Treatment of ureteric stones. Comparison of laser and pneumatic lithotripsy

Can stone migration be predicted preoperatively in ureteroscopic lithotripsy?

OBJECTIVE

In our study, we aimed to evaluate the parameters that are effective in predicting the possibility of stone migration during ureteroscopic lithotripsy.

PATIENTS AND METHOD

We divided our patients two group whom we applied ureteroscopic lithotripsy. Patients who migrated stones during ureteroscopic manipulation to the 1st group, and the patients who did not migrate stones to the second group were included. We measured the proximal ureter diameters of the patients in both groups on their computed tomography. We compared these values statistically. In addition, we determined a cut-off value for the ureter diameter to predict the possibility of stone migration.

RESULT

Especially, ureter diameters of patients with middle and lower ureter stones showed significant differences between groups. Also, stone sizes differed significantly between groups.

CONCLUSION

We concluded that the possibility of stone migration is high in patients with a ureter diameter higher than 7.45 mm in the middle and lower ureteric stones. Also, we believe that stone diameter and the surgeon's experience are effective factors in stone migration.

Giant urethral calculus in anterior urethral diverticulum: a case report

BACKGROUND

In this case report, giant calculus in the urethral diverticulum was found through ureteroscopy investigation, the pneumatic lithotripsy combined with ultrasound lithotripsy (PLCUL) was successfully performed to break down this rare and giant urethral calculus in the diverticulum without open surgery.

CASE PRESENTATION

A 82-year-old male presented to the urology department, complaining of frequent urination and dysuria. One giant, dark brown stone (6.5 × 6 × 5.5 cm) was revealed in the diverticulum of the anterior urethra using combination of local ultrasound, pelvic Computer Tomography (CT) and Magnetic Resonance Imaging (MRI). The stone was then successfully broken down via the PLCUL, and the emptied anterior urethral diverticulum was left untreated. In the 18 months' follow-up, no new calculus was found in urethral tract, anterior diverticula became gradually smaller, eventually disappeared.

CONCLUSION

In the treatment of giant calculus in the urethral diverticulum, this case report provides an effective method of lithotripsy in the clinical trials.

Comparison of Ho:YAG laser and pneumatic lithotripsy in the treatment of impacted ureteral stones: an analysis of risk factors

The aim was to compare pneumatic and holmium:yttrium-aluminum-garnet laser in the treatment of impacted ureteral stones with different locations and to identify the risk factors for complications. Between March 2005 and November 2012, a total of 230 patients underwent ureteroscopic lithotripsy for impacted stones. Of the patients, 117 had pneumatic and 113 had laser lithotripsy for the fragmentation of the stones. Treatment outcomes based on evidence of being stone free were evaluated. Preoperative, operative, and postoperative follow-up findings were analyzed and compared. There was a difference between the two groups according to overall stone clearance rate (93.8% vs. 80.3%, p = 0.002). There was no statistically significant difference for distal location between the laser and pneumatic groups (96.8% vs. 91.7%, p =0.288). For 10 patients with intrarenally migrated stones who were managed with flexible ureterorenoscopy in the same session, laser lithotripsy was more successful than pneumatic for proximal ureteral stone (94.4% vs. 67.9%, p = 0.007). The overall complication rate was 26.1%. There was no statistically significant difference between the two groups (29% vs. 23%, p = 0.296). Multivariate logistic regression analysis revealed that the proximal location was a statistically significant parameter for the occurrence of complications in both groups (p = 0.001 for PL, p = 0.004 for laser). The pneumatic and holmium:yttrium-aluminum-garnet laser lithotripsy are effective in the treatment of distal impacted stones. Both treatments with semirigid ureteroscopy are acceptable for proximal impacted ureteral stones, but holmium laser lithotripsy has an advantage of use with flexible ureteroscope for intrarenally migrated stone.

Treatment of ureteral stones: A prospective randomized controlled trial on comparison of Ho:YAG laser and pneumatic lithotripsy

OBJECTIVES

To study the treatment of ureteric stones by HO:YAG laser lithotripsy and pneumatic lithotripsy and to evaluate the results of the two treatment modalities to assess effectiveness and complications.

MATERIALS AND METHODS

Over 1-year period, a total of 79 patients with 82 ureteral stones were randomized into two groups. In group 1 (39 cases with 41 ureteral stones) ureteroscopic HO:YAG laser lithotripsy was performed using a rigid 8 Fr-ureteroscope (LL group). In group 2 (40 cases with 41 ureteral stones) pneumatic lithotripsy was performed in like manner. Efficacy safety and complications in both groups were analyzed.

RESULTS

A total of 79 patients with 82 calculi were treated. Two cases in LL group and one in PL group had bilateral ureteral stones. Mean stone size was 12.07 mm in LL group and 10.2 mm in PL group. Stones located in lower ureter in 30 cases on LL group and 29 cases in PL group. Proximal migration of stone occurred in 1 case on LL group and in 3 cases on PL group. Successful fragmentation occurred in 37 cases on LL group and in 30 cases on PL group. Stone-free rate after 1 month in the base of Kidney Ureter Bladder (KUB) and sonography was 95% in LL group and 80.5% in PL group. Ureteral perforation, urinoma, and urosepsis were not seen in both groups.

CONCLUSION

HO:YAG laser has advantages over PL in high efficacy of stone fragmentation and a low-retrograde migration of ureteral stone treatment. Other complication of ureteral stone treatment with LL and PL are the same and very rare.

Use of pneumatic lithotripsy for managing difficult CBD calculi

INTRODUCTION

About 7-12% of patients who harbor gallbladder calculi concomitant common bile duct (CBD) calculi are present. The treatment of gallbladder calculi has standardized in the form of laparoscopic cholecystectomy but management of CBD calculi is still evolving. Endoscopic removal of CBD calculi <2 cm in diameter is successful in 90-100% of cases but patients harboring stones >2 cm in diameter high failure rates can be seen. Traditionally, laparoscopically one can achieve success rate comparable to endoscopic surgery but large and impacted calculi may cause failures. If one uses pneumatic lithotripsy during laparoscopic management of CBD calculi one can achieve 100% stone clearance irrespective of size, degree of hardness and impaction. This study evaluates the feasibility of using pneumatic lithotripsy for CBD calculi. To our knowledge this is the 1st reported series of using pneumatic lithotripsy for CBD calculi.

MATERIAL AND METHODS

From June 2002 to June 2010 96 laparoscopic CBD explorations (LCBDE) were done for CBD calculi. Patients having choledocholithiasis with CBD diameter of >10 mm were taken for LCBDE while in patients with CBD diameter of <10 mm were referred for endoscopic clearance. Additionally ERCP failure cases were also subjected to LCBDE. Rigid nephroscope was used for LCBDE and usually calculi were removed by forceps only. In patients having large, hard &/or impacted calculi pneumatic lithotripsy were used for fragmentation.

RESULTS

Out of the 96 patients in 12 (12.5%) cases pneumatic lithotripsy was used for stone fragmentation. Out of these 12 cases 5 (41.6%) were ERCP failure cases. At a mean hospital stay of 2.5 days 100% stone clearance was achieved in all cases with no perioperative complication.

CONCLUSION

The present study shows how successfully pneumatic lithotripsy can be used to fragment large, hard &/or impacted CBD calculi. Pneumatic lithotripsy being user friendly easily available can reliably fragment CBD calculi in one session.

Pneumatic lithotripsy for large ureteral stones: is it the first line treatment?

OBJECTIVE

To evaluate the effectiveness of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of large ureteral stones.

METHODS

We reviewed, retrospectively, the records of 156 patients (122 male, 34 female) who had ureteral calculi larger than 10 mm that were treated with PL. Of these patients, 41 (26.3%) were treated primarily with PL and 115 (73.7%) were treated secondarily after unsuccessful extracorporeal shock wave lithotripsy (SWL). The mean stone diameter was 12.87 mm (range 10-20.5 mm). Results were evaluated 3 months after treatment by excretory urography and/or ultrasonography.

RESULTS

The overall stone-free and fragmentation rates (FRs) were 85.2 and 92.3%, respectively. Corresponding values were 60 and 84% for upper ureteral stones, 79.5 and 89.7% for middle ureter stones and 94.5 and 95.6% for lower ureteral stones, respectively. The main complications were migration of a complete stone or of fragments (7.1%), urosepsis (4.5%) and ureteral perforation (1.3%).

CONCLUSIONS

Although SWL is generally accepted as the first treatment option for ureteral stones because of its non-invasive nature, PL with ureteroscopy seems to be a good alternative with the advantage of higher success rates and quick stone clearance. Especially when we take the importance of quick stone removal into account for larger ureteral stones, which are more likely to have obstruction, impaction, or infection, we believe that PL may be chosen as the first line treatment rather than SWL for stones larger than 10 mm.

Operative Failure during Ureteroscopic Pneumatic Lithotripsy: Factors Affecting Successful Outcome

AIM

We aimed to evaluate the predictive factors that would in turn indicate stone migration and the effects of these factors on the ultimate success of the intervention.

METHOD

Patients were divided into two groups with respect to the migration of the stone treated. Group I: patients demonstrating stone migration during manipulation; group II: no migration of the stones noted. In the second phase of the study, the results of ureteroscopic management in 433 patients were evaluated with respect to the success rates obtained. Parameters such as stone size, stone burden, experience of the surgeon, length of the ureter proximal to the stone treated, and lastly transverse diameter of the ureter were noted in all patients as possible risk factors for stone migration.

RESULTS

Statistical analysis of ureteroscopic success in all patients revealed that there was a meaningful correlation with respect to the length of the proximal ureteral portion (p < 0.0001) and surgeon's experience (p = 0.004). p value for the correlation between stone burden and operative success was 0.056. There was no significant correlation between stone size (p = 0.51), ureter diameter (p = 0.78), and operative success.

CONCLUSION

Stones that are close to the renal pelvis and treated by inexperienced physicians are the ones most likely to migrate to the renal pelvis during manipulation with pneumatic lithotripsy.

Complications of pneumatic ureterolithotripsy in the early postoperative period

PURPOSE

To document the perioperative and early postoperative complications of pneumatic ureterolithotripsy.

PATIENTS AND METHODS

Between January 1997 and December 2003, pneumatic ureterolithotripsy was performed in 665 male and 314 female patients for stones >0.5 cm. The age range was 9 months to 72 years (mean 41 years). Preoperatively, intravenous urography, urinalysis, and urine culture were done. Cefepime 1 g was given as prophylactic antimicrobial therapy 1 hour prior to surgery. A plain film of the urinary tract was taken immediately before the procedure. The operations were carried out with the patient under general anesthesia. Rigid ureteroscopes (6.9F ACMI "micro-6" or 8F-10F Storz) and the Vibrolith (Elmed, Ankara, Turkey) pneumatic lithotripter were used. The fragments were extracted with forceps or baskets. Urinalysis and culture as a routine postoperative evaluation and a plain film or ultrasonogram of the urinary tract when needed were done 1 week after the procedure.

RESULTS

The stones were completely removed in 847 patients (86.5%); 783 (80%) of them went home on the day of surgery. A ureteral stent was needed in 401 patients (41.0%). Perioperative complications were migration of the stone into the kidney in 70 patients (7.2%), mucosal damage in 34 (3.5%), ureteral perforation in 17 (1.7%), ureteral avulsion in 4 (0.4%), and conversion to open surgery in 3 (0.2%). During the early postoperative period, flank pain (18.4%), pelvic discomfort (5.5%), macroscopic hematuria (7.3%), and urinary tract infection (5%) were recorded.

CONCLUSION

Ureterolithotripsy by a pneumatic lithotripter is a minimally invasive, highly tolerable procedure with a low complication rate and short hospital stay when performed meticulously with appropriate instruments.

Is Early Forceps Application Necessary in the Treatment of Distal Ureteral Stone with Dye-Laser and Pneumatic Lithotripsy?

We report the success and complication rates of pulsed dye-laser and pneumatic lithotripsy methods, as well as emphasizing the importance of early forceps application.

Materials and Methods

We retrospectively evaluated ureterorenoscopy performed in 900 patients, between April 1996 and May 2004, due to distal ureter stones. Following stone fragmentation, patients with stones ≤4 mm in diameter were accepted as stone-free and patients with stones >4 mm had them removed with forceps.

Results

In the laser treated group, the 1st stone-free rate in patients with a stone diameter ≤4 mm was 56.9%. In this group, when forceps were used in patients after fragmentation, the total stone-free rate increased to 96.8%. Likewise, while the 1st stone-free rate in the pneumatic group was 71.56%, the total stone-free rate increased to 96.73% after forceps application.

Conclusion

Both success and complication rates were found to be significantly higher in the pneumatic lithotriptor applied group.

Management of ureteral stones with pneumatic lithotripsy: report of 500 patients

PURPOSE

To evaluate the results of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of ureteral stones.

PATIENTS AND METHODS

We reviewed, retrospectively, the records of 500 patients (366 male, 134 female) with ureteral calculi treated by PL with the Swiss Lithoclast. Of these patients, 124 (24.8%) were treated primarily and 376 (75.2%) were treated secondarily after unsuccessful extracorporeal shockwave lithotripsy (SWL). The results were evaluated 3 months after treatment by excretory urography, ultrasonography, or both.

RESULTS

The over-all stone-free and fragmentation rates were 94.6% and 96.8%, respectively. These values were 97.1% and 98.5% for stones <or=10 mm and 83.7% and 89.1% for stones >10 mm, respectively. The main complications were stone migration (2.0%), urosepsis (3.0%), and ureteral perforation (1.4%).

CONCLUSIONS

While SWL is generally excepted as a first-line treatment option in ureteral stones because of its noninvasive nature, in situ lithotripsy, and especially PL, has higher success rates with minimal morbidity. Thus, PL seems to be a good alternative in patients in whom SWL was unsuccessful or not indicated and in patients who need early stone removal.

Utility of the lithoclast in the treatment of upper, middle and lower ureteric calculi

OBJECTIVE

The aim of this study was to evaluate the utility and efficacy of lithoclast in the treatment of upper, middle and lower ureteric calculi.

PATIENTS AND METHODS

Over a period of 6 1/2 years, we have treated 529 ureteric stones which failed to pass spontaneously within a 2-week period. Patients were evaluated for number, site, size and laterality of stones. Patients with ureteroscopy failure were excluded from the study. Once the stone(s) was (were) localised with the ureteroscope, it (they) was (were) treated with the Swiss lithoclast.

RESULTS

Complete fragmentation was achieved in 99% of cases with lower, 97% with mid and 71% with upper ureteric calculi, respectively. The lithotripsy time was only 8.6 minutes for stones < or =1 cm and 14.8 minutes for stones ranging from 1.1 to 2.0 cm. Completely fragmented stones cleared spontaneously within two weeks in 98% of cases and all patients were free of calculi one month after the procedure. Retreatment with the lithoclast was required in six patients for large residual fragments. The mean hospital stay was 1.2 days. Complications were encountered in 6.8% of cases and were managed conservatively.

CONCLUSIONS

Pneumatic lithotripsy is an excellent form of treatment for lower and mid-ureteric calculi. It is a very reliable, highly effective, rapid and safe procedure.

Comparative study of pulsed dye laser and pneumatic lithotripters for transurethral ureterolithotripsy

BACKGROUND

Clinical effectiveness and safety of the Swiss Lithoclast (Lithoclast) and the Candela MDL-2000 (MDL) in the treatment of lower ureteral stone were examined retrospectively.

METHODS

Eighty-six stones from 66 patients and 26 stones from 20 patients were treated by Lithoclast and MDL, respectively.

RESULTS

The stone-free rate on 3-month follow-up was 97% and 95% for the Lithoclast and MDL, respectively (no significant difference). The operation time was significantly shorter for the Lithoclast than for the MDL (90.2+/-50.2 vs 120.4+/-55.1 min; P<0.05). Postoperative analgesics were required significantly less frequently in Lithoclast (10/66 vs 11/20; P<0.01). Postoperative hospital stay was significantly shorter for Lithoclast (8.7+/-5.1 vs 12.1+/-4.2 days; P<0.01).

CONCLUSIONS

Swiss Lithoclast is an effective and less invasive modality for endoscopic treatment of lower ureteral stones.

Electrokinetic lithotripsy: safety, efficacy and limitations of a new form of ballistic lithotripsy

OBJECTIVE

To investigate the safety and efficacy of electrokinetic lithotripsy (EKL), a ballistic lithotripter which uses high-energy magnetic fields to propel an impactor to fragment calculi.

PATIENTS AND METHODS

The records and radiographs of 121 patients who underwent ureteroscopy using the EKL for stones in the upper (26), mid (28) or lower (67) ureter were reviewed retrospectively. Ureteroscopy was performed with an 8.5 F semi-rigid ureteroscope, through which a 3 F EKL probe was passed.

RESULTS

A total of 148 stones (mean stone size 11.5 mm, range 6-40) in 121 patients were treated using the EKL. One patient was lost to follow-up. Of 148 stones, 147 (99.3%) were fragmented, including five that had resisted fragmentation with either pulsed-dye laser or electrohydraulic lithotripsy. Despite this, only 45 of 56 patients (80%) with a single stone in the lower ureter were rendered stone-free after a single ureteroscopic procedure. Seven patients in this group (12%) required shock-wave lithotripsy for fragments that had been propelled into the kidney, while four patients (7%) required repeat ureteroscopy for retained ureteric fragments. Complications were limited to minor ureteric perforations in two patients, both of which were treated with a stent.

CONCLUSION

EKL is an inexpensive and reliable endoscopic method which fragments nearly all urinary calculi. Its limitations include the propulsion of fragments and the need to use an offset, semi-rigid ureteroscope. We recommend the use of a basket or graspers to remove fragments of >/=4 mm after EKL.

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.

Holmium: YAG lasertripsy for ureteric calculi: an experience of 300 procedures

OBJECTIVE

To assess the success of holmium:YAG lasertripsy in the management of ureteric calculi and to audit the complications of the procedure, with special reference to strictures in the ureter.

PATIENTS AND METHODS

A total of 300 ureteroscopic laser procedures were carried out on 265 patients (204 male and 61 female, median age 51 years, range 2-95) with ureteric calculi. At ureteroscopy, the calculi were present in the upper ureter in 44%, mid-ureter in 37% and lower ureter in 19% of patients; most calculi were > 5 mm. A 7.5 F Wolf semi-rigid ureteroscope was used and the holmium:YAG laser energy delivered using the Sharplan ML210 device at 0.8-1.0 J/pulse. The patients were followed up at approximately 6 weeks with limited intravenous urography or ultrasonography to assess clearance and the incidence of strictures.

RESULTS

Stones were completely cleared in 90% of the patients, with the best results in the lower and mid-ureter (97% and 96%, respectively) followed by the upper ureter (89%). Alternative procedures were required in only 17 (7%) patients; extracorporeal shock-wave lithotripsy in 13, percutaneous nephrolithotomy in two and open pyelolithotomy in two patients. Complications with ureteric perforation in 11 patients, including laparotomy for peritonitis in one, serious sepsis in two and strictures in 10 patients. Strictures were more common in association with impacted calculi in the upper ureter early in the series.

CONCLUSIONS

Holmium:YAG lasertripsy is a highly effective treatment for ureteric calculi, with strictures related to the treatment of difficult upper ureteric calculi.

Ureteroscopic lithoclast lithotripsy: a cost-effective option

Seventy-four consecutive cases of ureteral stones listed for ureteroscopic lithotripsy were studied prospectively. In all cases, the Wolf 7.5F or 9F ureteroscope was used in conjunction with the Swiss Lithoclast system. Dormia baskets were employed on four occasions to prevent forward propulsion of fragments. Ureteroscopic access to the stones was successful in 70 patients (95%). Lithoclast lithotripsy was successfully applied in 68 patients (92%), with complete fragmentation noted in 62 patients (91%), one requiring two sessions. The 6-week stone-free rate was 96% for these patients. Five patients with partial fragmentation had successful adjuvant SWL. The overall successful fragmentation rate was thus 84% (62 of 74) and 91% (67 of 74) in combination with adjuvant SWL. Cost analysis indicated a three-fold advantage for the Lithoclast over Candela lasertripsy. Ureteroscopic Lithoclast lithotripsy is a cost-effective treatment modality for ureteral stones.

Cost effectiveness of electrohydraulic lithotripsy v Candela pulsed-dye laser in management of the distal ureteral stone

To compare the efficacy, safety, and cost of the Candela laser lithotripter with those of the electrohydraulic (EHL) lithotripter in the management of distal ureteral stones, 24 patients with obstructing stones were randomized to laser lithotripsy or EHL. Ureteroscopy was performed with a 6.9F ACMI Miniscope under general anesthesia. Twelve patients were treated with laser lithotripsy using the Candela Air-Cooled MDL 2000 LaserTripter System with a 200-micron pulsed-dye laser fiber. Twelve patients were treated with the Herzog Electrohydraulic LithoTripter using the 1.9F fiber. The following issues were studied: stone-free rates, complications (intraoperative, postoperative, and late), and costs of the procedure. No difference was found in the stone-free or complication rates. One patient was found to have hydronephrosis at 6 months secondary to an unrelated proximal ureteral stone. There was no difference in the efficacy of laser lithotripsy and EHL in the management of distal ureteral stones, but EHL was found to be significantly more cost effective: the cost for EHL was +336 per case, whereas, the cost for lasertripsy was +4220 per case, a greater than 10-fold difference.

Intracorporeal pneumatic lithotripsy for ureteral and vesical calculi

To evaluate the effectiveness of pneumatic lithotripsy, 92 patients with 98 lower or mid-ureteric calculi and 8 with vesical calculi were treated with pneumatic lithotripsy (Swiss Lithoclast) under spinal anaesthesia. Successful stone fragmentation was achieved in 96 patients. In two patients their stones migrated to the upper ureter and renal pelvis during the procedure and so they were referred for extra corporeal shock wave lithotripsy. Total ureteral avulsion occurred in one patient and in another case attempts to dilate the stenotic ureteral orifice failed. In both cases, ureterolithotomy and ureteral reimplantation were performed. Pneumatic lithotripsy is found to be an easy, reliable and cost-effective method of endoscopic lithotripsy.