Percutaneous management of urolithiasis during pregnancy

Factors affecting the need for ureteral catheterization in symptomatic pregnancy hydronephrosis

PURPOSE

In our study, considering the clinical parameters we aimed to determine the most appropriate treatment approach for symptomatic gestational hydronephrosis and conditions requiring DJS insertion.

METHODS

Our study was a retrospective cross-sectional study and 137 patients were included. The patients were divided into two groups: those with conservative follow-up and those with DJS. Demographic and clinical data, the degree of HUN detected in urinary ultrasonography and the anteroposterior diameter of the renal pelvis were evaluated. Factors affecting the need for DJS between groups were investigated. Also, it was aimed to determine the cut-off value for the HUN degree and renal pelvis AP diameter in patients with DJS.

RESULTS

The presence of urinary system stones was statistically significantly higher in the group with DJS than in the group without DJS (p = 0.014). HUN degrees and AP diameter were statistically significantly higher in the DJS group (p < 0.001, p < 0.001, respectively). HUN degree and renal pelvis AP diameter were the two most important predictors for DJS insertion (p = 0.005, p = 0.015, respectively). The AP diameter cut-off value for DJS installation was determined as 20.5 mm.

CONCLUSION

Although there are conservative and surgical treatment options for symptomatic hydronephrosis of pregnancy, the factors at the decision point between these options are still a matter of debate. In our study, we concluded that the most important determinants at this decision point are the HUN degree and renal pelvis AP diameter. We think that the cut-off values we have determined for these markers will guide clinicians in deciding on treatment.

Management of urolithiasis in pregnancy: A systematic review and meta-analysis

PURPOSE

Management of nephrolithiasis is unique in pregnancy and requires multidisciplinary care. To identify the effectiveness or safety of temporary drainage or definitive treatment methods to manage urolithiasis in pregnancy.

METHODS

The search strategy aimed to find both published and unpublished studies was conducted in August 2021. Studies published in any language on any date were considered for inclusion.

RESULTS

Of a total of 3349 publications, 36 studies were included in our qualitative evaluation and 32 studies in the quantitative synthesis. The commonly reported method was stent insertion (n = 29 studies), pneumatic (n = 12), laser (n = 9) lithotripsy, and stone removal using any devices (basket, grasper, or forceps) (n = 11). In seven studies, the authors reported the outcomes of conservative management, and the results showed that the stone-free rate is 54%, and symptom relief occurred in 62% of women. Seven eligible studies reported that 79.9% of urolithiasis were expulsed through stent insertion, while this rate was 94.6% among percutaneous nephrostomy use in two included studies, 88.5% for pneumatic lithotripsy (n = 7 studies), and 76.4% for laser lithotripsy (n = 4 studies), or 95.4% for stone removal method. In addition, adverse events were reported in less than 10% of pregnant women.

CONCLUSIONS

The results showed that stent, pneumatic or laser lithotripsy, and ureteroscopic stone removal were the commonest used methods in the included studies. They can be effective and safe treatment approaches without major maternal or neonatal complications, and could be introduced as an effective and safe therapeutic method for urolithiasis during pregnancy. However, most of the included studies had moderate quality according to critical appraisal checklists. Further prospective studies are needed to reach a conclusion.

Urolithiasis in pregnancy: Advances in imaging modalities and evaluation of current trends in endourological approaches

OBJECTIVE

Given the challenges involved in diagnosis and treatment of pregnant women with urolithiasis, we aim to review the imaging modalities and current endourological management of these patients.

MATERIALS AND METHODS

We performed a review of the available literature on urolithiasis in pregnancy. This included evaluation, diagnostic imaging, and therapeutic options. The databases we searched from included Google Scholar and PubMed. A total of 346 abstracts were screened. After our inclusion/exclusion criteria were met, we were left with 42 sources: 18 retrospective studies, 10 reviews/meta-analyses, 8 sets of guidelines, 5 randomized control trials, and 1 prospective cohort.

RESULTS

We begin our review with the literature available on the safety and efficacy of imaging modalities in the surgical planning for urolithiasis in pregnant patients. This includes renal ultrasound, abdominal x-ray, computed tomography scan, and magnetic resonance imaging. While computed tomography may result in an added radiation exposure, with possible safety concerns, magnetic resonance imaging seems to be safer, however a less sensitive test. We next describe safety, efficacy, and outcomes of various surgical interventions for urolithiasis in pregnant patients. This encompasses ureteral stenting, percutaneous nephrostomy, ureteroscopy, extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. Ureteroscopy is a safer approach, but percutaneous nephrolithotomy offers higher stone-free rates. Using an evidence-based approach, we propose an algorithm for management of the pregnant women with renal colic.

CONCLUSION

Management of the pregnant women with suspected urolithiasis is a unique challenge for healthcare providers. A multi-disciplinary approach should be taken to optimize outcomes through an evidence-based approach.

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Nephrolithiasis in Pregnancy: Treating for Two

OBJECTIVES

To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines.

METHODS

A structured literature review was performed to determine highest quality of evidence guiding care for pregnant patients with symptomatic nephrolithiasis. PUBMED and EMBASE databases were searched using terms "pregnancy," "nephrolithiasis," or "pregnancy" and "renal colic" alone and in combination with "stone", "kidney stone," "ultrasound," "MRI," "CT," "percutaneous nephrostomy," "ureteral stent," or "ureteroscopy." All English-language abstracts were reviewed for relevance and full-length articles were reviewed for content. Articles published prior to 1990 were excluded, and priority for inclusion was given to multi-institutional studies and larger institutional studies, reflecting the highest level of current available evidence and most contemporaneous practice patterns.

RESULTS

Symptomatic nephrolithiasis affects less than 1% of pregnancies but poses unique diagnostic challenges due to the physiologic changes of pregnancy and risks of ionizing radiation exposure to the fetus. Ultrasound remains the imaging modality of choice. Most patients may be managed non-operatively, but drainage with percutaneous nephrostomy or ureteral stent may be performed if warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment.

CONCLUSIONS

Though rare, symptomatic nephrolithiasis poses significant clinical challenges due to the need to minimize risk for both mother and fetus with diagnostic and therapeutic interventions. A multi-disciplinary approach is paramount, as is shared decision making with the patient at each step of care.

Percutaneous nephrostomy placement in pregnant patients: a retrospective single center experience

Purpose: Literature on percutaneous nephrostomy (PCN) placement in pregnant patients is limited. The purpose of this case series of 20 pregnant patients was to report short term maternal and fetal outcomes in this population.Materials and methods: A 12-year retrospective study was performed on pregnant patients undergoing PCN. Clinical indications, technical success, maternal outcome, fetal outcome, and complications were obtained from the electronic medical record.Results: Indications for PCN placement included urolithiasis (40%), congenital ureteral dysfunction in the setting of prior ureteral repair (30%), obstruction associated pain (15%), infection (10%), and ureteral injury in the setting of surgery for ovarian torsion (5%). Catheter insertion was successful in all patients (n = 20), with one major complication (urosepsis). Follow up data was available in 19 patients (95%). Catheters were in situ for a median of 82 days. All patients had clinical and symptomatic improvement. Emergency C-sections were required in two cases. Radiation exposure data were available in 15 of 19 patients and revealed a median fluoroscopy time of 2.8 min, median cumulative dose of 43 mGy, and median dose area product of 635 µGy × m². No adverse fetal outcomes were recorded at time of delivery.Conclusion: PCN placement has good clinical results as a treatment option for ureteral obstruction in a pregnant cohort.

Safety and feasibility of percutaneous nephrolithotomy (PCNL) during pregnancy: A review of literature

OBJECTIVE

Management of nephrolithiasis during pregnancy can be challenging because of the potential risks to the mother and fetus. Diagnosis and treatment can be a dilemma owing to the anatomical and physiological changes, besides the limitation in the use of X-rays. The aim of this article was to identify any case series or case reports where percutaneous nephrolithotomy (PCNL) was used as a treatment modality for nephrolithiasis in pregnancy.

MATERIAL AND METHODS

A review of the literature was performed using Medline, EMBASE, CINAHL, and Scopus from 1990 to October 2019. A search was conducted using the following search terms: "urolithiasis," "renal stones," "stone disease," "kidney stones," "pregnancy," "pregnant," "percutaneous nephrolithotomy," "PNL," and "PCNL." The initial search strategy retrieved 52 articles, but after going through them, only 7 were suitable for inclusion in this review.

RESULTS

Overall, seven studies reported regarding 16 patients who underwent PCNL procedure during pregnancy. The patients were aged 18-34 years and had the procedure between 11 and 32 weeks of gestation. Most stones were in the renal pelvis or pelvic-ureteric junction and sized 8-40 mm, with the most common indication for the intervention being refractory pain. Most treatments used ultrasound guidance, and X-ray fluoroscopy was employed only in two cases. No complications occurred to the mother or fetus in any of the case reports, suggesting that PCNL is a safe and feasible treatment for patients with persistent symptoms when conservative treatment has failed.

CONCLUSION

All the reported cases of PCNL achieved stone-free status with no complications. Although PCNL has been evidenced to be safe, it must be performed by experienced endourologists after careful consultation with the obstetricians. Patient counseling and multidisciplinary team decision-making are paramount in such complex scenarios.

Conservative/surgical treatment predictors of maternal hydronephrosis: results of a single-center retrospective non-randomized non-controlled observational study

PURPOSE

To determine the parameters that may help the clinicians decide the best suitable treatment method for the pregnant women with symptomatic hydronephrosis which will be based on the easily accessible laboratory tests, monitoring methods and clinical symptoms.

METHODS

Digital data and documents of 246 pregnant women with symptomatic hydronephrosis who were hospitalized in our clinic between the dates of January 2011 and January 2016 were retrospectively evaluated. All patients were statistically evaluated in terms of age, symptomatic maximal anterior-posterior diameter of the renal pelvis (MADP), parity, C-reactive protein (CRP) level, white blood cell count (WBC), presence of pyuria, growth of urine culture, fever, serum urine and creatinine levels, visual analog scale (VAS) score of pre- and post-therapy and threatened preterm labor.

RESULTS

The study includes a total of 211 pregnant women with symptomatic hydronephrosis. In the second and third trimester groups, the surgical treatment group statistically provided higher levels of CRP, WBC and VAS. Mean MADP in the second trimester of the conservative and surgical groups where symptomatic hydronephrosis was on the right side was 16.67 ± 4.67 and 28.68 ± 7.70 mm, respectively. Mean MADP in the third trimester group of the conservative and surgical groups where symptomatic hydronephrosis was on the right side was 16.96 ± 5.96 and 28.85 ± 7.64 mm, respectively.

CONCLUSIONS

In patients with symptomatic pregnancy hydronephrosis, the likelihood of surgical treatment for CRP levels, WBC counts and VAS is high.

The Efficacy and Safety of Laser Lithotripsy in Pregnancy

Introduction: The aim of our study was to assess the efficacy and safety of laser lithotripsy in pregnant patients. Methods: In this retrospective study, we reviewed the 15 pregnant women who have been treated for ureteral stones with semi-rigid ureteroscope and holmium laser at our center between Januarys 2007and April 2015. Results: The mean age of patients and mean gestational age was 29.3 years old 27.3 weeks respectively. Mean size of stones was 7.84 mm. Twelve patients had renal colic, and hematuria was found in 3 cases. Irritative urinary symptoms such as frequency and urgency detected in 6 ones and 2 patients had fever. The stone of all patients were fragmented by using holmium laser lithotripter. In 5 patients stone residual fragments were removed by grasper while other 10 patients were left to pass fragments spontaneously. No intraoperative and postoperative urological or obstetric complication was seen. Conclusion: Laser lithotripsy is safe and efficacious in pregnant patients who have ureteral stone that does not respond to conservative management.

Stones in special situations

There are several special situations in which urinary lithiasis presents management challenges to the urologist. An in-depth knowledge of the pathophysiology, unique anatomy, and treatment options is crucial in order to maintain good health in these patients. In this review, we summarize the current literature on the management of the following scenarios: bladder stones, stones in bowel disease, during pregnancy, in association with renal anomalies, with skeletal deformities, in urinary diversions, and in children.

Renal colic during pregnancy: Diagnostic and therapeutic aspects. Literature review

Introduction

Renal colic during pregnancy is a rare urgency but is one of the most common non-obstetric reasons for hospital admission. The management often means a challenge for the urologist and gynecologist due to the complexity involved in preserving the maternal and fetal well-being.

Material and methods

We performed a literature search within the PubMed database. We found 65 related articles in English. We selected 36 for this review prioritizing publications in the last two decades.

Results

The anatomical and functional changes of the genitourinary system during pregnancy are well documented; also during pregnancy, there are several metabolic pro-lithogenic factors. The most common clinical presentation is flank pain accompanied by micro or macro hematuria. US provides data identifying renal obstruction shown by an increased renal resistance index. MRI allows differentiating the physiological dilatation from the pathological caused by an obstructive stone showing peripheral renal edema and renal enlargement. Low dose CT has been determined to be a safe and highly accurate imaging technique. Once the diagnosis is confirmed, the initial management of patients should be conservative. When conservative management fails the interventional treatment is mandatory, a urinary diversion of the obstructed renal unit either by a JJ stent or through a PCN catheter has to be done. The definitive management of the stone can be done in the postpartum or deferred ureteroscopy can be considered during pregnancy.

Conclusions

Renal colic during pregnancy is an uncommon urgency, so it is important for the urologist to know the management of this condition.

Definitive ureteroscopy and intracorporeal lithotripsy in treatment of ureteral calculi during pregnancy

Objective

To evaluate the outcome of using semi-rigid ureteroscopy with or without intracorporeal pneumatic lithotripsy vs. temporary ureteric JJ stenting in the management of obstructing ureteric calculi in pregnant women.

Patients and methods

This prospective comparative study comprised 43 pregnant women with obstructing ureteric calculi. The diagnosis was based on the acute flank pain as the main symptom, microscopic haematuria, and unilateral hydronephrosis on abdominal ultrasonography (US). The patients were randomly divided into two groups; those in group 1 (22 patients) were treated by temporary ureteric JJ stenting until after delivery, and those in group 2 (21) were treated definitively by ureteroscopic stone extraction with intracorporeal pneumatic lithotripsy. Postoperative complications and the degree of patient satisfaction were reported.

Results

An obstructing ureteric stone was identified by US in 68% and 76% of groups 1 and 2, respectively. In group 1, nine patients had mid-ureteric stones and 13 had stones in the lower ureter. In group 2, seven patients had mid-ureteric stones, whilst the stones were in the distal ureter in 14. No perioperative foetal complications were detected in any group and all patients completed the full term of pregnancy. In group 1, four patients had a postoperative urinary tract infection (UTI), and the JJ stent was exchanged in seven. Two patients in group 2 had a postoperative UTI.

Conclusions

Definitive ureteroscopy, even with intracorporeal pneumatic lithotripsy, is an effective and safe treatment for pregnant women with obstructing ureteric calculi. It has a better outcome and is more satisfactory for the patients than a temporary JJ stent.

Renal stones in pregnancy

Diagnosis and treatment of renal stones during pregnancy is a complex problem. Risks to the fetus from ionising radiation and interventional procedures need to be balanced with optimising clinical care for the mother. Management of such patients requires a clear understanding of available options, with a multidisciplinary team approach. In this review, we discuss the role of different diagnostic tests including ultrasound, magnetic resonance urography, and computerized tomography. We also provide an update on recent developments in the treatment of renal stones during pregnancy. Expectant management remains first-line treatment. Where definitive treatment of the stone is required, new evidence suggests that ureteroscopic stone removal may be equally safe, and possibly better than traditional temporising procedures.

Invasive management of proximal ureteral calculi during pregnancy

OBJECTIVE

To review our experience with invasive management of proximal ureteral calculi during pregnancy when conservative treatment fails.

METHODS

From February 2006 to September 2012, a total of 87 pregnant women received invasive management for proximal ureteral calculi in our center. Invasive management included the following: double-J stent insertion, percutaneous nephrostomy (PCN), and ureteroscopic lithotripsy (URSL). The medical records of these patients were reviewed retrospectively.

RESULTS

Of the 87 patients, 4 patients received PCN; 19 patients received cystoscopic double-J stent insertion, whereas 2 patients (10.5%) failed in guide wire inserting and switched to ureteroscopic aid; a total of 64 patients received URSL with holmium laser, in which 52 patients (81.2%) had complete fragmentation of calculi; in 9 patients (14.1%), stone fragments retrograde migrated to the renal pelvis; in 3 patients (4.7%), the stone could not be reached because of serious ureteral tortuosity. One patient (1.6%) patient had a threatened abortion, but this problem was resolved immediately using conservative treatment. All patients completed the full term of pregnancy, and no serious obstetric or urologic complications were observed.

CONCLUSION

For pregnant patients with proximal ureteral calculi, double-J stent insertion, PCN, and URSL all are effective and safe options when conservative treatment fails. They should be chosen on the basis of different patient's condition. However, patient's postoperative tolerance was poor for double-J stent insertion and PCN; URSL (especially with holmium laser lithotripsy) is more effective and should be considered as the preferred choice.

Challenges in interventional radiology: the pregnant patient

A pregnant patient presenting to interventional radiology (IR) has a different set of needs from any other patient requiring a procedure. Often, the patient's care can be in direct conflict with the growth and development of the fetus, whether it be optimal fluoroscopic imaging, adequate sedation of the mother, or the timing of the needed procedure. Despite the additional risks and complexities associated with pregnancy, IR procedures can be performed safely for the pregnant patient with knowledge of the special and general needs of the pregnant patient, use of acceptable medications and procedures likely to be encountered during pregnancy, in addition to strategies to protect the patient and her fetus from the hazards of radiation.

Kidney stones and pregnancy

Kidney stones are common and do not spare the pregnant population. Although a simple stone event is usually straightforward in the general population, it is complex during pregnancy. Acute nephrolithiasis is associated with a unique set of complications during pregnancy and, because of imaging limitations, diagnosis is challenging. Multidisciplinary care is the key in proper management decisions. The pathophysiology of kidney stone formation in the pregnant state is also unique. Herein, we discuss the complexity of kidney stones and pregnancy.

The efficacy and safety of ureteroscopy for ureteral calculi in pregnancy: our experience in 32 patients

The aim of this study was to investigate the efficacy and safety of ureteroscopy (URS) in pregnant women. A retrospective analysis was performed on 32 pregnant patients referred to our center between April 2005 and November 2010 with hydronephrosis requiring surgical intervention. A semirigid URS of 9.5 F was used in all patients. The mean age of patients was 27.8 years (range 20-39), and the mean gestation duration was 24 weeks (15-34). The ultrasound findings were diagnostic of obstructive ureteral calculi in 16 (50%) patients and the mean stone diameter was 8 mm. Spinal anaesthesia was performed in 22 (68.8%) patients, while general anaesthesia was performed in 7 (21.8%) patients. Ureteric stones were found in 27 (84.3%) patients during endoscopy, 10 being distal, 9 middle and 8 proximal. There were no stones in five patients. The stones were fragmented with pneumatic lithotripsy in 8 patients and with holmium laser in 17 patients and the fragments were retracted with forceps. Of the 32 patients, 19 (59.4%) required JJ stent insertion peroperatively. There was no serious complication intraoperatively, while urinary tract infection developed in four and renal colic in two patients postoperatively. In one patient, sepsis developed postoperatively, and improved with appropriate treatment. All babies were born normally. Semirigid ureteroscopy for diagnosing and treating ureteral calculi by intracorporeal pneumatic or holmium laser lithotripsy is a safe and reasonable treatment option for pregnant patients.

Ureteroscopy during pregnancy

Urolithiasis during pregnancy is an uncommon, but a serious medical problem. Options for the treatment of pregnant women with obstructing stones include ureteral stent placement, percutaneous nephrostomy tube placement, and ureteroscopic stone removal (URS). Although ureteral stent and nephrostomy tube placement have been the historically standard treatment option for pregnant women with obstructing stones, there is an emerging collection of literature that reviews the safety of URS for pregnant women. We performed a systematic review of MEDLINE and EMBASE from January 1966 through April 2009 to identify all literature on URS in pregnant women. Herein, we review the literature on URS during pregnancy, with a focus on the safety of this approach. We conclude that URS is an appropriate intervention in the pregnant population with urolithiasis; in all cases the procedure should be performed on a properly selected patient by a surgeon with appropriate experience and equipment. With such an approach, complication rates are low and success rates are high. A multidisciplinary approach should be emphasized as a key to a successful outcome.

Management of stone disease in pregnancy

PURPOSE OF REVIEW

Nephrolithiasis is a not infrequent complication of pregnancy. The occurrence of a stone event in a pregnant woman is a complex situation. Therefore, a clear understanding of the management options available and their relative advantages and disadvantages for this unique population is important.

RECENT FINDINGS

When initial, conservative measures have failed in the treatment of a pregnant woman suffering from an acute stone event, management options have historically been of a temporizing nature: generally, either ureteral stent placement or nephrostomy drainage. However, with recent advances in surgical technology and surgeon technique, a more definitive approach to these patients has become more widely adopted. Indeed, several recent case series have reported the complication rate for ureteroscopy during pregnancy to be low. Furthermore, a meta-analysis of case series of ureteroscopy during pregnancy suggests definitive endoscopic treatment is well tolerated in this patient population.

SUMMARY

In a pregnant patient without contraindications to ureteroscopy, the definitive endoscopic treatment of an acute stone event is a reasonable management strategy, should conservative measures fail. Although further investigation with randomized control trials is ideally needed to confirm these results, at present, the published case series and meta-analysis confirm the safety of ureteroscopy in pregnant patients in the appropriate setting. A multidisciplinary approach is key to the successful management of this complex patient population.

Semirigid ureteroscopy and pneumatic lithotripsy as definitive management of obstructive ureteral calculi during pregnancy

OBJECTIVES

To assess the results of semirigid ureteroscopy and intracorporeal pneumatic lithotripsy as a definitive treatment option for women presenting with obstructive ureteral calculi during pregnancy.

METHODS

A retrospective analysis was performed of 19 pregnant patients referred to our tertiary care center with ureteral obstruction necessitating surgical intervention from 1997 to 2007. The mean patient age was 22 years (range 18-27), and the mean gestation period was 20 weeks (range 14-34). Of the 19 patients, 21% were febrile, 32% had positive urine cultures, and 63% had pyuria and microscopic hematuria. Abdominal ultrasonography was the principle diagnostic test used. Six patients had history of renal stones before conception. The mean stone size was 11 mm, (range 8-18). Of the 19 patients, 58% had stones located in the proximal and 42% in the distal ureter. The stones were fragmented using a Swiss pneumatic lithoclast through a 6.9F/8F semirigid ureteroscope with the patient under general anesthesia. None of the patients underwent limited intravenous urography or computed tomography except for 1, who underwent plain x-ray of the kidneys, ureters, and bladder.

RESULTS

All patients had obstruction due to the ureteral calculi, and 79% patients had complete fragmentation of the calculi by ureteroscopy as the primary treatment. Of the 19 patients, 63% required ureteral stent insertion per operatively. No complications related to the procedure itself or the general anesthesia were recorded, and all patients completed the full term of pregnancy.

CONCLUSIONS

The results of our study have shown that semirigid ureteroscopy to diagnose ureteral calculi and treat them with intracorporeal pneumatic lithotripsy and ureteral stent insertion, as indicated, is the most efficient and definitive treatment modality in expectant women.

Urinary Stone Disease during Pregnancy: One Problem, Two Patients

Urolithiasis in pregnant women is a quite uncommon event: about one in 1500 pregnancies is complicated by urinary calculi and it occurs in 80–90% of the patients during the second or third trimester of pregnancy.

Several factors may predispose stone formation in the upper urinary tract during pregnancy: the “physiological” hydronephrosis, the gestational hypercalciuria, and an elevation in both glomerular filtration rate and renal plasma flow, associated with an increase of creatinine clearance and higher renal filtration rate of sodium, calcium, and uric acid. Flank or abdominal pain is the most common symptom associated with evident or microscopic hematuria. Differential diagnosis of pain varies according to its location: it could be of gastrointestinal or gynecologic origin.

Diagnosis is previously based on ultrasound evaluation. The use of radiation must be avoided during pregnancy, even if the risk of fetal injures depends on gestational age and radiation dosage. Most of the symptomatic ureteral stones affecting pregnant women pass spontaneously: therefore therapy could be conservative (hydration, analgesia, antibiotics, antiemetics) in the most of cases, although in the 15–30% of the cases it is necessary to adopt an active treatment, like percutaneous nephrostomy drainage, ureteral stent insertion or ureterorenoscopy.

The safety of ureteroscopy during pregnancy: a systematic review and meta-analysis

PURPOSE

We performed a literature review and analysis to compare the safety of ureteroscopic stone removal during pregnancy with findings from a set of contemporary studies of that procedure in nonpregnant patients.

MATERIALS AND METHODS

A systematic review of MEDLINE(R) and EMBASE(R) was done to identify all reports of ureteroscopic stone removal in pregnant women. Complications were stratified according to modified Clavien criteria. We then reviewed a contemporary, multi-national meta-analysis of ureteroscopic stone removal (American Urological Association/European Association of Urology 2007 Guideline for the Management of Ureteral Calculi) to define the complication rate in a series of nonpregnant patients. Complication rates in the 2 reviews were compared using Fisher's exact test.

RESULTS

A total of 14 reports of ureteroscopic stone removal in pregnant women were identified, representing 108 patients. Nine complications were noted. By Clavien criteria 2 complications were level 1, 6 were level 2 and 1 was level 3. When compared to the multinational meta-analysis of ureteroscopy in nonpregnant women, there was no significant difference in the ureteral injury and urinary tract infection complication rates (p = 0.191 and 0.597, respectively).

CONCLUSIONS

Our analysis shows that the safety of ureteroscopic stone removal in pregnant patients is not significantly different from the safety of that procedure in nonpregnant patients and in each cohort the complication rate is low. Therefore, ureteroscopic stone removal may reasonably be considered appropriate first line therapy in pregnant patients with stone disease.

Management of urinary calculi in pregnancy: a review

Nephrolithiasis during pregnancy can represent a clinical dilemma because of potential risks to both mother and fetus. While the incidence of symptomatic nephrolithiasis during pregnancy varies between 1 in 244 to 1 in 2000 pregnancies, the actual incidence is likely to be higher. A significant proportion of patients with asymptomatic renal calculi are detected incidentally in the nonpregnant population compared with pregnant women. Factors that contribute to the diagnostic challenges include anatomic and physiologic changes to the female urinary tract during pregnancy and the limitations on the use of ionizing radiation. The treatment of such patients requires a multidisciplinary team approach involving the urologist, obstetrician, and radiologist. The potential hazards of intervention (either surgical or medical) and anesthesia need to be considered carefully.

Urolithiasis in pregnancy

The presentation of urolithiasis is often dramatic, but rarely is it more anxiety provoking than during pregnancy. The evaluation and the intervention are often approached with trepidation as the health of the mother and the fetus must be taken into account. The typical diagnostic course and surgical management used in the nonpregnant population must be reevaluated in the expectant mother. Failure to promptly diagnose and manage urolithiasis during pregnancy may have adverse consequences for mother and child. The authors present a review of the relevant anatomic and physiologic changes of pregnancy as they affect stone disease and outline options for radiologic evaluation and surgical management.

Urologic Radiology During Pregnancy

The pregnant patient presents a unique diagnostic challenge to the urologist because the well-being of both the mother and fetus must be considered. Radiation exposure to the fetus during gestation presents risks such as cell death and teratogenic effects, carcinogenesis, and genetic effects, which must be considered when selecting diagnostic tests. However, with the exercise of good clinical judgment and the use of the armamentarium of diagnostic imaging modalities available, the pregnant patient can be managed with minimal, if any radiation exposure to the fetus.

Laparoscopic management of a retained heavily encrusted ureteral stent

The indwelling ureteral stent is a fundamental part of today's urologic practice. Since its introduction in 1978, many improvements have been made in stent design and composition to minimize patient discomfort. As a consequence, the patient can forget about the stent. A known and well-documented complication of this situation is encrustations of the ureteral stent which causes significant morbidity to the patient, and at times, they are very difficult to manage. Reports in the literature describe techniques that require several procedures and anaesthetic sessions to effect stent extraction. Here, we report the one-sitting laparoscopic management of a heavily encrusted and stuck DJ stent, with minimal morbidity and very short hospital stay. Laparoscopic management of this common urologic problem has not been reported before. A comprehensive discussion is also presented regarding the management of such problems and their prevention.

Urolithiasis in Pregnancy: Current Diagnosis, Treatment, and Pregnancy Complications

Urolithiasis complicates up to one in every 200 pregnancies; consequently, the practicing obstetrician should be aware of the symptoms of urolithiasis, the diagnostic procedures available for its diagnosis, and their associated risks. These include ultrasound, urography, and magnetic resonance imaging. Diagnosis of urolithiasis during pregnancy can be a challenge as a result of the normal physiological changes of pregnancy. Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. If spontaneous passage of the stone does not occur or if complications develop, urologic consultation should be obtained. Several obstetric complications have been associated with urolithiasis, including preterm labor and preterm premature rupture of membranes, although the reported rates of these complications in association with urolithiasis vary widely and overlap normal background rates. Given that urolithiasis will be encountered by most obstetricians, and that obstetricians are often on the front line of management for this condition, an appreciation of current diagnostic modalities, treatment protocols, and associated potential obstetric complications is warranted.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that urolithiasis is common in pregnancy, state that there are a variety of diagnostic procedures, summarize that conservative treatment is usually successful, and explain that complications of pregnancy usually occur when there is failure of conservative treatment.

Imaging for percutaneous renal access and management of renal calculi

Percutaneous renal stone surgery requires detailed imaging to define stone burden and delineate the anatomy of the kidney and nearby organs. It is also essential to carry out safe percutaneous access and to assess postoperative outcomes. The emergence of CT as the imaging modality of choice for detecting renal calculi and the ability of CT urography with or without three-dimensional reconstruction to delineate the collecting system makes this the most versatile and sensitive imaging modality for pre- and postoperative evaluation. At present, intravenous urogram continues to play an important role in the evaluation of patients considered for percutaneous nephrostolithotomy. Fluoroscopy re-mains the mainstay of intraoperative imaging, although ultrasound is a useful alternative. Selection and application of appropriate imaging modalities for patients undergoing per-cutaneous nephrostolithotomy enhances the safety and success of the procedure.

Percutaneous Nephrolithotomy in Early Pregnancy

We report on an 11-weeks pregnant woman, who under went a percutaneous nephrolithotomy without the use of X-rays during the procedure due to 8-mm left upper ureteric stone. In the available literature, we didn't find any reported case about percutaneous stone removal without the use of X-rays.

Success and Short-term Complication Rates of Percutaneous Nephrostomy during Pregnancy

Outcome of percutaneous nephrostomy creation during pregnancy was retrospectively studied. Catheter insertion was successful in all cases (N = 8; 3% of all nephrostomies over a 5-year period), with one major complication (sepsis) and three minor complications. Catheters remained in situ for a mean of 9.4 days until the stone passed (n = 1) or was removed on ureteroscopy (n = 2) or a ureteral stent was inserted (n = 5). Maternal outcome was normal in all cases, but there were two premature deliveries. Nephrostomy during pregnancy has acceptable technical and clinical results, but the possibility of an increased risk of septic complications (12.5% in this series) necessitates further study.

Percutaneous nephrolithotomy in early pregnancy

Most cases of urolithiasis in pregnancy are managed conservatively either with ureteric stents or percutaneous nephrostomy tubes, which need to be changed at regular intervals. Definitive management of the stone is usually delayed till after delivery. We describe a patient who presented with pyonephrosis in the fifth week of gestation, due to a stone obstructing the right ureteropelvic junction. This was managed by insertion of a nephrostomy tube. She declined nephrostomy tube/stent changes during the rest of her pregnancy and requested termination as an alternative. She successfully underwent percutaneous nephrolithotomy in the 14th week of pregnancy, with radiation exposure strictly localised to the kidney for 6 s. A healthy male baby was delivered at term.

Nephrolithiasis and pregnancy

PURPOSE OF REVIEW

Urolithiasis during pregnancy is not common, however, it is a difficult condition to both diagnose and treat. There are many safety concerns that must be considered for both the mother and fetus. In this review we detail the different options available to the urologist and we highlight a treatment algorithm that we use when faced with a pregnant patient suspect of having a urinary calculus.

RECENT FINDINGS

Changes in ultrasound, limited intravenous urograms and magnetic resonance imaging have improved our ability to diagnose urolithiasis in pregnancy. Additionally ureteroscopy has emerged not only as a diagnostic tool but also as a modality for definitive treatment that can safely be used during the intrapartum period.

SUMMARY

When diagnosing urolithiasis in the gravid patient, the first line study should be ultrasound, using change in resistive index and transvaginal ultrasound. If these are not diagnostic, then a limited intravenous urograms should be performed. Once a diagnosis has been established, initial treatment should be conservative since 70-80% of patients will pass their stones. When intervention is necessary, the placements of an internal stent or percutaneous nephrostomy tube or ureteroscopy with definitive stone treatment are all reasonable options.

1-step removal of encrusted retained ureteral stents

PURPOSE

Ureteral stents are prone to encrustation, which can create a problem at the time of removal. Reports in the literature describe techniques that require several procedures and anesthetic sessions to effect extraction. We describe our experience with 1-step removal of retained ureteral stents.

MATERIALS AND METHODS

A total of 12 retained calcified ureteral stents in 10 patients were treated between December 1998 and July 2002. The reason for stent placement was nephrolithiasis in 8 patients, ureteral obstruction due to malignancy in 1 and following endopyelotomy in 1. Stents were in place for a mean of 10 months (range 6 to 16). One patient had 2 retained stents in a single ureter. Stents were extracted using a holmium laser. The semirigid ureteroscope and/or flexible ureteroscope was advanced beside the retained ureteral stent and laser was used to fragment stone on and around the stent. The ureteroscope was advanced into the renal pelvis and any stone present was fragmented. The ureteroscope and stent were then removed.

RESULTS

Of the 12 stents 11 were managed by ureteroscopy alone. In 1 patient the upper stone burden was treated through a percutaneous tube previously placed for obstructive pyelonephritis. All patients were treated at 1 anesthetic session. Mean operative time was 93 minutes (range 45 to 225). All except 2 patients were discharged home in 23 hours. In 1 patient a perinephric abscess resolved with computerized tomography guided drainage. One patient required intravenous antibiotics for 48 hours for fever with subsequent resolution. No patients have had ureteral strictures to date.

CONCLUSIONS

Historically the management of retained calcified ureteral stents has involved several operations to render the patient stone-free and stent-free. We describe our approach to this difficult problem with only 1 session in the operating room, minimal morbidity and a short hospital stay.

A radiation perspective for treating loin pain in pregnancy by double-pigtail stents

OBJECTIVE

To review the risks of placing double-pigtail stents during pregnancy in women presenting with loin pain associated with hydronephrosis.

PATIENTS AND METHODS

A consecutive series of women presenting with loin pain and hydronephrosis in pregnancy were treated with double-pigtail ureteric stents. A flexible cystoscope was used to identify the ureteric orifice and to pass a guidewire into the renal pelvis under fluoroscopic guidance. Stents were placed using the exchange technique over a stiff guidewire. Procedures were carried out under none or limited sedoanalgesia. Screening times and radiation dose were recorded. Data were collected for the average uterine radiation dose from a variety of radiological procedures. Previous publications were reviewed to determine the lethal, teratogenic and carcinogenic risk to the developing fetus from radiation exposure.

RESULTS

Seven patients referred with symptomatic hydronephrosis during pregnancy were treated. The screening time during placement was minimized. The mean (range) uterus (i.e. fetal) dose was 0.40 (0.03-0.79) mGy. Most radiological procedures involve uterine doses of < 20 mGy, far below the 100 mGy that may result in fetal damage during periods of maximum radiosensitivity.

CONCLUSION

Minimized radiation exposure from a range of uroradiological procedures in pregnant women has limited fetal risk. The use of fluoroscopy for symptomatic hydronephrosis during pregnancy allows ureteric stents to be placed safely and reliably. The average excess risk to the fetus from this procedure is 1 in 43 000 of cancer induction and 1 in 100 000 of heritable disease, i.e. very small when compared with the natural incidence. Pregnancy should not exclude the use of appropriate diagnostic radiation exposure and urologists may conduct appropriate diagnostic and therapeutic procedures, taking care to limit X-ray exposure without fear of risk to the developing fetus.

Ureteroscopy and holmium:YAG laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy

OBJECTIVES

To review the results of holmium laser lithotripsy in a cohort of patients who presented with symptomatic urolithiasis in pregnancy. Symptomatic urolithiasis in pregnancy that does not respond to conservative measures has traditionally been managed with ureteral stent insertion or percutaneous nephrostomy. Holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy using state-of-the-art ureteroscopes represents an emerging strategy for definitive stone management in pregnancy.

METHODS

A retrospective analysis was conducted at two tertiary stone centers from January 1996 to August 2001 to identify pregnant patients who were treated with ureteroscopic holmium laser lithotripsy for symptomatic urolithiasis or encrusted stents. Eight patients with a total of 10 symptomatic ureteral calculi and two encrusted ureteral stents were treated. The mean gestational age at presentation was 22 weeks. The mean stone size was 8.1 mm. The stones were located in the proximal ureter/ureteropelvic junction (n = 3), midureter (n = 1), and distal ureter (n = 6).

RESULTS

Complete stone fragmentation and/or removal of encrusted ureteral stents were achieved in all patients using the holmium:YAG laser. The overall procedural success rate was 91%. The overall stone-free rate was 89%. No obstetric or urologic complications were encountered.

CONCLUSIONS

Ureteroscopy and holmium laser lithotripsy can be performed safely in all stages of pregnancy, providing definitive management of symptomatic ureteral calculi. The procedure can be done with minimal or no fluoroscopy and avoids the undesirable features of stents or nephrostomy tubes.

The current management of urolithiasis during pregnancy

The management of urolithiasis in pregnancy can present complex challenges to the urologist. However, if the principles discussed above are followed, these difficult clinical problems can be approached in a rational manner.