Flexible ureterorenoscopy versus extracorporeal shock wave lithotripsy for treatment of lower pole stones of 10-20 mm

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Shock wave lithotripsy and flexible ureterorenoscopy are acceptable treatment options for lower pole stones smaller than 10 mm, while percutaneous nephrolithotomy is the favoured treatment for stones larger than 20 mm. For treatment of lower pole stones of 10–20 mm, flexible ureterorenoscopy has a significantly higher stone‐free rate and lower retreatment rate than shock wave lithotripsy.

OBJECTIVE

• ? To compare the outcomes of flexible ureterorenoscopy (F‐URS) and extracorporeal shock wave lithotripsy (ESWL) for treatment of lower pole stones of 10–20 mm.

PATIENTS AND METHODS

• ? The database of patients with a single lower pole stone of 10–20 mm was examined to obtain two matched groups who were treated with F‐URS or ESWL. Matching criteria were stone length, side and patient gender.
• ? Stone‐free rates were evaluated 3 months after the last treatment session by non‐contrast computed tomography. Both groups were compared for retreatment rate, complications and stone‐free rate.

RESULTS

• ? The matched groups included 37 patients who underwent F‐URS and 62 patients who underwent ESWL. Retreatment rate was significantly higher for ESWL (60% vs 8%, P < 0.001).
• ? Complications were more after F‐URS (13.5% vs 4.8%), but the difference was not significant (P= 0.146). All complications were grade II or IIIa on modified Clavien classification.
• ? The stone‐free rate was significantly better after F‐URS (86.5% vs 67.7%, P= 0.038). One failure of F‐URS (2.7%) and five failures (8%) of ESWL were treated with percutaneous nephrolithotomy.
• ? Significant residual fragments in three patients (8%) after F‐URS were treated with ESWL, while significant residual fragments after ESWL in five patients (8%) were treated with F‐URS. Residual fragments (<4 mm) were followed every 3 months in one patient (2.7%) after F‐URS and in 10 patients (16%) after ESWL.

CONCLUSIONS

• ? For treatment of lower pole stones of 10–20 mm, F‐URS provided significantly higher stone‐free rate and lower retreatment rate compared with ESWL.
• ? The incidence of complications after F‐URS was not significantly more than after ESWL.

     

Management of ureteric stones

The contemporary management of ureteric stones is reviewed and evidence based recommendations about treatment are made. Stones measuring less than 4mm in diameter have a high chance of spontaneous passage and the main debate for optimum treatment of larger stones centres around the choice of shock wave lithotripsy or endoscopic management combined with laser fragmentation. Treatment recommendations should be based on patient preference, published evidence, local audit (surgeon expertise and availability of equipment) and cost. Artificial Neural Networks could become a useful tool for prediction of treatment outcome for ureteric stones, and further research is needed to clarify this potential. ESWL is less effective than ureteroscopy but it may prevent the need for more invasive treatment in a substantial proportion of patients. It should only be considered as initial treatment in patients with stones less than 10mm in size. The routine use of stents should be avoided as both fragmentation and stone free rates are noticeably lower. For larger stones, initial laser ureteroscopy serves better both for proximal or distal calculi and is more cost-efficient. Provided that no contraindications for general anaesthesia exist, laser ureterolithotripsy should be regarded as an excellent first line treatment modality for ureteric stone especially in greater stone burden. In the best hands, the outcome for endoscopic management of ureteric stone in all sites is better than ESWL and is cheaper, although equipment, expertise and experience are all required to achieve this superior outcome.     

Outcome of retrograde flexible ureterorenoscopy and laser lithotripsy for treatment of multiple renal stones

Objective

To evaluate the efficacy and safety of retrograde intrarenal surgery (RIRS) using flexible ureterorenoscopy (F-URS) and laser lithotripsy as a treatment option for multiple renal stones greater than 1 cm.

Ureteroscopic treatment of multiple distal-ureteral stones

BACKGROUND AND PURPOSE: Ureteroscopic intracorporeal lithotripsy for solitary distal-ureteral stones may be considered a first-line therapy. However, few reports that mention ureteroscopic procedures for multiple ureteral stones were found in the literature. Retrospectively, we reviewed our patients who were treated by ureteroscopy for multiple distal-ureteral stones. PATIENTS AND METHODS: Fifteen patients underwent ureteroscopic pneumatic lithotripsy for unilateral multiple distal-ureteral stones. Ten patients had two stones, four patients had three stones, and another patient had five stones. The average stone number per ureteral unit was 2.44, and the average stone size was 9.7 mm (range 3-23 mm). RESULTS: Eighty percent of the patients (12/15) who had unilateral stones were stone free after the first session of ureteroscopic pneumatic lithotripsy. Two patients underwent a second ureteroscopy procedure for the remaining stone or failure of ureteral access. Overall, 93.3% of the patients (14/15) were stone free. Ureteral perforation as a major complication occurred in one patient (6.6%), who was treated by open surgery. We did not routinely use Double-J ureteral stents after ureteroscopy. Only one patient required stenting because of failure of ureteral access. Steinstrasse was observed in three patients, but it resolved spontaneously in the early postoperative period. CONCLUSION: Ureteroscopic pneumatic lithotripsy has a high success rate with few complications for the treatment of unilateral multiple distal-ureteral stones. Ureteroscopic pneumatic lithotripsy seems very effective for such stones.     

Ureteric stents compromise stone clearance after shockwave lithotripsy for ureteric stones: results of a matched-pair analysis

OBJECTIVE

To identify the effect of the presence of a ureteric stent on the outcome of extracorporeal shockwave lithotripsy (ESWL), by comparing patients with ureteric stones with matched‐pair analysis.

PATIENTS AND METHODS

Patients undergoing ESWL with the Sonolith Vision lithotripter (Technomed Medical Systems, Vaulx‐en‐Velin, France) were identified from our prospectively maintained database. Only adult patients with a solitary, radio‐opaque, previously untreated ureteric stone were considered for further analysis. A follow‐up of ≥3 months with a plain abdominal film was used to identify residual fragments. Patients were exactly matched for gender, side, location in the ureter and size (in two dimensions, within ±2 mm). If both diameters could not be matched exactly, the size was extended to ±1 mm and then to ±2 mm of both diameters. An effort was finally made to match patients by age. The treatment outcome in terms of stone‐free rates was assessed and compared using McNemar’s test.

RESULTS

In all, 45 patients with a ureteric stent in place during ESWL were identified. The only patient who could not be adequately matched was a 40‐year‐old man with an 8 × 3 mm stone in the upper ureter. The best/closest match for age was selected. Most stones were in the upper ureter (77%); the mean stone size was 8.5 and 8.6 mm, respectively, with no statistical differences between the groups for age and size of stones (P = 0.41 and 0.86, Student’s t‐test). In 12 pairs, only patients with no stent were stone‐free, compared to two pairs where the patient with a stent was stone‐free. Using McNemar’s test, the odds ratio was 6.0 (95% confidence interval 1.3–55.2) and the difference between the groups was statistically significant (P = 0.016).

CONCLUSION

These results show that the presence of a stent is associated with a worse outcome after ESWL for ureteric stones. Ureteric stents should still be used in cases of obstruction, when there is a risk of sepsis, and in patients with intolerable pain or deteriorating renal function. However, their use in patients offered ESWL for ureteric stones should be considered with caution.     

Pediatric ureteroscopic stone management

PURPOSE: We reviewed our experience of 5 years using ureteroscopy with laser lithotripsy to treat stone disease in prepubertal children. MATERIALS AND METHODS: A retrospective review was performed of all ureteroscopic procedures performed in prepubertal children. RESULTS: A total of 33 ureteroscopic procedures were performed in 29 prepubertal children (15 males and 14 females) 5 to 144 months old (mean age 94 months, including 3 patients 24 months or younger). Stones were located in the renal pelvis in 1 case (3%), proximal ureter in 3 (9%), mid ureter in 5 (15%) and distal ureter in 24 (73%). Stone size ranged from 3 to 14 mm (mean 6). Eight patients required balloon dilation of the ureteral orifice. Followup ranged from 1 to 66 months (mean 11). Stone-free rate after initial ureteroscopy and laser lithotripsy was 88%, with all distal and mid ureteral stones (3 to 9 mm, mean 5) successfully treated. Three patients with proximal ureteral stones 7 to 14 mm in diameter (mean 10.3) required a secondary procedure (repeat ureteroscopy in 2 and shock wave lithotripsy in 1) to become stone-free. One patient with cystinuria and a renal pelvic stone measuring 14 mm required shock wave lithotripsy and percutaneous nephrostolithotomy. There were no major complications of ureteroscopy but there was 1 case of extravasation at the ureterovesical junction after balloon dilation that was managed with stent placement. CONCLUSIONS: Although more patients and longer followup are needed, ureteroscopy with laser lithotripsy is an excellent first line treatment for children with stones in whom conservative therapy fails, especially those with distal and mid ureteral stones. Patients with a stone burden of 10 mm or greater, especially in the proximal ureter, likely will require a secondary procedure to become stone-free.     

Safety and outcome of rigid ureteroscopy for management of ureteral calculi in children

PURPOSE: To present our experience with ureteroscopy for the treatment of pediatric ureteral calculi. PATIENTS AND METHODS: The records of 32 children with an average age of 8.7 years (range 2-15 years) treated with rigid ureteroscopy between June 1994 and July 2003 were reviewed. In 33 ureteral units, 8F rigid ureteroscopy was carried out 35 times to treat stone disease. Stones were located in the upper ureter in 2 cases, the middle ureter in 2 cases, and the lower ureter in 29 cases. Stone size ranged from 4 to 15 mm (mean 7 mm). Dilatation of the ureteral orifice was necessary in 10 procedures. RESULTS: The management of stone in 29 children (90.7%) was straightforward, and a single procedure was sufficient to clear the ureters. In 2 children (6.2%), repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%), it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 2 cases and with the holmium laser in 9; in the remaining 22 cases, the stones were removed without fragmentation. Intraoperative complications occurred in 3 children (9.3%) and consisted of extravasation (1 patient) and stone migration (2 patients). The early postoperative complications were hematuria in one patient and renal colic in another. Of the patients, 28 were followed 3 to 48 months. No stricture was detected at the site of stone impaction in any patient. CONCLUSION: In the hands of an experienced surgeon, ureteroscopy can be a safe and efficient treatment for ureteral stones in children.     

肾结石大小和部位对逆行性软性输尿管镜钬激光碎石手术效果的影响

目的 评价结石大小及部位与逆行性软性输尿管镜钬激光碎石术治疗肾结石的效果的关系.方法 回顾性分析从2006年3月至2009年3月在我院行逆行性软性输尿管镜下钬激光碎石术治疗肾结石的资料.结果 共180例肾结石患者,年龄18～80岁,平均51岁,其中男性102例,女性78例,经历了216次软性输尿管镜钬激光碎石治疗.结石...     

Pneumatic lithotripsy for large ureteral stones: is it the first line treatment?

Objective To evaluate the effectiveness of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of large ureteral stones. Methods We reviewed, retrospectively, the records of 156 patients (122 male, 34 female) who had ureteral calculi larger than 10 mm that were treated with PL. Of these patients, 41 (26.3%) were treated primarily with PL and 115 (73.7%) were treated secondarily after unsuccessful extracorporeal shock wave lithotripsy (SWL). The mean stone diameter was 12.87 mm (range 10–20.5 mm). Results were evaluated 3 months after treatment by excretory urography and/or ultrasonography. Results The overall stone-free and fragmentation rates (FRs) were 85.2 and 92.3%, respectively. Corresponding values were 60 and 84% for upper ureteral stones, 79.5 and 89.7% for middle ureter stones and 94.5 and 95.6% for lower ureteral stones, respectively. The main complications were migration of a complete stone or of fragments (7.1%), urosepsis (4.5%) and ureteral perforation (1.3%). Conclusions Although SWL is generally accepted as the first treatment option for ureteral stones because of its non-invasive nature, PL with ureteroscopy seems to be a good alternative with the advantage of higher success rates and quick stone clearance. Especially when we take the importance of quick stone removal into account for larger ureteral stones, which are more likely to have obstruction, impaction, or infection, we believe that PL may be chosen as the first line treatment rather than SWL for stones larger than 10 mm.     

Comparative results of shockwave lithotripsy for renal calculi in upper, middle, and lower calices

BACKGROUND AND PURPOSE: To assess the results of shockwave lithotripsy (SWL) for renal calculi in upper, middle, and lower calices according to the stone burden. PATIENT AND METHODS: A series of 52 female and 66 male patients with a mean age of 47.8 years and isolated single caliceal stones who underwent SWL monotherapy were enrolled. Stone burden, stone location, number of sessions/shockwaves, and auxiliary procedures were noted for each patient. Stones were located in the upper, middle, and lower calices of 35, 43, and 40, patients respectively, with mean stone burdens of 81.4 mm2, 75.2 mm2, and 96.3 mm2, respectively. Patients were evaluated with intravenous urography, plain film, or ultrasonography. Success was determined 3 months after the last session. Re-treatment rates were calculated. The effect of anatomic factors on the success of treatment for lower-caliceal stones also was determined. RESULTS: The mean stone burden, median number of treatment sessions, and mean number of shockwaves were 84.2 mm2, 2, and 4344, respectively. The auxiliary procedure rate was 16.1%, and the re-treatment rate was 71.2%. Failure was noted in 26 patients (22%). The stone-free rates for stones in the upper, middle, and lower calices were 82.8%, 83.4%, and 67.5%, respectively (P = 0.14). The stone-free rates for stones <100 mm2 and 100 to 200 mm2 were 91.2% and 65.5%, respectively (P = 0.001). The efficiency quotient was 49.8, 44.8, and 32.5 for upper-, middle-, and lower-caliceal stones, respectively. Infundibular length (P = 0.006) and infundibular width (P + 0.036) were significant in determining the stone-free rate after treatment of lower-caliceal stones. CONCLUSIONS: We recommend SWL as the first choice for treatment of stones <200 mm2 in the upper and middle calices. Extracorporeal lithotripsy is one of the options for lower-caliceal stones <200 mm2 but has high re-treatment and auxiliary-procedure rates in these cases.     

When is open ureterolithotomy indicated for the treatment of ureteral stones?

AIM: Improvements in extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy have almost eradicated the need for open surgery in ureteral stones. The aim of this study was to assess characteristics of patients who underwent open ureterolithotomy. METHODS: During a 5-year period, a total of 654 patients with ureteral stones were treated. Initial management consisted of ureteroscopy in 524 patients, ESWL in 62 patients and percutaneous nephrolithotomy (PCNL) in 12 patients. Open surgery was performed in 56 patients. Stone location, size and success rates were retrospectively analyzed. RESULTS: Ureteroscopy resulted in successful stone removal in 94%, 98% and 98.5% of proximal, mid and distal ureteral stones, respectively. A total of 14 patients with ureteroscopy failure were referred for open surgery. ESWL treatment resulted in success in 55 patients (88%), and those with ESWL failure were referred for either ureteroscopy (n = 3) or open surgery (n = 4). Open surgery was performed in a total of 56 patients, 38 of whom had been referred from other centers. Stone location was proximal ureter in 25 (44.6%) patients (stone size: 2-12 cm(2)), mid ureter in five (8.9%) patients (stone size: 2-6 cm(2)) and distal ureter in 26 (46.4%) patients (stone size: 4-9 cm(2)). A history of previous unsuccessful endourological procedure was observed in 33 (58%) of 56 patients. Children under age 16 (range 1-15 years) comprised 17.8% of patients undergoing open surgery. CONCLUSION: Open surgery, which is nowadays being replaced with laparoscopic techniques, is generally indicated for failed endourological procedures (58%), particularly in centers that do not have flexible ureteroscopy or laser lithotriptor, and in patients with larger stones (>3 cm). Children (17.8%) are also candidates for open surgery, if specifically designed endourological equipment is not available.     

Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

INTRODUCTION

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years.

METHODS

All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications.

RESULTS

PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion.

CONCLUSIONS

Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.     

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia

Objectives

To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys.

Methods

Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented.

Results

All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 ± 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11 ) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients; in 1 of them, ureteroscopy was needed.

Conclusions

ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.     

Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

An alternative treatment for high-burden ureteral stones: percutaneous antegrade ureteroscopy

The treatment of large proximal ureteral stones continues to be controversial. We evaluated the antegrade percutaneous approaches for the proximal ureteral stones in our clinic. In this study, 73 percutaneous antegrade ureteroscopy (PAU) operations applied to proximal ureteral stones between February 2005 and December 2009 were included. The stones were located between ureteropelvic junction and 4th lumbar vertebra. PAUs were applied through appropriate calyx with the patients in prone position. During operations, amplatz dilatators were used for dilatation, and pneumatic lithotripter was used for stone fragmentation. Patients were evaluated according to their success rate, complications, hospitalization period, and preference of drainage tube etc. Patients’ mean age was 52.21 years, the mean stone diameter was 19.47 mm (range 15–25), the mean stone burden was 283.76 ± 49.12 mm² (mean ± SD) (range 188.5–392.7) and the mean hospitalization time 1.69 days. Single access done in 68 patients and two accesses were needed in 5 patients. Sixty-eight patients (93.1%) became stone-free. Nephrostomy tubes were placed in 12 patients after operation, while tubeless approach was preferred in 61 patients. Complications were seen in five patients. There were not any complications reported during the follow-up period. PAU is an effective and safe treatment modality if appropriate calyx access was performed. The possibility of renal stone treatment in the same session is an important advantage of this modality.     

Paediatric percutaneous nephrolithotomy: setting new frontiers

OBJECTIVE: To assess the safety and outcome of paediatric percutaneous nephrolithotomy (PCNL) for atypical cases and compare the results with 'standard' unilateral paediatric PCNL. PATIENTS AND METHODS: We retrospectively reviewed children who had had a PCNL between December 1997 and December 2004. Patients were grouped as follows: group 1, aged >5-16 years with normal anatomy and normal renal function undergoing unilateral PCNL or staged bilateral PCNL; group 2, < or = 5 years with normal anatomy and renal function undergoing unilateral PCNL; group 3, undergoing bilateral simultaneous PCNL; group 4, impaired renal function in addition to renal stone disease; group 5, renal anatomical abnormality with calculi in the same kidney. Demographics, stone profile, procedure and outcome indicators were analysed for each group. RESULTS: In all, 188 consecutive PCNLs in 169 children were included (mean age 3.3-10.3 years, mean stone burden 19.1-33.3 mm in the five groups). The mean duration of PCNL was 69-115 min. Stone clearance was satisfactory with single tract access in 90-100% of patients. Transient postoperative fever was the commonest complication (12.5-51%) followed by hyponatraemia and hypokalaemia. Blood transfusion was required in 0-7.7%. The mean stone clearance rates were 47-90% in the five groups; additional extracorporeal shockwave lithotripsy increased the cumulative clearance rates to 90-100%. CONCLUSION: PCNL is safe for treating renal stones, with excellent results and minimal complications. Comparable results are achieved in the very young child, children with anatomically abnormal kidneys, children with impaired renal function and children with bilateral renal stones undergoing simultaneous bilateral PCNL. Hence none of these factors should be considered as relative contraindications.     

Factors associated with failure of extracorporeal shock-wave lithotripsy for ureteral stones using Dornier lithotripter U/50

BACKGROUND: In the present series of 170 patients who underwent extracorporeal shock-wave lithotripsy (SWL) treatment for ureteral stones, the authors determine which patients with ureteral stones had an unsuccessful outcome. METHODS: The records of 170 patients with ureteral stones who were treated with SWL using the Dornier lithotriptor U/50 (EMSE 140) between January 1998 and December 1999 were retrospectively investigated. One hundred and thirty-one patients were treated with SWL alone (single session, n = 98; multiple session, n = 33) and 39 patients required auxiliary treatment due to failure of SWL (33 with transurethral ureterolithotripsy (TUL), one with open lithotomy, and five with residual fragments who were followed up). These two groups were compared using multivariate logistic regression analysis. RESULTS: Lower ureteral stones and stones more than 12 mm in diameter were associated with a poor outcome of SWL. There were no significant differences in age, gender, number of stones, JJ stent placement, and degree of ureteral obstruction due to the stone between the two groups. The odds ratios of lower ureteral stones and stones > or = 12 mm were 4.18 and 2.57, respectively. CONCLUSION: Patients with distal ureteral stones and/or stones more than 12 mm in diameter were difficult to treat successfully with SWL. Alternatives such as TUL should possibly be considered as a first-line therapy for these stones.     

Salvage extracorporeal shockwave lithotripsy after failed distal ureteroscopy

BACKGROUND AND PURPOSE: When intervention is necessary, controversy remains as to the best treatment modality for stones of the distal ureter. In general, ureteroscopy is favored over extracorporeal shockwave lithotripsy (SWL) as the treatment of choice for distal ureteral stones. Although uncommon, ureteroscopy failures have traditionally necessitated repeat ureteroscopy to retrieve retained stone fragments. We evaluated the efficacy of salvage SWL for failed primary distal ureteroscopy in the community setting. PATIENTS AND METHODS: From December 1989 to December 2000, 6099 patients underwent SWL with the Dornier HM4 lithotripter at our institution. We retrospectively identified 31 patients who had undergone the SWL after a failed distal ureteroscopy. RESULTS: The average stone size in these patients was 9.4 mm, the average time interval from ureteroscopy to SWL was 17.2 days, and the average number of shockwaves delivered was 2386. All patients had had stents placed after ureteroscopy. Twenty-seven patients (87%) had resolution of their stone burden after one SWL session. The remaining four patients underwent additional procedures. CONCLUSIONS: Ureteroscopy is an effective modality for the treatment of distal ureteral stones. However, when unsuccessful, a salvage procedure may be necessary. Extracorporeal lithotripsy is a less invasive procedure with comparable success rates in the distal ureter. This report suggests that salvage SWL is an appropriate option for patients in whom distal ureteroscopic stone extraction fails.     

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.     

Ureteroscopic management of lower-pole stones in a pediatric population

PURPOSE: We report our experience with ureteroscopy to treat lower-pole calculi in children. PATIENTS AND METHODS: A retrospective review was conducted of all ureteroscopic procedures for lower-pole stone disease at a pediatric institution from 2000 through 2005. A total of 13 girls and 8 boys with a mean age of 15 years (range 1-20 years) underwent flexible ureteroscopy for lower-pole calculi. The mean stone burden was 12 mm. Stone-free status was defined by postoperative abdominal radiography, CT, or ultrasonography. RESULTS: Ureteral stenting was performed preoperatively in 38% and postoperatively in 71% of the patients. Ureteral-access sheaths were placed in 43%. There were no intraoperative or postoperative complications. With a mean follow-up of 11 months, 76% of the children were stone-free. The success rate for stones <15 mm was 93% v 33% for stones > or =15 mm (P = 0.01). CONCLUSION: Ureteroscopy and laser lithotripsy are safe and effective in children with lower-pole calculi. Ureteroscopy can be considered a primary treatment option for children with lower-pole calculi <15 mm.