Long-term results of transurethral lithotripsy with the rigid ureteroscope: injury of intramural ureter

Ureterorenoscopy: avoiding and managing the complications

Retrograde exploration of the ureter and kidneys is currently a widely used and well-established procedure to deal with problems of a diagnostic and therapeutic nature with reduced invasiveness. The process of miniaturizing the instruments combined with the steady improvement in video quality has continuously amplified its potential applications, maintaining the procedure safe and rapid. During an operation, however, unexpected events may condition a change to the programme or determine the onset of even more serious complications. Our aim is to analyze such events and complications and recommend potential solutions to prevent and/or deal with such happenings.

Complications of ureteroscopy

Ureteroscopy has undergone a dramatic evolution over the last two decades. Although ureteroscopic injury is the most common cause of ureteral trauma because of the large number of ureteroscopic procedures performed, improvements in instrumentation and technique have resulted in a reduced incidence of serious complications. Despite significant technologic advances, however, surgical misadventures still occur, some of which have lasting consequences. Careful attention to instrument selection and surgical technique are critical to reduce untoward events related to ureteroscopy. As such, adverse sequelae associated with ureteroscopy should be related to the underlying pathology itself rather than to the treatment.

Assessment of stricture formation with the ureteral access sheath

OBJECTIVES

To analyze the long-term incidence of ureteral stricture formation in a series of patients in whom a new-generation ureteral access sheath was used. A new generation of ureteral access sheaths has been developed to facilitate ureteroscopic procedures. However, some have questioned their safety and whether the device might cause significant ureteral trauma.

METHODS

Between September 1999 and July 2001, 150 consecutive ureteroscopic procedures with adjunctive use of an access sheath were performed. A retrospective chart review to April 2002 was done. Of the 150 patients, 130 underwent ureteroscopy for ureteral stones. Patients who underwent endoureterotomy or treatment of transitional cell carcinoma were excluded from this analysis. Sixty-two patients had follow-up greater than 3 months and were included in the analysis. Overall, 71 ureteroscopic procedures were performed, with 9 patients undergoing multiple procedures. Ninety-two percent of the patients had pathologic findings above the iliac vessels. The average patient age was 45.3 years (range 17 to 76), and 70% and 30% of the patients were male and female, respectively. The mean clinical follow-up was 332 days (range 95 to 821), and follow-up imaging was performed within 3 months after ureteroscopy in all patients.

RESULTS

The 10/12F access sheath was used in 8 ureteroscopic procedures (11.2%), the 12/14F access sheath in 56 (78.9%), and the 14/16F access sheath in 7 (9.8%). One stricture was identified on follow-up imaging of 71 procedures performed, for an incidence of 1.4%. The patient developed the stricture at the ureteropelvic junction after multiple ureteroscopic procedures to manage recurrent struvite calculi. The access sheath did not appear to be a contributing factor.

CONCLUSIONS

The results of our series indicate that the ureteral access sheath is safe and beneficial for routine use to facilitate flexible ureteroscopy. However, awareness of the potential ischemic effects with the use of unnecessarily large sheaths for long periods in patients at risk of ischemic injury should be considered. We advocate the routine use of the device for most flexible ureteroscopic procedures proximal to the iliac vessels.

A stone developed within the dilated intravesical ureter following ureteroscopy

A 58-year-old man presented with a stone within the dilated intravesical ureter, which was probably attributable to a previous ureteroscopy. Transurethral incision of the right intravesical ureter and lithotripsy were carried out without subsequent urinary tract impairment. Although some complications resulting from ureteroscopy, such as ureteral stricture, ureteral perforation and vesicoureteral reflux, have been reported, this complication is considered to be very rare.

Ureteroscopic lithotripsy using mini-endoscope and Swiss lithoclast: experience in 147 cases

To evaluate the efficacy of a semirigid mini-endoscope and the Swiss Lithoclast compared with a conventional rigid endoscope and ultrasound, the results of transurethral ureteroscopic lithotripsy in 147 patients over a period of 30 months were analyzed according to the type of ureteroscope (rigid v semirigid) and energy (ultrasound v Lithoclast) used. In the initial 25 cases (Group I), a conventional rigid ureteroscope and ultrasound were used. The latter 122 patients (Group II) were subjected to ureteroscopic lithotripsy using a miniscope and the Lithoclast. The results were superior in Group II with respect to the overall success rate (p = 1.6 x 10[-2]), first-attempt success rate (p = 2.9 x 10[-4]), and the need for ureteral dilation (P = 1.0 x 10[-6]) compared with Group I. There were no major complications. Overall, minor complications (hematuria and urinary tract infection) were observed in 25% of the cases. Further, the results of ureteroscopic lithotripsy in Group II were comparable to those of SWL in situ for upper ureteral calculi and better than for those located in the iliac and lower ureter as reported previously. Our results demonstrate that the Swiss Lithoclast provides effective fragmentation of even hard and smooth stones without increasing the complication rate. This lithotripter is reliable, safe, and simple to operate. In addition, the cost of maintenance is almost nil.

Ureteroscopic management of lower ureteral stones: two years' experience

A total of 140 ureteroscopies in 119 patients done between January 1992 and December 1994 at the Department of Urology, Hacettepe University Hospital, were reviewed. Factors such as previous ESWL therapy, previous surgery and use of in situ lithotripsy were noted. Success was defined as complete removal or disintegration and partial removal of the lower ureteral stones. All successes were confirmed by plain abdominal X-rays postoperatively. Of 140 stone manipulations attempted in 119 patients 106 (75.7%) were successful (in 80 by retrieval and in 26 by disintegration using electrohydraulic or laser). Perforation occurred in 4 of 13 cases where electrohydraulic lithotripsy was used for disintegration of stones. Extraction by ureteroscopic manipulation following extracorporeal shock wave lithotripsy (ESWL) was successful in all of the 12 cases of lower ureteral calculi. The success rate was found to be low for lower ureteral stones in patients with previous open surgery (2/9). A total of 43.2% of the patients were medically indicated to be hospitalized following the procedure with a mean hospitalization time of 5 days (ranging in between 1 to 7 days). Ureteroscopy is an effective method for management of lower ureteral stones. Use of the electrohydraulic lithotriptor may be associated with a high percentage of complications. Previous ESWL may be associated with a high rate of success. Results in patients with previous open surgery are not encouraging. Although all patients can be subjected to the procedure on an outpatient basis, a significant percentage need a short hospitalization.

Ureteric stricture formation following ureteric instrumentation in patients with a nephrostomy drain in place

OBJECTIVE

To determine what effect the presence of a nephrostomy, left on free drainage, might have on the rate of occurrence of ureteric strictures after ureteric instrumentation.

PATIENTS AND METHODS

Eighteen patients were identified in this unit who had had ureteric instrumentation while a nephrostomy was in place.

RESULTS

Eight of 11 patients in whom the nephrostomy was left open developed ureteric strictures. None of seven patients in whom the lumen was maintained by stenting and/or clamping of the nephrostomy developed strictures. The strictures needed dilatation and stenting in seven patients and the ureter had to be reimplanted in the other.

CONCLUSION

In patients in whom a nephrostomy is in place, the opening should be occluded after ureteric instrumentation or a stent should be inserted if it is to be left on free drainage.

Obliterative pyeloureteritis: a complication of stone disease in patients with urinary conduit diversion

In 4 patients with cutaneous urinary diversion who underwent percutaneous ureteral stone removal, similar ureteral complications developed as a result of severe ureteritis at the site of the stone. Ureteral narrowing occurred within days of percutaneous ureteral stone removal, progressing to complete occlusion in 2 cases. These complications led to prolonged hospitalization and additional procedures for each patient. One patient with an occluded ureter was lost to followup. Two patients responded satisfactorily to repeated ureteral dilations and prolonged stenting. One patient underwent excision of the affected ureteral segment. The average interval between tube placement and removal of tubes and stents was 15 weeks in 4 patients. The average inpatient period was 24 days. Patients with a cutaneous urinary conduit diversion may be at increased risk for complications following percutaneous treatment of ureteral stones. This risk may be secondary to an intense inflammatory response due to infection and other local factors.

Laser lithotripsy with the Candela MDL-2000 LaserTripter

The Yorkshire Lithotriptor Centre acquired a Candela MDL-2000 LaserTripter and a 7.2F Miniscope in February 1990. We present the results obtained in the first 200 patients referred for treatment of ureteric stones or stone fragments. Of 175 patients who were evaluable, 58 had upper ureteric stones, 41 mid-ureteric and 76 lower ureteric stones. Successful laser fragmentation was achieved in 77% of cases and a further 10% were rendered stone-free by the push-bang technique. Ureterolithotomy was required in 9% and the major complication rate was 4%. Ureteric dilatation was not used. Maximum laser energy was required to break 19% of the stones, but no stone was encountered which could not be broken. Laser lithotripsy with this system is highly effective at all levels of the ureter; it is safe and it complements ultrasound-guided extracorporeal lithotripsy.

Experience with the pulsed dye laser in management of ureteric calculi

Pulsed dye laser lithotripsy is a recently developed technique for the management of urinary calculi. This article reports the results of treatment of a cohort of patients managed with this technology. Post-treatment bed stay was generally less than 48 h, narcotic analgesia was not regularly required, and no significant post-treatment complications were encountered. This treatment appeared to complement an existing extracorporeal shockwave lithotripsy (ESWL) service at St Vincent's Hospital and may offer a financial advantage in the treatment of patients with urinary calculi.