Open mini-access ureterolithotomy: the treatment of choice for the refractory ureteric stone?

Place of extracorporeal shockwave lithotripsy in the treatment of urolithiasis in the region of Gharb Chrarda Bni Hssen (Morocco)

The extracorporeal shockwave lithotripsy (ESWL) is a minimally invasive therapeutic approach which has been widely used through the last years. The aim of this study was to evaluate the effectiveness of ESWL in the treatment of nephrolithiasis in Gharb Chrarda Bni Hssen area (North of Morocco). A retrospective study of 590 patients with urinary stone was conducted between February 2009 and January 2013 in the Centre of Lithotripsy Anoual Clinic Kenitra. The treatment consisted in one or several sessions of ESWL. Evaluation of efficiency was based on radiological examinations using abdominal echography during the consultation with the urologist after the last session. There were 306 males and 184 females aged 17-79 years. The medium size of stone was 12.3 ± 5 mm. The average number of sessions and shock waves were 4 and 2490, respectively. The shockwave session was continued until stone fragmentation was observed when 4000 shocks were given. Failure of stone fragmentation or the presence of fragments larger than 4 mm were indications of repeat ESWL sessions. 92% of patient stones were completely cleared (p < 0,05%). The majority of patients were asymptomatic. This data show that the ESWL is extremely successful in treating human kidney stone. It is the first line of choice as a treatment modality for this pathology by the population of this area.

Minimally invasive urology - Pearls, pitfalls and experience in the Caribbean

The Caribbean is made up of several independent nations and the availability of urology and more specifically endourology services varies widely between them. In this article we explore the history and current state of endourology in the English speaking Caribbean as well as the challenges faced within the region many of which are shared by the different territories.

Mini incision open pyeloplasty - Improvement in patient outcome

PURPOSE

To assess the subjective and objective outcomes of mini-incision dismembered Anderson-Hynes pyeloplasty in the treatment of primary ureteropelvic junction obstruction (UPJO).

MATERIALS AND METHODS

Between January 2008 to January 2013, Anderson-Hynes pyeloplasty was performed in 71 patients diagnosed with primary UPJO. Small subcostal muscle splitting incision was used in all cases. Sixteen patients with renal calculi underwent concomitant pyelolithotomy. Subjective outcome was assessed using visual pain analogue score (VAS). For objective assessment, the improvement in differential renal function (DRF) and radio-tracer wash out time (T1/2) on Tc-99m DTPA scan and decrease in hydronephrosis (HDN) on renal ultrasound (USG) and urography (IVU) were assessed.

RESULTS

Mean incision length was 5.2 cm. The average operating time and postoperative hospital stay was 63 (52-124) minutes and 2.5 (2-6) days respectively. Concomitant renal calculi were successfully removed in all the patients. Overall complication rates were 8.4% and overall success rate was 98.6% at median follow-up of 16 months. There was significant improvement in pain score (p=0.0001) and significant decrease in HDN after the procedure. While preoperative mean T1/2 was 26.7±6.4 minutes, postoperative half-time decreased to 7.8±4.2 minutes at 6 months and to 6.7±3.3 minutes at 1 year. Mean pre-operative DRF was 26.45% and it was 31.38% and 33.19% at 6 months and 1 year respectively.

CONCLUSIONS

Mini-incision pyeloplasty is a safe and effective technique with combined advantage of high success rates of standard open pyeloplasty with decreased morbidity of laparoscopic approach. Excellent functional and objective outcomes can be achieved without extra technical difficulty.

Prospective Randomized Comparison of Open versus Transperitoneal Laparoscopic Ureterolithotomy: Experience of a Single Center from Northern India

AIM

Prospective randomized study on transperitoneal laparoscopic ureterolithotomy (TPLU) versus open ureterolithotomy (OU) for treatment of large impacted ureteric stones (≥ 1.5 cm) and assessment of overall results.

MATERIAL & METHODS

In a prospective study between 2010 to 2012, 30 patients underwent TPLU and 30 OU based on 1:1 randomization. The operation was indicated primarily in 44 cases or after failed shock-wave lithotripsy/ureteroscopy in 16 cases. Two groups were compared for operative time, success rate, visual pain score, analgesic requirement, hospital stay, and postoperative complications. Statistical analysis was performed with SPSS® version 16.0 using Fisher exact or Mann-Whitney U tests with p < 0.05 considered statistically significant.

RESULTS

The difference in visual pain score (6.2 in TPLU group vs 3.1 in OU group on day 1; 4.8 vs. 2.4 on day 2) and tramadol requirements (184.32 mg in TPLU group vs. 150.87 mg in OU group on day 1; 97.34 mg vs. 65.56 mg on day 2) were statistically significant and more in OU. Hospital stay and convalescence were significantly lower in the TPLU. However, stone removal in one attempt was similar in both the groups.

CONCLUSION

Although successful stone removal rates are equal in both groups, TPLU is associated significantly with less postoperative pain, less analgesic requirement, shorter hospital stay and short convalescence in comparison to OU.

[Open surgery for upper urinary tract stones]

Open surgery for stones of the upper urinary tract has very few indications, failures or complications of other techniques, greater than 2cm stones, hard stones, anatomical abnormalities and complex stones. Open surgery for stone may be difficult and need specific tools. For the kidney, the anatrophic nephrotomy is an effective procedure which spares the renal function. For the ureter, the mini-ureterotomy is no more invasive than laparoscopy. The stone-free rate of open surgery is over 90%. The main complications are stenosis, fistula and infections.

[Management of proximal ureteral stones]

Proximal ureteral stone less than 4-6mm may initially be treated by surveillance. Generally, extracorporeal shockwave lithotripsy (ESWL) is the first line treatment for proximal ureteral stones, specially for stones less than 1cm. For stones greater than 1cm, the results of ureteroscopy (URS) are better than the results of ESWL and in these cases URS may be an option. In case of failure of ESWL, URS can be proposed. URS can be the first line treatment in case of severe ureteral obstruction with no urinary infection. Proximal ureteroscopy must be careful because severe complications are not infrequent. Open surgery has very rare indication. Metabolic check-up and annually follow-up with at least a renal imaging at three months are recommended.

Extracorporeal shockwave lithotripsy versus ureteroscopy for distal ureteric calculi: efficacy and patient satisfaction

OBJECTIVE

We compared the efficacy of extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) for the treatment of distal ureteral calculi with respect to patient satisfaction.

MATERIALS AND METHODS

This is a prospective study where a total of 212 patients with solitary, radiopaque distal ureteral calculi were treated with ESWL (n = 92) using Dornier lithotriptor S (MedTech Europe GmbH) or URS (n = 120). Patient and stone characteristics, treatment parameters, clinical outcomes, and patient satisfaction were assessed for each group.

RESULTS

The 2 groups were comparable in regard to patient age, sex, stone size, and side of treatment. The stone-free status for ESWL and URS at 3 months was 81.5% and 97.5%, respectively (p < 0.0001). In addition, 88% of patients who underwent ESWL versus 20% who underwent URS were discharged home the day of procedure. Minor complications occurred in 3.3% and 8.3% of the ESWL and URS groups, respectively (p = 0.127). No ureteral perforation or stricture occurred in the URS group. Postoperative flank pain and dysuria were more severe in the URS than ESWL group, although the differences were not statistically significant (p = 0.16). Patient satisfaction was high for both groups, including 94% for URS and 80% for ESWL (p = 0.002).

CONCLUSIONS

URS is more effective than ESWL for the treatment of distal ureteral calculi. ESWL was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was significantly higher for URS according to the questionnaire used in this study.