Urological problems following treatment of carcinoma of the cervix

One thousand one hundred and sixty-one cases of carcinoma of the cervix presenting over a 20-year period to 1982 were considered: 326 (28%) of these women developed urological problems, of whom 82 (7%) had major complications. Fistula formation occurred in 46 cases (4%), and was associated with active malignant disease in 33. Significant progressive ureteric obstruction occurred in 15 patients, 11 of whom had active malignancy. Overall, 35 (43%) of 82 patients with major urological problems had no evidence of active disease. Urinary diversion by ileal conduit proved to be a relatively simple and effective way of dealing with the serious problems, especially for patients with fistula formation and progressive ureteric obstruction, 67% and 73% of whom, respectively, underwent this procedure. More complex reconstructive surgery proved successful in a small number of selected patients, in whom there was no evidence of active tumour. Attempts to compromise with less definitive or over-ambitious procedures resulted in further complications and prolonged hospitalisation.     

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents.

BACKGROUND AND PURPOSE: Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique. PATIENTS AND METHODS: Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkin's lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements. RESULTS: Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested. CONCLUSION: Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.     

Useful technique for long-term urinary drainage by inlying ureteral stent. Six-year experience.

Endoscopically placed inlying ureteral stents have proved useful in the conservative management of patients with ureteral obstruction, urinary fistula, and malignancy and have obviated the need for operative intervention. In high-risk symptomatic patients with widespread malignancy, internal urinary diversion offers the opportunity for an improved quality of life without the surgical risk or potential morbidity of supravesical diversion. Potential candidates for this simple, safe, and effective technique include: those with postsurgical obstruction and/or fistula, retroperitoneal fibrosis, metastatic carcinoma, congenital ureteropelvic junction obstruction, as well as those with reversible obstruction from lymphoma and carcinoma of the prostate who are undergoing radiotherapy and/or chemotherapy. The focus of this report is on the technique we have found successful in providing us with stents that fit our individual patients. Readily available fabricated graduated ureteral catheter can be cut and shaped to particular measurements unlike prefabricated catheters. Minimal preparation time is demanded, and there is no need for extensive stocking of various catheter sizes.     

The role of percutaneous nephrostomy in malignant ureteric obstruction

OBJECTIVES: Uraemia as a result of malignant ureteric obstruction is a recognised event in those with advanced malignancy, usually of pelvic origin, which, if left untreated, is quickly a terminal event. Palliative decompression of the obstructed urinary system, either by percutaneous nephrostomy (PCN), ureteric stent or a combination of both is a recognised method of improving renal function, with presumed low morbidity. The aims of the study were to assess whether PCN placement in malignant ureteric obstruction provided any additional survival benefit or patient morbidity. PATIENTS AND METHODS: The case notes of 32 patients with a mean age of 68.1 years (16 male, 16 female) who underwent PCN drainage for malignant ureteric obstruction were retrospectively analysed. Data on the site of primary malignancy, mode of presentation, improvement in renal function, median survival, conversion to internal ureteric stents and intervention-related complications were collected for analysis. RESULTS: The median survival following PCN insertion was 87 days and was unrelated to the patient's age and renal function. Those patients with primary underlying gynaecological malignancies appeared to survive almost 4 times as long as those with underlying primary bladder cancer. Renal function took a mean of 16.8 days to reach a nadir. Almost 79% of patients were able to be discharged from hospital--each patient, however, being re-admitted back to hospital on average 1.6 times prior to their death through PCN or internal ureteric stent related events. Retrospective "useful quality of life" was seen in less than half of the patient cohort. CONCLUSIONS: In the presence of malignant ureteric obstruction, palliative percutaneous urinary diversion may be performed and is effective in improving renal function. However, long-term survival is limited and should, therefore, be performed only when the views and wishes of the patient and carers are taken into account and if there is a definitive treatment plan available for the patient as quality of life can be suboptimal.     

Current status of metal stents for managing malignant ureteric obstruction

Obstruction of the ureters caused by extrinsic compression from a primary tumour or retroperitoneal lymph node masses is not unusual in the course of advanced pelvic malignancies. Most of the cases are of gynaecological or gastrointestinal origin, and the situation can be aggravated by peri‐ureteric fibrosis, a long‐term adverse event of previous chemotherapy or radiotherapy. Undoubtedly upper urinary tract decompression and maintenance of ureteric patency, even as a palliative measure, is important in managing these patients. Options for upper tract decompression include percutaneous nephrostomy, retrograde stenting and open urinary diversion. Plastic stents have long been used for managing malignant ureteric obstruction, but their overall success remains limited. Plastic stents often fail to be placed correctly, require regular exchange, and are faced with a high incidence of encrustation and migration. For these reasons plastic stents have been unsuccessful for long‐term maintenance of ureteric patency. To overcome these limitations metal stents were introduced and recently developed in an effort to ensure better long‐term patency of the obstructed ureter, fewer hospital admissions for stent change and better overall quality of life. In the present review the clinical applications of different types of metal stents are discussed, with a specific focus on the latest advances and the future options for managing malignant ureteric obstruction.     

Manual Replacement of Double J Stent Without Fluoroscopy: (Double j stent replacement)

It is not always possible to replace a ureteric stent with a new one due to the fact that tumoral effect increases in ureter with time. We present our experience of manual replacement of double J stent without fluoroscopy. The data from 23 female patients who underwent double J stent replacement with a total of 110 times was retrospectively analyzed. The steps of technique are as follows: take out distal end of the double J stent through urethra to external urethral meatus cystoscopically, insert a 0.035-inch guide wire through double J stent to the renal pelvis or intra pelvicaliceal system, take out old double J stent over guide wire, slide new stent over guide wire and at external meatus level take out guide wire while gently sliding distal end of double J stent over guide wire into urethra. The mean age was 58.39 ± 9.21 years. Cervical, endometrial, and ovarian cancer were diagnosed in 16, 4, and 3 patients respectively. The mean follow-up and indwelling period were 13.8 ± 5.2, 3.8 ± 0.6 months, respectively. Increased pelvicaliceal dilatation, serum creatinine level, or renal parenchymal loss was not observed. Replacement of double J stents with this technique is easy and can be used successfully in distal ureteral obstructions.Key words: Gynecologic malignancies, Double J stent, Stent replacement, Ureteral stent, Ureteral obstructionPatients with malignant ureteric obstruction often have a poor life expectancy, and renal failure may develop as a result of urinary obstruction. The obstruction can be relieved by placement of a percutaneous nephrostomy tube or a ureteric stent. After Zimskind et al described ureteral stents first in 1967,¹ stents have been become widely used to eliminate the obstruction due to malignant or benign causes in any level of ureter for internal urinary diversion.Though there are many kinds of stents that are being produced, it is not always possible to get special double J stents, such as metallic, for malignant obstructions in every case. In addition to that, standard double J stents are used commonly in medical centers.The main trouble is that these standard stents have to be replaced within 4–6 months to avoid stent related complications such as encrustation, stone formation, obstruction, or infection.² But especially in obstructions caused by malignancies, it is not always possible to place the new stent after removal of the old one. We report our experience of replacement of double J stents with our technique, applied on 23 female patients with malignant ureteric obstruction.     

Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications

OBJECTIVE: To compare patients with and with no stenting after ureteroscopy for ureteric calculi, as placing such stents is routine, although many patients complain of pain and urinary symptoms. PATIENTS AND METHODS: In all, 45 patients with ureteric calculi amenable to ureteroscopic management were prospectively randomized into a stented (23) or an unstented (22) group. Standard ureteroscopic basketing and lithotripsy was used, through a ureteroscope (8.5 F) with or without ureteric dilatation. Symptom questionnaires were completed by the patients after treatment, and they were followed radiographically to assess stone-free rate and evidence of obstruction. RESULTS: There was no statistically significant difference in age, stone size, operative duration or hospital stay between the groups (P > 0.05). Furthermore, there was no statistical difference in flank pain or urinary symptoms (P > 0.05), except haematuria, between the groups; haematuria was more severe and prolonged in the stented group (P = 0.001). CONCLUSIONS: Uncomplicated ureteroscopy for removing calculi is safe with no stent after treatment, and after considering complications and side-effects we think that the routine use of ureteric stents after uncomplicated ureteroscopy for stone extraction is unnecessary.     

The use of internalised ureteric stents in renal transplant recipients

Since 1982, we have used internal indwelling ureteric stents for the management and prevention of ureteric reconstruction complications in 28 renal allograft recipients. A total of 30 stents were placed in 18 patients either diagnostically or therapeutically in the management of allograft ureteric obstruction. In 16 patients internal stents were placed at the time of reconstruction for primary ureteropyelostomy (3), secondary ureteropyelostomy (8), repeat reimplant (3) and repair of ureteric or pelviureteric junction injury (2). Complications included 3 episodes of transplant pyelonephritis, proximal stent migration (1), persistent bacteriuria (1) and prolonged healing of a ureteropyelostomy (1). Internalised ureteric stenting is a safe and effective means of managing or preventing ureteric reconstruction complications in renal transplant recipients.     

The thermo-expandable metallic ureteric stent: an 11-year follow-up

OBJECTIVE

To review our long‐term use of the thermo‐expandable metallic ureteric stent, (model 051, PNN Medical, Denmark) for ureteric obstruction, and review current reports on its use.

PATIENTS AND METHODS

Data were collected prospectively on all patients who had a Memokath 051 ureteric stent inserted between November 1996 and November 2007. The standard stent, and wide and dual expansion versions were used. The stricture characteristics were recorded in a standard way. All stents were inserted by one surgeon in the UK and internationally, following a standard protocol.

RESULTS

In all, 74 stents were inserted into 55 patients in the study period (mean age 60 years, range 11–90). The indications for metallic stenting included primary stenting for malignancy, failed conventional open and endoscopic techniques, palliation, and where significant comorbidity limited repetitive stent changes. In 28 patients the obstruction was caused by malignancy, whereas in 27 it was caused by recurrent benign disease. The mean (range) hospital stay was 1.43 (0–7) days. Imaging after insertion showed normal or improved functional drainage in all but three patients, with immediate complications including urinary extravasation (one), poor thermo‐expansion (one) and equipment failure (locking assembly) (one). Late complications included migration (13), encrustation (two) and fungal infections (three). In all, 14 patients needed reinsertion (mean of 7.1 months, range 1–14) after insertion for migration (eight), encrustation (two), stricture progression (three) and incorrect stent length (one). Overall, 29 patients have died with the stents in‐situ. The mean (range) follow‐up was 16 (4–98) months.

CONCLUSIONS

The thermo‐expandable metallic Memokath 051 ureteric stent offers effective and durable long‐term relief from ureteric obstruction, and is a safe alternative to conventional JJ stenting. In addition there is an emerging role in palliation and the primary management of ureteric strictures.     

Use of balloon catheters for ureteral occlusion in urinary leakage

PURPOSE: Urinary fistula after treatment for cancer constitutes a therapeutic dilemma, especially in patients who have had various other treatments. We report on 7 patients with urinary leakage, treated conservatively with ureteric occlusion by way of percutaneous transrenal balloon catheters. MATERIALS AND METHODS: The indication for ureteral occlusion was persisting urinary leakage despite diversion by nephrostomy and drainage with atransurethral catheter. All patients had had previous treatment because of pelvic malignancy. Small Foley balloon catheters and angioplasty catheters were used. These devices were inserted percutaneously in an antegrade fashion. RESULTS: In all but 2 of the patients the leakage ceased with the aid of these devices. Insufficient ureteral occlusion necessitated unilateral uretero-cutaneostomy in 1 patient. In another patient a vesico vaginal fistula was closed surgically. The maximum duration of occlusion was 169 (mean 94, range 45-169) days, without any evidence of ureteric pressure necrosis. Despite good overall results many adjustments and replacements of catheters were necessary because of recurrent urinary leakage caused by inadequate obstruction and/or leakage of the occluding catheters. CONCLUSIONS: We conclude that long-term ureteral occlusion with percutaneous transrenal balloon catheters appears to be safe and does not result in pressure necrosis. Using this approach, urinary fistula can heal in some patients without the need for open surgery.     

Modified ureterosigmoidostomy (Mainz Pouch II): a nonrefluxing stented vs unstented laparoscopic porcine model

OBJECTIVE

To describe a rapid and reproducible pure laparoscopic cystectomy and nonrefluxing modified continent urinary diversion (Mainz Pouch II), and to determine whether ureteric stenting decreases ureteric obstruction after surgery.

MATERIALS AND METHODS

After institutional review and approval, six female pigs (51–55 kg) had a laparoscopic cystectomy and urinary diversion using a modified Mainz Pouch II. Imbricating bowel over the extra‐intestinal ureteric segment created the nonrefluxing mechanism. All pigs had the same bowel preparation before a standard four‐port transperitoneal laparoscopic procedure, but three pigs received bilateral J ureteric stents and three did not. Body weights, radiographic imaging, serum electrolytes and renal function were monitored during the 6‐week survival period.

RESULTS

One stented pig developed bilateral pyelonephritis, renal obstruction and was killed. Including this pig, four of 12 renal units were obstructed, occurring more often in the stented pigs. There were no significant differences between the serum electrolytes before and after surgery or between the stented or unstented pigs. The surgery was quicker as experience increased. No pig developed hyperchloraemic metabolic acidosis. The nonrefluxing modification appeared to be effective, as reflux was only present in one renal unit.

CONCLUSIONS

Laparoscopic ureterosigmoidostomy, specifically the modified Mainz Pouch II, represents a viable and reasonable continent urinary diversion. The results suggest that there was no benefit in stenting in this pig model.     

Ureteric complications of renal transplantation.

Of 507 consecutive recipients of renal allografts, 45 developed a urological complication. In 39 patients (7.7%) ureteric problems were implicated and these comprised 30 cases of obstruction and 9 cases of ureteric necrosis presenting as urinary leakage. In 7 patients ureteric obstruction resolved following a period of nephrostomy decompression; 10 patients were reconstructed surgically and this was successful in 8, with 2 patients requiring further surgical procedures. Ten patients were successfully treated by percutaneous stenting after dilatation of the stricture. Stenting failed in 4 patients and in 1 patient caused rupture of a calix. All 10 stents have now been removed and there is no recurrence of stricture (follow-up 32.0 +/- 8.6 months). Of the remaining 3 grafts, 2 were removed and the other graft had percutaneous removal of a ureteric calculus. The 1-year survival rate of allografts in the ureteric complication group was 84.6%; in the recipients without a urological complication it was 81%. It was concluded that an active approach to ureteric problems following renal transplantation results in the rescue of the majority of allografts.     

Cutaneous ureterostomy as palliative diversion in adults with malignancy

Over a twenty-one-year period (1963-1984) 46 patients underwent a permanent urinary diversion using cutaneous ureterostomy. Thirty-seven of these patients had this method of diversion employed as palliation for pelvic malignancies. In 70 per cent of the patients diversion was done secondary to ureteral obstruction and in the other patients because of either severe lower urinary tract symptoms or a failed alternate form of diversion. Forty-nine per cent of the patients experienced a postoperative complication. The late postoperative complications were either related to the choice of diversion or presumed progression of the patient's disease. Palliative diversion is now best initially attempted with percutaneous nephrostomy or indwelling ureteral stents if bladder function allows. Cutaneous ureterostomy no longer is indicated as a primary form of palliative diversion, however, it may be used as an alternative to open nephrostomy tube placement or intestinal conduit should other more conservative forms of management fail. The presence of at least one dilated ureter is a prerequisite to the success of this form of diversion.     

Ureteroscopic removal of retained ureteral Double-J stents

At the Lahey Clinic Medical Center, Double-J stents are placed primarily for management of patients with calculi. They are used before extracorporeal shock-wave lithotripsy (ESWL) of large renal calculi or bilateral ESWL treatments and after ureteroscopic instrumentation or removal of calculi. They are also used for palliative urinary diversion for patients with ureteral obstruction secondary to pelvic cancer. Fluoroscopy with C-arm guidance is the standard radiologic technique employed for manipulation of all calculi and insertion of stents. Results have been good with the use of these stents, but in 3 patients the rigid ureteroscope was required to remove a retained Double-J stent.     

Clinical outcome of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction

Background: Previous studies have shown that self-expanding metal stents are an effective method for palliation of malignant biliary or duodenal obstruction. We present our experience with the use of simultaneous self-expandable metal stents for palliation of malignant biliary and duodenal obstruction. Methods: We performed a retrospective review of all patients undergoing simultaneous biliary and duodenal self-expandable metal stent placement between November 98 and May 2001. All the patients had documented evidence of biliary obstruction and symptomatic duodenal obstruction. The patients received endoscopic biliary stenting with biliary Ultraflex or Wallstents, and endoscopic duodenal stenting using enteral Wallstents. They were followed until their death. Results: We identified 18 patients (11 men and 7 women) whose mean age was 65 years, (range, 46–85 years). Malignancies included pancreatic 14 (78%), biliary 2 (11%), lymphoma 1 (5%), and metastatic 1 (5%) disorders. Ten patients previously had plastic biliary stents placed for past malignant biliary obstruction (4 patients had recurrent biliary obstruction). All the patients had evidence of duodenal obstruction. Combined metal stenting was successful in 17 patients. One procedure failed due to a tortuous duodenal stricture. All the patients had effective palliation of biliary obstruction, as evidenced by a decrease in the level of total bilirubin and alkaline phosphatase. Of the 17 patients with successful duodenal stenting, 16 had a good clinical outcome, with relief of obstructive symptoms. No immediate stent-related complications were noted. During the follow-up period, 12 patients died of progression of the underlying malignancy. None of the deaths were stent related. Median survival time was 78 days. Two patients had recurrent biliary obstruction from tumor ingrowth at 45 and 68 days, respectively. Both underwent restenting: one by endoscopic retrograde cholangiopancreatography (ERCP) and the other by percutaneous transhepatic cholangiography (PTC). Two other patients had recurrent duodenal obstruction, respectively, 36 and 45 days after the initial stenting. One obstruction was secondary to tumor ingrowth, and the other was caused by distal stent migration. Both patients had successful duodenal restenting. Conclusion: Combined self-expandable metal stenting for simultaneous palliation of malignant biliary and duodenal obstruction may provide a safe and less invasive alternative to surgical palliation with an acceptable clinical outcome. Simultaneous self-expandable metal stents should be considered as a treatment option for patients who are poor candidates for surgery.     

Ureteric embolization with stainless-steel coils for managing refractory lower urinary tract fistula: a 12-year experience

OBJECTIVE: To report our 12-year experience with radiological treatment (ureteric embolization) for refractory urinary fistula, as malignancy, radiation therapy, and/or chronic inflammation increase the risk of lower urinary tract fistula after surgical urinary diversion, which can lead to significant morbidity, and for patients who are not surgical candidates permanent nephrostomy drainage and ureteric embolization offer an alternative form of urinary diversion. PATIENTS AND METHODS: We retrospectively reviewed patients who had ureteric occlusion for refractory urinary fistula at our institution between 1993 and 2005. Stainless-steel coils, with or without gelatine sponge, were placed antegradely through a percutaneous nephrostomy tract. Patients were then managed by long-term nephrostomy drainage until death or definitive reconstructive surgery. RESULTS: In all, 29 patients (23 women and six men; mean age 59 years, sd 16) were identified who had urinary fistulae that were refractory to nephrostomy drainage alone. One patient had a history of severe perineal trauma and the remaining 28 had a history of cancer. Seventeen fistulae occurred in the setting of previous surgery, 20 patients had received adjunctive pelvic irradiation and 11 had had chemotherapy. In all, 52 ureters were embolized; occlusion was successful in all cases, with complete or near-complete (<1 pad/day) dryness within 3 days. No repeat embolization was required and there were no significant complications. Two patients were lost to follow-up. Three patients had definitive urinary diversion surgery and currently are well. One patient is alive and living with nephrostomy tubes; 23 patients have died. CONCLUSION: Ureteric embolization is a viable option for managing complex lower urinary tract fistulae in patients with a poor performance status. It can be used as definitive management in patients with a limited life-expectancy or as a temporary measure in those for whom another management plan is anticipated.     

The value of frozen-section analysis of ureteric margins on surgical decision-making in patients undergoing radical cystectomy for bladder cancer

OBJECTIVE: To prospectively investigate the value of routine frozen-section analysis (FSA) of the ureteric margin for detecting distal ureteric malignancy in patients undergoing cystectomy for bladder transitional cell carcinoma (TCC). PATIENTS AND METHODS: In all, 100 consecutive patients had a radical cystectomy for TCC of the bladder; routine FS biopsies were obtained from the lower ureters of all. Definitive pathology with step-sectioning of the lower ureters was reviewed, and the results of paraffin-wax embedded sections and FSA were compared. The true incidence of distal ureteric malignancy was identified and correlated with different clinical and pathological variables. RESULTS: There were 193 ureteric specimens examined; 16 ureters (8.3%) in 14 patients showed evidence of malignancy by FSA. True distal ureteric malignancy was diagnosed in 29 ureteric specimens (15%) in 24 patients. The sensitivity and specificity of the FSA were 45% and 98%, respectively, while the positive and negative predictive values were 81% and 91%, respectively. There was no significant correlation between distal ureteric malignancy and: patient age, tumour site or morphology, clinical or pathological staging, ipsilateral hydronephrosis, suspicious intraoperative ureter, biopsy or tumour grade, associated carcinoma in situ or nodal involvement. Male gender and positive intraoperative FSA were the only predictors significantly associated with distal ureteric malignancy by univariate analysis (P = 0.01 and <0.01, respectively). Both predictors remained significant on multivariate analysis. CONCLUSION: A positive ureteric FSA during cystectomy has a high predictive value in the diagnosis of distal ureteric malignancy, and is justified as an independent predictor in male patients with bladder TCC.     

Metallic stents for malignant and benign ureteric obstruction

OBJECTIVE: To report our experience of using metallic stents to treat ureteric obstruction caused by malignant or benign disease. PATIENTS AND METHODS: Nine patients with obstruction in 11 ureters caused by malignant or benign disease (mean age 61 years, range 35-82, mean follow-up 7 months, range 3-11) were treated using metallic stents. A balloon-expandable metallic stent was used in one patient and self-expandable metallic stents in the remaining eight. All stents were inserted via a percutaneous antegrade approach. RESULTS: Of the 11 ureters, nine remained patent with no further manipulation during the follow-up of 3-11 months. An additional stent was placed in continuity with the first in two ureters of two patients at 4 and 5 weeks after the first procedure because of persistent obstruction. After the second intervention, their obstruction was improved. Transient vesico-ureteric reflux occurred in two of three stented distal ureters, but the reflux resolved spontaneously within 2 months after stent implantation. Ureteric patency was maintained in all patients and no major complications related to stenting occurred during the follow-up. Two patients died from cervical cancer at 3 and 5 months after stenting. CONCLUSION: In patients with difficult ureteric obstructions a metallic stent provides a safe and effective alternative to an indwelling double-pigtail catheter or percutaneous nephrostomy.     

Extra-anatomic urinary diversion by subcutaneous catheter

Percutaneous nephrostomy has been one of most used palliative method of urinary diversion to treat cronic renal failure in neoplasic patients. Psychological and social factors meke this measure to be rejected by some patients even sin situations where this is the only action that would make their survival longer. The utilization of ureteral stents provides benefits to a certain percentage of patients, not being possible its usage in all the occassions. Urinary subcutaneous diversion can be a simple and well tolerated alternative for the patient. The following clinic case describes and approach implementing a subcutaneous stent in a 60-y-old male with a severe ureteric obstruction after failed management by endoscopy or open surgery.     

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.