for stone-free status, operation time, hospital stay, perioperative complications, and auxiliary procedures.

Results:

Of the 147 patients who took part in this study, 66 (45%) had undergone shock wave lithotripsy and 81 (55%) underwent ureteroscopy. At the 3-month follow-up, the overall stone-free rate in the shock wave lithotripsy group was 39/66 (59%) compared to 70/81 (86.4%) in the ureteroscopic laser lithotripsy group. Ureteroscopic laser lithotripsy achieved a highly significant stone-free rate (p = 0.0002), and the mean operative time, auxiliary procedures, and postoperative complication rates were comparable between the two groups.

Conclusion:

In terms of the management of proximal ureteral stones exceeding 15 mm in diameter, ureteroscopy achieved a greater stone-free rate and is considered the first-line of management. Shock wave lithotripsy achieved lower stone-free rate, and it could be used in selected cases.

Efficacy and safety of Ho:YAG laser lithotripsy for ureteroscopic removal of proximal and distal ureteral calculi

Background

Laser lithotripsy is an established endourological modality. Ho:YAG laser have broadened the indications for ureteroscopic stone managements to include larger stone sizes throughout the whole upper urinary tract. Aim of current work is to assess efficacy and safety of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral calculi in different locations.

Methods

88 patients were treated with ureteroscopic Ho:YAG laser lithotripsy in our institute. Study endpoint was the number of treatments until the patient was stone-free. Patients were classified according to the location of their stones as Group I (distal ureteric stones, 51 patients) and group II (proximal ureteral stones, 37). Group I patients have larger stones as Group II (10.70 mm vs. 8.24 mm, respectively, P = 0.020).

Results

Overall stone free rate for both groups was 95.8%. The mean number of procedures for proximal calculi was 1.1 ± 0.1 (1–3) and for distal calculi was 1.0 ± 0.0. The initial treatment was more successful in patients with distal ureteral calculi (100% vs. 82.40%, respectively, P = 0.008). No significant difference in the stone free rate was noticed after the second laser procedure for stones smaller versus larger than 10 mm (100% versus 94.1%, P = 0.13). Overall complication rate was 7.9% (Clavien II und IIIb). Overall and grade-adjusted complication rates were not dependant on the stone location. No laser induced complications were noticed.

Conclusions

The use of the Ho:YAG laser appears to be an adequate tool to disintegrate ureteral calculi independent of primary location. Combination of the semirigid and flexible ureteroscopes as well as the appropriate endourologic tools could likely improve the stone clearance rates for proximal calculi regardless of stone-size.

The clinical research office of the endourological society ureteroscopy global study: indications, complications, and outcomes in 11,885 patients

PURPOSE

To assess the current indications for ureteroscopy (URS) treatment, outcome in terms of stone-free rate, and intra- and postoperative complications using the modified Clavien grading system.

PATIENTS AND METHODS

The Clinical Research Office of the Endourological Society collected prospective data as part of the URS Global Study for consecutive patients treated with URS at centers around the world for 1 year. URS was performed according to study protocol and local clinical practice guidelines. The stone size and location were recorded and postoperative outcome and complications, graded according to the modified Clavien grading system, reported.

RESULTS

Between January 2010 and October 2012, 11,885 patients received URS at 114 centers in 32 countries; 1852 had only renal stones, 8676 had only ureteral stones, and 1145 patients had both types of stone. Fragmentation was performed principally using a laser device (49.0%) or a pneumatic device (30.3%); no device was used in 17.9% of the patients. A high stone-free rate (85.6%) was achieved. The large majority of patients did not receive any further treatment for renal or ureter stones (89.4%). The postoperative complication rate was low (3.5%). The most frequent complication was fever (1.8%); a blood transfusion was required in 0.2% of patients. The majority of complications were Clavien grade I or II (2.8% of patients).

CONCLUSION

URS is an established minimal invasive treatment for urinary stones with a high success rate and low morbidity. Recent advances have expanded the indication for urinary stones, which now ranges from treatment of smaller sized distal ureter stones by semirigid URS to larger sized renal pelvis stones treated by flexible URS.

Percutaneous nephrolithotomy versus ureteroscopic lithotomy for large (>15 mm) impacted upper ureteral stones in different locations: is the upper border of the fourth lumbar vertebra a good indication for choice of management method?

Abstract To determine whether treatment of patients with large (>15 mm) impacted upper ureteral stones depended on stone location, we prospectively evaluated the therapeutic outcomes, complications, safety, and effectiveness of percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotomy (URSL) in patients with stones higher and lower than the upper border of the fourth lumbar vertebra. Of the 174 patients analyzed, 83 (47.7%) underwent PCNL and 91 (52.3%) underwent URSL; all patients were followed up 1 month later and every 6 months for 18 months. Mean operation time (108.76±19.36 vs. 63.56±16.38 minutes, p<0.05) and postoperative hospital stay (2.49±1.23 vs. 5.36±1.98 days, p<0.05) were significantly longer in the PCNL than in the URSL group. The overall stone-free rates after 1 month were 96.4% and 75.8%, respectively, differing significantly for stones higher (97.8% vs. 57.5%, p<0.05) but not lower (94.7% vs. 90.2%) than the upper border of the fourth lumbar vertebra. The stone-retropulsion rate of URSL differed significantly for stones higher and lower than the upper border of the 4th lumbar vertebra (47.5% vs. 9.8%, p<0.05). Postprocedural complication rates were comparable in the URSL and PCNL groups, although the rate of auxiliary or salvage procedures was higher in the URSL group. The efficiency quotients (EQ) for PCNL and URSL were 0.93 and 0.59, respectively, with EQs in the URSL group differing significantly for stones higher and lower than the upper border of the fourth lumbar vertebra (0.40 vs. 0.82, p<0.05). Our findings indicate that treatment of impacted upper ureteral stones is dependent on stone location relative to the upper border of the fourth lumbar vertebra. URSL is unsuitable for stones at a higher location, whereas URSL and PCNL were equally effective for stones at a lower location.

Contemporary management of ureteral stones

CONTEXT

Ureteral calculi represent a common condition that urologists encounter in everyday practice. Several treatment options are available for calculi that do not pass spontaneously or are unlikely to do so.

OBJECTIVE

In this nonsystematic review, we summarize the existing data on contemporary management of ureteral stones focusing on medical expulsive therapy (MET) and different treatment modalities.

EVIDENCE ACQUISITION

A PubMed search was performed. We reviewed the recent literature on the management of ureteral calculi. Articles were considered between 1997 and 2011. Older studies were included selectively if historically relevant.

EVIDENCE SYNTHESIS

For stones that do not pass spontaneously or with MET, shock wave lithotripsy (SWL) and ureteroscopy (URS) are the most common and efficient treatment modalities. Both techniques have obvious advantages and disadvantages as well as different patterns of complications. For select cases or patients, other modalities may be useful.

CONCLUSIONS

Ureteral stones of up to 10mm and eligible for observation may be offered MET. For most ureteral calculi that require treatment, advances in SWL and URS allow urologists to take a minimally invasive approach. Other more invasive treatments are reserved for select "nonstandard" cases.

Value of focal applied energy quotient in treatment of ureteral lithiasis with shock waves

The treatment of ureteral lithiasis by extracorporeal shock wave lithotripsy (ESWL) is progressively being abandoned owing to advances in endoscopic lithotripsy. The purpose of this paper is to analyze the causes as to why ESWL is less effective-with a measurable parameter: focal applied energy quotient (FAEQ) that allows us to apply an improvement project in ESWL results for ureteral lithiasis. A prospective observational cohort study with 3-year follow-up and enrollment period was done with three groups of cases. In Group A, 83 cases of ureteral lithiasis were treated by endoscopic lithotripsy using Holmiun:YAG laser. In Group B, 81 cases of ureteral lithiasis were treated by ESWL using Doli-S device (EMSE 220F-XXP). In Group C, 65 cases of ureteral lithiasis were treated by ESWL using Doli-S device (EMSE 220F-XXP) (FAEQ >10). Statistical study and calculation of RR, NNT, Chi-square test, Fisher's exact test, and Student's t test were done. Efficiency quotient (EQ) and focal applied energy quotient [FAEQ = (radioscopy seconds/number of shock waves) × ESWL session J] were analyzed. From the results, the success rate of the treatment using Holmium:YAG laser lithotripsy and ESWL is found to be 94 and 48%, respectively, with a statistically significant difference (p < 0.001). Success rate of endoscopic laser lithotripsy for lumbar ureteral stones was 82% versus 57% of ESWL (p = 0.611). In Group B, FAEQ was 8.12. In Group C, success rate was 93.84% with FAEQ of 10.64%. When we compare results from endoscopic lithotripsy with Holmium:YAG laser in Group B with results from ESWL with FAEQ >10, we do not observe absolute benefit choosing one or the other. In conclusion, the application of ESWL with FAEQ >10, that is, improving radiologic focalization of the calculus and increasing the number of Joules/SW, makes possible a treatment as safe and equally efficient as Holmium:YAG laser lithotripsy in ureteral lithiasis less than 13 mm.

Emergency ureteroscopic lithotripsy in acute renal colic caused by ureteral calculi: a retrospective study

This work was conducted to evaluate the safety and efficacy of emergency ureteroscopic lithotripsy in patients with ureteral stones. From May 2003 to December 2010, 244 patients (184 men and 60 women, mean age 45.6 ± 12.7 years (range 22-73 years) were treated with emergency ureteroscopic lithotripsy for ureteral calculi. All patients were divided into three groups according to the stone location in the ureter. Intracorporeal lithotripsy when necessary was performed with the Swiss lithoclast. The overall stone-free status was defined as the complete absence of stone fragments at 4 weeks, postoperatively. A double J stent was inserted in selected patients if there was significant ureteral wall trauma, edema at the stone impaction site, suspected or proved ureteral perforation, and if the stone migrated to the kidney. The overall success rate was 90.6%. The success rates were different according to the stone site. The success rate of groups A, B and C was 69.4, 94.8 and 96.6%, respectively. The overall rate of ureteral stent insertion at the end of the procedure was 177/244 (72.5%). The rate of stent insertion was 41/49 (83.7%), 32/46 (69.6%) and 104/149 (69.8%) in groups A, B and C, respectively. The overall complication, failure, and stricture rate was 32/244 (13.1%), 23/244 (9.4%) and 0.8%, respectively. With the recent advances in ureteroscopic technology, intracorporeal probes and stone extraction devices, emergency ureteroscopy is found to be a safe and effective procedure with immediate relief from ureteral colic and ureteral stone fragmentation.

Predictive role of renal resistance indices in the extracorporeal shock-wave lithotripsy outcome of ureteral stones

OBJECTIVE

Doppler ultrasonography (US) can be used to measure renal blood flow and calculate resistance indices. Increased renal resistance indices have been suggested to be associated with upper urinary tract obstruction and may help clinical physicians to differentiate physiological hydronephrosis from urinary tract obstruction. The aims of this study were to investigate the value of renal resistance indices before extracorporeal shock-wave lithotripsy (ESWL) and to determine whether they were predictive of the ESWL outcome.

MATERIAL AND METHODS

Between May 2005 and May 2006, a total of 84 patients who suffered from ureteral stones with renal colic and were treated with ESWL in the emergency department were enrolled in this study. Blood urea nitrogen and serum creatinine were determined and urinalysis, abdominal plain film X-ray and color Doppler US were performed. The resistive index (RI) and pulsatility index (PI) of the three different measurements of renal upper, middle and lower poles were calculated for both the affected and contralateral kidneys.

RESULTS

Sixty of the 84 patients were found to be stone-free after follow-up, and the total stone-free rate was 71%. There was a statistically significant difference between the mean RI of the affected and contralateral kidneys in all patients: 0.672+/-0.046 vs 0.616+/-0.054 (p<0.001). Moreover, there were statistically significant differences between the stone-free group and the residual stone group regarding the RI (0.651+/-0.046 vs 0.723+/-0.029, respectively; p=0.003) and PI (1.143+/-0.162 vs 1.262+/-0.145, respectively; p=0.03) of the affected kidney.

CONCLUSIONS

Intrarenal resistance indices represent the integration of arterial compliance, pulsatility, and peripheral resistance. Higher pre-ESWL resistance indices correlate with lower ESWL treatment success rates. Doppler US performed before ESWL treatment can therefore aid in making a correct clinical decision.

[The future of ESWL]

With the introduction of the Dornier HM3 lithotripter, the successful history of extracorporeal shock wave lithotripsy (ESWL) for noninvasive treatment of urinary stones began about 25 years ago. The development of newer lithotripters has not been able to improve clinical efficacy because the shock wave parameters specifically responsible for stone disintegration or tissue trauma and pain induction have not yet been identified. Actual research in lithotripter technology deals with modification of the focal point. The evolution of endoscopic procedures, ureterorenoscopy, and percutaneous nephrolithotomy took longer but was more successful in terms of clinical efficacy. Nowadays, ESWL or an endoscopic procedure is offered as a reasonable option for most urinary stone cases. Therefore, economic aspects and the surgeon's expertise will become greater factors when a procedure is chosen. ESWL, with or without anaesthesia, will be an inherent part of future treatment modalities for urinary stones.

How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones?

PURPOSE

To analyze results of extracorporeal shockwave lithotripsy (SWL) for treatment of ureteral stones with two modern lithotripters.

PATIENTS AND METHODS

A consecutive series of 598 patients with ureteral stones was treated with the Modulith SLX Classic and Modulith SLX-F2 lithotripters. The mean (SD) age of the patients was 54 (17) years, and the mean (SD) stone surface area was 42 (34) mm2. Results were available for 580 patients.

RESULTS

Stone-free ureters were recorded in 563 (97.1%) patients. Stone-free rates were 96.1%, 97.8%, and 97.9%, for the proximal, middle, and distal ureter, respectively. The average number of SWL sessions needed was 1.31. For the proximal, middle, and distal ureter, one SWL session was sufficient in 73.1%, 66.7%, and 83.2% of patients, respectively. Assisting auxiliary procedures were used in 102 patients (18%). The total mean (SD) treatment time was 48 (26) minutes and the mean (SD) number of shockwaves was 3266 (2258). SWL for stones located in the proximal, middle, and distal ureter was carried out in the prone position in 38%, 88%, and 9%, respectively. For 90 patients primarily treated with a large focus, the re-treatment rate was the same as for patients treated with a standard focus. A stone treatment index used to assess the efforts, results, and complications was similar for the two lithotripters and for all stone locations. Thus both lithotripters had similar efficacy.

CONCLUSION

With consistent use of SWL, a stone-free rate of more than 97% can be attained, with a reasonable re-treatment rate and only modest use of assisting auxiliary procedures.

Ureteroscopic management of lower ureteric calculi: a 15-year single-centre experience

OBJECTIVE

To review our 15-year experience with ureteroscopic treatment of distal ureteric calculi and to determine the impact of improved technology and techniques on the efficacy, success and complications of the procedure.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 4512 patients who underwent 5133 ureteroscopic procedures for the treatment of distal ureteric calculi at our institution from January 1991 to December 2005. The patient and stone characteristics, treatment variables and clinical outcomes were assessed. Factors such as type of ureteroscope, procedure duration, procedure success, complication rate and hospital stay were evaluated. Data obtained from a cohort of patients that underwent the procedure from 1991 to 1995 (group 1) were statistical compared with those obtained from a cohort of patients from 1996 to 2005 (group 2). Logistic regression analysis was used to identify associated factors with the major complications of ureteroscopy.

RESULTS

Overall, the stone-free rate after the procedure was 94.6%, the mean (sd; range) operative duration was 43 (15.0; 25-120) min, the intraoperative complication rate was 6.67%, the postoperative complication rate was 9.9%, and the mean (sd) hospital stay was 1.7 (1.1) days. The clinical and radiological follow-up (mean 36.8 months) for 71.3% of eligible patients detected only 12 ureteric strictures (0.23%). On comparing group 1 with group 2, the overall success of ureteroscopic stone extraction improved from 85.7% to 97.3% (P < 0.001), significant ureteric perforation decreased from 3.3% to 0.5% (P = 0.05), ureteric avulsion decreased from 1.3 to 0.1% (P < 0.05), ureteric stricture decreased from 0.7% to 0.1% (P < 0.007), the mean (sd) procedure time significantly decreased from 75 (42.9) min to 36.5 (12.5) min (P < 0.001), and the mean hospital stay significantly decreased from 2.5 (1.6) days to 0.5 (1.2) days, with a trend toward outpatient treatment. Logistic regression analysis showed a significant association of the major ureteroscopic complications with increased operative duration, type of ureteroscope used, stone impaction, stone size and surgeon experience.

CONCLUSION

The present series shows the high success rate, with minor complications, that can be achieved with ureteroscopic treatment of distal ureteric calculi. Improvements in ureteroscope design, accessories, technique and experience have led to a significant increase in the success rate and decrease in the complication rate.

Pneumatic lithotripsy for large ureteral stones: is it the first line treatment?

OBJECTIVE

To evaluate the effectiveness of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of large ureteral stones.

METHODS

We reviewed, retrospectively, the records of 156 patients (122 male, 34 female) who had ureteral calculi larger than 10 mm that were treated with PL. Of these patients, 41 (26.3%) were treated primarily with PL and 115 (73.7%) were treated secondarily after unsuccessful extracorporeal shock wave lithotripsy (SWL). The mean stone diameter was 12.87 mm (range 10-20.5 mm). Results were evaluated 3 months after treatment by excretory urography and/or ultrasonography.

RESULTS

The overall stone-free and fragmentation rates (FRs) were 85.2 and 92.3%, respectively. Corresponding values were 60 and 84% for upper ureteral stones, 79.5 and 89.7% for middle ureter stones and 94.5 and 95.6% for lower ureteral stones, respectively. The main complications were migration of a complete stone or of fragments (7.1%), urosepsis (4.5%) and ureteral perforation (1.3%).

CONCLUSIONS

Although SWL is generally accepted as the first treatment option for ureteral stones because of its non-invasive nature, PL with ureteroscopy seems to be a good alternative with the advantage of higher success rates and quick stone clearance. Especially when we take the importance of quick stone removal into account for larger ureteral stones, which are more likely to have obstruction, impaction, or infection, we believe that PL may be chosen as the first line treatment rather than SWL for stones larger than 10 mm.