小儿肾结石的ESWL和PCNL治疗

目的　总结小儿肾结石ESWL和经皮微造瘘输尿管镜取石术 (mini PCNL)治疗经验。　方法　回顾性分析 10 5例小儿肾结石诊治资料 ,男 72例、女 3 3例 ,平均年龄 8.7岁。其中伴尿路畸形 2 1例 (2 0 .0 % )。ESWL治疗 68例 ;mini PCNL治疗 3 3例 ,4例联合ESWL ;改行开放手术 4例。　结果　 68例ESWL治疗 92次 ,结石完全排空 57例 (83 .8% ) ,1次ESWL治疗成功 47例 (69.1% ) ,2次治疗 18例 (2 6.5% ) ,3次治疗 2例 (4.4% ) ;2例石街经输尿管镜治疗成功。 3 3例mini PCNL治疗者 ,一期PCNL成功 2 4例 (72 .7% ) ,二期PCNL治疗 9例 (2 7.3 % ) ;3例伴肾盂输尿管连接部梗阻者同时行顺行肾盂输尿管内切开术 ,一期结石清除率 2 4例 (72 .7% ) ,二期结石清除率 2 9例(87.9% ) ,联合ESWL 4例 ,总结石清除率为 97.0 %。 4例开放手术中 2例同时行肾盂输尿管成形术 ,1例多发结石术后有残余结石。　结论　ESWL是治疗小儿肾结石安全、有效的首选方法 ;选择PCNL治疗应根据结石和设备技术情况 ,联合ESWL成功率更高     

Minimally invasive treatment of urinary tract calculi in children.

OBJECTIVE: To report experience of a broad multimodality approach to the treatment of calculi in children using extracorporeal shock wave lithotripsy (ESWL), ureteroscopy/laser lithotripsy, lithoclast and percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: The treatment and outcome were reviewed in 43 children managed by a range of minimally invasive modalities, either singly or in combination, between 1990 and 1997. These patients represent a selected group deemed suitable for minimally invasive management during a period of developing experience with these techniques. Of this cohort, six children had previously undergone open stone surgery and contributory metabolic abnormalities were identified in seven. ESWL was the sole treatment modality in 24 children (56%). In five children (12%) ureteroscopy/laser lithotripsy was combined with ESWL, eight (18%) underwent ureteroscopy/laser lithotripsy alone, whilst three with bladder stones were treated with the lithoclast. Combined therapy including PCNL was required in three patients. RESULTS: Of the 43 children treated, 38 (88%) were rendered stone-free. Metabolic disorders accounted for three of the five cases of residual calculi. Complications requiring intervention occurred in two children (7%) and three subsequently underwent open pyelolithotomy or ureterolithotomy after unsuccessful minimally invasive treatment. CONCLUSIONS: Used selectively, the range of minimally invasive procedures available for adults, including ureteroscopy and PCNL, can be safely and effectively extended to the treatment of urinary tract calculi in children. The role of open surgery will diminish further with the availability of specialized instruments for paediatric PCNL.     

Multimodal management of urolithiasis in renal transplantation

OBJECTIVE: To report the largest single series of renal transplant patients (adults and children) with urolithiasis, assess the risk factors associated with urolithiasis in renal transplant recipients, and report the outcome of the multimodal management by endourological and open procedures. PATIENTS AND METHODS: The records of all patients undergoing renal transplantation between 1977 and 2003 were reviewed. In all, 2085 patients had a renal transplant at our centre and 21 (17 adults and four children) developed urinary tract calculi. Their mode of presentation, investigations, treatments, complications and outcomes were recorded. Investigations included one or more of the following; ultrasonography (US), plain abdominal X-ray, intravenous urography, nephrostogram and computed tomography. Management of these calculi involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. RESULTS: Thirteen patients had renal calculi, seven had ureteric calculi and one had bladder calculi. The incidence of urolithiasis was 21/2085 (1.01%) in the series. Urolithiasis was incidentally discovered on routine US in six patients, six presented with oliguria or anuria, including one with acute renal failure, four with a painful graft, three with haematuria, one with sepsis secondary to obstruction and infection and in one, urolithiasis was found after failure to remove a stent. Ten patients (63%) had an identifiable metabolic cause for urolithiasis, two by obstruction, two stent-related, one secondary to infection and in six no cause was identifiable. Thirteen required more than one treatment method; 13 (69%) were treated by ESWL, eight of whom required multiple sessions; eight required ureteric stent insertion before a second procedure and four required a nephrostomy tube to relieve obstruction. Two patients had flexible ureteroscopy and stone extraction, three had a PCNL and one had open cystolithotomy. PCNL failed in one patient who subsequently had successful open pyelolithotomy. All patients were rendered stone-free when different treatments were combined. CONCLUSIONS: The incidence of urolithiasis in renal transplant patients is low. There is a high incidence of metabolic causes and therefore renal transplant patients with urolithiasis should undergo comprehensive metabolic screening. Management of these patients requires a multidisciplinary approach by renal physicians, transplant surgeons and urologists.     

Urolithiasis in the horseshoe kidney: a single-centre experience

OBJECTIVE

To report the operative management and subsequent stone‐free rates of patients with urolithiasis in a horseshoe kidney and treated at one centre.

PATIENTS AND METHODS

We retrospectively reviewed all patients presenting to our centre with a horseshoe kidney and urolithiasis over a 15‐year period. The stone burden, surgical management, complications and stone clearance rates were recorded.

RESULTS

In all, 55 patients with urolithiasis in horseshoe kidney were treated. Percutaneous nephrolithotomy (PCNL) was used in 60 renal units in 47 patients. Five patients had extracorporeal shock wave lithotripsy (ESWL), two had flexible ureteroscopy and one had a laparoscopic pyelolithotomy for a stone extending into the isthmus. PCNL was used for large stones (mean digitized surface area = 614.32 mm²) and required one to four stages to achieve an overall stone clearance rate of 88%. Stones were cleared at one sitting in 77% of PCNL procedures, completely cleared in two‐thirds of patients treated by ESWL, and in both who had flexible ureteroscopy and the one treated with laparoscopic pyelolithotomy. Complications were minimal, with 15% minor and 3% major complications in the PCNL group only.

CONCLUSION

Appropriate management of urolithiasis within the horseshoe kidney depends not only on stone burden, but also on stone location, calyceal configuration and malrotation. Stones can be cleared successfully in almost all patients providing that all techniques are available to the operating surgeon.     

Open stone surgery: Is it still a preferable procedure in the management of staghorn calculi?

We reviewed 43 patients with staghorn calculi to determine the effectiveness of various treatment modalities such as extracorporeal shock wave lithotripsy (ESWL) monotherapy, ESWL and percutaneous nephrolithotomy (PCNL) combined therapy, and open stone surgery. While ESWL monotherapy and ESWL+PCNL were performed in 25 and 8 patients, respectively, 10 patients underwent open stone surgery. Of the 25 patients treated with ESWL, 8 were stone-free, whereas 4 out of 8 patients treated with ESWL+PCNL and 8 out of 10 patients treated with open surgery were stone-free. The complications of ESWL monotherapy consisted of pyelonephritis in one patient, and stone street formations in three. In the group of ESWL+PCNL, one patient developed pyonephrosis, and another perinephritic abscess. No serious complication was noted in patients who underwent open surgery, but an average of 525 ml of blood transfusion was required. We conclude that open stone surgery, although invasive, is still beneficial in the treatment of staghorn calculi. Presented at the 10th Congress of the European Association of Urology, July 1992, Genoa.     

Treatment of staghorn calculi with extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy

Between August 1983 and August 1987, 72 staghorn calculi were treated in 66 patients. Treatment was with percutaneous nephrolithotomy (PCNL) in 30, extracorporeal shock-wave lithotripsy (ESWL) in 18, combination PCNL-ESWL in 23, and nephrectomy in 1. Complications occurred in 59 percent of patients and were twice as common after PCNL as after ESWL. Radiologic follow-up on 69 kidneys (97%) showed 58 percent were stone-free, 15 percent had residual sand or matchheads less than 5 mm, 17 percent had residual fragments of 5-15 mm, and 10 percent had greater than 15 mm residual stone burden. With a mean follow-up of thirty months, 2 of 40 stone-free patients had persistent asymptomatic Proteus urinary tract infections, and 4 of 22 patients with residual calculi less than or equal to 15 mm required additional operative treatment.     

Lithotripsy in the treatment of urinary lithiasis

Based on an extensive review of the literature and on our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones, particularly regarding the extracorporeal shock waves lithotripsy (ESWL) treatment nowadays. Few technical developments have changed medicine more within a short period of time than ESWL. Fifteen years after the first clinical application, ESWL has gained world-wide acceptance as first choice therapy for most forms of urolithiasis. Ninety-eight per cent of stones can be successfully fragmented by the application of shock-waves, but the ability of the kidney and ureter to clear the resulting fragments is far more important in terms of successful treatment outcome. Increasing experience with new ultrasound-guided lithotriptors has shown that there are some advantages: cost reduction, permanent monitoring and lack of exposure to ionising radiations. ESWL is a safe procedure for the treatment of urolithiasis; nevertheless some problems remain. In ureteric stones, ureteroscopy (rigid or flexible device) allows a rate of stone-free patients better than ESWL. For treatment of large staghorn calculi combined approach of PCNL and ESWL is preferred. For stones located at lower calyx, the stone-free rate in patients treated by ESWL fell to 50%, when unfavourable anatomy is present. The potential long-term renal damage, associated with ESWL in children, have delayed the acceptance of shock-waves into paediatric practice. Recent reports suggest that the renal damage, including the potential risk of hypertension induced by ESWL, is mild and transient. A subgroup of patients (e.g. solitary kidney, impaired renal function, children) required further attention. The fate of residual fragments is unclear. In some cases residual lithiasis tend to result in regrowth and further progression, although ESWL itself does not increase the recurrence rate of urolithiasis. Nevertheless follow-up of stone patients after ESWL is mandatory and the ultimate goal of treating stones by whatever means is to get the patient stone-free and prevent recurrence.     

移植肾尿路结石46例诊治体会

目的探讨肾移植术后尿路结石的诊断和治疗,提高长期存活率。方法回顾性分析1980年1月至2011年6月46例移植肾结石患者的临床资料。结果 35例为肉眼血尿,10例为体检时B超发现,1例为急性无尿发病,均无肾绞痛。移植肾结石24例,移植输尿管结石22例,结石大小0.7～2.0 cm,结石发病时间为术后3.5（0.4～15）年。42例行体外冲击波碎石（ES-WL）,其中3例无效行输尿管镜下钬激光碎石术和1例行经皮肾镜取石术（PCNL）,4例尿酸结石给予枸橼酸氢钾钠（友来特）药物治疗。随访3个月：42例ESWL中,结石排净36例（85.72%）,结石残留2例（4.76%）,4例（9.52%）无效改用腔镜治疗后结石排出;4例尿酸结石口服枸橼酸氢钾钠结石大部分排出。结论移植肾结石缺乏典型肾绞痛表现,体外冲击波碎石术是治疗移植肾结石安全、有效的主要方法。     

经皮肾穿刺造瘘碎石术联合体外冲击波碎石术治疗鹿角形肾结石

目的：探讨微创经皮肾穿刺造瘘碎石取石术(PCNL)联合体外冲击波碎石术(ESWL)治疗鹿角形肾结石的可行性。方法：对部分鹿角形结石93例，完全鹿角形结石34例，采用PCNL加ESWL加PCNL的“三明治”取石术。结果：127例均行一期穿刺取石，单通道取石78例，双通道取石38例，三通道取石21例。ESWL76例，2次以上PCNL99例。结石清除率85．03％，平均手术时间2h50min；平均住院15d。未发现明显出血等并发症。结论：PCNL加ESWL加PCNL的“三明治”取石术是一种治疗鹿角形肾结石的有效方法。     

Urolithiasis bei Kindern – rationelle Diagnostik, Therapie und Metaphylaxe

With a proportion of 1–5%, children constitute only a small number of all patients with urolithiasis. Nevertheless, pediatric stone disease is an important health care problem because of the high recurrence rate and the threat of progredient renal function impairment with consecutive loss of quality of life. Modern therapies, especially extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), have caused a revolution in the operative treatment spectrum. Open surgery is required for stone removal only rarely, such as for the simultaneous repair of urinary tract anomalies. The minimally invasive modalities of modern stone therapy – mainly ESWL as the treatment of first choice – have led to widespread disregard of stone metaphylaxis. The important principle that says an urinary stone is just a symptom and not the cause of the disease is often forgotten. So it must be noted that despite the high standard of care in Germany, not all problems regarding urinary stone disease are being resolved, particularly in childhood. This article presents the current knowledge of the most important aspects of stone therapy and the methods of treatment in children.     

微创经皮肾镜取石术联合Ⅱ期逆行输尿管软镜治疗复杂性肾结石96例

目的 探讨微创经皮肾镜取石术联合Ⅱ期逆行输尿管软镜治疗复杂性肾结石的安全性及有效性.方法 对九江学院附属都昌医院泌尿外科2012年1月至2014年12月收治的96例复杂性肾结石采用微创经皮肾镜取石术联合Ⅱ期逆行输尿管软镜治疗,并对临床资料进行回顾性分析.结果 所有手术均成功建立工作通道并有效行Ⅰ期微创经皮肾镜取石术,术后3～5d行二期逆行输尿管软镜治疗,Ⅱ期结石清除率为95.8％ (92/96).5例患者于术后行辅助体外冲击波碎石治疗,4例碎石后结石完全排出,1例结石残留,残留结石直径＜ 5mm.其中出现1例并发输尿管穿孔,1例感染,均予保守治疗后治愈.未出现气胸、大出血等重大并发症.结论 微创经皮肾镜取石术联合Ⅱ期逆行输尿管软镜治疗是一种复杂性肾结石安全、有效的方法,具有术中损伤小、住院时间短、恢复快、结石清除率高、并发症低等优点.     

Urolithiasis in children--rational diagnosis, therapy, and metaphylaxis

With a proportion of 1-5%, children constitute only a small number of all patients with urolithiasis. Nevertheless, pediatric stone disease is an important health care problem because of the high recurrence rate and the threat of progredient renal function impairment with consecutive loss of quality of life. Modern therapies, especially extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), have caused a revolution in the operative treatment spectrum. Open surgery is required for stone removal only rarely, such as for the simultaneous repair of urinary tract anomalies. The minimally invasive modalities of modern stone therapy - mainly ESWL as the treatment of first choice - have led to widespread disregard of stone metaphylaxis. The important principle that says an urinary stone is just a symptom and not the cause of the disease is often forgotten. So it must be noted that despite the high standard of care in Germany, not all problems regarding urinary stone disease are being resolved, particularly in childhood. This article presents the current knowledge of the most important aspects of stone therapy and the methods of treatment in children.     

斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石

目的：探讨斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石的安全性及有效性。方法2009年1月～2012年10月,采取斜仰卧截石位经皮肾镜联合输尿管镜治疗输尿管上段复杂结石67例,气管插管全麻,先行经皮肾镜处理结石,向下移位结石再行输尿管镜将移位结石碎石并经工作通道冲出。结果67例手术均一次完成,手术时间46～106 min,平均76 min。一次结石清除率92．5％（62/67）,结石残留5例,配合ESWL 2周后结石完全清除。均无大出血、输尿管撕脱、脏器损伤等并发症。结论斜仰卧截石位经皮肾镜联合输尿管镜处理输尿管上段复杂结石具有体位舒适,避免术中体位变换带来的不便,手术时间短,有利于术中麻醉监护,碎石取石效果好,并发症少的优点,治疗的安全性高,值得临床推广。     

LOWER CALICEAL STONE CLEARANCE AFTER SHOCK WAVE LITHOTRIPSY OR URETEROSCOPY: THE IMPACT OF LOWER POLE RADIOGRAPHIC ANATOMY

Purpose

We determine whether there is a significant relationship between the spatial anatomy of the lower pole, as seen on preoperative excretory urography (IVP), and the outcome after shock wave lithotripsy or ureteroscopy for a solitary lower pole caliceal stone 15 mm. or less.

Materials and Methods

Between January 1992 and June 1996, 34 patients with 15 mm. or less solitary lower pole stone underwent ureteroscopy with intracorporeal lithotripsy¹³ or extracorporeal shock wave lithotripsy (ESWL [dagger]) with a Dornier HM3 lithotriptor [dagger] ^[21]. On pretreatment IVP lower pole infundibular length and width, infundibulopelvic angle of the stone bearing calix were measured. Stone size and area were determined from an abdominal plain x-ray. A plain x-ray of the kidneys, ureters and bladder was obtained in all patients at a median followup of 12.3 and 8 months in the ureteroscopy and ESWL groups, respectively.[dagger] Dornier Medical Systems, Inc., Marietta, Georgia.

Results

After initial therapy the overall stone-free rate was 62 and 52% in the ureteroscopy and ESWL groups, respectively. Stone-free status after ESWL was significantly related to each anatomical measurement. Infundibulopelvic angle 90 degrees or greater, and infundibular length less than 3 cm. and width greater than 5 mm. were each noted to correlate with an improved stone-free rate after ESWL. In contrast, the stone-free rate after ureteroscopy was not statistically significantly impacted by these anatomical features, although a clinical stone-free trend was identified relating to a favorable infundibular length and infundibulopelvic angle. The infundibulopelvic angle was 90 degrees or greater in 4 stone-free patients (12% overall), including 2 who underwent ureteroscopy and 2 who underwent ESWL. On the other hand, in 2 and 4 stone-free patients (18% overall) who underwent ureteroscopy and ESWL, respectively, favorable radiographic features consisted of a short, wide but acutely angulated infundibulum with the infundibulopelvic angle less than 90 degrees, and infundibular length less than 3 cm. and width 5 mm. or greater. In contrast, in 4 and 6 patients (29% overall) who underwent ureteroscopy and ESWL, respectively, all 3 radiographic features were unfavorable with the infundibulopelvic angle less than 90 degrees, and infundibular length greater than 3 cm. and width less than 5 mm. In these cases the stone-free rate was 50 and 17% after ureteroscopy and ESWL, respectively.

Conclusions

The 3 major radiographic features of the lower pole calix (infundibulopelvic angle, and infundibular length and width) can be easily measured on standard IVP using a ruler and protractor. Each factor individually has a statistically significant influence on stone clearance after ESWL. A wide infundibulopelvic angle or short infundibular length and broad infundibular width regardless of infundibulopelvic angle are significant favorable factors for stone clearance following ESWL. Conversely, these factors have a cumulatively negative effect on the stone clearance rate after ESWL when they are all unfavorable. In ureteroscopy spatial anatomy has less of a role in regard to stone clearance but it may have a negative impact when there is uniformly unfavorable anatomy.     

Electromagnetic extracorporeal shock wave lithotripsy in children

Extracorporeal shock wave lithotripsy (ESWL) was performed for the treatment of urinary tract calculi in 28 children. All treatments were done with the standard Siemens Lithostar device in situ: no special adaptations for adequate positioning of children are required to target the stone precisely. A total of 42 calculi in 30 renal units was treated, requiring 50 ESWL sessions. The mean energy used was 16.4 kv. and the number of shock waves averaged 3,188. Mean fluoroscopy time per session was 1.5 minutes. In 26 of 50 sessions (52%) general anesthesia was needed for the child to remain perfectly still. A complete stone-free rate was achieved in 38 of 42 calculi (90.5%): after 1 session in 30 (71.4%), after 2 sessions in 6 (13.7%) and after 3 sessions in 2 (4.8%). Five staghorn calculi were treated with ESWL monotherapy. A complete stone-free result was obtained after 3 treatments in 2 patients, while 2 had residual fragments in the lower pole (5 mm. after 6 sessions and 11 months of followup in 1, and 7 mm. after 3 sessions and 3 months of followup in 1). A cystine staghorn stone necessitated open nephrolithotomy after 3 sessions without any fragmentation. One impacted sacroiliac ureteral stone required endoscopic laser lithotripsy. Except for these 2 failures no adjuvant procedures were needed. There were no intraoperative or postoperative complications and minor skin bruising at the coupling site after 3 treatments did not require any therapy. We conclude that electromagnetic ESWL with the standard Lithostar unit is a safe and effective method to treat calculi throughout the urinary tract in children.     

Management of pediatric urolithiasis in Pakistan: experience with 1,440 children

PURPOSE: We evaluated the efficacy and safety of different modalities for pediatric urolithiasis in a developing country in 2 eras, namely before and after the advent of minimally invasive surgery. MATERIALS AND METHODS: We retrospectively reviewed the records of 1,440 children younger than 14 years treated with various modalities during a 14-year period. From 1987 to 1995, 486 and 50 patients were treated with open surgery, and extracorporeal shock wave lithotripsy (ESWL, Dornier Medical Systems, Inc., Marietta, Georgia) and minimally invasive methods, respectively. Between 1996 and 2000, 518 and 386 children were treated with surgery and minimally invasive methods, respectively. RESULTS: Of the 1,440 children 795 (55.2%) had renal, 198 (13.8%) had ureteral and 447 (31%) had bladder calculi. Of the renal stones 556 (70%), 177 (22%) and 62 (7.8%) were treated with open surgery, ESWL and percutaneous nephrolithotomy, respectively. Of the ureteral calculi 85 (43%), 37 (18.6%) and 76 (38%) were managed by ESWL, ureterorenoscopy and open surgery, respectively. Of the bladder calculi 307 (68%), 77 (17.2%) and 63 (14%) were treated with open vesicolithotomy, transurethral pneumatic cystolithotripsy and ESWL, respectively. The renal stone clearance rate was 98% after open surgery, 84% after ESWL and 68% after percutaneous nephrolithotomy monotherapy at 3 months of followup. Similarly the ureteral stone-free rate was 54% after ESWL and 86.9% after ureterorenoscopy. Of the patients with bladder calculi 48% and 93% become stone-free after ESWL and transurethral pneumatic cystolithotripsy, respectively. CONCLUSIONS: The use of ESWL, percutaneous nephrolithotomy and ureterorenoscopy has resulted in treating a large number of children with a short hospital stay and early return to school. Open surgery is reserved only for complex 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.     

Sixteen years of experience with stone management in horseshoe kidneys

INTRODUCTION: Horseshoe kidney is the commonest congenital renal fusion anomaly, and is often complicated by urolithiasis. We focus on our 16 years of experience with stone management in horseshoe kidneys. MATERIALS AND METHODS: We reviewed the progress of 44 patients treated between 1987 and 2002. Shock wave lithotripsy (SWL) was used in 25 patients; the average stone surface area was 91 (range 10-1,600) mm2 and average follow-up was 36.5 (range 1-91) months. 19 patients underwent percutaneous nephrolithotomy (PCNL); the average stone surface area was 197 (range 6-2,400) mm2. Follow-up data are available for 8 patients and the average follow-up was 42.3 (range 3-144) months. RESULTS: In the SWL group the 3-month stone-free rate (SFR) was only 31%. In the PCNL group the SFR was 75% on the postoperative day-1 KUB. Complications occurred in 9 patients. CONCLUSIONS: Stone management in horseshoe kidneys is challenging: PCNL produces a higher SFR with minimal major complications and failed access. PCNL thus appears to be the preferred management option in patients with urolithiasis in horseshoe kidneys.     

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.     

Treatment for residual stones using flexible ureteroscopy and holmium laser lithotripsy after the management of complex calculi with single-tract percutaneous nephrolithotomy

This study validated the effectiveness and safety of the treatment for residual stones using flexible ureteroscopy (fURS) and holmium laser (0.6–1.2 J, 20–30 Hz) lithotripsy via a fiber with a 200-μm core diameter and 0.22 numerical aperture (NA) after the management of complex calculi with single-tract percutaneous nephrolithotomy (PCNL). Between January 2014 and June 2016, 27 consecutive patients with complex calculi underwent fURS and holmium laser lithotripsy after a planned single-tract PCNL. Among the 27 patients with complex calculi, 9 had full staghorn calculi, 7 had partial staghorn calculi, and 11 had multiple calculi. After the first single-tract PCNL session, the mean stone size and mean stone surface area were 18.0?±?10.7 mm and 181.9?±?172.2 mm², respectively. Treatment for residual stones with fURS and holmium laser lithotripsy was successfully completed and was performed without intraoperative complications. The mean operative time of the fURS procedure was 69.1?±?23.6 min, and the mean hospital stay was 5.3?±?2.4 days. The mean decrease in the hemoglobin level was 7.3?±?6.5 g/l. After the fURS procedure, the overall stone-free rate was 88.9%. The overall postoperative complication rate was 14.8% (Clavien grade I 11.1%; Clavien grade II 3.7%). The current approach tested here combines the advantages of both PCNL and fURS and effectively manages complex calculi with a high stone-free rate (SFR) (88.9%). This approach also reduced the number of treatment sessions, the number of percutaneous access tracts, and the blood loss and potential morbidity associated with multiple tracts.