Management of ureteral calculi: the debate continues

Ambulatory Minimally Invasive Endoscopic Combined Intrarenal Surgery in Management of Large Impacted Proximal Ureteral Calculi: A Feasibility Study at a Tertiary Referral Center

Aim: To conduct a comparative, nonrandomized study to assess the feasibility of mini-Endoscopic Combined Intrarenal Surgery (ECIRS) using supine Mini-percutaneous nephrolithotomy (PCNL) access (16F) in Galdakao-Modified Supine Valdivia position for managing proximal large-volume impacted ureteral calculi as ambulatory day-care surgery vis-a-vis standalone ureteroscopy (URS) with push-back PCNL, if needed. The primary aim was to study the outcomes and stone-free rates (SFRs). Secondary aim was to compare the intraoperative and short-term postoperative complications. Materials and Methods: Data of 60 patients undergoing ECIRS (Group 1) from January 2016 to December 2019 were collected prospectively in a nonrandomized fashion from a single center after Ethics Committee approval. A matched-paired analysis was performed with retrospectively collated data of 60 patients undergoing standard URS/pushback PCNL (Group 2) using analysis of variance, Fisher's exact test, and Chi-square test. p < 0.05 was considered statistically significant. Outcomes and Results: Group 1 patients had a significantly shorter procedure time vs Group 2 (42.1 ± 11.2 minutes vs 52.1 ± 13.7 minutes; p < 0.001). Group 1 (59/60) patients had an overall single stage SFR of 98.3%, which was significantly higher than single-stage SFR of 83% in Group 2 (50/60) (p < 0.002). Group 2 patients had a higher incidence of fever (10 vs 4, p = 0.01). However, there were no cases of sepsis in either group. Rest of the complications were comparable for both, as the need for ancillary procedures was significantly higher in Group 2 (10% vs 1.7%, p < 0.001). Patients were discharged on the same day in both groups. Conclusions: The findings of our study suggest that, in large and impacted proximal ureteric stones, combined minimally invasive endoscopic approach offers the best option to render the patient stone free by a single intervention. With better intra- and postoperative outcomes and safety profile, Mini-ECIRS may be considered as an ambulatory procedure in this setting.

Evaluation of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy for upper ureteral stone: randomized controlled study

PURPOSE

To determine the necessity of ureteral stent placement after retroperitoneal laparoscopic ureterolithotomy (RLU) for upper ureteral stones more than 1 cm.

PATIENTS AND METHODS

Between May 2006 and May 2009, 104 RLUs were performed as primary management of large upper ureteral stones. The patients were randomly divided into two groups: In group 1 (52 patients), RLU was performed without stent placement afterward, and in group 2 (52 patients), the stent was placed after RLU. The mean stone size was 16.8 cm in group 1 and 18.2 cm in group 2. The stent in group 2 was placed cystoscopically.

RESULTS

All procedures were performed successfully. The mean operative time was 48 minutes in group 1 vs. 65 minutes in group 2. The mean drainage time was 4.1 days in group 1 vs. 2.3 days in group 2. All the patients were followed up for a period of 6 months with no recorded cases of residual stone or ureteral stricture.

CONCLUSION

RLU for large upper ureteral stones could be considered as a primary line for treatment as regards the economic status in developing countries. Laparoscopic ureterolithotomy (LU) without stent placement for upper ureteral stones is safe, cost effective, has less operative time, and needs no auxiliary procedures when compared with the use of stent placement after LU, which adds costs and discomfort for the patient.

Impacted upper-ureteral calculi >1 cm: blind access and totally tubeless percutaneous antegrade removal or retrograde approach?

PURPOSE

To compare blind access and totally tubeless percutaneous antegrade removal and pneumatic transurethral ureterolithotripsy for the management of impacted upper-ureteral calculi >1 cm.

PATIENTS AND METHODS

Seventy patients (41 male, 29 female) with impacted upper-ureteral calculi >1 cm were selected in randomized order for pneumatic transurethral ureterolithotripsy (35 patients) or blind access and totally tubeless percutaneous nephrolithotomy (PCNL) (35 patients). Ultrasonography and intravenous urography were performed for all patients before surgery. After operation, plain films and ultrasonography were done.

RESULTS

In the PCNL group, blind access was achieved from the lumbar notch area in all 35 patients, but in 3 patients, the exposure was not optimal for approaching the ureteropelvic junction (UPJ). So we injected contrast material into the collecting system, and, under fluoroscopic control, another access was achieved. In 33 patients (94.3%), intact removal of the stones was performed. In the other two patients, we fragmented the stones with the Swiss Lithoclast by an antegrade approach. The success rate thus was 100%. The mean operative time was 38 minutes (range 25-48 minutes). In the transurethral lithotripsy group, 12 stones (34.2%) migrated upward to the pelvis of kidney, and 5 stones (14.2%) fragmented incompletely. In these cases, a double- J stent was inserted, and SWL was performed. In follow-up, plain films and ultrasonography showed complete clearance in these patients. Eighteen calculi (51.4%) fragmented completely with the Lithoclast. The mean operative time in this group was 34 minutes (range 20-58 minutes).

CONCLUSION

In the presence of moderate to severe hydronephrosis, blind access and totally tubeless PCNL is an effective option for large, impacted upper-ureteral calculi. Flexible ureteroscopy with laser lithotripsy is expensive and not readily available. Pneumatic transurethral ureterolithotripsy has a back-pressure effect and pushes back the calculi to the kidney. Thus, this procedure does not have satisfactory results in the management of these calculi.

Percutaneous antegrade removal of impacted upper-ureteral calculi: still the treatment of choice in developing countries

PURPOSE

To assess the safety and efficacy of antegrade percutaneous nephrolithotomy (PCNL) of large impacted proximal-ureteral calculi.

PATIENTS AND METHODS

Between July 1998 and October 2003, a total of 66 patients (43 male and 23 female; mean age 37.5 years) underwent PCNL for impacted proximal-ureteral calculi. The inclusion criteria were calculi >15 mm that were densely impacted and located between the ureteropelvic junction and the lower border of the 4th lumbar vertebra. The mean drop in hemoglobin, operating time, analgesic requirement, and hospital stay were assessed.

RESULTS

Sixty-five patients (98.5%) had complete calculus clearance in a single session through a single tract. The mean operating time and hospital stay were 47 minutes and 46 hours, respectively. The mean analgesic requirement was 65 mg of pethidine (meperidine). The mean follow-up was 14 months. There were no significant postoperative complications.

CONCLUSION

Antegrade PCNL is a safe and effective option for large, impacted proximal-ureteral calculi.

Treatment for extended-mid and distal ureteral stones: SWL or ureteroscopy? Results of a multicenter study

PURPOSE

In a randomized study, we analyzed the treatment results of ureterorenoscopy (URS) and shockwave lithotripsy (SWL) for extended-mid and distal ureteral stones. We investigated also, for reasons of cost effectiveness, the factors influencing the outcome, the complications, and the need for auxiliary procedures.

PATIENTS AND METHODS

In three regional hospitals, we selected 156 patients with extended-mid and distal ureteral stones. After randomization, 87 were treated with URS, and 69 with SWL. The treatment results were studied in relation to complications, the need for auxiliary procedures and stone factors, urinary tract infection (UTI), dilatation, and kidney function.

RESULTS

After retreatment of 45% of the patients, the stone-free rate after 12 weeks in the SWL group was 51%. After a retreatment rate of 9% of the patients in the URS group, the stone-free rate was 91%. Including the number of auxiliary procedures, we calculated the Efficiency Quotient (EQ) as 0.50 for SWL and 0.38 for URS. After correction and redefinition of auxiliary procedures, the EQ was 0.66. The mean treatment time for SWL was 52 minutes and for URS 39 minutes. General anesthesia was more frequently needed in URS patients. Complications occurred more often in the URS group (22 v 3 and 24 v 13, respectively). These were mostly mild, and all could be treated with a double-J stent, antibiotics, or analgetics. A lower stone-free rate was achieved in patients with larger (> or =11 mm) stones (75% v 85% for smaller stones in the URS group and 17% v 73% in the SWL group. In the URS group, the stone-free rate of patients with extended-mid ureteral stones was lower than that of patients with distal ureteral stones. Calculating the costs for URS and SWL appeared impossible because of the differences in available equipment.

CONCLUSION

The stone-free rate after URS is much higher than after SWL, and the EQ in our series was strongly dependent on definitions. The decision about how to treat a patient with an extended-mid or distal ureteral stone therefore should not be made primarily on the basis of cost effectiveness but rather on the basis of the availability of proper equipment, the experience of the urologist, and the preference of the patient.

Laboratory and clinical assessment of pneumatically driven intracorporeal lithotripsy

A pneumatically driven intracorporeal lithotripter (the Swiss Lithoclast) has recently been approved for use in the United States. We compared its performance in vitro with ultrasonic, electrohydraulic and laser lithotripsy devices using a standard plaster-of-Paris stone phantom. The probe sizes and output settings were identical to those used during clinical treatment. The fragmentation efficiency index (measured as the lithotripsy time needed to reduce the stone phantom to particles <2 mm divided by the initial stone weight) ranged from 5.0 to 8.5 min/g of stone mass, with this value increasing from pneumatic to electrohydraulic to laser and to ultrasonic lithotripsy. We also performed an objective study in a swine model, which showed no adverse consequence of pneumatic lithotripsy. Finally, we evaluated our initial 41 patients who had undergone pneumatic stone fragmentation. We treated 8 patients having 11 renal calculi, 30 patients having 37 ureteral calculi, and 3 patients having 6 bladder calculi employing pneumatic probes ranging in size from 0.8 to 2.0 mm. Stone fragmentation was successful in a single session in 95% of the ureteral calculi and 100% of both renal and bladder calculi. Stone analysis in 23 patients revealed 17 (74%) calcium oxalate monohydrate and 1 (4%) cystine calculi. Our clinical and laboratory assessment of this newly developed pneumatic lithotripsy device further validates its efficacy in fragmenting stone of all compositions and its overall safety associated with clinical application.

Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness

OBJECTIVES

To determine the efficacy and costs of extracorporeal shock-wave lithotripsy (ESWL) compared with ureteroscopy (URS) in the treatment of mid- and lower ureteric calculi.

PATIENTS AND METHODS

The records of patients treated primarily by ESWL and URS were analysed retrospectively. Treatment with ESWL included 63 patients (42 men and 21 women, mean age 52 years, range 23-78, 19 mid- and 44 lower ureteric calculi). All patients received 4000 shock waves at a mean energy setting of 18.1 kV. URS was used in 105 patients, with a 7.2 F miniscope or the 7.1 F flexible scope. Stones were fragmented with a pulsed-dye laser lithotripter at 504 nm and a power of up to 130 mJ (mean 53 mJ) using a 200 or 320 microns fibre. All ureteroscopies were performed with the patient under general (n = 17) or spinal (n = 87) anaesthesia in a mean treatment duration of 34 min. Stones were located in the mid-ureter in 24 patients and in the lower ureter in 80. The outcome was assessed by stone-free rates, re-treatment rates, time to become stone-free, complication and costs.

RESULTS

ESWL for mid- and lower ureteric calculi resulted in a success rate of 90% and 81%, respectively, compared with 96% and 99% for URS. However, patients treated with URS were stone-free within 2 days, whereas patients in the ESWL group required up to 4 months. The best results for ESWL were achieved with stones of < 50 mm2. The costs of URS were higher than those for ESWL.

CONCLUSIONS

ESWL provides a noninvasive, simple and safe option for the management of mid- and lower ureteric calculi, provided that the stones are < 50 mm2; larger stones are best treated by URS.

Contemporary management of ureteral stones

The management of ureteral stones has undergone revolutionary changes in the past 15 years. The parallel advances in extracorporeal shock wave lithotripsy, percutaneous and retrograde endoscopic access to the collecting system, and intracorporeal lithotripsy devices almost completely have supplanted the need for a traditional ureterolithotomy. The merits of the various technologies that are available are discussed as they apply to treating calculi in different ureteral segments.

Ureteric pelvic stones

There is still controversy among urologists on the best treatment for ureteric pelvic stones. Recent advances in ureteroscopy with new methods of stone fragmentation (laser, electrohydraulic and ballistic lithotripsy) and current availability of small semirigid and flexible ureteroscopes have made this procedure rapid, easy and safe. Similarly, improvement in ESWL technology has also facilitated identification and treatment of stones above the iliac bone ring. In just over eight years (3/'88 - 6/'96) we treated 355 ureteral pelvic stones. The first approach was ESWL in 252 cases (by Dornier HM3 in 176, Dornier MPL 9000 in 42, Piezolith Wolf 2300 in 39 and EM plus Dormia basket in 15), ureteroscopy in 38 (by electrohydraulic) lithotripsy in 31, ultrasound lithotripsy in 5 and Lithoclast in 2) and litholapaxy by Dormia basket in 58. The overall stone-free rate was 75.5%, 95.3% and 84.5% respectively. The second line of treatment in unsuccessful cases was ULL or Dormia basket extraction and ESWL in 7 cases only. The overall success rate was 100%. Only 3 patients underwent open surgery (0.7%). There were 5 cases of ureteral perforation during ULL, which did not require surgical repair. No major complications occurred with either ESWL or Dormia basket procedures. We consider in-situ ultrasound-guided ESWL as first choice in managing ureteral pelvic stones, as the procedure is rapid, safe and technically simple. Ureteroscopy is a salvage procedure after ESWL failure. Endoscopic removal by Dormia basket is still a safe, effective procedure for small stones.

Treatment of ureteric stones. Comparison of laser and pneumatic lithotripsy

OBJECTIVES

To study the treatment of ureteric stones by laser lithotripsy (LL) and pneumatic lithotripsy (PL), and to evaluate the results of the two treatment modalities to assess effectiveness, complications and cost benefits.

PATIENTS AND METHODS

Between January 1993 and February 1994 200 ureteric stones in 194 patients were fragmented intracorporeally, 48 by LL and 152 by PL. The ages of the patients ranged from 31 to 40 years with a male to female ratio of 2:1. All procedures were performed under general/regional anaesthetic in a day-care set-up. Patients were followed at weekly intervals. Re-treatment was carried out at 4 weeks where necessary.

RESULTS

The majority of the stones treated (84%) were in the lower third of the ureter, 69% measured 7-12 mm in diameter, and 61% were composed of calcium oxalate. Ninety-three per cent of the stones were fragmented in one treatment session. The overall stone-free status at 4 weeks was 95% for PL and 84% for LL. The non-fragmentation rate was 10% for LL and 1% for PL. Post-treatment complications were encountered in 8% of the patients treated by LL and 7% by PL.

CONCLUSIONS

Our experience shows that PL and LL both provide a safe and effective means of performing intracorporeal lithotripsy for smaller ureteric stones. However, PL is more effective in fragmenting larger and harder stones. Moreover, PL is more user-friendly and highly cost-effective compared with LL.

Retroperitoneal laparoscopic ureterolithotomy for multiple upper mid ureteral calculi

A 30-year-old man presented with upper mid ureteral calculi and gross hydroureteronephrosis. The 4 large and 2 small calculi were removed successfully using Gaur's technique of retroperitoneal laparoscopy.

Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients

Retroperitoneal endoscopic ureterolithotomy was successful in 9 of 12 patients who had calculi impacted in the upper and mid ureter with gross hydronephrosis and recurrent infection. This procedure was made possible by the technique of balloon retroperitoneoscopy recently described by the author.