Effectiveness of SWL for lower-pole caliceal nephrolithiasis: evaluation of 452 cases

Combined ureterorenoscopy for ureteral and renal calculi is not associated with adverse outcomes

Introduction

We intended to evaluate the feasibility and effectiveness of the simultaneous rigid and flexible ureteroscopic treatment of symptomatic ureteral and ipsilateral small simultaneous calyceal stones. Outcomes of combined therapy were compared with monotherapy alone.

Material and methods

In this retrospective study, group 1 consisted of 45 patients with middle or lower ureteral and ipsilateral small simultaneous calyceal stones treated by combined therapy. Group 2 included 45 patients with middle or lower ureteral stones only and treated by monotherapy. Stone characteristics, operative time, hospital stay, stone free rates, and complications were compared between groups 1 and 2. Stone free status was defined as no fragments and/or the presence of asymptomatic fragments smaller than 4 mm.

Results

Mean BMI were 29.3 ±0.9 kg/m² and 27.6 ±0.6 kg/m² in groups 1 and 2, respectively. Mean ureteral stone size (7.6 ±0.4 mm vs. 8.0 ±0.4 mm, p = 0.261) and ureteral stone burden (56.0 ±5.5 mm²vs. 54.8 ±6.1 mm², p = 0.487) were similar between groups. Mean renal stone size and renal stone burden for group 1 were 7.1 ±0.8 mm and 83.7 ±11.3 mm². The mean operative time was significantly longer (for a mean of 32.5±1.2 minutes) for group 1 (p = 0.001). Ureteral stents were left in 38 (84.4%) and 19 (42.2%) patients in group 1 and group 2 (p = 0.001). Hospital stay and complication rates were similar between groups. SFRs were 100% for ureteral stones in both groups and 88.9% for renal stones within group 1.

Conclusions

Simultaneous ureteroscopic treatment of the ureteral and ipsilateral small calyceal stones prolongs operative time and increases use of ureteral stent without leaving any residual renal stones.

The impact of pelvicaliceal features on problematic lower pole stone clearance in different age groups

AIM

Our aim was to evaluate the impact of pelvicaliceal variables in pediatric and adult age groups who underwent SWL for lower caliceal calculi.

METHODS

25 pediatric and 78 adult patients treated with extracorporeal shock wave lithotripsy (SWL) between 1996 and 2004 were enrolled into the study after exclusion of patients with hydronephrosis, major renal anatomic anomalies, non-calcium stones, history of recurrent stone disease and previous renal surgery. Lower pole infundibulopelvic angle (IPA), infundibular length (IL), infundibular width (IW) and pelvicaliceal volume were measured from pre-SWL intravenous urography. The pelvicaliceal stone load (PSL) index implicating the stone burden of each patient described as the relationship between stone volume and total estimated pelvicaliceal volume for stone-bearing kidney was also calculated.

RESULTS

Sixty-eight percent of adult and 80% of pediatric patients became stone-free after SWL. The statistical insignificance between PSL index (p=0.097) of two groups shows that both groups shared a similar stone burden. According to SWL outcome, mean IPA values of stone-free and residual patients were 46.85 degrees and 30 degrees in pediatric group, respectively (p=0.01), whereas these values were 48.08 degrees and 43.06 degrees in the adult group, respectively (p=0.352). In the pediatric age group, stone-free and cumulative success rates increased with increasing IPA but this correlation was statistically insignificant (p: 0.263).

CONCLUSIONS

Lower caliceal anatomy has a higher impact on stone clearance after SWL in pediatric patients and urologists can expect better SWL outcomes from pediatric population with solitary lower caliceal stone than adults under the same conditions.

Retrograde intrarenal lithotripsy outcome after failure of shock wave lithotripsy

PURPOSE

We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones not alleviated by shock wave lithotripsy (SWL).

MATERIALS AND METHODS

A total of 28 females and 53 males with a mean age of 53 years (range 18 to 86) were studied. They had been treated with a mean of 3.2 previous SWLs. Mean stone size was 9.2 mm (range 4 to 22) and the mean number of stones per patient was 1.27 (range 1 to 5) for a total of 103 stones overall. In 70 patients there was 1 stone. Rigid and flexible ureteroscopes were used in 8 and 67 cases, respectively, while a combined approach was used in 6. A holmium:YAG laser was used for fragmentation in 52 patients. Success was defined as stone-free status or residual fragments less than 3 mm.

RESULTS

The overall success rate was 67%. RIRL yielded a 46% stone-free rate. Of the 44 patients 17 (39%) had residual stones less than 3 mm, while 13 required ancillary procedures. There were no residual ureteral stones. Original stone size correlated inversely with the success rate. Most failures involved lower pole stones, in that laser fiber deflection prevented reaching them in 9 cases. The procedure was interrupted due to extravasation or bleeding in 5 patients and 6 had postoperative urinary tract infections (16% overall complication rate).

CONCLUSIONS

RIRL effectively and safely alleviated upper tract stones unresponsive to earlier SWL. It can be considered salvage therapy in such cases. RIRL is well suited for treating stones less than 2 cm with better stone-free rates than SWL in the same circumstances. Residual stones were more likely in lower pole cases.

Removal of asymptomatic ipsilateral renal stones following rigid ureteroscopy for ureteral stones

PURPOSE

To evaluate the feasibility and outcome of flexible ureteroscopic removal of small (<1-cm) asymptomatic renal stone(s) following rigid ureteroscopy for ureteral stones.

PATIENTS AND METHODS

Ten female and nineteen male patients underwent rigid ureteroscopy and holmium lasertripsy for removal of ureteral stone(s). All had asymptomatic renal stone(s) on the same side, which were then removed using flexible ureteroscopy. The renal stones were either removed intact with a tipless Nitinol basket or fragmented with the laser to small pieces (<2 mm), with basket removal of larger fragments. The number and size of stones, total operative time, added time needed for flexible ureteroscopy, and intraoperative and postoperative complications were recorded. Follow-up at 1 month included a plain abdominal film and renal ultrasonography or noncontrast CT scan.

RESULTS

Fifty-six renal stones with a mean size of 5.7 mm were treated. Fourteen patients had stones on the right side, and 15 had stones on the left. The mean total operative time was 56.5 minutes, with a mean added time of 16.7 minutes for flexible ureteroscopy. Stones were removed intact in 18 patients and fragmented in 8 patients, resulting in an immediate success rate of 90%. There were three failures. One-month follow-up confirmed all patients were either stone-free or had residual fragments <2 mm in diameter, with no new-onset hydronephrosis.

CONCLUSIONS

Removal of small asymptomatic renal stones at the time of ureteroscopy for ureteral stones appears safe and effective and requires little additional operative time.

Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi

OBJECTIVES

To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size.

METHODS

Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures.

RESULTS

Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred.

CONCLUSIONS

Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results

PURPOSE

The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined.

MATERIALS AND METHODS

A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less.

RESULTS

Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur.

CONCLUSIONS

Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.