Complete Stone Fragmentation Research Articles

PD37-03 PERCSAC: A NOVEL DEVICE TO PREVENT STONE FRAGMENT MIGRATION DURING PERCUTANEOUS LITHOTRIPSY

You have accessJournal of UrologyStone Disease: New Technology II1 Apr 2014PD37-03 PERCSAC: A NOVEL DEVICE TO PREVENT STONE FRAGMENT MIGRATION DURING PERCUTANEOUS LITHOTRIPSY Jodi Antonelli, Justin Friedlander, Jeffrey Gahan, Heather Beardsley, Margaret Pearle, and Jeffrey Cadeddu Jodi AntonelliJodi Antonelli More articles by this author , Justin FriedlanderJustin Friedlander More articles by this author , Jeffrey GahanJeffrey Gahan More articles by this author , Heather BeardsleyHeather Beardsley More articles by this author , Margaret PearleMargaret Pearle More articles by this author , and Jeffrey CadedduJeffrey Cadeddu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2021AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Up to 50% of patients with residual fragments after percutaneous nephrolithotomy (PCNL) experience a stone-related event. We developed a polyethylene sack (the PercSac) that fits over the shaft of a rigid nephroscope and is deployed in the collecting system to capture a stone, thereby containing fragments generated during PCNL and allowing for efficient and complete removal. We compared the efficiency of stone fragmentation and retrieval with and without the PercSac device in an in vitro percutaneous cystolitholapaxy model. METHODS Using a Limbs & Things® bladder model into which a 30F Amplatz working sheath was placed, 20 canine bladder stones matched for weight and volume were fragmented using a 24F rigid nephroscope and an ultrasonic lithotripter with and then without the PercSac. The total time for complete stone fragmentation and a gross assessment of the stone-free status of the bladder were recorded for each stone. RESULTS The mean stone weight and volume for the PercSac group was 2.63 +/- SD 0.95g and 1.68 +/- SD 0.63cm3, respectively. Similarly, the mean stone weight and volume for the group without the PercSac was 2.57 +/- SD 0.89g and 1.78 +/- SD 0.68cm3. The median time for complete stone fragmentation was significantly shorter in the PercSac group compared with the control group [182.0 sec (IQR= 108-221) vs 296.5 sec (IQR= 226-398), p= 0.004]. Likewise, the total time from insertion of the nephroscope into the bladder to completion of stone fragmentation was shorter for the PercSac group but this did not reach statistical significance [254.5 sec (IQR= 173-302) vs 296.5 sec (IQR= 226-398) respectively, p= 0.112]. The stone-free rate for the PercSac group was 100 vs 0% for the control group. CONCLUSIONS Ultrasonic lithotripsy using the PercSac device is more efficient and efficacious than traditional ultrasonic lithotripsy in a bladder model. This advantage may be even more pronounced during clinical PCNL where residual fragments migrate into difficult-to-access calyces. Further in vitro and in vivo testing in both kidney and bladder models is underway. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e946-e947 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jodi Antonelli More articles by this author Justin Friedlander More articles by this author Jeffrey Gahan More articles by this author Heather Beardsley More articles by this author Margaret Pearle More articles by this author Jeffrey Cadeddu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Biliary and Pancreatic Diseases Using a New Intraductal Endoscope

We aimed to evaluate a new single-operator mini-endoscope for its performance, feasibility, and safety in the management of biliary and pancreatic diseases. A retrospective analysis was conducted of 47 patients (19 men; mean age, 50.3 years) who underwent cholangioscopy with the Polydiagnost (Pfaffenhofen, Germany) Polyscope device via various approaches for diagnosis and treatment of biliary and pancreatic diseases between January 2011 and July 2012. Biliary pancreatic duct endoscopy was performed through a cystic duct, common bile duct, peroral, or sinus tract approach in 21, 9, 11, and 6 patients, respectively. Thirty-two cases with bile duct stones were treated by basket extraction or complete stone fragmentation, 3 cases with tumor were treated by tissue ablation, and 4 cases with stricture were treated by stenting. Seven patients who were diagnosed with suspected stones preoperatively were excluded. No complications and morbidity associated with the use of biliary and pancreatic endoscopy was observed in this study. Cholangioscopy using the Polyscope system is a safe and effective technique for diagnosing or excluding biliary and pancreatic diseases (stone, strictures, or tumor).

Comparison of Low-Power Laser and Ultrasound Litotripsy in the Management of Middle-Distal Ureteral Stones

To compare the success rates and complications of ultrasound and low-power Holmium laser-assisted ureteroscopy (URS) in managing middle-distal ureteral stones. We retrospectively analyzed the records of 90 patients with middle-distal ureteral stones who underwent ureteroscopic lithotripsy at our institution from May 2006 to April 2010. 45 patients were treated with ultrasound (mean size 6.7 mm), 45 patients with low-power Holmium laser (mean size 7.4 mm). The same ureteroscope (9.5/8ch rigid-Storz) was used to treat all the patients. Patients were monitored before the hospital discharge with abdominal radiograph and ultrasonography, and as outpatients after 3 months with abdominal radiograph, ultrasonography and urography in selected cases. We obtained a complete immediate fragmentation of stones in 27/45 (60%) patients with ultrasound, and in 36/45 (80%) patients after laser treatment. A proximal migration of stones was observed in 12/45 (26.8%) patients with ultrasound and 3/45 (6.6) with laser. We observed a ureteral perforation after laser treatment and no patient developed urosepsis. 6/45 (13.3%) patients who were treated with ultrasound underwent auxiliary therapy such as alkalizing therapy, 9/45 (20%) patients a second ureteroscopy, 9/45 (20%) a shockwave lithotripsy. No patient underwent an auxiliary shockwave treatment after laser, 6/45 (13.4%) patients underwent a second ureteroscopy. Operating time (20.33 vs 28.85 minutes) and hospitalization (3.6 vs 5.1 days) were shorter with laser if compared with ultrasound treatment. In our study the fragmentation rates of Holmium laser-assisted ureteroscopy were significantly better than with ultrasound in the middle-distal ureteral stones management. We did not have relevant complications using both procedures, and the need for auxiliary procedures was significantly less for Holmium laser-assisted ureteroscopy when compared with ultrasound.

Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians

Endoscopic procedures using electrohydraulic lithotripsy (EHL) or intraductal laser lithotripsy (ILL) are the methods of choice for managing difficult common bile duct (CBD) stones. This retrospective study examined 10 years of Swedish experience using a mother-baby endoscopic system to assist in the fragmentation of CBD stones by EHL and ILL. Between 1995 and 2006, 44 patients with a median age of 80 years underwent EHL or ILL at two Swedish centers after conventional endoscopic fragmentation of CBD stones had failed. Long-term follow-up assessment was conducted for 9 to 126 months (median, 53 months). Final stone clearance after EHL or ILL treatment with or without additional conventional endoscopic retrograde cholangiopancreatography (ERCP) was achieved for 34 (77%) of 44 patients. The results for 10 patients (23%) were defined as failures. Complete or partial stone fragmentation and definitive duct clearance were achieved in one session for 23 patients (52%). A second EHL or ILL attempt made in five cases of primary failure led to definitive stone clearance in three cases. Two patients experienced perioperative complications (stone basket impaction). Mild post-ERCP pancreatitis occurred for one patient and cholangitis for two patients. During long-term follow-up evaluation, recurrent CBD stones were found in one patient. Peroral endoscopic EHL or ILL, under direct cholangioscopic visualization by a mother-baby endoscopic system, is an effective treatment for difficult CBD stones. The technique can be used safely even in frail and elderly patients. However, several endoscopic attempts may be required before final stone clearance is achieved. The vast majority of patients may be expected to remain symptom free for a prolonged period.

A Simple Objective Method to Assess the Radiopacity of Urinary Calculi and its Use to Predict Extracorporeal Shock Wave Lithotripsy Outcomes

We describe an objective method to evaluate kidney stone radiopacity for use in selection of cases suitable for ESWL. We recruited 76 adult patients with a solitary 1 to 2 cm renal pelvic stone. All patients underwent routine plain x-ray of the urinary tract but an aluminum step wedge (Gammex) was adapted to the cassette before x-ray exposure. This x-ray was then digitized and analyzed by histogram to calculate the gray level of the stone and of each step of the aluminum step wedge. This allowed radiographic stone density to be expressed in mm aluminum equivalent. All patients also underwent abdominopelvic computerized tomography and then ESWL was started. Stone density on plain x-ray was 1.83 to 5.93 mm aluminum equivalent. There was a positive correlation between these values and stone attenuation values on computerized tomography (r(2) 0.83, p <0.005). The 12 patients in whom ESWL failed were found to have stones of significantly higher density than stones in patients with complete stone fragmentation (mean +/- SD 4.8 +/- 0.74 vs 3.35 +/- 0.88 mm aluminum equivalent, p <0.005). There was also a positive correlation between stone radiopacity in mm aluminum equivalent and the total number of shock waves required to achieve complete fragmentation (r(2) 0.66, p <0.005). The aluminum step wedge with plain x-ray of the urinary tract provides a good reference for objectively assessing the radiopacity of renal calculi.

Laser Lithotripsy with Direct Cholangioscopy for Complex Biliary Stones

Introduction: Biliary stones can be successfully removed in greater than 90% of patients during ERCP with balloon/basket catheters, with some requiring mechanical lithotripsy. Complicated stones that are unable to be managed with standard therapies often require more advanced modalities including extracoporeal shockwave lithotripsy (ESWL), electrohydraulic lithotripsy (EHL) and laser lithotripsy. We report our experience with endoscopic laser lithotripsy with direct cholangioscopy in patients with complex bile stones. Methods: Between March 2001 and November 2008, laser lithotripsy was used for the treatment of complicated biliary stones in 16 patients, reviewed retrospectively. For all procedures, a Holmium Laser was used under direct visualization using cholangioscopy with the SpyGlass System (Boston Scientific, Natick, USA) (15 cases) and, prior to 2006, a mother-daughter cholangioscope CHF B20 (Olympus, USA) (6 cases). Results: Sixteen patients (mean age 63 years, 25% men) with complex choledocholithiasis were treated with laser lithotripsy after failed stone clearance with ERCP using standard therapies including balloon/basket extraction and mechanical lithotripsy (mean 2.6 ERCP attempts). The mean stone size was 22.5mm and mean number of stones was 2.3. All procedures resulted in partial or complete stone fragmentation. Eight of the 16 patients (50%) had complete stone clearance after completion of laser lithotripsy. Eight patients without complete stone clearance received CBD stents and underwent subsequent ERCP with stone extraction using balloon/basket catheters and/or mechanical lithotripsy. All 16 patients eventually had complete resolution of stones. A total of 30 procedures (mean 1.9 ± 0.7 procedures) were performed, including 21 laser lithotripsy sessions (mean 1.4 ± 0.8). Two complications occurred: one patient had nausea and abdominal pain requiring admission post-procedure and one had a wire perforation in the cystic duct during an attempt at mechanical lithotripsy after laser lithotripsy. Conclusion: Resolution of complex biliary stones using laser lithotripsy can obtain in all cases, with few side effects but require a mean of 2.6 sessions. Laser lithotripsy with direct cholangioscopic visualization is safe and effective for treatment of complex biliary stones. Table 1Treatment Outcomes Complete Stone Clearance After Laser Session(s) 8/16 (50%) Persons Requiring Additional Therapy ∗ Additional therapy included CBD stenting with subsequent ERCP with balloon/basket retrieval and/or mechanical lithotripsy. 8/16 (50%) Final Stone Clearance 16/16 (100%) Procedure Complications Nausea/Pain Wire perforation 2 1 1 ∗ Additional therapy included CBD stenting with subsequent ERCP with balloon/basket retrieval and/or mechanical lithotripsy. Open table in a new tab

Biliary shock-wave lithotripsy. Fragmentation and lysis--a new procedure

Between September 1986 and April 1987, extracorporeal shock-wave lithotripsy, supplemented by oral chemolitholysis, was undertaken on 157 patients with symptoms of gallstones. Partial or complete stone fragmentation was achieved in 148 (94.3%). Freedom from stones was maintained under continuous chemolysis treatment for an average observation period of 8.5 weeks in 31 (19.7%). Considerable fragment reduction was obtained in 97 (61.8%), of whom 26 (16.6%) were demonstrated to have only minimal stone residues. Insufficient fragmentation and (or) no response to litholysis occurred in 29 (18.5%). These preliminary results suggest that, if there are moderately sized (less than 25 mm) and only a few (1-3) noncalcified cholesterol stones, these two methods in combination promise to be an effective alternative to cholecystectomy.

Is Pre-Shock Wave Lithotripsy Stenting Necessary for Ureteral Stones With Moderate or Severe Hydronephrosis?

We performed a prospective, randomized clinical trial to evaluate the outcome of ureteral stents for solitary ureteral stones 2 cm or less in moderately or severely obstructed systems using shock wave lithotripsy. Between 2001 and 2004, 186 patients who met study criteria were randomized into 2 groups. Group 1 received a pre-shock wave lithotripsy 6Fr Double-J stent and group 2 had no stent. Patients were treated with a Dornier MFL 5000 lithotripter. Results were compared in terms of clearance rates, number of shock waves and sessions, irritative voiding symptoms, incidence of complications and secondary interventions. Failure was defined as the need for additional procedure(s) for stone extraction. Overall 164 patients (88.2%) became stone-free after shock wave lithotripsy. Complete stone fragmentation was achieved after 1 to 3 and more than 3 session in 108 (58.1%), 30 (16.1%), 13 (7%) and 14 patients (7.5%), respectively. Ureteral stent insertion did not affect the stone-free rate, which was 84.9% and 91.4% in groups 1 and 2, respectively (p = 0.25). There was no statistical difference in the re-treatment rate, flank pain or temperature in the 2 groups. However, all patients in the stented group significantly complained of side effects attributable to the stent, including dysuria, suprapubic pain, hematuria, pyuria and positive urinary culture. Pretreatment stenting provides no advantage over in situ shock wave lithotripsy for significantly obstructing ureteral calculi. Shock wave lithotripsy is reasonable initial therapy for ureteral stones 2 cm or less that cause moderate or severe hydronephrosis.

A New Spin on the Entrapped Ureteral Calculus

We describe ureteroscopic lithotripsy using a revolving 1.5F tipless basket. After passing a laser fiber alongside the basket and performing lithotripsy, one uses a rotary wheel at the base of the basket handle to spin the stone to a different area for further fragmentation. This allows complete stone fragmentation, in contrast to traditional laser baskets, which bore a hole through the center of the stone. Irrigation flow testing demonstrated significant advantages with the 1.5F basket with or without a laser fiber alongside the basket compared with traditional baskets.

Percutaneous transhepatic cholangioscopic lithotripsy

Since 1983, 14 patients with intrahepatic and common bile duct stones have undergone percutaneous transhepatic cholangioscopic lithotripsy because the stones were too large to be removed using ordinary percutaneous transhepatic cholangioscopy. Stones were completely fragmented in seven cases (six with intrahepatic stones and one with common bile duct stone) and partially disrupted in five cases with intrahepatic stones. Intrahepatic duct angulation and stricture was the factor most often responsible for failure. All the disintegrated stones were removed by subsequent transhepatic cholangioscopy. Amongst the seven patients with complete stone fragmentation, six stones were found with electrohydraulic shock-wave lithotripsy and one with NdYAG laser lithotripsy. Complications of percutaneous transhepatic cholangioscopic lithotripsy using electrohydraulic shock waves were found in three cases, two had transient haemobilia and one had fever and chills after the procedures. They all recovered by conservative treatment. NdYAG laser treatment was expensive, time consuming and inconvenient to use. Percutaneous transhepatic cholangioscopic lithotripsy by using electrohydraulic shock wave is an effective and safe method to fragment biliary stones and to facilitate their removal.

Mechanisms of action in dual-pulse lithotripsy

Dual-pulse lithotripsy has emerged as a promising technique for a safer and more effective shock wave lithotripsy treatment. A single source and confocal sources of various design have been used to produce either synchronous or asynchronous dual pulses. It has been shown that dual pulses enhance stone comminution and reduce tissue injury in vivo and in vitro. Pressure doubling at the focus of synchronous confocal sources contributes to increased fragmentation by a combination of direct shock-wave effects and increased cavitation, while decreased cell damage near the focus is largely a result of cavitation mitigation by the second, delayed shock wave. It follows that weaker pulses may be used to achieve complete stone fragmentation while further protecting surrounding tissue. Twin sources may also be fired asynchronously to enhance or mitigate cavitation as well as to minimize tissue damage by dividing the impact over two tissue paths. Numerical calculations using the Gilmore model and primary radiation force model as well as high speed camera images show little evidence that bubble translation contributes to the observed bioeffects. These results and the history and mechanisms of dual-pulse lithotripsy will be reported. [Work supported by NIH PO1 DK43881 and RO1 DK55674.]

Ureteroscopy and holmium:YAG laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy

Objectives. To review the results of holmium laser lithotripsy in a cohort of patients who presented with symptomatic urolithiasis in pregnancy. Symptomatic urolithiasis in pregnancy that does not respond to conservative measures has traditionally been managed with ureteral stent insertion or percutaneous nephrostomy. Holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy using state-of-the-art ureteroscopes represents an emerging strategy for definitive stone management in pregnancy. Methods. A retrospective analysis was conducted at two tertiary stone centers from January 1996 to August 2001 to identify pregnant patients who were treated with ureteroscopic holmium laser lithotripsy for symptomatic urolithiasis or encrusted stents. Eight patients with a total of 10 symptomatic ureteral calculi and two encrusted ureteral stents were treated. The mean gestational age at presentation was 22 weeks. The mean stone size was 8.1 mm. The stones were located in the proximal ureter/ureteropelvic junction (n = 3), midureter (n = 1), and distal ureter (n = 6). Results. Complete stone fragmentation and/or removal of encrusted ureteral stents were achieved in all patients using the holmium:YAG laser. The overall procedural success rate was 91%. The overall stone-free rate was 89%. No obstetric or urologic complications were encountered. Conclusions. Ureteroscopy and holmium laser lithotripsy can be performed safely in all stages of pregnancy, providing definitive management of symptomatic ureteral calculi. The procedure can be done with minimal or no fluoroscopy and avoids the undesirable features of stents or nephrostomy tubes.

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal Shock Wave Lithotripsy in Children

Ureteroscopic management of recurrent renal cystine calculi.

Patients with recurrent cystine nephrolithiasis oftentimes require multiple procedures for stone removal. As the majority of cystine stones are resistant to the effects of shockwave lithotripsy, repeat percutaneous surgery is often required and may cause renal damage. Moreover, repeat percutaneous access may become more difficult as perinephric fibrosis develops. Small-caliber ureteroscopes along with the holmium laser now enable routine intrarenal ureteroscopic access to symptomatic renal stones. Herein, we present our experience in managing recurrent renal cystine calculi using flexible ureterorenoscopy and assess whether such an approach may be used as an alternative to percutaneous surgery in selected patients. Three patients with large-volume (mean diameter 22 mm) renal cystine stones were managed with a 7.5F flexible ureterorenoscope combined with holmium laser lithotripsy to fragment the stones completely. The mean treatment time was 97 minutes, with successful fragmentation in all cases. Two of the three patients were completely stone free on follow-up intravenous urography, with the third patient having only small-volume residual fragments in a lower pole calix. All patients are currently asymptomatic and are being maintained on high oral fluid intake, urinary alkalization with potassium citrate, and alpha-mercaptopropionylglycine to reduce urinary cystine excretion. Flexible ureterorenoscopy with holmium laser lithotripsy provides a reasonable alternative for the management for recurrent cystine calculi in patients who are not candidates for repeat percutaneous procedures. Although it is time consuming, complete stone fragmentation, along with clearance of fragments, can be achieved in the majority of patients.

RETROGRADE URETEROPYELOSCOPY FOR LOWER POLE CALICEAL CALCULI

Contemporary treatment of lower pole renal calculi includes extracorporeal shock wave lithotripsy, percutaneous nephrostolithotomy and retrograde ureteropyeloscopy. Success rates for shock wave lithotripsy are reduced in this setting, especially for stones greater than 1 cm. and/or in patients with anatomical variants. Percutaneous treatment, although effective, subjects the patient to increased morbidity. We studied the safety and efficacy of retrograde ureteroscopic treatment of lower pole intrarenal calculi. We evaluated 90 stone burdens localized to the lower pole and treated with a small diameter, actively deflectable, flexible ureteropyeloscope and a 200 micron holmium laser fiber. Stone burdens were classified as group 1--10 or less, group 2--11 to 20 and group 3--greater than 20 mm. in largest diameter. Patients with calculi less than 2.5 cm. were treated as outpatients unless concurrent medical conditions required hospitalization. Larger stones and partial staghorn calculi (group 3) frequently required 2-stage endoscopic procedures with retrograde intrarenal irrigation for 36 hours to clear debris. An acceptable immediate surgical outcome was defined as complete fragmentation reducing the stone burden to dust and 2 mm. or less fragments. Success was defined as clear imaging (that is stone-free) on renal sonography with minimum 3-month followup. Extreme anatomical variants, including a long infundibulum, acute infundibulopelvic angle and a dilated collecting system, were noted and correlated with surgical failures. Endoscopic access and complete stone fragmentation were achieved in 94, 95 and 45% of groups 1, 2 and 3, respectively. After a second treatment the success rate increased to 82% in group 3, with an overall rate of 91%. Of the 19 surgical failures 8 were secondary to inability to access the lower pole and 11 were secondary to inability to render the patient stone-free. In 2 of the 19 cases infundibular strictures hindered ureteroscopic access. In addition, of the anatomical variants a long lower pole infundibulum was the most statistically significant predictor of failure. Mean operative time ranged from 38 minutes for small to 126 for the largest calculi. There were no major complications. Overall stone-free rates with minimum 3-month followup were 82, 71 and 65% in groups 1, 2 and 3, respectively, and 88, 77 and 81%, respectively, in patients with an acceptable initial surgical outcome (that is excluding those with access failures from analysis). Retrograde ureteropyeloscopy is a safe and effective surgical treatment for lower pole intrarenal calculi.

Does the rate of extracorporeal shock wave delivery affect stone fragmentation?

Objectives. To evaluate the effect of the rate of shock wave delivery on stone fragmentation, because the optimal rate of shock wave administration has not yet been established. Methods. Standard phantom, ball-shaped, ceramic stones were placed in a net-like basket with a hole size of 2.2 mm and immersed in a specially designed water bath coupled with the Econolith 2000 lithotripter. One hundred eighteen stones (mean diameter 9.5 mm) were used. Shock waves were delivered at rates of 30, 60, 90, 120, and 150 shocks/min and at intensities of 15, 20, and 22.5 kV (electrohydraulic). The number of shocks required for complete fragmentation, determined by all fragmented particles falling through the basket holes, was recorded. Results. The most effective (fewer shocks needed for complete stone fragmentation) rate of shock wave delivery was 60 shocks/min. A statistically significant difference was demonstrated between the mean number of shocks required for complete stone fragmentation at the rate of 60 shocks/min and faster rates at all energy levels ( P <0.01) but not between the rate of 60 shocks/min and the rate of 30 shocks/min at all energy levels. Conclusions. The rate of shock wave administration during extracorporeal shock wave lithotripsy seems to influence stone disintegration. We demonstrated that extracorporeal shock wave lithotripsy is most effective when waves are delivered at 60 shocks/min.

Primary Endoscopic Treatment of Ureteric Calculi

Aim of the Study: In the post-ESWL period, ureteroscopy represented the solution giving a second choice in the treatment of ureteral calculi in case of failure of extracorporeal lithotripsy. The aim of this study is to review a wide series of ureteral stones in which ureteroscopy combined with endoscopic lithotripsy can be chosen as the first approach for the treatment of ureteral calculi. Methods: Between January 1994 and September 1997, 378 patients underwent ureteroscopy and endoscopic lithotripsy for ureteral stones with a miniscope associated with either a pneumatic or electropneumatic lithotriptor. Three different miniscopes were used: Olympus (8 Fr), Wolf (7 Fr) and Circon Acmi (7.7 Fr). 238 patients were male and 140 were female. The stones were localized in the upper tract of the ureter in 62 cases (16.4%), 96 (25.3%) in the mid ureter and 220 (58.3%) in the lower ureter. Results: A complete stone fragmentation with spontaneous expulsion of the fragments occurred in 354 patients (93.6%). In 22 patients (5.8%) the stones were accidentally pushed up and successfully underwent ESWL. In 38 patients (10%) the fragments were completely removed by basket. A single J polyethylene catheter was placed in 21 (5.5%) and a JJ stent in 147 patients (38.8%). The operative time ranged from 10 to 60 min, with an average time span of 32. In 22 cases (5.8%) an iterative ureteroscopy for stenosis or incomplete fragmentation was needed. Five cases (1.3%) of ureteral perforation were successfully treated by JJ stent, and only 1 case of ureteral avulsion (upper ureter) was treated by open surgery. In the attempt of overcoming an ureteral stenosis, we had 1 case (0.2%) of ureteral reimplantation. One patient (0.2%) underwent ureterolithotomy for an extremely narrow stenosis just before the ureteropelvic junction. No relevant complication was recorded in the postoperative period. Patients were dismissed after 1– 4 days (average 1.9). Up until now, no case of postoperative ureteral stricture has been observed, although we were not able to carry out a specific follow-up in all our patients. Conclusions: Ureteroscopy with miniscopes has a high success rate (93.6%) with low morbidity and can be given as a primary approach in the management of ureteral calculi. In the lumbar ureter (especially in women) this technique can represent a good alternative to ESWL in the treatment of obstructing stones (which need stenting) or when the patient asks for a ‘one-shot’ treatment.

Lithotripsy with miniscope: Clinical results of 193 consecutive patients

A retrospective analysis was carried out on 193 patients who underwent ureteroscopy for ureteral stones with a miniscope associated with either an electrohydraulic or a pneumatic lithotriptor. Complete stone fragmentation with spontaneous expulsion of the fragments occurred with just one session in 89.1% of cases. Nine patients underwent ureterolithotomy. The only complications were 3 ureteral lesions without perforation. The authors consider that with these mini instruments, there is a very low rate of morbidity connected with this procedure, which can therefore be given first option in the treatment of lower ureteral stones.

Intracorporeal Lithotripsy With the Holmium:YAG Laser

Purpose Preliminary evaluations of the holmium:YAG laser have demonstrated a variety of potential urological applications, including ablation of soft tissue lesions as well as stone fragmentation. We present our experience with the holmium:YAG laser for intracorporeal lithotripsy of urinary calculi. Materials and Methods During a 24-month period 75 patients underwent 79 laser procedures, including retrograde ureteroscopy for ureteral calculi (71) and fragmentation of caliceal stones remote from the nephrostomy tract during percutaneous nephrolithotripsy (8). Results Complete stone fragmentation without need for additional procedures or lithotripsy was achieved in 85 percent of the cases. Treatment failures included 1 case of stone migration, 7 incomplete fragmentation requiring other lithotripsy devices and 3 laser malfunction. One ureteral perforation occurred when the laser was activated without direct visual guidance. Conclusions The holmium: YAG laser has demonstrated its efficacy as a method of intracorporeal lithotripsy. Advantages include ability to fragment stones of all composition, and the multipurpose, multispecialty applications of the holmium wavelength. This laser has potential soft tissue effects, and careful attention to technique during lithotripsy is required to avoid ureteral wall injury.

Extracorporeal electromagnetic shock-wave lithotripsy for salivary gland stones.

Sialoadenectomy for sialolithiasis is necessary when the stone cannot be removed through the salivary duct. In addition, extracorporeal. shock-wave lithotripsy has recently become available for this purpose. The safety and efficacy of this method was assessed in 52 outpatients bearing stones with an average diameter of 6.76 mm in the submandibular or parotid gland. Anesthetics, sedatives, and analgesics were not required. Twenty-four of the 36 patients with submandibular gland calculi and all 16 with parotid sialolithiasis had complete stone disintegration or fragmentation of the calculi, with possible spontaneous clearance. Untoward effects were observed in 15 patients, namely localized skin petecchiae, transitory swelling of the gland, and self-limiting bleeding from the duct. No persistent damage of the salivary glands or adjacent structures was noted during a mean follow-up period of 10 months.