Changes in Urolithiasis Referral Patterns for Shock Wave Lithotripsy over a Decade: Was There Adherence to AUA/EAU Guidelines?

Objective

The primary objective was to assess changes in referral patterns of urolithiasis for shock wave lithotripsy (SWL) over a decade. The secondary objective was to evaluate the effect of the number of years of practice of referring physicians on these referral patterns.

Methods

A retrospective review of SWL database was performed for consecutive referrals for SWL at a tertiary stone center between December 1999 and December 2013. Patient demographics and stone characteristics were assessed. The stone location at the time of referral was used as the reference. Retreatments were excluded. In addition, years of practice of the referring physicians were calculated. The 2007 AUA/EAU guidelines on urolithiasis were considered as a reference.

Results

A total of 8,992 SWL treatments were included. After December 2007, there was a significant increase in the percentage of renal pelvic stones referred for SWL (23.0 vs. 27.1%, p < 0.001). Conversely, proximal ureteral stones significantly decreased after 2007 (24 vs. 18.2%, p < 0.001) including stones > 10 mm (5.1 vs. 2.9%, p < 0.001). Otherwise, there were no changes in the referral patterns for SWL of other stone locations before and after December 2007 (p > 0.05). Furthermore, percentage of stones referred for SWL by urologists practicing for less than 10 years significantly decreased after December 2007 (29.5 vs. 22.8%, p < 0.001).

Conclusions

The significant reduction in the referral of proximal ureteral stones after December 2007 corresponds to the latest AUA/EAU guidelines on management of ureteral stones.Key Words: Shock waves, Lithotripsy, Urolithiasis, Referral, Guidelines     

Laparoscopic Ureterolithotomy

Background and Objective:

The present study retrospectively analyzed the data of 213 patients who underwent laparoscopic ureterolithotomy.

Methods:

We retrospectively analyzed the data of 213 patients, in whom we performed conventional laparoscopic ureterolithotomy from April 2006 and January 2015 based on the diagnosis of an upper or middle ureteral stone. Patients with large ureteral stones (>15 mm) or a history of failed shock-wave lithotripsy or ureteroscopy were included in the study. Although the retroperitoneal approach was preferred for 170 patients, the transperitoneal approach was used in the remaining 43 patients.

Results:

The mean patient age was 39.3 ± 12.0 years (range, 18–73). The study population was composed of 78 (26.7%) female and 135 (63.3%) male patients. The mean stone size was 19.7 ± 2.5 mm. The mean operative time was 80.9 ± 10.9 minutes, and the mean blood loss was 63.3 ± 12.7 mL. Intraoperative insertion of a double-J catheter was performed in 76 patients. The overall stone-free rate was 99%. No major complication was observed in any patient. However, conversion to open surgery was necessary in 1 patient.

Conclusion:

With high success and low complication rates, laparoscopic ureterolithotomy is an effective and reliable method that ensures quick recovery and may be the first treatment option for patients with large, impacted ureteral stones, as well as for those with a history of failed primary treatment.     

Pediatric urolithiasis: experience at a tertiary care pediatric hospital

Objective

We aimed to determine the epidemiology, risk factors, clinical characteristics, evaluation and course of patients with urolithiasis at the Children’s Hospital of Eastern Ontario to improve current diagnostic and management strategies.

Methods

This was a retrospective study of children with newly identified urolithiasis between Jan. 1, 1999, and July 31, 2004. Cases were reviewed for demographics, presentation, family history, diagnostic methods and findings, metabolic and anatomic abnormalities, management, stone analysis and stone recurrence.

Results

Seventy-two patients (40 male, 32 female; mean age 11.3 yr) were assessed. Mean follow-up was at 1.5 years. Eighteen patients (25%) had a family history of stones. Flank pain (63%) was the most common presentation. Eighty-two percent of urinalyses showed microscopic hematuria. Imaging comprised abdominal plain film radiography (56%) and (or) abdominal ultrasonography (74%). The mean stone size was 5 mm. Forty-one percent (28/69) of patients who underwent metabolic investigation had an abnormality. Fourteen percent of patients (10/72) had a genitourinary anatomical abnormality. Thirty-four patients (47%) passed their stones spontaneously, 25 patients (35%) required surgical intervention and 13 patients (18%) had yet to pass their stone. The mean size of spontaneously passed stones was 4 mm. Of 42 stones analyzed, 39 (93%) were composed of calcium oxalate or phosphate. Seventeen (24%) patients had stone recurrence during follow-up.

Conclusion

Pediatric patients with stones present in a manner similar to adults. Abdominal plain film radiography and ultrasonography are the preferred initial radiological investigations in children as they limit radiation exposure. Metabolic abnormalities are common and may coexist with anatomic abnormalities, therefore investigations must rule these out. One-half of patients will pass their stones spontaneously. Recurrence rates are high and long-term follow-up is recommended.     

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.     

Comparison of imaging modalities for detection of residual fragments and prediction of stone related events following percutaneous nephrolitotomy

Introduction

Achieving stone free status (SFS) is the goal of stone surgery. In this study it is aimed to compare effectiveness of unenhanced helical computerized tomography (UHCT), KUB and ultrasonography (US) for detection of residual RFs and predicition of stone releated events following percutaneous nephrolitotomy (PNL).

Materials and Methods

Patients underwent PNL for radiopaque stones between November 2007 and February 2010 were followed. Patients were examined within 24-48 hours after the procedure by KUB, US and UHCT. For stone size 4 mm was accepted as cut off level of significance.Sensitivity and specificity of KUB and US for detection of RFs and value of them for prediction of stone related events were calculated.

Results

SFS was achieved in 95 patients (54.9%) and when cut off value of 4 mm for RFs was employed, SFS was achieved in 131 patients (75.7%). Sensitivity was 70.5% for KUB, and 52.5% for US. UHCT was shown to be significantly more efficient for detection of RFs compared to both KUB (p=0.01) and US (p=0.001). When cut off level of 4 mm employed, sensitivity of KUB and US increased to 85.7% and 57.1%. Statistical significant superiority of UHCT still remained (p value vs. KUB: 0.03 and p value vs. US: 0.008).

Conclusion

UHCT is the most sensitive diagnostic tool for detecting RFs after PNL. It has higher sensitivity regardless of stone size compared to KUB and US. Additionally UHCT has higher capability of predicting occurrence of stone related events.     

Retrograde intrarenal surgery in infants and preschool-age children

Objectives

The objectives of this study are to present our experience with retrograde intrarenal surgery for management of renal calculi in children less than 7 years old and to determine its safety and efficacy in this age group.

Methods

Patient demographics, stone location and size, use of ureteral access sheath, stone-free status, complication rates, and follow-up were evaluated.

Results

A total of 16 patients (9 boys and 7 girls; mean age, 4.2 years) underwent 17 procedures. The mean stone size was 11.5 mm (8-17 mm). Flexible ureteroscopy and laser lithotripsy were performed in all cases regardless of stone location. Dilation of the ureteral orifice was required in 5 cases (29.4%), and ureteral access sheaths were placed in 3 patients (17.6%). With a mean follow-up of 10.3 months, 88% of the children were stone free. The success rate for stones less than 10 mm was 100% and 81.8% for stones 10 mm or more (P < .05). There were no major complications, but there was 1 case of perforation and extravasation at the ureterovesical junction after balloon dilation that was managed with stent placement.

Conclusions

Retrograde intrarenal surgery is a safe and effective method for the treatment of intrarenal calculi, and it achieves reasonable results with minimal complications in children less than 7 years old.     

Outcomes of surgical management of deep infiltrating endometriosis of the ureter and urinary bladder

Objectives:

To report the outcomes of surgical management of urinary tract endometriosis and discuss the choice between conservative and radical surgery.

Materials and Methods:

We reviewed data concerning women managed for ureteral or bladder deep infiltrating endometriosis in 5 surgical departments participating in the CIRENDO prospective database. Preoperative data, surgical procedure data, and postoperative outcomes were analyzed.

Results:

Data from 30 women pooled in the database showed 15 women presenting with ureteral endometriosis, 14 women with bladder nodules, and 1 with both types of lesions. Ureterolysis was performed in 14 cases; the ureter was satisfactorily freed in 10 of these. In 4 women over 40 years old, who were undergoing definitive amenorrhea, moderate postoperative ureteral stenosis was tolerated and later improved in 3 cases, while the fourth underwent secondary ureteral resection and ureterocystoneostomy. Primary ureterectomy was carried out in 4 women. Two cases of intrinsic ureteral endometriosis were found in 5 ureter specimens. Four complications were related to surgical procedures on ureteral nodules, and 2 complications followed the removal of bladder endometriosis. Delayed postoperative outcomes were favorable with a significant improvement in painful symptoms and an absence of unpleasant urinary complaints, except for one patient with prolonged bladder denervation.

Conclusion:

Conservative surgery, in association with postoperative amenorrhea, can be proposed in a majority of cases of urinary tract endometriosis. Although the outcomes are generally favorable, the risk of postoperative complications should not be overlooked, as surgery tends to be performed in conjunction with other complex procedures such as colorectal surgery.     

Transcystic Approach to Laparoscopic Common Bile Duct Exploration

Background and Objectives:

One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures.

Methods:

From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space.

Results:

Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones.

Conclusion:

Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.     

Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter,Randomized, Double-blind,Placebo-controlled Trial

Background

Recent large high-quality trials have questioned the clinical effectiveness of medical expulsive therapy using tamsulosin for ureteral stones.

Renal colic and urolithiasis practice patterns in Canada: a survey of Canadian Urological Association members

Background:

We describe the practice variability of CUA (Canadian Urological Association) members and factors which predict these patterns for common stone scenarios.

Methods:

We asked 308 English- and 52 French-speaking CUA members to complete online surveys in their respective languages. We collected demographic information on fellowship training, shock wave lithotripsy (SWL) access, academic setting and whether they are at a hospital with regionalized surgical services. Respondents indicated their actual as well as ideal treatment for scenarios of renal, proximal and distal ureteric calculi.

Results:

In total, 131 urologists responded (36% response rate), all of whom treated urolithiasis. Of this number, 17% had endourology fellowship training, 76% had access to SWL, 42% were at an academic institution and 66% were at institutions with regionalized surgical services. Actual and ideal treatment modalities selected for symptomatic, distal and proximal ureteric stones (4, 8, 14 mm) were consistent with published guidelines. There were discrepancies between the use of ureteroscopy and SWL in actual versus ideal scenarios. Actual and ideal practices were congruent for proximal ureteric stones and asymptomatic renal calculi. In multivariate analysis, respondents were less likely to perform ureteroscopy on proximal 4- and 8-mm stones if they were at a hospital with regionalized surgical services (OR: 0.097; 95% CI: 0.01–0.76, p = 0.03 and OR: 0.330; 95% CI: 0.13–0.83, p = 0.02).

Interpretation:

There is clinical variability in the management of urolithiasis in Canada; however, management approaches fall within published guidelines. Type of hospital and access to operating room resources may affect treatment modality selection.     

Kienbock��s disease in a varsity football player: a case report and review of the literature

Objective:

To present the diagnostic, clinical features, and management of Kienbock’s disease and create awareness of the differential diagnosis of this condition in patients presenting with insidious, progressive dorsal wrist pain.

Clinical Features:

A 23-year old male varsity football player presented with insidious progressive dorsal sided wrist pain with reduced wrist flexion and extension. A diagnosis of Kienbock’s disease was made based on radiographs and magnetic resonance imaging.

Intervention and Outcome:

A 3mm ulnar-minus variance was found and a joint leveling procedure to shorten the radius was performed. Conservative therapy was provided pre and post surgical management.

Summary:

This case report demonstrates the importance of findings on radiographs, MRI, and clinical examination in the accurate diagnosis and management of a patient with wrist pain.     

Computed tomography versus ureteroscopy in identification of renal tract stone with ureteral stent in situ

INTRODUCTION

The aim of this study was to validate the use of non-contrast computed tomography (CT) with a ureteral stent in situ instead of ureteroscopy for identification of renal tract stones.

METHODS

All patients who had stents inserted for renal tract stones and underwent non-contrast CT with the stent in situ followed by ureteroscopy between May 2008 and October 2009 at The Canberra Hospital, Australia, were analysed retrospectively. Statistical analysis was performed to compare any differences between CT and ureteroscopy in the identification of stones.

RESULTS

Overall, 57 patients were included in the study. The difference between CT and ureteroscopy findings was statistically significant. CT identification of stones with a stent in situ had a sensitivity of 86%, a specificity of 46%, a positive predictive value of 63%, a negative predictive value of 76% and an accuracy of 67%.

CONCLUSIONS

Our study suggests that non-contrast CT is inferior to the ‘gold standard’ of ureteroscopy. It lacks sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Therefore, we cannot recommend using non-contrast CT to replace ureteroscopy.     

Is There a Role for Tamsulosin in the Treatment of Distal Ureteral Stones of 7 mm or Less? Results of a Randomised,Double-Blind,Placebo-Controlled Trial

Background

Numerous randomised trials have confirmed the efficacy of medical expulsive therapy with tamsulosin in patients with distal ureteral stones; however, to date, no randomised, double-blind, placebo-controlled trials have been performed.

Objective

The objective of this trial was to evaluate the efficacy of medical expulsive therapy with tamsulosin in a randomised, double-blind, placebo-controlled setting.

Design, setting, and participants

Patients presenting with single distal ureteral stones ≤7 mm were included in this trial.

Intervention

Patients were randomised in a double-blind fashion to receive either tamsulosin or placebo for 21 d. The medication was discontinued after either stone expulsion or intervention. Abdominal computed tomography was performed to assess the initial and final stone status.

Measurements and limitations

The primary end point was the stone expulsion rate. Secondary end points were time to stone passage, the amount of analgesic required, the maximum daily pain score, safety of the therapy, and the intervention rate.

Results

Ten of 100 randomised patients were excluded from the analysis. No statistically significant differences in patient characteristics and stone size (median: 4.1 mm [tamsulosin arm] vs 3.8 mm [placebo arm], p = 0.3) were found between the two treatment arms. The stone expulsion rate was not significantly different between the tamsulosin arm (86.7%) and the placebo arm (88.9%; p = 1.0). Median time to stone passage was 7 d in the tamsulosin arm and 10 d in the placebo arm (log-rank test, p = 0.36). Patients in the tamsulosin arm required significantly fewer analgesics than patients in the placebo arm (median: 3 vs 7, p = 0.011). A caveat is that the exact time of stone passage was missing for 29 patients.

Conclusions

Tamsulosin treatment does not improve the stone expulsion rate in patients with distal ureteral stones ≤7 mm. Nevertheless, patients may benefit from a supportive analgesic effect.

Clinicaltrials.gov

NCT00831701.     

Characteristics and outcomes of ureteroscopic treatment in 2650 patients with impacted ureteral stones

Purpose

To describe stone-free rates and complications of ureteroscopic treatment for impacted compared with non-impacted ureteral stones and evaluate predictive variables for impaction.

Methods

The Clinical Research Office of the Endourological Society prospectively collected 1 consecutive year of data from 114 centers worldwide. Patients eligible for inclusion were patients treated with ureteroscopy for ureteral stones. Patient characteristics, treatment details, and outcomes were compared with regard to stone impaction. Logistic regression analyses were conducted to explore predictive variables for ureteral stone impaction and to analyse the effect of impaction on outcomes.

Results

Of the 8543 treated patients, 2650 (31%) had impacted and 5893 (69%) non-impacted stones. The stone-free rate was 87.1% for impacted stones, which is lower compared with 92.7% for non-impacted stones (p?<?0.001). Intra-operative complication rates were higher for impacted stones (7.9 versus 3.0%, p?<?0.001). Significantly higher ureteral perforation- and avulsion rates were reported in the impacted stone group compared with the non-impacted stone group. No association between stone impaction and post-operative complications could be shown. Female gender, ASA-score?>1, prior stone treatment, positive pre-operative urine culture, and larger stones showed to be predictive variables for stone impaction.

Conclusions

Ureteroscopic treatment for impacted stones is associated with lower stone-free rates and higher intra-operative complication rates compared with treatment for non-impacted stones. The predictive variables for the presence of stone impaction may contribute to the identification of stone impaction during the diagnostic process. Moreover, identification of stone impaction may aid the selection of the optimal treatment modality.

     

Outpatient tubeless percutaneous nephrolithotomy: the initial case series

Introduction:

Percutaneous nephrolithotomy (PCNL) has traditionally been performed on an inpatient basis. To the best of our knowledge, this is the first report of tubeless PCNL on a completely outpatient basis. The purposes of this study were to assess the safety and efficacy of outpatient PCNL.

Methods:

We reviewed the initial consecutive outpatient tubeless PCNLs performed at our institution by a single surgeon. Patients were discharged home the day of surgery only after meeting strict discharge criteria. Preoperative, intraoperative and postoperative data were collected prospectively.

Results:

Outpatient tubeless PCNL was performed in 3 patients. The mean maximum stone diameter was 14 mm. The average hospital stay was 175 minutes. All 3 patients were discharged home in stable condition after meeting all of the inclusion criteria. There were no emergency room visits or hospital readmissions postoperatively. The mean follow-up period was 47 days. All stones were calcium oxalate and the stone free rate was 100%. There were no minor or major complications.

Conclusion:

In properly selected patients, outpatient tubeless PCNL is safe and effective. Our initial experience with outpatient PCNL has been favourable and warrants further investigation in a larger patient population.     

Is pre-operative imaging essential prior to ureteric stone surgery?

INTRODUCTION

The aim of this study was to identify patients not requiring ureteric stone surgery based on pre-operative imaging (within 24 hours) prior to embarking on semirigid ureteroscopy (R-URS) for urolithiasis.

METHODS

The imaging of all consecutive patients on whom R-URS for urolithiasis was performed over a 12-month period was reviewed. All patients had undergone a plain x-ray of the kidney, ureters and bladder (KUB), abdominal non-contrast computed tomography (NCCT-KUB) or both on the day of surgery.

RESULTS

A total of 96 patients were identified for the study. Stone sizes ranged from 3mm to 20mm. Thirteen patients (14%) were cancelled as no stone(s) were identified on pre-operative imaging. Of the patients cancelled, 8 (62%) required NCCT-KUB to confirm spontaneous stone passage.

CONCLUSIONS

One in seven patients were stone free on the day of surgery. This negates the need for unnecessary anaesthetic and instrumentation of the urinary tract, with the associated morbidity. Up-to-date imaging prior to embarking on elective ureteric stone surgery is highly recommended.     

Dual energy can accurately differentiate uric acid-containing urinary calculi from calcium stones

Purpose

To retrospectively evaluate the accuracy of dual-energy CT (DECT) in the detection of the chemical composition of urinary calculi in correlation with infrared spectroscopic stone analysis.

Methods

We reviewed the CT scans of 255 patients who underwent DECT due to a clinical suspicion of urolithiasis. Out of this group, we included 64 patients with clinically symptomatic urolithiasis requiring stone removal. After surgical removal of the stone by ureterorenoscopy, chemical composition was analyzed with infrared spectroscopy. We correlated DECT stone characterization results with chemical stone composition based on dual-energy indices (DEI). A total of 213 renal and ureteral stones could be removed and chemically analyzed.

Results

A total of 213 calculi were evaluated. Thirty eight out of sixty four (59 %) patients had >1 stone. DECT was used to differentiate stones by using DEI. Stones harboring calcium (CA) were color-coded in blue, while stones containing uric acid (UA) were colored red. Median DEI in UA-containing stones were 0.001. Non-UA-containing stones had a DEI between 0.073 for pure CA stones and 0.077 containing CA and other substances (p = 0.001; p = 0.03, respectively). Sensitivity of DECT was 98.4 % for differentiation of UA from non-UA-containing calculi. Specificity was 98.1 %. Mean effective radiation dose of DECT was 4.18 mSv (0.44–14.27 mSv), thus comparable to conventional CT scans of the abdomen. Conventional measurement of Hounsfield units did not correlate with stone composition.

Conclusion

DECT with image post-processing reliably discriminates UA-containing calculi from all other stones, but the study offered limitations. Discrimination within the non-UA stones cannot be reliably achieved but is clinically insignificant.

     

Robotic-Assisted Repair of Iatrogenic Ureteral Ligation Following Robotic-Assisted Hysterectomy

Background and Objectives:

Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy.

Methods:

We present a case report and review of the literature.

Results:

A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation.

Conclusion:

Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.     

Percutaneous Endoscopic Holmium Laser Lithotripsy for Management of Complicated Biliary Calculi

Background and Objectives:

Advances in endoscopic techniques have transformed the management of urolithiasis. We sought to evaluate the role of such urological interventions for the treatment of complex biliary calculi.

Methods:

We conducted a retrospective review of all patients (n=9) undergoing percutaneous holmium laser lithotripsy for complicated biliary calculi over a 4-year period (12/2003 to 12/2007). All previously failed standard techniques include ERCP with sphincterotomy (n=6), PTHC (n=7), or both of these. Access to the biliary system was obtained via an existing percutaneous transhepatic catheter or T-tube tracts. Endoscopic holmium laser lithotripsy was performed via a flexible cystoscope or ureteroscope. Stone clearance was confirmed intra- and postoperatively. A percutaneous transhepatic drain was left indwelling for follow-up imaging.

Results:

Mean patient age was 65.6 years (range, 38 to 92). Total stone burden ranged from 1.7 cm to 5 cm. All 9 patients had stones located in the CBD, with 2 patients also having additional stones within the hepatic ducts. All 9 patients (100%) were visually stone-free after one endoscopic procedure. No major perioperative complications occurred. Mean length of stay was 2.4 days. At a mean radiological follow-up of 5.4 months (range, 0.5 to 21), no stone recurrence was noted.

Conclusions:

Percutaneous endoscopic holmium laser lithotripsy is a minimally invasive alternative to open salvage surgery for complex biliary calculi refractory to standard approaches. This treatment is both safe and efficacious. Success depends on a multidisciplinary approach.