Endourological experience with cystine calculi and a treatment algorithm

Between May 1984 and January 1988, 18 patients (31 pyeloureteral units) with documented symptomatic cystine stones were treated. Stone size ranged from 5 to 56 mm. in largest diameter, with an average of 21 mm. All pyeloureteral units were treated initially by endourological methods, including ureteroscopy in 10, percutaneous ultrasonic lithotripsy in 9, extracorporeal shock wave lithotripsy (ESWL) in 10 and chemolysis in 2. Of the patients 10 required a combination of these technologies and 2 required an open operation. Of the 31 units 23 were free of stones when the patient was discharged from the hospital. Of 8 patients with retained stones only 3 had fragments greater than 3 mm. in diameter. Based on this experience an algorithm was developed for the urological management of cystine stones. Ureteral calculi may be removed by ureteroscopic techniques or manipulated into the renal pelvis and managed as renal stones. Cystine renal calculi of less than 1.5 cm. may be treated with ESWL monotherapy. Stones of 1.5 to 3 cm. may be treated with ESWL and dissolution, or percutaneous ultrasonic lithotripsy plus dissolution. Staghorn calculi may be treated by percutaneous ultrasonic lithotripsy plus ESWL and/or dissolution for retained fragments.     

Painless piezoelectric extracorporeal lithotripsy

A total of 693 stones in 438 renoureteral units from 426 patients 4 months to 84 years old was treated with a mobile piezoelectric lithotriptor using ultrasound stone localization. Of the units 37 per cent had solitary stones smaller than 1.5 cm. in diameter, (group 1), 32 per cent had multiple stones up to this size (group 2), 21 per cent had stones 1.6 to 2.5 cm. in diameter (group 3) and 10 per cent had calculi larger than 2.5 cm. in diameter (group 4). No sedation or analgesics were necessary in 96.2 per cent of the treatments. Of all stones 97.2 per cent were disintegrated, with 39 per cent of the units requiring repeat treatments usually on an outpatient basis. Of the patients 82 per cent had transient hematuria, 6 per cent had fever and 28 per cent temporarily took some type of analgesics within the first 3 months after treatment. Nine per cent of the patients required postoperative ancillary interventions. After 3 months 92 per cent of the renoureteral units in group 1, 73 per cent in group 2, 74 per cent in group 3 and 50 per cent in group 4 were free of stones. Piezoelectric extracorporeal lithotripsy proved to be as efficient as spark-gap lithotripsy, yet it was essentially painless. Ultrasound localization permits treatment of all renal stones but it restricts lithotripsy of ureteral stones to the most proximal and distal fourths of the ureter.     

Combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy

Eighty-seven patients with branched renal calculi were treated by a combination of percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. Stone debulking was achieved by percutaneous nephrolithotomy and residual stone fragments were destroyed by shock wave lithotripsy. Of the patients 70 (80 per cent) required 2 to 3 treatments, 12 (14 per cent) required 4 treatments and 5 (6 per cent) required 5 to 6 treatments. Results after 3 months indicated that 58 patients were free of stones, 3 had recurrent stones and 12 had disintegrated stone particles (less than 3 mm.) in the collecting system, while 13 were lost to followup. One patient had undergone nephrectomy. This treatment plan minimized the disadvantages of either technique when used alone and made open operative intervention unnecessary. Procedural and fluoroscopy times were reduced drastically compared to reported data on percutaneous nephrolithotomy only. We believe that more than 90 per cent of all branched calculi can be treated with this combined technique.     

Staghorn calculi: percutaneous extraction versus anatrophic nephrolithotomy

We compared the procedure time, success rates, complications and recovery times for percutaneous ultrasonic lithotripsy (75 cases) and anatrophic nephrolithotomy (25) in patients with staghorn stones. Although the frequency of retained stone fragments was higher in the former group (13.3 versus 0 per cent), the shorter total procedure time (average 155.1 versus 266.5 minutes), lesser need for blood transfusions (average 2 units packed red cells in 53 per cent of the patients versus 3.5 units in 70 per cent) and narcotics (average 16 versus 33 doses), and far more rapid return to work (average 14.3 versus 54.5 days after the patients were discharged from the hospital) strongly favor percutaneous over open stone removal.     

Unenhanced computerized axial tomography to detect retained calculi after percutaneous ultrasonic lithotripsy.

PURPOSE: We report our experience with unenhanced computerized axial tomography (CT) after percutaneous ultrasonic lithotripsy in patients thought to be at high risk for retained calculi. MATERIALS AND METHODS: CT was obtained in 121 patients (124 kidneys) within 12 to 36 hours of percutaneous ultrasonic lithotripsy for staghorn or large nonstaghorn renal calculi. Cases were grouped according to the CT findings as no retained calculi, insignificant retained calculi (fragments 1 to 3 mm.), retained calculi amenable to shock wave lithotripsy and retained fragments requiring second look percutaneous ultrasonic lithotripsy or flexible nephroscopy. RESULTS: No calculi were seen in 73 kidneys (59%) and retained calculi were identified in 51 (41%). Shock wave lithotripsy was used to treat 8 patients and another percutaneous ultrasonic lithotripsy or flexible nephroscopy was performed in 23 to remove retained stones. Insignificant calculi were noted in the remaining 21 patients. CONCLUSIONS: We believe that postoperative unenhanced CT is superior to plain renal tomography and is the best method to determine if a patient is stone-free after percutaneous ultrasonic lithotripsy. It helps to locate precisely those stones requiring a second percutaneous ultrasonic lithotripsy or nephroscopic extraction. An unenhanced renal CT devoid of calculi obviates routine postoperative second look flexible nephroscopy. We encourage others to consider this technique to define more accurately kidney stone status after percutaneous ultrasonic lithotripsy for large staghorn calculi or in any patient at high risk for retained calculi after percutaneous ultrasonic lithotripsy.     

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.     

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.     

Kidney stone removal: percutaneous versus surgical lithotomy

Percutaneous removal of most urinary tract calculi may be performed as a 1-stage effort with techniques and skills developed recently in the specialties of urology and radiology. Ultrasonic fragmentation of most calculi was done to permit their extraction. Percutaneous ultrasonic lithotripsy was performed on 250 consecutive (a single exception) patients bearing stones that required removal. Targeted calculi were removed successfully from 97 per cent of these patients. One patient required surgical lithotomy. The previous 100 patients with stones underwent surgical lithotomy with 96 per cent success. Complications of percutaneous ultrasonic lithotripsy appeared equitable with those of surgical lithotomy. Of the patients who underwent percutaneous ultrasonic lithotripsy 6 (6 per cent) required extended hospital days or additional procedures for management of complications. None of these patients required a surgical incision. Anesthesia times were similar for both groups--average 159 plus or minus 4 (standard error) minutes for percutaneous ultrasonic lithotripsy and 193 plus or minus 8 minutes for surgical lithotomy. Hospital recovery days averaged 5.5 plus or minus 0.3 for percutaneous ultrasonic lithotripsy and 8.4 plus or minus 0.5 for surgical lithotomy (p less than 0.01). Associated costs averaged $7,203 plus or minus 55 for lithotripsy and $8,849 plus or minus 660 for lithotomy (p less than 0.01). The number of narcotic administrations per patient (days 1 to 5 postoperatively) averaged 9.88 plus or minus 0.70 for lithotripsy and 16.82 plus or minus 0.78 for lithotomy (p less than 0.01). The average patient who underwent percutaneous ultrasonic lithotripsy felt capable of full activity 2.0 plus or minus 0.2 weeks following stone removal, whereas no patient who underwent previous surgical lithotomy recalls a recovery period of less than 3 weeks (p less than 0.01). We believe that most upper urinary tract calculi may be removed cost-effectively with a percutaneous approach. Compared to surgical lithotomy, percutaneous ultrasonic lithotripsy may result in rapid convalescence with diminished pain.     

Treatment of renal stones in children: a comparison between percutaneous nephrolithotomy and shock wave lithotripsy

PURPOSE: We compared the results of percutaneous nephrolithotomy and shock wave lithotripsy for the treatment of 1 to 2 cm renal stones in children. MATERIALS AND METHODS: The study included 166 children with renal stones 1 to 2 cm. A total of 75 patients (82 kidneys) were treated with percutaneous nephrolithotomy and 91 (93 kidneys) were treated with shock wave lithotripsy. Mean followup was 31 +/- 10 months (range 6 to 84). Both groups were compared regarding stone-free rate, re-treatment rate, complications and incidence of stone recurrence. RESULTS: Both groups were comparable regarding preoperative characteristics. Of the units treated with percutaneous nephrolithotomy 4 (4.9%) were associated with minor complications. Stone-free rate after a single session of percutaneous nephrolithotomy was 86.6% (71 units), and the remaining 11 kidneys with residual stones were successfully treated with repeat percutaneous nephrolithotomy in 7 and shock wave lithotripsy in 4. Therefore, a total of 78 units (95%) were stone-free after percutaneous nephrolithotomy monotherapy, and the overall stone-free rate at 3 months was 100%. Of the patients undergoing shock wave lithotripsy 1 (1.1%) had development of steinstrasse and was successfully treated with ureteroscopy. The overall re-treatment rate after shock wave lithotripsy was 55%. A total of 79 units (84.9%) were stone-free after shock wave lithotripsy monotherapy, whereas 7 (7.5%) with no gross response to treatment were treated with percutaneous nephrolithotomy and 7 with insignificant stones less than 4 mm were followed. Therefore, the overall stone-free rate at 3 months was 92.5%. The differences in stone-free rates and re-treatment rates significantly favored percutaneous nephrolithotomy, while the incidence of complications and stone recurrence at last followup were not significantly different between the groups. CONCLUSIONS: For treatment of 1 to 2 cm renal stones in children percutaneous nephrolithotomy is better than shock wave lithotripsy, yielding higher stone-free and lower re-treatment rates.     

Clinical experience of extracorporeal shock wave lithotripsy for cystine calculi

Thirty patients (16 men and 14 women) with cystine urinary stones were treated by extracorporeal shock wave lithotripsy (Dormer HM-3) from December 1984 through October 1989. The average patient age was 35.2 years with a range of 14 to 59 years. Seventy per cent of these subjects had had previous open surgical operations for stones. The cases consisted of 7 ureteral stones and 37 renal stones, including 15 staghorn calculi. An average of 1.3 session of ESWL was carried out to treat ureteral stones. Thirty-seven renal units with renal stone required 96 sessions of lithotripsy (average 2.6 sessions per unit). Seven patients with ureteral stones required auxiliary procedures, i.e., one transurethral lithotripsy (TUL), two percutaneous nephrostomies (PNS) and one open surgery. Thirty-seven renal stones, including staghorn calculi was treated by ESWL and auxiliary treatment of 21 TUL procedures, one PNS, 16 PNL procedures and one chemical chemolysis. Successful fragmentation (residual debris less than or equal to 4 mm) was achieved in 85.7% of ureteral stones, 90.9% of renal stones and 73.3% of staghorn calculi. The stone free rates of patients with ureteral stones, renal stones and staghorn calculi were 71.4%, 50.0% and 53.5%, respectively, at 3 months after ESWL. No serious complications were seen in this series. Fever above 38.5 degrees C was the most common complications (13.5%). Ureteral perforation was encountered once in TUL procedures. Transfusion and selective arterial embolization were needed for one case treated by PNL procedures. Although cystine stone is harder to be fragmented by ESWL than other stone composition, ESWL and endourology may be effective and safe procedures for cystine stone patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of ultrasonic disintegration on the outcome of percutaneous nephrolithotripsy

Concern has been expressed regarding the use of ultrasonic lithotripsy in the percutaneous treatment of renal calculi with the suggestion that high rates of retained stones may be experienced. Evaluation of 89 patients with stones confined to the renal pelvis treated both with and without ultrasonic lithotripsy were evaluated with regard to stone size, retained fragments, stone composition and previous renal surgery. It is felt that it is not the use of ultrasonic lithotripsy that leads to longer hospitalization and retained fragments, but rather the size of the renal calculi and the complexity of arrangement.     

经皮肾镜气压弹道联合超声碎石在处理上尿路结石中的临床价值

目的探讨常规24F通道经皮肾镜气压弹道联合超声碎石术（PCNL）在基层医院处理上尿路结石中的临床应用价值。方法回顾分析我院经皮肾镜术中采用瑞士EMSⅢ代气压弹道联合超声碎石清石系统处理的97例104侧上尿路结石患者临床资料,其中,结石位于左肾35例,右肾42例,双侧肾结石7例,输尿管上段结石13例。术中常规建立24F经皮肾工作通道,术后5d复查腹部平片（KUB）了解结石清除情况,观察手术的疗效及并发症。结果 91例患者成功建立24F经皮肾通道并行碎石,6例中转开放手术;PCNLI期净石率81.1%,18侧术后复查存在结石残留,2例行体外冲击波碎石术（ESWL）治疗,余均行Ⅱ期PCNL清石成功。结论 24F通道配合经皮肾镜气压弹道联合超声碎石术具有微创、安全、有效的特点,值得在有条件的基层医院推广应用。     

Combined percutaneous and extracorporeal shock wave lithotripsy for staghorn calculi: an alternative to anatrophic nephrolithotomy

Combinations of percutaneous and extracorporeal shock wave lithotripsy were performed on 46 patients with 52 staghorn calculi. Of the renal units 15 per cent had minute residual fragments but only 9.7 per cent with struvite had residual stones. The morbidity of this combined approach is less than that of anatrophic nephrolithotomy. We believe that the majority of staghorn calculi can be removed in this manner. Nephrostolithotomy should be the initial procedure in most instances. This less invasive approach is especially advantageous in patients at high risk for recurrence.     

超声引导经皮肾镜气压弹道联合超声碎石术治疗肾盏憩室结石7例报告

目的：评价经皮肾镜气压弹道联合超声碎石清石系统治疗肾盏憩室结石的疗效和安全性。方法：2007年2月～2009年1月应用超声引导下经皮肾微造瘘气压弹道联合超声碎石术治疗肾盏憩室结石患者7例。结果：7例肾盏憩室结石均一次性成功取出。术后随访2～21个月，未发现肾盏憩室结石复发。结论：超声引导经皮肾镜气压弹道联合超声碎石术是一种安全、有效的治疗方法，值得临床推广。     

一种改良超声碎石探针在高硬度上尿路结石行经皮肾镜碎石术中的临床应用

目的:评价一种改良超声碎石探针在高硬度上尿路结石行经皮肾镜碎石术(PCNL)中的临床疗效及安全性。方法:选取2017年12月至2018年10月在本院就诊的68例上尿路结石患者,其中输尿管上段结石9例,肾结石59例,所有结石CT值均>1300 Hu,均行PCNL。根据不同的碎石探针分为两组,其中34例应用北京汇福康超声气...     

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.     

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.     

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.     

Percutaneous stone extraction from 200 patients

More than 200 patients have undergone percutaneous stone extraction at our institution. With the percutaneous nephrostomy tract as the conduit to the urinary tract we have removed 95 per cent of the pelviocaliceal stones and 80 per cent of the ureteral stones with grasping forceps, baskets, ultrasonic lithotripsy or a combination of these procedures. Complications were few and patients returned to work sooner than after an open operation.     

Retrograde renoscopic fragmentation of moderate-size (1.5-3.0-cm) renal cystine stones

PURPOSE: We present a series of cystinuric patients with renal cystine calculi between 1.5 and 3.0 cm treated with retrograde renoscopy and intracorporeal lithotripsy and report our results, complications, and inpatient utilization with this approach. PATIENTS AND METHODS: The hospital and office charts of five consecutive patients with six treated renal units who underwent retrograde renoscopy and electrohydraulic lithotripsy for renal cystine stones between 1.5 and 3.0 cm were reviewed. Data on stone size and location, procedures performed, results, complications, and inpatient hospital days were compiled. RESULTS: Five of the six renal units were either rendered stone free or had fragments totalling 3 mm or less. Three renal units required only a single procedure, one required repeat ureteroscopy for Steinstrasse, and one required SWL and repeat ureteroscopy for Steinstrasse. One renal unit was left with a 6-mm fragment for which the patient refused further treatment. There were no major complications. The mean hospital stay was 1 day, and the mean number of procedures per patient was 1.3. CONCLUSION: Retrograde renoscopy and intracorporeal lithotripsy for renal cystine stones 1.5 to 3.0 cm is safe and effective and should be considered as an alternative to percutaneous nephrolithotomy in these patients.