The case for primary endoscopic management of upper urinary tract calculi: II. Cost and outcome assessment of 112 primary ureteral calculi

Ultrathin semirigid retrograde ureteroscopy versus antegrade flexible ureteroscopy in treating proximal ureteric stones 1-2 cm, a prospective randomized multicenter study

To compare the outcomes of using Ultrathin semirigid retrograde ureteroscopy and antegrade flexible ureteroscopy to treat proximal ureteric stones of sizes 1-2 cm. A prospective randomized multicenter study included patients who had proximal ureteric stones 1-2 cm, amenable for ureteroscopy and laser lithotripsy between August 2023 and February 2024. Two hundred thirty patients were divided evenly into two treatment groups. Group I included patients treated with antegrade flexible ureteroscopy and holmium laser stone fragmentation, and Group II included patients treated with retrograde ultrathin semirigid ureteroscopy. The study groups were compared in terms of patient demographics, stone access success, operation time, reoperation rates, peri-operative complications, and stone-free status. Group I included 114 patients, while Group II included 111. The mean age of the patients was 33.92 ± 10.37 years, and the size of the stones was 15.88 ± 3 mm. The study groups had comparable demographics and stone characteristics. The mean operative time was significantly longer in group I than in group II (102.55 ± 72.46 min vs. 60.98 ± 14.84 min, respectively, P < 0.001). Most reported complications were MCCS grades I and II, with no significant difference between the study groups. The stone-free rate after four weeks was 92.1% and 81.1% for groups I and II, respectively, which increased to 94.7% and 85.6% after eight weeks (P > 0.05). Antegrade flexible ureteroscopy is equivalent to retrograde ultrathin semirigid ureteroscopy in treating proximal ureteric stones regarding stone-free status and procedure-related morbidity. However, the antegrade approach has a longer operative time, greater fluoroscopy exposure, and longer hospital stays.

Is the 4.5-F ureteroscope (Ultra-Thin) an alternative in the management of ureteric and renal pelvic stones?

Objectives

To compare the 7.5–9.5F ureteroscope (URS) with the 4.5–6.5F URS (Ultra-Thin) in terms of success and complication rates in adult patients with ureteric and renal pelvic stones.

Patients and methods

In all, 41 patients treated with 7.5–9.5F semi-rigid URS (Group 1) and 33 patients treated with the Ultra-Thin (Group 2) were prospectively included in the study. All patients underwent holmium laser ureteroscopic lithotripsy. In each group, when the selected ureteroscopic intervention failed to reach or disintegrate the stone, the URS was replaced with the other one. Outcome criteria were: success and complication rates, stone size and stone surface area, operative time, laser time, usage of guidewire, and postoperative JJ-catheter placement.

Results

The ureteroscopic lithotripsy in 36 of 41 (87.8%) and 24 of 33 (72.7%) patients was completed without a need to replace the URS with the other one in groups 1 and 2, respectively (P = 0.67). After replacement of the 7.5–9.5F URS with the Ultra-Thin for patients who failed in Group 1, the overall stone-free rate (SFR) improved to 97.5% (P = 0.014). In Group 2, after replacement of the Ultra-Thin with the 7.5–9.5F URS for the failed patients, the overall SFR improved to 96.9% (P = 0.02). There was no significant difference between the groups for complications. Postoperative JJ stenting was significantly less in Group 2 (21.2%) in comparison to Group 1 (46.3%) (P = 0.02).

Conclusions

The Ultra-Thin has a similar success rate as the 7.5–9.5F URS in the treatment of ureteric stones and is a feasible option in patients in whom a conventional URS cannot be advanced through any segment of the ureter.

Could spinal anesthesia be a choice for retrograde intrarenal surgery

Objective:

In this study, we aimed to compare cases of retrograde intrarenal surgery performed under spinal or general anesthesia through investigating relevant parameters for the first time in the literature.

Material and method:

In total, 86 patients with diagnosis of kidney stone who were treated by retrograde intrarenal surgery were included in this randomized controlled prospective study. In total, 43 of these operations were performed under spinal anesthesia (group I) and 43 were performed under general anesthesia (group II). The groups were compared in terms of demographic features, American Society of Anesthesiologists score, duration of operation, complication rates, postoperative visual analogue scale, postoperative hospitalization period, stone-free rates, and cost value ratios.

Results:

There were no significant differences between the two groups in terms of demographic findings, preoperative stone loads, postoperative stone-free rates, complication rates and postoperative hospitalization periods (p > 0.05). Postoperative visual analogue scale scores and cost value ratios were found statistically significantly lower in the spinal anesthesia group (group I) when compared with the general anesthesia group (group II; p < 0.001).

Conclusion:

Performing retrograde intrarenal surgery in the presence of spinal anesthesia is equally effective with general anesthesia. Spinal anesthesia also appears to be a more advantageous method due to statistically significantly lower mean postoperative pain scores and treatment cost value ratios.

Flexible ureterorenoscopy in position or fusion anomaly: Is it feasible?

OBJECTIVE

To analyze the results of flexible ureterorenoscopy (F-URS) with holmium laser in the treatment of kidney stones with ectopic and fusion anomalies (horseshoe kidney and rotation anomalies).

METHOD

We reviewed data from 13 patients with fusion and ectopic renal anomalies that underwent F-URS from April 2011 to April 2017. We analyzed demographic and clinical data (age, gender, BMI, anatomical abnormality, location and dimension of the renal calculi) and perioperative data (method of treatment, stone-free rate, number of days with DJ catheter and perioperative complications).

RESULTS

The mean stone size was 12.23 +/- 5.43 mm (range 6-22mm), located in the inferior (58.33%) and middle (16.76%) calyceal units, renal pelvis (16.67%) and multiple locations (8.33%). All 13 patients were treated with Ho-Yag laser, using dusting technique (25%), fragmentation and extraction of the calculi (58.33%) and mixed technique (16.67%). We did not have any severe perioperative complication. After 90 days, nine patients (75%) were considered stone free.

CONCLUSION

Our data suggest that F-URS is a safe and feasible choice for the treatment of kidney stones in patients with renal ectopic and fusion anomalies.

Is There A Difference Between Presence of Single Stone And Multiple Stones in Flexible Ureterorenoscopy And Laser Lithotripsy For Renal Stone Burden < 300mm2 ?

In this study, we aim to evaluate and compare the effectiveness of flexible ureterorenoscopy (f-URS) for solitary and multiple renal stones with < 300 mm2 stone burden. Patients' charts who treated with f-URS for kidney stone between January 2010 and June 2015 were reviewed, retrospectively. Patients with solitary kidney stones (n:111) were enrolled in group 1. We selected 111 patients with multiple kidney stones to serve as the control group and the patients were matched at a 1:1 ratio with respect to the patient's age, gender, body mass index and stone burden. Additionally, patients with multiple stones were divided into two groups according to the presence or abscence of lower pole stones. Stone free status was accepted as complete stone clearence and presence of residual fragments < 2 mm. According to the study design; age, stone burden, body mass index were comparable between groups. The mean operation time was longer in group 2 (p= 0.229). However, the mean fluoroscopy screening time in group 1 and in group 2 was 2.1±1.7 and 2.6±1.5 min, respectively and significantly longer in patients with multiple renal stones (P=0.043). The stone-free status was significantly higher in patients with solitary renal stones after a single session procedure (p=0.02). After third month follow up, overall success rate was 92.7% in Group 1 and 86.4% in Group 2. Our study revealed that F-URS achieved better stone free status in solitary renal stones < 300 mm2. However, outcomes of F-URS were acceptable in patients with multiple stones.

The economics of stone disease

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

The Cost-Effectiveness of Treatment Modalities for Ureteral Stones

Additional intervention and medical treatment of complications may follow the primary treatment of a ureteral stone. We investigated the cost of the treatment of ureteral stone(s) within 45 days after initial intervention by means of retrospective analysis of the National Health Insurance Research Database of Taiwan. All patients of ages ≥20 years diagnosed with ureteral stone(s)( International Classification of Diseases, Ninth Revision, Clinical Modification/ICD-9-CM: 592.1) from January 2001 to December 2011 were enrolled. We included a comorbidity code only if the diagnosis appeared in at least 2 separate claims in a patient’s record. Treatment modalities (code) included extracorporeal shock-wave lithotripsy (SWL; 98.51), ureteroscopic lithotripsy (URSL; 56.31), percutaneous nephrolithotripsy (PNL; 55.04), (open) ureterolithotomy (56.20), and laparoscopy (ie, laparoscopic ureterolithotomy; 54.21). There were 28 513 patients with ureteral stones (13 848 men and 14 665 women) in the randomized sample of 1 million patients. The mean cost was 526.4 ± 724.1 United States Dollar (USD). The costs of treatment were significantly increased in patients with comorbidities. The costs of treatment among each primary treatment modalities were 1212.2 ± 627.3, 1146.7 ± 816.8, 2507.4 ± 1333.5, 1533.3 ± 1137.1, 2566.4 ± 2594.3, and 209.8 ± 473.2 USD in the SWL, URSL, PNL, (open) ureterolithotomy, laparoscopy (laparoscopic ureterolithotomy), and conservative treatment group, respectively. In conclusion, URSL was more cost-effective than SWL and PNL as a primary treatment modality for ureteral stone(s) when the possible additional costs within 45 days after the initial operation were included in the calculation.

Evaluation of Extracorporeal Shock Wave Lithotripsy (ESWL): Efficacy in Treatment of Urinary System Stones

Introduction:

Elimination of stone is determined by size and its localization. Stone from the ureter in 80% of cases can be eliminated spontaneously. If the stone by its characteristics is not spontaneously eliminated, taken are further steps and therapeutic protocols to solve this problem.

Material and methods:

The study was prospective, open and comparative. It was conducted at the Urology Clinic Clinical Center of Sarajevo University in the period from 2007 to 2013. The study included 404 patients with urinary tract lithiasis treated by ESWL. ESWL treatment is performed on the machine Siemens Model Lithostar Multiline, which has a combined ultrasonographic and fluoroscopic display, large energy density in order to obtain optimum focus (without damaging surrounding tissue) and minimal pain that on rare occasions requires for mild sedation-sedation.

Results:

From a total of 404 patients included in the study there were 234 (57.92%) male and 170 (42.08%) female patients. The most common type of stone both in female and male patients was calcium type. From a total of 262 calcium stones, 105 of them (40.07%) was present in female patients and 157 (59.92%) in male. Share of infectious type of stone in female patients was 63 (49.60%) and 64 among males (50.39%). Other stones were less abundant in both the gender groups and their total number was only 17. In women their frequency was 2 (13.33%) and 13 among males (86.67%). There was a significant difference in the frequency of different types of stones by gender (x2 = 11.47, p = 0.009).

Conclusion:

There was no statistically significant correlation between the number of treatments and localization of stones in the ureter, as well as a statistically significant correlation between the size of the stone and the localization of calculus in the ureter.

Outcomes of retrograde flexible ureteroscopy and laser lithotripsy for stone disease in patients with anomalous kidneys

Due to the presence of structural and anatomical differences that accompany anomalous kidneys, currently available endourological modalities such as SWL and PNL may be insufficient, or additional laparoscopic assistance may be required. The present study aims to evaluate the efficacy and safety of retrograde flexible ureterorenoscopic stone treatment in patients with kidney anomalies. Over the last 3 years, 25 patients with renal stones in anomalous kidneys were consecutively treated by flexible ureterorenoscopy and holmium:YAG laser lithotripsy. Among the 25 patients, fiberoptic or digital flexible ureterorenoscopies were performed for the management of horseshoe kidneys (n = 3), cross-fused ectopic kidney (n = 1), renal ectopies [n = 13; associated with pelvic (n = 6) or lumbar kidneys (n = 7)], renal malrotations (n = 4), and duplicate ureters (n = 4). For lithotripsy, 200 or 273 µm probes were used, and for stone retraction 1.3-1.9 Fr ZeroTip baskets were used. Success was defined as the complete absence of stones as evaluated with a CT scan 1 month after the operation. The mean patient age was 39.4 ± 15.75 years, and the mean stone size was 194.64 ± 103.93 mm(2) (range 50-393). Complete stone clearance was achieved in 16 patients (64%) after a single session. Seven of the patients with residual stones underwent a second session and the remaining three patients were subsequently treated with SWL. The overall complete clearance rate was 88% (22 patients) with ancillary procedures. There were no serious postoperative complications except for one case (4%) of urosepsis. Flexible ureterorenoscopy with holmium laser lithotripsy is a safe option for the treatment of renal stones in anomalous kidneys with satisfactory success rates.

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.

Simultaneous saline irrigation during retrograde rigid ureteroscopic lasertripsy for the prevention of proximal calculus migration

OBJECTIVE

In this paper, we analyze the clinical efficacy of a simultaneous saline irrigation method in treating upper-mid ureteral stone migration and evaluate its effectiveness during ureteroscopic lasertripsy.

METHODS

We prospectively evaluated 78 patients with a total of 95 upper-mid ureteral stones, which were treated with holmium:YAG lasertripsy. These patients were randomized into 2 groups. In Group 1 (39 cases with 44 ureteral stones), conventional ureteroscopic lasertripsy was performed. In Group 2, (39 cases with 51 ureteral stones), the simultaneous saline irrigation method was used during lasertripsy. There was no significant difference between the groups with regards to stone site, size or state of the upper urinary tract by spiral computed tomography or excretory urography. Data were analyzed regarding stone migration, lengths of time, and ureteral clearing for various stages of each procedure.

RESULTS

One patient in Group 2 (2%) experienced upward stone migration, while this occurred in 8 patients in Group 1 (20%). The operative time in Group 1 ranged from 35 to 55 minutes (mean: 44.8 ± 5.3), while in Group 2 it ranged from 40 to 69 minutes (mean: 50.4±3). There was no significant different in the operative times between the two groups (p < 0.05). Ureteral perforation, urinoma and urosepsis were not seen in both groups.

CONCLUSION

The simultaneous saline irrigation method demonstrated a statistically significant advantage over conventional methods. The operation can be performed persistently under clear vision, and since the stones cannot move upward, fragmented portions are easily flushed out. Our data suggest that this method is simple, safe and effective in preventing proximal stone migration during ureteroscopic lasertripsy.

Kidney stone volume estimation from computerized tomography images using a model based method of correcting for the point spread function

PURPOSE

We propose a method to improve the accuracy of volume estimation of kidney stones from computerized tomography images.

MATERIALS AND METHODS

The proposed method consisted of 2 steps. A threshold equal to the average of the computerized tomography number of the object and the background was first applied to determine full width at half maximum volume. Correction factors were then applied, which were precalculated based on a model of a sphere and a 3-dimensional gaussian point spread function. The point spread function was measured in a computerized tomography scanner to represent the response of the scanner to a point-like object. Method accuracy was validated using 6 small cylindrical phantoms with 2 volumes of 21.87 and 99.9 mm(3), and 3 attenuations, respectively, and 76 kidney stones with a volume range of 6.3 to 317.4 mm(3). Volumes estimated by the proposed method were compared with full width at half maximum volumes.

RESULTS

The proposed method was significantly more accurate than full width at half maximum volume (p <0.0001). The magnitude of improvement depended on stone volume with smaller stones benefiting more from the method. For kidney stones 10 to 20 mm(3) in volume the average improvement in accuracy was the greatest at 19.6%.

CONCLUSIONS

The proposed method achieved significantly improved accuracy compared with threshold methods. This may lead to more accurate stone management.

Flexible ureteroscopy and laser lithotripsy for bilateral multiple intrarenal stones: is this a valuable choice?

OBJECTIVE

To demonstrate the safety and efficacy of flexible ureteroscopy (FURS) and holmium laser lithotripsy as a valuable treatment of bilateral multiple intrarenal stones and stratify the efficacy by stone burdens ≤ 20 and >20 mm.

METHODS

Twenty-five patients with bilateral multiple intrarenal stones were treated with FURS and holmium lithotripsy at a single clinic. The operative time, stone-free rates (SFRs) per renal unit, stone compositions, number of procedures, serum creatinine, and complications were evaluated. The SFRs were evaluated with computed tomography and plain X-rays of the kidneys, ureters, and bladder. Renal ultrasound was performed 30 days after double-J stent removal to identify hydronephrosis and absence of stones. We defined a stone-free status as the absence of fragments in the kidney or fragments of <1 mm.

RESULTS

The total stone number was 128 with a mean stone burden per patient of 24 ± 5 (range 17-37 mm). The overall SFRs per renal unit after 1, 2, and 3 procedures were 70.0%, 92.0%, and 92.0%, respectively. The overall SFRs per renal unit for patients with a preoperative stone burden ≤ 20 and >20 mm were 100% and 85.7%, respectively. No major intraoperative or postoperative complications occurred. There were only 4 minor postoperative complications (16%).

CONCLUSION

Our study results firmly suggest that FURS with holmium laser lithotripsy represents a favorable alternative to external shock wave lithotripsy or percutaneous nephrolithotomy for select patients with bilateral multiple intrarenal stones, which have a satisfactory efficacy and low morbidity.

Effectiveness of single flexible ureteroscopy for multiple renal calculi

PURPOSE

To assess effectiveness of flexible ureteroscopy (fURS) in patients not with simple but with multiple unilateral renal stones.

PATIENTS AND METHODS

A database analysis was performed to identify patients with multiple unilateral intrarenal stones. Patients were treated using an 8.8F flexible ureteroscope. Patients were considered stone free if no residual stones were seen endoscopically and radiographically after the procedure. The efficiency and the safety of the procedures were analyzed.

RESULTS

Between 2006 and 2008, 1054 ureteroscopic procedures were performed in our department; 125 patients met the inclusion criteria. Holmium:yttrium-aluminum-garnet laser lithotripsy was necessary in 41 (32.8%) patients. The mean stone size was 11.93 ± 8.2 mm, with a mean stone burden of 83.7 ± 67.66 mm(2). The mean number of stones was 3.59 ± 3.57. Twenty-six (20.8%) patients had a stone burden ≥ 100 mm(2), and 99 (79.2%) a stone burden <100 mm(2). The overall stone-free rate after a single procedure of fURS was 74.4%. In the remaining 32 patients with residual stones, the mean stone burden dropped from 123.24 ± 84.36 mm(2) to 56.28 ± 52.53 mm(2). The stone-free rate in patients with a stone burden ≥ 100 mm(2) was 65.4% and 79.5% in patients with a stone burden < 100 mm(2), respectively. Complications have been recorded in seven (5.6%) patients, including urinary tract infection in four, ureteral perforation in one, and hematuria in two patients. No major complications occurred. All patients were treated conservatively.

CONCLUSIONS

fURS is an effective treatment option in patients with multiple unilateral renal stones. Single procedure stone-free rates are high with a low rate of only minor complications.

[Horseshoe kidney stones: benefit of flexible ureterorenoscopy with holmium laser]

OBJECTIVES

We aim to assess the outcome of the flexible ureterorenoscopy (F-URS) with holmium laser in treating horseshoe kidney (HSK) stones.

PATIENTS AND METHODS

We reviewed retrospectively the records of 18 patients with HSK stone (18 renal units) who underwent F-URS using holmium laser from December 2004 to October 2009. The mean age was 37.7±6.9 years. The F-URS used after the extracorporeal shock wave lithotripsy (ESWL) failure in eight patients (44.4%) and four patients (22.2%) had PCNL failure. The follow up visit range were between 4 and 6 weeks with plain radiograph (KUB) and renal ultrasound or non contrast computed tomography scan (NCCT). Success rate was defined as stone free or residual fragment less than 3 mm. Use of auxiliary procedures like ESWL were considered as treatment failure.

RESULTS

Eighteen patients, three females and 15 males with mean age was 37.7±6.9 years with HSK calculi underwent ureteroscopic management. The presenting symptoms were renal colic, urinary tract infection or hematuria. We found different HSK stone location (11 mixed calyceal, three mixed pelvic and calyceal and four pelvic). The average stone burden was 15.5±7.3 mm and the mean operative time was 112±9.4 minutes. All over procedures were 27, with mean average of 1.5 procedures per patient. The success rate was 89%.

CONCLUSION

The F-URS with holmium laser is an efficient minimal invasive procedure in treating HSK stones.

Semirigid ureteroscopy in management of large proximal ureteral calculi: is there still a role in developing countries?

OBJECTIVES

To evaluate the outcome and complications of the use of semirigid ureteroscopy (URS) together with intracorporeal pneumatic lithotripsy in the management of upper ureteral calculi >10 mm in diameter.

METHODS

A total of 75 patients (41 women and 34 men), with a mean age of 48 years (range 25-60), underwent primary URS for solitary radiopaque proximal ureteral calculi 10-20 mm in diameter (average 13.1). Dilation of the intramural ureter was done in 60 cases (80% of patients), and intracorporeal lithotripsy was required in 56 (74.6%). Ureteral catheters were left for drainage in 60% of patients, 26.7% were left unstented, and only 13.3% required an indwelling stent.

RESULTS

Of the 75 stones, 60 (80%) were successfully cleared after a single endoscopic procedure. Our initial stone-free rate was 90.6% at 2 weeks after the primary endoscopic procedure and had reached 98.6% at 3 months. Antegrade URS for migrating stones was done successfully in 6 cases in a tubeless fashion, and open ureterolithotomy was required in 1 case. No major complications were encountered. The minor complications included only mild extravasation and self-limited postoperative fever and hematuria. The risk factors for URS failure included male gender, the severity of the hydronephrosis, the severity of impaction, and the occurrence of extravasation.

CONCLUSIONS

The results of our study have shown that semirigid URS is a safe and successful alternative to open ureterolithotomy in the management of large proximal ureteral calculi in the absence of flexible instruments.

Flexible ureterorenoscopy with holmium laser in horseshoe kidneys

OBJECTIVES

To assess the outcome of flexible ureterorenoscopy (F-URS) with the holmium laser in treating stones in the horseshoe kidney (HSK).

METHODS

We retrospectively reviewed the records of 17 patients with a HSK stone (17 renal units) who had undergone F-URS with the holmium laser from December 2004 to May 2009. The presenting symptoms were renal colic, urinary tract infection, or hematuria. F-URS was used in as an alternative after the failure of shock wave lithotripsy in 8 patients (47%) and percutaneous nephrolithotomy failure in 4 patients (23.5%). Follow-up examination was performed after 4-6 weeks with plain radiography and either renal ultrasonography or noncontrast computed tomography. Success was defined as stone-free status or residual fragments <3 mm. The use of auxiliary procedures was considered to indicate treatment failure.

RESULTS

A total of 17 patients were included in the present study (3 females and 14 males). Their age was 16-52 years (mean age ± SD 34.7 ± 6.3). The HSK stone location was 7 mixed caliceal, 3 mixed pelvic and caliceal, and 7 pelvic. The average stone burden was 16 mm (range 7-35). The overall number of procedures was 25 (mean 1.5 procedures/patient). Of the 17 patients, 15 (88.2%) were rendered stone free.

CONCLUSIONS

The results of our study have shown that F-URS with the holmium laser is an efficient minimal invasive procedure for treating HSK stones.

SWL is More Cost-Effective than Ureteroscopy and Holmium:YAG Laser Lithotripsy for Ureteric Stones: A Comparative Analysis for a Tertiary Referral Centre

Background:

To identify the most cost-effective treatment for ureteric stones ≤15 mm in our department, by using an economic model to compare the total cost of shockwave lithotripsy (SWL) versus ureteroscopy with Holmium:YAG laser lithotripsy (URSL).

Patients and methods:

Data for patients treated with the same lithotriptor were retrospectively analyzed. The financial department provided data about the cost of procedures. This model accepted a 100% stone-free rate for URSL in outpatients, and a 50% rate of insertion of a ureteric stent. The cost for each procedure to render a patient stone-free was estimated by the following equations: costSWL = cost(initial SWL session) + [cost(SWL session) × retreatment rate] + [cost(URSL) × SWL failure rate] + [cost(stent insertion and removal) × rate] + [cost(KUB film) × 4] costURSL = cost(URSL) + [cost(stent removal) × 50%] + [cost(KUB film) × 2]

Results:

Records of 228 patients with previously untreated solitary radiopaque ureteric stones ≤15 mm were reviewed. The total cost for SWL (cSWL) was £1491/patient, while the total cost for URSL (cURSL) was £2195/patient. The difference was highest in the upper ureter (over £1000), and lowest in the distal part (URSL about 40% more expensive). For lower ureteric stones >10 mm, SWL was over £500 more expensive than URSL.

Conclusion:

Using data from the department to calculate cost-effectiveness for ureteric stones ≤15 mm a difference in favour of SWL versus URSL was found. Uniform guidelines incorporating cost are impossible considering differences between countries; each centre should probably assess their data individually.

Semirigid ureteroscopy for ureteral stones: a multivariate analysis of unfavorable results

PURPOSE

We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi.

MATERIALS AND METHODS

We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results.

RESULTS

The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively).

CONCLUSIONS

Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

Flexible ureteroscopy and laser lithotripsy for multiple unilateral intrarenal stones

BACKGROUND

External shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL) have been the standard of care for the treatment of intrarenal calculi.

OBJECTIVE

We sought to determine the safety and efficacy of flexible ureteroscopy and holmium laser lithotripsy for the treatment of multiple intrarenal calculi and further stratify the efficacy by stone burden less than and greater than 20mm.

DESIGN, SETTING, AND PARTICIPANTS

Patients with multiple unilateral renal calculi treated between 2000 and 2006 at a single tertiary academic center were retrospectively evaluated.

INTERVENTION

All patients underwent retrograde flexible ureteroscopy and holmium laser lithotripsy.

MEASUREMENTS

Stone-free status was determined by ureteroscopy 15 d after the last procedure and was defined as the absence of stones in the kidney or residual fragments <1mm. A renal ultrasound was performed 30 d after the last treatment to confirm the absence of stones and hydronephrosis.

RESULTS AND LIMITATIONS

Fifty-one patients were identified for a total of 161 intrarenal calculi with a mean stone size per patient of 6.6+/-3mm (range: 2-15). The mean number of stones per patient was 3.1+/-1 (range: 2-6). The mean number of primary procedures was 1.4+/-0.6 (range: 1-3). The overall stone-free rates after one and two procedures were 64.7% and 92.2%, respectively. The stone-free rates for patients with a stone burden greater than and less than 20mm were 85.1% and 100%, respectively. The overall complication rate was 13.6%; 97.6% of cases were performed as outpatient procedures. There are some limitations to this study, however: This is a retrospective review from a single institution, and our results are based on a relatively small sample size.

CONCLUSIONS

For select patients with multiple intrarenal calculi, flexible ureteroscopy with holmium laser lithotripsy may represent an alternative therapy to ESWL or PNL, with acceptable efficacy and low morbidity.

Economics of stone management

Cost, in addition to efficacy and morbidity, has become an important factor in determining the best therapeutic modality for a variety of disease states. A comprehensive literature search finds that, in general, for staghorn calculi, percutaneous nephrostolithotomy is more cost-effective than shock wave lithotripsy (SWL) for stones greater than 2 cm in any dimension, while SWL may be cost-effective for smaller stones. For ureteral stones, observation is the least costly treatment strategy. Among surgical options, ureteroscopy is less costly than SWL. For single and recurrent stone formers, medical prophylactic strategies involving drug therapy are more costly than conservative therapy involving dietary measures alone. However, drug strategies yield fewer stone recurrences.

Shock Wave Lithotripsy or Ureteroscopy for the Management of Proximal Ureteral Calculi: An Old Discussion Revisited

PURPOSE

The goal of treating ureteral calculi is to achieve complete stone clearance with minimal patient morbidity. Shock wave lithotripsy and ureteroscopy have become standards of care for ureteral calculi. However, the optimal choice of treatment depends on various factors, including stone size, composition and location, clinical patient factors, equipment availability and surgeon capability. Indications for and outcomes data on shock wave lithotripsy and ureteroscopy for proximal ureteral calculi were reviewed to provide recommendations on the optimal treatment choice for managing symptomatic ureteral calculi.

MATERIALS AND METHODS

A systematic review was performed based on an English literature search using the MEDLINE database between 1997 and 2005. The key words used were proximal ureteral calculi, ureteroscopy and shock wave lithotripsy.

RESULTS

A total of 87 articles were identified, of which 33 were selected for inclusion. Shock wave lithotripsy and ureteroscopy provided an excellent stone-free rate (86% to 90%) for stones less than 10 mm, whereas for larger stones ureteroscopy achieved better outcomes vs shock wave lithotripsy (67% vs 73%). Ureteroscopy was preferred over shock wave lithotripsy in patients with pregnancy or bleeding diathesis.

CONCLUSIONS

Ureteroscopy provides optimal stone clearance in patients with proximal ureteral calculi more than 10 mm. It is also recommended in patients with contraindications for shock wave lithotripsy. In patients with smaller stones (less than 10 mm) shock wave lithotripsy may be considered a reasonable alternative with outcomes similar to those of ureteroscopy.

Is the holmium:YAG laser the best intracorporeal lithotripter for the ureter? A 3-year retrospective study

PURPOSE

To study the efficiency and safety of holmium:YAG laser lithotripsy for ureteral stones.

PATIENTS AND METHODS

A series of 188 patients with 208 ureteral stones were treated with semirigid ureteroscopy and holmium:YAG laser lithotripsy from January 2003 to December 2005. Of the stones, 116 were lower ureteral, 37 middle ureteral, and 55 upper ureteral.

RESULTS

The success rate was 92.7% at the time of ureteroscopy and 96.7% at 3 months. The failures were secondary to retropulsion of the stones (3.3%). There were no perforations and one stricture. Stenting was done in 90% of patients.

CONCLUSIONS

The Holmium:YAG laser is an ideal intracorporeal lithotripter for ureteral calculi, with a high success rate and low morbidity.

Basket Design as a Factor in Retention and Release of Calculi in Vitro

PURPOSE

To compare stone retrieval and release from seven basket designs in vitro.

MATERIALS AND METHODS

We tested two tipped and one tipless NCompass models, three other tipless Nitinol designs (NCircle, Sur-Catch, and Dimension), and the Segura Hemisphere for their ability to retrieve and release single beads 8, 6, 5.6, and 5 mm diameter and multiple beads 3.6 mm diameter in both a ureteral and a caliceal model in three separate attempts.

RESULTS

In the ureteral model, all baskets were successful in retrieving all sizes of single beads. With multiple 3.6-mm beads, only the NCompass and Dimension designs were able to retrieve at least two of three beads in all attempts. With the exception of the Segura Hemisphere, all designs were successful in releasing all bead sizes. In the caliceal model, only the NCircle, Dimension, and tipless NCompass models were able to retrieve all bead sizes in 100% of the trials. The tipped NCompass and Hemisphere designs were unable to retrieve any beads in this model. The Sur-Catch basket was successful in the retrieval of large beads only. The Dimension articulating design was the only basket able to release all bead sizes in all attempts. The tipless NCompass basket did not release any of the beads once engaged.

CONCLUSION

Nitinol basket designs show excellent retrieval and release capabilities in the in-vitro ureteral model. The articulating Nitinol basket has the best stone-releasing capability of all baskets tested.

Holmium:YAG Lasertripsy with semirigid ureterorenoscope for upper-ureteral stones >2 cm

BACKGROUND AND PURPOSE

Shockwave lithotripsy (SWL) has a variable but low success rate for impacted stones of the upper ureter. Ureterorenoscopic stone manipulation is another option, the appropriateness of which decreases with increasing size of the stone. This report examines the feasibility and effectiveness of ureterorenoscopic holmium:YAG lasertripsy (URSL) for impacted upper-ureteral stone >2 cm.

PATIENTS AND METHODS

Twenty-six patients with impacted upper-ureteral stones >2 cm were treated with URSL using a 6/7.5F semirigid tapered ureterorenoscope and holmium:YAG laser under spinal anesthesia. Double-J ureteral stents were placed in all patients owing to the large stone burden and edema of the intraluminal mucosa. Success was defined as stone-free status on radiography at 1 month. Demographics, stone parameters, and outcomes were analyzed.

RESULTS

The retrograde accessibility rate of these stones was 96.2% (25 of 26). The stone-free rate achieved after one sitting was 84% (21 of 25). After an auxiliary treatment, the total stone free-rate reached 100%. In only one patient, who had a sharply angulated ureter, did access with the ureterorenoscope fail; this patient received open surgery. There were no intraoperative or postoperative complications.

CONCLUSIONS

Although 16% of patients need an auxiliary treatment, the holmium:YAG laser combined with a semirigid ureterorenoscope can be considered the first choice for large impacted upper-ureteral stones.

Effect of ureteral access sheath on stone-free rates in patients undergoing ureteroscopic management of renal calculi

OBJECTIVES

To evaluate the effect of ureteral access sheaths (UASs) on stone-free rates (SFRs) during ureteroscopic treatment of renal calculi. Several advantages of UASs during flexible ureteroscopy have been documented. However, no study has evaluated their impact on SFRs.

METHODS

We retrospectively reviewed all ureteroscopic cases for the management of renal stones performed at our Stone Center. Data were stratified according to the use or lack of use of the UAS. The groups were stratified by stone location within the kidney. Stone-free status was determined at 2 months postoperatively by either intravenous urography with tomograms or noncontrast renal computed tomography in patients with contrast allergies.

RESULTS

A total of 256 ureteroscopic procedures for the removal of renal calculi were performed between 1997 and 2003 (173 with UAS and 83 without). The groups were similar in age, sex, and stone burden. Stents were placed in nearly 80% of patients. The lower renal pole represented the most common presenting location. Stone displacement with a ureteroscopic basket for efficient fragmentation was necessary in 34%. The overall SFR in the UAS group and non-UAS group was 79% and 67%, respectively (P = 0.042). The SFRs were improved for calculi in all portions of the kidney.

CONCLUSIONS

In addition to facilitating ureteroscopic access, reducing costs, and lowering intrarenal pressures, the results of the current study suggest that UASs improve SFRs during the management of renal calculi. It is now our current practice to use the UAS routinely during ureteroscopic treatment of renal and upper ureteral calculi.

Therapeutic options for proximal ureter stone: Extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium: Yttrium-aluminum-garnet laser lithotripsy

OBJECTIVES

To compare the safety and cost-effectiveness of ureterorenoscopic holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy (URSL) with extracorporeal shock wave lithotripsy (ESWL) for proximal ureteral stones.

METHODS

This investigation assessed 220 patients with upper ureteral stones. Those in the ESWL group were treated on an outpatient basis using the Medispec Econolith 2000 (Medispec, Germantown, MD) under intravenous sedation. URSL was performed with a 6/7.5F semirigid tapered ureterorenoscope and holmium:YAG laser under spinal anesthesia on an inpatient basis. A successful outcome was defined as the patient being stone free on radiography 1 month after treatment. The stone size, success rate, postoperative complications, and cost were evaluated in each group.

RESULTS

A total of 220 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. The mean stone burden +/- SD was 58.7 +/- 3.1 mm2 in the ESWL group and 108.4 +/- 10.0 mm2 in the URSL group (P = 0.000). The accessibility of the semirigid ureterorenoscope for upper ureteral stones was 98.1% (101 of 103), and the stone-free rate achieved after one treatment was 83.2% (84 of 101). The initial stone-free rate of in situ ESWL was 63.9% (76 of 119). Significantly, the initial stone-free rate of the URSL group was superior to that of the ESWL group (P = 0.001). The average cost in the URSL group appeared to be lower than that in the ESWL group (P = 0.000).

CONCLUSIONS

The results of this study have demonstrated that URSL achieved excellent results for upper ureter calculi. In terms of cost and effectiveness, this procedure should be the first-line therapy for proximal ureter stones.

Safety and Efficacy of Ureteroscopic Lithotripsy for Ureteral Calculi Under Sedoanalgesia – A Prospective Study

OBJECTIVE

To establish the safety and efficacy of ureteroscopic lithotripsy (URSL) under sedoanalgesia.

PATIENTS AND METHODS

This study was conducted at Department of Urology (Banaras Hindu University, India) among 124 patients with ureteral stones, between July 2000 and August 2003. Majority of the patients (59.68%) presented with lower ureteric calculi, 24.19% presented with upper ureteric calculi and 16.13% had middle ureteric calculi. All patients were given injection diclofenac sodium (75 mg) promethazine hydrochloride (12.5 mg) deep intramuscular 30 minutes the before procedure. Injection midazolam 0.03 mg/kg body weight slowly given intravenously immediately before the procedure for achieving sedation. Injection fentanyl 50 mcg intravenously given slowly just before introducing the ureteroscope into ureter for achieving intravenous analgesia. Patients were observed for few hours after completion of procedure and oral questions were asked as per proforma, which included tolerance, intensity of pain and percentage of pain experienced by the patients. Patients were discharged thereafter.

RESULTS

87.10% of patients opined that the procedure was acceptable. Only 4.84% opined this procedure was painful. According to present pain intensity score (PPI) in this study 79.03 patients experienced only mild pain, 11.29% cases rated procedure as discomforting, 6.45 rated procedure as distressing and only 3.23% rated as horrible procedure. As per visual analogue scale for assessment of pain 80.65 of cases rated only 20% pain score (in a scale of 0-100). 9.68% cases rated 30% and 6.45% rated 50%. Only two patients in middle ureteric group rated 100% pain. Overall success rate in fragmenting stone was 91.94, where as for lower ureteric calculi it was 97.30%; for upper and, middle ureteric calculi it was 86.66% and 80%, respectively.

CONCLUSION

Ureteroscopic lithotripsy can be performed on day care basis under sedoanalgesia which is fairly tolerated by the patients with unremarkable complications and difficulty.

Mode of presentation and first line of management of non-recurrent urolithiasis in Kuwait

AIMS

To determine the incidence, mode of presentation, first line of management and composition of non-recurrent urolithiasis in Kuwait.

METHODS

Consecutive patients admitted between January 1999 and December 2002 with non-recurrent urolithiasis were prospectively analyzed.

RESULTS

The average annual incidence of hospital admission for non-recurrent urolithiasis in Kuwait was 43.44 per 100,000 population, representing men and women (ratio, 9:1) with a median age of 41.91 years. Of the hospital admissions for non-recurrent urolithiasis, 57.2% of cases were acute. Overall, the most predominant symptom was flank pain, while the least common symptom was acute urinary retention. Ureteroscopic stone manipulation was the most common initial treatment modality in the present series, as it was utilized in 43.3% and 37.09% for patients admitted on elective and emergency basis, respectively. Of the calculi available for chemical analysis, 91% contained calcium, 73% contained calcium oxalate, 17% contained mixed calcium and 1% contained calcium phosphate. The composition of the rest of the stones were urate in 7%, struvite in 1% and cystine in 1%.

CONCLUSIONS

Urolithiasis is a common disease in the Kuwait region that mainly presents with flank pain. Ureteroscopic calculus removal is the most common modality of treatment. The majority of the calculi seen in Kuwait contained calcium.

Assessment of Novel Ureteral Occlusion Device and Comparison with Stone Cone in Prevention of Stone Fragment Migration during Lithotripsy

PURPOSE

To present the initial ex-vivo results of a new ureteral-occlusion device (Cook Urological, Spencer, IN) for preventing the retrograde migration of particles during ureteroscopy and its comparison with the Stone Cone (Microvasive-Boston Scientific Corp., Spencer, IN).

MATERIALS AND METHODS

We designed an ex-vivo model using a porcine kidney with an intact ureter. Standardized plastic beads were placed in the proximal ureter. Each device was deployed proximal to the beads during ureteroscopy, and the number of beads impeded by each device was recorded.

RESULTS

The new device was successful at preventing retrograde migration of beads > or = 1.5 mm. Furthermore, 1.0-mm beads were impeded by the center of the device, although they passed through the periphery. The Stone Cone blocked the retrograde migration of beads > or = 2.5 mm.

CONCLUSION

The new occlusion device was efficacious in an ex-vivo model. It appears to prevent the migration of smaller particles than are blocked by the Stone Cone.

Extracorporeal Shockwave Lithotripsy Compared with Ureteroscopy for the Removal of Small Distal Ureteral Stones

INTRODUCTION

The treatment of small distal ureteral stones smaller or equal to 5 mm in size is still highly controversial. In distal ureteral stones larger than 5 mm in size, ureteroscopy (URS) has been shown in many studies to be superior to shockwave lithotripsy (SWL). The objective was to analyze the stone-free rate after treatment of distal ureteral stones with in situ SWL or URS.

MATERIALS AND METHODS

A total of 3,857 SWL treatments were performed at our institution between 1996 and 2001. During this period 45 in situ SWL procedures were performed with the Dornier MFL 5000 lithotripter on distal ureteral stones regardless of the stone size. A total of 262 URS treatments were performed on distal ureteral stones. URS for small (5 mm or less) distal ureteral stones was performed in 110 cases.

RESULTS

Distal ureteral stones smaller or equal to 5 mm in size were treated successfully stone free in 78% in one SWL session. Patients required a second SWL in 14% of the cases and 8% of the patients required a third SWL session. URS patients were successfully stone free after the procedure in 97% of the cases. Failed URS that needed an additional URS were performed in 2 and 1% of the patients had one SWL in situ treatment.

CONCLUSIONS

URS treatment has shown to be the therapy of choice for distal ureteral stones. It is more effective than SWL treatment in this stone location. In experienced hands URS is a safe though even more invasive procedure than SWL. This can be expected as urologists perform more than 40 URS procedures per year.

Management of ureteric stones

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.

[Ureteroscopy under intravenous analgesia with remifentanil]

In a prospective study, from September 2000 to September 2001, all ureteroscopies ( n=140) were performed under local and intravenous patient controlled analgesia using continuous infusion of remifentanil (Ultiva). The dosage of 0.15 micro g/kg/min was adapted to changing intraoperative pain (range 0.08-0.30 micro g/kg/min). Preoperative sedation with midazolam 2 mg was given 5 min prior to ureteroscopy. The efficacy of monitored anesthesia care ("Big MAC") was quantified by the patient using a visual analogue pain scale. A total of 97.1% (136/140) of the procedures were performed and finished under remifentanil. Only four male patients underwent conversion to general anesthesia due to insufficient analgesia. All but one patient would choose remifentanil again for first line anesthesia. Significant differences in pain scale values were noticed for male/female patients and ureteroscopies above/below the iliac vessel crossing. Side effects were rare being mainly hypoxic events (pO(2)<90% in 5.1%). Indication, intraoperative procedure, average surgery time (24 min), complications and primary success rate (96.6/90/63.3% stone free for distal/mid/proximal ureter, respectively) did not differ from the control group under general anesthesia. Ureteroscopies with remifentanil are safe, universally applicable because of refifentanil's organ independent esterase metabolism and as effective as general anesthesia. There is no need for PACU stay for patients due to the ultra-short drug half-life, and therefore remifentanil is cost effective and perfect in an outpatient setting.

[The frequency-doubled double-pulse Neodym:YAG laser lithotripter (FREDDY) in lithotripsy of urinary stones. First clinical experience]

Laser lithotripsy does not play an important role in urinary stone treatment, mostly due to ineffective fragmentation efficiency, and high purchase and maintenance costs. The aim of the following retrospective study was to show the clinical significance and efficiency of an innovative laser lithotripsy system for urinary stone treatment. Between November 1998 and October 1999, 48 patients were treated with the innovative frequency- doubled double-pulse Neodym: YAG laser lithotripter FREDDY. A total of 50 renal units were treated, 43 ureteroscopically, four ureterorenoscopically, three percutaneous-nephroscopically, and one bladder stone cystoscopically. With a median laser operation time of 5 min (range: 1-30 min) and a total procedure duration of 60 min (range: 15-180 min), a stone-free rate of upper ureteral stones of 62%, middle ureteral stones of 91% and distal ureteral stones of 100% were documented on the first day after treatment. In an observation period of 6 months, no complications were seen. In our experience Laser lithotripsy with FREDDY is an effective, simple and reliable method for the treatment of ureteral stones, with low purchase and maintenance costs. The extremely thin and highly flexible quartz fibre may extend the endoscopic spectrum to otherwise poorly accessible upper ureteral stones, the renal pelvis and renal calix stones. Therefore, a prospective validation study for comparison with ballistic lithotriptors is of great interest.

Current management of urolithiasis: progress or regress?

PURPOSE

To assess the impact of the development of less powerful second- and third-generation shockwave lithotripters on surgical stone therapy in light of recent advances in ureteroscopy and laser lithotripsy. As such, we sought to identify current trends in the treatment of stone disease, both at our university medical center and nationally, and to contrast them with the corresponding data from 1990.

PATIENTS AND METHODS

All urolithiasis procedures (ureteroscopy, SWL, open surgery, and percutaneous stone removal) performed in 1998 were compared with all urolithiasis procedures performed 8 years earlier (1990) at a single institution (Washington University, St. Louis). In addition, Medicare data for each year from 1988 through 2000 were collected from the Health Care Financing Administration to assess the national trends for open stone surgery, ureteroscopic stone removal, SWL, and percutaneous nephrolithotomy.

RESULTS

At Washington University, the number of percutaneous stone removals remained stable; however, the overall number of ureteroscopies increased by 53%, while the number of SWLs, decreased by 15%. The Medicare data likewise reflect a marked decrease in open stone surgery and a marked increase in ureteroscopic stone surgery with a slight increase in SWL. Utilization of percutaneous nephrolithotomy remained unchanged.

CONCLUSIONS

We believe this trend toward ureteroscopy is attributable to several factors: improved, smaller rigid and flexible ureteroscopes; the availability of more effective intracorporeal lithotripters (e.g., pneumatic and holmium laser), and the lack of development of lower cost, more effective SWL. This is an unfortunate trend, as we are moving away from the noninvasive treatment that was the hallmark of urolithiasis therapy at the beginning of the last decade toward more invasive endoscopic therapy. Increased research efforts in SWL technology are sorely needed.

Transureteral lithotripsy in pediatric practice

PURPOSE

The present study reviews ureteroscopy intervention for the treatment of ureteral stones in pediatric patients in the last 6 years at three institutions in Iran.

PATIENTS AND METHODS

Sixty-six ureteroscopies were performed in 66 prepubertal patients (mean age 9 years; range 2-15 years) with a male/female ratio of 31/35. Ultrasonography, plain film, or intravenous urography was performed in all cases. The mean stone size was 8 mm (range 5-15 mm). All the interventions were performed under general anesthesia with semirigid ureteroscopes of 8F to 11.5F. The stone was located in the left ureter in 32 patients and in the right in 34 patients. Stones were located in the distal ureter in 59 patients, in the midureter in 5, and in the proximal ureter in 2. Before ureteroscopy, ureteral dilatation with a balloon was done to 12F if necessary. If the calculus could not be removed with the basket (stone.8 mm), lithotripsy using ultrasonic, electrohydraulic (EHL), or pneumatic equipment was performed.

RESULTS

Ureteroscopy with an 11.5F, 9F, 8.5F, or 8F ureteroscope were performed in 26, 14, 5, and 21 patients, respectively, and ureteral dilatation was necessary in 23, 0, 0, and 2 cases, respectively. We were unable to introduce the ureteroscope into the ureter in three patients (two boys with an 11.5F ureteroscope and one girl with an 8.5F ureteroscope) with distal ureteral stones. The stones moved to the kidney in four patients. Stone management was with basketing alone in 14, EHL in 3, ultrasonic lithotripsy in 8, and ballistic lithotripsy in 34 patients. The stone-free rate was 88% (58 patients) at 48 hours postprocedure. The complication rate was 23% and included renal colic (1), gross hematuria (11), and pyelonephritis (3). No patient had obvious perforation or stricture of the ureter at 3-month follow-up.

CONCLUSION

Our series demonstrates the high success rate that can be achieved with ureteroscopic removal of ureteral calculi in children. Ureteroscopic treatment, especially with a small-caliber ureteroscope, should be considered the first choice for treatment of calculi in the distal ureter in children.

Ureteropyeloscopic treatment of ureteral and intrarenal calculi

Endoscopic lithotripsy is an essential part of the armamentarium at any complete stone treatment center. It is first-line therapy for complicated upper urinary tract calculi and for patients who fail primary extracorporeal shock wave lithotripsy. In the presented series, ureteroscopy is defined as a safe and particularly effective treatment for upper urinary tract calculi. Endoscope miniaturization, the Holmium laser, and refined surgical technique have positive results. Complications are less frequent today, even with in the most complex large stone burdens being addressed in a retrograde ureteroscopic way.