急诊输尿管镜钬激光碎石与体外冲击波碎石治疗输尿管结石并急性肾绞痛的疗效比较

目的比较急诊输尿管镜钬激光碎石（URL）与急诊体外冲击波碎石（ESWL）两种方法治疗输尿管结石引起的急性肾绞痛的疗效。方法2006年1月至2008年9月，采用Storz8／9F硬质输尿管镜、钬激光碎石机和DornierCompactS型低能量电磁式碎石机分别急诊治疗输尿管结石并肾绞痛175例和110例。所有病例均先行药物治疗症状无缓解后在急诊初诊12h之内接受急诊URL或急诊ESWL。结果对于输尿管上段结石，术后疼痛缓解率URL组虽优于ESWL组（93．94％和66．67％，P〈O．05），但碎石成功率（84．85％和83．33％，P〉0．05）及二周结石排净率（81．81％和77．78％，P〉0．05）均无显著差异。而对于输尿管中下段结石，术后疼痛缓解率（98．59％和92．39％）、碎石成功率（98．59％和91．30％）以及二周结石排净率（97．18％和94．78％）URL组均优于ESWL组fP〈0．05）。最大径10mm以内的结石URL组碎石成功率优于ESWL组（96．38和88．10％，P〈0．05）。最大径10mm以上的结石，术岳疼痛缓解率及2周排净率URL组均优于ESWL组（97．30％和69．23％，91．89％和61．23％，P〈0．05）。5RL及ESWL组并发症率分别为3．46％和2．73％（P〉0．05）。结论急诊URL和急诊ESWL均是输尿营结石并急性肾绞痛的安全、有效的治疗方法，对于输尿管上段结石或最大径不超过10mm的结石二首效果相当，而对于输尿管中下段结石或直径大于10rllm的结石来说，URL疗效优于ESWL。     

Rapid extracorporeal shock wave lithotripsy for proximal ureteral calculi in colic versus noncolic patients

OBJECTIVES: In delayed extracorporeal shock wave lithotripsy (ESWL) treatment, increasing stone impaction is associated with delayed stone clearance. Whether colic patients treated by rapid ESWL have the same time to stone clearance as noncolic patients, which supports the thesis that stones in both groups are nonimpacted, has not been investigated yet, and was the objective of this study. METHODS: A total of 82 patients were prospectively enrolled and treated with piezoelectric ESWL for a solitary proximal ureteral stone. Of these, 56 patients experienced at least one colic episode compared with 26 noncolic patients. Hydronephrosis has been assessed with the use of ultrasound and intravenous urography (IVU). Time to stone clearance after the first ESWL and stone-free rates after a follow-up period of 3 mo were recorded. RESULTS: In colic and noncolic patients, mean stone size was 7.8mm (p=0.7). Ultrasound-detected hydronephrosis was present in 88% versus 39% (p<0.0001), whereas IVU-detected hydronephrosis was present in 60% versus 7.7% (p=0.0001). Mean number of impulses applied was 8000+/-4000 versus 6700+/-3400 (p=0.1). Mean time to stone clearance was 9.5+/-12.1 d versus 4.6+/-3.8 d (p=0.1). Colic and noncolic patients were considered as treatment success in 83% and 81% after 3 mo of follow-up (p=0.9). CONCLUSIONS: Treatment outcome and time to stone clearance after rapid ESWL in colic patients compared with noncolic patients is comparable and independent of concomitant hydronephrosis. This finding suggests an absence of significant impaction in proximal ureteral stones treated within 24h after a first colic episode, enforcing the concept of performing rapid ESWL in patients harbouring proximal ureteral stones.     

Comparative study of extracorporeal shock wave lithotripsy outcomes for proximal and distal ureteric stones

Objective To assess the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy for isolated proximal ureteral calculi and compare it to that for isolated distal calculi. Patient and methods We treated 68 patients with isolated ureteral stones using MPL 9000. Stones were located in the proximal and distal ureters in 44 and 24 patients, respectively. Patients were stratified according to stone burden and degree of obstruction. Data of all patients were prospectively collected for stone burden, stone localization, number of sessions, number of shock waves, stone-free rates (SFRs), complications, re-treatment rates and auxiliary procedures. Outcomes regarding ureteral localization were compared. Results The overall SFR was 85.3% with a 41.2% re-treatment and 17.6% auxiliary procedure rate. The mean number of shock waves applied for each stone was not different among the two ureteral locations. The SFRs were 86.3% and 79.1% for proximal and distal ureteral stones, respectively (P = 0.17). For the group with stones <100 mm2, the SFR was 85.4% and 89.5% for the proximal and distal ureter, respectively. Although the degree of obstruction did not affect SFR of the entire group (P = 0.12) and the proximal ureter group (P = 0.96), it adversely affected SFR in the distal ureter (P = 0.017). Conclusions ESWL outcomes for the ureteral calculi support the use of lithotripsy particularly for stones <100 mm2. Treatment efficacy was not significantly different among stones localized in proximal and distal ureters. Degree of obstruction did not affect the ESWL outcomes in the proximal ureter, but it adversely affected SFR in the distal ureter.     

Management of ureteral stones by extracorporeal shock wave lithotripsy. 3 years of experience

From April 1985 to March 1987 181 patients with ureteral stones were treated by means of extracorporeal shock wave lithotripsy (ESWL). Management for proximal calculi changed from in situ ESWL treatment (group n = 27) or placement of a ureteral catheter below calculi (group II, n = 30) to retrograde stone manipulation into renal pelvis (group IV, n = 52) or ESWL treatment under intraoperative irrigation of saline in cases where repositioning failed (group III, n = 50). The best stone-free rate for upper ureteral stones was obtained in group IV with 96% after 6 weeks, presenting also the shortest hospital stay (4.2 days) and lowest quota of postoperative auxiliary procedures (2%). Stones, not being dislodged into renal pelvis (49%), could be treated successfully in 86% by irrigation with saline during ESWL (group III). The stone-free rate decreased in patients with in situ treatment (group I: 67%) or ureteral catheter placement (group II: 83%). Treatment of these stones increased the need of postoperative ancillary procedures to approximately 30%. For distal ureteral stones ESWL and preoperative Zeiss placement achieved a stone-free rate of 95%.     

Emergency extracorporeal shock wave lithotripsy (ESWL) for obstructing ureteral stones

OBJECTIVE: To evaluate emergency treatment of obstructing ureteral stones by in situ extracorporeal shock wave lithotripsy (ESWL) during acute renal colic. PATIENTS AND METHODS: From January 1994 to February 2000, 200 patients (mean age: 42 years) were treated by ESWL (EDAP LT-02) for obstructing ureteral stones causing acute renal colic refractory to medical treatment or recurring within 24hours of such treatment. Stones were visualised by fluoroscopic imaging and/or ultrasound. Follow-up included radiological and/or ultrasound examinations and lasted three months. RESULTS: Mean stone size was 7mm (3-20mm). At three months, 164/200 (82%) patients were stone-free. This rate ranged from 79% to 83% according to the location of the stone, and from 75% to 86% according to the size of the stone. These differences in rate were not significant. Two or three ESWL sessions were required in 79 patients. ESWL was well tolerated in 90% of patients. The only complication was a case of pyelonephritis requiring the placement of a JJ stent, administration of antibiotics, and distant ureteroscopy. The 36 patients, in whom ESWL failed, underwent ureteroscopy (n=23) or lithotripsy with a Dornier machine (n=13). CONCLUSION: Non-deferred ESWL for acute renal colic secondary to obstructing ureteral stones has a satisfactory success rate and very low morbidity.     

Rapid extracorporeal shock wave lithotripsy treatment after a first colic episode correlates with accelerated ureteral stone clearance

OBJECTIVES: To investigate the relationship between delay in extracorporeal shock wave lithotripsy (ESWL) after a first colic and subsequent time to complete stone clearance. METHODS: This prospective, non-randomized study included 94 patients treated with ESWL for unilateral solitary proximal ureteral stones after at least one episode of colic pain. Time between the first onset of colic pain and ESWL and stone clearance was recorded. The pretherapeutic degree of hydronephrosis has been assessed using ultrasound. RESULTS: Mean stone size was 7.9 +/- 2.3 mm and mean time before ESWL after a first colic was 93.4 +/- 143.5 h. At 3 months, 3 patients were lost to follow-up. In 76.9% of patients stones were completely cleared and a further 3.3% harbored residual fragments < or =3 mm. Delay in treatment after a first colic correlated with subsequent time to stone clearance (p < 0.0001). Mean time to stone clearance in patients treated within 24h was 6.4 +/- 6.3 days compared with 16.0 +/- 17.8 days for those treated later (p = 0.008). Maximum stone diameter correlated with time to stone clearance (p = 0.031), but the degree of hydronephrosis did not. CONCLUSIONS: Rapid ESWL after a first onset of colic pain resulted in accelerated stone clearance independent of the degree of hydronephrosis but had no impact on the need for auxiliary procedures.     

Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study.

146 patients whose ureteral stones did not pass spontaneously participated in a prospective study on optimal management. Patients were offered two treatment options: extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS). The stone was treated with the technique preferred by the patient. In case of treatment failure after first-line therapy, patients again could decide on how to proceed. Stone analysis could be obtained from 72.6% patients. ESWL was the primary treatment in 66.4% patients. In 2 patients, ESWL was the secondary treatment after failed URS. URS was the first-line therapy in 33.6% patients. In 29 patients URS was done after failed ESWL. For analgesia, sedoanalgesia or spinal anesthesia were used. Analgesia was required in 74.2% ESWL and 100% URS sessions. Following ESWL, 70.1% patients became stone free. In 29.9% ESWL failed. Distal stones had a higher failure rate than proximal or mid-ureteral calculi. Distal stones treated without success were significantly larger than those treated successfully. Failures were switched to URS. Stone analysis could be obtained in 26 patients with failed ESWL: 23/26 consisted of pure whewellite or mixed whewellite stones. Clinically relevant complications were not observed. After URS, 94.9% of the patients became stone free. In distal stones, the stone-free rate was 97.5%. There was only 1 relevant complication: a proximal ureteral lesion requiring surgical repair. Our study demonstrates that URS is a safe and highly effective treatment option for ureteral stones. In patients with distal ureteral stones, it should be offered as a first-line treatment. When whewellite is expected as the stone mineral, URS is the treatment of choice.     

输尿管插管注水配合体外冲击波碎石治疗输尿管结石

目的　探讨输尿管内注水体外冲击波碎石术治疗难治性输尿管结石的临床疗效。　方法　对 5 98例难治性输尿管结石采取逆行输尿管插管 ,输尿管内高压 (10 0ml/ 5min)注入生理盐水 ,同时进行体外冲击波碎石。　结果　患者一周内排石率 10 0 %。一周内结石排净率 77% (4 60 / 5 98) ,两周内结石排净率 98% (5 85 / 5 98) ,两个月结石排净率 10 0 %。　结果　输尿管插管注水配合体外冲击波碎石是治疗难治性输尿管结石的良好方法。     

Immediate in situ ESWL as monotherapy in acute obstructive urolithiasis: useful or not?

Thirty-two patients with acute obstructive urolithiasis were treated without intervention (stent, nephrostomy tube) within 72 hours after onset of symptoms by extracorporeal shock wave lithotripsy (ESWL). Relief of obstruction, proven sonographically, was obtained within 48 hours in 78.6% of the patients and 90.6% were stone-free 6 weeks after treatment. Best results were obtained for proximal ureteral stones while the influence of stone volume did not appear to be significant. Whereas our stone-free results for treatment of calculi smaller than 5 mm (92.3%) can be criticized because without treatment these stones may pass spontaneously, a high success rate for larger stones (89.4%) was also noted. These results for in situ ESWL compare favorably to those of ESWL with stent bypass and suggest that ESWL monotherapy should be considered as a noninvasive first line therapy when treating acute obstructive urolithiasis.     

Estudio prospectivo que compara la litotricia extracorpórea y la ureteroscopia en el tratamiento de la litiasis de uréter distal

PurposeTo compare the efficacy of ureteroscopy and extracorporeal shock wave lithotripsy (ESWL) in treating distal ureteral calculi and evaluate the best treatment alternative for this disease.Material and methodsA total of 104 patients with distal ureteral calculi requiring surgical intervention were enrolled and observed in a prospective follow-up. For ESWL, a Modulix SLX Storz lithotriptor was used and for ureteroscopy, a Storz 33 cm semi-rigid ureteroscope with a diameter of 7,5 to 9,5 french and a 6-degree optic. Out of the patient total, 54 patients underwent ESWL and 50 underwent ureteroscopy. 62 patients were men and 42 women; mean age in the ESWL group was 49.72, and in the ureteroscopy group, 52,16. Mean calculus size for ESWL was 8.29mm and 8,96 mm for ureteroscopy. A P<.05 was considered statistically significant.ResultsMean procedure time for ESWL was 55 minutes in men and 45 minutes in women. For ureteroscopy, procedure time was 80 minutes for men and 55 minutes for women. For ESWL, the mean hospital stay was 4.8 hours (same-day discharge for all patients). Mean hospital stay for ureteroscopy patients was 22 hours. 7% of ESWL patients experienced complications compared with 7.9% of those undergoing ureteroscopy. At the 30-day follow up, 74.3% of ESWL patients were stone free, while 92,3% of the ureteroscopy patients were stone free (P<.05).ConclusionsBased on the results of this study, ureteroscopy is a better method for treating distal ureteral calculi because of its stone free rates and because the difference in complication rates was not significant.     

Extracorporeal shock-wave lithotripsy (ESWL) monotherapy for stones in lower ureter.

Extracorporeal shock-wave lithotripsy (ESWL) has been accepted as the method of choice for most upper urinary tract calculi. However, in cases of stones in the lower ureter, ureteroscopic procedures have generally been preferred. Using the Dornier HM3 lithotriptor with modifications in the patient's position, we were able to successfully treat 155 unselected cases of lower ureteral calculi. The average stone size was 9.6 mm (range 5-23 mm). One hundred forty-three patients had stones located below the lower margin of the sacroiliac joint. These patients were placed in a supine position. The stones were visualized radiologically without use of a ureteral catheter in 78 percent of the patients; in 22 percent a ureteral catheter was inserted prior to ESWL to aid in stone localization. In 145 patients (94%) treatment was completed in one session; 10 patients (6%) required two sessions. Of the patients, 38 percent were free of stones one day after ESWL; 97 percent became stone free within three months, and only 3 patients required endoscopic manipulation, after ESWL. Twelve patients had stones in the midureter overlying the sacroileum. They were placed in the prone position, and the calculi were visualized with the aid of a ureteral catheter. All these patients became free of stones one month after treatment. There were no significant treatment-related complications except for bacteremia in 1 case. In view of the remarkable efficacy, negligible complication rate, and shorter hospital stay as compared to ureteroscopic stone manipulations, we recommend high energy ESWL as the primary monotherapy of mid and lower ureteral stones.     

Anesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones

Stones in the proximal, mid and distal ureter in 375 consecutive patients were treated with extracorporeal shock wave lithotripsy (ESWL) in a technically unmodified Dornier HM3 lithotriptor without regional or general anesthesia. Adequate followup was available in 162 patients with proximal, 62 with mid and 146 with distal ureteral stones. The fraction of patients with stone-free ureters within 3 months after ESWL was 96, 97 and 97%, respectively. Of all patients only 13 (3.6%) had residual stones or fragments in the ureter after 3 months. The average number of ESWL sessions was 1.34 for all patients, and 1.36, 1.45 and 1.38 for those with proximal, mid and distal ureteral stones, respectively. A ureteral catheter with saline irrigation was used whenever it was possible to insert a ureteral catheter. Only 15 stones were pushed up to the kidney during catheterization and all other stones were treated in situ. There were more retreatments in patients in whom the stone had not been bypassed by a catheter at the initial ESWL session. During at least 1 treatment session 238 patients had a ureteral catheter with the tip above the stone. Approximately half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous half of all patients were treated after only premedication with pethidine and diazepam, and cutaneous anesthesia with an anesthetic cream containing lidocaine-prilocaine (for proximal and mid ureteral stones). Small supplements of pethidine and diazepam were given to the other patients during the ESWL session. In situ ESWL of ureteral stones as described is a convenient, efficient and attractive procedure that, applied in a consequent manner, theoretically might result in a successful outcome in up to 98% of the patients.     

The effectivity and morbidity of URS as auxiliary therapy after ESWL

We were interested in the effectivity and morbidity of URS as an auxiliary treatment in patients who underwent ESWL for ureteral (n = 71) and kidney stones (n = 31). Between 1991 and 1995, 102 URS were performed for treatment of ureteral fragments. 28 (27.5%) were located in the proximal, 24 (23.5%) in the middle and 50 (49%) in the distal ureter. In 25 cases, fragments were found as "Steinstrasse". In the same period of time, 2554 patients with ureteral stones were treated with ESWL alone, therefore the overall rate of URS was low (4%). URS alone had a stonefree success rate of 58.9%. The success rate depended on the location of the ureteral stone: proximal 25%, middle 50% and distal 82%. URS combined with ESWL showed an overall success rate of 97.9%. Finally, only 2 patients (2.1%) required an open surgery. 29.3% of the stones were treated by extraction only. The extraction of stone was the most frequent procedure to remove the fragments after ESWL. The rate of complications were 6.9%. None of the patients suffered from late complications like stricture of the ureter. The URS for the treatment of stone fragments after ESWL has been shown to be an effective and safe procedure with a low rate of complications.     

Management of lower and middle ureteral calculi "in situ" using the Dornier MFL-5000 lithotripter

A new successful approach in treating lower and middle ureteral calculi in situ was undertaken utilizing the Dornier MFL-5000. From August 19, 1989 to February 7, 1990, 46 consecutive cases were treated representing 60 stones (54 lower, 6 middle). The average size of treated stones was 12 mm. Ten cases (21.1%) had two stones and two cases (4.2%) had three stones. Stones were not displaced and no ureteral catheter was used except in one case, a female, 28 years of age, with a lower ureteral stone, where the stone had to be displaced proximally using a double balloon ureteral catheter to follow FDA protocol in order to avoid the ovaries. Minimal IV sedation was required in 97.7% of the patients and only 2.1% required general anesthesia. Different positioning techniques were implemented. One (2.1%) out of 46 cases required retreatment. The average length of stay in the hospital was 1.2 days. No complications occurred to date. Follow-up, 48 hours post-treatment, revealed 94.6% stone-free. At 3 month's follow-up, 100% were stone-free.     

Efficacy of expulsive therapy using nifedipine or tamsulosin,both associated with ketoprofene,after shock wave lithotripsy of ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) is currently considered one of the main treatments for ureteral stones. Some studies have reported the effectiveness of pharmacologic therapies (calcium antagonists or alpha-blockers) in facilitating ureteral stone expulsion after ESWL. We prospectively evaluated the efficacy, after ESWL, of nifedipine on upper-middle ureteral stones, and tamsulosin on lower ureteral stones, both associated to ketoprofene as anti-edema agent. From January 2003 to March 2005 we prospectively evaluated 113 patients affected by radiopaque or radiolucent ureteral stones. Average stone size was 10.16 ± 2.00 mm (range 6–14 mm). Thirty-seven stones were located in the upper ureter, 27 in the middle ureter, and 49 in the lower ureter. All patients received a single session of ESWL (mean number of shock waves: 3,500) by means of a Dornier Lithotripter S (mean energy power for each treatment: 84%). Both ultrasound and X-ray were used for stone scanning. After treatment, 63 of 113 patients were submitted to medical therapy to aid stone expulsion: nifedipine 30 mg/day for 14 days administered to 35 patients with upper-middle ureteral stones (group A1) and tamsulosin 0.4 mg/day for 14 days administered to 28 patients with stones located in the distal ureter (group A2). The remaining 50 patients were used as a control group (29 upper–middle ureteral stones—B1—and 21 lower ureteral stones—B2—), receiving only pain-relieving therapy. No significant difference in stone size between the groups defined was observed. Stone clearance was assessed 1 and 2 months after ESWL by means of KUB, ultrasound scan and/or excretory urography. A stone-free condition was defined as complete stone clearance or the presence of residual fragments smaller than 3 mm in diameter. The stone-free rates in the expulsive medical therapy group were 85.7 and 82.1% for the nifedipine (A1) and tamsulosin (A2) groups respectively; stone-free rates in the control groups were 51.7 and 57.1% (B1 and B2, respectively). Five patients (14.3%) in group A1, 5 (17.8%) in group A2, 14 (48.3%) in group B1 and 9 (42.8%) in group B2 were not stone-free after a single ESWL session and required ESWL re-treatment or an endoscopic treatment. Medical therapy following ESWL to facilitate ureteral stone expulsion results in increased 1- and 2-month stone-free rates and in a lower percentage of those needing re-treatment. The efficacy of nifedipine for the upper-mid ureteral tract associated with ketoprofene makes expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for ureteral stones.     

Utility of ureteral stent for stone street after extracorporeal shock wave lithotripsy

We reviewed the records of the 530 patients with urinary stones (renal stones: 243; ureter stones 287) who received extracorporeal shock wave lithotripsy (ESWL) (MFL5000; Dornier), from January 1995 to July 2002, retrospectively and determined whether the ureteral stent affected the incidence rate of stone street (SS). We also assessed the effect of ureteral stent on the subsequent management for SS. Forty patients (7.5%) developed SS. Twenty patients were inserted a ureteral stent prior to ESWL (stent group), and 20 patients were performed ESWL without a ureteral stent (in situ group). In the stent group, the most common (80.0%) location for SS was in the upper third ureter, while in the in situ group, SS mostly developed in the distal third ureter (60.0%). The incidence of SS did not differ significantly between the two groups when the size of renal and ureter stones was below 30 and 20 mm, respectively. When the renal stones were larger than above 30 mm, the incidence of SS in the stent group was significantly higher than that in the in situ group. SS disappeared spontaneously with stone passage in 10 of the patients in in situ group, but in only 1 patient in the stent group. In the stent group, 15 patients were treated for SS by removal of ureteral stent regardless of stone diameter. We conclude that ESWL should be performed without a ureteral stent when the stone diameter is below 20 mm. When the ureteral stent is thought to interfere with the delivery of stone fragments, the decision to remove it should be made as soon as possible.     

The effectivity and morbidity of URS as auxiliary therapy after ESWL I. Teil: Sicherheit und Effektivit?t der URS als auxili?re Behandlung nach ESWL

We were interested in the effectivity and morbidity of URS as an auxiliary treatment in patients who underwent ESWL for ureteral (n = 71) and kidney stones (n = 31). Between 1991 and 1995, 102 URS were performed for treatment of ureteral fragments. 28 (27.5 %) were located in the proximal, 24 (23.5 %) in the middle and 50 (49 %) in the distal ureter. In 25 cases, fragmentes were found as “Steinstrasse”. In the same period of time, 2554 patients with ureteral stones were treated with ESWL alone, therefore the overall rate of URS was low (4 %). URS alone had a stonefree success rate of 58.9 %. The success rate depended on the location of the ureteral stone: proximal 25 %, middle 50 % and distal 82 %. URS combined with ESWL showed an overall success rate of 97.9 %. Finally, only 2 patients (2,1 %) required an open surgery. 29.3 % of the stones were treated by extraction only. The extraction of stone was the most frequent procedure to remove the fragments after ESWL. The rate of complications were 6.9 %. None of the patients suffered from late complications like stricture of the ureter. The URS for the treatment of stone fragments after ESWL has been shown to be an effective and safe procedure with a low rate of complications.     

Noninvasive anesthesia,analgesia and radiation-free extracorporeal shock wave lithotripsy for stones in the most distal ureter: experience with 165 patients

PURPOSE: Spontaneous ureteral stone passage often causes severe renal colic, especially when the stone passes through the narrow ureteral orifice. In these situations noninvasive anesthesia-free, analgesia-free and radiation-free extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia) is a valuable tool. It can be performed at any time without needing any further patient preparation. MATERIALS AND METHODS: A total of 165 patients underwent ESWL using the Lithostar Ultra device (Siemens, Erlangen, Germany). Only ureteral calculi within 5 cm. of the ureterovesical junction were included in this study. Patients were treated while supine and stones were localized by ultrasound through the filled bladder without x-ray exposure. Treatment was started without anesthesia or analgesia and analgesics were administered only at patient request during treatment. RESULTS: Of the patients 93% were treated without anesthesia or analgesia and 7% required a single intravenous dose of 25 mg. pethidine. Postoperatively renal colic developed in 40 patients (24%). In 4 cases (2.4%) renal drainage was required for analgesia resistant pain or obstructive pyelonephritis. On day 1 after ESWL 90% of the patients were stone-free or had fragments 2 mm. or less, while 10% had residual fragments 3 mm. or greater. Of all patients 7% were re-treated once. At 3 months postoperatively 129 of the 130 evaluable patients (99%) were stone-free. CONCLUSIONS: ESWL of stones located in the most distal ureter using the Lithostar Ultra device is effective, safe and radiation-free. It is done without anesthesia and in most cases without analgesics. This simple and noninvasive procedure is an excellent first line treatment modality for prevesical stones and it represents a valid alternative to conservative management or invasive endoscopy.     

Extracorporeal shock wave lithotripsy of proximal and distal ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) was used for treatment of 105 patients with ureteral stones. There were 77 stones in the upper part of the ureter, i.e. above the pelvic brim, and 28 in the lower part, i.e. below the sacroiliac joint. Successful fragmentation was attained in 101 (96%). In 93% of the patients with stones in the upper ureter and in 100% with stones in the lower ureter the fragments were eliminated completely. In 87% of the patients with stones in the upper ureter, a ureteral catheter was introduced under local anesthesia but without fluoroscopic control. It was thereby possible to remove 30% of the stones from the ureter to the kidney. For the remaining stones, saline was infused through the catheter during ESWL. For patients with stones in the lower part of the ureter, a ureteral catheter was passed in 79% and saline infused during treatment. Whereas some form of anesthesia was used for treatment of all upper ureteral stones, 89% of the treatments for lower ureteral stones were performed without anesthesia. Auxiliary procedures after ESWL were limited to four ureteral catheter manipulations for distal stones. Four proximal stones which remained unaffected by ESWL had to be treated by open surgery (3 stones) or percutaneous surgery (1 stone). Of 82 ureteric stones treated in situ the success fragmentation rate was 95%. The average number of ESWL sessions was 1.04 for both proximal and distal ureteral stones.     

Outcome and safety of extracorporeal shock wave lithotripsy as first-line therapy of lower pole nephrolithiasis

INTRODUCTION: The aim of this study is to assess the efficiency of extracorporeal shock wave lithotripsy (ESWL) as initial therapy for isolated lower pole kidney stones smaller than 20 mm. PATIENTS AND METHODS: During a 24-month period 116 patients with previously untreated single stones under 20 mm in diameter were treated with a Dornier lithotripter S. They were analyzed with regard to stone site and size, number of ESWL sessions, auxiliary measures, retreatment rates, complications and the time taken for stone clearance. RESULTS: 76 patients (65.5%) became stone free, 50 of them (43.1%) within 3 months after ESWL. Depending on stone size the stone-free rates were 67.1% for patients with a stone diameter of <10 mm (59 of 88 patients), and 60.7% for stone diameters between 10 and 20 mm (17 of 28 patients). Complications during and after treatment were rare, i.e. the necessity of ureteral stent insertion due to colic (n = 10), endoscopic stone removal (n = 2), acute pyelonephritis (n = 1), stonestreet (n = 1) and 1 case of hematoma not requiring intervention. The recurrence rate during follow-up (13.2-36.9, mean 25.0 months) was low: 16 patients (13.8%) had recurrent or persistent stones, and 74 patients (63.8%) had no evidence of urolithiasis. CONCLUSIONS: ESWL is a safe and efficient first-line therapy for treatment of isolated small lower pole kidney stones with acceptable stone-free rates, low morbidity, few complications and a low stone recurrence rate.