Extracorporeal shock wave lithotripsy with the Storz Modulith SL20: the first 500 patients.

Our initial experience of extracorporeal shock wave lithotripsy (ESWL) with the Storz Modulith SL20 is reported. A total of 500 patients with 551 renal and 120 ureteric stones, mean diameter 11.9 mm, underwent 746 treatments; 68.2% of patients required a single treatment. The mean treatment rate for renal calculi was 1.4 and for ureteric calculi it was 1.5, rising to 4.2 for staghorns; 62.2% of treatments were performed on an out-patient basis. Analgesia (intravenous fentanyl) was required in 60.9% of treatments for renal calculi but in only 38.2% of those for ureteric calculi. The overall stone-free rate at 3 months was 77.6%, with a further 14.7% of patients having fragments less than 3 mm in diameter that required no further treatment. The stone-free rate was dependent on the site of the stone, with the majority of residual fragments lying in a lower pole calix. There were few complications. The Modulith is an efficient and safe lithotripter capable of treating stones in the kidney and throughout the ureter.     

Role of Extracorporeal Shock Wave Lithotripsy in Management of Upper Ureteric Stones

Introduction

The treatment options for upper ureteric stones range from open surgeries to minimally invasive and non invasive techniques. Presently the two most frequently used options for upper ureteric calculi that require intervention are extracorporeal shock wave lithotripsy (ESWL) and ureterorenoscopy (URS) with contact lithotripsy applied by attaining endoscopic access to the calculi.

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.     

Is extracorporeal shock wave lithotripsy the preferred treatment option for elderly patients with urinary stone? A multivariate analysis of the effect of patient age on treatment outcome

OBJECTIVES: To investigate the effect of patient age on the stone-free rate (SFR) in patients with urinary calculi treated by extracorporeal shockwave lithotripsy (ESWL). PATIENTS AND METHODS: In all, 2192 solitary radio-opaque urinary stones of 5-15 mm were identified in adult patients receiving primary ESWL. Patients were divided into three age groups, i.e. < or = 40, 41-60 and >60 years (579, 1026 and 587 patients, respectively). Multiple logistic regression was used to assess the effect of age and other possible predicting factors (gender, stone characteristics, e.g. side, site and size, and the type of lithotripter used) on the SFR at 3 months after treatment. RESULTS: The overall adjusted odds ratios (95% confidence interval) for the SFR for those aged 41-60 and >60 years (taking those aged < or= 40 years as the reference) were 0.708 (0.573-0.875; P = 0.001) and 0.643 (0.506-0.818; P < 0.001). However, if the patients were divided into those with renal or ureteric stones, only the SFR of the former was affected by age, and the adjusted odds ratios were 0.665 (0.512-0.864; P = 0.002) and 0.629 (0.470-0.841; P = 0.002), respectively. Ageing had no effect on the SFR for ureteric stones. CONCLUSION: The SFR after ESWL for renal stones, but not ureteric stones, was significantly lower in older patients. Further studies on the effects of ageing on renal stone clearance after ESWL are needed to improve stone management in the elderly population.     

Extracorporeal shock wave lithotripsy in children: equivalent clearance rates to adults is achieved with fewer and lower energy shock waves

OBJECTIVE

To compare the outcome, safety and efficiency of extracorporeal shock wave lithotripsy (ESWL) using an electromagnetic lithotripter for upper urinary tract stones in children and adults.

PATIENTS AND METHODS

We retrospectively reviewed data over a 5‐year period for patients with solitary, renal and upper ureteric stones measuring <2 cm in whom ESWL was the treatment method. Group A consisted of 44 children (mean [sd ] age 5.9 [4.4] years) and group B of 562 adults (mean [sd ] age 40.9 [13.1] years). The number and energy of SWs used was not predetermined and was tailored until adequate fragmentation was achieved. Initial stone reassessment was performed at 48 h and monthly thereafter. The number of SWs, intensity of SWs, stone‐free rate, auxiliary procedure rate, re‐treatment rate, complication rate and effectiveness quotient (EQ) were assessed in each group.

RESULTS

The stone‐free rate with ESWL was 84% in children and 87% in adults (P = 0.78). The EQ was 77% and 75% in children and adults, respectively (P = 0.56). The mean (sd ) number of SWs and energy required per session was 950 (349) and 11.83 (0.48) kV in children and 1262 (454) and 12.36 (0.34) kV in adults (P < 0.001). The re‐treatment, auxiliary procedure and complication rates were similar in both groups.

CONCLUSION

ESWL is as safe and effective in children as in adults for solitary renal and upper ureteric stones that are <2 cm. Children required significantly fewer and lower energy SWs to achieve equivalent results.     

Treatment of ureteric lithiasis with retrograde ureteroscopy and holmium:YAG laser lithotripsy vs extracorporeal lithotripsy

OBJECTIVE

To analyse the efficiency of extracorporeal shockwave lithotripsy (ESWL) vs retrograde ureteroscopy and holmium:YAG laser lithotripsy, as ESWL is successful in 67–90% of cases but endoscopic lithotripsy with pneumatic lithotrites or lasers is successful in 90–96% of distal ureteric calculi, and holmium:YAG lithotripsy is effective in proximal ureteric calculi.

PATIENTS AND METHODS

From April 2006 to April 2008 we assessed 164 patients undergoing ureteric lithiasis in two homogeneous groups: group A included 83 treated with retrograde ureteroscopy and holmium:YAG endoscopic lithotripsy, and group B, 81 treated by ESWL. For laser lithotripsy we used 2071 mJ pulses at 3–6 Hz, with a mean of 1105 pulses and 2.5 kJ of total energy. ESWL was carried out using 37.5–87.5 mJ shock waves, a mean of 3650 shock waves and 187.6 J, with a radioscopy time of 1–4 min. The results were assessed after 3 weeks with plain films and ultrasonography, or urography. The efficiency of each procedure was assessed by calculating the relative risk, and results compared using the chi‐square or Student’s t‐test. The efficiency quotient (EQ) was determined for both procedures, and the focal applied energy quotient (FAEQ) used to assess ESWL.

RESULTS

The overall success rate for retrograde ureteroscopy and laser lithotripsy was 96.4% (80/83 patients), with an EQ of 0.52; a JJ catheter was placed in 67 patients. The success rate for the first ESWL session was 48%, and after repeat ESWL was 64% (52/81 patients), giving an EQ of 0.39. For successful treatments the FAEQ was 9.22, vs 6.47 for the failures (P < 0.005). There was a significant difference (P < 0.001) favouring laser lithotripsy, with an absolute benefit of 46% (95% confidence interval 33.8–57.9%), and number needed to treat of 2 (2–3), but no significant differences for lumbar ureteric calculi.

CONCLUSIONS

Endoscopic lithotripsy with the holmium laser is more effective than ESWL, but for lumbar ureteric calculi ESWL is therapeutically recommended as it is less invasive.     

Urinary lithotripsy in children. Multicenter study of the Pediatric Urology Study Group]

The authors present the results of a survey conducted among French paediatric urologists belonging to the Groupe d'Etudes en Urologie Pédiatrique (GEUP) (Paediatric Urology Study Group). This study, based on 122 cases observed in 13 centres, is not exhaustive, but is nevertheless statistically significant. The preoperative assessment confirms the usual findings of urinary stones in children: pyelonephritis, haematuria and abdominal pain, the usual presenting complaint, concomitant malformative uropathy (10% of cases) and a predominance of calcium stones. More than 200 stones were treated, larger than 10 millimeters in diameter in one-third of cases. Renal stones, mainly caliceal (more than 50%), included 11 staghorn calculi. This study also included 22 ureteric stones, mainly in the pelvic ureter, and 2 bladder stones. Lithotripsy was ultrasound-guided in 2/3 of cases and required general anaesthesia in about 3/4 of cases. Ureteric catheterization was required in 19 infants preoperatively, but in only 2 infants (stein strasse) postoperatively. One or two lithotripsy sessions were sufficient in most cases, but 4 sessions were necessary in 5 patients, to the same kidney in 1 case. The mean hospital stay was 2 to 3 days, but the procedure was performed on an outpatient basis in 15 cases. The immediate postoperative course was uneventful and asymptomatic. This survey revealed about 10% of complete failures, corresponding to solitary caliceal stones in 2/3 of cases; 29 partial failures were essentially due to lower caliceal stones and staghorn calculi; 84 successes (stone-free), mainly pelvic or simple caliceal stones. Scintigraphy did not reveal any immediate postoperative impairment of renal function. This study reported a success rate of about 70%, regardless of the type of apparatus used. Assessment of the results of ESWL requires sufficient follow-up both concerning the outcome of fragmented stones and evaluation of possible functional repercussions. This survey defines the main indications: although ESWL can be applied to most stones, some stones constitute poor indications (cystine stones, stenotic malformative uropathy) or dubious indications: small lower caliceal stones, densely calcified staghorn calculi in older children. This study confirmed the efficacy and low morbidity of ESWL in children. A prospective study needs to be conducted according to a rigorous protocol in order to refine the technique and indications while reducing the possible long-term risks.     

Role of computed tomography with no contrast medium enhancement in predicting the outcome of extracorporeal shock wave lithotripsy for urinary calculi

OBJECTIVE: To evaluate the usefulness of urinary calculi attenuation values from non-contrast computed tomography (NCCT) in predicting the outcome of treatment by extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS: We evaluated 112 patients with solitary renal and upper ureteric calculi of 0.5-2 cm undergoing ESWL. All patients had NCCT at 120 kV and 240 mA on a spiral CT scanner. During each ESWL session 3000 shock waves were given to a maximum of 3.0 kV. A final X-ray of the kidney, ureters and bladder was taken 12 weeks after the last ESWL session. Fragments of < or = 5 mm were regarded as clinically insignificant residual fragments (CIRF). The calculi retrieved were analysed by X-ray diffraction and the results assessed by comparing the mean density (as measured in Hounsfield units, HU) with the number of ESWL sessions and clearance. RESULTS: In all, 82 (76%) patients had complete clearance of stones and 26 (24%) had CIRF. There was a linear relationship between the calculus density and number of ESWL sessions required. Of patients with calculi of < or = 750 HU, 41 (80%) needed three or fewer ESWL sessions and 45 (88%) had complete clearance. Of patients with calculi of > 750 HU, 41 (72%) required three or more ESWL sessions, and 37 (65%) had complete clearance. The best outcome was in patients with calculus diameters of < 1.1 cm and mean densities of < or = 750 HU; 34 (83%) needed three or fewer ESWL sessions, and the clearance rate was 90%. The worst outcome was in patients with calculus densities of > 750 HU and diameters of > 1.1 cm; 23 (77%) needed three or more ESWL sessions and the clearance rate was only 60%. The calculus density was a stronger predictor of outcome than size alone. CONCLUSIONS: The use of NCCT for determining the attenuation values of urinary calculi before ESWL might help to predict the treatment outcome, and so might help in planning alternative treatment in patients with a likelihood of a poor outcome from ESWL.     

Extracorporeal lithotripsy of ureteric calculi using the Dornier HM-3 lithotriptor.

Over a 5-year period (November 1984-November 1989), we treated 356 patients with ureteric calculi; 170 were treated by extracorporeal shock wave lithotripsy (ESWL) on a Dornier HM-3 lithotriptor. The calculi (n = 176) were uniformly distributed along the length of the ureter: 44 were just below the pelviureteric junction, 59 were lumbo-iliac, 42 were in the upper bony pelvis and 32 in the lower bony pelvis. The mean diameter of the upper ureteric calculi was 10 mm and for the others it was 8 mm. Thirty-four patients with acute obstructive pyelonephritis required pre-ESWL drainage of the urine. X-ray localisation required intravenous urography during lithotripsy in 52 cases (30%). On plain X-ray the following day 170 stones (96%) were judged to have disintegrated. The 6 patients whose stones were not fragmented received further treatment (ureterotomy (4) and ureteroscopy (2)). Five patients required additional treatment because of pain or fever (catheterisation (3) and ureterotomy (2)) and 2 patients had a second lithotripsy owing to insufficient fragmentation. Four patients were lost to follow-up. In 153 patients (90%) the fragments were eliminated completely, 146 in the first month and the remainder before the sixth month. No serious sequelae were observed. In addition to the 5 patients who required supplementary treatment. 11 patients with pain or fever needed medical treatment. We recommend first intention in situ ESWL for all ureteric calculi.     

Use of the holmium:YAG laser for ureterolithotripsy in children

OBJECTIVE: To review our experience with rigid ureteroscopy and holmium:YAG laser for treating ureteric calculi in children. PATIENTS AND METHODS: The study included 35 children who were treated with rigid ureteroscopy for ureteric calculi between November 1997 and June 2003 (15 boys and 20 girls; mean age 6.2 years, range 1-14). The mean (range) stone size was 8 (4-15) mm and the duration of anaesthesia 46.6 (15-90) min. The stone was in the distal third of the ureter in 33 children and in the proximal third in two. We used a 7.5/8/10 F rigid ureteroscopes with routine dilatation of the ureteric orifice. For lower ureteric stones, lithotripsy was carried out with holmium:YAG laser in 29 cases, a pneumatic impactor in two and forceps extraction in two. Both stones in the proximal ureter were pushed back into the collecting system. All the ureters were stented using JJ stents in 31 and ureteric catheters in four cases. The mean postoperative follow-up was 12 (2-30) months. RESULTS: Excluding the two stones pushed back, the stone-free rate after a one-stage procedure was 82% (27/33). With repeated procedures in the six (ESWL in two) remaining cases the success rate was 97% (32/33). The ureter was perforated in two patients within the first five in the series. There was no pyelonephritis or gross haematuria after surgery. CONCLUSION: Ureteroscopy and lithotripsy using the holmium:YAG laser is effective and safe for treating ureteric stones in children, in experienced hands. The results would be even better using smaller and flexible ureteroscopes.     

经皮F16与F24肾造瘘通道治疗上尿路结石（附156例报告）

目的 探讨与评价F16、F24两种经皮肾造瘘通道治疗上尿路结石的方法与疗效。方法分别采用F16与F24两种经皮通道治疗上尿路结石156例。结果采用Ⅰ期、Ⅱ期，F16与F24两种经皮肾造瘘通道、输尿管镜及F20．8的经皮肾镜，用气压弹道及三代超声气压弹道碎石设备，成功处理156例上尿路结石，其中包括鹿角状结石、多发性肾结石、体外冲击波碎石（extracor-poreal shock wave lithotripsy，ESWL）治疗失败、孤立肾、马蹄肾结石、开放取石术后复发及输尿管上段结石，肾结石清除率89．8％，输尿管结石清除率99％。结论合理选择F16及F24两种经皮肾通道治疗上尿路结石，具有微创、恢复快、并发症少、安全性高的特点，可有效避免出血、感染等严重并发症，并可提高手术效率，两者结合效果更佳。     

Treatment of 2019 cases with upper urinary tract calculi using a piezoelectric lithotriptor ESL-500A

PURPOSE: We evaluated the results of extracorporeal shock wave lithotripsy (ESWL) in a large number of cases with upper urinary tract calculi, and reported the strategy how to improve the efficacy and safety of ESWL. PATIENTS AND METHOD: Eight hundred fifteen patients with renal calculi and 1,204 patients with ureteral calculi were treated using a piezoelectric ultrasound-guided lithotriptor, Toshiba ESL-500A. Auxiliary measures were needed in 51 cases (2.5%) and 1,968 cases (97.5%) were treated by in situ procedures. ESWL was performed with the optimal positioning of the patient and under the continuous monitoring by ultrasound system. The visibility of stones was improved by removal of abdominal gas and administration of diuretic agent to dilate the ureter. Cases with urinary tract infection were medicated by antibiotics and the obstruction of the urinary tract was cleared away as soon as possible. RESULTS: Including the cases with residual fragments less than 4 mm, the success rates at one month after the treatment were 97.7% and 98.7% for the renal and ureteral calculi, respectively. The mean numbers of sessions were 1.49 for renal calculi and 1.16 for ureteral calculi. Multiple sessions were required in 24.2% of renal calculi and 12.0% of ureteral calculi. No serious complication has been observed except for three cases, which were sepsis after ESWL, anuria in a solitary kidney, and pyonephrosis caused by Steinstrasse with urinary infection, respectively. CONCLUSION: ESWL using ESL-500A is an efficient treatment of upper urinary tract calculi which has higher pulverization rate and fewer complications in the adequate procedure.     

Clinical experience and results of ESWL treatment for 3,093 urinary calculi with the Storz Modulith SL 20 lithotripter at the Singapore general hospital

We study the outcome of 2,700 patients treated for 3,093 urinary calculi over a period of 60 months. All patients underwent Extracorporeal Shock Wave Lithotripsy (ESWL) treatment using the Storz Modulith SL20, predominantly on an outpatient basis (99.9% using intravenous pethidine for analgesia). The treatment outcome of 1,666 renal calculi and 1,427 ureteric calculi were analysed and stratified according to size and site. Follow-up status at 3 months was available for 91.8% of patients. For renal calculi, the overall success rate was 81% (re-treatment rate 29.7%). The majority of failures were stones larger than 2 cm and those situated in the lower pole of the renal calyces. The overall success rate for ureteric calculi is 85% with similar clearance rates throughout the ureter (re-treatment rate 22.8%). Failures were predominantly with stones larger than 2 cm. For the entire series, the morbidity rate requiring hospital admission was 2.9%, there was no mortality. The commonest cause for admission was for pain control (1.8%). To our knowledge, our experience with this lithotriptor is the largest to date. We have demonstrated that ESWL with Storz Modulith SL20 is safe, well tolerated and highly effective for the treatment of urolithiasis.     

Primary in situ extracorporeal shock wave lithotripsy in the management of ureteric calculi: results with a third-generation lithotripter.

OBJECTIVE: To review the results of primary in situ extracorporeal shock wave lithotripsy (ESWL) for the treatment of ureteric stones using a third-generation lithotripter, the Dornier MFL 5000 (Dornier Medizentechnic, Germany). PATIENTS AND METHODS: The study comprised a retrospective review of treatment outcome in 180 patients with 196 stones who were treated with primary in situ ESWL, assessing the success of this approach and establishing reasons for failure. RESULTS: At the 3-month follow-up, 88% of patients were stone-free; 21 patients failed ESWL and were treated by ureteroscopic stone extraction with no complications. Stone-free rates were 90% for upper ureteric, 89% for middle-third and 86% for lower-third calculi. Twenty-one patients required auxiliary procedures in the form of JJ stenting or nephrostomy. Failure of ESWL was associated with stone size (>1.3 cm) but not location or inadequate treatment. CONCLUSION: Where prompt access to ESWL is available, primary in situ ESWL remains an effective form of treatment for all ureteric calculi, although stone-free rates are lower for larger stones.     

Impact of anatomical pielocaliceal topography in the treatment of renal lower calyces stones with extracorporeal shock wave lithotripsy

AIM: There is wide consensus that the lowest success rate of extracorporeal shock wave lithotripsy (ESWL) is in the complete clearance of renal stones located in the lower calyces. We assess the effectiveness of extracorporeal shock wave lithotripsy monotherapy for lower pole renal calculi to determine the relationship between the spatial anatomy of lower pole and the outcome of ESWL. METHODS: We evaluated 107 patients who were treated for solitary lower pole renal stones less than 20 mm in diameter with ESWL. The spatial anatomy of the lower pole, as defined by the lower infundibulopelvic angle, infundibular length and infundibular width, was measured by preoperative intravenous pyelography, while the stone location and size were determined by using abdominal plain X-ray. All patients were followed up at 1 and 3 months with abdominal plain X-ray and ultrasonography. RESULTS: Only 62 patients (58%) became stone free, while 45 (42%) retained residual fragments. A small lower infundibulopelvic angle, a long infundibular length and a tight infundibular width are unfavorable for stone clearance after ESWL. CONCLUSIONS: ESWL is the treatment of choice for most renal and ureteral stones. However, stone clearance from the lower pole following ESWL is poor and significantly affected by the inferior pole collecting system anatomy. Therefore, we believe it is important to evaluate these anatomical factors when deciding on the best treatment for lower pole renal calculi.     

Extracorporeal shock-wave lithotripsy or ureteroscopy as primary treatment for ureteric stones: a retrospective study comparing two different treatment strategies

OBJECTIVE: Our extracorporeal shock-wave lithotripsy (ESWL) lithotripter with ultrasound localization technique was replaced in 1999 by a Storz SLX-MX lithotripter with both X-ray and ultrasound detection possibilities. Before replacing our lithotripter, most ureteric stones were treated with ureteroscopy (URS); subsequently, almost all patients underwent ESWL as primary treatment. The aim of this retrospective study was to compare the results of these two treatment strategies in all consecutive patients attending our hospital in 1998 and 2000 for ureteric stone treatment. MATERIAL AND METHODS: The medical records of all patients treated for ureteric stones in 1998 and 2000 were reviewed. In 1998, 173 ureteric stones were treated. Primary treatment was URS in 124 patients, push back/ESWL in 24, ESWL in 21 and open surgery in four. In 2000, 176 ureteric stones were treated: 158 with ESWL and 18 with URS. ESWL or URS monotherapy was defined as ESWL or URS, respectively as the only stone-treatment therapy, with or without the use of a ureteric catheter or nephrostomy tube. Treatment success was defined as a stone-free ureter. RESULTS: In 1998, the success rate for URS monotherapy was 95%, with a retreatment rate (sessions per stone situation) of 1.06. Corresponding figures for ESWL monotherapy in 2000 were 90% and 1.69. All URS patients received general anaesthesia; ESWL patients received opiods. Complication rates were 6% for URS and 3% for ESWL. In the URS group, 4/8 complications were considered to be major. CONCLUSION: ESWL should be considered the first-line treatment for ureteric stones because of its non-invasive nature, lack of a requirement for general anaesthesia and low complication rates.     

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.     

Retrograde ureteroscopy for distal ureteric stone removal in children

OBJECTIVE: To compare the efficacy and safety of ureteroscopy plus intracorporeal lithotripsy (ULT) with extracorporeal shock wave lithotripsy (ESWL) for treating distal ureteric calculi in childhood, as such stones are commonly treated by ESWL as the first option in adults but there is no agreement on the method of treating them in children. PATIENTS AND METHODS: From July 2002 to July 2003, children presenting with ureteric stones were consecutively randomized for treatment using ULT or ESWL. The two groups were matched for age, sex and stone position in the distal ureter. A 7.5 F ureteroscope combined with a ballistic lithotripter or holmium-YAG laser was used for ULT. ESWL was administered using a second-generation lithotripter. The success rate, effectiveness quotient, complication rate and hospitalization were evaluated and compared using Student's t-test (chi-square) and Fisher's exact test as appropriate. In all, 31 patients (21 girls and 10 boys, mean age 7.2 years, range 2-17) were treated, by ULT in 17 (12 girls and five boys) and ESWL as a primary procedure in 14 (five boys and nine girls). RESULTS: After one ULT, all the girls and four boys, and after ESWL, four girls and two boys, were rendered stone-free at the first treatment. The total stone-free rate was 16 of 17 for ULT and six of 14 for ESWL (P = 0.004). Eight patients had a second ESWL and three then became stone-free. The five patients in whom both ESWL treatments failed had a successful ULT. There was no significant difference between the groups in complication rate and hospitalization. General anaesthesia was required in all patients <12 years old treated by ULT or ESWL. The calculated efficiency quotient for treating distal ureteric calculi was significantly lower for ESWL than ULT (P < 0.05). CONCLUSIONS: ULT should be recommended as the treatment of choice for distal ureteric calculi in children; using small ureteroscopes the target stone was treated safely and effectively.     

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%.     

Endourological experience with cystine calculi and a treatment algorithm

Between May 1984 and January 1988, 18 patients (31 pyeloureteral units) with documented symptomatic cystine stones were treated. Stone size ranged from 5 to 56 mm. in largest diameter, with an average of 21 mm. All pyeloureteral units were treated initially by endourological methods, including ureteroscopy in 10, percutaneous ultrasonic lithotripsy in 9, extracorporeal shock wave lithotripsy (ESWL) in 10 and chemolysis in 2. Of the patients 10 required a combination of these technologies and 2 required an open operation. Of the 31 units 23 were free of stones when the patient was discharged from the hospital. Of 8 patients with retained stones only 3 had fragments greater than 3 mm. in diameter. Based on this experience an algorithm was developed for the urological management of cystine stones. Ureteral calculi may be removed by ureteroscopic techniques or manipulated into the renal pelvis and managed as renal stones. Cystine renal calculi of less than 1.5 cm. may be treated with ESWL monotherapy. Stones of 1.5 to 3 cm. may be treated with ESWL and dissolution, or percutaneous ultrasonic lithotripsy plus dissolution. Staghorn calculi may be treated by percutaneous ultrasonic lithotripsy plus ESWL and/or dissolution for retained fragments.