Transurethral ureteroscopic removal of ureteral calculi

Rigid ureteroscopy was used for transurethral removal of ureteral stones. Calculi were extracted under direct vision using flexible grasping forceps or a stone basket. If the size of the stone precluded the use of these techniques, we disintegrated the stone using an electro-hydraulic lithotriptor (EHL) or ultrasonic lithotriptor (USL). Between January, 1985 and October, 1985, 35 ureteroscopic procedures were performed for removal of ureteral stones. In 27 cases (77%) the stone was removed successfully. All stones could be removed in mid and lower ureter. However, in upper ureter, the success rate was only 50%. In 8 instances, ureteroscopy failed to remove the ureteral calculus and 6 underwent percutaneous nephrolithotomy, 2 open surgery. Of the ureteral stones, 12 were removed with grasping forceps or a basket manipulation. EHL and USL were used successfully to remove calculi in 15 cases. To make smooth passage of the ureteroscope, a 6F UPJ occlusion balloon catheter was introduced into the ureter and the balloon was inflated in the intramural ureter for 24 hours preoperatively. We have found this to be a useful procedure for smooth passage of the ureteroscope. Most common complication of ureteroscopic stone removal was fever (29%). In 1 case, the ureter was penetrated by the scope. The patient was treated with an indwelling ureteral catheter for 2 weeks. After the catheter was removed, an excretory urogram demonstrated normal ureter without extravasation or obstruction. We conclude that ureteroscopic stone removal can be done safely with careful passage of the scope and careful manipulation of calculi.     

A new technique for the transurethral or percutaneous removal of renal stones

This new technique uses a cystoscopically placed torque guide wire and catheters to deliver a stone basket to the renal calix containing the stone. Under fluoroscopic control the basket, placed through a 9F catheter, is used to dislodge and capture the stone. The stone-containing basket and catheter then are removed transurethrally or percutaneously. This procedure was used to remove small caliceal stones in 3 patients undergoing ureteral stone manipulation, and it facilitated the percutaneous removal of a larger stone in the upper pole infundibulum in 1 patient.     

Extracorporeal shock wave lithotripsy in situ treatment for ureteral stones

Three hundred and sixteen patients with ureteral stones were treated in situ (without retrograde stone manipulation) with and without stent bypass (DJ stent, ureteral catheter). Results were generally better with stent bypass, but only marginally so for stones larger than 10 mm in diameter. Regardless of whether or not the ureter was stented, lower ureteral stones were more difficult to fragment than upper ureteral stones and pre-sacral stones did not respond well to in situ treatment. We observed that evaluation of stone disintegration and fragment evacuation could only be properly assessed after approximately 3 weeks post-ESWL.     

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

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

Percutaneous renal and ureteric stone extraction. Report on the first 500 operations

A consecutive series of the first 500 percutaneous renal and ureteric stone extractions in 451 patients was analysed. During the period studied, percutaneous extraction was offered to all patients with conventional indication for stone removal except a few, very early ureteric stone patients in whom open lithotomy was carried out. Ureteroscopy and extracorporeal shock wave lithotripsy had not come into routine use. Four hundred and seventy-eight stone operations (96%) could be performed by the percutaneous route; early in the series, 21 open operations and one transurethral Dormia basket extraction were performed, mainly because of failed mobilisation of ureteric stones (12 patients) or various peroperative complications (9 patients). The target stones were completely removed in 88% of all percutaneous procedures, with the best results in the largest group of patients with 6-20 mm solitary stones or 2-3 stones less than or equal to 10 mm. Stones in the ureter and pelvi-ureteric junction without any other concomitant stones were all completely removed. Bleeding was the most frequent peroperative complication. No kidney was lost. An 84-year-old man died of intercurrent disease postoperatively.     

Extracorporeal piezoelectric shockwave lithotripsy of ureteral stones: are second-generation lithotripters obsolete?

BACKGROUND: The role of extracorporeal shockwave lithotripsy (SWL) for ureteral calculi is still being debated. We evaluated our results in a large series to clarify the role of this modality. PATIENTS AND METHODS: A total of 478 patients with solitary ureteral stones were treated by in situ piezoelectric extracorporeal shockwave lithotripsy (SWL) using a Wolf Piezolith 2300 ultrasound-guided lithotripter. Two hundred fifty stones (52.3%) were located in the upper ureter and 228 (47.7%) in the distal ureter. Seventy of the upper ureteral stones were located in the ureteropelvic junction and 180 in the lumbar ureter. The diameter of the stones ranged from 5 to 30 mm. Four hundred sixty-seven patients were followed up for a mean of 4 months. RESULTS: Four hundred forty patients (94.2%) were stone free after in situ SWL alone. Complete removal of all stone fragments was achieved in 95.4% of the 216 patients with calculi of 5 to 10 mm in diameter, in 94.3% of the 229 with stones of 11 to 20 mm, and in 81.8% of the 22 with calculi of 21 to 30 mm. In situ treatment completely removed 61 of 69 ureteropelvic junction stones (88.4%), 166 of 175 lumbar stones (94.8%), and 213 of 223 distal ureteral stones (95.5%). In situ treatment failed in 27 stones (5.8%). After 4 months, 12 stone fragments and 15 unfragmented stones persisted despite retreatments and required endoscopic procedures. The mean number of sessions and shockwaves per patient was 1.8 and 4884, respectively. Morbidity was low. Renal colic in 57 patients (11.9%) was managed successfully by analgesics. In 36 patients, stone fragments obstructed the ureter; in 28 of these 36 (78%), the obstruction was resolved and the patients were stone free after in situ retreatments alone. All these results were achieved on an outpatient basis without sedation or local or general anesthesia. CONCLUSION: Piezoelectric SWL is an effective and noninvasive method for eliminating ureteral stones. Second-generation ultrasound-guided lithotripters are not yet obsolete.     

Nonoperative removal of giant common bile duct calculi

Endoscopic sphincterotomy has allowed us to extract relatively large stones from the common bile duct as compared with other methods utilizing a T-tube tract or the percutaneous transhepatic route. Twenty-four patients with large stones over 20 mm in diameter were selected and reviewed from a series of 469 sphincterotomy patients. Eleven stones passed into the duodenum spontaneously, the maximal size of which was 30 by 43 mm. Passage occurred within 4 days after sphincterotomy in 27 percent, 5 to 7 days after the procedure in 55 percent, and 8 to 13 days after the procedure in 18 percent and was accompanied by cholangitis in 55 percent of the patients. The small diameter of the stone and common bile duct dilatation down to the distal end seemed to be the factors favoring stone delivery. Five stones were removed using ordinary basket catheters by duodenoscopy; however, the largest one required 28 attempts. More recently, four stones were efficiently extracted after destruction by electrohydraulic or mechanical lithotripsy. Failure of removal in five patients was mainly due to a lack of space around the stone for basket manipulation or occurrence of severe cholangitis. Further refinements in technique in this regard are needed.     

Transurethral uretero-lithotripsy of ureteral stones in Osaka City University

During the 39 months since the introduction of transurethral lithotripsy (TUL) for the treatment of ureteral stones at our hospital in August 1985, TUL was performed a total of 200 times in 178 patients with ureteral stones. Among them, 111 patients had left ureteral stones and 65 had right ureteral stones, while 2 patients had ureteral stones in both sides. The stones were divided into upper ureteral stone (84 patients) and lower ureteral stone (94 patients) at above and below the iliac brim. 89% of the stones were less than 2 cm in diameter. Most of the patients were given lumbar anesthesia, and a guide wire was inserted into the ureter. The ureter was dilated with a ureteral bougie, and a 13F or 14F Storz ureteroscope was inserted. The stones were disintegrated by an ultrasound lithotripto and removed using forceps and a basket catheter. After the TUL procedure, a double J catheter was indwelled and removed within 5 days. The results were evaluated by DIP which was done 2 to 3 months after TUL. The success rate included residual stones less than 4 mm in diameter, as they could be spontaneously discharged. As a result, the success rate for upper ureteral stones was 53%, and it was higher for smaller stones. On the other hand, the success rate for lower ureteral stones was 85% and significantly higher. The main reasons for failure were the upper migration of the stones (60%) and inability to insert the ureteroscope up to the stone due to ureterostenosis and ureteral perforation (39%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Ureteral meatotomy by Sachse urethrotome in the management of lower ureteral stones

From January 1981 to June 1985 inclusive 170 patients were hospitalized for transurethral ureteral stone manipulation. A meatotomy with the Sachse urethrotome was done in 46 of these patients because the stone was impacted in the intramural ureter or the basket containing the stone became impacted. This method resulted in successful endoscopic removal of the stones in 43 patients.     

Clinical experiences of 35 cases with upper urinary tract stones by extracorporeal shock wave lithotripter (MEDSTONE 1000)

We made clinical trials of the extracorporeal shock wave lithotripter (MEDSTONE-1000) in patients with upper urinary tract stones. Thirty-five cases (total 40 trials) treated during the period of October 1987 through March 1988 were enrolled in this study. The ages of the cases ranged from 22 to 65 (average 43.9) years old, comprising 23 men and 12 women. The site of presence of urinary tract stones was the renal pelvis and calyx in 28 cases and the upper ureter in 7 cases. The size of the stone was smaller than 1 cm in 15 cases, 1 to 2 cm in 12 cases, 2 to 3 cm in 7 cases and larger than 3 cm in 1 case. 13 patients with renal stones were treated with double-J stent catheter and all patients with ureteral stones were treated with the ureteral balloon catheter or flexible-tip ureteral catheter as preoperative manipulation. In 26 cases epidural anesthesia was used and the others were treated under general anesthesia. Stone targetting was determined by two oblique radiographs from separate axes. The intensity of shock waves was mainly 24 KV and the maximum shock wave counts to break up stones were 6800 shots. The size of the broken stone fragments was less than 2 mm in 24 cases (68.5%) and 2 to 5 mm in 10 cases (28.6%), which indicated that the procedure was very effective. However, one case in whom the stone could not be broken was with cystinuria. After three months the fragments completely passed in 22 cases (64.7%) and the residual fragments larger than 5 mm were left in 2 cases (5.9%).(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison between an in vitro ureteroscopic stone size estimation and the stone size measurement with the help of a scale on stone baskets

Introduction

Endoscopic treatment of ureter stones and renal calculi relies on the surgeon’s estimation of the stone size for both lithotripsy and removal of stones or stone fragments. We therefore compared precision and reliability of the endoscopic estimation of stone size by the surgeon with measurements on a scale on a stone basket.

Materials and methods

Two surgeons (one high experienced and one low experienced) first estimated, then measured the size of 12 stones differing in size and color using different stone baskets (2.5, 3.0, 4.0 Ch) each via a semirigid renoscope in an artificial ureter under water repeatedly on two different days. All together, we had 288 measurements and 288 estimations.

Results

On the whole, the accuracy of the estimation diminished with bigger stones. There is an increasing underestimation with increasing stone size. Factors, which significantly influence the estimation, are the operating surgeon, the color of the stone, the time sequence, and the size of the closed basket, which was held beside the stone. The accuracy of the measurement of the stone baskets is not as good as the estimation. The small 2.5-Ch basket is the most accurate in measuring big stones (>6 mm), the 3.5 Ch in intermediate stones (3–6 mm), the big basket (4.0 Ch) in small stones (<3 mm).

Conclusion

This first attempt at validation of a scale on stone baskets shows different results for each basket which could be systematically improved. Until now, the estimation of the surgeons is better than the measurement, but it is also influenced by factors like the surgeon or the color of the stone.

     

Extracorporeal shock wave lithotripsy with EDAP LT-01 lithotriptor

Extracorporeal shock wave lithotripsy (ESWL) by EDAP LT-01 was used to treat 77 patients with upper urinary tract stones. A total of 218 sessions were performed for 111 stones in 52 kidney units and 41 stones in 37 upper ureter units, and 77% of the 52 kidney stone units and 62% of the 37 ureter units were completely disintegrated. The success of fragmentation of kidney stones differed with the size of the stone, 96% of the stones less than 21 mm and 63% of the 8 stones between 21 and 30 mm were successfully fragmented. The success of fragmentation of ureteral stones differed auxiliary manipulation. Eighty-one percent of the 21 ureteral stones moved into the kidney, were successfully disintegrated, but 40% of the 20 stones unmoved could be disintegrated with retrograde manipulation. Of the 62 successful units, 89% became stone free within 3 months. Complications were subcapsular renal hematoma in 3 patients and obstruction in 5 patients. The initial 25 patients were treated under epidural anesthesia and 52 patients were treated without anesthesia. The results show that the indication of ESWL with LT-01 is better for the stones smaller than 30 mm and the indication should be determined after a couple of sessions for stones greater than 30 mm. ESWL with LT-01 can be performed on an out-patient basis without anesthesia in many cases.     

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.     

Routine ureteral dilatation is not necessary for ureteroscopy

Purpose: To present our experience in ureteroscopic lithotripsy and stone extraction without ureteral dilatation. Patients and methods:A total of 134 consecutive patients (80 male and 54 female), with a mean age of 36.4 (18–65) years underwent ureteroscopic stone removal. The stones were located in the lower, middle, and upper parts of the ureter in 92, 18 and 24 patients and the mean stone diameters were 9.2 (6–15) mm, 10.5 (8–15) mm and 8.8 (8–10) mm, respectively. A semirigid ureteroscope 8 F in size was used without any ureteral dilatation. The stones were fragmented by a pneumatic lithotripter in the ureter and the fragments were removed by a basket catheter or stone forceps. All patients were re-evaluated with a plain film on postoperative first day and with intravenous urography (IVU) at 3 months. Residual fragments bigger than 3 mm were accepted as treatment failure. Results: The mean operation time was 44 (20–120) minutes. After the operation, the stone-free rate was 89/92 (97%) for lower, 15/18 (83%) middle and 18/24 (75%) upper ureteral stones, respectively. Double J catheter replacement was needed in 13 patients due to impacted stone and/or failed procedure. Ureteral perforation did not occur in any patient. Patients were discharched from hospital within 6–24 hours. No ureteral stricture was encountered during the follow-up period. Conclusion: Our experience suggests that ureteroscopic interventions could be easily performed for all parts of ureter without previous dilatation of the ureter.10th European Symposium on Urolithiasis on June 11–14, 2003, Istanbul, Turkey.     

Nonoperative extraction of retained common duct stones.

Nonoperative extraction of retained common duct stones was successful in 17 patients during the past two years. Eleven required only one manipulation; the largest number of manipulations required was five. The Burhenne catheter and Dormia basket were employed frequently, but were not always effective. When difficulties occurred with their use, Mazzariello biliary forceps resulted in successful stone extraction, particularly in the management of impacted stones. Extraction procedures were performed under fluoroscopic control, usually on an outpatient basis. Recently, we have employed a flexible fiberoptic endoscope that allows visual investigation of suspected defects and decreases fluoroscopic exposure. These results indicate that all patients with retained common duct stones are candidates for sinus tract manipulation six weeks after common duct exploration. It is recommended that secondary operations for retained common duct calculi not be performed until nonoperative extraction has been given an appropriate trial.     

The stone cone: a new generation of basketry

PURPOSE: We designed a device to minimize ureteral stone migration during intracorporeal lithotripsy, decrease the likelihood of stone and/or basket entrapment, and extract whole stones and fragments. MATERIALS AND METHODS: Nitinol and stainless steel wires were configured into expandable tapered cones, which were placed cephalad to in vitro and in vivo concretions, and used to trap and extract stones as well as other test material. Safety features were evaluated by measuring the release of ball bearings and the tension needed to unwind the coils of the cone, which were greater than 4 mm. in diameter. We treated 4 patients with ureteral calculi using the Stone Conedagger to prevent migration and extract fragments. RESULTS: The cone-shaped devices expanded to occlude the test devices and human ureters, and prevented stone migration. They extracted whole concretions and fragments greater than 1.5 mm. The cone-shaped basket released a 5.5 mm. ball bearing at an average 0.127 pounds of tension when pulled through a 5 mm. plastic orifice. Coils greater than 4 mm. in diameter were straightened at a tension of 0.10 to 0.14 pounds. Stone migration during intracorporeal lithotripsy was prevented in the 4 patients with ureteral calculi, in whom large and small fragments were safely extracted. CONCLUSIONS: The Stone Cone may be placed via a ureteral catheter and opened cephalad to a ureteral stone to prevent stone migration during intracorporeal lithotripsy. It may extract whole stones and fragments greater than 1.5 mm. It is designed, so that its coils greater than 4 mm. in diameter release concretions too wide for the ureter or ureteral orifice after approximately 0.127 pounds of tension are applied. Because of these features, the Stone Cone represents a new generation of basketry appropriate to the era of ureteroscopy and intracorporeal lithotripsy. It is worthy of further clinical study.     

Extracorporeal shock wave lithotripsy of proximal and distal ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of 105 patients with ureteral stones. There were 77 stones in the upper part of the ureter, i.e. above the pelvic brim, and 28 in the lower part, i.e. below the sacroiliac joint. Successful fragmentation was attained in 101 (96%). In 93% of the patients with stones in the upper ureter and in 100% with stones in the lower ureter the fragments were eliminated completely. In 87% of the patients with stones in the upper ureter, a ureteral catheter was introduced under local anesthesia but without fluoroscopic control. It was thereby possible to remove 30% of the stones from the ureter to the kidney. For the remaining stones, saline was infused through the catheter during ESWL. For patients with stones in the lower part of the ureter, a ureteral catheter was passed in 79% and saline infused during treatment. Whereas some form of anesthesia was used for treatment of all upper ureteral stones, 89% of the treatments for lower ureteral stones were performed without anesthesia. Auxiliary procedures after ESWL were limited to four ureteral catheter manipulations for distal stones. Four proximal stones which remained unaffected by ESWL had to be treated by open surgery (3 stones) or percutaneous surgery (1 stone). Of 82 ureteric stones treated in situ the success fragmentation rate was 95%. The average number of ESWL sessions was 1.04 for both proximal and distal ureteral stones.     

Percutaneous nephrolithotomy in horseshoe kidney

Two patients with renal pelvic stone in a horseshoe kidney who underwent a percutaneous nephrolithotripsy (PNL) are presented. Case 1 was a 36-year-old man with a 20 x 12 mm right renal pelvic stone in a horseshoe kidney. Case 2 was a 47-year-old man who had been followed up at our clinic for a horseshoe kidney and was found to have a 15 x 10 mm left renal pelvic stone. We found that percutaneous removal of renal pelvic stones can be performed safely in a horseshoe kidney. It appears that to remove stones from the renal pelvis in a horseshoe kidney 4 items must be considered. 1) The anatomical relationships of the horseshoe kidney to other viscera and blood vessels should be confirmed before surgery utilizing computerized tomography or ultrasound sonography. 2) The occlusion ureteral catheter should be inserted up to the renal pelvis to prevent small fragments from falling into the ureter. 3) The rigid nephroscopy should be introduced through the most appropriate calyx, so that its manipulation could be limited. 4) The fragmentation of stones should be performed from the peripheral surface of a stone to prevent from migrating into another calyx. We believe this is only the sixth and seventh documented cases involving a horseshoe kidney.     

A fundamental study on expansive splitter lithotripsy

The application of expansive splitter for industrial use to lithotripsy was studied. A natural rubber latex catheter 350 mm in length, 3.5 mm in diameter and 0.1 mm in thickness was newly developed for prevention from alkalization by expansive splitter. Expansive pressure generated by expansive splitter was measured to calculate the fragmentation time of urinary stones. Urinary stones 20, 30 or 40 mm in diameter were expected to be fragmented in 7.5, 9 and 11 minutes. Human bladder stone 55 x 54 x 33 mm in size was divided into two parts in 24 minutes using expansive splitter. The fragmentation test of model calculi was performed to decide the boring length necessary for the fragmentation of urinary stones. The necessary boring length was a half of the stone diameter in stones smaller than 20 mm in diameter and was 3/4 of it in stones larger than 30 mm in diameter. A tolerance test of the catheter was performed. When the used catheters for splitting were immersed in water, no change was observed in pH, in spite of the elevation of pH from 6.6 to 12.3 when the splitter itself was immersed in water. No leakage of water from the catheter was observed in this tolerance test. Histological change on the epithelium of the bladder and the renal pelvis by expansive splitter was examined. The mucosa of the dog; bladder and the pig renal pelvis, to which expansive splitter was made contact, showed no histological change after 30, 45 or 60 minutes after the contact. In conclusion, expansive splitter enclosed in the natural rubber latex catheter can be employed for clinical use to fragment urinary calculi in endourological procedures.     

Retrograde transureteral approach: a safe and efficient treatment for recurrent cystine renal stones

Most patients presenting cystinuria require multiple urological procedures during their lifetime. In this kind of patients the availability of minimally invasive procedure represents an advantage of minimizing the cumulative morbidity of several repeated treatments. Herein we report our experience using ureterorenoscopy (URS) for the treatment of recurrent renal cystine stones. From 2003 to 2007, 10 patients (4 males and 6 females) with one or multiple recurrent renal cystine stones underwent URS. Overall, 21 procedures have been performed. Mean maximum diameter of stones was 11.2 mm (range 5–30 mm). Either 8–9.5 F semirigid or 7.9 F flexible ureteroscopes were used. In 6 cases, stones were removed using a basket; in 9 procedures laser lithotripsy with flexible scope was performed; in 6 cases renal calculi were pulled down in the ureter using flexible instrument and then shattered with laser introduced by semirigid instrument. Stone-free status was defined as the absence of any residual fragment. A complete stone clearance was obtained in 15 out of 21 procedures (71%). In 5 cases (24%) significant residual fragments occurred; in the remaining case (5%) URS was ineffective. In 5 out of these unsuccessful procedures, stone clearance was obtained with auxiliary treatments. The last patient has not been treated yet. No major complications occurred as a result of the procedures. URS offers excellent advantages in case of recurrent hard calculi such as cystine stones. Minimally invasive procedures allow satisfactory outcomes, improving patients’ quality of life.