Laser lithotripsy with the Candela MDL-2000 LaserTripter

Laparoscopic ureterolithotomy for large lower ureteral stone: a case series report

Background

Identifying the precise location of the lower ureter is crucial in not only ureteral surgeries but also the other surgeries that may cause ureteral injury. Although a variety of approaches have been applied to detect the location of the lower ureter, the majority of them had an association with several complications or be difficult to perform perfectly or be time-consuming.

Case presentation

Seven patients with distal ureteric stones of the size ranged from 2 to 3 cm. All patients entered the study after signing the informed consent, and the case report is based on CARE guidelines. After specifying the inner ring of the inguinal canal, the posterior peritoneum was opened and dissected from an area of 2 cm medial and 2 cm inferior to the inner ring. Thereafter, the stone was extracted from the precise location of them, which was identified by ureteral pinching.

Conclusion

We assumed that we were easily able to identify the site of the lower ureter through 2 cm medial and 2 cm inferior to the inner ring. The result of our study on seven patients demonstrated that this maneuver can minimize the time of surgery and no complications have been seen while this approach was applied.

Laparoscopic Transperitoneal Ureterolithotomy for Recurrent Lower-Ureteral Stones Previously Treated with Open Ureterolithotomy: Initial Experience in 11 Cases

PURPOSE

To evaluate transperitoneal ureterolithotomy by laparoscopy (TPUL) for the management of recurrent lower-ureteral stones previously treated with open surgery.

PATIENTS AND METHODS

Between January 2003 and June 2006, 11 patients (mean age 35.2 years) with recurrent large (mean size 2.8 cm) lower-ureteral calculi and normal renal function underwent TPUL. Seven stones were on the left side, and the remaining four were on the right side. These stones were recurrent after previous open ureterolithotomy. Earlier attempts with ureteroscopy (for three patients) had failed.

RESULTS

The TPUL was successful in all cases. The mean operating time was 85.2 minutes. Two patients required no narcotic analgesics, while the other patients received a mean of 2.3 10-mg doses of morphine sulfate for postoperative pain relief. The mean hospital stay was 3.8 days. The mean convalescence period was 13.7 days. There were no major intraoperative or postoperative complications. Prolonged urine leakage for 7 and 9 days occurred in two patients, which was managed conservatively. All patients were asymptomatic, stone free, and without obstruction or stricture formation on follow-up that included abdominal ultrasonography and plain films after 6 weeks and intravenous urography after 6 months. There was no deterioration of renal function.

CONCLUSIONS

Laparoscopic transperitoneal ureterolithotomy is a feasible technique for the management of recurrent lower-ureteral stones after previous open ureterolithotomy that are not amenable to ureteroscopy or SWL. It is a minimally invasive, less-morbid alternative to open transperitoneal ureterolithotomy.

Complications of ureteroscopy

Ureteroscopy has undergone a dramatic evolution over the last two decades. Although ureteroscopic injury is the most common cause of ureteral trauma because of the large number of ureteroscopic procedures performed, improvements in instrumentation and technique have resulted in a reduced incidence of serious complications. Despite significant technologic advances, however, surgical misadventures still occur, some of which have lasting consequences. Careful attention to instrument selection and surgical technique are critical to reduce untoward events related to ureteroscopy. As such, adverse sequelae associated with ureteroscopy should be related to the underlying pathology itself rather than to the treatment.

Holmium laser lithotripsy for ureteral calculi: an outpatient procedure

A retrospective review was conducted to evaluate the efficacy of ureteroscopic lithotripsy using the holmium laser with a semirigid endoscope in a newly established day surgery center. In 1996, 69 consecutive patients (40 male and 29 female) with a mean age of 46.7 (range 21-73) years and ASA status I or II underwent ureteroscopic lithotripsy for their ureteral calculi using the holmium laser (365-micron fiber; power setting 0.5-1.4 J/5 Hz) and 8.5F semirigid ureteroscope in a day surgery setting. Stone features, postoperative pain scores, readmissions, and complications were evaluated. Eighteen upper, 17 middle, and 34 lower ureteral stones were treated, with a mean size measuring 12.1 (5-45) mm. The mean operative time was 61 minutes including the anesthetic time (range 15-150 minutes), and the success rate was 91% (63/69). The complication rate was 10% (7/69) including four unscheduled readmissions (6%). Telephone follow-up on postoperative Day 1 and Day 3 revealed mean pain scores of 2 and 1, respectively (on a 0-10 scale) and an analgesic requirement of 1 tablet of Dologesic (containing 32.5 mg of dextropropoxyphene + 320 mg of paracetamol) four times a day on both days. Ureteroscopic lithotripsy using the holmium laser and a semirigid endoscope is highly successful and well tolerated and carries a low complication rate. It is indicated as an ambulatory and minimally invasive treatment modality in low-risk patients with ureteral stones.

Holmium: YAG laser damage to ureteral guidewire

The holmium:yttrium-aluminum-garnet (holmium:YAG) laser effectively fragments urinary calculi of all compositions. Complications have been minimal and mostly attributable to the ureteroscopy as opposed to the laser. We report a case in which the polytetrafluoroethylene (PTFE) coating of a ureteral guidewire was broken with the holmium:YAG laser and remained in the collecting system after the guidewire was removed postoperatively. The patient required cystoscopy to remove the guidewire coating.

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

In 232 patients with ureteral stones, lasertripsy was used as primary treatment or as second-line therapy after extracorporeal shockwave lithotripsy (SWL). In all patients, a semirigid 6.5F ureteroscope or a flexible 6F ureteroscope was used. Lithotripsy was performed employing an alexandrite laser with an energy of 50 to 65 mJ. The immediate success rate was 67.5% for stones in the upper ureter, 86.1% for those in the midureter, and 94.5% for those in the distal ureter. In 16.5% of the treatments, it was necessary to insert a double-J stent. A perforation of the ureter happened in two patients (0.9%), but no laser-related complications were seen. Stone fragmentation was not dependent on stone composition or size. Using small semirigid or flexible ureteroscopes, lasertripsy of ureteral stones is a minimally invasive treatment with an insignificant complication rate. In case of midureteral stones, our results revealed a higher immediate stone-free rate than is reported in the literature after treatment by SWL, and we can therefore recommend lasertripsy as primary treatment. For upper ureteral stones, lasertripsy can be recommended as a helpful auxillary procedure. Furthermore, in cases of distal ureteral stones, lasertripsy challenges SWL as the primary treatment.

Clinical experience with holmium:YAG laser lithotripsy of ureteral calculi

BACKGROUND AND OBJECTIVE

We recently acquired a holmium:YAG laser with wavelength of 2.1 microns. We would like to report our success in using this machine for laser lithotripsy.

STUDY DESIGN/PATIENTS AND METHODS

Forty-seven ureteroscopic laser lithotripsies were performed in 44 patients (three bilateral stones) over a 6 month period. Four stones were in the upper ureter, six in the middle ureter, and 37 in the lower ureter. The holmium laser beam was delivered via a 400 micron flexible quartz fiber through a 7 Fr rigid ureteroscope during the procedure. The stone size varied from 4 to 21 mm.

RESULTS

The success rate was 91%. Most of the stones were fragmented to less than 2 mm in size. Larger fragments were removed with a Dormia basket (six cases) for stone clearance. Endoscopic laser ureterotomy was performed in two patients with stricture below the stone. One patient required conversion to open ureterolithotomy, and three required subsequent Extracorporeal Shock Wave Lithotripsy. A low complication rate was observed.

CONCLUSION

The pulsed holmium:YAG laser is safe and effective for use in ureteroscopic laser lithotripsy.

In situ piezoelectric extracorporeal shock wave lithotripsy of ureteric stones

OBJECTIVE

To evaluate the efficacy of the EDAP LT 02 lithotripter for the in situ treatment of ureteric calculi.

PATIENTS AND METHODS

One hundred consecutive patients presenting with ureteric calculi were treated with in situ piezoelectric extracorporeal shock wave lithotripsy (ESWL) using the EDAP LT 02 lithotripter. There were 49 patients with upper, nine with mid and 42 with lower ureteric stones. The largest diameter of the stones varied from 7 to 21 mm (mean 9.6 mm). Mild or severe hydronephrosis was present in 53 cases. Mid and lower ureteric stones were treated with the patients in the prone position, with no anaesthesia or pre-medication, and upper ureteric stones in the supine position, with intravenous sedation in 44 cases.

RESULTS

Localization of the stones was easy in 81 cases and more difficult in 19, but an intravenous pyelogram was only necessary in three cases. The number of sessions per patient varied from 1 to 3 (mean 1.17). Complete success rate was achieved in 75% of patients and partial success (residual stones < or = 3 mm) in 6%. The stone-free rate was statistically affected by stone size but was independent of stone localization or the degree of obstruction. The rate of infective and obstructive complications was 14% and auxiliary treatments were necessary in 5% of patients.

CONCLUSION

In situ piezoelectric ESWL with the EDAP LT 02 device is a convenient and efficient method for the treatment of ureteric stones.

Laparoscopic ureterolithotomy: the results of an initial series, and an evaluation of its role in the management of ureteric calculi

OBJECTIVE

To evaluate the place of laparoscopic ureterolithotomy in the management of ureteric calculi for which extracorporeal shockwave lithotripsy (ESWL) and endourological techniques are unsuitable.

PATIENTS AND METHODS

Laparoscopic ureterolithotomy was attempted in nine patients (eight men, one woman) with an age range of 26-81 years (mean 55.5) who had large, long standing and impacted calculi in the upper and mid ureter. The stone size ranged from 5 to 28 mm (mean 13.2) and stone duration ranged from one to 24 months (mean 8.2). The transperitoneal route was used in six patients and the extraperitoneal route in three but was converted to a transperitoneal approach in two.

RESULTS

The stone was successfully removed in all nine patients. The operative time ranged from 80 to 260 minutes (mean 158). No intra-operative complication was encountered and no patient required a blood transfusion. Post-operative complications included urinary leak and fever. The post-operative stay ranged from 2 to 13 days (mean 5.2).

CONCLUSIONS

Laparoscopic ureterolithotomy has definite advantages over open ureterolithotomy. Furthermore, the more difficult a stone is for treatment by ESWL and endourological techniques, the more suitable it is for laparoscopic removal. For large, hard, long-standing and impacted ureteric calculi, one laparoscopic ureterolithotomy as initial therapy may be preferable to multiple endourological and ESWL procedures.