A 10-year experience of managing ureteric calculi: changing trends towards endourological intervention--is there a role for open surgery?

Access and Fluoroscopy Time Difference in Patients Undergoing Prone Percutaneous Nephrolithotomy (PCNL) With Ureteric Catheter Placement in Supine Versus Lithotomy Position

Objective: To compare the operative and fluoroscopy time in two different methods of ureteral stent insertion before prone percutaneous nephrolithotomy (PCNL).

Materials and method: Over 12 months, 124 patients with urolithiasis who went through prone PCNL were included in our study. All the patients had kidney stones and were divided into two groups based on the method of ureteral catheter insertion. This was done with the help of flexible or rigid cystoscopy in to group A and group B, respectively. Both groups had an equal number of patients, i.e., 62. The main outcome variables assessed were access time (from intubation to placement of access sheath) and fluoroscopy time during access.

Results: The categorical variables (age, gender, site of the stone) between the two groups were comparable. The access time in groups A and B were 48±4.30 and 77±10 minutes, respectively. The fluoroscopy times in groups A and B were 52±14.63 and 116±47.77 seconds, respectively. A statistically significant difference (p-value < 0.05) was observed for both the access and fluoroscopy time. None of the patients in either of the groups had a misplaced ureteral catheter requiring repositioning.

Conclusion: Flexible cystoscope-assisted insertion of ureteral catheter prior to PCNL significantly reduces operative time, fluoroscopy time, and consequently radiation exposure during PCNL.

Should ureteroscopy be performed for patients after ureteral reconstruction with autologous onlay flap/graft?

Background

To analyze the safety and clinical significance of performing ureteroscopy after ureteral reconstruction with autologous onlay/graft. To describe the ureteroscopic appearances of the appendiceal onlay flap and lingual mucosa graft.

Methods

Beginning in August 2018, we conducted a prospective cohort study of autologous onlay/graft techniques to repair ureteral strictures. The perioperative data of 42 patients who had undergone surgery more than 6 months prior were collected prospectively. During the postoperative follow-up, ureteroscopy was performed in 27 patients (64.3%) after surgery (group A), and ureteroscopy was not performed in the other 15 patients (35.7%) (group B). We carried out a comparative study of these two groups of patients. Analyses were conducted mainly on complications related to ureteroscopy and the success rate of ureteral reconstruction surgery.

Results

There were no significant differences in patient demographic data or the length of ureteral reconstruction between the two groups (P>0.05). For the ureteroscopy group, the median time from repair surgery to ureteroscopy was 3 (range, 2-7) months, there was no poor healing of the anastomosis, and the ureteral lumen of all patients was unobstructed. Some expected observations can be found in the ureteral lumen, such as mucosa edema, stones, follicles and granulation tissue. Among the 27 patients, one patient (3.7%) developed bleeding intraoperatively and 7 patients (25.9%) were found to have low-grade (Clavien-Dindo I and II) postoperative complications, including 5 cases of fever and 2 cases of bleeding. The mean follow-up times of patients in group A and group B were 16.7±6.4 and 19.0±10.1 months, respectively. The objective success (imaging showed hydronephrosis ease) rate of the two groups was 100%. The subjective success (symptom relief) rates of group A and group B were 96.3% and 100%, respectively.

Conclusions

Patients after autologous onlay flap/graft ureteroplasty do not need to undergo routine ureteroscopy unless there is aggravation of hydronephrosis or other indications for ureteroscopy, such as stones.

The Effect of Ureteric Stenting on Female Sexual Function: A Prospective Cohort Study

Background and objective Urolithiasis is a highly prevalent disease worldwide, with Pakistan belonging to the stone belt of Asia. The usage of the double J (DJ) stent is highly effective when it comes to the management of urolithiasis. However, studies investigating the side effects of DJ stent placement on sexual function in individuals are scarce. In this study, we aimed to assess the impact of DJ stent placement on sexual function in women. Methods After obtaining ethical approval, a prospective study was conducted at a university hospital from June 2018 to September 2019. All sexually active women requiring semi-rigid ureteroscopy (URS) or flexible URS [retrograde intrarenal surgery (RIRS)] were enrolled. Women with DJ stent placement (Group A) were compared to women who did not require DJ stent (Group B). The outcome variable was to assess temporary sexual dysfunction after DJ stent placement using the standardized Female Sexual Functionality Index (FSFI) in English or its validated vernacular version. The FSFI was completed at four weeks, and again at three months, following URS/RIRS. Results Of the 106 sexually active women initially included in the study, 69 were found to be eligible for final analysis. In Group A, the mean FSFI score at the initial presentation was 31.54 ±4.37. The mean FSFI score at four weeks was lower compared to the baseline score (0 time): 13.96 ±5.5 (p<0.05). At three months, the mean FSFI score returned to near baseline at 32.053 ±5.35 with no significant difference (p=0.65). In comparison to women in Group B, the mean FSFI score at four weeks was significantly lower in Group A (28.87 ±6.59 vs. 13.96 ±5.49; p<0.05). However, there was no significant difference between the mean FSFI scores at any of the three time points within Group B. Conclusion DJ stent insertion results in transient postoperative sexual dysfunction in women, which resolves spontaneously within a span of three months after stent removal.

Current scenario of endourological treatment of kidney stones in brazil: results of a national survey

Objective:

To elucidate the current scenario of endourology in Brazil for the treatment of urinary lithiasis, with an emphasis on regional differences and the reasons why certain techniques are still underutilized.

Materials and Methods:

An electronic questionnaire was sent by email to the 4,745 members of the Brazilian Urological Society (BSU) in 2016 to collect information on the 3 main endourological procedures used in the treatment of nephrolithiasis: Semi-rigid ureteroscopy (URS), Flexible ureteroscopy (F-URS) and percutaneous nephrolithotripsy (PCNL).

Results:

A total of 1,267 urologists answered the questionnaire. It was observed that the vast majority perform URS (95.6%), while 80.2% perform F-URS and only 72.1% perform PCNL. Regarding the surgical volume, most perform up to 10 procedures per month (73.4% to 88.2%) and the main impediment was the lack of patients with the pathology (42.1% to 67.7%). The lack of equipment or hospital infrastructure was one of the main limiting factors for rigid (23%) and flexible (38.1%) URS, mainly in the North and Northeast regions of the country. Regarding PCNL, most of them reported lack of practical experience in the method (29.9%). Finally, most urologists expressed interest in taking courses in endourology.

Conclusion:

Ureteroscopy, rigid or flexible, is already well established in the country, requiring the direction of more resources for its practice, especially in less developed regions. Regarding PCNL a significant part of Brazilian urologists still lack practical experience in this procedure, emphasizing the need for greater investment in teaching this technique.

Endoscopic Management of Ureteric Stones: Our Initial Experience

Aims:

The aim of this study is to present our initial experience with intracorporeal pneumatic ureterolithotripsy highlighting the pattern of patients’ clinical presentation, techniques, and limitation of the procedure.

Materials and Methods:

This is a retrospective study of cases of ureteric stones managed over a period of 18 months in a private hospital. Data obtained include patients’ sociodemography, clinical presentation, stone burden, procedural technique, complication, and need for a secondary procedure. Data were analyzed using the Statistical Package for the Social Sciences version 21.

Results:

The total number of patients managed was 20 with an age range of 28–75 years and a mean of 48.2 ± 12.4 years. Majority of them, i.e., 11 (55%) were middle aged. Female gender was more predominant, 11 (55%). Flank pain was the most common mode of presentation. Right-sided stone occurred in 9 (45%), left sided in 7 (35%), and bilateral in 4 (20%). Stone location was in the upper ureter in 4 (16.7%), mid-ureter in 7 (29.2%), and lower ureter in 13 (54.2%). The stone size ranged from 6 to 18 mm with a mean of 9.7 ± 2.5 mm. Four patients (20%) required initial bilateral ureteric stenting before definitive procedure to allow for recovery from sepsis and/or nephropathy. All patients had double-J stenting and were discharged 2 days after the procedure. The procedure was successful in 19 (95%) with 100% stone clearance rate and complete resolution of symptom without any complication. One patient (5%) had a very hard upper ureteric stone which retropulsed into the renal pelvis requiring open nephrolithotomy.

Conclusion:

Endoscopic treatment of ureteric stone with intracorporeal pneumatic lithotripsy is a safe and effective treatment modality. It is, however, limited in the management of hard upper ureteric stone, especially those that are close to the pelviureteric junction due to the risk of retropulsion of the stone into the kidney.

Do Preoperative Alpha Blockers Facilitate Ureteroscope Insertion at the Vesico-Ureteric Junction? An Answer from a Prospective Case-Controlled Study

Objective: To evaluate whether alpha blockers facilitate the navigation of the ureteroscope through the ureteric orifice, if administered preoperatively, based on the role of alpha blockers, mainly tamsulosin, in medical expulsive therapy of ureteric calculus. Methods: A prospective, case-control study of 174 patients who underwent ureteroscopic stone removal for lower or mid ureteral calculi between November 2014 and March 2016 was carried out. We included patients >14 years of age who were planned for ureteroscopic stone removal. We divided the patients into two groups, including those who were not prescribed alpha blockers prior to surgery (Group A: no alpha blocker) and those patients who were started on alpha blockers, tamsulosin 0.4 mg, 3 days prior to surgery (Group B: alpha blocker). We excluded patients with stone size >1 cm, spontaneous stone passage prior to surgery, unable to perform ureteroscopy (URS), and previous history of ureteroscopic intervention. Results: Our study included 124 patients, among whom 60 patients were prescribed alpha blockers preoperatively (Group B). The mean age of the study population was 37.62+9.74 (15–64 years) and the mean stone burden was 38.92+8.21 (15.94–58.12 mm2). The difference in rate of ureteroscope negotiation through the ureteric orifice between Groups A and B was not statistically significant (p=0.57). Conclusions: In URS, preoperative administration of alpha blockers failed to improve technical ease and lower complication rate. Further large group, multi-centre studies are required todiscover a definitive role of alpha blockers prior to URS.

The truth about laser fiber diameters

OBJECTIVE

To measure the various diameters of laser fibers from various manufacturers and compare them with the advertised diameter.

METHODS

Fourteen different unused laser fibers from 6 leading manufacturers with advertised diameters of 200, 270, 272, 273, 365, and 400 μm were measured by light microscopy. The outer diameter (including the fiber coating, cladding, and core), cladding diameter (including the cladding and the fiber core), and core diameter were measured. Industry representatives of the manufacturers were interviewed about the diameter of their fibers.

RESULTS

For all fibers, the outer and cladding diameters differed significantly from the advertised diameter (P <.00001). The outer diameter, which is of most practical relevance for urologists, exhibited a median increase of 87.3% (range, 50.7%-116.7%). The outer, cladding, and core diameters of fibers with equivalent advertised diameters differed by up to 180, 100, and 78 μm, respectively. Some 200-μm fibers had larger outer diameters than the 270- to 273-μm fibers. All packaging material and all laser fibers lacked clear and precise fiber diameter information labels. Of 12 representatives interviewed, 8, 3, and 1 considered the advertised diameter to be the outer, the cladding, and the core diameter, respectively. Representatives within the same company frequently gave different answers.

CONCLUSION

This study suggests that, at present, there is a lack of uniformity between laser fiber manufacturers, and most of the information conveyed to urologists regarding laser fiber diameter may be incorrect. Because fibers larger than the advertised laser fibers are known to influence key interventional parameters, this misinformation can have surgical repercussions.

Training the resident in percutaneous nephrolithotomy

Objective

From the trainers’ perspective percutaneous nephrolithotomy (PCNL) is one of the most challenging endourological procedures. In this review we examine the problems arising when training residents in PCNL, and how to facilitate this process.

Methods

The recommendations are derived from discussions and consensus during the First European Urolithiasis Society (EULIS) meeting held in London in September 2011. In addition, we searched Medline for articles identified using the keywords ‘training’, ‘percutaneous surgery’, ‘renal calculi’, ‘PCNL’, ‘virtual reality’ and ‘simulators’. We also assessed the effect of modern technology, including the availability of virtual reality models vs. operating room training, and how international organisations like EULIS and European Urological Association can help.

Results

The difficulty of training residents in PCNL is partly due to the complexity of obtaining a safe access to the kidney for lithotripsy. The most common way of obtaining access is guided by imaging only, and usually only fluoroscopic imaging is available. This has the potential for injuring structures from the skin to the renal capsule. Minor vascular injuries are relatively common, although most are self-limiting. Visceral injuries that are particularly important are pleural and less commonly colonic injuries, but they are more complex and often require additional procedures.

Conclusions

Teaching the skills is more challenging than performing PCNL. In most urological training programmes it is difficult to incorporate teaching and training skills when performing PCNL. To train an academic stone doctor, proficiency in the safe conduct of PCNL is mandatory.

Impact of preoperative ureteral stenting on stone-free rates of ureteroscopy for nephroureterolithiasis: a matched-paired analysis of 286 patients

OBJECTIVE

To determine the effect of preoperative ureteral stenting on success rates of ureteroscopy (URS) for nephroureterolithiasis.

MATERIALS AND METHODS

We retrospectively evaluated patients who underwent URS for nephroureterolithiasis without preoperative indwelling ureteral stents. These patients were matched according to age, sex, body mass index, and stone side, size, site, and number of stones per patient, with patients who had been prestented before URS. Patient data, stone-free rates (SFRs), and complications were compared.

RESULTS

The study included 286 patients (143 stented vs 143 nonstented). The mean stone size was 5.69 ± 3 mm. The mean number of stones per patient was 1.35 ± 0.7. The overall SFR after 1 URS procedure was 90.9% and higher in prestented than in nonstented patients (95.1% vs 86.7%, P ≤ .013). For ureteral stones, the SFR was 99% in prestented and 90% in nonstented patients (P ≤ .0048). The SFR did not differ between the groups for ureteral stones <5 mm, but was higher in prestented than in nonstented patients for ureteral calculi ≥ 5 mm (98.2% vs 83.3%, P ≤ .0105). For urinary calculi ≥ 5 mm, the overall SFR was higher in prestented than in nonstented patients (93.3 vs 78.3%, P ≤ .0054). Perioperative complications occurred in 27 patients (9.4%; Clavien I, 6.6%; Clavien IIIb, 2.8%) without differences between the groups.

CONCLUSION

URS is a safe and efficacious procedure for the treatment of nephroureterolithiasis. Preoperative ureteral stent placement is associated with higher SFRs compared with nonstented patients for urinary calculi ≥ 5 mm. Nonstented patients with urinary calculi ≥ 5 mm should be informed about the risk for a second-look URS procedure.

Complications and outcomes following extracorporeal shock wave lithotripsy: a prospective study of 3,241 patients

Extracorporeal shock wave lithotripsy (SWL) has become the least invasive treatment modality with high success rates for urinary calculi; however, its established efficacy has been associated with a number of side effects and complications. This study sought to further evaluate the incidence rate and management of the post-SWL complications and also the efficiency of procedure in a large scale of patients. During a 51-month period, 3,241 consecutive adult patients with the mean age of 38.1 years (range 15-75) and urinary calculi (>or=4 mm) underwent SWL at our referral center and were followed for 3 months prospectively. Overall, 3,614 stones [kidneys (83.5%), ureters (15.8%) and bladder (0.7%)] in 3,241 patients were treated requiring 7,245 SWL sessions. Stone-free state occurred in 71.5% calculi and success rate in 79.8% patients. The re-treatment was necessary in 37.2% patients. Auxiliary procedure and efficiency quotient were 5.6% and 0.50, respectively. SWL success rate decreased as the stone size increased (P < 0.0001). The stone-free rate was correlated with the location of the stone. During the study period, 4,075 complications occurred in our patients. Colicky pain (40%) was the most frequent symptom followed by gross hematuria (32%) and steinstrasse (24.2%). Symptomatic bacteriuria developed in 9.7% patients; Escherichia coli (30.4%) was the most causative organism. In conclusion, the complication rate following SWL was high in our study; however, the majority was mild and managed conservatively or with the minimal intervention. Moreover, the management of urinary calculi in adults using SWL was proved to be safe and efficient, particularly for ureteral stones <10 mm, renal pelvic stones <20 mm, and bladder stones <30 mm.

Comparison of systemic stress responses between percutaneous nephrolithotomy (PCNL) and open nephrolithotomy

BACKGROUND AND PURPOSE

Stimulation of patient's immune response and therefore increasing inflammatory indices in patients who underwent invasive treatment methods for kidney stone removing can be predictable. In the present study, we tried to evaluate the differences of inflammatory indices in percutaneous nephrolithotomy (PCNL) and compared them with open stone surgery in patients with kidney stones.

PATIENTS AND METHODS

In a clinical trial study, 15 adult patients that scheduled to undergo PCNL and 15 patients who were candidate for open stone surgery matched for sex and age were included. Body temperature and concentrations of white blood cell, hemoglobin, C-reactive protein, interleukin-6, 24-hour urine cortisol levels, fibrinogen, TNF-alpha, and total antioxidant status (TAS) were measured. Pain severity was also measured on the basis of verbal rating scale (VRS). All measurements were recorded immediately before and 24 hours after operation.

RESULTS

Patients that underwent open surgery had more severe pain than PCNL group (P = 0.001). Postoperative fever in the first group was more prevalent than other group (P = 0.020). Also, surgery time (P < 0.001), and total length of stay in hospital (P < 0.001) were higher in open surgery group. Differences rate of white blood cell (P = 0.003), C-reactive protein (P = 0.005), 24-hour urine cortisol level at 24 and 48 hours after open surgery were significantly more than PCNL (P = 0.02, P = 0.048, respectively).

CONCLUSION

According to the higher postoperative complications and patient's inflammatory response in open stone surgery in comparison with PCNL, stone removing by PCNL has lower impact in terms of stress response in comparison to open surgery to the treatment of kidney stones.

[Diagnosis and therapy of acute ureteral colic]

Acute ureteral colic presents with a complex of acute and characteristic flank pain that usually indicates the presence of a stone in the urinary tract. Diagnosis and management of renal colic have undergone considerable evolution and advancement in recent years. The application of noncontrast helical computed tomography (CT) in patients with suspected ureteral colic is one major advance in the primary diagnostic process. The superior sensitivity and specificity of helical CT allow ureterolithiasis to be diagnosed without the potential side effects of contrast media. Initial management is based on three key concepts: (A) rational and fast diagnostic process (B) effective pain control (C) and understanding of the impact of stone location and size on the natural course of the disease and definitive urologic management. These concepts are discussed in this review with reference to contemporary literature.

A randomized clinical trial of lidocaine jelly for prevention of inadvertent retrograde stone migration during pneumatic lithotripsy of ureteral stone

PURPOSE

We studied the efficacy of lidocaine jelly instillation proximal to the ureteral stone during intracorporeal lithotripsy using a semirigid ureteroscope for the prevention of retrograde migration and improvement in stone-free rate.

MATERIALS AND METHODS

From November 2006 to September 2007, 50 patients with 5 to 18 mm ureteral stones undergoing ureteroscopic removal using pneumatic lithotripsy were randomized into 2 groups. Group 1 (25 patients) had lidocaine jelly instilled proximal to the stone before and after fragmentation, and group 2 was the control group (25 patients). Ureteroscopy was performed using an 8 or 6.4Fr semirigid ureteroscope. A 5Fr ureteral stent was advanced beyond the stone. Lidocaine jelly (2 ml) was instilled and lithotripsy was performed with a Swiss LithoClast . A 5Fr ureteral catheter was left in place for 24 hours. Patients were followed at 24 hours with plain x-ray of the kidneys, ureters and bladder, and at 2 weeks with noncontrast enhanced computerized tomography of the kidneys, ureters and bladder.

RESULTS

The 2 groups were comparable with regard to age and stone size. Stone or stone fragment migration occurred in 4% and 28% of patients in groups 1 and 2, respectively, and this difference was statistically significant (p = 0.002). At 2 weeks followup with imaging the stone-free rate was 96% and 72% in groups 1 and 2, respectively, and this difference was also statistically significant (p = 0.045). Although the mean operative time was slightly longer in the treatment group (33.56 +/- 13 vs 35.84 +/- 12.5 minutes) the difference was not significant (p = 0.450).

CONCLUSIONS

Lidocaine jelly instillation proximal to ureteral calculi during lithotripsy is an effective method of preventing retrograde stone displacement as well as significantly improving the stone-free rate.

Rigid ureteroscopy for ureteral stones: factors associated with intraoperative adverse events

PURPOSE

To analyze some of the factors that may be associated with a higher incidence of complications during management of ureteral stones by rigid ureteroscopy.

PATIENTS AND METHODS

We reviewed all ureteroscopic interventions aimed at stone extraction and/or fragmentation in our institution from 2001 through 2005. A total of 442 interventions were eligible for inclusion. Our focus was concentrated on (1) patient characteristics (age, gender, duration of symptoms, history of urinary schistosomiasis, and history of surgery involving the affected ureter), (2) stone characteristics (number, length, width, and level of the ureter affected), (3) the affected reno-ureteral unit (which side was affected, the kidney's ability to excrete contrast medium, and the status of the ureter proximal and distal to the stone), and finally (4) experience level of the surgeon in charge (junior v senior). The occurrence of intraoperative adverse events was considered a dependent variable and was statistically related to each of the above factors as independent variables.

RESULTS

Intraoperative adverse events were encountered in 121 interventions including stone migration in 54, minor mucosal injuries in 24, ureteral perforation in 12, ureteral avulsion in 2, and aborted procedure due to bleeding or edema in 29. Symptomatology present for more than 3 months, a negative history of schistosomiasis, a positive history of ureteral surgery, stones above the ischial spines, stones >5 mm in width, a dilated proximal ureter, kidneys that failed to excrete contrast medium, and involvement of a more junior urologist were factors that were associated with a statistically significantly higher incidence of intraoperative complications.

CONCLUSIONS

Rigid ureteroscopic stone manipulation remains a procedure that should be handled cautiously. Existence of any of the above risk factors should alert urologists, particularly at training centers, to adopt all possible precautionary measures.

How efficient is extracorporeal shockwave lithotripsy with modern lithotripters for removal of ureteral stones?

PURPOSE

To analyze results of extracorporeal shockwave lithotripsy (SWL) for treatment of ureteral stones with two modern lithotripters.

PATIENTS AND METHODS

A consecutive series of 598 patients with ureteral stones was treated with the Modulith SLX Classic and Modulith SLX-F2 lithotripters. The mean (SD) age of the patients was 54 (17) years, and the mean (SD) stone surface area was 42 (34) mm2. Results were available for 580 patients.

RESULTS

Stone-free ureters were recorded in 563 (97.1%) patients. Stone-free rates were 96.1%, 97.8%, and 97.9%, for the proximal, middle, and distal ureter, respectively. The average number of SWL sessions needed was 1.31. For the proximal, middle, and distal ureter, one SWL session was sufficient in 73.1%, 66.7%, and 83.2% of patients, respectively. Assisting auxiliary procedures were used in 102 patients (18%). The total mean (SD) treatment time was 48 (26) minutes and the mean (SD) number of shockwaves was 3266 (2258). SWL for stones located in the proximal, middle, and distal ureter was carried out in the prone position in 38%, 88%, and 9%, respectively. For 90 patients primarily treated with a large focus, the re-treatment rate was the same as for patients treated with a standard focus. A stone treatment index used to assess the efforts, results, and complications was similar for the two lithotripters and for all stone locations. Thus both lithotripters had similar efficacy.

CONCLUSION

With consistent use of SWL, a stone-free rate of more than 97% can be attained, with a reasonable re-treatment rate and only modest use of assisting auxiliary procedures.

A retrospective study of ureteroscopy performed at the sultan qaboos hospital, salalah from august 2001 -august 2006

In the modern era of management of disorders of the upper urinary tract, ureteroscopy forms an important part in the armamentarium for the diagnosis and treatment of a variety of disorders that occur in the upper urinary tracts. The modern ureteroscopes have better vision and are less traumatic, making ureteroscopy a relatively safe procedure. Major complications are rare. An audit of a total of 128 ureteroscopies done in the Department of Urology over a six year period from August 2001 till August 2006 at the Sultan Qaboos Hospital, Salalah, was undertaken. The results are discussed in detail and compared with results from other centers. The management of a rare but dreaded major complication is discussed in detail.

Shock wave lithotripsy is effective and safe for distal ureteral calculi in children

We evaluated the effectiveness of the Siemens Lithostar Modularis lithotriptor for the management of distal ureteric calculi in children. Between 2004 and 2006, 29 children with distal ureteric calculi were treated in our stone center with the Siemens Lithostar Modularis (Siemens Medical Solutions, Inc.) Effectiveness of lithotripsy, retreatment and efficacy quotient rates, and complications were assessed. The series consisted of 18 (62%) boys and 11 (38%) girls with an age range of 1-13 years (average age 7.0 +/- 3.5). Under fluoroscopic guidance, children were treated with a maximum 3,000 shocks at an average of 2.2 +/- 0.3 kV. Mean stone size was 8.2 +/- 3.2 mm (range 4-18). Success was defined as the lack of any visible stone fragments on posttreatment radiological evaluation. The mean number of sessions required was 1.5 +/- 0.8/patient (range 1-4). Complete clearance rate at 3 months was 86.2%. Re-treatment and efficacy quotient rates for distal ureteral stones were 41.4 and 55.6%, respectively. Complications such as urinary tract infection or steinstrasse occurred in 2 (6.9%) patients. Minor complications included petechial skin hemorrhage at the site of entry of shock waves in all patients. Our results show that shock wave lithotripsy for distal ureteral calculi with the Siemens Lithostar Modularis lithotriptor has a high success rate (86.2%) and efficacy quotient (55.6%) with negligible complications in children.

Results of Percutaneous Endoscopic Ureterolithotomy Compared to that of Ureteroscopy

Percutaneous endoscopic ureterolithotomy is not a well-known method for the treatment of impacted ureteral stones. The authors performed a retrospective study to compare the effectiveness of this procedure to ureteroscopy for the treatment of ureteral calculi. Impacted ureteral stones were removed in 93 patients by percutaneous endoscopic ureterolithotomy (Group 1). In 142 patients, ureteroscopy was performed for the treatment of the ureteral stones (Group 2). The same instruments were used to carry out percutaneous endoscopic ureterolithotomy as were used for percutaneous nephrolithotomy. During these interventions, a direct percutaneous puncture and extraction of the stones was performed. The average diameter of the stones was 11 +/- 4 mm in Group 1 and 7 +/- 2 mm in Group 2. The average operating time was 32 +/- 11 minutes in Group 1 and 41 +/- 29 minutes in Group 2. The average duration of hospitalization following the operations was 7.2 +/- 3.1 days in Group 1 and 3.5 +/- 2.5 days in Group 2. In Group 1, the average time of the operations was significantly lower (p 0.006), and the duration of postoperative hospital stay was significantly higher (p < 0.001), compared to Group 2. In Group 1, retroperitoneal hematoma occurred in 1 patient and prolonged urine leakage was detected in 2 cases, whereas in Group 2, pyelonephritis occurred in 5 patients following the operation. In conclusion, the operating time of percutaneous endoscopic ureterolithotomy is shorter and the rate of complications comparable with that of ureteroscopy. Percutaneous endoscopic ureterolithotomy is suggested for the removal of impacted ureteral stones instead of open surgical ureterolithotomy.

When is open ureterolithotomy indicated for the treatment of ureteral stones?

AIM

Improvements in extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy have almost eradicated the need for open surgery in ureteral stones. The aim of this study was to assess characteristics of patients who underwent open ureterolithotomy.

METHODS

During a 5-year period, a total of 654 patients with ureteral stones were treated. Initial management consisted of ureteroscopy in 524 patients, ESWL in 62 patients and percutaneous nephrolithotomy (PCNL) in 12 patients. Open surgery was performed in 56 patients. Stone location, size and success rates were retrospectively analyzed.

RESULTS

Ureteroscopy resulted in successful stone removal in 94%, 98% and 98.5% of proximal, mid and distal ureteral stones, respectively. A total of 14 patients with ureteroscopy failure were referred for open surgery. ESWL treatment resulted in success in 55 patients (88%), and those with ESWL failure were referred for either ureteroscopy (n = 3) or open surgery (n = 4). Open surgery was performed in a total of 56 patients, 38 of whom had been referred from other centers. Stone location was proximal ureter in 25 (44.6%) patients (stone size: 2-12 cm(2)), mid ureter in five (8.9%) patients (stone size: 2-6 cm(2)) and distal ureter in 26 (46.4%) patients (stone size: 4-9 cm(2)). A history of previous unsuccessful endourological procedure was observed in 33 (58%) of 56 patients. Children under age 16 (range 1-15 years) comprised 17.8% of patients undergoing open surgery.

CONCLUSION

Open surgery, which is nowadays being replaced with laparoscopic techniques, is generally indicated for failed endourological procedures (58%), particularly in centers that do not have flexible ureteroscopy or laser lithotriptor, and in patients with larger stones (>3 cm). Children (17.8%) are also candidates for open surgery, if specifically designed endourological equipment is not available.

The (soon forgotten) art of open stone surgery: to train or not to train?

To date, open stone surgery is now performed in a very limited number of selected cases. A review of our own cases revealed that open surgery constituted 1% of all procedures. These procedures were mostly ablative, or operations to deal with complications of failed minimally invasive therapies. Given two continuing trends towards sub-specialisation in urology on the one hand, and minimally invasive therapy on the other, the question arises whether and how sub-specialised stone surgeons should and can learn open stone surgery. Is it merely a lost art not to be bothered with, or is it something worthwhile preserving? This article discusses the pros and cons of the argument and suggests centralisation of complex stone cases as a possible way out of the dilemma.

Is there still a role for open surgery in the management of renal stones?

PURPOSE OF REVIEW

In the last few decades, with the improvement in endourological surgery and the invention and evolution of extracorporeal shock-wave lithotripsy, the indications for open surgery in stone disease have become rare, although open surgery still has a role in selected cases. In this review we discuss the current indications of open surgery for the elimination of urinary calculi.

RECENT FINDINGS

A MEDLINE and MeSH search was performed to evaluate currently available guidelines on open stone surgery and identify the evidence-based medicine that support the role of open surgery in treating urinary lithiasis. The latest papers published on open stone surgery are reviewed and conclusions are drawn, based on their results.

SUMMARY

Open stone surgery should be avoided in most cases, but should be considered for those patients in whom a reasonable number of less invasive procedures would not be useful. The most common indications for open stone surgery include complex stone burden, failure of extracorporeal shock-wave lithotripsy or endourological treatment and anatomical abnormalities (such as ureteropelvic junction obstruction and infundibular stenosis with or without renal caliceal diverticulum). The level of evidence for the currently available guidelines is not adequate, mainly because of lack of properly designed, large prospective randomized trials that compare different treatment options.

Treatment of impacted lower third ureteral stones with the use of the ureteral access sheath

We present our experience with the use of the ureteral access sheath for the management of small impacted lower third ureteral stones, in comparison with more standard techniques. Ninety-eight consecutive patients, aged 18-73 years (mean 48.5), with small (diameter < or = 10 mm) impacted lower third ureteral stones (< 5 mm in 56, and 5-10 mm in 42 patients) were randomly managed with either a 12/14F coaxial ureteral dilator/sheath and a 7.5F flexible ureteroscope (group A; 48 patients), or with balloon dilatation and the 7.5F flexible ureteroscope (group B; 50 patients). In both groups, stones were grasped and extracted with a basket, and when necessary they were disintegrated with a 1.9F electrohydraulic lithotripsy (EHL) probe. Postoperatively, excretory urography was performed at 1 month and patients were followed-up for 1 year. The mean operative time was 45.5 min in group A, and 58.5 min in group B (P<0.05). EHL was performed in 16 (33.3%) patients of group A, and in 12 (24%) patients of group B. In group B, balloon dilatation was performed in 28 (56%) patients. Ureteral perforation was revealed in 4 (8%) patients of group B. The follow-up imaging tests showed stone-free status in 46 (95.8%) patients of group A and in all (100%) patients of group B. No long-term complications were recorded. Endoscopic management of small impacted lower third ureteral stones with the ureteral access sheath is a quicker and safer procedure, in comparison with the more standard approach, bearing comparable efficacy.

Appropriate cutoff for treatment of distal ureteral stones by single session in situ extracorporeal shock wave lithotripsy

OBJECTIVES

To determine an appropriate cutoff for treatment by single session in situ extracorporeal shock wave lithotripsy for a prevesical stone by determining the differences in the efficiency quotient (EQ).

METHODS

This was a review of a series of patients who underwent shock wave lithotripsy for a primary, single, prevesical stone from January 1995 to June 2003. All 153 patients were treated using a Dornier MPL 9000 lithotripter in the prone position under intravenous sedation. The stone size was measured in two dimensions (parallel and perpendicular to the long axis of the ureter). The EQ was calculated using a standard formula.

RESULTS

Of the 153 patients, 141 (92.2%) were stone free within a mean period of 12.2 +/- 12.2 days (EQ 68.8). No significant complications occurred, and none of the patients required admission. The treatment failed in 10 patients (6.5%), who subsequently required an ancillary procedure (ureteroscopy). Statistically, we found 7 mm to be an appropriate cutoff for treatment using in situ shock wave lithotripsy. The EQ for stones greater than 7 mm and those 7 mm or smaller was 58 and 81, with a stone-free period of 13.6 +/- 12.9 and 10.9 +/- 11.6 days, respectively.

CONCLUSIONS

Ultrasound-guided shock wave lithotripsy is an efficient and safe modality for the treatment of prevesical stones 7 mm or less. Using an echo-guided lithotripter, the treatment was a radiation-free, day care procedure performed under intravenous sedation. Only 11% of our patients required repeat treatment.

Present Practice and Treatment Strategies in Endourological Stone Management

OBJECTIVES

The European Society of Urological Technology (ESUT) conducted a survey in order to assess and record the current trends between urologists with regard to the application of endourological stone management to identify trends and differences in treatment strategies among urologists.

METHODS

A total of 695 certified urologists and urological residents answered the ESUT Endourological Stone Management Questionnaire. There were 136 (28.7%) chief urologists, 240 (50.6%) staff urologists and 98 (20.7%) residents. The respondents were classified according to both the geographical origin (in four groups: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE) and Outside Europe (OE)), and department size (number of urological beds per department: small < or = 25, medium 26-50 beds, large > 50 beds) in order to identify any differences in the replies.

RESULTS

On average, 40.1 newly diagnosed patients and 73.6 revisits with urolithiasis are seen a month per department. According to the replies, there are no significant differences in total numbers of treatments in ESWL and/or endourological stone managements amongst the geographically based groups. Monthly, on average 68.5 ESWL treatments and 23.0 URS are performed per department. A significant majority of surveyed urologists performs URS with a rigid or semi-rigid instrument (79%) instead of a flexible instrument (21%, p = 0.003). URS is more frequently performed outside Europe (p = 0.02) with a more frequent use of dormia catheters (p < 0.001). On average, 20.9 double g-stents are placed monthly in each department, most commonly before or after endourological procedures (p < 0.001). Percutaneous procedures are performed by 69.6% of the respondents with a mean of 16.8 PNL procedures a month. PNL for stone management is mainly performed in Eastern Europe and non-European countries (p = 0.017). Nephrostomy tubes are used by 77.7% of the responding urologists. Monthly, 13.1 nephrostomy tubes are placed, mostly during PNL or after endourological procedures (40.7%).

CONCLUSION

The data obtained from the 695 urologists and residents provides information on the performed procedures and the use of material. In general, respondents from different geographical locations perform similar procedures and use identical material; however URS and PNL are performed more frequently outside of Europe, whereas laser lithotripsy is frequently used in Northern European counties.

Removal of ureteral stones with extracorporeal shock wave lithotripsy and ureteroscopic procedures. What can we learn from the literature in terms of results and treatment efforts?

A literature review was made to obtain information on the treatment efforts required for a successful removal of ureteral stones when extracorporeal shock wave lithotripsy (ESWL) or ureteroscopic stone extraction or disintegration (URS) were used as primary procedures. Data were collected from 59 reports on ESWL and 23 on URS. The study thereby comprised 20,659 patients primarily treated with ESWL and 5,520 treated with URS. A treatment index (TI) was formulated from the total number of patients (N(TOT)), the number of stone free patients (N(SF)), the number of patients with retreatment (N(RE)), auxiliary procedures (N(AUX)) and general or regional anaesthesia (N(ANE)). The difference between the TI and the efficiency quotients normally used was the incorporation of the factor N(ANE) that reflected the need for general or regional anaesthesia. TI had the following form: TI = N(SF)/(N(TOT) + N(RE) + N(AUX) + N(ANE). When the groups of treated patients were considered in this way, TI was significantly higher for the patients treated with ESWL than for those treated with URS (P = 0.007). The median (range) for the groups of ESWL-treated patients was 0.50 (0.25-0.90) and for patients treated with URS 0.42 (0.26-0.94). For the combined groups of patients, the TI-values were 0.54 and 0.40, respectively. Although the average retreatment for URS was only 2.2% compared with 12.1 percent for ESWL, the need for general/regional anaesthesia was 94.3% and 28.3% in the two groups, respectively. The advantage of a lower rate of retreatment in patients primarily referred to URS was thus obviously counterbalanced by the much higher need for anaesthesia. For ureteral stones treated with ESWL in the author's department using Dornier HM3, MFL 5000, and Modulith SLX lithotripters, stone free rates of 96%, 97% an 95% were associated with TI-values of 0.61, 0.60 and 0.63, respectively. Both ESWL and URS are excellent procedures for the removal of stones from the ureter. In addition to the different degrees of invasiveness, the need for anaesthesia has to be considered in an objective comparison of the two methods.

An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi

BACKGROUND

At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol.

PATIENTS AND METHODS

A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years.

RESULTS

Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus.

CONCLUSION

A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

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.

Open mini-access ureterolithotomy: the treatment of choice for the refractory ureteric stone?

OBJECTIVE

To report the experience in one centre of the efficacy and safety of open mini-access ureterolithotomy (MAU) and to discuss relevant current indications.

PATIENTS AND METHODS

MAU was undertaken in 112 patients (mean age 38 years, range 26-57) between 1991 and 2001; the details and outcomes are reviewed. The mean (range) stone size was 12 (8-22) mm, with 30 stones in the upper, 69 in the mid- and 13 in the lower ureter. In 15 cases the stones were impacted and there were signs of infection in the proximal ureter.

RESULTS

MAU was successful in 111 patients; the one failure was caused by proximal stone migration early in the series. The mean (range) operative duration was 28 (10-44) min and the hospital stay 42 (24-72) h; 33 patients were in hospital for 24 h, 72 for 48 h and seven for 72 h. The blood loss was minimal, at 50 (30-150) mL. The drain was removed after 5 (5-7) days. Patients reported using opioid or nonsteroidal anti-inflammatory analgesia for a mean of 4 (1-7) days after surgery. The mean time to resumption of work was 16 (8-35) days.

CONCLUSIONS

MAU is a safe and reliable minimally invasive procedure; its role is mainly confined to salvage for failed first-line stone treatments but in selected cases, where a poor outcome can be predicted from other methods, it is an excellent first-line treatment.