Outcomes of primary ureteroscopic lithotripsy: The role of maximum ureteral wall thickness at the site of stone impaction

OBJECTIVES

To verify if the maximum thickness of the ureteral wall at the stone site (m-UWT) can affect the outcomes of primary retrograde ureteroscopic lithotripsy (P-URSL) within a single-center dataset.

MATERIAL AND METHODS

We retrospectively reviewed data on 354 consecutive URSL performed from January 2020 to May 2022 at "Fondazione Poliambulanza" in Brescia (Italy). We included patients older than 18 years who underwent URSL for a single ureteral stone with a maximum diameter ranging from 5 to 10 mm. Patients with anatomical abnormalities, a positive preoperative urinary culture, or without a NCCT performed during the acute event were excluded. Patients were treated in an emergency setting (P-URSL within 48 h from the diagnosis of acute ureteral colic) or in a delayed one (D-URSL after a period of maximum 90 days of ureteral double-j stenting). For the resulting 139 patients we recorded demographic, clinical and stone-related features and perioperative data. We processed these data by univariate and multivariate analysis, and with a logistic regression analysis.

RESULTS

Of the 139 included procedures, 63 were P-URSL and 76 D-URSL. At the univariate analysis we found that stone diameter (OR 0.845, p = 0.017), stone volume (OR 0.023, p = 0.001), stone density (OR 0.998, p = 0.000) and m-UWT (OR 0.499, p = 0.013) are predictors of P-URSL. Stone density (OR 0.998, p = 0.002) is an independent predictor of P-URSL at the multivariate analysis. At a logistic regression analysis, a distal ureteric position (OR 0.189, p = 0.014), stone diameter (OR 1.289, p = 0.006), and m-UWT (OR 2.297, p = 0.02) were found to be statistically significant predictors of incomplete stone clearance in patients undergoing P-URSL. m-UWT is the only predictor of short-term postoperative adverse events in patients undergoing P-URSL (OR 3.386, p < 0.001). From a descriptive analysis, it emerged that an increased m-UWT (>2 mm) significantly correlates to an endoscopic finding of ureteritis' signs and to an increase in operative time, hospital stay and post-procedural stenting time. A m-UWT greater than 2 mm also correlates with a lower stone free rate (SFR) and with a significant increase in both short and long-term postoperative complications.

CONCLUSIONS

Our study confirmed a connection between m-UWT and poor endoscopic findings, as well as a direct correlation with the main morphometric parameters of the stone and finally with the outcomes of P-URSL itself. Further studies are necessary to validate our results, so that m-UWT might be routinely considered a useful tool in the decision-making process for P-URSL.

Assessment of the incidence and risk factors of postoperative urosepsis in patients undergoing ureteroscopic lithotripsy

Introduction

Ureteroscopic lithotripsy (URSL) is an approved, minimally invasive, low-risk procedure for urolithiasis treatment. However, some patients may develop urinary tract infection (UTI) post-procedure, eventually leading to urosepsis. Determining the predictors of infection after URSL would help identify patients at a high risk of urosepsis, thereby enabling the early implementation of effective treatment. Therefore, we aimed to establish the incidence and predictors of urosepsis after URSL.

Material and methods

We assessed 231 patients who underwent URSL using a holmium laser. The incidence of urosepsis during the 30-day post-treatment period was analysed, and potential predictors of urosepsis, including patient characteristics and individual clinical factors, were examined.

Results

Statistical analysis revealed that 16.88% of patients had a confirmed positive urine culture before the procedure. Post-procedure urosepsis occurred in 4.76% of patients. Univariable analysis revealed that 3 factors were significantly associated with the risk of postoperative urosepsis: double-J stent insertion before URSL, pre-operative positive urine culture, and MDR pathogen found preoperatively. In multivariable analysis, only positive urine culture remained significantly associated with the risk of urosepsis after URSL.

Conclusions

Patients with positive urine culture before URSL are at significantly higher risk of urosepsis in the postoperative period. Hence, urine culture should be routinely performed before planned endoscopic urolithiasis treatment.

Efficacy of Robot-Assisted Ureteroureterostomy in Patients with Complex Ureteral Stricture after Ureteroscopic Lithotripsy

BACKGROUND

Ureteral stricture (US) postureteroscopic lithotripsy (URSL) has emerged as a severe complication with the widespread use of laser technology. Furthermore, managing a complex US is challenging. Therefore, this study evaluated the efficacy of robot-assisted ureteroureterostomy (RAUU) in addressing US post-URSL and analyzed the pathology of transected ureteral tissues to identify the risk factors for US.

METHODS

we conducted a prospective cohort study on patients who underwent RAUU for URSL-induced US from April 2021 to May 2023.

RESULTS

A total of 14 patients with a mean age of 49.8 years were included in this study. The mean stricture length on radiography was 22.66 ± 7.38 mm. Nine (64.2%) patients had experienced failure with previous interventions. The overall success rate was 92.9%, both clinically and radiographically, without major complications, at a mean follow-up of 12.8 months. The pathological findings revealed microcalcifications and a loss of ureteral mucosa in 57.1% and 28.6% of patients, respectively.

CONCLUSIONS

The RAUU technique shows promise as a viable option for US post-URSL in appropriately selected patients despite severe pathological changes in the ureter. Therefore, the migration of microcalcifications to the site of ureteral perforation may be a significant factor contributing to US development.

Challenges of Retrograde Ureteroscopic Procedures in Overweight Patients

BACKGROUND

Obesity and urolithiasis are both prevalent conditions that have an impact on the healthcare system. The ureteric diameter and accessibility play a crucial role in the management of urolithiasis in both overweight and normal weight patients. Studies have shown that obesity can lead to changes in ureter diameter where excessive body fat can exert pressure on the kidneys, causing them to enlarge in size and this enlargement can result in a compression of the adjacent structures, including the ureter. The aim of this study is to assess the incidence of intraoperative challenges faced during retrograde ureteroscopic procedures in overweight patients with ureteric and renal calculi.

METHODS

We retrospectively reviewed patients who underwent retrograde ureteroscopic surgery (RURS) for urolithiasis from 1st January 2021 until 30th August 2023. The outcome and any complications were documented and compared with the patient's Body Mass Index (BMI). All patients who undergo RURS in our facility have to have a Non-Contrast CT scan prior to surgery. Procedural success was determined by the ability to obtain access to the stone site intraoperatively and stone-free status in kidney, ureter, and bladder (KUB) X-ray post-operatively. Post-operative complications were recorded up to two weeks post-operatively and classified according to the Calvein Dindo Classification.

RESULTS

Our total sample size was 146 patients out of which 75 were overweight and 71 were normal weight patients. In 34 (45%) of overweight patients' access to the ureter was restricted due to a narrow ureteric orifice with ureteroscopy not successful; on the contrary 13 (18%) of normal weight patients faced this same issue. This was statistically significant with a p-value of .004. The stone clearance rates were 91% and 95% in overweight and normal weight patients respectively, which is higher in normal weight patients however this difference was not found to be a statistically significant finding (p-value .028). Overweight patients had 12% Grade I and 8% Grade II complications whereas normal weight patients had 11% Grade I complications and 1.4% Grade II with no higher-grade complications.

CONCLUSION

Retrograde ureteroscopic procedures are a safe treatment modality for patients with urolithiasis in both overweight and normal weight populations. They are shown to have similar success rates between both populations once ureteric access is obtained. However, access failure rates are shown to be slightly higher in overweight patients. Hence, further preoperative patient counselling and technical considerations should be undertaken.

Effect of moxibustion on ureteral stent-related symptoms after ureteroscopic lithotripsy

OBJECTIVES

To observe the clinical efficacy of moxibustion combined with western medication on ureteral stent-related symptoms after ureteroscopic lithotripsy (URL).

METHODS

One hundred and fifty patients with upper urinary tract calculus implanted with ureteral stents after URL were randomly divided into a moxibustion group (50 cases, 1 case dropped out), a placebo moxibustion group (50 cases, 3 cases dropped out) and a blank control group (50 cases). No intervention was performed in the blank control group. On the basis of oral administration with tamsulosin hydrochloride sustained release capsule (starting from the first day after surgery, once a day, 0.2 mg each time, continuously for 4 weeks), in the moxibustion group, moxibustion was operated at Guanyuan (CV 4) and bilateral Shenshu (BL 23); the sham-moxibustion was delivered at the same acupoints in the placebo moxibustion group, once daily, 6 times a week, for 15 min in each treatment. The duration of treatment was 4 weeks. Before treatment, and after 1, 2 and 4 weeks of treatment, the scores of lower urinary tract symptoms, body pain, general health, work performance and satisfaction of sexual matters were compared among the 3 groups. The tract calculus clearance rate, urinary infection and the oral administration of painkillers were compared after 4 weeks of treatment in the 3 groups.

RESULTS

The scores of lower urinary tract symptoms, body pain and general health after 1 week of treatment, and the scores of lower urinary tract symptoms, body pain, general health and work performance after 2 and 4 weeks of treatment were lower than those before treatment in the 3 groups (P<0.01). The scores of lower urinary tract symptoms and body pain in the moxibustion group after 1, 2 and 4 weeks of treatment were lower than those in the blank control group and the placebo moxibustion group (P<0.01, P<0.05) respectively. The score of general health in the moxibustion group was lower than that in the blank control group after 1 week of treatment (P<0.01), and lower than those of the blank control group and the placebo moxibustion group after 2 and 4 weeks of treatment (P<0.01, P<0.05). Regarding the score of work performance, it was lower in the moxibustion group after 1 and 2 weeks of treatment compared with those in the blank control group (P<0.05, P<0.01), and lower than those of the blank control group and the placebo moxibustion group after 4 weeks of treatment (P<0.01, P<0.05). The tract calculus clearance rate in the moxibustion group was 95.9% (47/49), higher than that in the blank control group (80.0%, 40/50, P<0.05). The proportion of oral administration of painkillers in the moxibustion group (28.6%, 14/49) and the placebo moxibustion group (40.4%, 19/47) was lower than that in the blank control group (76.0%, 38/50, P<0.01) respectively.

CONCLUSIONS

Moxibustion combined with western medication relieves lower urinary tract symptoms and body pain, and accelerate the recovery of general health and work performance in the patients after URL.

Correlation of the Degree of Hydronephrosis and Computed Tomography Value of Calculi with Efficacy of Ureteroscopic Lithotripsy in Patients with Upper Urinary Tract Infectious Calculi

OBJECTIVE

The correlation of the degree of hydronephrosis and computed tomography (CT) value of calculi with the efficacy of ureteroscopic lithotripsy (URSL) in patients with upper urinary tract infectious calculi was explored.

METHODS

The clinical data of 152 patients with upper urinary tract infectious calculi and on URSL in Shanghai Baoshan District Wusong Central Hospital from November 2019 to November 2021 were collected for retrospective analysis. All patients received CT examination before surgery. According to the therapeutic effect of URSL, all patients were divided into the non-calculi group (NCG, n = 101) and residual calculi group (RCG, n = 51), which were compared in terms of the degree of hydronephrosis and CT value of calculi. Then, the correlation of the degree of hydronephrosis and CT value of calculi with the efficacy of URSL in patients was analysed.

RESULTS

No significant difference in clinical data was found between the groups (p > 0.05). Patients in the NCG group had lower degree of hydronephrosis than those in the RCG group (p < 0.05), and the NCG had lower CT value of calculi (p < 0.001). Spearman rank correlation analysis showed that the degree of hydronephrosis in patients with upper urinary tract infectious calculi was negatively correlated with the efficacy of URSL (r = -0.676, p < 0.001), and the CT value of calculi in such patients was negatively correlated with the efficacy of URSL (r = -0.795, p < 0.001).

CONCLUSIONS

The degree of hydronephrosis and CT value of calculi were negatively correlated with the efficacy of URSL. Both can be used to predict clinical efficacy and have clinical guiding value for the formulation of treatment plans in patients with urinary tract infectious calculi.

A nomogram for predicting the risk of residual stone fragments after ureteroscopy

Background

The residual stone fragment is a tremendous issue after ureteroscopic lithotripsy and requires urologists to evaluate the condition of patients comprehensively. Our study aimed to construct a nomogram to make a personalized prediction of postoperative residual stone rate (RSR).

Methods

We implemented a retrospective cohort study in the Department of Urology, Shanghai General Hospital. A total of 277 patients undergoing ureteroscopy (URS) were enrolled in our study. Among them, 186 patients were included in the training group and the remaining 91 patients comprised the testing group. We utilized stepwise forward algorithm and logistic regression analysis to build predictive models and selected the best model based on Akaike's information criterion (AIC). The model was assessed by receiver operating characteristic (ROC) curves and the Hosmer-Lemeshow (HL) test. We also conducted decision curve analysis (DCA) to demonstrate the net benefit of the model. The independent testing group was used to validate the practicability of the nomogram.

Results

The severity of hydronephrosis, stone location, the transverse diameter of stone, hypertension, and white blood cell (WBC) were found to be significant predictive variables for RSR after URS. The area under the curve (AUC) of the training group was 0.7203 and that of the testing group was 0.7280. Besides, the nomogram also presented great calibration and accepted net benefit in a wide range of probabilities.

Conclusions

Our study achieved a predictive nomogram with excellent application value for urologists to assess RSR and make personalized treatment decisions.

Comparison of the Efficacy of Different Surgical Approaches for Complicated Impacted Proximal Ureteral Calculi Based on a New Scoring Standard: A Matched-Pair Analysis

Objective: To compare the clinical efficacy of ureteroscopic lithotripsy (URSL) and percutaneous nephrolithotomy (PCNL) in the treatment of complicated impacted proximal ureteral calculi using a new scoring standard. Methods: The data of 45 patients with complicated impacted proximal ureteral calculi (score ≥3 points) who underwent URSL were collected in this retrospective study between January 2015 and April 2021. The definition and scoring standards for preoperative high-risk factors associated with stones included whether the diameter of the stone was >2 cm, stone density was >1000 HU, there was a history of lithotripsy, the degree of hydronephrosis was greater than moderate, and there was an infection. Scores for stones were then assigned (yes = 1, no = 0), and the complicated stone case was defined as a total stone score ≥3 points. During the same period, PCNL was used in 171 patients with complicated impacted proximal ureteral calculi. Forty-five patients were selected as the control group and matched at a 1:1 ratio to index URSL cases regarding age, sex, and body mass index. Perioperative data were compared between the two groups. Results: All 90 operations were completed effectively. Compared to the URSL group, the surgical duration of the PCNL group was significantly shorter (53.69 ± 25.07 vs 73.46 ± 27.12 minutes, p < 0.05), stone-free rate (SFR) was significantly higher (93.3% vs 68.9%, p < 0.05), and total treatment cost was lower (US $1678.61 ± 714.86 vs US $3901.45 ± 1069.46, p < 0.05). Conversely, the URSL group had a shorter hospital stay (3.68 ± 2.70 vs 6.39 ± 3.34 days, p < 0.05). There was a significant difference in complication rate between the two groups regarding Clavien grade I, II, or III complications (20.0% in URSL group vs 8.9% in PCNL group, p = 0.037). Conclusion: PCNL had a better SFR and higher surgical efficacy, whereas URSL had a shorter perioperative period, but a lower initial SFR. PCNL is often more advantageous for complicated impacted proximal ureteral calculi.

Emergency extracorporeal shock wave lithotripsy: A study on feasibility and efficacy in stone clearance and reducing morbidity in ureteric and renal stones with colic

OBJECTIVES

Evaluation of safety, efficacy, and feasibility of emergency extracorporeal shockwave lithotripsy (eESWL) in combating obstructing stones with colic on emergency basis.

MATERIALS AND METHODS

From November 2019 to November 2021, 102 subjects underwent emergency ESWL for obstructing ureteric and renal stones with colic within 24 h of presentation.

RESULTS

Patients in this study belonged to age group of 18-67 years with mean being 39 years consisting of 85 males and 22 females (M:F = 85:22). Mean stone dimensions were 8.26 mm in length and 7.65 mm in width. A total of 42 patients had their stone in kidney or upper ureter while 24 patients had stone in mid ureter and remaining patients (n = 36) had stone in lower ureter. About 65 patients had their stone completely cleared after single ESWL session while 20 patients required multiple sessions to achieve complete clearance. Of these 17 patients (16.67%) were not rendered stone free even after three sessions and had to undergo ureteroscopic lithotripsy (URSL). Overall Stone Free Rate (SFR) was 83.33%. For stone attenuation of ⩽900 HU, SFR was 97.18% while for >900 HU it was only 51.61%.

CONCLUSION

eESWL is safe, feasible, and efficacious noninvasive alternative for definitive management of obstructing ureteral and renal stones with colic as far as stone clearance and rapid and definitive pain relief are concerned and that too with very minimal morbidity without the need for admission and hence can reduce the prolonged waiting period for endoscopic stone surgery in any high-volume tertiary care hospital. Length, width, and attenuation of stone were found to be the main factors dictating the success of eESWL.

Status epilepticus in a patient with intractable epilepsy caused by renal colic due to a ureter stone

Introduction

Epilepsy has a variety of seizure-inducing factors. Epileptic seizures caused by renal colic are extremely rare.

Case presentation

A 22-year-old woman with intractable epilepsy was brought to our hospital as an emergency case, because of vomiting and status epilepticus. She had implanted a vagus nerve stimulator in the left anterior chest at the age of 20 years. Computed tomography showed a ureter stone in the right distal ureter. On the second day of hospitalization, ureteroscopic lithotripsy was performed under general anesthesia. The patient's seizures were controlled to a frequency of once a month or less in the four months after discharge.

Conclusion

We encountered a rare case of the frequency of status epilepticus increased by renal colic due to a ureter stone. Ureteroscopic lithotripsy was effective in controlling the frequency of status epilepticus increased by renal colic.

Cost-effectiveness of using stone cone, balloon dilator, stone basket, and entrapment device in ureteroscopic laser lithotripsy for ureteric stones

Objective

To evaluate the costs and stone-free rates of ureteroscopic laser lithotripsy (ULL) performed with and without auxiliary equipment and to compare first-time ULL with total treatment.

Methods

One hundred patients who underwent first-time ULL without the use of auxiliary equipment because its unavailability comprised the no-device ULL (ndULL) group. Additionally, 100 patients who underwent first-time ULL with the use of auxiliary equipment when necessary comprised the device ULL (dULL) group.

Results

In the ndULL and dULL groups, the stone-free rates after first-time ULL were 72% and 94% and the mean cost was US $1037 ± 15.10 and US $1452 ± 19.80 per case, respectively, with a statistically significant difference. The stone-free rates at the end of treatment were 98% and 99%, respectively, without a statistically significant difference. When secondary treatment costs were added to the first ULL costs after failed treatment, the mean total cost was US $1625 ± 12.60 in the ndULL group and US $1566 ± 11.01 in the dULL group without a statistically significant difference.

Conclusions

The stone-free rates and costs after first-time ULL were significantly different between the groups. However, after total treatment, there was no statistically significant difference between the two groups.

Comparison of the effects of retroperitoneoscopic ureterolithotomy and ureteroscopic lithotripsy in the treatment of upper ureteral calculi

ABSTRACT

This study compares the efficacy of retroperitoneoscopic ureterolithotomy (RPUL) and ureteroscopic lithotripsy (URL) in the treatment of upper ureteral calculi.The clinical data of 150 patients with upper ureteral calculi who underwent RPUL and 136 patients who underwent URL between January 2014 and October 2019 were retrospectively analyzed. The operation time, postoperative hospital stay, operation success rate, stone clearance rate, and surgical complications were evaluated between the two groups.For the RPUL and URL groups, respectively, the average operation time was 74.5 ± 24.6 minutes and 54.5 ± 13.2 minutes; the postoperative hospital stay was 5.8 ± 1.4 days and 3.2 ± 1.2 days; the operation success rate was 96.0% (144/150) and 85.3% (116/136); the incidence rate of complications was 3.5% (5/144) and 17.5% (18/103); and the stone clearance rate was 100% (144/144) and 88.8% (103/116), which were all statistically significant (P < .05).Both RPUL and URL had the advantages of low trauma and fast recovery rate for patients with upper ureteral calculi. However, patients who underwent RPUL showed higher success and fewer complication rate. RPUL might be a safe and effective laparoscopic method for the treatment of patients with upper ureteral calculi.

Fluoroscopy-free minimally invasive ureteral stricture balloon dilatation: a retrospective safety and efficacy cohort study

Background

Traditional ureteral stricture balloon dilation was performed with fluoroscopic assistance. The use of a C-arm X-ray machine delivered hazardous radiation to both surgeons and patients. In attempt to eliminate the radiation hazard, we developed a F4.5/6.5 ureteroscope assisted intraoperative X-ray free balloon dilation surgical approach to treat ureteral stricture and to verify its safety and efficacy. Specifically, this method had not been previously reported in the literature.

Methods

We demonstrated an intraoperative X-ray free balloon dilation with detailed step-by-step procedures description and video illustration. Clinical data of patients undergoing minimally invasive endourological treatment for ureteral stricture between February 2015 and November 2019 were retrospectively analyzed. All steps of X-ray free balloon dilation were carried out under direct vision of a ureteroscope, and two indwelling F7 ureteral stents were used for 3 months postoperatively. Preoperative, intraoperative, and postoperative clinical data were evaluated, and follow-up results were reported. Successful outcome was defined as disappearance of preoperative symptoms, relief of hydronephrosis and stable of renal function. Univariate and multivariate prognostic analyses were performed.

Results

We identified 109 patients who received endourological treatment for ureteral stricture in our hospital's medical database. After excluding patients undergone simple catheter dilation, endoureterotomy and other treatment method, 76 patients received balloon dilation without intraoperative fluoroscopic guidance were included in our study. 4/76 patients report a grade II complication (urinary tract infections, UTIs) according to Clavien Dindo classification. In the 22.5 months median follow-up time, the one-year cumulative success rate and two-year cumulative success rate were 85.9% and 80.2% (61/76), respectively, and the majority (13/15, 86.7%) recurrence of ureteral stricture or hydronephrosis deterioration were found within two years after surgery. The longer stenotic lesion length (>5 mm) or multiple ureter stenosis and compromised blood supply of ureter were significantly associated with postoperative stenosis recurrence.

Conclusions

X-ray free endoscopic balloon dilation is a safe and effective procedure that could be performed on patients with ureteral stenosis.

Effect of perioperative selective alpha-1 blockers in non-stented ureteroscopic laser lithotripsy for ureteric stones: a randomized controlled trial

Introduction

The aim of this studywas to assess the efficacy of perioperative alpha-1 blockers on improving the success rate and decreasing complications of non-stented ureteroscopic laser lithotripsy for ureteric stones.

Material and methods

A randomized control trial was conducted at two high volume urological centers from September 2017 to December 2018. We enrolled 150 patients with lower ureteric stones. They were randomly divided into two groups. Patients in group A, underwent non-stented ureteroscopy using Ho-YAG laser for stone disintegration and received alpha-1 blockers for one week preoperatively and another two weeks postoperatively. Patients in group B, underwent non-stented ureteroscopy and laser and received a placebo.

Results

One hundred and twenty patients were available for analysis at the end of our study. There was no statistically significant difference found between both groups regarding demographic data and stone parameters. The need for intraoperative ureteric dilatation was 32.7% and 51.6% for both groups A and B respectively with a statistically significant difference. The incidence of lower urinary tract symptoms (LUTS) and the need for analgesics were higher in group B with a statistically significant difference.

Conclusions

Administration of perioperative tamsulosin seems to not only to significantly decrease the need for intra-operative dilatation and hence operative time, but also leads to a significant decrease in the development of postoperative LUTs, postoperative pain and the need for analgesia and hospital stay.

Complete ureteral stenosis after ureteroscopic lithotripsy successfully managed using a simultaneous retrograde and antegrade flexible ureteroscopic approach

Both retrograde and antegrade approach contributed to the success of a delicate endoscopic procedure. Even when guidewire did not pass thorough to the stenosis lesion, lightning and contrast reagents contributed the way through to the stenosis lesion.

Management of urolithiasis in patients with chronic kidney disease

Context

Management of urolithiasis in patients with chronic kidney disease.

Aims

To ascertain the best method surgical or noninvasive.

Settings and Design

This was a single-institute study.

Subjects and Methods

A total of 50 patients of CKD with urolithiasis were enrolled in this comparative study. Clinical evaluation, biochemical evaluation, and radiological imaging were done. The management strategies were individualized to patient need. Following procedure, imaging and biochemical assessment were done to assess the stone clearance and improvement in the renal parameters. Intraoperative and postoperative complications are also noted. The patients were followed up to 6 months.

Statistical Analysis Used

Statistical Package for the Social Sciences version 21.0 software was used for statistical analysis.

Results

The mean age of the patients was 55.22 ± 10.76 years (range 28-76). Majority were male (76%) and had unilateral involvement. The mean preoperative hemoglobin (Hb), urea, creatinine, and total leukocyte count (TLC) were 9.49 ± 0.84 g%, 71.13 ± 24.09 mg/dl, 4.71 ± 2.45 mg/dl, and 8.67 ± 1.81 thousands/cumm, respectively. Percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL) were the most common procedures performed in 23 (46%) and 12 (24%) patients, respectively. In 5 (10%) patients, PCNL with URSL was used. The clearance rate for different techniques ranged from 40% (PCNL with URSL) to 91.7% (URSL alone). The overall clearance rate was 78.3%. Fever (40%) and deranged renal function test requiring hemodialysis (16%) were the most common postoperative complications. Postoperatively, a significant decline in the mean Hb, serum (S.) urea, and S. creatinine was observed. The mean TLC levels showed a significant increase. During follow-up, S. creatinine levels showed consistent decline. Auxiliary procedures were needed in six (12%) cases. There were two (4%) mortalities.

Conclusions

The management of urolithiasis among CKD patients requires individualized approaches. The selection of appropriate strategy results in good outcome and minimum complications.

Subcapsular Renal Hematoma Following Ureteroscopic Lithotripsy: An Uncommon Complication of a Common Procedure-A Report of Two Cases

Objective: To highlight the unusual complication of subcapsular renal hematoma (SRH) after a seemingly simple ureteroscopic lithotripsy (URSL), to try and identify the predisposing factors that lead to this complication, and steps that can be taken to further decrease the incidence of this rare but potential life-threatening complication. Methods: We highlight two cases of obstructed ureteral stones with upstream hydronephrosis who presented with colicky pain. Both underwent URSL with 8F/9.8F semirigid ureteroscope and were found to have postprocedure SRH. Results: Both our patients were managed conservatively with culture-directed intravenous antibiotics. One patient needed intervention in the form of aspiration of the hematoma. Follow-up ultrasound revealed complete resolution of the hematoma in both the cases and are doing fine on follow-up. Conclusion: Various risk factors have been identified, which predispose an individual to this complication and all endourologists must take certain precautionary measures such as decreased operative time and perfusion pressures, treating urinary tract infections and preoperative optimization of hypertension, diabetes, and chronic kidney disease (CKD) to further decrease the incidence of SRH. Management is conservative in majority of cases with percutaneous drainage and antibiotics, with surgery being reserved for hemodynamically unstable patients.

Analysis of the efficacy of holmium laser and pneumatic ballistic in the treatment of impacted ureteral calculi

To explore the safety and effectiveness of ureteroscopic holmium laser lithotripsy (UHLL) and ureteroscopic pneumatic lithotripsy (UPL) in the treatment of impacted ureteral calculi (IUC).Clinical data of 280 patients in our hospital from April 2016 to May 2019 were retrospectively collected and analyzed, including 136 cases of UHLL group and 144 cases of UPL group. The general clinical data, operation time, intraoperative bleeding volume, hospital stay, stone-free rate (SFR), and surgical complications were collected and analyzed in 2 group.Compared with UPL group, the operation time of UHLL group was significantly reduced (27.25 ± 8.39 vs 34.32 ± 10.57, P < .05), but the hospitalization cost was significantly increased (9.25 ± 0.75 vs 8.24 ± 0.51, P < .05). In terms of total SFR, the UHLL group was significantly higher than the UPL group (93.38% vs 83.33%, P = .011). For proximal IUC, compared with the UPL group, the SFR of the UHLL group was significantly increased (88.33% vs 70.31%, P = 0.005). For distal IUC, there was no significant difference in SFR (97.37% vs 93.75%, P = .638) between the UHLL group and UPL group. There were no significant differences in the complications of local mucosal injury, hematuria, febrile urinary tract infection, ureteral perforation, and urinary sepsis in the 2 groups (P > .05). However, the UHLL group was significantly lower in stone residual rate than the UPL group (6.61% vs 16.67%, P = .001).This study found that UHLL and UPL are safe and effective in the treatment of IUC, but UHLL has the advantages of shorter operation time and high SFR in the treatment of IUC.

[Effect of transcutaneous electrical acupoint stimulation on catheter related bladder discomfort after ureteroscopic lithotripsy]

OBJECTIVE

To verify the efficacy of transcutaneous electrical acupoint stimulation (TEAS) on catheter related bladder discomfort after ureteroscopic lithotripsy.

METHODS

Sixty male patients with selective ureteroscopic lithotripsy under general anesthesia were randomly divided into a TEAS group (30 cases, one case dropped off) and a sham TEAS group (30 cases, 2 cases dropped off). Before anesthesia induction, the patients in the TEAS group were treated with TEAS at Guanyuan (CV 4), Zhongji (CV 3), Zusanli (ST 36) and Sanyinjiao (SP 6) for 30 min, with disperse-dense wave, frequency of 2 Hz/ 15 Hz and current intensity of 6 to 10 mA. The patients in the sham TEAS group were treated with the same TEAS device at the same acupoints, but no electrical stimulation was given. After 30 min, anesthesia induction started. The total dosages of propofol and remifentanil in the two groups were recorded, and the time of operation and anesthesia, the time of wake-up and the time of stay in postanesthesia care unit (PACU) were recorded. The postoperative recovery was evaluated 5 min (T₁) after wake-up, 1 h (T₂), 2 h (T₃) and 6 h (T₄) after the operation, including the severity of urinary tract irritation and visual analogue scale (VAS) score. The occurrence of adverse reactions was observed, such as nausea and vomiting, dizziness and headache.

RESULTS

The dosage of remifentanil in the TEAS group was significantly lower than that in the sham TEAS group (P<0.05); but the dosage of propofol had no significant difference between the two groups (P>0.05). Compared with the sham TEAS group, the incidence of more-than-moderate urinary tract irritation symptoms in the TEAS group was reduced (P<0.05), and the VAS scores 1 and 2 h after operation were reduced (P<0.05).

CONCLUSION

The 30-min TEAS at Guanyuan (CV 4), Zhongji (CV 3), Zusanli (ST 36) and Sanyinjiao (SP 6) before anesthesia induction could significantly control the severity of postoperative urinary tract irritation in patients with ureteroscopic lithotripsy, reduce the dosage of anesthetic drugs and relieve postoperative pain.

Trends of upper urinary tract stone management in a high volume stone center in Saudi Arabia, 12 years analysis

Introduction:

Urolithiasis is a common urological problem globally with tremendous health and economic burden. In Saudi Arabia, an estimation has shown that the risk of developing a stone episode is 50% higher than that in Western countries. About 20% of males would experience at least one episode by 70 years of age. The introduction of minimally invasive and noninvasive methods such as shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotripsy (PCNL) has driven the urologists to more complex decision-making with a noted variance in management options.

Objectives and Methods:

The objective of the study was to observe the trend of upper urinary tract stone management in our institution in the past 12 years.

Methods:

Charts of patients who underwent upper urinary tract lithotripsy procedures of any kind were reviewed. The information obtained included, patient's age, surgeon, surgery type, stone size, stone location, and duration of surgery.

Analysis:

The data obtained were from 2006 to 2016. Excel sheets used for the collection of data and SPSS software was used for analysis.

Results:

The results showed that the majority of the patients were males accounting for 65%. ESWL was the predominant approach from 2006 to 2010. In 2006, ESWL accounted for 77.7% of the cases, 76% in 2007, 70% in 2008, 64% in 2009, and 62% in 2010. However, in 2011, the rates dropped to almost 18% and URS rates have increased from a few cases per year to 64%. The frequency of URS continued to rise through the years until 2015 where URS rates reached 75%. During the 12-year period, URS is the most common upper tract procedure conducted when compared to ESWL and PCNL, accounting for 63%, 16%, and 20%, respectively.

Conclusion:

In our institution, the frequency of URS rose over the years being the most abundant procedure done. ESWL rates have decreased over the years.

Pediatric bilateral ureteral stone successfully removed using single-use flexible ureteroscopy with a holmium: YAG laser

A 12-year-old boy received steroid for his minimal change nephrotic syndrome for 10 years, and bilateral renal and ureteral stones and hydronephrosis were observed. Single-use flexible ureteroscopy is usable for pediatric lithotripsy with Ho: YAG laser.

Dual ureteral stent placement after redo laser endoureterotomy to manage persistent ureteral stricture

INTRODUCTION

Endourological intervention is a minimally invasive approach for the management of ureteral strictures. Contraindications to this approach include active infection, strictures of sizes >2 cm, and failure of endoureterotomy. This report demonstrates a case of successful dual stent placement after redo endoureterotomy.

CASE PRESENTATION

A recurring ureteral stricture in a 69-year-old woman, who had undergone ureteroscopic lithotripsy for a right ureteral calculus 60 months earlier, was successfully managed by redo endoureterotomy. The procedure involved insertion of dual ureteral stents after endoluminal incision and balloon dilation. Ureteral stents were removed 8 weeks after the operation. No significant complications or signs of stricture were observed 42 months after endoscopic repair.

CONCLUSION

This minimally invasive and effective technique of dual ureteral stent placement following laser endoureterotomy successfully managed the recalcitrant ureteral stricture in a case with failed single stent placement following endoureterotomy.

Clinical Effectiveness of Single Pigtail Suture Stent on Patient Comfort: A Double-Blind Prospective Randomized Trial

Background: A double-pigtail ureteral stent (DPUS) can cause untoward symptoms, such as urgency, frequency, urinary incontinence, hematuria, and body pain that are bothersome to patient's quality of life (QoL). By reducing the quantity of material in the bladder, it could be reasonable to decrease stent-related symptoms (SRSs). We aimed to evaluate the tolerability of single pigtail suture stent (SPSS) with a validated questionnaire after uncomplicated retrograde semirigid ureteroscopic lithotripsy (URSL). Materials and Methods: A total of 130 patients who underwent ureteral stent placement after URSL for unilateral symptomatic ureteral stones with <15 mm diameter were randomized prospectively into two groups. Polyurethane ureteral stent (6 Fr, 24 or 26 cm) was placed in all patients, which was removed postoperatively with a mean of 14 days. There were 65 patients in both groups. All subjects completed the ureteral stent symptoms questionnaire (USSQ), which explores the SRSs. The questionnaires were conducted on the day of stent removal (at week 2) with the stent in situ and 4 weeks after removal (at week 6, poststent). The severity of SRSs and QoL were compared between the two groups. Results: SPSS was associated with perfect effect on all domains of USSQ, except from sexual and general health index scores. Pain index scores, visual analog scores (VAS), and analgesic requirements in SPSS group were found significantly low compared with those in the DPUS group. The QoL scores were significantly better in patients indwelling SPSS. Conclusion: SPSS is a potentially beneficial option to minimize ureteral SRSs after uncomplicated URSL.

Safety of a Novel Thulium Fiber Laser for Lithotripsy: An In Vitro Study on the Thermal Effect and Its Impact Factor

Introduction: To investigate the thermal effect on the water by a novel thulium fiber laser (TFL) designed for lithotripsy and evaluate the safety of this laser for clinical use. Materials and Methods: An in vitro experimental setup was constructed. A test tube filled with saline was immersed in an electric water bath, and a TFL fiber and a thermal probe were inserted into it. Saline was irrigated into the tube and pumped out synchronously at the same speed by two pumps, respectively, to maintain convection when needed. Then, continuous TFL firing of different power settings was imposed to saline in the tube for 60 seconds, on the conditions of different irrigation rates. The temperature was recorded every 5 seconds during the whole trial, and each trial was repeated five times. Safety threshold of temperature increase (STTI) was determined comparing with the deemed safe temperature of 43°C in vivo. Results: On condition of 0 mL/min irrigation rate, STTI was 6.5°C, and water temperature increase (WTI) caused by ≥15 W settings surpassed STTI after 20 seconds of laser firing; on condition of 15 mL/min irrigation rate, only WTI caused by the highest 30 W power setting surpassed STTI after 45 seconds of laser firing. When irrigation rate was added up to 25 and 50 mL/min, WTIs caused by all power settings were below STTIs in a 60-second experiment. High frequency and low pulse energy combinations caused a slightly higher WTI compared with low frequency and high pulse energy, given a constant power and irrigation rate. Conclusion: Power setting and irrigation rate collaboratively play a critical role in WTI during TFL lithotripsy, and it is safe to use TFL referring to the thermal effect as long as there is moderate irrigation, while TFL power should be lowered enough when irrigation is ceased.

Oxidative Stress and Hemostatic Parameters in Patients With Nephrolithiasis Before and After Ureteroscopic Lithotripsy

Purpose

In patients with nephrolithiasis, oxidative stress, especially lipid peroxidation is observed. Moreover, various invasive methods [including extracorporeal shock wave lithotripsy (ESWL)] for treatment of nephrolithiasis may induce not only the oxidative stress, but they may modulate hemostasis. The study was aimed to evaluate the oxidative damages of lipids and proteins in patients with nephrolithiasis (before and after ureteroscopic lithotripsy – URSL). The aim of the present study was also determine selected parameters of hemostasis in these patients.

Methods

56 patients with nephrolithiasis and 49 healthy participants were included: 30 men and 26 women (for patient group); 27 men and 22 women (for healthy group). We measured the level of selected typical two biomarkers of oxidative modification of lipids [such as the production of thiobarbituric acid reactive substances (TBARS) and isoprostane concentration (8-isoPGF_2α)] and two biomarkers of oxidative damages of proteins (carbonylation and the level of thiol groups) in patients with nephrolithiasis (before and after URSL). The following parameters of hemostasis were measured: blood platelet count, the level of fibrinogen and D-dimer, and coagulation times (the activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT) of plasma).

Results

Different levels of plasma lipid peroxidation were observed in patients with nephrolithiasis before URSL and after URSL. However, no such difference in the level of oxidative damage to plasma proteins was observed. In addition, the tested hemostasis parameters were not influenced by the presence of nephrolithiasis, nor by treatment with URSL.

Conclusion

We suggest URSL does not induce the oxidative modifications of plasma proteins and does not change hemostatic parameters in patients with nephrolithiasis.

Enterorenal Fistula as an Unusual Complication from Ureteroscopic Lithotripsy: A Case Report

Background: This case highlights an enterorenal fistula as a rare complication from ureteroscopic lithotripsy. Case Presentation: A 56-year-old woman with significant obesity, decompensated cirrhotic and ascitic liver disease, hypertension, type 2 diabetes mellitus, and nephrolithiasis treated with five prior ureteroscopic lithotripsies for a partial left staghorn stone presented to the emergency department (ED) with worsening left flank pain and sepsis. A CT scan of the abdomen and pelvis with contrast showed a large left perinephric hematoma. She underwent drain placement and during fluoroscopic imaging, there was a fistula from the left subcapsular hematoma/abscess to the proximal descending colon. The patient wished to proceed with a surgical course involving nephrectomy with hemicolectomy despite extensive counseling regarding her high mortality risk. However, because of worsening nutritional status as well as several other high-risk comorbidities, a shared decision was made with the patient to postpone the procedure. The patient was discharged to a skilled nursing facility for nutritional optimization and prehabilitation; however, she continued to decline with recurrent sepsis and cirrhosis-related complications and unfortunately passed away. Conclusion: A subscapular hematoma evolving into a perinephric abscess is a rare but known complication of ureteroscopic lithotripsy; however, this patient developed an enterorenal fistula that has yet to be reported after repeated ureteroscopy.

Ureteroscopic lithotripsy in the Trendelenburg position for extracting obstructive upper ureteral obstruction stones: a prospective, randomized, comparative trial

OBJECTIVE

To introduce a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi.

MATERIALS AND METHODS

Between June 2014 and May 2017, 192 patients were enrolled in this study. Patients were randomly assigned to one of two groups: group A, ureteroscopic lithotripsy (URSL) in the Trendelenburg position; or group B, URSL in the standard position. Baseline information, including gender, age, body mass index (BMI), stone side, stone size and hydronephrosis grade, was collected and determined preoperatively. Stone-free rate (SFR) was evaluated 3 weeks after surgery and was defined by the absence of residual stones or the presence of residual stones <2 mm in diameter. Operation time, hospital stay, stone migration, operative complications and SFR were assessed and compared between the two groups.

RESULTS

There were no statistically significant differences in gender, age, BMI, stone side, stone size, serum creatinine or hydronephrosis grade between the two groups (all p > 0.05). There were no significant differences in the postoperative hospital stay or postoperative complications between the two groups (all p > 0.05), but the differences in operative time, stone migration and SFR between the two groups were statistically significant (p < 0.05).

CONCLUSION

This study introduced a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi. The Trendelenburg position can improve the SFR and may provide an optional surgical method for treating upper ureteral calculi.

Percutaneous nephrostomy via the central venous catheter in combination with selective ureteroscopic lithotripsy for the treatment of ureteral stones in the middle-upper segment

Objective

To explore the therapeutic outcome and significance of preoperative percutaneous nephrolithotomy (PCNL) via the central venous catheter in combination with two-step hard ureteroscopic lithotripsy for the treatment of ureteral stones in the middle-upper segment.

Methods

The success rate and the occurrence of severe infection and perirenal hematoma were analyzed retrospectively in 37 patients who received preoperative PCNL via the central venous catheter in combination with two-step hard ureteroscopic lithotripsy for the treatment of ureteral stones in the middle-upper segment in our hospital between July 2012 and November 2014.

Results

The operation duration was 12-38 min with a mean of 18.5 min. The procedure was performed successfully in all patients without the postoperative occurrence of perirenal hematoma in any patient. No severe infection occurred in any patient according to the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis (2012).

Conclusion

Preoperative PCNL via the central venous catheter can significantly improve the success rate of ureteroscopic lithotripsy for the treatment of ureteral stones in the middle-upper segment, and reduce postoperative occurrences of severe infection and perirenal hematoma.

Simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy for ureteral calculi combined with renal staghorn calculi

OBJECTIVES

To investigate the efficacy, safety, and cost-effectiveness of simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy for ureteral calculi combined with contralateral renal staghorn calculi.

METHODS

The present prospective controlled trial had been registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR-ONRC-13004146). Patients with ureteral calculi and contralateral renal staghorn calculi were enrolled into the staged (ureteroscopic lithotripsy first followed by a staged percutaneous nephrolithotomy) or the simultaneous (synchronous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy) treatment group according to the odd or even number of the last hospitalization number. All patients signed informed consent. The primary outcomes were the stone-free rate and total hospital costs. The second outcomes were the operative and anesthesia times, the complication rate, and hospital stay.

RESULTS

A total of 51 patients were enrolled into the staged group and 52 patients were enrolled into the simultaneous group. There were no statistically significant differences in patients' characteristics. The overall stone-free rate was 94.1% in the staged group and 92.3% in the simultaneous group. No severe complication was observed. The total hospital stay of the staged group was longer, and it was negatively correlated to different procedures. The cost in the staged group was higher, and it was correlated with total operation time and postoperative hospital stay.

CONCLUSIONS

Simultaneous ureteroscopic lithotripsy and contralateral percutaneous nephrolithotomy represent safe and effective procedures, and they can be considered as a first-line treatment for selected patients presenting with ureteral calculi combined with contralateral renal calculi.

Pre-emptive tramadol could reduce pain after ureteroscopic lithotripsy

PURPOSE

Optimal analgesia in ambulatory urology patients still remains a challenge. The aim of this study was to examine if the pre-emptive use of intravenous tramadol can reduce pain after ureteroscopic lithotripsy in patients diagnosed with unilateral ureteral stones.

MATERIALS AND METHODS

This prospective pilot cohort study included 74 patients diagnosed with unilateral ureteral stones who underwent ureteroscopic lithotripsy under general anesthesia in the Urology Clinic at the Clinical Center of Serbia from March to June 2012. All patients were randomly allocated to two groups: one group (38 patients) received intravenous infusion of tramadol 100 mg in 500 mL 0.9%NaCl one hour before the procedure, while the other group (36 patients) received 500 mL 0.9%NaCl at the same time. Visual analogue scale (VAS) scores were recorded once prior to surgery and two times after the surgery (1 h and 6 h, respectively). The patients were prescribed additional postoperative analgesia (diclofenac 75 mg i.m.) when required. Pre-emptive effects of tramadol were assessed measuring pain scores, VAS1 and VAS2, intraoperative fentanyl consumption, and postoperative analgesic requirement.

RESULTS

The average VAS1 score in the tramadol group was significantly lower than that in the non-tramadol group. The difference in average VAS2 score values between the two groups was not statistically significant; however, there were more patients who experienced severe pain in the non-tramadol group (p<0.01). The number of patients that required postoperative analgesia was not statistically different between the groups.

CONCLUSION

Pre-emptive tramadol did reduce early postoperative pain. The patients who received pre-emptive tramadol were less likely to experience severe post-operative pain.