Treatment Selection and Outcomes: Ureteral Calculi

Role of Noncontrast Computed Tomography Parameters in Predicting the Outcome of Extracorporeal Shock Wave Lithotripsy for Upper Urinary Stones Cases: A Meta-analysis

RATIONALE

Extracorporeal shock wave lithotripsy (ESWL) is widely considered the primary approach for managing urinary tract stones. This study aimed to assess the predictive factors associated with non-contrast computed tomography (NCCT)-based parameters of upper urinary stones in relation to the outcomes of ESWL.

MATERIALS AND METHODS

A systematic search was conducted in PubMed, ScienceDirect, Web of Science, and Cochrane Library to identify all relevant studies published up to June 3, 2023. Several NCCT-based parameters to predict ESWL outcomes, comprised of mean stone density (MSD), skin-to-stone distance (SSD), and stone size, were extracted and analyzed using Review Manager software.

RESULTS

Out of 979 publications screened, a total of 39 publications, involving 7869 patients, were enrolled in the analysis. The pooled estimate demonstrated significant differences between MSD, and stone size between successful and failure of stone fragmentation groups, in which lower values of these parameters are associated with successful ESWL outcomes.

CONCLUSION

The results from the current study suggested that lower NCCT parameters, notably MSD, SSD, and stone size, are significantly associated with successful ESWL outcome. However, additional large-scale prospective studies are required to utilize these parameters effectively, and the optimal cutoff value should be determined.

A Prospective Evaluation of the Association of Ureteral Wall Thickness With Intraoperative Stone Impaction in Ureteroscopy

Background and objective In this study, we aimed to analyze the association of ureteral wall thickness (UWT) measured on non-contrast CT (NCCT) with stone impaction as found in ureteroscopy (URS). Materials and methods We analyzed 43 patients who underwent URS and pneumatic/laser lithotripsy for ureteric stones from May to November 2022. The UWT was measured by an experienced radiologist on NCCT. Clinical predictors of the impacted stone were calculated by univariate and multivariate regression analysis. The receiver operating characteristic (ROC) curve was calculated for the UWT cutoff to apply it for impaction with different parameters. We also evaluated the association of intra- and postoperative parameters of the two groups with UWT. Results Out of the 43 patients with stones, 26 (60.46%) patients had impacted stones. Univariate analysis was used to analyze the site (left-sided stone impacted more commonly), stone size, stone density [Hounsfield unit (HU)], hydronephrosis, UWT, and duration between initial presentation and surgery, and multivariate analysis was utilized to assess stone density, as well as UWT's association with impacted stones. The ROC curve showed a cutoff of 3.5 mm for UWT with an accuracy of 0.83. High UWT (≥3.5 mm) was associated with a significantly lower stone-free rate, more complications, and mean operative time as compared to low UWT (<3.5 mm) (p<0.05). Conclusion Based on our findings, high UWT is associated with high rates of impacted stones and a lower stone-free rate when compared to low UWT.

Comparative study between Tamsulosin, Silodosin and Tadalafil as a medical expulsive therapy for lower ureteral stones

OBJECTIVE

To compare the efficacy of Tamsulosin, Silodosin and Tadalafil as a medical expulsive therapy for treatment of distal ureteral calculi.

PATIENTS AND METHODS

Over a period of 6 months (January 2022 to June 2022) this prospective randomized study was conducted on 170 patients with distal ureteric stone ≤ 10 mm. Patients were randomly divided into three groups. Patients in group A received Tamsulosin 0.4mg, in group B received Silodosin, and in group C receive Tadalafil 5 mg. Therapy was given for a maximum of 4 weeks. The rate and time of stone expulsion, the analgesic use, attacks of colic and hospital visits for pain, and adverse effects of drugs were recorded.

RESULTS

Among 170 patients who were enrolled in study, 20 were lost to follow-up (7, 8, 5 in group A, B, And C respective-ly). There was a significant higher stone passage rate in group C than group A and B (90% vs. 70% and 76% respectively; p-value = 0.043) and shorter expulsion time in group C (8.7 ± 3.3 days) vs. group A (12.5 ± 5.2 days) and group B (11.3 ± 4.2 days) with (p-value = 0.001)(highly statistically significant with p-value < 0.001) and increased amount of analgesics required in group A (225 ± 115.7 mg) and group B (163 ± 77.5 mg) when compared with group C (120 ± 55.3 mg).

CONCLUSION

Tadalafil is more effective than Tamsulosin and Silodosin in treatment of patients with distal ureteric stones ≤ 10 mm as regard stone expulsion rate, expulsion time with decreased number of colicky episodes and side effects.

Can shock wave lithotripsy lead to impaction of ureteral stones?

BACKGROUND

One of the underlying reasons for shock wave lithotripsy (SWL) resistance is the ureteral stone impaction. This study aimed to investigate the accuracy of the hypothesis, suggesting that SWL per se can be the reason for ureteral stone impaction.

METHODS

One hundred and seventy-six patients were enrolled in the study. Data of the patients (N.=50) treated with SWL and subsequent semirigid ureteroscopic laser lithotripsy (SULL) in our center between January 2014 and January 2020 were retrospectively reviewed compared with the data of the patients (N.=126) who underwent SULL without prior SWL treatment during the same period. Patients reported to have ureteral stone impaction during SULL were compared with those without stone impaction in terms of demographic parameters, stone characteristics and clinical data, including symptom duration and presence or absence of SWL history.

RESULTS

The success rate of SULL was determined as 80.1% (141/176). Univariable analysis revealed statistically significant differences between the patients with and without stone impaction concerning stone diameter, stone volume, pre-SULL SWL history, symptom duration and ureteral wall thickness (UWT). Multivariable logistic regression analysis revealed that symptom duration and UWT were independent predictive factors for ureteral stone impaction.

CONCLUSIONS

Symptom duration and UWT are independent predictors of ureteral stone impaction. Symptom duration and UWT should be considered during treatment planning and informed consent process before proceeding with SULL.

Ureteral wall thickness and distal ureteral density in patients with residual fragments after Ho:YAG laser semi-rigid ureterolithotripsy

Recent data suggest that greater ureteral density distal to ureteral stones or increased ureteral wall thickness (UWT) can predict impacted stones. The aim of our study was to evaluate if patients with residual fragments present with greater ureteral density and larger UWT when compared to stone-free patients. From January onward, a consecutive series of patients undergoing semi rigid Ho:YAG laser ureterolithotripsy (ULT) for ureteral stones were enrolled. A non-contrast enhanced computed tomography (CT) scan was performed before the procedure to evaluate distal ureteral density (DUD) and wall ureteral thickness (UWT) at the site of ureteral stones. Patients with residual fragments were compared to stone-free patients using a matched-pair analysis (1:1 scenario). Cases were matched sequentially using the following criteria: age, gender, body mass index (BMI), stone length, hydronephrosis, location of stones, and mean Hounsfield unit (HU) of the stone. Overall, 160 patients were enrolled, mean age was 57.9 ± 14 years, mean BMI was 25.8 ± 4 kg/m2, mean length of the stone was 10.6 ± 4.9 mm, and mean UWT was 1.4 ± 1.6 mm. A total of 150/160 (94%) patients presented hydronephrosis; mean HU stone was 868 ± 327; mean DUD was 54 ± 17.8 HU. Ureteral distal density (51.7 vs 56.6; p = 0.535) and ureteral distal thickness (1.39 vs 1.54; p = 0.078) were similar in both groups of patients. In our study, the evaluation of distal ureteral density does not predict stone-free rate. Further studies should evaluate the role for preoperative computer tomography in predicting surgery outcome.

Evaluation of the relation between size of stone and its attenuation measured by Hounsfield units and the total laser energy required to fragment it

BACKGROUND

Anticipating the total laser energy (TLE) of Holmium YAG laser required for ureteroscopic (URS) lithotripsy is essential to guide urologists in selecting the optimal fiber size. This study aimed at evaluating the relationship between stone size and stone attenuation measured by HU as predictors for the TLE during the procedure.

METHODS

We conducted an observational prospective cohort study of patients undergoing URS lithotripsy at the Urology department of Ain Shams University Hospitals from September 2018 to September 2019 with the use of a holmium YAG laser as the lithotripsy method. Patients' demographic and clinical characteristics, stone location, stone size, stone attenuation measured by HU from the non-contrast CT, TLE, and procedure time were recorded. Data were analyzed using Jamovi software (version 2.0 for macOS).

RESULTS

Forty patients were included in the study (22 males and 18 females) with a mean age of 57.8 years. The mean stone size was 9.8 mm³, the mean HU was 858.8 units, and the mean TLE was 3.5 KJ. Both stone size and stone attenuation measured by HU were positively correlated with TLE (r = 0.81 and 0.84, respectively; p < 0.001 for both). Further, regression analysis showed that both variables could significantly predict the TLE (ß = 0.001 and 0.71, respectively).

CONCLUSIONS

Both stone attenuation, as measured by HU, and stone size positively correlate with TLE required for URS lithotripsy. Therefore, both HU and stone size can predict the TLE, which will be helpful to guide the urologist in selecting the optimal fiber size for the procedure.

Ureteral wall thickness is an independent parameter affecting the success of extracorporeal shock wave lithotripsy treatment in ureteral stones above the iliac crest

BACKGROUND

To investigate the relationship between ureteral wall thickness (UWT) and other variables of patients who underwent extracorporeal shock wave lithotripsy (SWL) in the primary treatment of the ureteral stone above the iliac crest level.

MATERIAL AND METHODS

A total of 147 patients aged 18 years and older, who underwent SWL in our clinic between December 2016 and December 2019 for the treatment of ureteral stones above the iliac crest level and had non-contrast enhanced abdominal computed tomography scans before the procedure were included in the clinical study. The results were evaluated at 3 months after SWL. The absence of residual fragments was considered as stone-free status, and the existence of any size residual fragment was considered as treatment failure.

RESULTS

In our study, the mean age of the patients was 42.4 ± 12.8 years, and the stone-free rate was 92.5%. The median transverse stone size was 7.5 mm (min 2.8-max 15), and the median UWT was 4.2 mm (1-8.7). In the multivariate analysis, UWT (P = .002) and multiple stone presence (P = .027) were found to be independent factors affecting stone-free status. In the receiver operating characteristic curve analysis, the optimal threshold value for UWT was determined as 5.25 mm.

CONCLUSIONS

We found that UWT was the most important independent variable associated with increased failure in SWL treatment. The presence of multiple stones was another independent factor that increased the failure rates. Using SWL technology through experience accumulated with the mechanical hardware of the machine, we can select patients who are more suitable for this treatment and improve treatment outcomes.

Can we successfully predict the outcome for extracorporeal shock wave lithotripsy (ESWL) for medium size renal stones? A single-center experience

BACKGROUND

Extracorporeal shock wave lithotripsy (ESWL) is one of the most used modalities in treatment of renal stones, but its effectiveness can be influenced by many factors related to the patient or the stone itself which may affect the success of stone disintegration. The aim of our study was to investigate the predictive value of some patient and stone-related factors for ESWL success for renal stones.

METHODS

A total of 100 patients with single radiopaque renal stone 10-20 mm in diameter, undergoing ESWL were enrolled in this study. All patients had non contrast computed tomography (NCCT) done before ESWL. We evaluated body mass index (BMI), skin-to-stone distance (SSD), stone size and Hounsfield density comparing these values between stone free (SF) and residual stone (RS) groups.

RESULTS

Of the 100 patients, 70% had successful disintegration. There was no significant difference between stone free (SF) and residual stone (RS) groups as regard age or BMI. Meanwhile, there was a significant difference between SF and RS groups as regard stones' density and SSD, with higher values in RS group but there was statistically insignificant difference as regard stone size (p = 0.522). Using logistic regression analysis, we found that Hounsfield unit (HU) was better in predicting successful disintegration than SSD but without statistical significance.

CONCLUSION

HU and SSD are the independent predictive factors for ESWL outcome, and they should be considered when planning ESWL in treatment of medium size renal stones.

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.

Antegrade mini-percutaneous flexible ureteroscopy versus retrograde ureteroscopy for treating impacted proximal ureteric stones of 1-2 cm: A prospective randomised study

Objectives

To prospectively assess the safety and effectiveness of antegrade mini-percutaneous (miniperc) ureteroscopy (URS) and compare it with the conventional retrograde URS (RURS) approach in treating impacted proximal ureteric stones of 1–2 cm.

Patients and methods

The study included 60 patients admitted to the Department of Urology, Alexandria Main University Hospital, presenting with impacted proximal ureteric stones of 1–2 cm. Patients were randomly divided into two groups: Group A, were treated with RURS using a semi-rigid or flexible ureteroscope to access the stone; and Group B, were treated by antegrade miniperc URS, were a 14-F renal tract was obtained to pass a ureteric access sheath, then a flexible ureteroscope was used going downwards to the stone. Holmium laser was used for stone fragmentation. A JJ stent was inserted in all cases. Follow-up with non-contrast computed tomography was performed after 2 weeks.

Results

Both groups were comparable in terms of patient demographics and stone criteria. The stone-free rate was significantly higher in Group B (83.3%) compared to Group A (60%). The mean (SD) operative time was significantly shorter in Group A vs Group B, at 64.7 (±17.7) vs 112.0 (±15.3) min; while the mean lithotripsy time was comparable between the groups. The mean radiation exposure time was significantly less in Group A (11 s) compared to Group B (200 s). Both groups where comparable concerning minor complications, with no major complications.

Conclusion

Antegrade miniperc flexible URS is safe and more effective than RURS for treating large impacted proximal ureteric stones.

Abbreviations

ESWL: extracorporeal shockwave lithotripsy; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; miniperc: mini-percutaneous; PCNL: percutaneous nephrolithotomy; PCS: pelvi-calyceal system; SFR: stone-free rate; (R)URS: (retrograde) ureteroscopy

Prevention of stone retropulsion during ureteroscopy: Limitations in resources invites revival of old techniques

Objective

To compare a modified technique using the Dormia basket vs Stone Cone for stone entrapment to avoid proximal stone migration during ureteroscopic pneumatic lithotripsy of ureteric stones.

Patients and methods

Our study included all patients with ureteric stones of <15 mm who underwent ureteroscopic pneumatic lithotripsy from January 2015 to September 2018. The study had two arms that were conducted over two consecutive periods; the first included 72 patients in whom we used the Stone Cone (Group 1) and the second included 86 patients in whom we started to use a Dormia basket with a modification (Group 2) to guard against proximal stone migration.

Results

Both groups were comparable for gender, age, and stone characteristics. Lower ureteric stones were the most prevalent as they represented 62.5% and 60.5% in groups 1 and 2, respectively; while upper ureteric stones were respectively found in 16.7% and 17.4%. Chemical stone analysis revealed that calcium oxalate stones were most predominant accounting for 51.3% and 51.1% in groups 1 and 2, respectively. Most of the stones were radio-opaque stones representing 57% and 58.1% in groups 1 and 2, respectively. There was a significant difference in operative time, with a mean (SD) operative time was 50.9 (11.2) in Group 1 vs 58.3 (12.4) min in Group 2 (P < 0.001). The success rate, defined as no retropulsion of stone fragments, was 97.7% in Group 2 vs 91.7% in Group 1 (P < 0.01). Complications were minor and comparable between the groups. There was no difference in hospital stay between the groups, but the cost assessment favoured Group 2.

Conclusion

We found that our modified-basket stone entrapment technique compared favourably with the Stone Cone to guard against stone retropulsion during ureteroscopic pneumatic lithotripsy. Our modification to the basket was found to be feasible, efficient, safe, reproducible and cost-effective in preventing proximal stone migration. This procedure is particularly suitable in cost-limited environments.

Could ureteral wall thickness have an impact on the operative and post-operative parameters in ureteroscopic management of proximal ureteral stones?

AIM

To evaluate the possible impact of stone impaction in terms of ureteral wall thickness (UWT) on the success and procedure related parameters of ureteroscopic management in proximal ureteral calculi.

PATIENTS AND METHODS

82 patients with proximal ureteric stones were included and were divided into 2subgroups where UWT was> 5mm in 38 cases; and <5mm in 44 cases. Stone size, degree of hydronehrosis, diameter of proximal ureteral luz, UWT and patient's demographics were evaluated. Semi-rigid ureteroscopy with Ho-YAG laser was performed and the possible impact of UWT as an objective parameter for stone impaction on the success rates and procedure related parameters was evaluated.

RESULTS

Mean patient age and stone size values were 47.55±1.78 years and 8.17±0.29mm respectively. Regarding the impact of UWT value at the stone site for the parameters mentioned above stone free rates particularly at 1-week after the procedure was higher in group 2 and the rate of residual fragments as well as the need for double J stent placement was higher in group 1. Additionally, mean duration of the procedures was significantly longer in Group 1 during which pathologic alterations were significantly higher in ureteral wall at stone site were observed in these cases (P=.0243).

CONCLUSIONS

UWT may be used to predict the success of ureteroscopic management and other procedure related parameters for proximal ureteral stones in an effective manner. With this approach a more rational operative plan with higher success rates, limited complications and auxiliary procedures could be made.

Noncontrast Computed Tomography Parameters for Predicting Shock Wave Lithotripsy Outcome in Upper Urinary Tract Stone Cases

Kidney stones are a major public health concern with continuously increasing worldwide prevalence. Shock wave lithotripsy (SWL) is the first line treatment choice for upper urinary tract calculi with ureteroscopy and has advantages of safety and noninvasiveness, but the treatment success rate of SWL is lower than that of other therapies. It is therefore important to identify predictive factors for SWL outcome and select a suitable treatment choice for patients with upper urinary tract calculi. In recent years, computed tomography (CT) has become the gold standard for diagnosis of upper urinary tract calculi. Several factors based on CT images, including skin-to-stone distance, mean stone density, stone heterogeneity index, and variation coefficient of stone density, have been reported to be useful for predicting SWL outcome. In addition, a new method of analysis, CT texture analysis, is reportedly useful for predicting SWL outcomes. This review aims to summarize CT parameters for predicting the outcome of shock wave lithotripsy in stone cases in the upper urinary tract.

Stone heterogeneity index on single-energy noncontrast computed tomography can be a positive predictor of urinary stone composition

The aim of this study was to investigate the correlation between stone composition and single-energy noncontrast computed tomography (NCCT) parameters, including stone heterogeneity index (SHI) and mean stone density (MSD), in patients with urinary calculi. We retrospectively reviewed medical records of 255 patients who underwent operations or procedures for urinary stones or had spontaneous stone passage between December 2014 and October 2015. Among these, 214 patients with urinary calculi who underwent NCCT and stone composition analyses were included in the study. Maximal stone length (MSL), mean stone density (MSD), and stone heterogeneity index (SHI) were determined on pretreatment NCCT. The mean MSD (454.68±177.80 HU) and SHI (115.82±96.31 HU) of uric acid stones were lower than those of all other types. Based on post hoc tests, MSD was lower for uric acid stones than for the other types (vs. CaOx: P<0.001; vs. infection stones: P<0.001). SHI was lower for uric acid stones than for the other types (vs. CaOx: P<0.001; vs. infection stones: P<0.001) Receiver operating characteristic curves of uric acid stones for MSD and SHI demonstrated that SHI (cut-off value: 140.4 HU) was superior to MSD (cut-off value: 572.3 HU) in predicting uric acid stones (P<0.001).

Medical Expulsive Therapy for Distal Ureteral Stones: Tamsulosin Versus Silodosin in the Turkish Population

Introduction

Our aim was to contribute a study that includes a higher patient population to the limited number of studies comparing tamsulosin and silodosin in the treatment of distal ureteral stones.

Material and methods

Patients who presented with renal colic to the urology emergency clinic and were diagnosed with ureteral stones and followed-up with conservative treatment between January 2010 and January 2016 were retrospectively screened. According to the inclusion-exclusion criteria, the patients were divided into three groups. Group 1: 150 patients followed with watchful waiting (WW), Group 2: 156 patients who received 0.4 mg of tamsulosin daily, and Group 3: 159 patients who received 8 mg of silodosin daily. The side effects of the used drugs, duration of stone reduction, and expulsion rates were evaluated and compared separately.

Results

A total of 465 patients were included in the study. No statistically significant difference was found in terms of age, gender, and stone size among the groups. The patient characteristics and results are shown in Table 1. The differences in stone expulsion rate between the groups in the first week were calculated using the Chi-square test and found to be non-significant (p = 0.155); whereas, the stone expulsion rates between Group 1 versus Group 2 and Group 1 versus Group 3 were found to be significantly different after the second and third week.

Conclusion

According to our results, no statistically significant superiority between tamsulosin and silodosin was shown in the treatment of distal ureteral stones in the Turkish population.

Radiological noninvasive assessment of ureteral stone impaction into the ureteric wall: A critical evaluation with objective radiological parameters

PURPOSE

To determine the predictive value of certain radiological parameters for an objective asssessment of the presence of ureteral stone impaction.

MATERIALS AND METHODS

Seventy-nine patients with a single proximal ureteral stones were retrieved from the departmental database. Both clinical and particularly radiological data of all cases were well evaluated on this aspect. In addition to the time period between the first colic attack and definitive management; diameter of proximal ureter and renal pelvis, longitudinal and transverse stone size, Hounsfied unit (HU) of the stone and lastly ureteral wall thickness at the impacted stone site were all carefully evaluated and noted.

RESULTS

Patients had a single proximal ureteral stone. While mean age of the cases was ranged 20 to 78 years; mean stone size was 15.62±4.26 mm. Evaluation of our data demonstrated that although there was a statistically significant correlation between ureteral wall thickness and patients age, transverse diameter of the stone, ureteral diameter just proximal to the stone, renal pelvic diameter and the duration of renal colic attacks; no correlation could be demonstrated between patients sex and the HU of the stone.

CONCLUSIONS

Prediction of the presence and degree of proximal ureteral stone impaction is a challenging issue and our data indicated a highly significant correlation between ureteral wall thickness and the some certain radiological as well as clinical parameters evaluated which will give an objective information about the presence of impaction which may in turn be helpful in the follow-up and also management plans of such calculi.

Comparative efficacy of tadalafil versus tamsulosin as the medical expulsive therapy in lower ureteric stone: a prospective randomized trial

Introduction

In recent years, medical expulsive therapy has been used in the management of distal ureteric stones as a supplement to conservative treatment. Therefore, we conducted a prospective randomized study to evaluate the possible role of tadalafil individually in comparison with proven tamsulosin therapy in ureteric stone expulsion.

The aim of this study is to compare the safety and efficacy of a phosphodiesterase-5 inhibitor (tadalafil) and an α-1 blocker (tamsulosin) as medical expulsive therapy for distal ureteric calculi.

Material and methods

Between August 2014 and October 2015, 207 patients who presented with distal ureteric stones of size 5–10 mm were randomly divided into two groups: tadalafil (Group A) and tamsulosin (Group B). Therapy was given for a maximum of 4 weeks. Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up, endoscopic treatment and adverse effects of drugs were noted. Both groups were compared for normally distributed data by percentage, analysis of variance, and T-test. All the classified and categorical data were analyzed for both groups using the chi-square test.

Results

A statistically significant expulsion rate of 84.0% in Group A compared with 68.0% in Group B (P value = 0.0130), and shorter stone expulsion time in Group A (14.7±3.8) in comparison to Group B (16.8 ±4.5) was observed. Statistically significant differences were noted in renal colic episodes and analgesic requirement in Group A than Group B. No serious adverse effects were noted.

Conclusions

Tadalafil is safe, efficacious, and well tolerated as medical expulsive therapy for distal ureteric stones. This study showed that tadalafil increases ureteric stone expulsion quite significantly along with better control of pain and significantly lower analgesic requirement.

Stone heterogeneity index as the standard deviation of Hounsfield units: A novel predictor for shock-wave lithotripsy outcomes in ureter calculi

We investigated whether stone heterogeneity index (SHI), which a proxy of such variations, was defined as the standard deviation of a Hounsfield unit (HU) on non-contrast computed tomography (NCCT), can be a novel predictor for shock-wave lithotripsy (SWL) outcomes in patients with ureteral stones. Medical records were obtained from the consecutive database of 1,519 patients who underwent the first session of SWL for urinary stones between 2005 and 2013. Ultimately, 604 patients with radiopaque ureteral stones were eligible for this study. Stone related variables including stone size, mean stone density (MSD), skin-to-stone distance, and SHI were obtained on NCCT. Patients were classified into the low and high SHI groups using mean SHI and compared. One-session success rate in the high SHI group was better than in the low SHI group (74.3% vs. 63.9%, P = 0.008). Multivariate logistic regression analyses revealed that smaller stone size (OR 0.889, 95% CI: 0.841–0.937, P < 0.001), lower MSD (OR 0.995, 95% CI: 0.994–0.996, P < 0.001), and higher SHI (OR 1.011, 95% CI: 1.008–1.014, P < 0.001) were independent predictors of one-session success. The radiologic heterogeneity of urinary stones or SHI was an independent predictor for SWL success in patients with ureteral calculi and a useful clinical parameter for stone fragility.

Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2-4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

Impaction of ureteral stones into the ureteral wall: Is it possible to predict?

To determine the possible predictive value of certain acute phase reactants CRP and ESR as well as radiologic parameters on the degree of impaction in ureteral stones. A total of 80 adult patients with a single opaque proximal ureteral stone were evaluated. A non-contrast CT was performed in all cases and all possible radiologic predictive parameters calculated. Additionally, to outline the degree of impaction at the stone site, two serum acute phase reactants namely CRP and ESR levels were also assessed. Patients were divided into two groups as follows; Group 1 (n:42) patients with normal CRP levels and Group 2 (n:38) patients with elevated levels of CRP. The data obtained in the subgroups were first comparatively evaluated with radiological parameters and the possible correlation between CRP values and these parameters was well evaluated. While the serum CRP levels were normal in 42 cases, they were elevated in 38 cases. Evaluation of the data from CRP subgroups and radiologic parameters showed that elevated levels of serum CRP were closely related with mean values of ureteral wall thickness (UWT) as well as mean level of hydronephrosis with a statistically significant difference. Additionally, a correlation analysis between serum CRP levels and all other parameters mentioned above demonstrated a statistically significant correlation between UWT, degree of hydronephrosis and serum ESR values. Evaluation of serum CRP and ESR values could let us to predict the UWT, a parameter which is closely related with the degree of stone impaction.

Flexible Ureteroscopy Can Be More Efficacious in the Treatment of Proximal Ureteral Stones in Select Patients

Purpose. We aimed to compare and evaluate the outcomes and complications of two endoscopic treatment procedures, semirigid ureteroscopy (SR-URS) and flexible ureteroscopy (F-URS), in the treatment of proximal ureteral stones (PUS). Methods. SR-URS (group 1) was done on 68 patients whereas 64 patients underwent F-URS (group 2) for the treatment of PUS. Success rate was defined as the absence of stone fragments or presence of asymptomatic insignificant residual fragments < 2 mm. Outcomes and complications were recorded. Results. The differences were statistically not significant in age, gender, body mass index (BMI), and stone characteristics between groups. Mean ureteral stone size was 9.1 ± 0.4 mm and 8.9 ± 0.5 mm for groups 1 and 2. Mean operative time was 34.1 ± 1.5 min and 49.4 ± 2.3 min for groups 1 and 2 (p = 0.001). SFRs were 76.5% and 87.5% for groups 1 and 2 (p = 0.078). Two major complications (ureteral avulsion and ureteral rupture) occurred in group 1. Conclusion. F-URS is safer and less invasive than SR-URS in patients with PUS. There is no statistically significant difference in the efficacy of either technique. Nonetheless we recommend F-URS in the management of PUS as a first-line treatment option in select cases of proximal ureteral calculi.

Safety and efficacy of using the stone cone and an entrapment and extraction device in ureteroscopic lithotripsy for ureteric stones

Objective

To assess the safety and efficacy of using a stone cone and an entrapment and extraction device (N-Trap®, Cook Urological, Bloomington, IN, USA) to avoid stone retropulsion during ureteroscopic lithotripsy for ureteric stones.

Patients and methods

This retrospective comparative study included 436 patients treated with ureteroscopic lithotripsy for a single ureteric stone from February 2011 to January 2014. The diagnosis of a stone was confirmed by plain spiral computed tomography in all cases. Patients were divided according to the ureteric occlusion device applied to avoid stone retropulsion during pneumatic lithotripsy into three groups; group 1 (156) had no instruments used, group 2 (140) in whom the stone cone was applied, and group 3 (140) in whom the N-Trap was used. Patient demographics, stone criteria, operative duration and complications, and success rates (complete stone disintegration with no upward migration) were reported and analysed statistically.

Results

The stone was in the lower ureter in >55% of patients in all groups. The mean (SD) of maximum stone length was 9.8 (2.5), 10.4 (2.8) and 9.7 (2.9) in groups 1–3, respectively. The use of the stone cone or N-Trap did not significantly increase the operative duration (P = 0.13) or complication rates (P = 0.67). There was a statistically significant difference (P < 0.001) favouring groups 2 and 3 for retropulsion and success rates, being 83.3% in group 1, 97.1% in group 2 and 95.7% in group 3.

Conclusion

The stone cone and N-Trap gave high success rates in preventing stone retropulsion during ureteric pneumatic lithotripsy. Both devices caused no increase in operative duration or complications when used cautiously.

Laparoscopic management of distal ureteric stones in a bilharzial ureter: Results of a single-centre prospective study

OBJECTIVE

To determine the efficacy and safety of the laparoscopic management of an impacted distal ureteric stone in a bilharzial ureter, as bilharzial ureters are complicated by distal stricture caused by the precipitation of bilharzial ova in the distal ureter. These cases are associated with poorly functioning and grossly hydronephrotic kidneys that hinder the endoscopic manipulation of the coexistent distal high burden of, and long-standing, impacted stones.

PATIENTS AND METHODS

We used laparoscopic ureterolithotomy, with four trocars, to manage 51 bilharzial patients (33 men and 18 women; mean age 40.13 years) with distal ureteric stones. The ureter was opened directly over the stone and the stone was extracted. A JJ stent was inserted into the ureter, which was then closed with a 4-0 polyglactin running suture.

RESULTS

The mean stone size was 2.73 cm. Conversion to open surgery was required in only one patient. The mean operative duration was 92 min, the postoperative pain score was 20-60, the mean (range) number of analgesic requests after surgery was 1.72 (1-3), comprising once in 21 patients, twice in 23 and thrice in seven. The mean hospital stay was 2.74 days, and the total duration of follow-up was 7-12 months. The stone recurred in four patients and a ureteric stricture was reported in two. All patients were rendered stone-free.

CONCLUSION

Laparoscopy is a safe and effective minimally invasive procedure for distal ureteric stones in a bilharzial ureter with hydronephrosis.

Impact of using thiocolchicoside during endoscopic ureteral calculi removal: A preliminary study

OBJECTIVE

To evaluate the effects of thiocolchicoside during endoscopic treatment of ureteral calculus.

MATERIAL AND METHODS

Between May 2014 and December 2014, 498 consecutive patients were enrolled. Exclusion criteria were operations under general anaesthesia, chancing laser lithotripter settings, and urinary tract infection. All patients were divided into three groups: Group 1 consisted of patients who were not administered thiocolchicoside, group 2 consisted of patients who were administered 5 mg thiocolchicoside, and group 3 consisted of patients who were administered 10 mg thiocolchicoside. Demographic, perioperative, and postoperative data were recorded. Complications were noted according to Clavien-Dindo classifications. A p value of p ≤ 0.05 was considered statistically significant.

RESULTS

A total of 427 patients (319 male and 108 female) with full data were investigated. Mean age was 43.3 ± 13.3 years. There were 157 patients in group 1, 141 patients in group 2, and 129 patients in group 3. Stone migration and operation time were significantly lower in groups 2 and 3 than in group 1 (respectively; p < 0.001, p = 0.03). However, usage of jj stents was significantly lower in group 3 than in the other groups (p < 0.001).

CONCLUSION

Stone migration can be decreased by using locally administered thiocolchicoside in irrigation solution during endoscopic treatment of ureteral calculus. Additional doses may decrease usage of jj stents and operation time.

Ureteral wall thickness at the impacted ureteral stone site: a critical predictor for success rates after SWL

The aim of the study was to determine the possible predictive value of certain patient- and stone-related factors on the stone-free rates and auxiliary procedures after extracorporeal shock wave lithotripsy in patients with impacted proximal ureteral calculi. A total of 111 patients (86 male, 25 females M/F: 3.44/1) with impacted proximal ureteral stones treated with shock wave lithotripsy were evaluated. Cases were retrieved from a departmental shock wave lithotripsy database. Variables analyzed included BMI of the case, diameter of proximal ureter and renal pelvis, stone size and Hounsfield unit, ureteral wall thickness at the impacted stone site. Stone-free status on follow-up imaging at 3 months was considered a successful outcome. All patients had a single impacted proximal ureteral stone. While the mean age of the cases was 46 ± 13 years (range 26-79 years), mean stone size was 8.95 mm (5.3-15.1 mm). Following shock wave lithotripsy although 87 patients (78.4%) were completely stone-free at 3-month follow-up visit, 24 (21.6%) cases had residual fragments requiring further repeat procedures. Prediction of the final outcome of SWL in patients with impacted proximal ureteral stones is a challenging issue and our data did clearly indicate a highly significant relationship between ureteral wall thickness and the success rates of shock wave lithotripsy particularly in cases requiring additional procedures. Of all the evaluated stone- and patient-related factors, only ureteral wall thickness at the impacted stone site independently predicted shock wave lithotripsy success.

A comparison of antegrade percutaneous and laparoscopic approaches in the treatment of proximal ureteral stones

Purpose. To compare the effectiveness and safety of retroperitoneal laparoscopic ureterolithotomy (RLU) and percutaneous antegrade ureteroscopy (PAU) in which we use semirigid ureteroscopy in the treatment of proximal ureteral stones. Methods. Fifty-eight patients with large, impacted stones who had a history of failed shock wave lithotripsy (SWL) and, retrograde ureterorenoscopy (URS) were included in the study between April 2007 and April 2014. Thirty-seven PAU and twenty-one RLU procedures were applied. Stone-free rates, operation times, duration of hospital stay, and follow-up duration were analyzed. Results. Overall stone-free rate was 100% for both groups. There was no significant difference between both groups with respect to postoperative duration of hospital stay and urinary leakage of more than 2 days. PAU group had a greater amount of blood loss (mean hemoglobin drops for PAU group and RLU group were 1.6 ± 1.1 g/dL versus 0.5 ± 0.3 g/dL, resp.; P = 0.022). RLU group had longer operation time (for PAU group and RLU group 80.1 ± 44.6 min versus 102.1 ± 45.5 min, resp.; P = 0.039). Conclusions. Both PAU and RLU appear to be comparable in the treatment of proximal ureteral stones when the history is notable for a failed retrograde approach or SWL. The decision should be based on surgical expertise and availability of surgical equipment.

Should we place ureteral stents in retroperitoneal laparoscopic ureterolithotomy?: Consideration of surgical techniques and complications

Purpose

There is some debate over the necessity of ureteral stenting after laparoscopic ureterolithotomy. We evaluated the need for ureteral stenting after retroperitoneal laparoscopic ureterolithotomy (RLU).

Materials and Methods

Between January 2009 and January 2013, 41 patients underwent RLU to remove upper ureteral stones. The retroperitoneal approach was used in all patients by a single surgeon. A double J (D-J) stent was placed in the first 17 patients after the procedure but not in any of the next 24 patients.

Results

The mean patient age, serum creatinine levels, and stone size were not significantly different between the two groups. The stone-free rate was 100%. The mean operative time was significantly shorter in the stentless group than in the stent group (59.48 minutes vs. 77.88 minutes, p<0.001). Parenteral analgesic use and anticholinergic medication use were observed in the stent group only. The blood loss, drain removal day, and hospital stay were not significantly different between the two groups. No other significant complications occurred during or after the operation in any patients.

Conclusions

RLU is a safe and effective treatment modality for large impacted ureteral stones. In this study, D-J stent placement was not necessary after RLU. In the future, large-scale studies of RLU without D-J stenting, especially on the frequency of the development of complications according to the surgical technique, may be needed.

Comparative efficacy of tamsulosin versus tamsulosin with tadalafil in combination with prednisolone for the medical expulsive therapy of lower ureteric stones: a randomized trial

PURPOSE

To compare the safety and efficacy of tamsulosin and tamsulosin with the phosphodiesterase-5 inhibitor tadalafil in combination with prednisolone as medical expulsive therapies for lower ureteric stones.

MATERIALS AND METHODS

Between July 2011 and December 2012, 62 adult patients presenting with distal ureteric stones sized 5 to 10 mm were randomized equally to treatment with tamsulosin (group A) or tamsulosin with tadalafil (group B). Therapy was given for a maximum of 6 weeks. In addition, patients in groups A and B were given 5-mg prednisolone once daily (maximum 1 week). The stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up and endoscopic treatment, and adverse effects of the drugs were noted. Statistical analyses were done by using Student t-test and chi-square test.

RESULTS

There was a higher expulsion rate (83.9% in group B and 74.2% in group A) and a lower time to expulsion in both treatment groups than in historical controls used in earlier studies. However, these results were not statistically significant (p=0.349, p=0.074, respectively). Statistically significant differences were noted in hospitalization for colic and analgesic requirement, which were less in group B than in group A. There were no serious adverse events. Another important finding was improvement in erectile function in group B.

CONCLUSIONS

Medical expulsive therapy for distal ureteric stones using tamsulosin and tadalafil with prednisolone is safe and efficacious. Also, the prescription of tadalafil in cases of erectile dysfunction with the development of lower ureteric stones may provide additional advantages.

Efficacy of retroperitoneal laparoscopic ureterolithotomy for the treatment of large proximal ureteric stones and its impact on renal function

PURPOSE

The purpose of this study was to evaluate the efficacy of retroperitoneal laparoscopic ureterolithotomy for the management of large proximal ureteric stones and the impact of this treatment on postoperative renal function.

METHODS

The data of 12 patients (7 men and 5 women; mean age, 68.5 ± 8.9 years) with large pyeloureteral junction (2 cases) and upper ureteral (10 cases) stones (25.3 ± 7.4 mm) that had undergone retroperitoneal laparoscopic ureterolithotomy were reviewed. Renal function was analyzed by the estimated glomerular filtration rate (eGFR) and renal scintigraphy using 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) before and 3 months after surgery.

RESULTS

The mean operative time was 129.5 ± 21.4 minutes, with a mean blood loss of 64.4 ± 78.2 mL. The mean duration of hospital stay after surgery was 6.4 ± 2.7 days, and the mean duration of stenting was 7.2 ± 1.7 weeks. A stone clearance rate of 100% was achieved, and no patient developed ureteric stricture. 99mTc-MAG3 scintigraphy showed that laparoscopic removal of calculi did not affect renal function, but did improve ureteral occlusion.

CONCLUSIONS

Retroperitoneal laparoscopic ureterolithotomy is a safe and effective treatment option for reducing ureteral obstruction in select patients with large proximal ureteric stones.

Prospective Randomized Comparison of Open versus Transperitoneal Laparoscopic Ureterolithotomy: Experience of a Single Center from Northern India

AIM

Prospective randomized study on transperitoneal laparoscopic ureterolithotomy (TPLU) versus open ureterolithotomy (OU) for treatment of large impacted ureteric stones (≥ 1.5 cm) and assessment of overall results.

MATERIAL & METHODS

In a prospective study between 2010 to 2012, 30 patients underwent TPLU and 30 OU based on 1:1 randomization. The operation was indicated primarily in 44 cases or after failed shock-wave lithotripsy/ureteroscopy in 16 cases. Two groups were compared for operative time, success rate, visual pain score, analgesic requirement, hospital stay, and postoperative complications. Statistical analysis was performed with SPSS® version 16.0 using Fisher exact or Mann-Whitney U tests with p < 0.05 considered statistically significant.

RESULTS

The difference in visual pain score (6.2 in TPLU group vs 3.1 in OU group on day 1; 4.8 vs. 2.4 on day 2) and tramadol requirements (184.32 mg in TPLU group vs. 150.87 mg in OU group on day 1; 97.34 mg vs. 65.56 mg on day 2) were statistically significant and more in OU. Hospital stay and convalescence were significantly lower in the TPLU. However, stone removal in one attempt was similar in both the groups.

CONCLUSION

Although successful stone removal rates are equal in both groups, TPLU is associated significantly with less postoperative pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison to OU.

Computed tomography-based novel prediction model for the stone-free rate of ureteroscopic lithotripsy

The purpose of this study was to evaluate whether computed tomography (CT) parameters can predict the success of ureteroscopic lithotripsy (URSL) and establish a model for predicting the success rates of a single URSL procedure for the treatment of a single ureteral stone. We retrospectively reviewed the records of 237 patients who underwent URSL for ureteral stones diagnosed by CT between January 2009 and June 2012. Stone-free status was defined as the absence of stones or residual stone fragments <2 mm by ureteroscopy and plain abdominal radiography. We analyzed the correlations between the outcome of URSL and the patients' sex, age, height, body weight, body mass index, and history of ureteral stone. Stone factors such as the diameter (D), stone height (H), volumetric stone burden (VSB; D(2) × H × 5 mm × π × 1/6), estimated stone location (ESL; number of axial cut images between the stone and uretero-vesical junction), tissue rim sign (RS; 0-3), perinephric edema (0-3), hydronephrosis (0-3), and Hounsfield unit (HU) were also analyzed. We then developed a model to predict the probability of successful URSL by applying a logistic model to our data. The success rate of URSL was 85.7% (203/237). Univariate analysis found that stone diameter, length, VSB, ESL, HU and RS significantly affected the stone-free rate. Multivariate analysis indicated that stone diameter, ESL and RS independently influenced the stone-free rate. The logistic model indicated that success rates = 1/[1 + exp{-6.146 + 0.071(D) + 0.153(ESL) + 1.534(RS)}] with an area under the receiver operating characteristic curve of 0.825. Stone diameter, ESL, and RS were independent predictors of the outcome of a single URSL for a single ureteral stone.

Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position

Context:

The treatment for patients with large impacted proximal ureteral stone remains controversial, especially at institutions with limited resources.

Aim:

The aim of this study is to compare and to evaluate the outcome and complications of two main treatment procedures for impacted proximal ureteral calculi, retrograde ureterolithotripsy (URS), and percutaneous antegrade ureterolithotripsy (Perc-URS).

Settings and Design:

Our inclusion criteria were solitary, radiopaque calculi, >15 mm in size in a functioning renal unit. Only those patients in whom the attempt at passing a guidewire or catheter beyond the calculus failed were included in this study.

Patients and Methods:

Between January 2007 and July 2011, a total of 52 patients (13 women and 39 men) with large impacted upper-ureteral calculi >15 mm and meeting the inclusion criteria were selected. Of these, Perc-URS was done in 22 patients (group 1) while retrograde ureteroscopy was performed in 30 patients (group 2). We analyzed operative time, incidence of complications during and after surgery, the number of postoperative recovery days, median total costs associated per patient per procedure, and the stone-free rate immediately after 5 days and after 1 month.

Statistical Analysis Used:

Bivariate analysis used the Student t-test and the Mann-Whitney test to compare two means and Chi-square and Fisher's exact tests to compare two percentages. The significance level was set at 0.05.

Results:

The mean age was 42.3 years (range 22-69). The mean stone sizes (mm) were 34 ± 1.2 and 29.3 ± 1.8 mm in group 1 and 2, respectively. In the Perc-URS group, 21 patients (95.45%) had complete calculus clearance through a single tract in one session of percutaneous surgery, whereas in the URS group, only 20 patients (66.7%) had complete stone clearance (P = 0.007). The mean operative time was higher in the Perc-URS group compared to group 2 (66.5 ± 21.7 vs. 52.13 ± 17.3 min, respectively; P = 0.013). Complications encountered in group 1 included transient postoperative fever (2 pts) and simple urine outflow (2 pts). Ten patients (33%) of group 2 experienced failure: Migration to the kidney (3 pts), ureteral perforation (2 pts), tortuosity of the ureter (2 pts), and epithelial polyps (2 patients). Group 1 patients had an average visual analog (VAS) pain score of 47 mm compared with 31 mm in group 2 patients. The mean hospital stay (days) in group 1 was higher than the group 2 (2.27 ± 0.8 vs. 1.67 ± 0.6, respectively; P = 0.01). The mean analgesia requirement for group 1 (paracetamol chlorhydrate + codeine 12 ± 3 g) was significantly more compared with group B (6.8 ± 2 g) (P < 0.01). The difference in average blood loss between the two groups was not statistically significant. Total costs was slightly higher in group 1 but the difference was not statistically significant between the two groups (15000 vs. 13400 MDH respectively; P > 0.05). After 1 month, the stone free-rate remained higher in group 1 (95.5% vs. 66.7%, respectively; P = 0.012).

Conclusions:

In our series, Perc-URS is a safe and efficient treatment option for proximal ureteral stone, especially when the stone size is superior to 15 mm with the presence of moderate or severe hydronephrosis.

Randomized controlled trial to compare the safety and efficacy of naftopidil and tamsulosin as medical expulsive therapy in combination with prednisolone for distal ureteral stones

Purpose

To compare the safety and efficacy of naftopidil and tamsulosin with prednisolone as medical expulsive therapy for distal ureteric stones.

Materials and Methods

Between July 2010 and March 2012, 120 adult patients presenting with distal ureteric stones of size 5 to 10 mm were randomized equally to tamsulosin (group A), naftopidil (group B) or watchful waiting (group C). Tamsulosin or naftopidil was given for a maximum of four weeks. In addition patients in group A and B were given 5 mg prednisolone once daily (maximum one week). Stone expulsion rate, time to stone expulsion, analgesic use, number of hospital visits for pain, follow-up and endoscopic treatment and adverse effects of drugs were noted. Statistical analyses were done using chi-square test, Mann-Whitney test and analysis of variance.

Results

There was a statistically higher expulsion rate in groups A (70%) and B (87.5%) as compared to group C (32.5%) (p<0.001). The expulsion rates were not statistically different between groups A and B (p=0.056). The mean time to expulsion was comparable between groups A and B but longer in group C. Analgesic use was significantly lower in groups A and B. Average number of hospital visits for pain, follow-up and endoscopic treatment was similar in all groups. There was no serious adverse event.

Conclusions

Medical expulsive therapy for the distal ureteric stones using either naftopidil or tamsulosin in combination with prednisolone is safe and efficacious.

Two-step minipercutaneous ureterolithotripsy under multimodal analgesia for complicated impacted calculi in proximal ureter

OBJECTIVE

To suggest minipercutaneous ureterolithotripsy using the mininephroscope as an alternative process for impacted stones of the upper ureter because these stones can be challenging to treat and can produce severe symptoms.

MATERIALS AND METHODS

We report our results of cases in which the percutaneous approach using 2-step minipercutaneous ureteroscopy with the mininephroscope was used to achieve relief from the stone, with minimal anesthesia risks. A total of 54 patients (33 men and 21 women) presented with impacted stones in the proximal ureter. The mean stone size was 16.2 mm (range 10-21). All patients were treated with 2-step minipercutaneous antegrade ureterolithotripsy under multimodal analgesia.

RESULTS

The mean operative time was 49 minutes (range 40-110). Placement of the percutaneous drainage tube was quick and was performed with the patient under local anesthesia. The minipercutaneous session followed several days later, with the patient under multimodal anesthesia. The initial stone-free rate was 94%. The stone-free rate 2 months after the procedure was 100%. All procedures were well tolerated by the patients (group mean visual analog scale score 3.1 ± 0.7 standard deviation). No severe adverse events were noted. The mean hospital stay was 5.3 days (range 3-12).

CONCLUSION

In selected emergency cases of impacted proximal ureteral stones, the approach of the initial insertion of a nephrostomy tube followed by a second session of antegrade ureterolithotripsy using the mininephroscope is a safe and effective alternative treatment, especially, because it can be accomplished with minimal anesthesia requirements.

Determination of renal stone composition in phantom and patients using single-source dual-energy computed tomography

PURPOSE

This study aimed to characterize the urinary tract stones in phantom and patients using single-source dual-energy computed tomography.

MATERIALS AND METHODS

Twenty stones of pure crystalline composition (uric acid [UA], struvite, cystine, and calcium oxalate monohydrate) were assessed in a phantom and 11 patients (age 39-67 years) with urinary tract stones were evaluated. An initial low-dose unenhanced CT (tube potential, 120 kilovolts [peak]; milliampere range, 150-450; noise index, 26; section thickness, 5 mm) followed by a targeted dual-energy computed tomography acquisition on a single-source dual-energy computed tomography (Discovery CT 750 HDCT, GE) was performed. Uric acid and non-UA stones were defined using a 2-material decomposition (material density-iodine/water) algorithm. The stone effective atomic number (Zeff) was used to subclassify non-UA stones. The stone attenuation (Hounsfield unit) was also studied to determine its performance in predicting the composition. Ex vivo chemical analysis of the stone served as a criterion standard.

RESULTS

Of the 59 verified stones (phantom, 20; patients, 39; mean size, 6 mm), there were 16 UA and 43 non-UA type. The material density images were 100% sensitive and accurate in detecting UA and non-UA stones. The Zeff accurately stratified struvite, cystine, and calcium (calcium oxalate monohydrate) stones in the phantom. In patients, Zeff identified 83% of calcium stones (n = 24), and in stones of mixed type, it resembled dominant composition. The Hounsfield unit measurements alone were 71% sensitive and 69% accurate in detecting the UA stones.

CONCLUSIONS

Single-source dual-energy computed tomography can accurately predict UA and non-UA stone composition in vitro and in vivo. Substratification of non-UA stones of pure composition can be made in vitro and in vivo. In stones of mixed composition, the Zeff values reflect the dominant composition.

Transperitoneal versus retroperitoneal laparoscopic ureterolithotomy: a prospective randomized comparison study

PURPOSE

We compared laparoscopic transperitoneal and retroperitoneal ureterolithotomy approaches, and determined whether one technique is superior to the other.

MATERIALS AND METHODS

In this prospective randomized study from January 2009 to May 2012, 48 patients with proximal or mid ureteral stones underwent transperitoneal laparoscopic ureterolithotomy or retroperitoneal laparoscopic ureterolithotomy. The randomization occurred on a 1:1 basis. Groups 1 and 2 consisted of patients who underwent transperitoneal laparoscopic ureterolithotomy and retroperitoneal laparoscopic ureterolithotomy, respectively. Demographic and clinical characteristics as well as postoperative data were collected and analyzed. Statistical analysis was performed with SPSS® version 15.0 using the Fisher exact and Mann-Whitney U tests with p <0.05 considered statistically significant.

RESULTS

The difference in visual pain analog score and mean tramadol requirement on days 1 and 2 between the 2 groups was statistically significant, and was higher in group 1 (p <0.05). Postoperative hospital stay and paralytic ileus rates were significantly higher in group 1 (p <0.05). The differences in total operative time and intracorporeal suturing time between the 2 groups were not statistically significant. However, successful stone removal was equal in the 2 groups.

CONCLUSIONS

For proximal or mid ureteral large and impacted stones, transperitoneal laparoscopic ureterolithotomy is significantly associated with pain, greater tramadol requirement, ileus and longer hospital stay than retroperitoneal laparoscopic ureterolithotomy. However, successful stone removal remains the same in both groups.

Longitudinal stone diameter on coronal reconstruction of computed tomography as a predictor of ureteral stone expulsion in medical expulsive therapy

OBJECTIVE

To evaluate stone diameter and ureteral dilation using computerized tomography as a predictor of ureteral stone expulsion after medical expulsive therapy.

MATERIALS AND METHODS

We retrospectively reviewed the records of 328 patients with symptomatic ureteral stones <10 mm on axial computerized tomography images, who were treated with alpha blockers for 2 weeks. Computerized tomography scans were also performed 2 weeks after medical expulsive therapy to confirm ureteral stone expulsion. Patients were divided into upper ureteral stones and lower ureteral stones above and below the iliac vessels, respectively. Transverse stone diameter and longitudinal stone diameter were defined as the largest stone diameter determined on the axial and coronal computerized tomography images, respectively. Ureteral diameter was determined on one computerized tomography slice proximal to each ureteral stone on axial computerized tomography images, and the ratio of ureter-to-stone diameter was defined as ureteral diameter divided by transverse stone diameter.

RESULTS

Among 328 patients, the stone expulsion rate was 44.1% in 145 upper ureteral stones and 69.4% in 183 lower ureteral stones. Transverse stone diameter, longitudinal stone diameter, ureteral diameter, and the ratio of ureter-to-stone diameter were significantly lower in patients with ureteral stone expulsion in upper ureteral stones and lower ureteral stones (P < .001 for all parameters). Logistic regression analysis revealed that only longitudinal stone diameter was a significant predictor of stone expulsion in patients with upper ureteral stones (odds ratio 0.580, P = .040) and lower ureteral stones (odds ratio 0.415, P = .012).

CONCLUSION

Longitudinal stone diameter was a significant predictor of stone expulsion in patients with upper ureteral stones and lower ureteral stones after medical expulsive therapy. Measurement of stone diameters in coronal reconstruction may help to better choose a patient who is suitable for medical expulsive therapy.

Fragmentation without extraction in ureteral stones: outcomes of 238 cases

We aimed to evaluate the success rates, auxiliary procedures and complications after ureteroscopic lithotripsy (URS) during which the fragments left in situ for spontaneous passage after complete disintegration into a acceptable (<4 mm) size. 238 patients with ureteral stones were treated with URS between 2005 and 2011, and disintegrated fragments (<4 mm) were left in situ for spontaneous passage. Patients were followed with radiography for 3 months and evaluated with respect to the success rates (stone-free), auxiliary procedures, complication rates and additional analgesic requirement. The median age was 42.2 ± 13.7 years, and overall stone size was 8.79 ± 2.94 mm. Significantly lower rate of stone-free status was achieved in proximal stones (p < 0.05). A second URS was necessary in 5% (n = 12) of the patients. Double-J catheter placement during initial URS did not cause any change in the rate of secondary URS (p = 0.620). Additional oral or intramuscular analgesia was required in 41% (n = 97) and 25% (n = 59) of the patients, respectively, after discharge. The overall stone-free rate was 95% and mean time to complete clearance was 5 days. Severe colic pain within 24 h was noted in 21 (9%), and transient hydro-ureteronephrosis in 31 (13%) patients, as minor complications. Leaving the fragments (<4 mm) in place for spontaneous passage following a successful disintegration in URS could be a reasonable approach with acceptable and comparable stone-free rates, and this approach appears to give chance of shortening the duration of operation and also avoiding from the potential morbidity of repeated manipulations during the both further disintegration and extraction.

Acute postoperative pain after ureteroscopic removal of stone: incidence and risk factors

Purpose

Ureteroscopic removal of stones (URS) has been widely used to treat ureteral stones because it is comparatively safe, has a high success rate, and enables patients to rapidly return to their daily routines. However, some patients experience pain after URS, but the incidence of acute post-URS pain remains largely unknown. This study aimed to investigate the incidence of acute postoperative pain after URS and the associated risk factors.

Materials and Methods

Data for 143 consecutive patients who underwent URS from June 2008 to December 2010 were collected. After excluding 8 patients who developed intraoperative complications, the patients were divided into two groups according to postoperative pain on the first postoperative day. Acute postoperative pain was defined as a pain score greater than 4 on a visual analogue pain scale (normal range, 0 to 10). Various factors were analyzed to identify the risk factors that could predict acute postoperative pain after URS.

Results

The stone-free rate without URS intraoperative complications was 95.5%. A total of 21 (14.6%) patients experienced postoperative pain on the first postoperative day. Young age, psychiatric illness, history of urinary tract infection, use of a stone basket, large stone size, and prolonged operation time were identified as risk factors for acute postoperative pain.

Conclusions

The incidence of acute postoperative pain is not that low and should not be overlooked, because it is associated with postoperative complications that could result in an unscheduled hospital admission or visit. Active pain control should be contemplated after URS in young patients and in those with a history of urinary tract infection, psychiatric illness, large stone size, and prolonged operation time.