Flexible ureteroscopy. Diagnostic and therapeutic significance. Apropos of 15 cases

The authors analyse the results of a preliminary report of 15 cases of ureteric stones treated by flexible ureterorenoscopy and one case of radiolucent renal stone in the left lower renal calyx. Stone fragmentation was complete in 11 cases with 1 small residual fragment in the lower ureter, 1 perforation was immediately operated without any further complication and in one case, it was impossible to advance into the ureter. Flexible ureterorenoscopy is valuable for diagnosis of filling defects in the lower calyx and for treatment of stones in the upper and middle ureter.     

Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: the first prospective clinical study

OBJECTIVE: To present the results of the first clinical study of a synchronous twin-pulse technique for extracorporeal shock-wave lithotripsy (ESWL), which is effective for in vitro stone fragmentation and safe when assessed in vivo on animal tissue. PATIENTS AND METHODS: Fifty patients with urinary stones (35 men and 15 women) were enrolled and treated with the TWINHEADS lithotripter. The entry criteria were: age > or = 18 years, with a radio-opaque single stone in the kidney or upper ureter, a normal laboratory profile (serum creatinine, liver function, blood, bleeding and clotting times, and prothrombin concentration). The exclusion criteria included lower ureteric stones, patients with urinary tract infection, obstructed urinary tract distal to the stones, or congenital abnormalities. All patients received one session and were evaluated by ultrasonography (US), urinary tract plain X-ray, and complete laboratory investigations before and immediately after treatment, and after 2, 14 and 30 days. Patients requiring re-treatment at the 14-day visit received a second session and were re-evaluated after 7 and 14 days. RESULTS: The mean (sd, range) stone size (longest diameter) was 12.3 (2.6, 9-18) mm. Intravenous sedation was used in 30 patients. There was mild haematuria in 25 patients on the day of treatment. During the follow-up there was no evidence of haematoma, gross renal injury, upper urinary tract obstruction or significant changes in the laboratory investigations. After 14 days, 17 patients (34%) were free of stones, with residual stones of < or = 5 mm in 20 (40%); they were free of stones at the 1-month follow-up. Thirteen patients (26%) had residual stones of 6-9 mm, but the stones were half or less of the original size. Patients with residual stones of > 5 mm had another ESWL session and were free of stones within 14 days. Thus all patients were rendered stone-free within 1 month. CONCLUSIONS: Synchronous twin-pulse ESWL is promising, seems safe and effective for treating patients with renal and upper ureteric lithiasis.     

Ureteroscopic management of recurrent renal cystine calculi

BACKGROUND AND PURPOSE: Patients with recurrent cystine nephrolithiasis oftentimes require multiple procedures for stone removal. As the majority of cystine stones are resistant to the effects of shockwave lithotripsy, repeat percutaneous surgery is often required and may cause renal damage. Moreover, repeat percutaneous access may become more difficult as perinephric fibrosis develops. Small-caliber ureteroscopes along with the holmium laser now enable routine intrarenal ureteroscopic access to symptomatic renal stones. Herein, we present our experience in managing recurrent renal cystine calculi using flexible ureterorenoscopy and assess whether such an approach may be used as an alternative to percutaneous surgery in selected patients. PATIENTS AND METHODS: Three patients with large-volume (mean diameter 22 mm) renal cystine stones were managed with a 7.5F flexible ureterorenoscope combined with holmium laser lithotripsy to fragment the stones completely. RESULTS: The mean treatment time was 97 minutes, with successful fragmentation in all cases. Two of the three patients were completely stone free on follow-up intravenous urography, with the third patient having only small-volume residual fragments in a lower pole calix. All patients are currently asymptomatic and are being maintained on high oral fluid intake, urinary alkalization with potassium citrate, and alpha-mercaptopropionylglycine to reduce urinary cystine excretion. CONCLUSION: Flexible ureterorenoscopy with holmium laser lithotripsy provides a reasonable alternative for the management for recurrent cystine calculi in patients who are not candidates for repeat percutaneous procedures. Although it is time consuming, complete stone fragmentation, along with clearance of fragments, can be achieved in the majority of patients.     

Extracorporeal shockwave lithotripsy, endourology and open surgery: the management and follow-up of 200 patients with urinary calculi

The management and follow up of 200 consecutive patients with renal and ureteric calculi are presented. The primary treatment of 185 (92.5%) was by extracorporeal shockwave lithotripsy (ESWL), of whom three (1.6)%) with large calculi underwent percutaneous nephrolithotripsy (PCNL) prior to ESWL as a planned combined procedure. Twelve (6%) were treated by PCNL or ureterorenoscopy (URS) as their definitive treatment and three (1.5%) by conventional open renal and ureteric surgery. The average in-patient stay was 3.8 days and most returned to normal activity within one day of discharge. Of the 185 patients 102 (55%) required no analgesia after treatment by ESWL, 29 (15.6%) required parenteral analgesia and the rest were comfortable with oral non-narcotic medication. Thirty (16%) required auxillary treatment by percutaneous nephrostomy (PCN), PCNL and URS following ESWL for obstructive complications from stone particles. Two required further ESWL and one PCNL at three months for large fragments. Overall, open surgery was required for only 1% of renal calculi and 13% of ureteric stones. These results are consistant with the extensive West German experience confirming that most urinary calculi are now best managed by ESWL and endoscopic techniques. Where these facilities are available open surgery should only be necessary for less than 5% of upper urinary tract stones.     

Pulsed dye laser lithotripsy--the Toa Payoh Hospital experience.

We report our experience with pulsed dye laser lithotripsy in the treatment of 100 ureteric stones in 95 patients over a 14-month period from July 1989 to September 1990. The overall rate of successful stone fragmentation was 97%. There was a low incidence of minor complications--mild haematuria, ureteric colic and urinary tract infection; ureteric perforation occurred in only 3 patients, all of whom were successfully treated conservatively. Pulsed dye laser lithotripsy is a safe and effective mode of treatment for ureteric stones. Current indications for laser fragmentation of stones are ureteric stones, impacted pelviureteric junction stones and Steinstrasse.     

Flexible ureterorenoscopy: prospective analysis of the Guy's experience

OBJECTIVE: To report our outcomes with small diameter, actively deflectable flexible ureterorenoscopy from a prospective database. PATIENTS and METHODS: 114 flexible ureterorenoscopies were performed in 105 patients (mean age, 49.5 years; range, 19-85 years; 71 males, 34 females) over a 9-month period. Of these, 101 were for refractory stones following failed ESWL and 13 for diagnostic reasons. An Olympus URF P3 flexible ureteroscope with pressure irrigation was used. Electrohydraulic lithotripsy was used to fragment stones and the fragments were retrieved with Graspit, triradiate graspers or tipless baskets. RESULTS: Stents had previously been placed in 53% and dilatation of the ureteric orifice was necessary in 15%. In the stone group, the median operating time was 55 min (range, 15-210 min) and the median screening time 2.2 min (range, 0.3-9.1 min). Success was defined as complete stone clearance or good fragmentation to 2 mm or less. Overall success in this group was 72.3%. There was no statistically significant difference between lower and other calyces (P=0.83 Chi-square test). Successful outcome was achieved in 72% for stone size 10 mm or less, 80% for 11-20 mm and 50% for greater than 20 mm. Two or more procedures were needed in 8 patients. In the diagnostic group, the median operating time was 45 min (range, 20-60 min) and the median screening time 2 min (range, 0.3-8.3 min). The majority were for upper tract filling defects. Access and successful diagnosis was achieved in all cases. The major complication rate was 2.6%. The ureteroscope needed repair once during this series. CONCLUSIONS: Flexible ureterorenoscopy is an effective diagnostic and therapeutic tool in a select group of patients. It should be considered for ESWL-resistant upper tract stones but the results are poor in stones larger than 20 mm and percutaneous nephrolithotomy may be a better option in these patients.     

纤维胆道镜在复杂上尿路结石手术中的应用

目的探讨纤维胆道镜在复杂上尿路结石手术中的应用价值。方法将纤维胆道镜应用于输尿管多发结石、输尿管结石并肾结石以及输尿管结石移位的手术中，取出结石。结果21例中19例纤维胆道镜取石成功(其中1例有2米粒大结石残留于肾盏内，出院后2周内排出)，2例失败后改行传统手术。结论纤维胆道镜应用于复杂上尿路结石手术中，治疗效果较好、损伤小，是一种安全有效的方法，值得推广应用。对于用纤维胆道镜取石困难、估计损伤较大的病例．采用传统方法延长切口取石为宜。     

Holmium:YAG laser for urinary stones

OBJECTIVE: To evaluate the results of Holmium:YAG (Ho:YAG) laser lithotripsy in the treatment of urinary stones. MATERIAL AND METHODS: Between 1993 and 1997, 59 patients with 85 urinary stones were treated with the Ho:YAG laser lithotripsy. Retrospective evaluation was done on the 64 procedures available, comprising 53 ureteric, 8 bladder, and 2 renal calculi, and one stone in a ureterocele. RESULTS: The Ho:YAG laser fragmented all types of calculi. Of 38 patients, 29 (76%) with ureteric stones were stone-free and 7 (18%) had stone fragments smaller than 2 mm left 1-3 months after the lithotripsy, resulting in a total clinical success rate of 95%. The procedure caused four ureteric perforations. One ureteric stricture, after repeated treatments for a Steinstrasse formation, led to nephrectomy. CONCLUSIONS: The Ho:YAG laser was reliable and effective for most of the urinary stones. The largest stones in any location, and stones of hard composition, however, were treated with combined disintegration methods. Four minor ureteric perforations and one ureteric stricture were related to laser use.     

纤维胆道镜在上尿路结石手术中的应用

目的:探讨纤维胆道镜在上尿路结石手术中的应用价值。方法:为31例复杂上尿路结石(多发肾结石、输尿管多发结石、输尿管结石并肾结石)患者施行手术,5例输尿管切开取石术中结石移位时应用纤维胆道镜协助取石。结果:35例取石成功,1例多发肾结石患者有2颗结石残留于肾盏内,术后2个月体外冲击波碎石术(extracorporeal shock wave lithotripsy,ESWL)治疗后排出,2例输尿管粘膜和1例肾盂粘膜损伤出血。结论:纤维胆道镜用于上尿路结石手术,尤其是复杂性上尿路结石手术,有助于取尽结石,对患者损伤小,是一种安全有效的方法,值得临床推广应用。     

顺行输尿管软镜碎石术治疗尿流改道后上尿路结石分析

目的：评价顺行输尿管软镜碎石术治疗各种尿流改道后上尿路结石的临床应用价值、安全性及疗效。方法：2009年1月～2012年2月采用顺行输尿管软镜碎石术治疗尿流改道后上尿路结石患者19例,其中左侧13例,右侧5例,双侧1例;输尿管结石12例,肾结石5例,同时合并肾结石和输尿管结石2例。4例采用C臂X线引导,15例采用B超引导肾造瘘。11例一期行经皮肾造瘘＋顺行输尿管软镜碎石术;8例合并感染及急性梗阻患者一期行经皮肾造瘘,1周后二期行输尿管软镜碎石术。结果：19例患者均取得手术成功,平均手术时间为（61±21）min,平均住院时间为（5．6±3．2）d,术中出血量均〈50ml,术中及术后均未发生严重并发症。17例经历一次碎石程序即完全清除,2例经过2次碎石程序。术后4周复查CT,仅1例显示肾盂残留小片状结石,一期结石清除率达94．7％。平均随访15个月,2例患者复发,显示结石复发率为10．5％（2／19）,1例经过ESWL得到成功治疗,另1例再次顺行输尿管软镜碎石治疗成功。结论：顺行输尿管软镜是处理尿流改道后上尿路结石治疗的首选方式,具有安全性高、手术成功率高、结石清除率高、复发率低、并发症少等优点,值得临床推广应用。     

Clinical experience with extracorporeal shock wave lithotripsy (ESWL) in upper urinary tract stones

We treated 100 patients of upper urinary tract stone using extracorporeal shock wave lithotripsy (ESWL), from April to October 1986. Eighty-six of the patients were treated by ESWL monotherapy, and the other cases required further treatment, such as percutaneous nephrostomy (PCN), percutaneous nephrolithotomy (PNL), and transurethral ureterolithotripsy (TUL). On the X-ray film obtained from one to three months after ESWL, 73 patients had no stones, 8 patients had sandy stones, 7 patients had small fragments less than 5 mm, 2 patients had large stones equal to or greater than 5 mm and 10 patients could not be followed up. Therefore, 97.7% of all patients were successfully treated. In conclusion, ESWL is considered to be an ideal method to treat upper urinary tract stones, and soon will become the first choice of treatment of urolithiasis together with the progress in endourological techniques.     

Treatment of renal pelvic calculi using the rigid ureterorenoscope

Ten patients with renal pelvic stones were treated by rigid ureterorenoscopy. Ultrasound lithotriptor and biopsy forceps were used for disintegrating the stones. The stones of 5 patients were disintegrated into small fragments that passed spontaneously within 2 months after the procedure. The stones of 2 failed to disintegrate for migration of the stones into the calices. Retention of the large fragments in the calices occurred in 3 patients. Residual fragments of urate were dissolved completely by urine alkalinization 5 months later in 1 patient. In another patient the fragment had fallen into the ureter and it was extracted by ureterorenoscopy 8 months later. After all, the success rate was 70% in this series. The disintegration of stones in the small intrarenal pelvis has proved to be difficult when they are approached by retrograde ureterorenoscopy. There were 2 complications of ureterorenoscopy: extravasation of urine from the renal sinus, and from the upper ureter. These minor injuries were treated by stenting without sequelae.     

尿流改道后输尿管结石的处理（附8例报告）

目的：评价尿流改道后输尿管结石的治疗方案。方法：回顾性分析8例尿流改道后输尿管结石的处理方法,术前泌尿系腹部平片、泌尿系彩超、肾输尿管膀胱CT平扫明确为输尿管结石,所有患者对症治疗,随访观察1周,患者如结石未自行排出,行体外冲击波碎石术（ESWL）或逆行输尿管镜钬激光碎石。结果：2例患者输尿管结石自行排出;3例患者行ESWL,1例碎石后结石成功排出;5例行逆行输尿管软镜碎石成功。8例患者结石治疗后均未出现并发症。结论：尿流改道后输尿管结石的处理包括短期随访观察、ESWL及逆行输尿管软镜碎石治疗。逆行输尿管软镜碎石是安全有效的,可作为尿流改道患者输尿管结石的理想治疗方法之一。     

Extracorporeal shock wave lithotripsy in children. Efficacy, complications and long-term follow-up.

OBJECTIVES: Extracorporeal shock wave lithotripsy (ESWL) is effective and safe for the treatment of upper urinary tract calculi in adults. Some speculations concerning possible damages from ESWL on the growing kidney have been raised. METHODS: From January 1990 to December 1998, 64 children (30 girls and 34 boys; 8 months to 15 years old, mean 5.6 years) with a total of 83 stones of the upper urinary tract were treated by ESWL (Lithostar). Preoperative evaluation included history, physical examination, routine blood tests, urinalysis, urine culture, intravenous urography and optional renal scintigraphy. The impulse rate per treatment varied from 750 to 4,000 (mean 2,996). After acute treatment, routine follow-up included renal ultrasound, blood pressure controls, laboratory tests and eventually plain film X-ray. RESULTS: Successful fragmentation of the stones was achieved in all patients. In 54% the patients were free of stones treated at the time of discharge. At 3 months after treatment radiographic studies showed no residual fragments in 80% of the treated children. 83% of the treated stones were cleared entirely. The remaining fragments were clinically insignificant. An average of 2.5 ESWL treatments per child in general anesthesia were required. Stone analysis showed 20 calcium oxalate, 38 calcium phosphate, 12 struvite, 2 uric acid and 9 cystine calculi. Ureteral stents were placed in 43%. No significant urinary infection was seen under antibiotic prophylaxis. Only 3 children showed a recurrence (1 x cystinuria with low compliance and 2 x struvite). There was no case of renal scarring. No change in renal function or blood pressure was found compared to the preoperative values. Hematuria and proteinuria disappeared in all children who were free of stones. Renal ultrasound revealed no growth difference between treated and untreated renal units. CONCLUSIONS: In childhood, ESWL is an efficacious and safe treatment of stones of the upper urinary tract. The long-term follow-up after ESWL with a second-generation lithotriptor did not show any signs of damage to the growing kidney. Sometimes repeated ESWL treatments are justified by the low rate of complications.     

Flank position ureterorenoscopy: new positional approach to aid in retrograde caliceal stone treatment

BACKGROUND AND PURPOSE: Clearance of lower pole stones and complex maneuvers such as basket repositioning remain challenging in ureteroscopic treatment of caliceal stone burdens. We describe the initial use of flank position ureteroscopy (FPU) with modifications to aid in the treatment of complex caliceal urolithiasis. We hypothesized that gravitational force acting on caliceal stones and fragments during holmium laser treatment would result in fragments being repositioned into the dependent renal pelvis, allowing enhanced treatment. PATIENTS AND METHODS: Eleven patients with complex upper tract stone disease (aggregate stone burden 1.5-5 cm) were treated using FPU. Patients were positioned with the stone-containing side superior. Flexible cystoscopy followed by flexible ureterorenoscopy and intracorporeal lithotripsy were performed. We utilized several modifications of the technique, including a radiolucent table and rotational C-arm fluoroscopy unit. Once all stones and particles fell into the dependent renal pelvis, additional laser fragmentation was simple. RESULTS: We observed the expected advantage of gravitational drainage of particles and stone into the renal pelvis during procedures. In many cases, fragments passed partially down the ureter during treatment. Basket repositioning of stones was not necessary. One complication, collecting system perforation during access, was treated with stent placement and successful delayed FPU. Seven patients were stone free at follow-up. Four patients with stone burdens >3 cm had approximately 80% stone burden reduction, but residual asymptomatic lower-pole particles (2-6 mm) remained, with several clearing with a secondary procedure. CONCLUSIONS: The use of FPU for the performance of complex renal stone treatment is a useful aid. Further refinement and comparison with standard technique is ongoing.     

46例输尿管软镜联合钬激光碎石治疗上尿路结石失败原因分析

目的 分析输尿管软镜钬激光碎石术治疗上尿路结石手术失败的原因.方法 回顾本院2014年10月至2016年3月施行的472例软尿管软镜钬激光碎石术治疗上尿路结石病例,筛选46例手术失败病例,记录手术失败的原因,并进行分析.结果 手术失败的原因包括输尿管狭窄或扭曲因素19例(41.3％);肾盂输尿管与肾下盏漏斗部夹角过小11例(23.9％);未找到肾盏憩室结石开口4例(8.7％);肾内感染8例(17.4％);设备有关因素2例(4.3％);操作因素至输尿管损伤2例(4.3％).结论 术前留置1～2周双J管,充分抗感染治疗,常规行肾脏CT及IVU检查,术中留置安全导丝,操作轻柔,必要时经皮肾镜取石术是输尿管软镜钬激光碎石术处理上尿路结石成功的关键.     

输尿管软镜治疗孤立肾上尿路结石34例临床观察

目的探讨输尿管软镜治疗孤立肾上尿路结石的疗效及手术技巧。方法 2012年1月至2013年12月对34例孤立肾上尿路结石患者行输尿管软镜碎石术,其中先天性孤立肾2例,对侧肾切除所致孤立肾8例,对侧肾萎缩(无功能肾)24例;萎缩肾有17例既往行开放手术,4例曾有多次体外冲击波碎石史。34例患者中有21例为孤立肾经皮肾镜术后残留结石,23例患者术前留置D-J管1~4周,11例患者术前无D-J管留置。结果手术时间40~125min,30例均一次碎石成功,单次手术碎石总成功率为88.2%(30/34),其中17例患者术后1月复查腹部平片(KUB)未见明显残留结石,13例患者残留结石4mm;3月后再次复查,结石均完全排出;2例患者因术中角度原因未能完全碎石,术后结合ESWL,但仍有残留结石4mm,1例患者行二次输尿管软镜碎石,间隔时间1月,术后1月复查无明显结石残留;1例孤立肾铸性结石先后行3次软镜,每间隔时间1月,术后复查结石完全排出。结论输尿管软镜治疗孤立肾上尿路结石是安全有效的,特别适用于孤立肾经皮肾镜术后残留结石,其结石排净率高、并发症低,可以作为孤立肾上尿路结石,特别是孤立肾经皮肾镜术后残留结石的首选。     

Ureteric stone management using a second generation lithotriptor.

A series of 209 consecutive patients with ureteric calculi underwent 296 extracorporeal shock wave lithotripsy treatments on the Siemens Lithostar over a 25-month period; 123 stones were upper ureteric, 30 mid-ureteric and 56 lower ureteric; 46.9% were right-sided stones, 53.6% were left-sided and 0.5% (1 patient) were bilateral. On referral, 60 patients had stents and 15 had nephrostomies for obstruction. All treatments were performed without anaesthesia except for 9 patients in whom stent insertion or ureteroscopic manipulations were attempted concomitant to ESWL. The average number of treatments was 1.42, with 27.5% of patients requiring more than 1 treatment. The average number of shocks per treatment was 3995 and the average hospital stay was 1.79 days. Complete clearance of the stone was achieved in 82% of upper ureteric stones, 89% of mid-ureteric and 80% of lower ureteric stones. The facility for X-ray localisation of stones allows a high proportion of ureteric calculi to be treated successfully by ESWL, including the more taxing middle and lower ureteric calculi.     

输尿管软镜治疗儿童肾结石11例临床分析

目的探讨输尿管软镜在儿童肾结石的应用价值。方法回顾性研究2011年10月至2013年3月对11例儿童肾结石患者行输尿管软镜钬激光碎石取石术,男9例,女2例;年龄6~15岁,平均(9.7±3.1)岁;结石大小13~21mm,平均(16.0±2.7)mm。术前2周留置F5双J管,术中经导丝置入输尿管软镜鞘,置入输尿管软镜,寻及结石,使用200μm钬激光光纤碎石,功率设定在0.8~1.0J,频率设定为8~10Hz。术后留置F5双J管,术后1月复查泌尿系彩超及腹部正位片了解结石清除情况。结果输尿管软镜一次性结石清除率为82%。手术患者均无输尿管穿孔、黏膜撕脱、菌血症等并发症。手术时间40~85min,平均(57.0±12.2)min;术后住院3~5d,平均(3.5±0.8)d。结论输尿管软镜治疗儿童肾结石是安全、有效的。     

输尿管软镜钬激光碎石术在马蹄肾结石中的应用

目的:探讨输尿管软镜钬激光碎石术治疗马蹄肾结石的安全性及有效性。方法:回顾性分析2005年1月～2010年12月采用输尿管软镜钬激光碎石术治疗马蹄肾结石13例患者资料。结石直径平均为1.7(1.2～2.3)cm。主要临床症状为腰痛、尿路感染、血尿。6例患者有ESWL史,2例曾行经皮肾镜取石术。术前1周均留置双J管,均行尿培养、静脉尿路造影及双肾CT检查。术中均先放置输尿管扩张鞘,然后置入输尿管软镜抵达肾盂。术后第1天及2个月复查KUB平片、B超或双肾CT平扫。术后检查无残石或结石残块<3mm视为碎石成功。结果:13例患者均顺利放置镜鞘并置入输尿管软镜,进镜成功率100%。患者碎石成功12例(92.3%)。1例术后结石残块略大于3mm,行ESWL处理。平均手术时间90min,平均住院2d。无手术并发症发生。术后症状均消失。结论:输尿管软镜钬激光碎石术治疗马蹄肾结石是一种可供选择的安全、有效、微创治疗方法。