Is extracorporeal shockwave lithotripsy suitable treatment for lower ureteric stones?

Extracorporeal shock wave lithotripsy for distal ureteric stones: which is the ideal approach?

OBJECTIVE

To compare the safety and efficacy of different approaches using ESWL for management of distal ureteric stone in an attempt to select the ideal one.

PATIENTS AND METHODS

This is a prospective randomized single-center study conducted on patients with lower third single radiopaque ureteric stone with size less than 15 mm. Patients were randomized into three groups, group A: Supine transgluteal, group B: Modified prone and group C: Prone position (80 patients each). The success of the procedure was assessed by NCCT and is defined as complete stone removal or had only clinically insignificant fragments (< 3 mm) for a maximum of three sessions. The success rate, rate of complications, pain intensity by visual pain scale and patients' satisfaction rate were compared among the three study groups.

RESULTS

Data of 240 patients were analyzed (80 in each group). Overall, no significant difference has been observed among all groups regarding demographic data, stone and treatment characteristics. The overall success rates for treatment after the last session were 86.3%, 65% and 62.5% in the three study groups, respectively, with a statistically significant difference for group A. Regarding pain perception and complication rate, all groups were comparable. Patient satisfaction is significantly better in group A versus the other two groups.

CONCLUSION

Our study has confirmed better efficacy profile and patients' satisfaction rate of ESWL in the supine position (transgluteal approach) than other different known approaches for the treatment of distal ureteral stones.

Efficacy of Extracorporeal Shockwave Lithotripsy with Patients Rotated Supine or Rotated Prone for Treating Ureteral Stones: A Case-Control Study

PURPOSE

To improve the therapeutic efficacy of extracorporeal shockwave lithotripsy (SWL) for ureteral stones by attempting semilateral/rotated approaches. There has been no study that shows the advantage of rotated positions.

PATIENTS AND METHODS

Two hundred forty-eight (group 1) and 156 (group 1R) patients with proximal-ureteral stones were treated by the Dornier Lithotriptor U15/50 in the supine and rotated-supine position, respectively. When residual calculi remained in the middle-distal ureter, group 1 subjects underwent subsequent sessions in the ordinary prone position, and Group 1R patients were treated in the rotated-prone position. Sixty-two (group 2) and 60 (group 2R) patients with primary middle-ureteral stones were treated in the prone and rotated- prone position, respectively, while 110 (group 3) and 98 (group 3R) patients with distal-ureteral stones were treated in the prone and rotated-prone position, respectively.

RESULTS

Although the stone-free rate was not different in group 1 (94.8%) and 1R (97.4%), the number of sessions required for Group 1R patients to be stonefree (mean 1.49) was less than for Group 1 patients (mean 1.74; p=0.023). Group 1R patients tolerated a higher shockwave intensity than group 1 patients for sessions in the proximal ureter (p=0.042). The stone-free rate for Groups 1 and 1R for booster sessions in the middle- distal ureter was 85.4% and 100%, respectively (p=0.059). The stone-free rate for groups 2R (95.0%) and 3R (98.0%) was higher than that for groups 2 (83.9%) and 3 (89.1%) (p=0.046; p=0.011).

CONCLUSION

These effortless modifications bring about a superior outcome when treating ureteral calculi with SWL.

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.

Optimal treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus ureteroscopy

BACKGROUND

The optimal treatment for distal ureteral calculi remains controversial. We present data from our institution to compare the efficacy of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy with different lithotripsy modalities (URSL).

METHODS

From January 1994 to September 1997, 954 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar) in 524 patients and ureteroscopy (Wolf 8.0F instrument and Swiss Lithoclast) in 430 patients. Stone sizes and patient ages were similar in these two groups.

RESULTS

In the SWL group, the 3-month stone-free rate was 87%, and the effectiveness quotient (EQ) was 68.7%. In the URSL group, there was a 96% stone-free rate with an EQ of 92.1%. The SWL treatment was more expensive than URSL.

CONCLUSION

At our institution, ureteroscopy is more efficacious than SWL for the treatment of distal ureteral calculi. In selected patients who had stones >10 mm with evidence of impaction and severe colic pain, we strongly suggest that URSL is the best choice.

Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi

OBJECTIVES

The efficacy, safety, feasibility, and outcome of in situ treatment applied to select proximal ureteral calculi was assessed and analyzed with a view to avoiding auxiliary interventions and providing high clearance rates in the shortest possible time. We studied the impact of several clinically important variables, including power index, degree of hydroureteronephrosis (HDUN), stone size, and composition on the efficacy of sequential in situ boosted extracorporeal shock wave lithotripsy (ESWL) in a select group. The power index requirement for the in situ boosted protocol and the impact of the stone size/composition, degree of HDUN, and clearance rates were also analyzed.

METHODS

An in situ (no instrumentation) boosted protocol was applied to 130 primary unimpacted proximal ureteral calculi with no prior intervention. A typical session with the Siemens Lithostar Plus comprised 3000 shock waves, in installments of 500, deployed at a power setting of 1 to 4 kV with a gradual stepwise escalation. Sequential boosted additional sessions of ESWL were administered on days 2, 7, and 14, tailored to the degree of fragmentation, clearance status, and amount of residual stone bulk. Several parameters (shock waves, kilovolts used, fluoroscopy time, number of sessions, stone size, composition, fragmentation, clearance, and HDUN) were recorded and the results analyzed statistically.

RESULTS

The results were excellent in 83.8%, with a mean duration to complete clearance of 11.3 days. In situ ESWL failed in 7.69%, and the auxiliary intervention rate was 10.7%. Pre-ESWL HDUN was present in 78.3%, the mean power index was 184.6/session/case, and the average stone burden was 8.9 mm(2). Calcium oxalate monohydrate was the most common stone (56%). Renal colic was the most common side effect observed. The power index, fragmentation at the first session, and stone size were found to be the most favorable significant variables affecting stone clearance. The degree of HDUN, number of sessions, and stone composition did not significantly impact the clearance rates.

CONCLUSIONS

In situ boosted ESWL should be the first-line therapeutic modality in select unimpacted primary proximal ureteral stones.

A comparative analysis of nephrostomy, JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones

OBJECTIVES

To determine the optimal method of treatment for ureteric stones causing complete obstruction, treated by insertion of a JJ stent or a nephrostomy tube, followed by extracorporeal shock wave lithotripsy (ESWL) or by urgent in situ ESWL if readily available.

PATIENTS AND METHODS

The study comprised a retrospective analysis of 82 consecutive patients who presented with ureteric stones causing complete obstruction. Twenty-six had a percutaneous nephrostomy (PCN, group 1) and 40 had a JJ stent (group 2) placed to relieve the obstruction, and the stones were subsequently treated by ESWL. Sixteen patients underwent urgent in situ ESWL without recourse to either a JJ stent or a PCN (group 3). The choice of the procedure was not determined by stone size, site or other factors, but mainly by the attending surgeon's preference or the availability of urgent ESWL. The success rate was measured by the disintegration of the stone and spontaneous passage after ESWL; failure was defined as the need for additional procedure(s) for stone extraction.

RESULTS

Urgent in situ ESWL (group 3) had a median (95% confidence interval) success rate of 81 (54-96)%, compared with 70 (53-83)% in group 2 and 54 (33-73)% in group 1.

CONCLUSION

If facilities are available, urgent in situ ESWL appears to be the choice of treatment for obstructing ureteric stones. If such facilities are not available, a JJ stent may offer better success than a PCN. A prospective controlled trial is necessary to confirm these findings.

Treatment of lower ureteral stones: extracorporeal shockwave lithotripsy or intracorporeal lithotripsy?

OBJECTIVE

In this study, 1121 patients with lower ureteral stones were evaluated to compare the effectiveness of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy with three different lithotripsy modalities.

METHODS

Of these patients, 726 were treated with SWL, whereas 430 underwent ureteroscopy, with pneumatic lithotripsy (PL), ultrasonic lithotripsy (USL), and electrohydraulic lithotripsy (EHL) performed in 125 (29.0%), 276 (64.2%), and 29 (6.8%) patients, respectively. Thirty-five patients underwent both types of treatment because of unsuccessful SWL therapy.

RESULTS

In the SWL group, the stone-free rate was 42.2% and the fragmentation rate was 59.5%. These values were 96.8% and 98.4% for PL, 89.4% and 90.5% for USL, 93.1% and 96.5% for EHL, respectively.

CONCLUSIONS

These data show that SWL was less effective than ureteroscopic lithotripsy (p < 0.001). The PL modality had the highest stone-free and fragmentation rate, and EHL had the highest complication rate (43.5%). Ureteroscopic lithotripsy is the most effective treatment choice in lower ureteral stones no matter which kind of energy is used, and PL is the most effective and least morbid approach.

The treatment of ureteric calculi before and after the introduction of extracorporeal shockwave lithotripsy

Indications and treatment results of ureteric calculi one year before and one year after the introduction of ESWL were analysed in 169 consecutive patients. Sex, age, former stone operation, stone localisation and stone size were not significantly different in the two groups. Before ESW1 47% of the patients received treatment against 54% after the introduction (p > 0.3). There was no tendency towards treatment of smaller calculi. Expectedly, the number of endoscopies and ureterolithotomies was significantly reduced (p < 0.05). The treatment period (from first contact till final control) was longer with ESWL, but not significantly. Judged from the length of the hospital stay there was no major economic benefit from ESWL. In conclusion, ESWL with a second generation lithotriptor is suitable for in situ treatment of ureteric calculi. It should be first choice for ureteric calculi.

In situ extracorporeal shock wave lithotripsy for primary ureteric calculi

OBJECTIVE

To determine the efficacy of the Lithostar lithotriptor for the in situ treatment of primary ureteric stones.

METHODS

We reviewed, retrospectively, our experience with 283 patients with primary ureteric stones treated with extracorporeal shock wave lithotripsy (ESWL) using the Lithostar lithotriptor. No attempts were made to manipulate the stones. The majority of the patients were treated using only intravenous analgesia. Auxiliary measures were used in 84 patients (29.6%). There were 112 patients (39.6%) with upper, 53 (18.7%) with middle, and 118 (41.7%) with lower ureteric stones.

RESULTS

A single ESWL session was needed for 200 patients (70.6%), two for 49 patients (17.3%), and more than two sessions for 34 patients (12%). Of the 248 patients who had adequate follow-up, 220 (88.7%) were stone free, 14 (5.65%) had some residual stone, while 14 (5.65%) patients failed to respond to the treatment. Patients' gender and body weight influenced the treatment and the clearance rate numerically without any statistical significance. The stone site was the most significant factor influencing the final result. Stones larger than 10 mm and the presence of hydronephrosis adversely affected the treatment.

CONCLUSIONS

In situ ESWL of ureteral stones with the Lithostar device is a convenient and efficient method of treating calculi within the whole length of the ureter without the need for any manipulation.

The scope and place of ultrasound-monitored extracorporeal shock wave lithotripsy in a multimodality setting and the effects of experiential, audit-evoked changes on the management of ureteric calculi

OBJECTIVE

To assess the results from ultrasound-monitored extracorporeal shock wave lithotripsy (ESWL) for ureteric stones, to compare the results with other treatment modalities and to evaluate experiential audit-evoked gains.

PATIENTS AND METHODS

A review of the records of 109 patients with ureteric stones who were treated during 1990 (Group I) and 69 patients treated by ESWL during the first 10 months of 1991 (Group II), was carried out. All patients with a steinstrasse or fragments secondary to ESWL were excluded from the study.

RESULTS

Of the 109 patients in Group I, 63 were treated with ESWL, nine underwent ureteroscopic push-up of the stone and 11 underwent catheter push-up prior to ESWL, 28 underwent ureteroscopic extraction/fragmentation, five underwent post-ESWL ureteroscopy and 29 underwent open ureterolithotomy (nine after failed ureteroscopy). Ureteroscopy was successful in fragmentation/extraction of 19 of 28 (68%) stones and 95% of patients were stone-free at 3 months. All patients who underwent ureterolithotomy and 84% who underwent ESWL (and post-ESWL ancillary procedures) were stone-free at 3 months. All patients who underwent ureterolithotomy, 51% of those who underwent ureteroscopy and 56% of patients who underwent ESWL needed only one treatment. The mean stone burdens of patients in Groups I and II were comparable but more patients presented with larger stones (> 15 mm length, > 100 mm2 surface area) in Group II. The stone-free rates for ESWL monotherapy with ESWL increased from 84% in 1990 to 92% in 1991. A higher proportion of stones were treated in situ in 1991 and a stent was used less frequently in obstructed ureters. Post-ESWL procedures fell from 8% in 1990 to 6% in 1991 and the proportion of patients who required more than one treatment fell from 44% in 1990 to 14% in 1991.

CONCLUSIONS

The choice of treatment for patients with ureteric stones is critical but will vary depending on the individual's circumstances, the availability of equipment, costs and time required to perform the procedure. The results obtained using ESWL for ureteric stones improved considerably over the course of the study as a result of experience and refinement of the technique. Stones located in more difficult systems such as in kidneys with a thin cortex and those located above the ischial spine were no longer subjected to ESWL. Audit of the results obtained following treatment allows identification of problem areas, alerts physicians to alternative methods of treatment and gives an objective quantification of experience, assisting rational decision making with consequent improved success.

In situ echoguided extracorporeal shock wave lithotripsy of ureteric stones with the Dornier MPL 9000: a multicentric study group

OBJECTIVE

To study the efficacy of the Dornier MPL 9000 lithotripter with a real time ultrasound transducer in the localization and treatment of upper and prevesical ureteric stones.

PATIENTS AND METHODS

Two-hundred and eighty-five patients with pre-vesical ureteric stones and 247 patients with upper ureteric stones underwent extracorporeal shock wave lithotripsy (ESWL) using ultrasound targeting, under no regional or general anaesthesia.

RESULTS

At follow-up after 3 months 97% of patients with pre-vesical stones and 96% with upper ureteric stones were stone free. Ninety-nine patients were treated more than once. The average number of sessions of ESWL for all patients was 1.19 (1.17 for patients with prevesical stones and 1.22 for those with upper ureteric stones). Ureteric stenting was employed in 6% of cases. The infrequent use of ureteric stenting did not reduce ESWL efficacy, nor increase either the complication or the retreatment rates. In many cases upper urinary tract dilatation was provoked by administering intravenous fluid and a diuretic.

CONCLUSION

In situ echoguided ESWL is a simple, safe and effective technique for treating ureteric stones which can be detected on ultrasound.

Stryker frame adaptation of the HM3 lithotriptor for treatment of distal ureteral calculi

Treatment of distal ureteral stones with the Dornier HM3 lithotriptor depends on the localization and positioning of the calculus from a transgluteal approach. We found the Stryker frame gantry modification preferable to the standard gantry for treatment of stones in the distal ureter. We report the use of this gantry adaptation in 22 cases of distal ureteral stones. The calculi were localized in 100% of the cases and were fragmented successfully with 1 treatment in 89%. In no case was the procedure aborted secondary to nonvisualization of the calculus. Failure to disintegrate the stone requiring retreatment occurred in 11% of the cases, and was attributed to stone characteristics and not due to difficulty with visualization or placement of the calculus within the F2 focus. The average fluoroscopic time was 45 seconds. The Stryker frame modification to the standard Dornier HM3 lithotriptor allows for improved visualization and easier localization of distal ureteral calculi compared to the standard gantry.

"In situ" echo-guided extracorporeal shock wave lithotripsy of ureteral stones. Methods and results with Dornier MPL 9000

In 285 patients with prevesical ureteral stone and 247 with upper ureteral stone, extracorporeal shock wave lithotripsy (ESWL) was performed with the Dornier MPL 9000 ultrasonographic targeting device. All these stones were treated "in situ" and without regional or general anaesthesia. At 3-month follow-up 96.8% of the patients treated for prevesical stone and 95.5% of those with upper ureteral stone were stone-free. ESWL was repeated once or twice in 99 cases; the average number of sessions was 1.2 for all patients (similar for prevesical and upper ureteral stones). Sparse use of ureteral stenting (6.2% of cases) did not seem to reduce the efficacy of ESWL or increase complications or need for retreatment. Intravenous fentanyl analgesia was given to 40.9% of the patients and intravenous infusion of a furosemide solution was employed in many cases to give adequate dilation of the urinary tract. In situ echo-guided ureteral ESWL is simple, safe and efficacious and can be the technique of choice for sonographically detectable ureteral stone.

Extracorporeal shock wave lithotripsy of ureteric stones with the Modulith SL 20

A series of 138 patients with ureteric calculi was treated by in situ extracorporeal shock wave lithotripsy (ESWL) during the clinical introduction of the Modulith SL 20. This machine represents a newly developed lithotriptor with an electromagnetic cylinder as shock wave source and a dual localisation system consisting of in-line ultrasound and an integrated fluoroscope C-arm. During the first 2 months, 12 patients (phase 1) were treated under ultrasound localisation alone; during the next 5 months, 37 patients (phase 2) were treated using dual imaging modalities with reduced peak pressure (max. 18 kV = 800 bar); during the final 7 months, 89 patients (phase 3) were treated under ultrasonic and fluoroscopic localisation combined with an increased maximal shock wave pressure (20 kV = 1024 bar). The introduction of fluoroscopic targeting (phases 2 and 3) resulted in satisfactory localisation of calculi in the mid-ureter, previously limited by use of only coaxial ultrasound. The extension of stone localisation to the whole length of the ureter was associated with a marked decrease in treatment time, reflecting the easy handling of the dual localisation system. The rise in generator voltage (phase 3) improved the disintegration rate from 81% (phase 2) to 85%, whereas the number of impulses remained unchanged. However, the rate of auxiliary procedures following ESWL (adjuvant and curative) was reduced from 33% (phase 2) to 24.5%. Thus the Modulith SL 20 in its final design enables in situ ESWL to be the treatment of choice for all ureteric calculi, rendering special positioning techniques or multiple treatment unnecessary.

Does Transurethral Laser Ureterolithotripsy Justify its Cost?

A prospective consecutive series of 64 patients who underwent transurethral laser ureterolithotripsy using a 7.2F semirigid ureteroscope was compared to the immediately preceding consecutive series of 98 patients who had undergone ultrasound lithotripsy using rigid 9.5F or 12.5F ureteroscopes. The distribution of the calculi by size and composition in both series was similar. There was a higher proportion of upper ureteral calculi in the laser lithotripsy series. The success rate for a first attempt at laser lithotripsy was 92.2% versus 71.4% for the ultrasound series (p less than 0.01). When the stone could be reached ultrasound and laser lithotripsy had a fragmentation rate of 97%. The principal reason for the difference in results was the poorer ability to reach calculi when using the larger rigid ureteroscopes. One patient who had failed ultrasound lithotripsy was successfully treated with laser lithotripsy a year later. The overall morbidity was less for laser lithotripsy. The 3-year cost-benefit analysis revealed a smaller difference in cost than expected and the 5-year analysis was advantageous for laser lithotripsy because of its higher success rate. Savings were also realized in the laser series because of the higher proportion of subjects treated as outpatients, and a lower mean duration of hospitalization and time missed from work. For our center with an annual work load of approximately 100 cases laser lithotripsy achieved a superior cost-benefit ratio.

Extracorporeal shock-wave lithotripsy (ESWL) monotherapy for stones in lower ureter

Extracorporeal shock-wave lithotripsy (ESWL) has been accepted as the method of choice for most upper urinary tract calculi. However, in cases of stones in the lower ureter, ureteroscopic procedures have generally been preferred. Using the Dornier HM3 lithotriptor with modifications in the patient's position, we were able to successfully treat 155 unselected cases of lower ureteral calculi. The average stone size was 9.6 mm (range 5-23 mm). One hundred forty-three patients had stones located below the lower margin of the sacroiliac joint. These patients were placed in a supine position. The stones were visualized radiologically without use of a ureteral catheter in 78 percent of the patients; in 22 percent a ureteral catheter was inserted prior to ESWL to aid in stone localization. In 145 patients (94%) treatment was completed in one session; 10 patients (6%) required two sessions. Of the patients, 38 percent were free of stones one day after ESWL; 97 percent became stone free within three months, and only 3 patients required endoscopic manipulation, after ESWL. Twelve patients had stones in the midureter overlying the sacroileum. They were placed in the prone position, and the calculi were visualized with the aid of a ureteral catheter. All these patients became free of stones one month after treatment. There were no significant treatment-related complications except for bacteremia in 1 case. In view of the remarkable efficacy, negligible complication rate, and shorter hospital stay as compared to ureteroscopic stone manipulations, we recommend high energy ESWL as the primary monotherapy of mid and lower ureteral stones.

In situ prone ESWL for the treatment of lower ureteral stones: experience with 28 patients

Twenty-eight patients with lower ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) in the prone position over the period of 7 months between March 1990 and September 1990. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. Satisfactory disintegration was achieved in 93 per cent of patients. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent had residual fragments less than or equal to 4 mm in diameter. Twenty-one per cent of patients required repeat treatments. For only 2 patients general anaesthesia was required (7 per cent). There were no remarkable complications except for haemospermia which resolved spontaneously 15 days after treatment. It was concluded that in situ prone ESWL is an effective and safe procedure for the treatment of lower ureteral stones.

Extracorporeal shock wave lithotripsy for ureteral calculi

Second generation tubless lithotriptors allow for easy prone positioning of patients, resulting in increased use of extracorporeal shock wave lithotripsy (ESWL) for calculi in the ureter, especially in the mid and lower third portions. The 3-month stone-free rate with single stones using a Dornier HM3 and a Medstone STS lithotriptor in the upper ureter was 79% (316 patients) and 81% (188), respectively, while in the mid ureter it was 60% (20 patients) and 81% (32), respectively, and in the lower ureter it was 80% (5 patients) and 85% (26), respectively. The retreatment rate with single stones using the Dornier HM3 and the Medstone STS devices was 5% and 4%, respectively, in the upper ureter, 13% and 12%, respectively, in the mid ureter, and 0% and 5%, respectively, in the lower ureter. The second procedure rate after ESWL with single stones using the Dornier HM3 and the Medstone STS units was 6% and 6%, respectively, in the upper ureter, 15% and 16%, respectively, in the mid ureter, and 0% and 17%, respectively, in the lower ureter. Expectant management is still an acceptable method to treat small ureteral stones, and it is questionable whether ESWL is the appropriate treatment for lower third ureteral stones compared to equally effective and less expensive ureteroscopy.

Extracorporeal shock-wave lithotripsy for distal ureteric calculi

The results of 67 consecutive patients referred to the New South Wales Lithotripter Centre with distal ureteric calculi were evaluated. All these patients were treated on the Dornier HM3 Lithotripter. Distal ureteric calculi were classified as those at, or distal to, the proximal margin of the sacro-iliac joint. Eleven patients with stones overlying the sacro-iliac joint were treated in the prone position, while 56 patients with stones distal to the sacro-iliac joint, were treated in the saddle (astride) position. Of the 64 patients in whom follow-up was available, 44 (69%) were rendered totally stone free by extracorporeal shock-wave lithotripsy (ESWL). Lithotripsy has proved an effective treatment for distal ureteric calculi and has rendered 69% of patients stone free with minimal morbidity. Stones overlying the sacro-iliac joint can be successfully treated in the prone position.

Lumbar ureteric stones: which is the best treatment?

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

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

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

Treatment options for ureteral calculi: endourology or extracorporeal shock wave lithotripsy

Two therapeutic methods, endourology and extracorporeal shock wave lithotripsy (ESWL), can be used in the treatment of ureteral calculi. In a retrospective analysis during a 2-year period 236 patients treated with endourological procedures and 71 who underwent ESWL with a Siemens Lithostar were analyzed as to the success rate, effectiveness quotient, complication rate and hospitalization. The mean stone size was 1.12 cm. in the endourology group and 1.03 cm. in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated endourologically and without retreatment. In the ESWL group success was obtained in 90.1%, with an 11.2% retreatment rate. The retreatment rate was higher (25.0%) for calculi in the mid ureter. The group treated endourologically had a better success rate and no retreatment was necessary. On the other hand, the group treated with ESWL had a shorter hospitalization and a lower complication rate. Followup ranged from 11 to 60 months (mean 48 months) in the endourology group and 7 to 29 months (mean 11 months) in the ESWL group. These observations showed that in situ ESWL therapy with the Siemens Lithostar device is the method of choice for upper ureteral stones. Lower ureteral calculi should be treated endoscopically. Mid ureteral stones larger than 1 cm. had better results with endoscopic procedures and those smaller than 1 cm. had better results with ESWL.

Anesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones

Stones in the proximal, mid and distal ureter in 375 consecutive patients were treated with extracorporeal shock wave lithotripsy (ESWL) in a technically unmodified Dornier HM3 lithotriptor without regional or general anesthesia. Adequate followup was available in 162 patients with proximal, 62 with mid and 146 with distal ureteral stones. The fraction of patients with stone-free ureters within 3 months after ESWL was 96, 97 and 97%, respectively. Of all patients only 13 (3.6%) had residual stones or fragments in the ureter after 3 months. The average number of ESWL sessions was 1.34 for all patients, and 1.36, 1.45 and 1.38 for those with proximal, mid and distal ureteral stones, respectively. A ureteral catheter with saline irrigation was used whenever it was possible to insert a ureteral catheter. Only 15 stones were pushed up to the kidney during catheterization and all other stones were treated in situ. There were more retreatments in patients in whom the stone had not been bypassed by a catheter at the initial ESWL session. During at least 1 treatment session 238 patients had a ureteral catheter with the tip above the stone. Approximately half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous anesthesia with an anesthetic cream containing lidocaine-prilocaine (for proximal and mid ureteral stones). Small supplements of pethidine and diazepam were given to the other patients during the ESWL session. In situ ESWL of ureteral stones as described is a convenient, efficient and attractive procedure that, applied in a consequent manner, theoretically might result in a successful outcome in up to 98% of the patients.