Ureteroscopy: Current Practice and Long-Term Complications

Purpose

We compared a current cohort of patients who underwent ureteroscopy to a cohort from the early 1980s to determine changes in success, indications and long-term complications of the procedure.

Materials and Methods

A chart review was performed of 194 patients who underwent 209 ureteroscopic procedures at our institution during 1992. This group was then statistically compared to 317 patients who underwent 346 ureteroscopies between 1982 and 1985.

Results

The current indications for ureteroscopy were calculus extraction (67% of the cases), diagnosis (28%) and stent manipulation (5%). These indications differed from those of the early series, in which 84% of all ureteroscopies were performed for calculus extraction and 16% for diagnosis. Overall ureteroscopic success rate increased from 86 to 96% (p <0.001). Success of stone extraction improved from 89 to 95% (p = 0.08, distal success rate 95 to 97% and proximal success rate 72 to 77%). Success of diagnostic inspections increased from 73 to 98% (p <0.001). In the early series failure was usually due to inability to traverse the ureter (54% of the cases), while currently failure is due almost exclusively to impassable ureteral strictures (63%). The overall complication rate decreased from 20 to 12% (p = 0.01) and the rate of significant complications decreased from 6.6 to 1.5% (p <0.05). Clinical followup (mean 36 months) for all patients and radiological followup (mean 9.8 months) for 67% of eligible patients detected only 1 ureteral stricture. The remaining patients were asymptomatic after the ureteroscopic procedure.

Conclusions

Improvements in ureteroscope design, accessories and technique have led to a significant increase in the success of diagnostic and therapeutic ureteroscopy while decreasing morbidity. Outpatient ureteroscopic stone extraction, particularly for distal ureteral calculi, is almost uniformly successful with low morbidity. The long-term complication rate of ureteroscopy is 0.5%.     

复杂输尿管条件下的分期输尿管镜术

目的 探讨输尿管镜术中应对输尿管缩窄、扭曲、痉挛,或黏膜游离度大等复杂状况的有效方法.方法 2005-2008年收治因输尿管缩窄(28例)、扭曲(7例)、痉挛(11例)或黏膜游离度大(10例)等原因致术中无法安全顺利进镜的患者.均为单侧输尿管结石或肾盂肾盏内结石.均行IVU检查明确结石部位及分肾功能.其中结石位于输尿管中下段20例,上段21例,肾盂或肾盏内结石15例.肾盂或肾盏内结石直径1.0～1.8 cm,平均1.4 cm;输尿管结石直径0.8～1.8 cm,平均1.1 cm.肾盂扩张1.4～3.0 cm,平均2.2 cm.采用9.8 F Wolf输尿管硬镜,进镜困难者尝试换用8 F Storz硬镜,仍无法顺利进镜者改二期手术.C臂X线机监视下将超滑导丝经梗阻部位进入肾盂,留置5 F双J管.术后预防性使用抗生素3 d.2周后拔除双J管,并以输尿管硬镜处理输尿管内结石,使用输尿管软镜处理肾盂肾盏内结石.结果 56例放弃一期手术后均成功留置双J管.41例输尿管结石中,16例输尿管上段结石被推回肾盂内.二期输尿管镜手术中,56例均成功进镜,25例输尿管结石以输尿管硬镜成功碎石,31例肾盂肾盏内结石以输尿管软镜成功碎石.结论 对于因输尿管缩窄、痉挛、扭曲或黏膜游离度大导致无法安全顺利进镜患者,安置导丝留置双J管2周后行输尿管镜手术常可顺利进镜.一期术后应预防性使用抗生素.

Abstract：

Objective To discuss the feasibility and benefits of staged ureteroscopic laser lithotripsy in complicated cases. Methods From May 2005 to May 2008, the staged ureteroscopic procedure was done in 56 cases for ureteric stricture, kinking, spasm or high mobility of ureteric mucosa. Encountering difficulties, with the guide wire settled in place, the endoscopic procedure was ended and a ureteral stent was set. A second ureteroscopic procedure was carried out two weeks later. Results There was no difficulty for the insertion and the advancing of the ureteroscope two weeks later in all 56 cases. Among the 41 cases previously having the ureteric calculi, the stone was pushed into the kidney by the stent in 16 cases. There was no surgical complication during the second procedure. After three months the complete evacuation rate of the calculus was 96.4%. No patient experienced a fever >39.1 ℃ after the first attempt. Conclusions For complicated cases, such as ureteric stricture, spasm, kinking and high mobility of the ureteric mucosa which hinder the safe advancing of the ureteroscope, staged ureteroscopic procedure might be a safe and effective choice.     

Safety and Efficacy of Ureteroscopic Lithotripsy for Ureteral Calculi Under Sedoanalgesia – A Prospective Study

Objective: To establish the safety and efficacy of ureteroscopic lithotripsy (URSL) under sedoanalgesia. Patients and methods: This study was conducted at Department of Urology (Banaras Hindu University, India) among 124 patients with ureteral stones, between July 2000 and August 2003. Majority of the patients (59.68%) presented with lower ureteric calculi, 24.19% presented with upper ureteric calculi and 16.13% had middle ureteric calculi. All patients were given injection diclofenac sodium (75 mg) promethazine hydrochloride (12.5 mg) deep intramuscular 30 minutes the before procedure. Injection midazolam 0.03 mg/kg body weight slowly given intravenously immediately before the procedure for achieving sedation. Injection fentanyl 50 mcg intravenously given slowly just before introducing the ureteroscope into ureter for achieving intravenous analgesia. Patients were observed for few hours after completion of procedure and oral questions were asked as per proforma, which included tolerance, intensity of pain and percentage of pain experienced by the patients. Patients were discharged thereafter. Results: 87.10% of patients opined that the procedure was acceptable. Only 4.84% opined this procedure was painful. According to present pain intensity score (PPI) in this study 79.03 patients experienced only mild pain, 11.29% cases rated procedure as discomforting, 6.45 rated procedure as distressing and only 3.23% rated as horrible procedure. As per visual analogue scale for assessment of pain 80.65 of cases rated only 20% pain score (in a scale of 0–100). 9.68% cases rated 30% and 6.45% rated 50%. Only two patients in middle ureteric group rated 100% pain. Overall success rate in fragmenting stone was 91.94, where as for lower ureteric calculi it was 97.30%; for upper and, middle ureteric calculi it was 86.66% and 80%, respectively. Conclusion: Ureteroscopic lithotripsy can be performed on day care basis under sedoanalgesia which is fairly tolerated by the patients with unremarkable complications and difficulty.     

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.     

Ureteroscopic lithotripsy in Trendelenburg position for proximal ureteral calculi: a prospective,randomized, comparative study

Purpose

We conducted a prospective, randomized, comparative study to compare the clinical outcome between the Trendelenburg position ureteroscopic lithotripsy (tURSL) and the conventional position ureteroscopic lithotripsy (cURSL) for the management of single proximal ureteral stone.

Methods

From January 2012 to September 2013, consecutive patients with single proximal ureteral calculi less than 2 cm and planned for ureteroscopic lithotripsy at our institution were enrolled in this study. The eligible patients were randomized into cURSL group and tURSL group according to sequence of random numbers generated by computer. In tURSL group, patients were turned into a Trendelenburg lithotomy position with head down 30° while the conventional lithotomy position was applied in cURSL group. URSL was performed using a 6/7.5F semi-rigid ureteroscope with holmium laser. When retropulsion occurred, the stones fragments were followed by semi-rigid ureteroscope up to the renal collecting system. The Olympus P5 flexible ureteroscope was used if there was any suspicion of stone migration into lower calices or incomplete stone fragmentation by semi-rigid ureteroscope. Patients’ demographics between the two groups, perioperative course, clinical outcome and complication rates were compared. Data were analyzed using Chi-square test, Fisher’s exact test or Student’s t test. Binary logistic regression analysis was applied to estimate the effects of surgical position and stone size on stone migration.

Results

A total of 355 cases were finally analyzed in this study (176 in cURSL group and 179 in tURSL group). The mean operative time was significantly prolonged in cURSL group than in tURSL group, while the stone-free rate (SFR) at 4 weeks was significantly higher in tURSL group. A statistically significant difference was found in stone migration rate between the two groups (26.7 vs. 43.6 %, P = 0.001). In the stone migration subsetting, less stones fragments were found to migrate into lower calices in tURSL stone migration subgroup (P = 0.000). Also, the flexible ureteroscope utilization as well as the operative time was significantly decreased in tURSL stone migration subgroup (25.5 vs. 72.3 %, P = 0.000), (44.96 ± 11.0 min vs. 59.17 ± 9.2 min, P = 0.000) with higher SFR after retrograde intrarenal surgery (RIRS) (96.2 vs. 74.5 %, P = 0.000).

Conclusion

The tURSL was safe and highly efficacious for the management of proximal ureteral calculus, especially in nonobese patient. Even with important stone migration risk, it rendered higher SFR and less operative time compared with cURSL. Moreover, less utilization of flexible ureteroscope and decreased deflection time in tURSL could potentially reduce the medical cost.     

Cost-effectiveness and efficiency of shockwave lithotripsy vs flexible ureteroscopic holmium:yttrium-aluminium-garnet laser lithotripsy in the treatment of lower pole renal calculi

Study Type – Therapy (cost effectiveness) Level of Evidence 2b What’s known on the subject? and What does the study add? Stone management economics is a complex issue. FURS and SWL are recognised treatment option for lower pole kidney stones. There are paucity of data comparing cost implication and effectiveness of both treatment options. Both treatment modalities are equally efficacious. FURS incurred greater cost burden compared to SWL in the UK setting. In the present economic circumstance, clinicians should also consider cost‐impact, patient’s preference and specific clinical indication when counselling patients for treatment.

OBJECTIVE

• ? To compare the cost‐effectiveness and outcome efficiency of extracorporeal shockwave lithotripsy (SWL) vs intracorporeal flexible ureteroscopic laser lithotripsy (FURS) for lower pole renal calculi ≤20 mm.

PATIENTS AND METHODS

• ? Patients who had treatment for their radio‐opaque lower pole renal calculi were categorized into SWL and FURS group.
• ? The primary outcomes compared were: clinical success, stone‐free, retreatment and additional procedure rate, and perceived and actual costs.
• ? Clinical success was defined as stone‐free status or asymptomatic insignificant residual fragments <3 mm.
• ? Perceived cost was defined as the cost of procedure alone, and the actual cost included the cost of additional procedures as well as the overhead costs to result in clinical success.

RESULTS

• ? The FURS (n= 37) and SWL (n= 51) group were comparable with respect to sex, age, stone size and the presence of ureteric stent.
• ? The final treatment success rate (100% vs 100%), stone‐free rate (64.9% vs 58.8%), retreatment rate (16.2% vs 21.6%) and auxillary procedure rate (21.6% vs 7.8%) did not differ significantly.
• ? The mean perceived cost of each FURS and SWL procedure was similar (£249 vs £292, respectively); however, when all other costs were considered, the FURS group was significantly more costly (£2602 vs £426, P= 0.000; Mann–Whitney U‐test).

CONCLUSION

• ? SWL was efficacious and cost‐effective for the treatment of lower pole renal calculi ≤20 mm.

     

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.     

急诊输尿管镜治疗输尿管结石并顽固性肾绞痛的应用价值

目的：探讨急诊输抹管镜下取（碎）石术瀹疗输尿管结石外顽剧性肾绞痛的临床应用价值。方法：采用急诊输尿管镜下取（碎）白术治疗输尿管结石并顽固性肾绞痛患者300例,其中上段结石35例,中段结石87例,下段结石178例。较小结石用取石钳取出,较大者用气压弹道碎石。结果：上、中、下段结石治疗成功率分别为74．3％、95．4％、97．75％;未出现输尿管黏膜撕脱、断裂、菌血症等严重并发症。结论：急诊输尿管镜下治疗输尿管结石并顽固性肾绞痛安全有效,损伤小,可作为首选方法之一。     

电子输尿管软镜联合U100Plus激光治疗上尿路2～3 cm结石的疗效研究

目的探讨电子输尿管软镜联合U100Plus激光治疗上尿路2～3 cm结石的安全性及有效性。 方法回顾性分析广州中医药大学金沙洲医院及广州医科大学附属第五医院2018年2月至2018年6月应用电子输尿管软镜结合U100Plus腔内激光碎石系统治疗66例上尿路2～3 cm结石的临床资料,记录术后1个月结石清除率,观察手术效果及围手术期并发症（Clavin-Dindo分级）情况。 结果平均结石直径（2.3±0.3）cm,单次碎石成功率100%。平均碎石时间（56±24） min,平均术后住院时间（2.3±1.2）d。术后1个月结石清除率为87.9%。手术并发症发生率为9.09%（6例）,其中Ⅰ级4例,3例术后体温>38.5℃,1例反复疼痛需镇痛;ⅢA级2例,术后1个月形成输尿管石街,再次手术清石。 结论电子输尿管软镜联合U100Plus激光治疗上尿路2～3 cm结石,碎石效率高,并发症少,结石清除率高。     

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.

Holmium:YAG laser ureteroscopic lithotripsy for ureteric calculi in children: predictive factors for complications and success

Objectives

To evaluate the impact of age, stone size, location, radiolucency, extraction of stone fragments, size of ureteroscope and presence and degree of hydronephrosis on the efficacy and safety of holmium:YAG (Ho:YAG) laser lithotripsy in the ureteroscopic treatment of ureteral stones in children.

Methods

Between October 2011 and May 2013, a total of 104 patients were managed using semirigid Ho:YAG ureterolithotripsy. Patient age, stone size and site, radiolucency, use of extraction devices, degree of hydronephrosis and size of ureteroscope were compared for operative time, success and complications.

Results

In all, 128 URS were done with a mean age of 4.7 years. The mean stones size was 11 mm. Success rate was 81.25 %. Causes of failure were 12.5 % access failure, 1.5 % extravasation and 4.7 % stone migration. Overall complications were 23.4 %. Failure of dilatation and extravasation were detected only in children <2 years old. Extravasation was significantly higher in smaller ureters and cases with stone size >15 mm. Stone migration was significantly higher in upper ureteric stones.

Conclusions

Failure and complications rates in Ho:YAG ureterolithotripsy were significantly affected by younger age (<2 years), upper ureteric stones and smaller ureters but were not related to stone radiolucency or degree of hydronephrosis. Larger stones (>15 mm) were associated with increased complications. After multivariate analysis, the age of the patients remained significant predictor for failure of dilatation and stone migration, while size of the ureter was the only significant predicting factor for failure.     

Staging lymphadenectomy in patients with localized high risk prostate cancer: comparison of the laparoendoscopic single site (LESS) technique with conventional multiport laparoscopy

Background

Laser lithotripsy is an established endourological modality. Ho:YAG laser have broadened the indications for ureteroscopic stone managements to include larger stone sizes throughout the whole upper urinary tract. Aim of current work is to assess efficacy and safety of Ho:YAG laser lithotripsy during retrograde ureteroscopic management of ureteral calculi in different locations.

Methods

88 patients were treated with ureteroscopic Ho:YAG laser lithotripsy in our institute. Study endpoint was the number of treatments until the patient was stone-free. Patients were classified according to the location of their stones as Group I (distal ureteric stones, 51 patients) and group II (proximal ureteral stones, 37). Group I patients have larger stones as Group II (10.70 mm vs. 8.24 mm, respectively, P = 0.020).

Results

Overall stone free rate for both groups was 95.8%. The mean number of procedures for proximal calculi was 1.1 ± 0.1 (1–3) and for distal calculi was 1.0 ± 0.0. The initial treatment was more successful in patients with distal ureteral calculi (100% vs. 82.40%, respectively, P = 0.008). No significant difference in the stone free rate was noticed after the second laser procedure for stones smaller versus larger than 10 mm (100% versus 94.1%, P = 0.13). Overall complication rate was 7.9% (Clavien II und IIIb). Overall and grade-adjusted complication rates were not dependant on the stone location. No laser induced complications were noticed.

Conclusions

The use of the Ho:YAG laser appears to be an adequate tool to disintegrate ureteral calculi independent of primary location. Combination of the semirigid and flexible ureteroscopes as well as the appropriate endourologic tools could likely improve the stone clearance rates for proximal calculi regardless of stone-size.

     

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.     

URETEROSCOPIC MANAGEMENT OF INTRARENAL CALCULI

Purpose

To determine its potential role in stone therapy, we evaluated our experience with the ureteroscopic removal of intrarenal calculi in 100 patients. We review the indications, techniques, stone-free and overall success rates, and complications.

Materials and Methods

From July 1994 to December 1996 ureteroscopic stone removal was attempted in 100 patients a mean of 52 years old who had renal calculi. Indications for treatment included concurrent ureteral stones in 56 cases, and failed extracorporeal shock wave lithotripsy, medical or percutaneous management as well as obesity and anatomical anomalies. There were 2 or more calculi in the affected kidney in 68 patients and stones greater than 6 mm. in 67. Treatment of intrarenal calculi was performed with flexible ureteroscopes, a laser or electrohydraulic lithotriptor and endoscopic graspers. The number and size of calculi were noted in each patient. Stone-free and overall success rates defined as 1 residual fragment less than 3 mm. were noted at 1 and 3-month followup visits.

Results

The overall success rate was 89%. Ureteroscopic treatment of intrarenal calculi resulted in a 77% stone-free rate. Of the 23 patients with residual calculi 12 (52%) had a single residual fragment less than 3 mm. The targeted stone was removed or fragmented in 98 patients (98%) and no ureteral calculi remained postoperatively. As expected, the number and size of the original stones inversely correlated with the success rate. There were no intraoperative complications, and only 3 urinary tract infections and 3 fevers were noted postoperatively.

Conclusions

The use of smaller diameter ureteroscopes, better working instruments and more effective lithotriptors allow calculi in all parts of the collecting system to be engaged and treated. Success rates throughout the whole collecting system are comparable to if not better than those of extracorporeal shock wave lithotripsy and percutaneous approaches.     

Holmium laser lithotripsy for ureteral calculi: predictive factors for complications and success

PURPOSE: To define possible predictive factors for success and complications for ureteroscopic holmium laser lithotripsy procedures. PATIENTS AND METHODS: All 105 ureteroscopic holmium laser lithotripsy procedures performed between 1996 and 2005 were analyzed. Data recorded were sex, age, stone size, stone location, complications, success rate (stone-free rate after 3 months), operative time, and surgeon experience for this procedure. For further analysis, surgeon experience was divided into four groups based on the number of procedures performed. Multivariate analysis was used to define possible predictive factors for complications and successful procedures. RESULTS: Total success rate was 84.8%. Complications were present in 13 patients (12.4%). Success rate was significantly (P = 0.03) related to surgeon experience, with 92.9% success in the most experienced group and 50% in the least experienced group. Furthermore, significantly more complications occurred with decreased experience (P = 0.03): complication rate was 4.2% in the highest experience group and 41.7% in the least experienced group. In our series, sex, stone location, size, and age did not significantly influence complication and success rates. CONCLUSION: Surgeon experience is a predictive factor for complications and success for ureteroscopic holmium laser lithotripsy for ureteric calculi. Experienced surgeons have fewer complications, and the success rate is higher. Sex, stone location, size, and age were not significantly related to complication or success rates.     

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.     

Transurethral ureteroscopic removal of ureteral calculi

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

Prognostic variables for shockwave lithotripsy (SWL) treatment success: no impact of body mass index (BMI) using a third generation lithotripter

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Therapy success in SWL treatment differs between individuals. According to recent studies done with first and second generation lithotripters, different prognostic variables like stone size, stone location, stone composition, age of patient and BMI have been shown to have prognostic relevance for outcome after SWL treatment. This study has been performed with a newer, third generation lithotripter. According to this study, BMI has no impact on SWL treatment success. Therefore, SWL treatment with newer generation lithotripters should be considered for the treatment of kidney stones in overweight and obese patients.

OBJECTIVE

? To investigate the effect of different variables including body mass index (BMI) on therapy outcome in patients with upper urinary tract stones treated with a third generation lithotripter, as BMI has been reported to be an independent predictor for stone‐free status after extracorporeal shockwave lithotripsy (SWL) performed with first or second generation lithotripters.

PATIENTS AND METHODS

? In all, 172 patients with kidney stones with a mean (range) size of 9.2 (3.0–32.0) mm were included in the study. ? In all, 91 patients (52.9%) were treated with a ureteric stent in situ. ? For SWL therapy a third generation, electromagnetic lithotripter (Siemens Lithoskop^TM) was used. Stone‐free status was reached, when no more treatable stones were present (no stone or stone < 3 mm). ? BMI, stone size and localization, age, gender, treatment parameters and ureteric stent in situ were evaluated for their prognostic relevance on therapy success.

RESULTS

? The mean (range) BMI of all patients was 27.8 (19.0–58.6) kg/m². ? Patients were categorized into two groups: A) patients that were stone free after one treatment; B) patients with residual stones. The mean (sd ) BMI was 27.4 (4.6) kg/m² and 28.4 (6.1) kg/m² for A and B, respectively. ? Univariate and multivariate analysis for freedom of stones showed that only stone size (P < 0.01) and presence of a ureteric stent (P= 0.01) were independent prognostic variables. ? BMI had no significant influence on therapy outcome (P= 0.51).

CONCLUSIONS

? Using a third generation lithotripter, BMI was not an independent predictor of stone‐free rate after SWL therapy of kidney stones. ? This effect might be attributed to a greater penetration depth of the shockwave energy. Stone size and a ureteric stent in situ were the only variables with prognostic significance.     

The impact of extracorporeal piezoelectric lithotripsy on the management of ureteric calculi: an audit

The presentation and management of 153 patients with ureteric calculi requiring active treatment over a 12-month period were reviewed; 74% of patients had primary ureteric calculi and 26% had ureteric calculi composed of fragments resulting from extracorporeal piezoelectric shockwave lithotripsy (EPL) to renal calculi; 32 patients (21%) had more than 1 calculus or a steinstrasse. The primary procedures included were in situ EPL (n = 54), push-bang (44), retrograde ureteroscopy (40), Dormia basket extraction (6), push-pull (1), antegrade ureteroscopy (1) and combinations of these (7). The success of the primary procedure could not be predicted from stone size, site or duration in the ureter, but upper tract dilatation was significantly less (p less than 0.01) in the successful group. The overall success rate for complete stone extraction was 97%, but 54 patients (35%) required more than 1 procedure to achieve this. In situ EPL and push-bang, as either primary or secondary procedures, were successful in treating 79 patients (52%); 2 patients required ureterolithotomy (1.3%). The overall complication rate was 18%. Since EPL is only successful in treating approximately half of ureteric calculi, a range of other treatments should be available to maintain a low rate of open surgery.     

输尿管硬镜碎石术治疗输尿管上段结石的疗效影响因素分析

目的探讨输尿管硬镜钬激光碎石术治疗输尿管上段结石的疗效影响因素。 方法回顾分析2012年1月至2018年12月我院泌尿外科收治的1 704例输尿管上段结石行输尿管硬镜钬激光碎石病例的临床资料,并根据手术结果分为成功组（n=1560）和失败组（n=144）,对两组参数进行比较,并采用Logistic回归分析方法,分析影响输尿管上段结石患者行输尿管硬镜钬激光碎石成功率的相关因素。 结果1 704例患者一次碎石成功1 560例,总碎石成功率为91.5%。结石的侧别、结石停留时间、集合系统宽度、结石CT值、结石数目、是否存在上镜困难对输尿管上段结石碎石成功率有显著影响（P<0.05）,但是否存在上镜困难是碎石成功与否的独立影响因素,与是否一次清石成功呈显著负相关（回归系数=-1.233,P<0.01）。 结论输尿管硬镜碎石治疗输尿管上段结石成功率高,其疗效与多种因素相关,是否存在上镜困难可能是主要影响因素。输尿管硬镜碎石术仍然是输尿管上段结石外科微创治疗的理想选择术式。