Retrograde Ureteroscopic Treatment for Upper Ureteral Stones: A 5-Year Retrospective Study

The association between ureteral wall thickness and need for additional procedures after primary ureteroscopy in patients with ureteral stones above the iliac crest

PURPOSE

To examine the parameters affecting the need for additional procedures in the primary ureteroscopy treatment in patients with ureteral stones above the iliac crest level.

METHODS

Seventy-one patients were included in the study who were ≥ 18 years old and had undergone ureteroscopy (URS) for ureteral stones above the iliac crest level between 2018-2020 and had a non-contrast-enhanced abdominal computed tomography before the procedures were included in the study. Patients and stone characteristics were prospectively collected. The results were evaluated six weeks after URS. The absence of any residual fragment was thought to indicate stone-free status. The patients with failure were referred for the additional procedures.

RESULTS

The median patient age was 51 years [interquartile range (IQR): 18-66]. The median transverse stone diameter was 9.5 mm (IQR: 7.1-11.4), and the median ureteral wall thickness (UWT) was 5.8 mm (IQR: 4.3-6.5). In the univariate analysis, UWT (p < 0.001), presence of multiple stones (p = 0.008), and stone length (p = 0.022) affected stone-free status. The multivariate analysis revealed UWT as the only independent factor affecting the need for additional procedures after URS (p = 0.028). In the receiver operating characteristic curve analysis, the best threshold value for UWT according to the outcomes was identified as 5.8 mm.

CONCLUSION

Ureteral wall thickness was the only independent parameter determining the need for additional procedures and affecting the treatment outcomes after the URS procedure.

Study of ureteral and renal morphometry on the outcome of ureterorenoscopic lithotripsy: The critical role of maximum ureteral wall thickness at the site of ureteral stone impaction

Purpose:

The purpose is to study the association of stone, ureteral, and renal morphometric parameters with the relevant outcome variables, i.e., complication rate, stone-free rate (SFR), and operating time of ureterorenoscopic lithotripsy. Although a safe procedure, it still occasionally has major complications. Computed tomography (CT) scan is often performed to diagnose ureteral calculi, providing opportunities for ureteral morphometry that may have a bearing on the outcome of the procedure.

Materials and Methods:

Ureteric, renal, and stone morphometric parameters were measured from CT of the abdomen and pelvis of the 110 patients with ureteral calculi who underwent ureteroscopic lithotripsy (URSL). Data were collected retrospectively in 25 patients and prospectively in 85 patients. Association of these parameters with the outcome variables of the procedure mentioned above was studied.

Results:

On univariate analysis, body mass index, stone size, and maximum ureteral wall thickness (MUWT) were found to have a significant association with URSL complications, SFR, and duration of surgery. On multivariable analysis, only MUWT was found to be an independent risk factor for URSL complications. In 90% of total patients with residual stones, MUWT was found to be >4.8 mm.

Conclusion:

Ureteral wall thickness of >4.8 mm is associated with prolonged duration of surgery and lower SFR. Patients with ureteral wall thickness of >4.8 mm at the site of ureteral stone who are planned for URSL must be counseled about the higher chances of residual stones and the need for additional procedure.

Could ureteral wall thickness have an impact on the operative and post-operative parameters in ureteroscopic management of proximal ureteral stones?

AIM

To evaluate the possible impact of stone impaction in terms of ureteral wall thickness (UWT) on the success and procedure related parameters of ureteroscopic management in proximal ureteral calculi.

PATIENTS AND METHODS

82 patients with proximal ureteric stones were included and were divided into 2subgroups where UWT was> 5mm in 38 cases; and <5mm in 44 cases. Stone size, degree of hydronehrosis, diameter of proximal ureteral luz, UWT and patient's demographics were evaluated. Semi-rigid ureteroscopy with Ho-YAG laser was performed and the possible impact of UWT as an objective parameter for stone impaction on the success rates and procedure related parameters was evaluated.

RESULTS

Mean patient age and stone size values were 47.55±1.78 years and 8.17±0.29mm respectively. Regarding the impact of UWT value at the stone site for the parameters mentioned above stone free rates particularly at 1-week after the procedure was higher in group 2 and the rate of residual fragments as well as the need for double J stent placement was higher in group 1. Additionally, mean duration of the procedures was significantly longer in Group 1 during which pathologic alterations were significantly higher in ureteral wall at stone site were observed in these cases (P=.0243).

CONCLUSIONS

UWT may be used to predict the success of ureteroscopic management and other procedure related parameters for proximal ureteral stones in an effective manner. With this approach a more rational operative plan with higher success rates, limited complications and auxiliary procedures could be made.

Worldwide Use of Antiretropulsive Techniques: Observations from the Clinical Research Office of the Endourological Society Ureteroscopy Global Study

INTRODUCTION

Retropulsion, defined as unintended migration of a stone under the influence of the fragmentation device in ureteroscopy (URS) procedures, occurs in 2% to 60% of the cases. Antiretropulsive devices (ARDs) have been studied in experimental and small clinical studies. The current study aims at describing the worldwide usage of ARD and the outcomes related to their usage.

METHODS

The Clinical Research Office of the Endourological Society URS Global Study enrolled 11,885 patients who underwent URS and stone fragmentation for ureteral and/or renal stones. Of the 11,885 treated patients, 9877 were treated for ureteral stones, and data were available on stone migration and ARD use.

RESULTS

Of all procedures, 14.5% were performed with the use of an ARD. Less stone migration (-2.0%; p = 0.050), higher stone-free rates (SFRs) (2.8%; p < 0.001), and shorter length of stay (-4.7%; p = 0.001) were observed in the antiretropulsive group.

CONCLUSIONS

When an ARD is used during URS, less migration, higher SFRs, and shorter length of hospital stay are observed. This effect is independent from baseline differences and corrected for other treatment characteristics.

Does a retropulsion prevention device equalize the surgical success of Ho:YAG laser and pneumatic lithotripters for upper ureteral stones? A prospective randomized study

To establish if a retropulsion prevention device for ureteral stones equalizes surgical success and push-back rates of Ho:YAG laser and pneumatic lithotripters for upper ureteral stones. Patients with upper ureteral stones (n = 267) were treated endoscopically at the Department of Urology between April 2014 and December 2015. Patients were randomly assigned to pneumatic and Ho:YAG laser lithotripters as group-1 and group-2, respectively. Lithotripsy was performed with Stone Cone^TM in both groups. The surgical success rate on the first postoperative day was 81.5 % (n = 106) and 90.6 % (n = 116) for group-1 and group-2, respectively, and the difference between the groups was statistically significant (p < 0.05). The relation between stone size and surgical success was statistically significant for both groups (p < 0.01). Surgical success for the stones closer than 2 cm to the UPJ was 23.1 % for the pneumatic group versus 64 % for the laser group (p < 0.01). Lithotripsy time was significantly longer in group-2 (16.48 ± 4.74 min) than group-1 (12.24 ± 3.95 min) (p < 0.01). Ho:YAG laser lithotripsy is more successful than pneumatic lithotripsy for upper ureteral stones and a retropulsion prevention device does not equalize the surgical success of Ho:YAG laser and pneumatic lithotripters for upper ureteral stones on the first postoperative day and one month after surgery. Although the success rate of the first month after surgery is higher in group-2, the difference is not statistically significant.

Ureteral wall thickness at the impacted ureteral stone site: a critical predictor for success rates after SWL

The aim of the study was to determine the possible predictive value of certain patient- and stone-related factors on the stone-free rates and auxiliary procedures after extracorporeal shock wave lithotripsy in patients with impacted proximal ureteral calculi. A total of 111 patients (86 male, 25 females M/F: 3.44/1) with impacted proximal ureteral stones treated with shock wave lithotripsy were evaluated. Cases were retrieved from a departmental shock wave lithotripsy database. Variables analyzed included BMI of the case, diameter of proximal ureter and renal pelvis, stone size and Hounsfield unit, ureteral wall thickness at the impacted stone site. Stone-free status on follow-up imaging at 3 months was considered a successful outcome. All patients had a single impacted proximal ureteral stone. While the mean age of the cases was 46 ± 13 years (range 26-79 years), mean stone size was 8.95 mm (5.3-15.1 mm). Following shock wave lithotripsy although 87 patients (78.4%) were completely stone-free at 3-month follow-up visit, 24 (21.6%) cases had residual fragments requiring further repeat procedures. Prediction of the final outcome of SWL in patients with impacted proximal ureteral stones is a challenging issue and our data did clearly indicate a highly significant relationship between ureteral wall thickness and the success rates of shock wave lithotripsy particularly in cases requiring additional procedures. Of all the evaluated stone- and patient-related factors, only ureteral wall thickness at the impacted stone site independently predicted shock wave lithotripsy success.

Pneumatic lithotripsy versus holmium:YAG laser lithotripsy for the treatment of single ureteral stones: a prospective, single-blinded study

OBJECTIVE

The aim of this prospective single-blinded study was to analyze the stone-free (SF) rates between pneumatic lithotripsy (PL) and laser lithotripsy (LL) for the treatment of single and primary ureteral stones and to evaluate potentially predictive factors of a SF status.

MATERIAL AND METHODS

From January 2010 to January 2011, 133 consecutive patients with single and primary ureteral stones were prospectively enrolled. Uni- and multivariate logistic regression were performed to estimate predictive factors of a SF status.

RESULTS

The SF rate in the PL group was 80.7 and 86.1% in the LL group (p = 0.002). Success rates with regard of stone position were not significantly different between groups. At univariate logistic regression, middle ureteral stone (OR 3.33, p = 0.04), distal ureteral stone (OR 4.4, p = 0.02), LL (OR 3.05, p = 0.04) and Hounsfield units (HUs) (OR 1.07, p = 0.03) were significantly predictive factors of a SF status. At a multivariate logistic regression, middle ureteral stone (OR 5.58, p = 0.01), distal ureteral stone (OR 7.87, p < 0.01), LL (OR 2.4, p = 0.02) and HUs ≥1,200 (OR 1.15, p = 0.02) were significantly associated with a SF status.

CONCLUSIONS

LL significantly influences the SF status after ureteroscopy, allowing a higher SF rate when compared to PL. HUs may significantly influence this success rate.

Retrograde, antegrade, and laparoscopic approaches to the management of large upper ureteral stones after shockwave lithotripsy failure: a four-year retrospective study

PURPOSE

We compare the success rate and complications of retrograde ureteroscopy, laparoscopic ureterolithotomy, and percutaneous nephrolithotomy for the management of large upper ureteral stones.

PATIENTS AND METHODS

We retrospectively analyzed data from 73 patients with large (≥1 cm) upper ureteral stones at two institutions from January 2010 to May 2013. Twenty-two patients underwent retrograde ureteroscopy (group ULS), 30 patients underwent percutaneous nephrolithotripsy (group PCNL), and 21 patients underwent laparoscopic ureterolithotomy (group LS) for removal of upper ureteral stones. CT, intravenous urography, and ultrasound were performed 1 week and 1 month after surgical removal.

RESULTS

There were no significant differences in age, sex, or stone size among the three groups. Mean estimated blood loss and mean hospital stay showed a statistically significant difference among the three groups. Success rates in the PCNL, LS, and ULS groups were 100%, 90.5%, and 77.3%, respectively. The procedures of two patients in group LS were converted to open surgery because of the inability to find the ureteral stone in one patient and an adhesion too difficult to dissect in the other. The procedures of two patients in the ULS group were converted to LS, and those of three patients were converted to PCNL because of severe edema impaction at the site of the stone, a sharply angulated ureter obstruction, upward migration of the stone (seven patients), and intraoperative complications (two patients).

CONCLUSIONS

Percutaneous antegrade nephrolithotomy is a safe and effective minimally invasive treatment for patients with large upper ureteral stones that has several advantages over retrograde ureteroscopy and laparoscopic ureterolithotomy. Thus, percutaneous antegrade nephrolithotomy is recommended as a safe and good treatment option for large upper ureteral stones. A combined procedure (e.g., ureteral push-back and percutaneous removal) can be considered in some patients.

Management of impacted proximal ureteral stone: Extracorporeal shock wave lithotripsy versus ureteroscopy with holmium: YAG laser lithotripsy

Objective:

Prospective evaluation of the efficacy and safety of the extracorporeal shock wave lithotripsy (SWL) and ureteroscopy with Holmium: YAG laser lithotripsy (URSL) as a primary treatment for impacted stone in the proximal ureter.

Patients and Methods:

A total of 82 patients with a single impacted stone in the proximal ureter were included in the study. Patients were allocated into two groups according to patient preference for either procedure. The first group included 37 patients who were treated by SWL and the second group included 45 patients treated by URSL. The preoperative data and treatment outcomes of both procedures were compared and analyzed.

Results:

There was no difference as regards to patient and stone characters between the two groups. There was significantly higher mean session number and re-treatment rate in the SWL group in comparison to URSL group (1.5 ± 0.8 vs. 1.02 ± 0.15 session, and 43.2% vs. 2.2%, respectively). At one month, the stone-free rate of the URSL group was statistically significantly higher than that of the SWL group (80% vs. 67.6%, respectively). The stone-free rate at three months was still higher in the URSL group, but without statistically significant difference (80.2% vs. 78.4%, respectively). There was no statistically significant difference in the rate of complications between the SWL and URSL (24.3% vs. 15.6%, respectively).

Conclusion:

Both procedures can be used effectively and safely as a primary treatment for impacted stone in the proximal ureter; however, the URSL has a significantly higher initial stone-free rate and lower re-treatment rate.

Endoscopic holmium laser treatment for ureterolithiasis

INTRODUCTION

The rapid development and invention of ever more technologically advanced ureterorenoscopes as well as other instruments used in fragmenting ureteral stones have made the traditional surgical treatment of ureterolithiasis very rare.

MATERIAL AND METHODS

We investigated 727 patients treated for ureterolithiasis. 769 ureteroscopic lithotripsies (URSL) with the holmium laser were performed. We evaluated the relation of the stone size, the section of the ureter involved, length of time of the stone within the ureter and the condition of the urinary tract to the results of the ureterolithiasis treatment.

RESULTS

A good result of breaking up the stone and passing its fragments out of the ureter within 3 months following the first URSL was observed in 642 (90.9%) out of 706 patients. The remaining 64 (9.1%) patients required additional procedures: ESWL was performed on 44 patients; URSL was repeated for 20 patients. The most serious early post-URSL complications involved: urinary tract infection with symptoms of urosepsis in 10 patients, leading to death in 1 case, ureteral perforation in 3 patients, including 1 case presenting a periureteral leak that necessitated a surgical intervention.

CONCLUSIONS

URSL with the holmium laser is an effective and safe method for treating ureterolithiasis.

Systematic evaluation of a novel foot-pump ureteroscopic irrigation system

INTRODUCTION

To evaluate forces exerted on a stone with different ureteroscopic irrigation systems.

METHODS

A 3 mm steel simulated stone was welded to a 3F stone basket and inserted into the working channel of a 4.5F Wolf semirigid ureteroscope. The basket shaft was attached to a 50 g load cell. The urterescope was placed in a ureteral model (14F silicon tubing). Simulated blood (McCormick™ Red Dye, 1 dye drop/15 mL H(2)O) was dripped adjacent to the stone at 12 drops/min. Endoirrigation devices were attached to the ureterscope and irrigation was applied at a rate sufficient to maintain visualization of the stone. Force on the stone was measured with the following endoirrigation systems: Boston Scientific™ Single-Action-Pump System (SAP) hand-pump and NuVista Medical™ Flo-Assist(®) foot-pump.

RESULTS

No significant difference (p=0.19) in the number of pumps required to maintain a clear endoscopic field was found between the SAP (0.20±0.075/second) and Flo-Assist device (0.25±0.056/second). The pump duration of the Flo-Assist was found to be less (1.12±0.40 seconds) than the SAP (1.35±0.31 seconds), but not significantly different (p=0.24). The average maximum impulse was significantly lower (p=0.0002) for the SAP (8.34×10(-5) Ns) than the Flo-Assist (1.96×10(-3) Ns). Total maximum impulse (2.02×10(-5) Ns) for the SAP and total average impulse (5.51×10(-6) Ns) were found to be lower than the Flo-Assist device. The Flo-Assist had a total maximum impulse of 4.49×10(-4) Ns and total average impulse of 8.85×10(-6) Ns, however, these differences were not statistically significant.

CONCLUSION

The hand-pump (SAP) and foot-pump (Flo-Assist) irrigation devices tested require comparable amounts of pumps for similar durations of time to maintain endoscopic visualization. Overall, the SAP device exerts less average maximum force on the stone than the Flo-Assist device.