A prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy

PURPOSE: A prospective randomized controlled trial was performed to determine whether stents may be eliminated after uncomplicated ureteroscopic lithotripsy for ureteral stones. MATERIALS AND METHODS: A total of 58 patients underwent uncomplicated ureteroscopic intracorporeal lithotripsy. After stone fragmentation patients were randomized to a nonstented (29) or a stented (29) treatment group. Intracorporeal lithotripsy was performed with the holmium laser in 57 cases and by electrohydraulic lithotripsy in 1 without balloon dilation or the extraction of stone fragments. Patients were followed 1, 6 and 12 weeks postoperatively. In stented cases the stent was removed at 1 week. Outcome measures included postoperative symptoms assessed with a visual analog scale, postoperative analgesic requirements, complications and the stone-free rate. RESULTS: At 1 week the symptoms of flank pain, abdominal pain, dysuria and frequency were significantly greater in the stented group (p <0.005). There were no differences in symptoms in the groups at subsequent followup visits. There was no difference in treatment groups in terms of the amount of analgesic required in the recovery room or during 1 week after ureteroscopy. Similarly there was no difference in the number of patients requiring antiemetics. One patient in the stented group required hospitalization for genitourinary sepsis and 1 patient in the nonstented group visited the emergency room for postoperative vomiting. The stone-free rate was 100% in each group. CONCLUSIONS: These results demonstrate that after ureteroscopic intracorporeal lithotripsy with the holmium laser patients with a stent have significantly greater irritative and painful symptoms than those without a stent in the early postoperative period. There was no difference in nonstented and stented ureteroscopy with respect to complications or stone-free status. Therefore, we believe that routine stenting after ureteroscopic intracorporeal lithotripsy with the holmium laser is not required as long as the procedure is uncomplicated and performed without balloon dilation of the ureteral orifice.     

Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications

PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.     

Stenting versus non-stenting after non-complicated ureteroscopic manipulation of stones in bilharzial ureters

BACKGROUND: Stents were used routinely after ureteroscopy to prevent postoperative ureteral obstruction. However, because of the recognized complications of stents, non-stenting is the new trend after uncomplicated ureteroscopy. The wall of the bilharzial ureter is characteristically thick and may be calcified. The aim of this study is to see if the non-stenting trend could be applied to ureteroscopic manipulation of stones in bilharzial ureters. PATIENTS AND METHODS: In this prospective study, 56 patients, with evidence of bilharzial lesions in the urinary tract, undergoing ureteroscopy for distal ureteral stones were included. After successful uncomplicated stone fragmentation and extraction, patients were randomized into two groups. Group A includes 28 patients in whom double J 6-Fr polyurethane stents were placed for 3 weeks. Group B includes 28 non-stented patients. Postoperative fever, loin pain, lower urinary tract symptoms and change in the degree of hydronephrosis were reported. RESULTS: There was no significant difference in the mean age of patients and stone size in both groups. The mean operative time was 43 +/- 14 min in group A and 38 +/- 11 in group B. There was no significant difference in the mean loin pain score, in the first postoperative 48 h, in both groups (4.4 +/- 0.8 in group A and 4.9 +/- 0.5 in group B). Patients in group A had, significantly, more flank pain with voiding (P < 0.01), voiding pain (P = 0.04), frequency (P = 0.01) and urgency (P = 0.04). Radiologic follow-up was available for 24 patients in group A and 23 patients in group B at the 3-month visit. Hydronephrosis had improved in all patients, in both groups, with no evidence of ureteral stricture. CONCLUSION: Routine placement of stents after uncomplicated ureteroscopy for distal ureteral stones is unnecessary in bilharzial ureters. Moreover, it might be unadvisable because lower urinary tract symptoms and voiding loin pain are more in patients with ureteral stents and hydronephrosis is equally improved in stented and non-stented patients.     

Routine ureteral stenting is not necessary after ureteroscopy and ureteropyeloscopy: a randomized trial

BACKGROUND AND PURPOSE: Retrospective studies have suggested that routine stenting can be avoided following ureteroscopy. We prospectively analyzed the need for routine ureteral stent placement in patients undergoing ureteroscopic procedures. PATIENTS AND METHODS: Fifty-five consecutive patients (60 renal units) were randomized into either a stent or a no-stent group following ureteroscopy with either a 7.5F semirigid or a 7.5F flexible ureteroscope for treatment of calculi (holmium laser or pneumatic lithotripsy) or transitional-cell carcinoma (holmium laser). Intraoperative variables assessed included total stone burden, the need for ureteral dilation, and overall operative times. All patients were evaluated by questionnaire on postoperative days 0, 1, and 6 with regard to pain, frequency, urgency, dysuria, and hematuria. RESULTS: Of the 60 renal units treated, 38 received ureteral stents (mean 5.2 days), and 22 were treated without a stent. All 10 patients requiring ureteral balloon dilation had stents placed and were removed from the analysis. There was no significant difference between the groups with regard to age, sex, or stone burden. Operative time was decreased in the no-stent group (43 minutes v 55 minutes; P = 0.013). Flank discomfort was significantly less common in the no-stent group on days 0, 1, and 6 (P = 0.004, P = 0.003, P < 0.001, respectively), as was the incidence of suprapubic pain on day 6 (P = 0.002). There was no difference in urinary frequency, urgency, or dysuria between the groups on postoperative day 1, but all these symptoms were significantly reduced in the no-stent group on day 6 (P < 0.001, P < 0.001, P = 0.002, respectively). There was no significant difference in patient-reported postoperative hematuria in either group. One patient in each group developed a urinary tract infection. One patient in the no-stent group developed ureteral obstruction in the postoperative period that necessitated stenting, and one patient in the stent group experienced stent migration necessitating removal. CONCLUSIONS: Routine ureteral stenting does not appear to be warranted in those patients who do not require ureteral dilation during ureteroscopic procedures. Ureteral stent placement following ureteroscopy may be avoided, thereby reducing operative time, surgical costs, and patient morbidity.     

腔内微创技术治疗妊娠并发输尿管结石

目的探讨腔内微创技术处理妊娠并发输尿管结石的疗效和安全性。方法回顾性分析37例妊娠并发输尿管结石患者的临床资料和治疗方法。结果 37例超声检查发现输尿管结石。37例患者肾绞痛、发热等症状消失,结石一次取净32例(86.49%),残留结石者5例(13.51%),5例只留置双J管,于产后行体外冲击波碎石术(ESWL),37例孕妇均安全渡过围产期,无输尿管穿孔等并发症。结论妊娠并发输尿管结石首选超声检查。经尿道输尿管镜腔内微创技术治疗妊娠期并发输尿管结石具有微创、安全、有效的特点,值得临床推广应用。     

经输尿管镜碎石术后留置支架管与否的探讨

目的 探讨不复杂性输尿管结石经输尿管镜碎石术后是否需要常规留置支架管。方法 回顾性分析2002年3月-2005年3月我院450例不复杂性输尿管结石行输尿管镜钬激光碎石术患者的资料。患者被分为三组：A组196例（放置双J管），B组185例（放置临时输尿管导管），C组69例（不放置支架管）。手术时间、术后无石率和并发症作为评价的指标。结果 三组患者手术时间比较，A、B两组显著长于C组；术后患者血尿的发生率和持续时间，A、B两组显著高于C组；术后患者肋腹区疼痛、尿频／尿急、排尿困难、尿路感染和输尿管狭窄的发生率，三组之间无显著差异；术后1个月输尿管无石率三组均为100％。结论 经输尿管镜钬激光治疗不复杂性输尿管结石术后放置支架管与否应视术中情况。所有病例均常规留置支架管是不必要的。     

Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial

BACKGROUND AND PURPOSE: Insertion of a ureteral stent is routinely done after ureteroscopy. Recently, several authors have questioned routine stenting after ureteroscopy for distal ureteral stones. We report our results of a randomized study comparing ureteroscopy with and without placement of stents for distal ureteral stones. PATIENTS AND METHODS: A total of 48 patients undergoing ureteroscopy for distal ureteral stones were randomized to a stented group (N = 26) or a nonstented group (N = 22). Ureteroscopy was carried out with Wolf 8.5F semirigid endoscope, and the Swiss Lithoclast was used as the source of energy. Any stent was removed at 3 weeks. Patients were assessed for success, operative time, postoperative pain score, analgesic requirement, stent-related symptoms, and risk of ureteral stricture formation. Baseline variables were not significantly different in the two groups. RESULTS: There was no significant difference in the two treatment groups with regard to need for ureteral dilation, use of intracorporeal lithotripsy, or occurrence of intraoperative and postoperative complications. A successful outcome was achieved in 100% of both groups. The mean pain score on day 0 was 5.23 +/- 0.95 of 10 in the stented group and 4.82 +/- 0.96 in the nonstented group; this difference was not statistically significant. Similarly, the analgesic requirement in the two treatment groups was not significantly different. However, patients with stents had significantly more pain (including flank pain with voiding: P = 0.01), urgency (P = 0.04) and dysuria (P <0.01). Radiologic follow-up was available for 83.33% of the patients at the 3-month visit. None of the patients had evidence of ureteral stricture or residual stone fragments. CONCLUSION: In select patients undergoing ureteroscopy for distal ureteral stones, stents can be safely omitted. Patients without stents have significantly fewer lower-urinary symptoms of pain, urgency, and dysuria and are not at risk of increased complications. Avoiding stents may be particularly cost effective in developing countries.     

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.     

Nonstented versus routine stented ureteroscopic holmium laser lithotripsy: a prospective randomized trial

We conducted a prospective, randomized study to evaluate whether postoperative ureteral stenting is necessary after ureteroscopic holmium laser lithotripsy. A total of 115 consecutive patients with distal or middle ureteral calculi amenable to ureteroscopic holmium laser lithotripsy were prospectively randomized into stented group (n = 58) and nonstented group (n = 57). The stent was routinely placed in the treated ureter for 2 weeks. The outcomes were measured with postoperative patient symptoms, stone-free rates, early and late postoperative complications, and cost-effectiveness. The postoperative symptoms were measured with Ureteral Stent Symptom Questionnaire (USSQ). All patients completed a 12-week follow-up. There was no significant difference between two groups with respect to the patient age, stone size, stone location and mean operative time. According to the USSQ, the symptoms of the stented group were significantly worse compared to the nonstented group (P = 0.0001). In the stented group, two patients had high fever for 1 week after the operation, stent migration was found in two patients, and the stents had to be removed earlier in five patients because of severe pain or hematuria. The cost of the stented group was significantly higher than the nonstented group. The stone-free rate was 100% in both groups. No hydronephrosis or ureteral stricture was detected by intravenous pyelogram in the 12th week postoperative follow-up. In conclsion, we believe that routine stenting after ureteroscopic intracorporeal lithotripsy with the holmium laser is not necessary as long as the procedure is uncomplicated for distal or middle ureteral calculis less than 2 cm.     

The role of stenting in relieving loin pain following ureteroscopic stone therapy for persisting renal colic with hydronephrosis

Objective To prospectively define the role of the double J-stent placement following ureteroscopic stone therapy in providing a pain-free postoperative period for patients with persisting loin pain and documented hydronphrosis. Material and methods The study cohort consisted of 27 patients (mean age: 38.59 years; range: 22–60 years) who had undergone ureteroscopic intervention due to ureteral stone. All of the patients reported loin pain which did not respond to medical therapy associated with various degrees of hydronephrosis documented by ultrasound and/or an excretory urogram. The patients were randomized to either a stented (18 patients) or stentless (nine patients) group following semirigid ureteroscopy (7.5/12 Fr) for the treatment of ureteral calculi (pneumatic lithotripsy). The mean diameter of the stones was 7.7 mm (range: 3–13 mm). Intra-operative balloon ureter orifice dilatation was routinely performed. All patients were evaluated between 0 and 6 days postoperative for loin pain and lower urinary tract symptoms. Results Nine patients had loin pain in the first few days following the operation and were in need of intramuscular and/or intravenous analgesics. Of these, four were stented patients (4/18; 22.2%) and five were stentless patients (5/9; 55.5%). Lower urinary tract symptoms were not clinically significant and did not affect the quality of life in terms of loin pain, with the exception of one patient in whom the stent had dropped into the bladder. Conclusion We believe that stenting in patients with documented hydronephrosis manifesting in persisting renal colic is recommended. As ureteroscopic therapy may aggregate the edema of ureter mucosa, double J-stent placement may play an important role in offering patients a postoperative period free of loin discomfort. However, further prospective trials should be designed to evaluate the criteria for stentless ureterorenoscopy.     

尿道黏膜麻醉下输尿管镜技术处理输尿管中下段石街

目的探讨尿道黏膜表面麻醉下输尿管镜技术治疗输尿管中下段石街的可行性及临床效果。方法2008年10月～2012年10月,对37例输尿管中下段石街行输尿管镜下碎石取石术。门诊手术。2％利多卡因尿道黏膜表面麻醉,将输尿管镜表面涂体腔器械导入润滑剂（舒泰）后置入,气压弹道碎石,术后均不留置输尿管支架管。结果治疗成功36例,1例男性左输尿管中段石街病人不能耐受而入院行腰麻硬膜外联合麻醉处理。手术时间15—54min,平均37min,无发热,无明显腰痛及尿频、尿急等膀胱刺激症状。结论尿道黏膜表面麻醉下输尿管镜手术治疗输尿管中下段石街,可以不放置输尿管支架管,既简便,又安全可靠。     

Stent positioning after ureteroscopy for urinary calculi: the question is still open

OBJECTIVES: We conducted a study to assess the need for routine ureteral stenting after ureteroscopic stone removal using Lithoclast pneumatic intracorporeal lithotripsy. MATERIALS AND METHODS: A total of 104 patients, prospectively divided in two groups to receive (group A, 52 patients) or not (group B, 52 patients) a stent after stone removal, underwent ureteroscopy for the treatment of ureteral lithiasis. The procedure was performed with the patient under either general or epidural anesthesia. A semirigid ureteroscope (Wolf 8.9 Fr) was used in all cases and intracorporeal lithotripsy with ballistic energy was performed. In group A a double pigtail ureteral 4.8 or 6 Fr polyurethane stent was placed following ureteroscopy. All patients were closely evaluated on follow-up examinations. The outcomes measured were postoperative patient pain, lower urinary tract symptoms, the need for hospital care as a result of the postoperative pain and late postoperative complications. RESULTS: The two patient groups were comparable with respect to the baseline variables of patient gender and age, stone location and mean stone size. Mean operative time plus or minus standard deviation (S.D.) in group A was 42 +/- 15 minutes (range 20-65) compared to 37 +/- 20 (range 15-60) in group B. Operative time was not significantly longer when a stent was placed (p = 0.17). At day 3 the mean visual analog pain score in group B was much higher than in group A (p = 0.01). Dysuria, hematuria and frequency/urgency were more prevalent in the stented group, although without statistically significant difference. Readmission to the hospital for unremitting pain was necessary in 12 of 104 patients (11.5%) all being in unstented group (p < 0.05). The incidence of anatomical ureteral narrowing on IVP at 6 months follow-up was not statistically different between the two groups. CONCLUSIONS: In our experience, using Swiss Lithoclast ballistic energy to fragment stones, routine stent placement is advisable also after uncomplicated ureteroscopic lithotripsy without ureteral dilation. Further prospective randomized studies are needed to assess the role of stenting after ureteroscopic lithotripsy, considering different energies sources, scopes, diameter and site of the stones in the ureter.     

Is ureteral stenting necessary after uncomplicated ureteroscopic lithotripsy? A prospective, randomized controlled trial

PURPOSE: We conducted a prospective, randomized controlled study to investigate the advantages and disadvantages of ureteral stenting after ureteroscopic lithotripsy. MATERIALS AND METHODS: A total of 60 patients who underwent ureteroscopic lithotripsy were equally randomized into a stented or a nonstented group. The inclusion criteria were stone 6 to 10 mm., absence of polyp or stricture in the ureter and no mucosal injury during ureteroscopy. The operation was performed with a 6Fr rigid ureteroscope without ureteral dilation and stones were fragmented with a 1.9Fr electrohydraulic lithotriptor without extraction. A 7Fr double pigtail stent was placed in the stented group for 3 days after ureteroscopy. Urinalysis, plain x-ray and renosonography were performed before and after lithotripsy in each patient. Subjective symptoms and pain score were recorded on admission to the hospital and 3 days postoperatively. RESULTS: The stone-free rate was 100% in each group and preoperative hydronephrosis equally resolved in both groups. Mean pain score plus or minus standard deviation improved significantly in the nonstented (6.33 +/- 1.81 preoperatively to 2.30 +/- 1.93 postoperatively, paired Student's t test p <0.0001) and stented (7.10 +/- 1.03 to 2.30 +/- 2.22, p < 0.0001) group. There was no statistical difference in pain reduction between the 2 groups (p = 0.18). The amount of extra parenteral analgesic used was similar in both groups. One patient in the nonstented group visited the emergency room for postoperative renal colic, 25 (83.3%) patients in the stented group complained of at least 1 irritative bladder symptom and only 4 (13.3%) in the nonstented group experienced bladder discomfort. CONCLUSIONS: After uncomplicated ureteroscopic electrohydraulic lithotripsy patients without ureteral stenting tend to have similar renal function recovery and satisfactory pain reduction with less irritative symptoms compared to those treated with a ureteral stent. We suggest that it is not necessary to place a ureteral stent routinely after uncomplicated ureteroscopic electrohydraulic lithotripsy for stones smaller than 1 cm.     

Rigid transurethral ureteroscopy

Since March 1984 we have performed ureteroscopy in 58 patients. The indications were ureteric calculi in 49 cases and dilatation of ureteric strictures, evaluation of unexplained haematuria, evaluation of ureteric filling defects and the insertion of ureteric stents in the remainder. Stone removal was successful in 33 patients (67%). We have found rigid ureteroscopy to be a time-consuming procedure with a high risk of minor injury, but long-term complications are uncommon and we believe that rigid ureteroscopy should be the procedure of choice for the management of calculi in the lower and middle thirds of the ureter.     

Indications of stented uncomplicated ureteroscopic lithotripsy: a prospective randomized controlled study

The purpose of our trial was to evaluate whether stents could be eliminated after uncomplicated ureteroscopic lithotripsy for ureteral stones and the indications of ureteral stent placement. A total of 228 patients underwent uncomplicated ureteroscopic intracorporeal lithotripsy. After the procedures, patients without marked ureteral edema, polypoid change or stent placement were treated as a control group. The other patients were randomized to two groups. Patients were followed on the first postoperative day, 6 and 12 weeks, postoperatively. In stented cases the stent was removed after 1 week. Outcome measures included visual analog scale assessment, postoperative analgesic requirements, complications and the stone-free rate. On the first postoperative day the symptoms of flank pain, dysuria and frequency were significantly greater in the stented group (P < 0.0001). The overall perioperative complication rate, including fever, pyuria, flank and loin pain, was 3.3% (3/90) in group 1, 16.9% (12/71) in group 2, and 41.8% (28/67) in group 3. We believe that in selected patients undergoing ureteroscopy for ureteral stone, stents can be safely omitted. Patients without stents have significantly less stent-related symptoms and are not at higher risk of complications with smooth ureteral mucosa. When there is ureteral edema or polypoid change with pyuria, ureteral stents should be indwelled to avoid severe postoperative complications.     

Prestenting improves ureteroscopic stone-free rates

PURPOSE: Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease. PATIENTS AND METHODS: A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups. RESULTS: Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (17/36, 47%) or infection (13/36, 37%). Strict stone-free rates after ureteroscopic treatment were 47% in the 79 procedures without previous stents, compared with 67% in the 36 procedures with prestenting (P < 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54% v 78%, respectively (P < 0.02). Complications were not significantly different in the two groups (P = 0.70). CONCLUSION: Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases.     

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.     

Ureteric calculi in children: preliminary experience with holmium:YAG laser lithotripsy

OBJECTIVE: To determine the efficacy and safety of holmium:YAG laser lithotripsy in children with ureteric calculi. PATIENTS AND METHODS: Between 1999 and 2003, 28 ureteroscopic laser procedures were carried out on 26 children (14 boys and 12 girls, mean age 6.5 years) with ureteric calculi. The mean (range) stone size was 1.21 (0.4-2.2) cm. At ureteroscopy the calculi were in the upper ureter in six (23%), mid-ureter in five (19%) and lower ureter in 15 (58%) patients. A rigid 8 F ureteroscope was used and the Ho:YAG laser energy delivered at 0.6-1.4 J and 6-10 Hz. All patients were evaluated after 3 months with intravenous urography to confirm stone clearance and to exclude ureteric stricture formation. RESULTS: The overall stone-free rate was 92% (24 children) after 28 ureteroscopic procedures. Stones were completely cleared in 83%, 80% and 100% of the procedures in the upper, mid- and lower ureters, respectively. In two children the procedure failed; they were salvaged by ureterolithotomy in one and extracorporeal shockwave lithotripsy in the other. During the procedures, a ureteric perforation was caused by several factors, including a technically difficult procedure and higher laser energy. At the mean (range) follow-up of 18 (3-39) months, low grade vesico-ureteric reflux was detected in two children, and there were no ureteric strictures in any. CONCLUSION: Holmium:YAG laser lithotripsy is an efficient and safe treatment for ureteric calculi in children.     

Use of double-pigtail stents in extracorporeal shock wave lithotripsy

Double-pigtail stents are placed commonly in patients before extracorporeal shock wave lithotripsy to prevent ureteral obstruction from steinstrasse. The use of double-pigtail stents in lithotripsy patients with a moderate stone burden was studied in a prospective randomized trial. Patients with unilateral renal stone(s) with at least 1 diameter between 7 and 25 mm. were eligible for the study. Fifty patients were randomized to a control or stented group. Double-pigtail stents with an attached suture were placed immediately before extracorporeal shock wave lithotripsy in the stented group. Stents were removed by the patients 1 week after lithotripsy. A survey on pain and associated symptoms was completed by patients at 1 and 14 days after treatment. There was no statistical difference in flank or abdominal pain, nausea, vomiting, temperature or use of analgesics at 1 and 14 days after extracorporeal shock wave lithotripsy in the control and stented groups. All patients in the stented groups complained of side effects attributable to the stent including urinary frequency and urgency, bladder pain, hematuria and flank pain with urination. Of 25 patients with stents 7 (27%) had early removal because of severe irritation, early migration or accidental removal. Among the patients with follow-up x-rays 1 month after treatment 17 of 21 (81%) in the control group and 12 of 19 (63%) in the stented group showed no evidence of remaining stones. The use of double-pigtail stents is not beneficial in patients with a moderate stone burden. Double-pigtail stents are associated with considerable patient discomfort but no decrease in symptomatic ureteral obstruction or final stone eradication rate.     

A prospective randomized controlled trial on ureteral stenting after ureteroscopic holmium laser lithotripsy

PURPOSE: A prospective randomized controlled trial was conducted to evaluate whether postoperative ureteral stenting is necessary after ureteroscopic laser lithotripsy. MATERIALS AND METHODS: A total of 58 patients with unilateral ureteral stones were randomized into either stented or unstented groups. Ureteroscopic laser lithotripsy was performed using a semirigid ureteroscope (6.5/7Fr) and holmium laser without ureteral orifice dilation. There were no selection criteria regarding stone size, location, preoperative ureteral obstruction and hydronephrosis. Endoscopic evidence of stone impaction or mucosal edema/damage did not exclude a patient from the study. Ureteral perforation on completion retrograde pyelogram was the only intraoperative criterion for study exclusion. Postoperative pain scores and symptoms were recorded. Excretory urography was performed to document stone-free status and stricture formation. Radionuclide scan was performed selectively to exclude functional obstruction when ureteral narrowing was found on excretory urogram. RESULTS: Mean stone size +/- SD was 9.7 +/- 4.0 mm. (range 4 to 27). Proximal ureteral stones accounted for 43% of all stones. Stented and unstented groups were comparable with respect to demographic data, stone parameters, preoperative obstruction and hydronephrosis. There was no significant difference in operating time, laser energy used, stone impaction and mucosal edema/damage between the 2 groups. Postoperative pain and symptoms were more severe and frequent (p <0.05) in the stented group. However, there was no difference in the incidence of postoperative sepsis and unplanned medical visits. The stone-free and stricture formation rates showed no statistical difference between the 2 groups. CONCLUSIONS: Ureteral stenting is not necessary after uncomplicated ureteroscopic laser lithotripsy for ureteral stones. Ureteral stent increases the incidence of pain and urinary symptoms but does not prevent postoperative urinary sepsis and unplanned medical visits. Severity of preoperative obstruction and intraoperative ureteral trauma were not shown to be determining factors for stenting.