Treatment of ureteral calculi by extracorporeal shock wave lithotripsy

We reviewed 465 cases of ureteral calculi treated at J?m? Urological Hospital using a Dornier HM3 lithotripter during the period from October 1985 to February 1989. The 336 men and 122 women ranged from 11 to 78 years old with a mean age of 42.2. The stone size ranged from 4 mm to 30 mm with a mean length of 10.6 mm. Complete stone elimination by ESWL was achieved in 431 of the 465 cases (92.7%). The success rate was best for stones in the lower ureter, which was 98.1 per cent (53/54). For upper and mid ureteral calculi it was 92.4 per cent (363/393) and 83.3 per cent (15/18), respectively. ESWL after push up made 100 per cent (30/30) of patients completely free of stones, while ESWL after bypass 93.0 percent (106/114) and ESWL in situ 91.9 per cent (295/321). The rate of residual stone increases in proportion to the age of patients. Minor side effects such as fever and pain were observed. Our results suggest that ESWL currently is the first therapeutic option for the majority of ureteral calculi.     

Treatment of lower ureteral calculi with extracorporeal shock wave lithotripsy

A group of 70 patients presenting with stones in the lower third of the ureter was treated with extracorporeal shock wave lithotripsy using a Dornier HM3 lithotriptor. For adequate radiological stone visualization a sitting position was used in 68 patients, while 2 with calculi overlying the sacroiliac joint required placement in the prone position. All but 1 patient had additional endoscopic maneuvers before treatment, consisting of the passage of a Zeiss sling around the stone in 40 and, when this was not possible, a ureteral stent in 29. The over-all success rate was 94.2 per cent (66 of 70 patients) with 3 patients having retained fragments and 1 requiring an open operation. The combination of new positioning techniques and relatively simple endoscopic maneuvers makes treatment of lower ureteral stones feasible and safe with the Dornier lithotriptor.     

Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use center

We reviewed our experience with extracorporeal shock wave lithotripsy therapy in 138 patients who presented with mid and upper ureteral calculi. In the patients who had successful stone manipulation back into the renal collecting system the success rate was significantly higher compared to that for stones treated primarily within the ureter (92.8 versus 80.8 per cent, p less than 0.05). Among the stones treated within the ureter the success rates appeared to be similar for stones treated in situ (83.3 per cent) compared to those treated when a catheter could be placed alongside the calculus (79.3 per cent). Higher voltage and more shock waves were administered to stones treated within the ureter compared to stones that were manipulated back into the kidney. However, this increase power did not enhance the success rate. In addition, it appears that a plain film of the abdomen obtained within 24 hours of lithotripsy treatment is a good predictor of success as defined by the rate free of stones at 6 weeks of followup. Our results from a community-based multi-use lithotripsy center suggest that ureteral stone manipulation should be attempted before extracorporeal shock wave lithotripsy for mid and upper ureteral calculi.     

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.     

Management of upper ureteral calculi with extracorporeal shock wave lithotripsy

The results of 471 extracorporeal shock wave lithotripsy treatments in 465 patients with solitary ureteral stones managed by several different techniques are reported. In situ treatment was performed in 123 cases without instrumentation and in 47 after placement of a ureteral catheter. Retrograde stone manipulation was performed in 245 cases immediately before extracorporeal shock wave lithotripsy and an additional 56 were manipulated with ureteral stent placement at least 1 week before extracorporeal shock wave lithotripsy. The success rate was significantly greater if the stone was manipulated into the kidney before extracorporeal shock wave lithotripsy. Significantly less energy (p less than 0.0001) was required for complete disintegration if the stone was free floating in the kidney. The need for subsequent procedures was significantly less (p less than 0.0001) for stones manipulated successfully into the kidney. Complications were infrequent, with the most common being ureteral perforation in 5.1 per cent of the cases, all of which were managed conservatively. Extracorporeal shock wave lithotripsy is the treatment of choice for proximal ureteral calculi because it is less morbid than percutaneous approaches and provides significantly better results than ureteroscopy. An attempt at manipulation of proximal ureteral calculi back into the kidney should be made before extracorporeal shock wave lithotripsy.     

Treatment of ureteral calculi with extracorporeal shock wave lithotripsy using the Lithostar device

Shock wave requirements for fragmentation and the ultimate outcome after extracorporeal shock wave lithotripsy (ESWL) with the Lithostar device were analyzed in 107 renal units with solitary ureteral calculi. In situ treatment was done in 54 stones without prior manipulation and in 15 after failure of endoscopic manipulation. A total of 25 ureteral calculi was treated after bypass with a ureteral catheter or stent and 13 after push back to the pelvicaliceal system. Shock wave requirement for fragmentation was significantly higher for calculi of 101 to 400 mm. X mm. when compared with the requirement for smaller calculi. Shock wave requirement was also significantly higher for patients with similar sized stones treated in the prone compared to the supine position. The average number of shock waves required for disintegration was not significantly different among in situ or any of the manipulation categories of similar sized stone populations. Over-all satisfactory clearance was achieved in 77.5% of the treated ureteral calculi. Clearance status was unaffected by size up to 400 mm. X mm. and the position of the patient during treatment (prone or supine). Clearance of ureteral stones treated in situ without prior manipulation (76.5%) was numerically inferior, although statistically insignificant, to that for successfully manipulated calculi (bypassed 88% and pushed back 92.3%) but it was significantly better than the outcome obtained after failed manipulation (46.2%). ESWL with the Lithostar device is a successful mode of treatment within the entire ureteral length, and a vigorous attempt at push back before lithotripsy is unnecessary.     

体外冲击波碎石治疗单发输尿管结石及疗效预测

目的探讨体外冲击波碎石术（ESWL）治疗输尿管结石疗效的影响因素,并建立预测模型。方法2008年1月至2011年2月接受ESWL治疗的输尿管结石患者1116例,随访3个月。用X^2检验或t检验、秩和检验进行单因素分析来研究患者性别、年龄、身高、体重、病程、临床症状和结石特征等因素与疗效的关系,多因素分析采用Logistic逐步回归分析（Forward：LR法）,建立Logistic回归预测模型。结果ESWL单次治疗输尿管结石成功率84．3％（941／1116）。单因素分析发现结石部位、结石长短径及肾绞痛对疗效均有影响。Logistic回归分析则显示结石部位、结石长短径及肾绞痛决定治疗的成功率,预测模型对碎石成功率的解释力良好（X^2=117．434,P〈0．001）,并通过拟合优度检验（X^2=5．261,P=0．729）,预测总体准确率为83．8％。结论结石部位、结石长短径及肾绞痛是ESWL治疗输尿管结石成功率的重要决定因素。     

Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral calculi

In contrast to the majority of renal calculi, in situ extracorporeal shock wave lithotripsy (ESWL) for upper ureteral stones is still controversial. Some centers recommend retrograde mobilization of the calculus into the renal pelvis prior to ESWL as a routine procedure (UC + ESWL). To evaluate the efficiency of in situ ESWL for upper ureteric stones, we initiated a prospective clinical trial. From July 1985 to January 1986, 122 patients presented with upper ureteral calculi, necessitating a total of 146 different procedures: 88 in situ ESWL; 31 UC + ESWL; 15 antegrade ureteroscopies (URS); 6 retrograde URS; 2 open surgery (ureterolithotomy, nephrectomy), and 4 patients were managed conservatively. Of all 99 patients treated at the lithotripter, 80 patients received in situ ESWL (no emergency case, no location problems): in 60 patients (75%) the stone could be disintegrated in one session; 8 patients (10%) required a second ESWL session due to partial fragmentation. Retrograde mobilization using a ureteral catheter or URS was necessary in 9 patients due to failure of in situ ESWL (11%) and, in only 3 patients, we had to remove the stone by antegrade URS (4%). In conclusion, 96% of all upper ureteric stones suitable for primary ESWL could be treated by a noninvasive (in situ ESWL) or minimally invasive (UC + ESWL) procedure. Therefore we recommend in situ ESWL for these calculi. Primary retrograde mobilization is only indicated in case of location problems (stone close to the spine, obesity, skeleton deformation) or emergency cases (colic, hydronephrosis). Antegrade URS should be performed if retrograde mobilization fails or in emergency cases (acute pyelonephritis, following percutaneous nephrostomy, after clinical stabilization). The rate of open surgery is below 2%.     

Treatment of distal ureteral calculi with extracorporeal shock wave lithotripsy. Experience with 264 cases

Ureteroendoscopy is used by most authors to approach distal ureteral calculi. With increasing experience extracorporeal shock wave lithotripsy (ESWL) of distal ureteral calculi has gained importance. The success rate of 96% in a large series of 264 consecutive patients treated in this manner, confirmed the results of other authors. Excluding women of child-bearing age and very large calculi (over 2 cm), ESWL is a suitable treatment modality for distal ureteral calculi.     

Treatment of proximal ureteral calculi: holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy

PURPOSE: We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. MATERIALS AND METHODS: A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. RESULTS: Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. CONCLUSIONS: Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.     

钬激光碎石术与体外冲击波碎石术治疗输尿管结石的疗效比较

目的　比较输尿管镜钬激光碎石术与体外冲击波碎石术 (ESWL)治疗输尿管结石的有效性和安全性。　方法　采用输尿管镜钬激光碎石术治疗输尿管结石 15 9例 16 8侧 ,其中结石直径≥ 1cm者 76侧 ,<1cm者 92侧。ESWL治疗输尿管结石 319例 334侧 ,其中结石直径≥ 1cm者 14 3侧 ,<1cm者 191侧。比较两组手术时间 结石排净率 手术并发症发生率指标的差异。　结果　对直径≥ 1cm和 <1cm的输尿管结石钬激光碎石术治疗平均手术时间分别为 5 8min和 4 3min ,短于ESWL的平均手术时间 6 8min和 5 6min(P <0 .0 1) ;钬激光碎石术对直径≥ 1cm的输尿管结石 3个月结石排净率为 92 % ,高于ESWL的 6 1% (P <0 .0 1) ;对直径 <1cm的输尿管结石钬激光碎石术和ESWL的 3个月结石排净率分别为 95 %和 85 % (P >0 .0 5 )。钬激光碎石术组并发症发生率为 4 .8%( 8/ 16 8) ,ESWL组无明显并发症发生。　结论　输尿管镜钬激光碎石术治疗直径≥ 1cm的输尿管结石疗效明显优于ESWL ,而直径 <1cm的结石二者疗效差异无显著性 ,ESWL为直径 <1cm结石的首选治疗方法     

电磁式体外冲击波碎石的应用体会和输尿管镜碎石治疗输尿管结石的差别

目的比较电磁式体外冲击波碎石与输尿管镜碎石治疗输尿管结石的效果。方法选择我科室2015年7月至2017年10月就诊的150例输尿管结石患者,随机分为2组,体外冲击波组75例采用电磁式体外冲击波碎石术治疗,输尿管镜组75例采用输尿管镜碎石术治疗,对比两组临床疗效、结石大小、手术时间及并发症发生情况。结果体外冲击波组结石直径1 cm碎石成功率为95.24%,输尿管镜组结石直径1 cm为73.33%,差异具有统计学意义(P0.05),结石直径≥1 cm且2 cm和结石直径≥2 cm两组差异无统计学意义(P0.05),体外冲击波组总碎石成功率合计88.00%,输尿管镜组为72.00%,两组差异具有统计学意义(P0.05);体外冲击波组术后并发症发生率为9.33%,输尿管镜组为21.33%,差异具有统计学意义(P0.05)。结论电磁式体外冲击波碎石治疗对于1.0 cm的输尿管结石效果较好,且减少并发症发生。     

Treatment of large renal calculi with extracorporeal shock wave lithotripsy monotherapy

One hundred and twenty patients with large renal calculi (greater than 3 cm), who had not undergone previous stone-debulking procedures, were treated with extracorporeal shock wave lithotripsy (ESWL) monotherapy using a Dornier HM3 lithotripter. Stones were divided into four categories according to Rocco's classification: 20 C2, 25 C3, 51 C4 and 24 C5. Repeated treatments were necessary in 13 patients, while planned two-stage treatments were performed in 8. Pretreatment adjunctive endourological maneuvers (except for the placement of ureteral stents for visualization of 37 contrast-negative stones) were used in 16 cases (13.3%) and posttreatment maneuvers in 20 (16.6%). Open surgery was necessary in 6 patients, including one nephrectomy. Complete elimination of all concrements was documented in 74 patients (61.6%): 63 within 3 months and 11 within 6-12 months. The stone-free rates for different categories were: 80% for C2, 64% for C3, 58.8% for C4 and 50% for C5. The stone-free rate for contrast-negative calculi was 83.7% (31/37), and for radiopaque ones 51.8% (43/83) (p less than 0.001). It is concluded that ESWL monotherapy is an adequate treatment choice for some categories of large radiopaque stones and for all radiolucent ones.     

输尿管结石行体外冲击波碎石治疗后发生输尿管狭窄的危险因素分析

目的探讨输尿管结石经体外冲击波碎石治疗后发生狭窄的危险因素。方法收集2006年7月至2011年7月就诊于我院首次行体外冲击波碎石治疗的输尿管结石患者的临床资料,先对所取临床指标进行单因素分析,然后进行Logistic多因素回归分析。结果共收集行体外冲击波碎石的输尿管结石患者174例,其中发生术后输尿管狭窄的患者15例,狭窄发生率为8.62%,单因素分析显示:结石长径、肾积水程度、结石嵌顿时间以及碎石次数与术后输尿管狭窄发生相关,多因素Logistic回归分析结果显示:结石长径、肾积水程度以及碎石次数是患者发生输尿管狭窄的独立危险因素。结论对于肾积水程度较重、结石长径较大、预期碎石次数较多的输尿管结石患者,行体外冲击波碎石后发生狭窄的可能性相对较高,在治疗选择上应更加慎重,提倡选择体外冲击波碎石之外更加安全有效的治疗方式。     

Comparison of transurethral ureteroscopy and extracorporeal shock wave lithotripsy for treatment of ureteral calculi

Ureteral calculi were treated by transurethral uretereoscopy and extracorporeal shock wave lithotripsy (ESWL), and the results were compared. Rigid transurethral ureteroscopy was performed in 50 patients, and 10 of 22 stones located in the upper ureter and 25 of 29 stones located in the lower ureter were successfully extracted. On the other hand, we treated 88 patients with upper ureteral stones by ESWL and achieved a success rate of 89.8%. We therefore conclude that for upper ureteral stones, ESWL is the more effective treatment and, for lower ureteral stones, transurethral ureteroscopy.     

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.     

Calcification of ureteral stent treated by extracorporeal shock wave lithotripsy

A patient with stones presented with large calcifications of the J ends of a Double-J stent that had been placed in the ureter for an obstructing ureteral stone 1 month previously. The J end located in the renal pelvis was treated with extracorporeal shock wave lithotripsy and the calcification was disintegrated completely. This noninvasive procedure appears to be the method of choice in the treatment of such complications.     

Morbidity associated with patient positioning in extracorporeal shock wave lithotripsy of distal ureteral calculi

In 115 patients with 123 distal ureteral stones located below the lower border of the sacroiliac joint, in situ extracorporeal shock wave lithotripsy (ESWL) was performed with a Siemens Lithostar Lithotriptor. Our initial experience with the prone position in 8 out of 49 cases did not reveal stone fragmentation and on the final treatment sessions shock waves were allowed to enter via the obturator or sciatic foramen whilst the patients were in the supine position, in order to compare the results of treatments performed in both positions. The mean number of treatment sessions per patient, mean number of shock waves per treatment sessions, mean shock voltage per session and mean fluoroscopy time per session were significantly lower in the supine group than in the prone group (p<0.05 for all variables). ESWL of the distal ureteral stones in the prone position seems to have an associated patient morbidity when we compare the results of treatments performed in both positions.     

Rapid extracorporeal shock wave lithotripsy for proximal ureteral calculi in colic versus noncolic patients

OBJECTIVES: In delayed extracorporeal shock wave lithotripsy (ESWL) treatment, increasing stone impaction is associated with delayed stone clearance. Whether colic patients treated by rapid ESWL have the same time to stone clearance as noncolic patients, which supports the thesis that stones in both groups are nonimpacted, has not been investigated yet, and was the objective of this study. METHODS: A total of 82 patients were prospectively enrolled and treated with piezoelectric ESWL for a solitary proximal ureteral stone. Of these, 56 patients experienced at least one colic episode compared with 26 noncolic patients. Hydronephrosis has been assessed with the use of ultrasound and intravenous urography (IVU). Time to stone clearance after the first ESWL and stone-free rates after a follow-up period of 3 mo were recorded. RESULTS: In colic and noncolic patients, mean stone size was 7.8mm (p=0.7). Ultrasound-detected hydronephrosis was present in 88% versus 39% (p<0.0001), whereas IVU-detected hydronephrosis was present in 60% versus 7.7% (p=0.0001). Mean number of impulses applied was 8000+/-4000 versus 6700+/-3400 (p=0.1). Mean time to stone clearance was 9.5+/-12.1 d versus 4.6+/-3.8 d (p=0.1). Colic and noncolic patients were considered as treatment success in 83% and 81% after 3 mo of follow-up (p=0.9). CONCLUSIONS: Treatment outcome and time to stone clearance after rapid ESWL in colic patients compared with noncolic patients is comparable and independent of concomitant hydronephrosis. This finding suggests an absence of significant impaction in proximal ureteral stones treated within 24h after a first colic episode, enforcing the concept of performing rapid ESWL in patients harbouring proximal ureteral stones.