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

Safety and efficacy of palliative transurethral resection of the prostate for lower urinary tract obstruction in patients with metastatic prostate cancer: a meta-analysis

PURPOSE

This meta-analysis aims to assess the safety, efficacy, and outcomes of palliative transurethral resection of the prostate (TURP) for relieving urinary obstruction in patients with metastatic prostate cancer.

METHODS

A comprehensive literature search was performed across PubMed, MEDLINE, Scopus, Web of Science, and Google Scholar to identify studies published before August 2024. The included studies reported pre- and post-treatment outcomes in patients undergoing palliative TURP for urinary obstruction. Data were analyzed using Comprehensive Meta-Analysis and Review Manager software. Study quality was evaluated using the Newcastle Ottawa Scale, and bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions tool.

RESULTS

Eight studies, including 3,080 patients with advanced prostate cancer, were included. Palliative TURP significantly reduced postvoid residual urine volume by a mean difference of 50.41 milliliters (95% confidence interval: 39.49-61.34, p < 0.00001) and improved the symptom score by 14.13 points (95% confidence interval: 10.03-18.23, p < 0.00001). However, no significant change was observed in the urinary flow rate (mean difference: 4.31 milliliters per second, p = 0.23). Reported complications included repeat TURP (23.4%), incontinence (13.9%), catheterization (10.8%), and TURP syndrome (2.7%).

CONCLUSION

Palliative TURP effectively improves urinary symptoms and reduces urinary retention in patients with metastatic prostate cancer. While it offers symptomatic relief, the risk of postoperative complications should be carefully considered in treatment planning.

Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture

Objective

To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy (npPCNL) for the management of large proximal ureteral stones.

Methods

We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL. Depending on stone size, in-toto stone removal or lithotripsy using the Lithoclast® Trilogy (EMS Medical, Nyon, Switzerland) was performed. Perioperative parameters including operative time (from start of puncture to the skin suturing), stone extraction time (from the first insertion of the nephroscope to the extraction of all stone fragments), and the stone-free rate were evaluated.

Results

Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi. The median age and stone size of treated patients were 58 (interquartile range [IQR]: 51-69) years and 19.3 (IQR: 18.0-22.0) mm, respectively. The median operative time and stone extraction time were 25 (IQR: 21-29) min and 8 (IQR: 7-10) min, respectively. One case (2.7%) of postoperative bleeding and two cases (5.4%) of prolonged fever were managed conservatively. The stone-free rate at a 1-month follow-up was 94.6%.

Conclusion

The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter. Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Korean Society of Endourology and Robotics (KSER) recommendation on the diagnosis, treatment, and prevention of urolithiasis

This article provides evidence-based recommendations and expert opinions to aid urologists in making optimal decisions regarding managing urolithiasis in various clinical scenarios. The most frequently asked questions by urologists in their clinical practice have been collected and answered in the form of FAQs; based on the latest evidence and expert opinions. The natural history of urolithiasis is divided into active treatment and silent phases, with the active treatment stage divided into typical and special situations and peri-treatment management. The authors address 28 key questions, offering practical guidance for the proper diagnosis, treatment, and prevention of urolithiasis in clinical practice. This article is expected to be served as a valuable resource for urologists.

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.

Non-Papillary Access for the Percutaneous Antegrade Treatment of Renal and Ureteral Stones

OBJECTIVE

To evaluate the feasibility and success of medial non-papillary percutaneous access for the antegrade treatment of different locations of ureteral stones, with and without concomitant renal stones.

METHODS

We performed an analysis of prospectively collected data of 72 patients, being subjected to percutaneous antegrade ureterolithotripsy. Stones located anywhere in the ureter with or without concomitant renal stones were included. A 12Fr, 22Fr, or 30Fr percutaneous tract dilation was performed based on the size of the stone pelvicalyceal system. Perioperative and demographic parameters were gathered and evaluated. The Lithoclast Trilogy (EMS Medical, Nyon, Switzerland) High-power holmium laser devices Cyber Ho 150 (Quanta System, Samarate, Italy) or MOSES Pulse 120H (Lumenis Ltd, Yokneam, Israel) were used for lithotripsy.

RESULTS

The average age and cumulative stone size of the patients were 57.9 ± 27.1 years and 24.2 ± 5.4 mm, respectively. The mean manipulation time was 36.9 ± 14.8 minutes. The mean hospitalization time was 2.5 ± 0.5 days and the average hemoglobin loss was 1.02 ± 0.18 gr/dL. The stone-free rate after percutaneous antegrade ureterolithotripsy was 95.8 % (69 patients), while the overall complications rate was 5.6 %, with 3 cases of fever and one case of prolonged hematuria that were treated conservatively.

CONCLUSION

Non-papillary percutaneous antegrade ureterolithotripsy is a safe and reliable technique for the treatment of patients with ureteral stones, with or without the co-existence of renal stones. A high stone-free rate of 95.8% was reported at 1-month after the surgery carrying a weighted risk of developing postoperative complications.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

Flexible ureterorenoscopy (RIRS) vs. Mini- percutaneous nephrolithotomy (MINI-PCNL) for renal stones 20–30 mm a prospective randomized study

Background

To evaluate the safety and efficacy of mini percutaneous nephrolithotomy (mini PCNL) and retrograde intrarenal surgery (RIRS) in treatment of kidney stones 20–30 mm.

Methods

A prospective randomized study of 70 patients who presented to the urology department with calyceal or renal pelvic stone of 20–30 mm between September 2017 and September 2019. Patients were randomly divided into two groups, Group A (Mini PCNL) consists of 35 patients who were treated with mini PCNL and Group B (RIRS) consists of 35 patients who were Achieving success of the technique was considered when the patient is stone-free or has radiologically insignificant residual fragments < 4 mm.

Results

The demographic data in this study were comparable in both groups. The stone size was 20.43 ± 2.2 mm in group A & 20.5 ± 2.1 in group B, with no statistical significance. Meanwhile, the operative time in group A was 59.71 ± 19.44 min and in group B was 80.43 ± 14.79 min with statistical significance difference (p value < 0.001), while Fluoroscopy time had a mean of 8.11 ± 2.05 min in group A & 5.8 ± 1.98 min in group B with statistically significant diffrence (p value < 0.001). The stone free rate (SFR) was 88.6% in mini PCNL and 82.9% in RIRS with no statistically significant difference (p value: 0.5).

Conclusion

RIRS and mini PCNL can be an effective and alternative option for treatment of renal stones 2–3 cm. Both techniques have relatively similar SFR but RIRS showed more operative time, on contrary Mini-PCNL has more operative and postoperative complications. A multicenter studies with larger numbers of patients will be more effective to confirm these results.

Ureteral wall thickness at the stone site: A critical predictor of success and complications in children undergoing semi-rigid ureteroscopy

INTRODUCTION

We retrospectively assessed the role of ureteral wall thickness (UWT) at the ureteral stone site in predicting the stone-free status and the complication rates in children undergoing semi-rigid ureterorenoscopy (URS).

PATIENTS AND METHODS

The children who underwent URS and had undergone non-contrast abdominal computerized tomography before the URS were included in the study. The following protocol was used to determine the outcome. Immediately before removing the stent, all children were evaluated by ultrasound (US) and plain film (KUB) for residual stones in the upper urinary tract and after removing the double J stent, the presence of stone fragments in the ureter was checked with URS. The children were considered stone-free if no residual fragments were identified in radiologic imaging and the evaluation of the ureter by URS. The case was accepted as a failure if any fragments were seen on immediate US, KUB, and/or during URS just after the stent removal. The patients who could not complete the standard primary URS procedure due to stone-related reasons (patients for whom we could not pass the safety guidewire behind the stone and/or the procedure was terminated due to pyuria during the procedure) were also accepted as a failure. The possible factors related to the patient, stone, ureter, and the operation that could affect the outcome and the complications following the URS were evaluated.

RESULTS

The children's median age was six years (1-17 years). Among the 89 children included in the study, 69 (78%) were stone-free, and 20 (22%) presented residual stone after the first URS session. The ROC analysis revealed that a UWT value of 4.5 mm (sensitivity 60%, specificity 92%) was the optimal cut-off value predictive of the URS outcome. The regression analysis revealed UWT >4.5 mm (p = 0.006) and multiple stone presentation (p = 0.005) as independent risk factors for residual stone. Complications were detected in 15 (17%) children. Thick ureteral wall (p = 0.012) and longer operative time (p = 0.016) were defined as the independent risk factors for complications.

DISCUSSION

Increased UWT is associated with the adverse outcomes of URS due to tissue hypertrophy, edema, and mucosal bleeding may cause difficulty in removing the stone. The thick ureteral wall might increase the risk of complications due to the necessity of manipulating the instruments or the involuntary forceful use of instruments while removing the stone.

CONCLUSION

UWT was the only independent variable affecting both increased failure and complication rates in children undergoing URS.

An In vitro Study of Orthosiphon stamineus (Misai Kucing) Standardized Water Extract as a Chemolytic Agent in Urolithiasis

BACKGROUND

Orthosiphon stamineus was reported to have diuretic effects in experimental rats, and this leads to inhibition of kidney stones through the abundant levels of minerals and flavonoids in it. This study aimed to determine the in vitro effects of O. stamineus water extract as a potential chemolytic agent in urolithiasis.

MATERIALS AND METHODS

In this prospective experiment, a total of 15 stone samples collected from patients who underwent stone extraction were used in each concentration (4 mg/ml, 2 mg/ml, and 1 mg/ml) of the O. stamineus extract and control solution. The effects of pH change in the chemolysis of the stones were assessed using the O. stamineus extract 4 mg/ml under pH 7 and 8.

RESULTS

The percentage weight reduction of calcium oxalate stone was highest in the 4 mg/ml concentration. O. stamineus extract 4 mg/ml showed a better effect in terms of chemolytic action on calcium oxalate stone than the potassium citrate solution (70% vs. 41%). Regarding the calcium oxalate stone, the percentage weight reduction has shown about 70% in the pH 5, 48% in pH 7, and <10% in pH 8. The percentage weight reduction of uric acid stone was determined as 47%, 11%, and 14% for pH 5, 7, and 8, respectively. The percentage weight reduction of combination stone was 40%, 60%, and 80% in the pH 5, pH 7, and pH 8, respectively. Data analysis showed that the percentage weight reduction of combination stone was significantly different between acidic, neutral, and alkaline conditions (P = 0.027).

CONCLUSIONS

In this in vitro study, we are able to show that O. stamineus water extract do have some dissolving capability of urinary stones.

'Boxing in the corner': A modified retrograde approach for the management of proximal ureteric stones of 1-2 cm

Objectives: To study a modification to the conventional retrograde ureteroscopic approach for treating proximal ureteric stones of 1–2 cm; we intentionally push the stone from the proximal ureter into a favourable calyx then the flexible ureteroscope is used to fragment the trapped stone using laser lithotripsy (‘boxing in the corner’).

Patients and methods: The study was conducted in a randomised prospective manner and included 100 patients who presented with a single proximal ureteric stone of 1–2 cm. We randomised the patients into two equal groups: Group A (50 patients) underwent the conventional retrograde technique (CRT) and Group B (50 patients) underwent the modified retrograde technique (MRT) with the primary intention of relocating the stone into a favourable calyx. Intended relocation of the proximal ureteric stone in the MRT group was achieved in a stepwise manner. All intraoperative parameters and postoperative outcomes were recorded and compared between the two groups.

Results: There was no statistical significant difference in terms of the patients’ demographics and stone criteria between the two groups. The stone-free rate (SFR) was significantly higher in Group B (92%) compared to Group A (78%) (P = 0.049). Fluoroscopy time was significantly longer in Group B (P < 0.001), while operative time, lithotripsy time and hospital stay were comparable. There was no difference between the groups regarding complications.

Conclusion: The MRT was found to be safe and more effective than the CRT for treating proximal ureteric stones of 1–2 cm, with a significantly higher SFR.

Abbreviations CONSORT: Consolidated Standards of Reporting Trials; ESWL: extracorporeal shockwave lithotripsy; fURS: flexible ureteroscope; NCCT: non-contrast CT; SFR: stone-free rate; YAG: yttrium-aluminium-garnet

Laparoscopic surgery for upper ureteral calculi in geriatric patients: 5 years experience

OBJECTIVE

We have reviewed the success of laparoscopic calculi surgeries in geriatric patients.

METHODS

A retrospective analysis was performed on the laparoscopic ureterolithotomy surgeries performed at our central between January 2014 and January 2019 to treat upper ureteral calculi in geriatric patients. Among the patients who underwent these surgeries, we evaluated data on 24 cases whose records could be fully retrieved.

RESULTS

The age interval of the patients was 60-73 years, and the mean age was 63 ± 3.43 years. The size of the calculi was 19-24 mm, and mean size was 20.2 ± 2.5 mm. Because stone disease was present previously, 5 of these patients underwent endoscopic intervention, whereas two underwent open surgery. Sixteen of these patients had a history of unsuccessful shock wave lithotripsy (SWL) or ureterorenoscopy. The calculi-free rate was 100%. According to the modified Clavien classification, no major perioperative and postoperative complications were observed. The duration of hospital stay was 1-3 days, and the mean duration of stay was 1.6 ± 0.9 days.

CONCLUSION

We believe that owing to the high success and low complication rates, laparoscopic ureterolithotomy can be the first option of treatment for geriatric patients with impacted large calculi, with a history of unsuccessful SWL or ureterorenoscopy (semirigid, flexible).

Laparoscopic ureterolithotomy versus ureteroscopic laser lithotripsy for large proximal ureteral stones: a systematic review and meta-analysis

INTRODUCTION

To review current studies and conduct a meta-analysis on the topic of laparoscopic ureterolithotomy (LU) versus ureteroscopic lithotripsy (URSL) with holmium laser for large proximal ureteral stones.

EVIDENCE ACQUISITION

A systematic research of PubMed, Ovid, Scopus (up to March 2019), and citation lists was performed to identify eligible comparative studies. All studies comparing LU versus URSL with holmium laser in proximal ureteral stones were included. Statistical analyses were performed using the Cochrane Collaboration's Review Manager (RevMan) 5.3 software.

EVIDENCE SYNTHESIS

Overall, seven studies were included in analysis involving 884 patients (LU 387; URSL 497). Our meta-analysis showed that LU group had bigger stone size than URSL group (WMD 0.19 cm; P=0.001). LU group was associated with longer operative time (WMD 36.29 min; P<0.001), and length of hospital stay (WMD 1.24 d; P=0.04). However, LU group showed better initial stone-free rate (OR 11.03; P<0.001), and final stone-free rate (OR 22.37; P<0.001). There were no significant differences in all complications (RR 1.06; P=0.76). While, LU group had fewer Clavien Dindo score ≥3 complications (RR 0.21; P=0.002), fewer ureteral stricture (RR 0.26; P=0.04), and lower need of auxiliary procedures (RR 0.09; P<0.001) compared with URSL group.

CONCLUSIONS

LU could provide a higher stone-free rate and fewer severe complications compared with URSL with holmium laser for large proximal ureteral stones. More importantly, LU could also reduce the postoperative ureteral stricture rate.

Laparoscopic Ureterolithotomy vs Ureteroscopic Lithotripsy for Large Ureteral Stones

Background and Objectives:

The purpose of this study was to compare two methods (transperitoneal laparoscopic ureterolithotomy [TLU] and a combination of ureteroscopic lithotripsy [UL] with retrograde intrarenal surgery [RIRS]) designed for the treatment of large proximal ureteral calculi so that their associated complications and stone-free rates could be assessed.

Methods:

A total of 100 patients from three different hospitals who were diagnosed with large upper ureteral stones (≥15 mm) were treated via TLU (n = 48) or UL-RIRS (n = 52). They were treated between March 2012 and May 2014. The study compared the complications, success rate, patient characteristics, and the operation time between the two groups.

Results:

The immediate stone clearance rate after a single session was higher in the TLU group than in the UL-RIRS group (100% vs 73.1%, P = .005). However, there was no significant difference in the stone-free rates between the two groups three months after the last procedure was performed (100% vs 96.1%, P = .655). Regarding patients with a history of early-failure extracorporeal shock-wave lithotripsy, there was no significant difference in the stone-free rate between the two groups three months after the last procedure (100% vs 94.4%, P > .05). Further, overall complication rates between the groups were not statistically different (P = .261).

Conclusion:

This study demonstrates that TLU is an effective and safe procedure to treat large impacted upper ureteral stones. When compared to UL-RIRS, TLU showed equivalent efficacy and safety, though there were failed first-line treatments.

Minimally Invasive Percutaneous Nephrolithotomy versus Retrograde Intrarenal Surgery for Upper Urinary Stones: A Systematic Review and Meta-Analysis

Minimally invasive percutaneous nephrolithotomy (mini-PCNL) and retrograde intrarenal surgery (RIRS) are both alternatives for PCNL to treat renal calculi. This study is aimed at comparing the stone-free rate (SFR) and other surgery parameters of two approaches for treating upper urinary calculi. We performed this meta-analysis in September 2016 by searching studies about mini-PCNL and RIRS for treating upper urinary calculi in various databases, and RevMan v.5.3 was applied. Three randomized controlled trials and ten nonrandomized trials were included, involving a total of 1317 patients. Meta-analysis showed that mini-PCNL group led to a higher SFR [odds ratio: 1.96; 95% confidence interval: 1.46–2.64; P < 0.00001] but brought a larger postoperative decrease in hemoglobin levels compared with RIRS. RIRS provided a shorter hospital time. There was no significant difference in operation time. Higher postoperative complications were detected in the mini-PCNL, but the difference was not significant. Grade I and III complications did not vary between two procedures, but grade II complications were of lower incidence in RIRS group. In the light of these results, compared with RIRS, mini-PCNL provided significantly higher SFR and efficiency quotient for managing calculi; however, it resulted in higher incidence of postoperative complications, larger hemoglobin drops, and longer hospital stay.

Characteristics and outcomes of ureteroscopic treatment in 2650 patients with impacted ureteral stones

Purpose

To describe stone-free rates and complications of ureteroscopic treatment for impacted compared with non-impacted ureteral stones and evaluate predictive variables for impaction.

Methods

The Clinical Research Office of the Endourological Society prospectively collected 1 consecutive year of data from 114 centers worldwide. Patients eligible for inclusion were patients treated with ureteroscopy for ureteral stones. Patient characteristics, treatment details, and outcomes were compared with regard to stone impaction. Logistic regression analyses were conducted to explore predictive variables for ureteral stone impaction and to analyse the effect of impaction on outcomes.

Results

Of the 8543 treated patients, 2650 (31%) had impacted and 5893 (69%) non-impacted stones. The stone-free rate was 87.1% for impacted stones, which is lower compared with 92.7% for non-impacted stones (p < 0.001). Intra-operative complication rates were higher for impacted stones (7.9 versus 3.0%, p < 0.001). Significantly higher ureteral perforation- and avulsion rates were reported in the impacted stone group compared with the non-impacted stone group. No association between stone impaction and post-operative complications could be shown. Female gender, ASA-score >1, prior stone treatment, positive pre-operative urine culture, and larger stones showed to be predictive variables for stone impaction.

Conclusions

Ureteroscopic treatment for impacted stones is associated with lower stone-free rates and higher intra-operative complication rates compared with treatment for non-impacted stones. The predictive variables for the presence of stone impaction may contribute to the identification of stone impaction during the diagnostic process. Moreover, identification of stone impaction may aid the selection of the optimal treatment modality.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-017-2028-2) contains supplementary material, which is available to authorized users.

Rigid ureteroscopic lithotripsy versus percutaneous nephrolithotomy for large proximal ureteral stones: A meta-analysis

Object

To compare the safety and efficacy of rigid ureteroscopic lithotripsy (rigid URSL) and percutaneous nephrolithotomy (PCNL) in treating large proximal ureteral stones.

Methods

A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science databases was performed to find out relevant studies. After literature screening according to the predetermined inclusion and exclusion criteria, data of eligible studies was extracted and then a meta-analysis was conducted via RevMan 5.3 software.

Results

Five randomized controlled trials (RCTs), one prospective and four retrospective cohort studies involving 837 patients were included. Patients underwent rigid URSL were associated with shorter operation time (WMD, -23.66min; 95%CI, −45.00 to -2.32; p = 0.03), shorter hospital stay (WMD, -2.76d; 95%CI, −3.51 to −2.02; p< 0.00001), lower 3rd-day (RR, 0.73; 95%CI, 0.66 to 0.82; p < 0.00001) and 1st-month (RR, 0.82; 95%CI, 0.77 to 0.87; p < 0.00001) stone-free rate, higher risk of conversion to other surgical procedures (RR, 4.28; 95%CI, 1.93 to 9.46; p = 0.0003), higher incidence of migration (RR, 28.49; 95%CI, 9.12 to 89.00; p < 0.00001) and ureteral perforation (RR, 6.06; 95%CI, 1.80 to 20.44; p = 0.004), lower risk of fever (RR, 0.64; 95%CI, 0.42 to 0.97; p = 0.04), transfusion (RR, 0.19; 95%CI, 0.04 to 0.85; p = 0.03) and hematuria (RR, 0.38; 95%CI, 0.25 to 0.57; p < 0.0001). No significant difference was observed in terms of incidence of embolization, pain and ureterostenosis. When cohort studies or studies in which flexible ureteroscopy was used as an intraoperative auxiliary procedure were excluded, we both found that most of the results kept stable.

Conclusions

Both PCNL and rigid URSL are safe for patients with large proximal ureteral stones while PCNL is more effective in stone clearance.

Comparison of the clinical efficacy and safety of retroperitoneal laparoscopic ureterolithotomy and ureteroscopic holmium laser lithotripsy in the treatment of obstructive upper ureteral calculi with concurrent urinary tract infections

The aim of this study is to compare the clinical efficacy and safety of retroperitoneal laparoscopic ureterolithotomy (RPLU) and ureteroscopic holmium laser lithotripsy (UHLL) as two minimally invasive procedures in managing obstructive upper ureteral calculi with concurrent urinary tract infections (UTI). The retrospective study included 189 patients who underwent unilateral obstructive upper ureteral stones with concurrent UTI from January 2007 to November 2014 at our institution. Patients received RPLU (81 cases) or UHLL (108 cases). All patients received preoperative anti-infection treatment (indwelling ureteral stent and/or preoperative antibiotics). Collected data, including sex, age, stone size, success rate, operation duration, post-operation hospitalization time, and post-operation complications, were compared. All patients were followed up for more than 6 months after surgeries, and no ureterostenosis occurred. The study included 189 patients, 41 (21.7 %) females and 148 (78.3 %) males with a medium age of 52 years (range 22-81 years). All surgeries were successfully performed without conversion to open surgery. Stone size in the RPLU group was larger than that of the UHLL group (16.1 ± 1.4 vs. 10.4 ± 1.6 mm, P = 0.012). Operative duration (P = 0.009) and hospitalization time (P < 0.001) in the UHLL group were significantly shorter than those in the RPLU group, whereas stone clearance rate was significantly higher in the RPLU group (100 vs. 88.9 %, P = 0.002). Of note, postoperative fever was more common in patients treated with UHLL (15 cases) versus RPLU (4 cases) (13.9 vs. 4.9 %, P = 0.043). Moreover, in the UHLL group, three patients without a preoperative indwelling ureteral stent were complicated with sepsis, which was not seen in RPLU group. In our study, the safety and stone clearance rate of RPLU are better than those of UHLL in the treatment of unilateral upper ureteric calculi with concurrent UTI. Preoperative antibiotics and indwelling ureteral stent may reduce the risk of postoperative infections.

CUA Guideline: Management of ureteral calculi

The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.

Flexible Ureteroscopy versus Retroperitoneal Laparoscopic Ureterolithotomy for the Treatment of Proximal Ureteral Stones >15 mm: A Single Surgeon Experience

OBJECTIVE

To compare safety and effectiveness of flexible ureteroscopy (F-URS) and laparoscopic retroperitoneal ureterolithotomy (L-RU) in treatment of proximal ureteral stones larger than 15 mm.

MATERIALS AND METHODS

This study included 103 patients treated with L-RU (Group I), and 80 patients treated with F-URS (Group II) due to proximal ureteral stones larger than 1.5 cm, in a single center. Patients' characteristics and procedure-related parameters including success rate, operation time, hospital stay, postoperative visual analogue scale (VAS) scores, auxiliary procedures, and complications were compared between Groups I and II.

RESULTS

It was seen that both methods were effective in the treatment of large ureteral stones; however, R-LU provided a higher stone-free rate (100 vs. 87.5%), a lower complication rate (10.6 vs. 23.7%), and a shorter operation time (65.4 vs. 75.1 min). On the other hand, patients treated with F-URS had less postoperative pain, a shorter hospital stay, a faster return to daily activities.

CONCLUSIONS

For treatment of large proximal ureteral stones, L-RU provides significantly higher success and lower retreatment rate compared with F-URS. Our results also indicate that R-LU, which has been regarded as an invasive procedure is not as invasive as it is thought to be, and it must be kept in mind that F-URS may cause complications despite its noninvasive nature.

Retroperitoneal laparoscopic ureterolithotomy in comparison with ureteroscopic lithotripsy in the management of impacted upper ureteral stones larger than 12 mm

OBJECTIVE

To compare the results of ureteroscopic lithotripsy (URSL) with retroperitoneal laparoscopic ureterolithotomy (RPLU) as two minimally invasive techniques in the management of proximal ureteral stones larger than 12 mm.

PATIENTS AND METHODS

From January 2009 to October 2013, patients with impacted unilateral upper ureteral stones larger than 12 mm were enrolled including 182 males and 93 females with a medium age of 40 years (22-72 years). Patients were randomized to receive URSL (139 cases) with semirigid ureteroscope or RPLU (136 cases).

RESULTS

Stone size was similar in RPLU and URSL groups (13.8 ± 1.9 vs 13.6 ± 1.4 mm, P = 0.312). Operating time and hospitalizing days in URSL group were significantly shorter than those in RPLU group (P < 0.001), whereas stone clearance rate was significantly higher in RPLU group (97.1 vs 89.9 %, P = 0.017). Ureteral strictures happened higher in URSL group (5 patients, 3.6 %) than RPLU group (2 patients, 1.5 %) with no statistical significance, while the strictures requiring surgical intervention were significantly higher in URSL group (4 cases) (2.9 vs 0 %, P = 0.046).

CONCLUSION

RPLU could provide better stone clearance rate than semirigid URSL for upper ureteral impacted stones larger than 12 mm. It may also reduce the chance of surgical intervention for postoperative ureteral stricture.

A comparison of antegrade percutaneous and laparoscopic approaches in the treatment of proximal ureteral stones

Purpose. To compare the effectiveness and safety of retroperitoneal laparoscopic ureterolithotomy (RLU) and percutaneous antegrade ureteroscopy (PAU) in which we use semirigid ureteroscopy in the treatment of proximal ureteral stones. Methods. Fifty-eight patients with large, impacted stones who had a history of failed shock wave lithotripsy (SWL) and, retrograde ureterorenoscopy (URS) were included in the study between April 2007 and April 2014. Thirty-seven PAU and twenty-one RLU procedures were applied. Stone-free rates, operation times, duration of hospital stay, and follow-up duration were analyzed. Results. Overall stone-free rate was 100% for both groups. There was no significant difference between both groups with respect to postoperative duration of hospital stay and urinary leakage of more than 2 days. PAU group had a greater amount of blood loss (mean hemoglobin drops for PAU group and RLU group were 1.6 ± 1.1 g/dL versus 0.5 ± 0.3 g/dL, resp.; P = 0.022). RLU group had longer operation time (for PAU group and RLU group 80.1 ± 44.6 min versus 102.1 ± 45.5 min, resp.; P = 0.039). Conclusions. Both PAU and RLU appear to be comparable in the treatment of proximal ureteral stones when the history is notable for a failed retrograde approach or SWL. The decision should be based on surgical expertise and availability of surgical equipment.

Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position

Context:

The treatment for patients with large impacted proximal ureteral stone remains controversial, especially at institutions with limited resources.

Aim:

The aim of this study is to compare and to evaluate the outcome and complications of two main treatment procedures for impacted proximal ureteral calculi, retrograde ureterolithotripsy (URS), and percutaneous antegrade ureterolithotripsy (Perc-URS).

Settings and Design:

Our inclusion criteria were solitary, radiopaque calculi, >15 mm in size in a functioning renal unit. Only those patients in whom the attempt at passing a guidewire or catheter beyond the calculus failed were included in this study.

Patients and Methods:

Between January 2007 and July 2011, a total of 52 patients (13 women and 39 men) with large impacted upper-ureteral calculi >15 mm and meeting the inclusion criteria were selected. Of these, Perc-URS was done in 22 patients (group 1) while retrograde ureteroscopy was performed in 30 patients (group 2). We analyzed operative time, incidence of complications during and after surgery, the number of postoperative recovery days, median total costs associated per patient per procedure, and the stone-free rate immediately after 5 days and after 1 month.

Statistical Analysis Used:

Bivariate analysis used the Student t-test and the Mann-Whitney test to compare two means and Chi-square and Fisher's exact tests to compare two percentages. The significance level was set at 0.05.

Results:

The mean age was 42.3 years (range 22-69). The mean stone sizes (mm) were 34 ± 1.2 and 29.3 ± 1.8 mm in group 1 and 2, respectively. In the Perc-URS group, 21 patients (95.45%) had complete calculus clearance through a single tract in one session of percutaneous surgery, whereas in the URS group, only 20 patients (66.7%) had complete stone clearance (P = 0.007). The mean operative time was higher in the Perc-URS group compared to group 2 (66.5 ± 21.7 vs. 52.13 ± 17.3 min, respectively; P = 0.013). Complications encountered in group 1 included transient postoperative fever (2 pts) and simple urine outflow (2 pts). Ten patients (33%) of group 2 experienced failure: Migration to the kidney (3 pts), ureteral perforation (2 pts), tortuosity of the ureter (2 pts), and epithelial polyps (2 patients). Group 1 patients had an average visual analog (VAS) pain score of 47 mm compared with 31 mm in group 2 patients. The mean hospital stay (days) in group 1 was higher than the group 2 (2.27 ± 0.8 vs. 1.67 ± 0.6, respectively; P = 0.01). The mean analgesia requirement for group 1 (paracetamol chlorhydrate + codeine 12 ± 3 g) was significantly more compared with group B (6.8 ± 2 g) (P < 0.01). The difference in average blood loss between the two groups was not statistically significant. Total costs was slightly higher in group 1 but the difference was not statistically significant between the two groups (15000 vs. 13400 MDH respectively; P > 0.05). After 1 month, the stone free-rate remained higher in group 1 (95.5% vs. 66.7%, respectively; P = 0.012).

Conclusions:

In our series, Perc-URS is a safe and efficient treatment option for proximal ureteral stone, especially when the stone size is superior to 15 mm with the presence of moderate or severe hydronephrosis.

Percutaneous nephrolithotomy versus ureteroscopic lithotomy for large (>15 mm) impacted upper ureteral stones in different locations: is the upper border of the fourth lumbar vertebra a good indication for choice of management method?

Abstract To determine whether treatment of patients with large (>15 mm) impacted upper ureteral stones depended on stone location, we prospectively evaluated the therapeutic outcomes, complications, safety, and effectiveness of percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotomy (URSL) in patients with stones higher and lower than the upper border of the fourth lumbar vertebra. Of the 174 patients analyzed, 83 (47.7%) underwent PCNL and 91 (52.3%) underwent URSL; all patients were followed up 1 month later and every 6 months for 18 months. Mean operation time (108.76±19.36 vs. 63.56±16.38 minutes, p<0.05) and postoperative hospital stay (2.49±1.23 vs. 5.36±1.98 days, p<0.05) were significantly longer in the PCNL than in the URSL group. The overall stone-free rates after 1 month were 96.4% and 75.8%, respectively, differing significantly for stones higher (97.8% vs. 57.5%, p<0.05) but not lower (94.7% vs. 90.2%) than the upper border of the fourth lumbar vertebra. The stone-retropulsion rate of URSL differed significantly for stones higher and lower than the upper border of the 4th lumbar vertebra (47.5% vs. 9.8%, p<0.05). Postprocedural complication rates were comparable in the URSL and PCNL groups, although the rate of auxiliary or salvage procedures was higher in the URSL group. The efficiency quotients (EQ) for PCNL and URSL were 0.93 and 0.59, respectively, with EQs in the URSL group differing significantly for stones higher and lower than the upper border of the fourth lumbar vertebra (0.40 vs. 0.82, p<0.05). Our findings indicate that treatment of impacted upper ureteral stones is dependent on stone location relative to the upper border of the fourth lumbar vertebra. URSL is unsuitable for stones at a higher location, whereas URSL and PCNL were equally effective for stones at a lower location.

Experience of mini-percutaneous nephrolithotomy in the treatment of large impacted proximal ureteral stones

OBJECTIVES

To evaluate the efficacy and safety of mini- percutaneous nephrolithotomy (PCNL) in the treatment of large impacted proximal ureteral stones.

METHODS

We retrospectively reviewed the outcomes of 163 patients who underwent mini-PCNL between January 2006 and August 2010. Mean age was 48.6 years and mean stone size was 18.4 mm. Hydronephrosis and/or hydroureterosis appeared in all patients. In the prone position, percutaneous access (16-Fr sheath) was established by placement of an access needle into the intended calyx under fluoroscopic guidance or combined with ultrasound guidance for complete obstruction by stones while the contrast agent cannot transit. Pneumatic or ultrasonic probes were used throughout ureterorenoscopy for lithotripsy. The ureteral stents and nephrostomy tube were placed at the end of the procedure. Mean drop in hemoglobin, operative time, success rate, hospital stay, and complications were assessed.

RESULTS

Mini-PCNL operations were performed successfully in all patients. Mean operation time was 37 min. Mean postoperative hospital stay was 3.6 days. All cases were followed up for 6-20 months. No major complications like hemorrhage, perforation or organic injury were noted during the operation or postoperatively. The stone-free rate in all patients was 95.7%. Calculus had no recurrence during the follow-up period. Hydronephrosis and hydroureterosis disappeared or were relieved.

CONCLUSIONS

Mini-PCNL is a safe and effective therapy for large impacted proximal ureteral stones.

Treatment of large impacted proximal ureteral stones: randomized comparison of minimally invasive percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy

OBJECTIVE

To provide appropriate evidence for treatment planning of patients with an impacted proximal ureteral stones ≥1.5 cm in size, by analyzing the therapeutic outcomes for those undergoing minimally invasive percutaneous antegrade ureterolithotripsy and retrograde ureterolithotripsy.

PATIENTS AND METHODS

From September 2010 to November 2011, eligible patients with impacted proximal ureteral stones ≥1.5 cm in size referred to our institute were considered for this study. The closed envelope method was used to randomize the enrolled patients to mini-PCNL (30) or retrograde ureterolithotripsy (29). The efficiency quotient (EQ) was calculated to specifically address the efficiency for both the techniques. All preoperative and postoperative data for both groups were recorded.

RESULTS

The initial stone-free rate was 93.3% in the mini-PCNL group and 41.4% in the URSL group (p < 0.001). However, the overall stone-free rate at the 1-month follow-up visit after initial treatment was 100% in the mini-PCNL group and 89.7% in the URSL group (p = 0.07). The EQs for the mini-PCNL and URSL groups were 0.83 and 0.50, respectively.

CONCLUSIONS

Our study shows that mini-PCNL removal of large impacted proximal ureteral calculi can achieve higher stone-free rates and safe.

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.

Semirigid ureteroscopy in management of large proximal ureteral calculi: is there still a role in developing countries?

OBJECTIVES

To evaluate the outcome and complications of the use of semirigid ureteroscopy (URS) together with intracorporeal pneumatic lithotripsy in the management of upper ureteral calculi >10 mm in diameter.

METHODS

A total of 75 patients (41 women and 34 men), with a mean age of 48 years (range 25-60), underwent primary URS for solitary radiopaque proximal ureteral calculi 10-20 mm in diameter (average 13.1). Dilation of the intramural ureter was done in 60 cases (80% of patients), and intracorporeal lithotripsy was required in 56 (74.6%). Ureteral catheters were left for drainage in 60% of patients, 26.7% were left unstented, and only 13.3% required an indwelling stent.

RESULTS

Of the 75 stones, 60 (80%) were successfully cleared after a single endoscopic procedure. Our initial stone-free rate was 90.6% at 2 weeks after the primary endoscopic procedure and had reached 98.6% at 3 months. Antegrade URS for migrating stones was done successfully in 6 cases in a tubeless fashion, and open ureterolithotomy was required in 1 case. No major complications were encountered. The minor complications included only mild extravasation and self-limited postoperative fever and hematuria. The risk factors for URS failure included male gender, the severity of the hydronephrosis, the severity of impaction, and the occurrence of extravasation.

CONCLUSIONS

The results of our study have shown that semirigid URS is a safe and successful alternative to open ureterolithotomy in the management of large proximal ureteral calculi in the absence of flexible instruments.

Antegrade flexible ureteroscopy for bilateral ureteral stones in a patient with severe hip joint ankylosis

In the past several decades there has been a remarkable development of small-caliber, flexible ureteroscopes and various ancillary instruments for stone manipulation and retrieval. Percutaneous antegrade ureteroscopy can be substituted in select cases for retrograde ureteroscopy. We report a case of a 60-year-old man with severe ankylosis in both hip joints who was diagnosed with bilateral ureteral stones. The patient underwent antegrade flexible ureteroscopy and laser lithotripsy. This case illustrates the role of antegrade flexible ureteroscopy combined with the holmium:YAG laser as a minimally invasive, safe, and effective technique for the management of stones in a patient who cannot undergo a retrograde approach.

A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi

OBJECTIVES

To conduct a prospective randomized study comparing both techniques for the management of solitary radio-opaque upper ureteral stones < 2 cm in diameter. The ideal treatment for upper ureteral stones > 1 cm size remains to be determined with shock wave lithotripsy (SWL) and ureteroscopy (URS) being acceptable options.

METHODS

A total of 200 patients were included in the study. They were randomized into 2 equal groups. Group A underwent in situ SWL as a primary therapy. Group B underwent URS, using semirigid URS with intracorporeal lithotripsy. Efficiency quotient (EQ), cost analysis, and predictors of failure were estimated for both techniques.

RESULTS

For stones of size > or = 1 cm, the initial stone-free rate for URS and SWL was 88% and 60%, respectively. The estimated EQ was 0.79 and 0.43 for both techniques respectively. For stones < 1 cm, the initial stone-free rate for URS and SWL was 100% and 80%, respectively. The estimated EQ was 0.88 and 0.70 for both techniques, respectively. The mean cumulative costs were significantly more in SWL group (P <.05). Predictors of URS failure included; male gender, failure to pass guidewire beyond the stone, and extravasation. Predictors of SWL failure included large stone size > 1 cm, calcium oxalate monohydrate stone, and higher degrees of hydronephrosis.

CONCLUSIONS

URS with intracorporeal lithotripsy is an acceptable treatment modality for all proximal ureteral calculi, particularly stones > 1 cm. SWL should remain the first-line therapy for proximal ureteral calculi < or = 1 cm because of the less invasive nature and lower anesthesia (i.v. sedation).

[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.

[Diagnosis and therapy of acute ureteral colic]

Acute ureteral colic presents with a complex of acute and characteristic flank pain that usually indicates the presence of a stone in the urinary tract. Diagnosis and management of renal colic have undergone considerable evolution and advancement in recent years. The application of noncontrast helical computed tomography (CT) in patients with suspected ureteral colic is one major advance in the primary diagnostic process. The superior sensitivity and specificity of helical CT allow ureterolithiasis to be diagnosed without the potential side effects of contrast media. Initial management is based on three key concepts: (A) rational and fast diagnostic process (B) effective pain control (C) and understanding of the impact of stone location and size on the natural course of the disease and definitive urologic management. These concepts are discussed in this review with reference to contemporary literature.

Treatment of large impacted proximal ureteral stones: randomized comparison of percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy

PURPOSE

We compared the safety and efficacy of percutaneous antegrade ureterolithotripsy with retrograde ureterolithotripsy for large impacted proximal ureter stones in a prospective randomized manner.

MATERIALS AND METHODS

A total of 91 patients with large impacted proximal ureteral stones, defined as stones >1 cm in size located between the ureteropelvic junction and the lower border of the fourth lumbar vertebra, were prospectively randomized for antegrade (44) or retrograde (47) ureterolithotripsy. Failure of the procedure (conversion to an open procedure), intraoperative and postoperative morbidity, operative time, hospital stay, stone clearance at discharge home, and follow-up were analyzed in each group.

RESULTS

The main complications were bleeding (2.3%; 1 of 43) for the antegrade procedure and ureteral injury (2.3%; 1 of 44) for the retrograde procedure. Percutaneous antegrade ureterolithotripsy was associated with longer operative times (75.4+/-11.8 v 30.6+/-7.8 minutes; P<0.001), longer hospital stay (6.3+/-0.5 v 2.1+/-0.4 days; P<0.001), and a longer interval to return to normal activities (7.8+/-0.7 v 2.7+/-0.6 days; P<0.001). Nevertheless, the percutaneous antegrade procedure had a higher stone-free rate both at discharge home (95.3% v 79.5%; P=0.027), and 1 month post-procedure (100% v 86.4%; P=0.026).

CONCLUSIONS

Percutaneous antegrade ureterolithotripsy is a valuable treatment modality for impacted proximal ureteral calculi larger than 1 cm, and achieves higher stone-free rates than those of retrograde ureteroscopy with holmium:YAG laser lithotripsy. The drawbacks of the antegrade procedure are longer operative time and hospital stay.

Comparison of percutaneous nephrolithotomy and ureteroscopic lithotripsy in the management of impacted, large, proximal ureteral stones

The optimal treatment for large, impacted, proximal ureteral stones remains controversial. We report our experience and compare treatment outcomes in patients with single, impacted, proximal ureteral stones undergoing percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL). Between January 2005 and January 2006, a total of 53 consecutive patients with solitary, impacted, proximal ureteral stones > 15 mm in diameter who had undergone PCNL or URSL treatments were enrolled in this study. The mean age was 48.5 +/- 11.8 years. PCNL and URSL were performed in 22 and 31 patients. Stone burdens in the PCNL and URSL groups were 232.8 +/- 113.2 mm2 and 150.3 +/- 70.3 mm2, respectively. The efficiency quotient (EQ) for the PCNL and URSL groups was 0.95 and 0.67, respectively. The stone-free rate at the 1 month follow-up was 95.4% in the PCNL group and 58% in the URSL group (p < 0.001). Two patients in the PCNL group had blood loss requiring transfusion. Eight patients had stones showing upward migration during the URSL procedure, and these stones were subsequently treated by extracorporeal shock wave lithotripsy and PCNL. For an impacted, proximal ureteral stone > 15 mm in diameter, PCNL had better stone-free rates and could simultaneously treat coexisting renal stones. However, URSL had the advantages of shorter operative times, shorter postoperative hospital stays, and fewer postoperative complications.

Treatment Selection and Outcomes: Ureteral Calculi

The most important recent advances in the management of ureteral calculi have been the development of medical expulsive therapy to facilitate passage of ureteral stones, such that many calculi that would previously have required procedural treatment now exit the ureter with only pharmacologic treatment; and the improvements in ureteroscopic technology that have enabled retrograde ureteroscopy to become a first-line option for most ureteral stones. Shock wave lithotripsy still plays an important role for many ureteral calculi, particularly smaller ones, and the addition of percutaneous/antegrade ureteroscopy and laparoscopic ureterolithotomy rounds out the treatment options for large or impacted stones. Selection of treatment based upon factors such as size, location, and others will optimize outcome for patients who have ureteral calculi.

Percutaneous nephrostomy for removal of large impacted upper ureteral stones

The treatment for patients with large impacted proximal ureteral stone remains controversial. Extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy are the most popular treatment options due to their minimal invasive nature. However, percutaneous nephroscopic ureterolithotripsy is still important. Between June 2004 and March 2006, a total of 24 patients under went percutaneous antegrade nephrostomy for the removal of large impacted proximal ureteral stones of size > 15 mm. Combined ultrasonic and pneumatic lithotripters were used for the stone fragmentation. Twenty-three (95.8%) of the 24 patients were stone-free after one session of surgery. The mean operation time was 125.4 +/- 49.5 minutes (range, 45-170 minutes) and the mean postoperative hospital stay was 4.7 +/- 2.0 days (range, 4-12 days). Among the 24 patients, six experienced transient postoperative fever that could be controlled with appropriate antibiotics and supportive treatment, and two had blood loss requiring blood transfusion. We suggest that percutaneous nephroscopic ureterolithotripsy is a safe and efficient treatment option for the removal of large impacted proximal ureteral stones.

Rapid, economical treatment of large impacted calculi in the proximal ureter with ballistic ureteral lithotripsy and occlusive, percutaneous balloon catheter: the high pressure irrigation technique

PURPOSE

We describe our innovative technique for the treatment of large calculi (greater than 1.5 cm) of the proximal ureter.

MATERIALS AND METHODS

Between 2003 and 2005 we positioned an 8Ch pyelostomy in 25 patients diagnosed with impacted calculi of the proximal ureter greater than 1.5 cm on ultrasound, direct x-ray of the abdomen, and/or computerized tomography and subsequent retrograde pyelography. After 30 days all patients underwent combined treatment in the Valdivia supine position, including positioning a 0.035-inch guidewire through the pyelostomy into the ureter up to above the calculus, pyelostomy removal and insertion onto the guide of a 7Ch balloon occlusion catheter, which was inflated in the ureter immediately above the calculus. Ureteral lithotripsy was done with an 8.5 to 11.5Ch ureteroscope (Wolf, Dudley, Massachusetts) with a 6Ch operating channel and a Calcusplit ballistic probe, alternating high antegrade pressure by the balloon catheter and retrograde pressure using the ureteroscope, as required. After lithotripsy and fragment dislocation the ureteroscope was retracted with rapid flow antegrade irrigation. At the end of the procedure after antegrade contrast medium followup the balloon catheter was retracted as far as the pelvis as a nephrostomy. We analyzed operative time, the number of postoperative recovery days, the incidence of complications during and after surgery, and the stone-free rate immediately, after 5 days and after 1 month.

RESULTS

Average calculus size was 1.7 cm. Ten patients presented with multiple ureteral bending upon diagnosis, which was no longer found at surgery with a consequent lack of difficult ureteroscope feeding. Significant edema downstream of the calculus was present in all cases. High pressure irrigation, a rigid ballistic probe and retrieving forceps enabled the dislocation of even larger fragments from the original calculous site in all cases. Antegrade high pressure irrigation after lithotripsy enabled the complete clearance of calcareous fragments as far as the bladder without the need for ancillary maneuvers. We observed no cases of calcareous fragment push-back. No retroperitoneal extravasation, or pyelolymphatic or pyelovenous backflow was observed. Average procedure time was 33 minutes. The renal-ureteral stone-free rate was 100% at the end of the procedure and all calcareous fragments were in the bladder. We did not observe any ureteral lesions. In no case was there onset of fever. Average postoperative hospitalization was 2 days. Followup with contrast material after 5 days showed a renal-ureteral stone-free rate of 100% and a bladder stone-free rate of 84%. The nephrostomy was removed at an average of 5.5 days.

CONCLUSIONS

Compared to the techniques described in the medical literature our method appears to have certain advantages, including a mini-invasive approach to the renal pelvis compared to that of percutaneous nephrolithotomy with protection of the renal parenchyma from high pressure, rigid ureteroscope use, which provides a high level of maneuverability and low operating costs, ballistic probe use, which provides lower costs and higher speeds than the laser, and balloon catheter use, which removes the risk of push-back and enables push-down of the fragments without any further ancillary maneuvers. The balloon catheter also enables contrast medium followup and immediate postoperative drainage. The speed of the procedure and the ability to adjust antegrade or retrograde flow with variable pressure and direction make this technique highly suitable for the complete resolution of large, impacted calculi of the proximal ureter.

Results of Percutaneous Endoscopic Ureterolithotomy Compared to that of Ureteroscopy

Percutaneous endoscopic ureterolithotomy is not a well-known method for the treatment of impacted ureteral stones. The authors performed a retrospective study to compare the effectiveness of this procedure to ureteroscopy for the treatment of ureteral calculi. Impacted ureteral stones were removed in 93 patients by percutaneous endoscopic ureterolithotomy (Group 1). In 142 patients, ureteroscopy was performed for the treatment of the ureteral stones (Group 2). The same instruments were used to carry out percutaneous endoscopic ureterolithotomy as were used for percutaneous nephrolithotomy. During these interventions, a direct percutaneous puncture and extraction of the stones was performed. The average diameter of the stones was 11 +/- 4 mm in Group 1 and 7 +/- 2 mm in Group 2. The average operating time was 32 +/- 11 minutes in Group 1 and 41 +/- 29 minutes in Group 2. The average duration of hospitalization following the operations was 7.2 +/- 3.1 days in Group 1 and 3.5 +/- 2.5 days in Group 2. In Group 1, the average time of the operations was significantly lower (p 0.006), and the duration of postoperative hospital stay was significantly higher (p < 0.001), compared to Group 2. In Group 1, retroperitoneal hematoma occurred in 1 patient and prolonged urine leakage was detected in 2 cases, whereas in Group 2, pyelonephritis occurred in 5 patients following the operation. In conclusion, the operating time of percutaneous endoscopic ureterolithotomy is shorter and the rate of complications comparable with that of ureteroscopy. Percutaneous endoscopic ureterolithotomy is suggested for the removal of impacted ureteral stones instead of open surgical ureterolithotomy.

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.