Late sequelae of the management of ureteral calculi with the ureterorenoscope

Ureteral stricture after ureteroscopy for stones: A prospective study for the incidence and risk factors

Context:

A ureteral stricture is a serious complication of ureteroscopy (URS) that was reported in the literature in highly variable rates from 0.2% to 24%.

Aims:

Our aims are to estimate the incidence and to detect the risk factors of ureteral stricture after URS.

Settings and Design:

This is a prospective, case-series study.

Materials and Methods:

During the period from May 2015 to August 2016, 251 adult patients underwent 263 URS for the treatment of 304 ureteral stones. Postoperative regular follow-up was done for 12 months by ultrasound. Computed tomography urography and diuretic renogram were performed for the cases developed hydronephrosis to confirm and detect the level of the stricture.

Statistical Analysis:

IBM SPSS Statistics for Windows, Version 19.0, Armonk, NY: IBM Corp. used for data analysis. Chi-square and Fisher's exact tests were used to compare between qualitative variables. Mann–Whitney test was used to compare between two quantitative variables in case of nonparametric data. Multiple logistic regression analysis was done to measure the risk factors. P value was considered statistically significant when <0.05.

Results:

The mean age was 43.5 years (standard deviation [SD]: ±13.6), and the mean body mass index was 28.39 (±3.96). The mean total stone burden was 12.8 mm (SD: ±5.9). Bilateral URS was performed in 12 cases. The mean operative time was 54.8 min (SD: ±22.68). Initial and final stone-free rates were 83.3% and 100%, respectively. The overall complications rate was 28.1%. Stricture occurred in four cases (1.5%).

Conclusions:

In our experience, the incidence of post-URS ureteral stricture is low. The impacted stone is the most common cause of URS complications and hence stricture formation.

Ureteroscopy and laser stone fragmentation (URSL) for large (≥1 cm) paediatric stones: Outcomes from a university teaching hospital

INTRODUCTION

The treatment of large renal stones (≥1 cm) in paediatric patients is challenging. The usual treatment options include percutaneous nephrolithotomy (PCNL) or shockwave lithotripsy (SWL). There is a rise in the use of ureteroscopy and laser stone fragmentation (URSL) for paediatric stones; however, outcomes of treatment for large renal stones in this age group are still largely unknown.

OBJECTIVE

To investigate the outcome of URSL for large paediatric renal stones ≥1 cm treated at the present institution over the last 5 years.

METHODS

A retrospective review was performed of outcomes from the prospectively maintained stone database. Only paediatric patients undergoing ureteroscopic (rigid or flexible ureteroscopy (URS)) procedures for stones ≥1 cm were included. Patient demographics, operative details, stone burden, hospital stay, complications and stone clearance were recorded and analysed.

RESULTS

From April 2010 to June 2015, 18 paediatric patients with a mean age of 10.4 years (range 3.6-15) underwent 35 ureteroscopic procedures for large stones (≥1 cm). The stone location was in the kidney (n = 14), ureter (n = 1), and in both the kidney and ureter for the remaining three patients. Nine patients had multiple stones. There was a preceding history of PCNL in four patients, with one patient having URS combined with a PCNL. The mean follow-up was 2.7 years (range 0-5). A postoperative stent was inserted in 21 (60%) patients. The overall stone-free rate (SFR) was 89% for a mean of 1.8 procedures per patient (range 1-4) - see Summary Table below. There was an inability to access stone within a lower pole calyx in one patient, despite maximum deflection of the ureteroscope. No intra- or post-operative complications were noted, and mean hospital stay was 1.1 days (range 0-5).

DISCUSSION

Published papers in adult literature have shown that ureteroscopy and laser fragmentation (URSL) is a viable alternative to PCNL. Newer equipment and improved techniques have resulted in SFRs being comparable with PCNL. A recent systematic review reported an SFR of 91% for large adult stones (>2 cm) for a mean 1.45 procedures per patient, and an overall complication rate of 8.6%. The present study has also demonstrated excellent outcomes in the use of ureteroscopy and laser fragmentation for the management of large paediatric stones with no complications.

CONCLUSION

The results show that paediatric URSL for large stones achieves a good SFR with minimal morbidity and is a good treatment option in established endourological units.

The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: A long-term study at two academic centres

OBJECTIVE

To determine the incidence of symptomatic and 'silent' obstruction after ureteroscopic procedures.

PATIENTS AND METHODS

In all, 1980 patients underwent ureteroscopy for ureteric calculi in two large centres. The methods of disintegration, auxiliary procedures used and type of stenting were considered. Intraoperative complications, in addition to the size and site of the stone, were assessed in relation to postoperative obstruction. The mean (range) follow-up was 42 (12-68) months, with patients assessed after 3-6 months and yearly thereafter. The postoperative evaluation included an assessment of pain, renal ultrasonography, a plain abdominal film, intravenous urography, and a diuretic renal scan in some cases to confirm obstruction.

RESULTS

The success rate of stone removal was 98.5%. The failures were related to the size of the stone (>2 cm; P < 0.001). In eight patients there was a ureteric perforation, and six of these developed a ureteric stricture. A stricture also occurred in 12 patients (0.6%) during the follow-up; these included nine of 204 with stones of >2 cm (4.4%), compared to three (0.17%) of 1746 patients with stones of <2 cm (P < 0.001). Fourteen patients presented with pain (0.7%), and five had no obstruction, while in nine (0.46%) the pain was associated with obstruction. There was silent obstruction in three cases (0.15%). The negative and positive predictive values for pain were 99.8% and 64.3%, respectively.

CONCLUSIONS

Radiographic surveillance for stricture formation and obstruction is mandatory in patients who are symptomatic after ureteroscopy, and for up to 18 months in patients with intraoperative complications or with a stone of >2 cm in the proximal 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.

Does stone dimension affect the effectiveness of ureteroscopic lithotripsy in distal ureteral stones?

OBJECTIVE

To investigate whether stone dimension is a restrictive factor for ureterorenoscopic procedures.

MATERIALS AND METHODS

A group of 416 patients who had undergone ureterorenoscopic pneumatic lithotripsy (URS-PL) for lower ureteral stones between January 1999 and June 2006 in our clinic had been evaluated retrospectively. Two hundred and seventy (270, 64.9%) patients were men and 146 (35.1%) were women. The mean age of the patients was 36.61 (+/- 12.43) years. Patients were grouped according to stone dimension; 193 patients with stones smaller than 1 cm being group 1 and 223 patients with stones > or = 1 cm in dimension being group 2. Stone-free rate, operative time and rate of complications of the groups were compared. Pearson's correlation test, chi2 test, Fischer's exact test and Student's t-test were used for the statistical analysis. The p value was accepted as being meaningful if p < 0.05.

RESULTS

For group 1, the mean operative time was 39.19 (+/- 18.33) min. Proximal stone migration in five and false passage formation in three patients was observed. Three patients were stone-free after a second session of URS-PL. The cumulative stone-free rate was 97.4% (188/193). For group 2, the mean operative time was 48.5 (+/- 11.31) min. About 208 (93.27%) patients were stone-free after the first session and an additional eight patients became stone-free after the second session of URS-PL. False passage, ureteral perforation, ureteral avulsion and stricture were observed in four, six, one and one patients, respectively. No proximal stone migration was observed. The cumulative stone-free rate was 96.86% (216/223).

CONCLUSIONS

The effectiveness of ureterorenoscopy (URS) in the treatment of distal ureteral stones was independent of stone dimension. However, the operative time was longer and the rate of perforation was higher in stones with a diameter > or = 1 cm. On the other hand, the migration rate was higher in stones < 1 cm in diameter. Generally speaking, there was no meaningful effect of stone dimension on complication rates.

Handling and prevention of complications in stone basketing

OBJECTIVE

To review the incidence, risk factors, and treatment options of intraoperative and postoperative complications of stone basketing in urology with emphasis on certain principles that must be upheld to prevent those complications.

METHODS

A literature search was performed using the MEDLINE database on stone basketing between 1970 and 2005.

RESULTS

Iatrogenic trauma due to retrieval of a stone is well known but the exact incidence is difficult to ascertain. Rarely, stone basketing can cause major trauma to the ureter, such as avulsion or intussusception, requiring open or laparoscopic intervention for ureteral continuity restoration. Mucosal abrasion, ureteral perforation, and stricture formation have also been described as complications of stone basketing. Occasionally, the engaged or broken basket can provoke anxiety even for experienced urologists. Factors that increase the risk of complications, strategies for repair, and techniques for prevention are discussed extensively.

CONCLUSION

Infrequent, surgical misadventures during stone basketing can occur and must be treated appropriately. Careful attention to instrument selection and surgical techniques and awareness of risk factors and type and site of potential injury are essential to reduce these complications.

Treatment of Ureteral Stones Using Holmium:YAG laser

INTRODUCTION

There has been a steady increase in the number of ureteroscopic laser lithotripsy. In addition to its soft tissue applications Holmium:YAG laser has also been found an excellent intracorporeal lithotripter for all kinds of stones. We here present the results of patients treated with Holmium:YAG laser lithotripsy in our clinic.

METHODS

Between June 1997 and December 2002, 205 patients with a diagnosis of ureteric calculi were treated with ureteroscopy using Holmium:YAG laser as an intracorporeal lithotriptor. The stones were localized in the distal ureter in 158 patients (77), middle and proximal ureter in 47 patients (23). Stones ranged in size from 5 x 5 mm to 20 x 10 mm and the operation time was about 35 minutes (ranged 25-65 minutes). Follow-up evaluations have done at first and third months.

RESULTS

The ureteral stone could not be reached in 10 patients (4.8). Stone fragmentation or removal was accomplished in all other patients. Four patients (1.9) had proximal migration of the fragments and later treated with extra corporeal shock wave lithotripsy, and three patients (1.5) had ureteral perforation. They were managed by double J stent placement. Two of the patients had ureteral obstruction on the third month of procedure. One of the patients was treated with open surgery. For the other one, ureteroscopic balloon dilatation was performed and catheterized by double J stent and there wasn't any complication after the removal of stent.

CONCLUSIONS

Ureteroscopic Holmium:YAG laser lithotripsy is a safe, technically feasible and efficacious treatment for ureteral stones.

Midstream urine culture and sensitivity test is a poor predictor of infected urine proximal to the obstructing ureteral stone or infected stones: a prospective clinical study

PURPOSE

This prospective study was performed to determine if midstream urine (MSU) culture and sensitivity (C&S) alone could adequately predict infected urine proximal to the obstructing ureteral stone or the infected stones. Can pelvic urine C&S predict infected stones?

MATERIALS AND METHODS

A prospective clinical study was performed on all patients undergoing ureterorenoscopy and lithotripsy for ureteral stones with obstruction between December 1, 2000 and January 31, 2002. We obtained MSU, renal pelvic urine and fragmented stones for culture and sensitivity. An analysis of the data was performed to assess statistical association.

RESULTS

A total of 73 patients who fulfilled the criteria were recruited. Of these patients 25 (34.3%) had positive stone culture, 43 (58.9%) had positive pelvic urine and 21 (28.8%) patients had positive MSU C&S. Stone and pelvic C&S were positive simultaneously in 17 (23.3%) cases, MSU and stone C&S were positive in 8 (10.9%) cases, whereas pelvic and MSU C&S were positive in 13 (16.4%) cases (p = 0.03). MSU C&S had a sensitivity of 30.2% and specificity of 73% to detect pelvic urine C&S positivity. MSU C&S had a low positive predictive value and negative predictive value (NPV) in relation to infected pelvic urine (positive predictive value = 0.62, NPV = 0.42). Pelvic urine C&S had a NPV of 0.73 in detecting noninfected stones.

CONCLUSIONS

The results of this study suggest that in obstructive uropathy secondary to a stone MSU C&S is a poor predictor of infected urine proximal to the obstruction and infected stones.

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.

Salvage extracorporeal shockwave lithotripsy after failed distal ureteroscopy

BACKGROUND AND PURPOSE

When intervention is necessary, controversy remains as to the best treatment modality for stones of the distal ureter. In general, ureteroscopy is favored over extracorporeal shockwave lithotripsy (SWL) as the treatment of choice for distal ureteral stones. Although uncommon, ureteroscopy failures have traditionally necessitated repeat ureteroscopy to retrieve retained stone fragments. We evaluated the efficacy of salvage SWL for failed primary distal ureteroscopy in the community setting.

PATIENTS AND METHODS

From December 1989 to December 2000, 6099 patients underwent SWL with the Dornier HM4 lithotripter at our institution. We retrospectively identified 31 patients who had undergone the SWL after a failed distal ureteroscopy.

RESULTS

The average stone size in these patients was 9.4 mm, the average time interval from ureteroscopy to SWL was 17.2 days, and the average number of shockwaves delivered was 2386. All patients had had stents placed after ureteroscopy. Twenty-seven patients (87%) had resolution of their stone burden after one SWL session. The remaining four patients underwent additional procedures.

CONCLUSIONS

Ureteroscopy is an effective modality for the treatment of distal ureteral stones. However, when unsuccessful, a salvage procedure may be necessary. Extracorporeal lithotripsy is a less invasive procedure with comparable success rates in the distal ureter. This report suggests that salvage SWL is an appropriate option for patients in whom distal ureteroscopic stone extraction fails.

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.

Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study

PURPOSE

We performed a prospective randomized study to determine appropriate first line treatment for distal ureteral stones.

MATERIAL AND METHODS

Between January 1996 and October 1997, 80 patients with distal ureteral stones (40 smaller than 5 mm. and 40 larger than 5 mm.) were randomized and treated with extracorporeal shock wave lithotripsy or ureteroscopy with a 9.5 or 6.5F semirigid ureteroscope.

RESULTS

Ureteroscopy was significantly better in terms of operative time, fluoroscopy time and time to achieve a stone-free state. The smaller the stones, the greater the difference between the 2 treatment modalities.

CONCLUSIONS

For distal ureteral stones we recommend ureteroscopy as first line treatment.

Early postureteroscopy vesicoureteral reflux--a temporary and infrequent complication: prospective study

BACKGROUND

Early complications after ureteroscopy include discomfort, renal colic, urinary infection, and hematuria. Vesicoureteral reflux has been reported as a late complication. The presence of early vesicoureteral reflux after ureteroscopy has not been investigated.

METHODS

Forty patients were randomly selected for a study in which early vesicoureteral reflux after ureteroscopy was searched for through retrograde cystography.

RESULTS

In four patients (10%), vesicoureteral reflux was found. Follow-up cystograms 2 weeks after ureteroscopy were normal in all four.

CONCLUSION

These results suggest that early vesicoureteral reflux after ureteroscopy is rare and that if it appears, it is of low grade and temporary.

Secondary ureteroscopy: results and management strategy at a referral center

PURPOSE

In an era when extracorporeal shock wave lithotripsy occupies a dominant place in the treatment of urolithiasis ureteroscopy retains an important role in certain circumstances. While often a definitive procedure, ureteroscopy can be associated with potential risks and complications. The treatment of patients who have undergone a failed attempt at ureteroscopic stone retrieval or have a complication may be complex. As a tertiary care stone referral center we review our experience with performing salvage ureteroscopy following a previous unsuccessful attempt at endoscopic stone removal.

MATERIALS AND METHODS

Between May 1990 and February 1996, 79 patients were referred following an unsuccessful attempt at retrograde endoscopic or basket manipulation for ureteral calculi. A retrospective review of the outcomes of these patients was conducted. Of the patients 11 presented with associated complications, which included ureteral perforation (4), intramural false passage (1) and fever or sepsis (6). Complications were managed by early establishment of urinary tract drainage by stenting or nephrostomy. Among patients without complications elective salvage ureteroscopy was performed.

RESULTS

Ureteroscopy was used in 79 patients with a successful outcome (stone-free) in 75 (95%). Followup imaging with renal ultrasound or excretory urography at least 3 months after secondary ureteroscopy was available in 65 patients and showed no evidence of hydronephrosis or delayed stricture formation.

CONCLUSIONS

Treating the patient who undergoes a failed attempt at ureteroscopy may be problematic and requires access to a wide array of endourological equipment. Each subsequent treatment should be individualized with consideration given to stone size, location and general health. In the presence of a ureteral injury establishment of early urinary tract drainage is essential. Following stabilization, secondary ureteroscopy can be performed yielding high stone-free rates with minimal complications.

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.

Ureteroscopy: current practice and long-term complications

PURPOSE

We compared a current cohort of patients who underwent ureteroscopy to a cohort from the early 1980s to determine changes in success, indications and long-term complications of the procedure.

MATERIALS AND METHODS

A chart review was performed of 194 patients who underwent 209 ureteroscopic procedures at our institution during 1992. This group was then statistically compared to 317 patients who underwent 346 ureteroscopies between 1982 and 1985.

RESULTS

The current indications for ureteroscopy were calculus extraction (67% of the cases), diagnosis (28%) and stent manipulation (5%). These indications differed from those of the early series, in which 84% of all ureteroscopies were performed for calculus extraction and 16% for diagnosis. Overall ureteroscopic success rate increased from 86 to 96% (p < 0.001). Success of stone extraction improved from 89 to 95% (p = 0.08, distal success rate 95 to 97% and proximal success rate 72 to 77%). Success of diagnostic inspections increased from 73 to 98% (p < 0.001). In the early series failure was usually due to inability to traverse the ureter (54% of the cases), while currently failure is due almost exclusively to impassable ureteral strictures (63%). The overall complication rate decreased from 20 to 12% (p = 0.01) and the rate of significant complications decreased from 6.6 to 1.5% (p < 0.05). Clinical followup (mean 36 months) for all patients and radiological followup (mean 9.8 months) for 67% of eligible patients detected only 1 ureteral stricture. The remaining patients were asymptomatic after the ureteroscopic procedure.

CONCLUSIONS

Improvements in ureteroscope design, accessories and technique have led to a significant increase in the success of diagnostic and therapeutic ureteroscopy while decreasing morbidity. Outpatient ureteroscopic stone extraction, particularly for distal ureteral calculi, is almost uniformly successful with low morbidity. The long-term complication rate of ureteroscopy is 0.5%.

Efficacy of retrograde endopyelotomy in children

PURPOSE

Endopyelotomy has been performed extensively in adults for the treatment of ureteropelvic junction obstruction. To determine its applicability to the pediatric population we reviewed our experience with retrograde endopyelotomy in children.

MATERIALS AND METHODS

Eight children 4 to 15 years old were treated with retrograde endopyelotomy and results were compared to those of a concurrent group of 8 treated with open pyeloureteroplasty.

RESULTS

Retrograde endopyelotomy was done in all of our patients with lower ureteral dilatation (as an adjunct measure in 5). Seven patients had symptomatic and radiographic improvement. The patient in whom the procedure failed had a crossing lower pole vessel. Postoperative analgesia, length of hospitalization and cost were lower in the endopyelotomy group.

CONCLUSIONS

Retrograde endopyelotomy is feasible in children older than age 4 years and it results in reduced morbidity. The success rate is high but open surgery remains the standard, particularly when a crossing lower pole vessel is identified preoperatively.

One-session bilateral ureteroscopy: is it safe in selected patients?

The aim of this study was to investigate the possibility to perform bilateral ureteroscopy in one session and to determine the procedure's indications and complication rate. Twenty-two patients underwent bilateral ureteroscopy in one session. Eighteen patients had bilateral lithiasis of the lower ureteral third, three patients had unexplained haematuria and one had unexplained bilateral hydronephrosis. The rigid ureteroscope was used in cases with stones and the flexible one in cases with haematuria and hydronephrosis. Ureteral catheters were placed in all patients. The overall stone-free rate was 83.3%. The procedure failed to confirm a diagnosis in 2 patients with unexplained haematuria. Follow-up included IVU and retrograde cystogram 3 months after the procedure and a renal scan one year later. No major complication was observed. It is concluded that bilateral ureteroscopy in one session can be performed safely in selected patients. The method does not yield major complications and saves patients from a second procedure and a second anaesthesia.

Endoscopic management of total ureteral occlusion and ureterovaginal fistula

Between August 1991 and June 1994, endoureterotomy was performed in nine patients for total ureteral occlusion. Four of these patients had an associated ureterovaginal fistula. The total ureteral occlusions were iatrogenic in eight patients and the result of trauma in one. The prone split leg position was used to facilitate simultaneous antegrade and retrograde ureteroscopy in all nine patients. The "cut-to-the-light" technique was utilized in six patients and a new technique employing a fascial incising needle was used in five patients. Five patients developed ureteral strictures within 5 months of the primary procedure that were corrected endoscopically. With a mean follow-up of 22 months, all nine patients have a successful outcome. Endoscopic management of difficult urteral disease such as total urteral occlusion and ureterovaginal fistula is a useful alternative to open surgery.

Submucosal calculi: endoscopic and intraluminal sonographic diagnosis and treatment options

After shock wave lithotripsy and endoscopic lithotripsy, occasionally a patient has persistent ureteral fragments associated with ureteral obstruction. After lithotripsy, stone fragments may be embedded in the ureteral mucosa, and they may become completely submucosal and associated with obstruction. Others may be hidden in iatrogenic ureteral outpouchings, while still others may be extruded from the ureter entirely. We present 20 patients who were referred after previous treatment failed to clear fragments or who had residual obstruction. The majority of patients had failed endoscopic fragment retrieval or shock wave lithotripsy and were referred with ureteral obstruction. All patients were reevaluated by repeated upper tract endoscopy with small diameter endoscopes. As an adjunct to ureteral endoscopy, a 6F, 20 MHz. ultrasound probe was placed transureterally to determine the depth and location of stones. A total of 15 patients in this series had hyperechoic foci with shadowing consistent with submucosal or periureteral stone fragments. A decision for treatment was based upon the location as noted by sonographic and fluoroscopic visualization of intramucosal and submucosal fragments. Calculi more than 4 mm. from the lumen were not removed without evidence of obstruction. Multiple, small (speckled) fragments embedded in the mucosa were often associated with subsequent stricture. Solitary fragments within the wall of the ureter could be removed with relief of obstruction. The risk of embedding calculi submucosally during lithotripsy should be recognized. Submucosal fragments causing obstruction should be removed endoscopically. Totally extruded calculi may be left in situ safely.

The role of ureteroscopy as a diagnostic and therapeutic tool in various indications

Ureteroscopy is now in routine use for the diagnosis and treatment of various pathologies in the upper urinary tract. We report here on our experience in diagnostic and therapeutic applications of the 11.5 F rigid ureteroscope in 85 patients and 88 ureters. An overall success rate of 68.18% (60/88) was achieved when therapeutic and diagnostic interventions were evaluated together. Success rate was 66.65% in the treatment of ureteral stones (all locations), 100% in the removal of retained catheters, and 81.82% in diagnostic interventions. Frequencies of complications like postoperative fever, stone migration, and various degrees of ureteral perforation were 5.68%, 5.68%, and 7.95%, respectively, consistent with current literature. We conclude that rigid ureteroscopy can be safely applied for appropriate indications in the hands of competent urologists.

Bilateral same session ureteroscopy

During a period of 4 years we performed 15 bilateral 1-session ureteroscopic examinations in 13 patients. Indications included bilateral ureteral and/or renal calculi, unexplained hydronephrosis, hematuria or filling defects, and bilateral ureteral stent placement in situations when conventional retrograde methods of stent placement failed. Balloon or hydraulic intramural ureteral dilation was performed in all cases before rigid or flexible endoscopy. There were no major short-term or long-term complications resulting from bilateral 1-session ureteroscopy.

Treatment of ureteral stones by extracorporeal shock wave lithotripsy: with ureteral catheter or in situ?

Many authors recommend that stone manipulation or catheter placement be attempted before SWL of ureteral stones. We tried to insert ureteral catheters before SWL on the unmodified Dornier HM3 machine in all patients treated for solitary ureteral stones between April 1986 and December 1991, succeeding in 77.5% (n = 395) of those for whom adequate follow-up is available for analysis. The stone-free rates with SWL alone in the series of 510 patients were 93% in patients with catheters and 75% in patients without catheters. An additional 6% of the patients in both groups became stone free with the aid of ureteroscopy. Eventually, only 0.5% of the patients with a catheter and 1.7% of the patients without a catheter had residual fragments. Among patients with a ureteral catheter after any procedure, 58.7% had no need for pain relief medication and no fever; the figure in the patients treated without a catheter was 74.4%. Although the success rate of SWL for ureteral stones is higher with a ureteral catheter in place, the incidence of complications also is higher. We recommend trying in situ SWL initially for patients with a ureteral stone.

Treatment of urinary tract stones

Replacement of open surgery with minimally invasive techniques for treating stones in the renal tract has greatly reduced patients' morbidity and mortality and the period of hospitalisation and convalescence. Extracorporeal shockwave lithotripsy does not require anaesthesia and requires little analgesia so that treatment can be given on an outpatient basis, and there is no wound to heal. Only a small puncture site is needed for percutaneous endoscopic lithotomy, and with the advent of prophylactic antibiotics there are few complications. Of renal stones, about 85% can now be successfully treated by extracorporeal lithotripsy alone, and almost all of the stones too large or hard for lithotripsy can be treated endoscopically, with ultrasonic or electrohydraulic probes being used to fragment the stone. Stones in the upper and lower thirds of the ureter can be treated by extracorporeal lithotripsy, but stones in the middle third, which cannot normally be visualised to allow focusing of the shockwaves, usually require ureteroscopy. Nearly all bladder stones can be treated by transurethral endoscopy with an electrohydraulic probe. Only the largest renal tract stones still require open surgery.

The fate of the iatrogenic retroperitoneal stone

Ureteral perforation with resultant retroperitoneal stone expulsion is a recognized complication of ureteroscopy. In a 5-year retrospective review of 400 cases we identified a 1.3% incidence of iatrogenic retroperitoneal stone dislodgment. Average followup was 21 months. Four cases were managed with observation and 1 required surgical correction of a ureteropelvic junction stricture. We discuss the management of this problem, which begins with thorough radiographic documentation in the perioperative period. Aggressive ureteroscopic manipulation and attempted stone retrieval are not warranted, and a ureteral stent should be placed. Radiographic followup and clinical observation confirm the low morbidity associated with retroperitoneal urinary stones. Patient understanding of the extra-ureteral stone location is essential to avoid misdiagnosis and mismanagement by uninformed physicians in the future.

Extracorporeal shock wave lithotripsy for distal ureteral stones

A retrospective analysis of distal ureteral calculi treated by extracorporeal shock wave lithotripsy (ESWL*) as the primary mode of therapy was performed. Using the Dornier HM3 unit 312 patients underwent a total of 326 ESWL procedures. Several pretreatment procedures, including placement of ureteral catheters were used to help with stone localization. Early fragmentation and 3-month stone-free rates were analyzed. Of the patients 81% were stone-free at 3 months. We reviewed 27 failures, revealing a higher incidence of impacted stones and stones greater than 1 cm. Complications were few and minor. ESWL is a safe and effective treatment option for distal ureteral calculi.

Morphological and physiological changes in the urinary tract associated with ureteral dilation and ureteropyeloscopy: an experimental study

The gross and microscopic effects of four common modes of ureteral dilation and ureteroscopy were examined in 26 renoureteral units in 13 minipigs. Acutely, ureters subjected to mechanical (bougie, Teflon, or balloon) ureteral dilation and ureteropyeloscopy (UPS) demonstrated active mucosal bleeding with multiple sites of perforation, whereas ureters subjected to hydraulic dilation and UPS were significantly less traumatized. Two weeks after mechanical ureteral dilation and UPS, 3 of 6 ureters were obstructed radiographically, whereas all 7 hydraulically dilated ureters were unobstructed. By 6 weeks, all radiographic evidence of obstruction had resolved in the mechanically dilated group. While 5 of 6 mechanically dilated ureters showed extensive scarring with muscle loss 4 to 6 weeks after dilation, no scarring was seen in those ureters dilated hydraulically. Renal pelvic pressure (RPP) was measured continuously with a nephrostomy catheter in vivo during (bougie, Teflon, balloon and hydraulic) ureteral dilation and UPS. Renal pelvic pressure during rigid ureteroscopy approximated the resting pelvic pressure plus the irrigant height above the kidney or set pressure on a hydraulic pump, plus a "scope effect" which was characterized by a 20 to 25 mm. Hg increase in RPP produced by moving the endoscope in the ureter without flow. The effects on RPP of continuous bladder drainage with a uretheral catheter and renal pelvic decompression with an open-ended ureteral catheter passed into the renal pelvis through the ureteroscope working channel were also examined. The maximum RPP was evaluated in vitro in a separate group of 16 freshly harvested pig kidneys of similar weight examined immediately after sacrifice and was found to be 439 mm. Hg. We also studied the immediate and long-term effects of low (< 120 cm. H2O or 90 mm. Hg) versus high (> 200 cm. H2O or 150 mm. Hg) RPP on renal histology. Acutely, high pressure caused diffuse denudation and flattening of the caliceal urothelium, submucosal edema and congestion not seen in calyces subjected to low irrigant pressure. Four to six weeks later, there was a higher incidence of columnar metaplasia, subepithelial nests and pericalyceal vasculitis in calyces subjected to high pressure as compared with those subjected to low irrigant pressure. Acutely, renal tubules subjected to high irrigant pressure demonstrated marked vacuolization and degeneration, whereas tubules subjected to low pressure appeared normal. At 4 to 6 weeks, focal scarring was seen in 5 of 7 kidneys subjected to high irrigant pressure, whereas no scarring was noted in all 6 kidneys subjected to low irrigant pressure.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of balloon dilation of ureter on upper tract dynamics and ureteral wall morphology

Sixteen male Yucatan minipigs underwent balloon dilation of the right ureterovesical junction (UVJ) and lower ureter to twice its normal caliber. With the bladder open, bilateral upper tract dynamics measurements under different perfusion rates (0.5, 2, and 4 ml/min) were recorded predilation, immediately after dilation, and 1, 2, 3, 4, and 6 weeks after dilation. Immediate and late antegrade nephrostograms, suprapubic cystograms, and right antegrade nephrostograms (oblique view) were taken. In the chronic experiment, no difference in renal pelvic pressure (Ppvs) was detectable between the control and dilated sides immediately after dilation. Only at 4 ml/min was there a statistically significant increase in the Ppvs of the dilated ureter 1 week after dilation when compared with the controls. At 2 weeks, this obstructive change had disappeared. At 3, 4, and 6 weeks, Ppvs of the dilated ureter declined progressively in comparison with the control side, but the difference was not statistically significant. At 6 weeks, Ppvs of the dilated ureter decreased significantly compared with predilation readings only at 4 ml/min. Immediate antegrade radiologic evaluation revealed that 69% of the experimental animals had no extravasation, while 31% showed variable degrees of extravasation, which disappeared completely on late antegrade nephrostograms (6 weeks). Grade 2 reflux occurred in 33% of the experimental animals at 1 week and had disappeared at 6 weeks. Histologic examinations at 1, 2, and 3 weeks revealed a nonhomogeneous pattern of ureteral damage, ranging from total rupture to much less dramatic injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Ureteral stents and flexible ureterorenoscopy

Numerous methods of dilating the intramural ureter for ureteroscopy are effective when used by experts, but none is ideal. In the authors' experience, a ureteral stent left indwelling for 1 or, better, 2 weeks usually is the safest, most reliable, and least traumatic method.

Endoureterotomy for treatment of ureteral strictures

Advances in endosurgical technology have provided the urological surgeon with an alternative to open surgery for the treatment of ureteral strictures. We report the use of an endoscopic intraureteral incision (endoureterotomy) followed by balloon calibration to treat benign ureteral strictures in 13 patients. With an average subjective and objective followup among successful endoureterotomies of 20 months (all cases 12 months or greater), the overall success rate for this procedure is 62%. Of these patients 5 also received triamcinolone injections into the stricture bed following incision and dilation. This method appeared to influence favorably subsequent ureteral patency. The only operative complication was a urinoma, which resolved without intervention. Endoureterotomy appears to be a safe and reasonably effective modality for the treatment of ureteral stricture disease.

Ureteroscopy without routine balloon dilation: an outcome assessment

A retrospective analysis of 156 rigid ureteroscopic stone procedures in 145 patients revealed successful manipulation in 90%. The stone-free rate after adjunctive procedures was 95%. Access was achieved without balloon dilation in all but 18 patients. There were 24 perforations, occurring in 31% of proximal, 8% of mid ureteral and 8% of distal stone manipulations. Of the evaluable patients 63% underwent radiographic assessment for stricture disease, 75% at 6 months or more after the procedure. The stricture rate was 3.5% in all patients and 5.9% in patients with perforations. Of 37 patients evaluated for vesicoureteral reflux only 1 had reflux. Questionnaire followup was obtained for 74% of the patients (mean followup 2.6 years) and 32% felt normal within 3 days. Postoperative symptoms included flank pain (13%), renal colic (12%), pelvic discomfort (30%) and Double-J stent related complaints (49%). Of the patients 15% have reported recurrent stones. Ureteroscopy is effective and well tolerated, and it has minimal long-term complications.

Lumbar ureteric stones: which is the best treatment?

We reviewed retrospectively 145 patients presenting ureteral calculi above the iliac crest. According to the treatment three groups were established. Group 1 was represented by 24 patients submitted to posterior ureterolithotomy; group 2, 100 patients treated by endourologic procedures; and group 3, 21 patients treated by extracorporeal shock-wave lithotripsy (ESWL). Success rate considered as complete removal of all calculous material was 100 percent in the posterior ureterolithotomy group, 92 percent in the endourologic group, and 94.7 percent in the ESWL group. Hospitalization, anesthesia, and complication rates were minimal in patients submitted to ESWL. One may conclude that ESWL is the treatment of choice for lumbar ureteric calculi.

Balloon dilation of the distal ureter to 24F: an effective method for ureteroscopic stone retrieval

Early in our ureteroscopic experience, in an effort to facilitate retrieval of ureteral calculi with the 11.5F and 12.5F rigid ureteroscopes, the distal ureter was routinely balloon dilated to 24F. Among 131 ureteroscopic procedures all consecutive 108 distal ureteral calculi were successfully removed. However, only 65% of 23 upper ureteral calculi were extracted. A followup excretory urogram (6 weeks or later) in 86 patients revealed no distal ureteral strictures. A followup cystogram in 30 patients showed low grade vesicoureteral reflux in 20% of the patients and none of these individuals was symptomatic. As such, balloon dilation of the distal ureter to 24F appears to be well tolerated. Presently, given the advent of smaller ureteroscopes and lithotriptor probes, such extensive ureteral dilation is necessary only in a minority of patients with distal ureteral calculi. In these few patients with calculi resistant to lithotripsy balloon dilation of the ureter to 24F may allow for successful, safe stone extraction, thereby precluding open ureterolithotomy.

Does extracorporeal shockwave lithotripsy cause hypertension?

Several series have suggested that the incidence of hypertension following extracorporeal shockwave lithotripsy (ESWL) may be as high as 8%. In this study, changes in blood pressure and the incidence of hypertension have been observed in 733 patients 12 to 44 months after renal ESWL on the Dornier HM3. The incidence of hypertension following ESWL was 8.1%. In patients with a pre-ESWL diastolic pressure less than 90 mmHg, the incidence of those with a diastolic greater than or equal to 100 mm Hg post-operatively was significantly greater than that predicted by historical data. There was no overall change in the mean blood pressure of the group. The hypertensive risk of ESWL remains unclear. However, blood pressure surveillance should be performed following ESWL and a prospective study is required.

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

We treated 208 patients with ureteral calculi via transurethral lithotripsy using the rigid ureteroscope between March 1985 and April 1988. A total of 220 ureteroscopic procedures was performed in 217 ureters. Complete removal was achieved after 180 procedures (81.8%) and incomplete removal was achieved after 9 (4.1%). In 31 cases (14.1%) the stone could not be removed because of various reasons. Ureteral disruption was observed in 1 case (0.5%), which was treated successfully with reconstruction. Ureteral perforation occurred in 15 cases (6.8%) and was treated successfully except for 1 patient (0.5%) in whom ureteral stricture was observed requiring reconstruction. From long-term followup of sequential excretory urography and voiding cystography, mild stricture at the vesical end of the ureter was noted in 3 of 86 ureters (3.5%) and vesicoureteral reflux was noted in 7 of 73 (9.6%). These results indicate that the injury to the intramural ureter might arise from the passage of the ureteroscope resulting in stricture and vesicoureteral reflux.

Treatment of distal ureteral stones in the horse riding position

From August 1986 through March 1987, 102 patients with 110 distal ureteral stones were treated in 110 sessions with the standard Dornier HM-3 lithotriptor in the so-called horse riding position. The majority of the patients (70 of 110, 63.7%) were treated for distal stones alone, whereas in a third (40 of 110, or 36.3%) treatment was performed for distal and upper stone localization during the same session. Additional treatment besides extracorporeal shock wave lithotripsy was necessary in 12.7% of the patients. Of the 110 patients 89.4% were without residual stones after a mean of 17.3 days. This modified position of the patient, which is specific to the Dornier HM-3 lithotriptor, makes possible treatment of distal ureteral stones with results comparable to those of endoscopic management but with less major complications (4.7%). A total of 7 patients had anal blood loss in the early postoperative period. Rectal bleeding ceased within 36 hours after treatment. The position also allows for treatment of stones at other, more proximal locations without great modifications to the position during the same session.

Ureteral stones: the results of primary in situ extracorporeal shock wave lithotripsy

The use of a Siemens Lithostar* for in situ disintegration of 212 ureteral stones in 207 patients was evaluated. Followup data were available on 133 patients (136 stones). Of the stones 121 (88.1 per cent) have been cleared with in situ extracorporeal shock wave lithotripsy alone. These results strongly suggest that in situ extracorporeal shock wave lithotripsy is an effective and noninvasive method to treat ureteral stones.