Role of lasertripsy in the management of ureteral calculi: experience with alexandrite laser system in 232 patients

Effect of stone composition on operative time during ureteroscopic holmium:yttrium-aluminum-garnet laser lithotripsy with active fragment retrieval

OBJECTIVE

To assess whether the stone composition affects the operative time of ureteroscopic holmium:yttrium-aluminum-garnet laser lithotripsy (ULL) with active fragment retrieval. The chemical composition of a calculus is known to affect the efficacy with which it is fragmented by a device, such as pneumatic, laser, or shock wave lithotripter. Previous studies examining the efficacy of holmium:yttrium-aluminum-garnet laser lithotripsy have been performed in vitro, but it is not known whether the operative time is significantly affected by the chemical composition of a patient's stone.

METHODS

We selected all patients who had undergone ULL for stone disease from July 2008 to January 2011 for a retrospective chart review. We used a standardized operative technique of fragmentation and active retrieval of all fragments identified on full inspection of the entire collecting system using rigid and flexible endoscopes. The stone composition was defined as the presence of a single predominant (>51%) component. Statistical analysis was performed on a per-procedure basis relative to the stone burden, as measured in minutes of operative time per gram of stone.

RESULTS

A total of 187 cases of unilateral ULL with active retrieval of stone fragments confirmed to have a single predominant chemical composition met the inclusion criteria. When accounting for the weight of the recovered stone, no difference was found in the operative time among the apatite, brushite, cystine, calcium oxalate monohydrate, calcium oxalate dihydrate, and uric acid stones.

CONCLUSION

Although stone composition is widely recognized as an important procedural variable, especially for shock wave lithotripsy, it appears to have little effect on the overall operative time for holmium:yttrium-aluminum-garnet lithotripsy when using active fragment retrieval.

Intracorporeal lithotripsy. Update on technology

The number and variety of devices currently available for endoscopic lithotripsy reflect the reality that no single device is ideal in all situations. Although the search for the universal lithotriptor continues, the urologist must consider several factors if faced with the decision of which device to purchase. Perhaps foremost among these factors is the clinical situation with which one commonly deals. For example, although the smaller, flexible probes such as EHL or laser demonstrate considerable utility if used ureteroscopically, the larger stone burden associated with today's percutaneous nephrolithotripsy population often is treated more efficiently with one of the mechanical devices employing a larger, rigid probe, such as ultrasound or the Lithoclast. Similarly, the type and size of endoscopic equipment at one's disposal have a significant impact on which device to purchase or use. There are physical constraints affecting which device may or may not be used, rigid versus flexible endoscope, working channel caliber, and offset versus end-on-port. The skill and experience of the surgeon is also a factor of obvious importance, particularly if one is using a modality with a relatively narrow margin of safety such as EHL. Likewise, the training and experience of nursing personnel is a factor, especially regarding the use of lasers, which require certified personnel who are well versed in laser safety. Finally, in today's environment one must carefully evaluate cost in terms of not only initial capital outlay but also ongoing charges for disposable and maintenance items. Thus, the decision of which device to purchase is complex and requires careful evaluation of all of the previously noted variables. Likewise, if one is fortunate enough to have more than one device available, the decision of which lithotriptor to employ requires a similar decision based on sound surgical judgment.

Primary treatment of ureteral stones by new multiline lithotripter

BACKGROUND AND OBJECTIVES

During the last 15 years, a second and a third generation of lithotripters have been developed. We present the results achieved by primary extracorporeal shockwave lithotripsy (SWL) of ureteral calculi treated with the new Multiline Lithotripter (Siemens).

PATIENTS AND METHODS

From April 1996 until February 1997, 50 men and 17 women ages 19 to 82 (mean 50.9) years, underwent SWL as a primary treatment of ureteral stones at the Department of Urology, University of Düsseldorf. Data were analyzed retrospectively. More than half (60%) of the 67 patients had left ureteral stones. The most frequent site was proximal (46%) followed by distal (37%). The mean stone diameter was 9 mm. A total of 118 treatments were performed.

RESULTS

The success rates of SWL monotherapy for upper, mid, and lower ureteral calculi were 71%, 82%, and 72%, respectively. Although in 62% of the cases, complete, and in 33% partial, stone disintegration was achieved, auxiliary procedures (ureteral stenting, nephrostomy, and ureteroscopy) were necessary in 43% of the patients. Renal hematoma occurred in two patients, who were treated for upper ureteral calculi. Two thirds of the patients were discharged from the hospital free of stones.

CONCLUSIONS

Primary SWL treatment of ureteral stones with the new Multiline showed good results in about 84% of cases, although 43% of patients required auxiliary procedures. The occurrence of renal hematoma after the treatment of upper ureteral stones is an unexpected complication and makes reduction of the applied energy necessary if the kidney lies within the field of shockwave application.

Safety and efficacy of the Alexandrite laser for the treatment of renal and ureteral calculi

OBJECTIVES

To assess the safety and efficacy of the Alexandrite laser for intracorporeal lithotripsy of renal and ureteral stones in conjunction with ureterorenoscopy or percutaneous nephrostolithotomy.

METHODS

We retrospectively analyzed the records of 137 patients with 169 calculi in 143 renoureteral units who were treated with the Alexandrite laser via a retrograde (91.5%) or antegrade (8.5%) endoscopic approach.

RESULTS

Adequate intraoperative fragmentation of the stone was observed in 88.8% of the cases. No intraoperative complications were attributable to the laser. At a mean follow-up of 34 days, the overall stone-free rate was 74.4%. The stone-free rate for ureteral stones (n = 115) was 80%, whereas the stone-free rate for renal stones (n = 22) was only 44%. In the best subgroup of ureteral stones (10 mm or less in the distal ureter), the stone-free rate was 97.4%.

CONCLUSIONS

The Alexandrite laser is a safe modality for intracorporeal lithotripsy and is highly effective for ureteral stones less than 10 mm in size.