Morbidity associated with indwelling internal ureteral stents after shock wave lithotripsy

Placement of internal ureteral stents before extracorporeal shock wave lithotripsy of large stone burdens has decreased the incidence of post-extracorporeal shock wave lithotripsy colic, secondary endoscopic procedures and prolonged hospital stays. However, indwelling stents have an associated patient morbidity and intolerance. A telephone survey of 50 patients (average stone burden 28 mm.) who were discharged from the hospital after treatment with an indwelling internal polymer stent was performed with a standard questionnaire. Symptoms reported with in situ internal ureteral stents included gross hematuria (42 per cent), fever or chills (20 per cent), and persistent discomfort or pain in the bladder and/or flank (26 to 38 per cent). Of the patients 44 per cent reported moderate to intolerable discomfort that was relieved by removal of the stent. The degree of symptoms was not associated with stent composition, style or length, or the presence of a transurethral string. Five patients had premature migration or dislodgment of the internal stent and 4 reported episodes of obstructive pyelonephritis requiring removal of an impacted stent or endourological intervention. Internal ureteral stents placed before extracorporeal shock wave lithotripsy have an identifiable patient morbidity while indwelling and, therefore, they should be used judiciously according to the stone burden, renal anatomy and body habitus.     

Ureteral stenting during extracorporeal shock wave lithotripsy: help or hindrance?

We retrospectively reviewed the outcome of extracorporeal shock wave lithotripsy in patients with renal calculi less than 3 cm. in size who were treated at a large multi-user lithotripsy center. Patients in whom indwelling ureteral stents were placed before lithotripsy treatment were subjected to higher levels of total power (shocks times voltage), yet the rate free of stones did not differ from those treated without a stent. In addition, the patients with internal ureteral stents experienced a significantly higher incidence of urinary urgency (43 versus 25 per cent) and hematuria (40 versus 23 per cent) than nonstented patients, respectively (p less than 0.05). Also, the duration of bladder discomfort was longer for stented patients (26 versus 13 per cent) as was the duration of urinary frequency (31 versus 16 per cent), compared to nonstented patients (p less than 0.05). The results suggest that use of an indwelling ureteral stent may not contribute to a higher rate free of stones for the treatment of small to medium sized renal calculi and, in fact, it may make the treatment more uncomfortable for the patient than performing lithotripsy without ureteral stenting. Of course, in selected cases (solitary kidney, large stone burden and aid in stone localization) ureteral stenting has a useful adjunctive role in extracorporeal shock wave lithotripsy.     

Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience

A total of 982 patients underwent 1,416 treatments with extracorporeal shock wave lithotripsy for upper urinary tract calculi between February 23 and December 17, 1984. A single treatment was performed in 90 per cent of the patients. Morbidity was extremely low and hospital stay was short (3.0 days). Adjunctive procedures were required in 13 per cent of the patients. Of the kidneys 72 per cent were free of stones at the 3-month followup, while 23 per cent contained small (less than 5 mm.), asymptomatic fragments believed to be passable spontaneously. Only 1 per cent of the patients required surgical removal of the calculi. Morbidity was related directly to stone burden, while results were inversely related to stone burden. Extracorporeal shock wave lithotripsy is the preferred form of management for symptomatic upper ureteral and renal calculi less than 2 cm. in diameter.     

Extracorporeal shock wave lithotripsy monotherapy: experience with piezoelectric second generation lithotriptor in 642 patients

Extracorporeal shock wave lithotripsy monotherapy was performed in 642 patients for 1 year with an EDAP-LT01 piezoelectric lithotriptor. Of 642 patients 398 completed extracorporeal shock wave lithotripsy treatment and 244 still are undergoing multiple extracorporeal shock wave lithotripsy sessions. The 398 patients had renal (64.6 per cent) or ureteral (35.4 per cent) stones 0.6 to 4.8 cm. in diameter (mean 1.4 cm.). No general or regional anesthesia was required except in 7 children. Among 398 patients who completed extracorporeal shock wave lithotripsy the rate free of stones was 73.4 per cent and the rate of clinically insignificant residual fragments was 12.8 per cent. The success rate (rate free of calculi plus that of clinically insignificant renal fragments) ranged from 95.6 per cent for stones 0.6 to 1.0 cm. in diameter to 52.6 per cent for stones larger than 3.0 cm. (mean 86.2 per cent). The number of treatment sessions in 343 patients with successful results increased in accordance with the stone size, with an average of 1.6 sessions. Double-J* stents were placed in 7 patients and ureteral catheterization was performed in 11 as post-extracorporeal shock wave lithotripsy adjunctive measures. The steinstrasse phenomenon was noted in 14 patients, of whom only 1 required Double-J stenting. There were no significant complications. Therefore, extracorporeal shock wave lithotripsy monotherapy with the piezoelectric lithotriptor is considered to be a safe and efficient outpatient procedure for the initial treatment of urinary stones regardless of stone sizes.     

Treatment of complete staghorn calculi by extracorporeal shock wave lithotripsy monotherapy with special reference to internal stenting

Extracorporeal shock wave lithotripsy monotherapy was used to treat 41 patients with complete staghorn calculi. In 20 patients polyethylene angiographic pigtail catheters were inserted prophylactically as ureteral stents and the other 21 patients did not receive stents. Prophylactic stenting reduced the incidence of complications and the need for percutaneous nephrostomy tubes to relieve subsequent ureteral obstruction. Internal stenting maintained the sterility of the urinary tract and reduced the average hospital stay by a third. Residual stone fragments representing less than 5 per cent of the original stone mass remained in 56 per cent of the patients, particularly in those with hydronephrotic kidneys. We suggest that extracorporeal shock wave lithotripsy monotherapy with prophylactic stenting is the preferred treatment for noninfected complete staghorn calculi.     

Use of double-pigtail stents in extracorporeal shock wave lithotripsy

Double-pigtail stents are placed commonly in patients before extracorporeal shock wave lithotripsy to prevent ureteral obstruction from steinstrasse. The use of double-pigtail stents in lithotripsy patients with a moderate stone burden was studied in a prospective randomized trial. Patients with unilateral renal stone(s) with at least 1 diameter between 7 and 25 mm. were eligible for the study. Fifty patients were randomized to a control or stented group. Double-pigtail stents with an attached suture were placed immediately before extracorporeal shock wave lithotripsy in the stented group. Stents were removed by the patients 1 week after lithotripsy. A survey on pain and associated symptoms was completed by patients at 1 and 14 days after treatment. There was no statistical difference in flank or abdominal pain, nausea, vomiting, temperature or use of analgesics at 1 and 14 days after extracorporeal shock wave lithotripsy in the control and stented groups. All patients in the stented groups complained of side effects attributable to the stent including urinary frequency and urgency, bladder pain, hematuria and flank pain with urination. Of 25 patients with stents 7 (27%) had early removal because of severe irritation, early migration or accidental removal. Among the patients with follow-up x-rays 1 month after treatment 17 of 21 (81%) in the control group and 12 of 19 (63%) in the stented group showed no evidence of remaining stones. The use of double-pigtail stents is not beneficial in patients with a moderate stone burden. Double-pigtail stents are associated with considerable patient discomfort but no decrease in symptomatic ureteral obstruction or final stone eradication rate.     

Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy

Two new therapies, percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy, are revolutionizing the treatment of upper urinary tract calculi. We report the success and morbidity rates in 110 patients undergoing percutaneous nephrostolithotomy and 982 patients treated with extracorporeal shock wave lithotripsy. Staghorn calculi were excluded from this series. The over-all success rate (free of stones plus small asymptomatic residual fragments) was comparable with both modalities (percutaneous nephrostolithotomy 98 per cent and extracorporeal shock wave lithotripsy 95 per cent), although the presence of residual fragments was more common in kidneys treated with extracorporeal shock wave lithotripsy (24 versus 7 per cent). Patient morbidity as measured by temperature elevation, length of postoperative stay, pain and blood loss was significantly less (p less than 0.05) with extracorporeal shock wave lithotripsy than with percutaneous nephrostolithotomy. Re-treatment rates were similar with both procedures, and tended to increase in relation to increasing stone size and stone number. Post-treatment ancillary procedures (cystoscopy and stone manipulation, and percutaneous nephrostomy) were used more frequently with extracorporeal shock wave lithotripsy. Because of its efficacy and low morbidity, we conclude that extracorporeal shock wave lithotripsy is the treatment of choice for upper urinary tract calculi less than 2 cm. in diameter. However, percutaneous nephrostolithotomy will continue to have a primary role in the management of larger stones and cystine stones, and it will be used as a secondary procedure after unsuccessful extracorporeal shock wave lithotripsy treatments. In addition, because of the complimentary nature of these 2 new technologies certain complex stones, such as staghorn calculi, may be handled best by a combination of the 2 techniques.     

Ureteral stone manipulation before extracorporeal shock wave lithotripsy

We randomized 75 patients with solitary ureteral calculi that could not be dislodged by ureteral catheterization to receive instillation of saline, 2 per cent lidocaine viscous solution or dilute surgical lubricant before repeat stone manipulation with ureteral catheters. Of the stones irrigated with saline 76 per cent were returned to the pelvis along with 60 per cent of the lidocaine group and 48 per cent of the surgical lubricant treated stones. There was no statistical significance among the 3 groups. The success rates for upper, mid and lower ureteral stones were 80, 54 and 30 per cent, respectively. Of stones 0.5 cm. or less and between 0.6 and 1.0 cm. 77 and 72 per cent, respectively, were manipulated successfully but only 38 per cent of the stones larger than 1.0 cm. could be dislodged. Extracorporeal shock wave lithotripsy was successful in treating pelvic and ureteral stones, although higher kilovolt settings and additional shocks were necessary to fragment the ureteral stones completely. Percutaneous nephrostomy or ureteral meatotomy was required in 10 per cent of the patients with impacted ureteral stones following in situ extracorporeal shock wave lithotripsy but in only 4 per cent of the patients with stones successfully returned to the pelvis. Of the ureteral stones 17 per cent were treated with repeat extracorporeal shock wave lithotripsy. No patient with pelvic stones required repeat treatment. Retrograde manipulation of ureteral stones is an effective adjunctive procedure before extracorporeal shock wave lithotripsy.     

Extracorporeal shock wave lithotripsy in patients with a solitary kidney

Extracorporeal shock wave lithotripsy was used to treat 68 patients with renal calculi in a solitary kidney. Epidemiological information, including stone number, size and location, was similar to that of other patients treated with extracorporeal shock wave lithotripsy. Renal function as measured by serum creatinine changed negligibly in the majority of the patients. Three patients had transient serum creatinine elevations greater than 2 mg. per dl. that were caused by obstruction from stone fragments. There were 2 perirenal hematomas that required transfusion. One patient required retrograde manipulation of a ureteral stone before extracorporeal shock wave lithotripsy, while 6 required stone manipulations after therapy for steinstrasses. Of 59 patients evaluable after extracorporeal shock wave lithotripsy 58 (98.3 per cent) had a successful result: 38 (64.4 per cent) were completely free of stones and 20 (33.9 per cent) had clinically insignificant residual fragments. Extracorporeal shock wave lithotripsy is effective and safe in a solitary renal unit. We believe that in most patients it is the procedure of choice. Attention to fever, urine output and fragment size perioperatively is crucial.     

In situ extracorporeal shock wave lithotripsy for upper ureteral stones: Experience with 65 patients

A total of 65 patients with 67 upper ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) between March 1990 and September 1990. For stone disintegration the electrohydraulic shock wave lithotripter Tripter XI (Direx) was used. Eighty-seven per cent of stones showed satisfactory disintegration after the first treatment and a further 9 per cent after repeat treatments. The stone-free rate at 12 weeks was 85 per cent. General anaesthesia was needed in only 12 per cent of patients. The retreatment rate was 13 per cent. It was concluded that in situ ESWL is an effective procedure with negligible morbidity for treating upper ureteral stones.     

Extracorporeal shock wave lithotripsy for ureteral stones: a retrospective analysis of 417 cases

We treated 417 patients with upper ureteral stones with extracorporeal shock wave lithotripsy. All patients with obstructing stones underwent retrograde manipulation, which was successful in 57 per cent. Management of obstructing stones in situ (215 patients) with and without decompression of the collecting system required additional treatments in 13 per cent and ancillary procedures in 25 per cent. Nonocclusive ureteral stones were not manipulated. Treatment of these stones in situ slightly increased the need for postoperative ancillary procedures, compared to successful repositioning into the kidney (5.9 versus 3 per cent). Secondary treatments, however, were necessary as often as with occlusive stones. The main reason for failure of extracorporeal shock wave lithotripsy was the lack of fluid around an impacted stone. An energy absorptive effect of muscle tissue for stones projecting on the psoas muscle could not be demonstrated. The best and most consistent results were obtained when the stone was manipulated successfully into the renal collecting system.     

Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use center

We reviewed our experience with extracorporeal shock wave lithotripsy therapy in 138 patients who presented with mid and upper ureteral calculi. In the patients who had successful stone manipulation back into the renal collecting system the success rate was significantly higher compared to that for stones treated primarily within the ureter (92.8 versus 80.8 per cent, p less than 0.05). Among the stones treated within the ureter the success rates appeared to be similar for stones treated in situ (83.3 per cent) compared to those treated when a catheter could be placed alongside the calculus (79.3 per cent). Higher voltage and more shock waves were administered to stones treated within the ureter compared to stones that were manipulated back into the kidney. However, this increase power did not enhance the success rate. In addition, it appears that a plain film of the abdomen obtained within 24 hours of lithotripsy treatment is a good predictor of success as defined by the rate free of stones at 6 weeks of followup. Our results from a community-based multi-use lithotripsy center suggest that ureteral stone manipulation should be attempted before extracorporeal shock wave lithotripsy for mid and upper ureteral calculi.     

Treatment of prevesical ureteral calculi by extracorporeal shock wave lithotripsy

Since August 1985 extracorporeal shock wave lithotripsy has been performed in 39 patients with prevesical ureteral stones, including 3 with steinstrasse after extracorporeal shock wave lithotripsy of kidney stones. Female patients less than 40 years old were excluded because of the theoretical possibility of harm to the ovary by shock waves. Via a modified technique with the patient in a flat position, x-rays and shock waves enter through the foramen obturatum. High total power (high number of shocks and high kilovoltage) led to complete stone disintegration and a success rate of 95 per cent was achieved. While ureterorenoscopy should be more restricted, extracorporeal shock wave lithotripsy is the method of choice for the treatment of distal ureteral stones.     

Can extracorporeal shock wave lithotripsy eradicate persistent urinary infection associated with infected stones?

Infected renal stones can be treated by extracorporeal shock wave lithotripsy but it still is not clear whether successful stone fragmentation and the disappearance of all macroscopic stone fragments guarantee eradication of the infection. Therefore, a prospective study was done in 135 patients with renal or upper ureteral stones associated with persistent urinary tract infection. The urinary infection was localized in each patient by bilateral ureteral catheterization. Upper tract infection in the kidney containing the stone was found in 75.6 per cent of the cases. A total of 94 patients completed treatment with extracorporeal shock wave lithotripsy and were followed for 3 to 16 months (mean followup 6.4 months). A marked correlation between the incidence of residual macroscopic stone fragments and the presence of persistent infection was noted. Of the 51 patients who became free of stones 48 (94 per cent) had sterile urine. Only 3 of the 51 patients had persistent infection in the treated kidney despite complete disappearance of the stones. In 45 of the 59 patients with stones smaller than 2 cm. (76 per cent) the infection was eradicated, whereas of the 35 with larger stones the urine became sterile in only 13 (37 per cent). We conclude that extracorporeal shock wave lithotripsy can be endorsed for treatment of small infected stones but it is inadequate for treatment of stones larger than 2 cm. unless combined with percutaneous nephrolithotripsy or chemical dissolution of the residual infected fragments.     

In situ prone ESWL for the treatment of lower ureteral stones: Experience with 28 patients

Twenty-eight patients with lower ureteral stones underwent in situ extracorporeal shock wave lithotripsy (ESWL) in the prone position over the period of 7 months between March 1990 and September 1990. For stone disintegration the spark gap shock wave lithotripter Tripter XI (Direx) was used. Satisfactory disintegration was achieved in 93 per cent of patients. The stone-free rate at 12 weeks was 82 per cent, and 11 per cent had residual fragments less than or equal to 4 mm in diameter. Twenty-one per cent of patients required repeat treatments. For only 2 patients general anaesthesia was required (7 per cent). There were no remarkable complications except for haemospermia which resolved spontaneously 15 days after treatment. It was concluded that in situ prone ESWL is an effective and safe procedure for the treatment of lower ureteral stones.     

The use of the Magnetip double-J ureteral stent in urological practice

The Magnetip* double J type ureteral stent has been used in a wide variety of clinical urological settings. We reviewed the use of the stent in 50 patients. In 45 patients stents were placed in conjunction with extracorporeal shock wave lithotripsy, stone manipulation, obstruction due to pregnancy or malignancy, pyeloplasty and ureteroneocystostomy. In 83 per cent of the attempts the stent was placed successfully. Retrieval with the Magnetriever* was accomplished in 86 per cent of the cases (100 per cent in female and 76 per cent in male patients). Details of stent use are described.     

Management of upper ureteral calculi with extracorporeal shock wave lithotripsy

The results of 471 extracorporeal shock wave lithotripsy treatments in 465 patients with solitary ureteral stones managed by several different techniques are reported. In situ treatment was performed in 123 cases without instrumentation and in 47 after placement of a ureteral catheter. Retrograde stone manipulation was performed in 245 cases immediately before extracorporeal shock wave lithotripsy and an additional 56 were manipulated with ureteral stent placement at least 1 week before extracorporeal shock wave lithotripsy. The success rate was significantly greater if the stone was manipulated into the kidney before extracorporeal shock wave lithotripsy. Significantly less energy (p less than 0.0001) was required for complete disintegration if the stone was free floating in the kidney. The need for subsequent procedures was significantly less (p less than 0.0001) for stones manipulated successfully into the kidney. Complications were infrequent, with the most common being ureteral perforation in 5.1 per cent of the cases, all of which were managed conservatively. Extracorporeal shock wave lithotripsy is the treatment of choice for proximal ureteral calculi because it is less morbid than percutaneous approaches and provides significantly better results than ureteroscopy. An attempt at manipulation of proximal ureteral calculi back into the kidney should be made before extracorporeal shock wave lithotripsy.     

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.     

Ureteral stones: the results of primary in situ extracorporeal shock wave lithotripsy

The use of a Siemens Lithostar* for in situ disintegration of 212 ureteral stones in 207 patients was evaluated. Followup data were available on 133 patients (136 stones). Of the stones 121 (88.1 per cent) have been cleared with in situ extracorporeal shock wave lithotripsy alone. These results strongly suggest that in situ extracorporeal shock wave lithotripsy is an effective and noninvasive method to treat ureteral stones.     

Endoscopic treatment for severe encrusted ureteral stent left in place for 3 years

A 52-year-old man had bilateral ureteral stents placed before treatment for ureteral and renal stones, but did not return for treatment and follow-up. Three years later, he complained of hematuria and vertigo. An abdominal X-ray revealed large renal and ureteral stones rising from and enveloping the stent. A bilateral percutaneous nephrostomy was placed. The right ureteral stent was easily removed with a cystoscope. The left ureteral stone was separated from the stent by ureteroscopic lithotripsy (TUL) and percutaneous nephroscopic lithotripsy (PNL). The left stent was torn off and difficult to remove because of encrustation. It was finally removed through an endoscopic procedure. Right PNL and extracorporeal shock wave lithotripsy (ESWL) were performed and all stones and stents were extracted. He was stone-free at 4 months.