Lithotripsy Time Research Articles

Giant pyohydronephrosis in a febrile haemodialysis patient

A 73-year-old man had been receiving regular haemodialysis initially via arteriovenous fistula for 3 years and had been using a cuffed dual-lumen permanent catheter (HemoStarTM, BardTM, US) for the preceding year due to vascular access failure. He was referred to our hospital owing to an intermittent fever up to 38°C throughout the preceding month. Repeated blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Fever was persistent despite intravenous administration of teicoplanin for 2 weeks. Upon admission, the HemoStarTM was immediately removed and vancomycin was intravenously administered since catheter-related infection was suspected. However, the fever still persisted, and blood cultures and the tip of HemoStarTM were negative for bacteria. Echocardiography showed no evidence of vegetation. By further survey of possible infection, computed tomography of the abdomen revealed a giant left hydronephrosis and hydroureter with thinning of the renal parenchyma (Figure 1a) due to obstruction by a ureteral stone at the fourth lumbar level (Figure 1b). We placed a pig-tailed catheter in the left renal pelvis and drained out 1400 ml of pus-like material, which displayed a positive culture forMRSA. Following adequate pus drainage and antibiotic treatment, his fever subsided dramatically. Tracing back his history, he had stones in the left kidney, which were treated with extracorporeal shock-wave lithotripsy several times. ‘Giant hydronephrosis’ is a rare condition defined by the presence of 1000 ml or more fluid in the collecting system of kidney [1]. The ureteropelvic junction is the most common site for developing giant hydronephrosis [2]. Stones, congenital ureteral narrowing and ureteropelvic tumours are the major causes [2]. Fever was the initial symptom in the present case; however, the definite diagnosis was made 2 months later. This is typical for this type of occult condition. Unless the physician has a high level of suspicion, recognition of giant hydronephrosis may be delayed and further impeded in the presence of end-stage renal failure. To prevent the infectious complications of giant hydronephrosis, it is mandatory to make an early diagnosis whenever possible. In a febrile haemodialysis patient who was refractory to antibiotic treatment, clinical suspicion of pyohydronephrosis should be aroused, especially in a subject having renal stone history.

The Management of Renal Caliceal Calculi with a Newly Designed Ureteroscope: A Rigid Ureteroscope with a Deflectable Tip

To evaluate the indications for, and the effects of, the management of renal caliceal calculi with deflectable tip rigid ureteroscopy. We designed a new deflectable tip rigid ureteroscope, and 175 patients with renal caliceal calculi received deflectable tip rigid ureteroscopic lithotripsy with a holmium laser. From December 2003 to December 2007, the procedure was successfully performed in all patients with a mean operative time of 28 minutes (range 19-45 min). The mean size of renal caliceal stones was 1.3 cm (range 0.8-2.4 cm). Seventeen patients had concurrent proximal ureteral calculi. The mean lithotripsy time was 11 minutes (range 5-22 min), and the mean discharge time was 3 days after operation. The overall stone-free rate at the 1-month follow-up was 83%. Ureteroscopic lithotripsy with the novel deflectable tip rigid ureteroscope is a safe procedure and combines the advantages of rigid and flexible ureteroscopy, especially for renal caliceal calculi of relatively small size.

70 W Holmium:Yttrium-Aluminum-Garnet Laser in Percutaneous Nephrolithotomy for Staghorn Calculi

To investigate the safety and efficacy of the high-power (70 W) holmium laser in percutaneous nephrolithotripsy (PCNL) for staghorn calculi. From December 2004 to March 2008, 438 consecutive patients (456 renal units) with > or =4-cm staghorn stones underwent PCNL with a pulsed holmium:yttrium-aluminum-garnet (Ho:YAG) laser using a 1000-microm end-firing optical fiber. For the first 106 patients (group A; average stone size 5.6 +/- 0.8 cm), a 30 W (3.0 J/pulse; 10 pulse/sec) laser was used, whereas for the other 332 patients (group B; average stone size 5.8 +/- 0.8 cm), the laser power was set at 3.0 J/pulse with a frequency of 20 pulses/sec. For stones in a calix visible with the nephroscope but unreachable with a laser, the mucosa of the calix was split with a 100 W holmium laser to fragment the stones further. Moreover, a porcine model for assessing the safety of the high-power holmium laser was developed. All patients had successful PCNL. The average lithotripsy time in group B was significantly shorter than that in group A (44 +/- 11.5 minutes vs 69 +/- 14.8 minutes; P < 0.05). No patient had a severe complication. In addition, 39 patients underwent calix splitting with no hemorrhage during or after the operation. The glomerular filtration rate of the treated kidney, reexamined 6 months after the operation, had improved greatly (45.12 vs 31.91 mL/min; P < 0.05). Pathologic evaluation of porcine kidneys exposed to high-power laser firing showed no damage. The high-power Ho:YAG laser enhances lithotripsy efficacy by "vaporizing" and "bursting" the stone quickly, reducing lithotripsy time significantly. This is an effective and safe treatment for patients with large renal stones.

Treatment Time Reduction Using Tandem Shockwaves for Lithotripsy: AnIn VivoStudy

Reducing extracorporeal shockwave lithotripsy (SWL) time by increasing the shockwave rate of the lithotripter has been tested in the past; however, basic research and treatment outcomes revealed that this is not convenient. The purpose of this study was to use an animal model to demonstrate that SWL treatment time can be reduced significantly without sacrificing stone fragmentation efficiency using tandem shockwaves. A tandem research lithotripter was used to treat 50 artificial kidney stones implanted into the kidneys of 50 rabbits. Standard single-pulse and tandem shockwaves were compared in two different scenarios: Without a fluid-filled expansion chamber and with a fluid-filled expansion chamber surrounding the stone. The presence of fluid surrounding the stone enhances fragmentation in both the standard and tandem modes. No significant difference in fragmentation efficiency was recorded between the standard and tandem SWL with stones surrounded by fluid; however, the treatment time with tandem shockwaves was reduced by 50%. Significantly shorter SWL treatments may be possible in the future using tandem shockwaves on urinary stones that are surrounded by fluid.

Ureteroscopic Laser Lithotripsy versus Ballistic Lithotripsy for Treatment of Ureteric Stones: A Prospective Comparative Study

Objectives: This study was undertaken to compare the results of laser (Ho:YAG) and pneumatic (ballistic) intracorporeal lithotripsy for ureteric calculi in terms of efficacy, safety and complications. Methods: 55 patients having ureteric calculus were randomly allocated into pneumatic lithotripsy (PL) and laser lithotripsy (LL) groups. Swiss lithoclast was used for PL (3 atm pressure and 12 Hz frequency) and the VersaPulse PowerSuite was used for LL. Appropriate statistical tests were applied. Results: 30 patients (34 stones) were treated with LL and 25 patients (25 stones) with PL. Both groups were comparable in profile. Mean lithotripsy time was 24.03 ± 9.51 min in the LL group and 19.80 ± 4.44 min in the PL group (p = 0.027). The immediate stone clearance rate was higher in the LL group (p = 0.001), but it was comparable at 4 weeks (p = 0.097). Stone migration occurred in 16% of cases in the PL group. No major complication was observed in either group. Conclusions: We conclude that both laser and pneumatic energies are effective and safe for intracorporeal lithotripsy. Laser lithotripsy takes more time but provides earlier stone-free status.

Holmium : YAG Laser Lithotripsy for Urolithiasis in Dogs

Laser lithotripsy has been used as an alternative to surgical removal of uroliths in a number of species. To determine the effectiveness of laser lithotripsy for removing urocystoliths, urethroliths, or both in dogs, and to determine the influence of dog (chronological order of lithotripsy, endoscope type, sex, body weight) and urolith (total urolith and urocystolith number, presence or absence of urethroliths, largest urolith dimension, and urolith composition) factors on outcome. Twenty-five client-owned dogs with urocystoliths, urethroliths, or both were included. Male dogs were required to weigh > or =6.8 kg. A single-arm prospective clinical trial. Laser lithotripsy was performed under general anesthesia. Main outcomes included procedure success and lithotripsy time. Predictors of procedure success and lithotripsy time were selected using logistic and linear regression modeling, respectively. The procedure was successful in 21 of 25 dogs. The procedure was successful more often and in less time in female spayed than in male neutered dogs. Sex was identified as a predictor of success. Univariable analysis showed that sex, endoscope type, and chronological order in which the dog received lithotripsy were significantly associated with lithotripsy time. Stepwise linear regression modeling identified sex, body weight, >10 uroliths, and largest urolith dimension as predictors of lithotripsy time. Laser lithotripsy is an effective procedure for the removal of urocystoliths, urethroliths, or both with rare important adverse effects and some limitations in male dogs.

Neodymium:Yttrium Aluminum Garnet laser for mini-percutaneous treatment of upper urinary tract stones

To observe the efficacy and safety of mini-percutaneous nephrolithotomy with Neodymium: Yttrium Aluminum Garnet (Nd-YAG) laser in the treatment for upper urinary tract stones, from December 2005 to September 2006, 31 patients with renal stones, 15 patients with ureteral stones and 7 patients with renal and ureteral stones underwent mini-percutaneous nephrolithotomy with Nd-YAG laser by combination of rigid ureteroscope and flexible ureteroscope under B-ultrasound guidance. Clinical data including operation time, lithotripsy time, complications and stone-free rate were analyzed retrospectively. Our study showed that the percutaneous renal access (F14-F18) was successfully established under B-ultrasound guidance in all cases. Immediate phase: lithotripsy was performed in 47 cases through single tract, and in one case through two tracts. Delayed phase II lithotripsy was done in 5 cases of renal stones. Operation time ranged from 55 to 180 min with an average time of 100+/-15 min. Lithotripsy time was from 25 to 135 min and the average lithotripsy time was 65+/-11 min. No severe complications occurred in our series. Complex renal stones were cleared in 34 of 38 cases (89.5%). All ureteral stones were completely removed in 15 cases (100%). It was concluded that mini-percutaneous nephrolithotomy with Nd:YAG laser for the treatment of upper urinary tract stones by combination of rigid ureteroscope and flexible ureteroscope has the advantages of effectiveness, mini-invasion, shorter operative time and safety.

Refinements in treatment of large bladder calculi: Simultaneous percutaneous suprapubic and transurethral cystolithotripsy

Objectives To present a combined endourologic approach to treat bladder calculi consisting of simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Methods We report on a series of 12 consecutive patients with bladder stone burdens of 40 mm or greater. Percutaneous 30F access was obtained under cystoscopic control. Fragmentation and stone removal were performed simultaneously by two urologists using a Swiss lithoclast, holmium laser, and/or ultrasound lithotriptor through both percutaneous and transurethral routes. Suprapubic and transurethral catheters were placed postoperatively. Results Twelve patients with a median age of 66 years (range 33 to 80) were treated by simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Six underwent transurethral resection of the prostate at the completion of stone clearance. The median stone size was 60 mm (range 40 to 80), and the median lithotripsy time was 56 minutes (range 45 to 70). The median postoperative hospitalization was 2.7 days (range 2 to 5), and complete stone clearance was achieved in all cases. One patient, who underwent concomitant transurethral resection of the prostate, developed urinary retention 1 week postoperatively and was successfully treated by temporary transurethral catheterization. One patient with a positive urine culture preoperatively developed fever on the first postoperative day and was treated with intravenous antibiotics according to the antibiogram results for 5 days. No other complications had occurred after a median follow-up of 10 months (range 3 to 15). Conclusions Simultaneous percutaneous suprapubic and transurethral cystolithotripsy appears to be a safe approach for the management of large bladder calculi and may shorten the total fragmentation time. It can be combined with transurethral resection of the prostate without prolonging hospitalization. The simultaneous use of two modalities of stone fragmentation represents an effective and minimally invasive way of treating large bladder calculi.

Utility of the lithoclast in the treatment of upper, middle and lower ureteric calculi

The aim of this study was to evaluate the utility and efficacy of lithoclast in the treatment of upper, middle and lower ureteric calculi. Over a period of 6 1/2 years, we have treated 529 ureteric stones which failed to pass spontaneously within a 2-week period. Patients were evaluated for number, site, size and laterality of stones. Patients with ureteroscopy failure were excluded from the study. Once the stone(s) was (were) localised with the ureteroscope, it (they) was (were) treated with the Swiss lithoclast. Complete fragmentation was achieved in 99% of cases with lower, 97% with mid and 71% with upper ureteric calculi, respectively. The lithotripsy time was only 8.6 minutes for stones < or =1 cm and 14.8 minutes for stones ranging from 1.1 to 2.0 cm. Completely fragmented stones cleared spontaneously within two weeks in 98% of cases and all patients were free of calculi one month after the procedure. Retreatment with the lithoclast was required in six patients for large residual fragments. The mean hospital stay was 1.2 days. Complications were encountered in 6.8% of cases and were managed conservatively. Pneumatic lithotripsy is an excellent form of treatment for lower and mid-ureteric calculi. It is a very reliable, highly effective, rapid and safe procedure.

Pneumatic lithotripsy for the management of ureteric calculi.

To determine the efficacy of Swiss lithoclast in the management of ureteric calculi and complications encountered in lithoclasty. A prospective observational study. Department of Urology, Lahore General Hospital, Lahore (October 1999 - September 2001). Thirty ureteric stones (in 20 subjects) were treated over a 2-year period. Site, size and number of stones were noted in these patients. Swiss lithoclast, introduced through a ureteroscope, was used to break the stone. The Lithotripsy time was 30 min. Stone breakage was assessed by plain X-ray KUB or retrograde pyelography. Fragmentation was complete in 90 % cases. At one week follow up, 90% of patients were stone-free and at 3 months follow-up 95 % of patients had spontaneous passage of the fragments. Re-treatment was required in 5% cases. Mean hospital stay was 2.4 days. Complications (including both significant and minor) occurred in 25% of cases. Lithoclasty is safe, simple and effective procedure for ureteric calculi. However, complications of the procedure may prolong the usual 48 hours hospital stay seen in uncomplicated cases.

4614 Is endoscopic balloon dilation for removal of bile duct stones associated with an increased rate of pancreatitis or hyperamylasemia?

Background: EBD is an alternative to sphincterotomy (EST) for removal of bile duct stones in selected patients. EBD carries a reduced risk of bleeding and preserves sphincter function but may be associated with an increased risk of pancreatitis. Aim: to study the rate of hyperamylasemia and pancreatitis after EBD and EST and to investigate predictors for occurrence. Methods: 202 consecutive patients with bile duct stones of all sizes were randomized to EBD (8 mm balloon) or EST after deep cannulation of the bile duct#. Pancreatitis was defined as epigastric pain 24 hrs after the ERCP combined with at least a threefold rise in serum amylase level. Asymptomatic hyperamylasemia was defined as at least a threefold rise in the absence of epigastric pain. Results: 22 patients with prior BIIgastrectomy were excluded from the analysis. See table. Logistic regression of sex, age, stone characteristics, EBD vs. EST, additional EST after EBD, need for mechanical lithotripsy, pancreatography, and procedure time, identified EBD as the only significant predictor for asymptomatic hyperamylasemia. Conclusions: EBD is associated with an increased rate of asymptomatic hyperamylasemia. No difference in the rate of pancreatitis was observed. #Lancet 1997: 349:1124-9.

Ungated Medstone Outpatient Lithotripsy

Ungated lithotripsy has raised the specter of possible cardiac arrhythmias. We reviewed ungated outpatient lithotripsy performed on 82 patients to evaluate the incidence of arrhythmias encountered and time saved. All patients were chosen in a random nonselected, prospective fashion. All treatments were performed on a mobile Medstone 1050 STS lithotriptor. The incidence of arrhythmias was 21%. All but 2 arryhthmias were benign and all reversed with gating. No arrhythmias occurred during treatment of right ureteral stones. In the left ureter only 1 patient had benign premature ventricular contractions during treatment. Arrhythmias occurred at 20 to 24 kv. in 20% of patients with right renal stones and 31% with left renal stones. All arrhythmias resolved with gating. No arrhythmias were encountered at an energy level of less than 20 kv. There was no evidence of electrocardiographic changes up to 1 hour after treatment. Pharmacological manipulation to maintain a heart rate of 100 may allow a treatment time of approximately 24 minutes. With ungating the rate may reach 120, allowing for a treatment time of approximately 20 minutes. In this series average ungated lithotripsy time was 36 minutes. In comparison, the average treatment time in 20 patients undergoing gated lithotripsy was 38.7 minutes. It is not clear from this study whether persistent ungated lithotripsy would have precipitated any life threatening arrhythmias since our practice has been to terminate the procedure and re-gate the shocks at the first sign of any persistent change in cardiac rhythm. Our data indicate that ungated lithotripsy with the Medstone device is safe when simple monitoring rules are followed.

The outcome of pneumatic lithotripsy for the management of ureteric calculi

Various methods have been adopted for the removal of ureteric calculi around the world. Ureteroscopic pneumatic lithotripsy has been used to treat ureteric calculi for more than a decade. Owing to its low price and high degree of effectiveness, it has become the most popular ureteroscopic device amongst many others. Moreover, ureteroscopy has become the method of choice for the quickest way of rendering patients stone-free. To determine successful stone fragmentation by ureteroscopic pneumatic lithotripsy in the management of ureteric calculi as well as intra-operative and post-operative complications related to it. A prospective and descriptive study. The study was conducted in Section of Urology, Department of Surgery, B&B Teaching Hospital, Kathmandu University. The data was collected from April 2005 to April 2006. Ninety-two consecutive patients having ninety-five ureteric stones were treated with intracorporeal pneumatic lithotripsy over a period of one year. The size, side, number and site of stones along with the results of preoperative routine investigations were noted in the patients. The pneumatic lithotripter was introduced through a 10 or 8 Fr rigid ureteroscope (Karl Storz) to break the stone/s. Successful stone fragmentation, lithotripsy time, intra-operative and post-operative complications and duration of hospital stay were recorded. Complete stone fragmentation was achieved in about 80 % of cases. The mean lithotripsy time was 17.66 minutes. About 76% of patients were stone-free at one week follow-up after the procedure, 92% by the end of eight weeks while 100% stone-free status was achieved by the end of 12 weeks. The mean hospital stay was 1.82 days and complications (both significant and minor) occurred in 51 % of cases. However, majority of them were minor and successfully managed. Intra-operative pneumatic lithotripsy is a minimally invasive, effective and rapid procedure for the management of ureteric calculi. Though it can give rise to considerable complications, they are mainly minor. Moreover, both complications and failure rates can be reduced if patients with ureteric calculi are properly selected. It seems to be a good alternative in patients where extracorporeal shockwave lithotripsy is unsuccessful or not indicated and in patients who need early stone removal.

Clinical effects of Poly- Flexible Ureteroscopy combined with ultrasound guided all seeing needle Microperc to treatment of Lower Pole Renal Calculi larger than 2cm with infundibulopelvic angle less than 60 degrees

Objective: To observation on Poly- Flexible Ureteroscopy(FURS) retrograde intrarenal surgery (RIRS) combined with ultrasound guided all seeing needle Microperc to treatment of Lower Pole Renal Calculi larger than 2cm stone with infundibulopelvic angle（IPA）less than 60 degrees.&#x0D; Method: From January 2016 to January 2017, 63 patients with IPA angle less than 60 degrees in our hospital were treated with Poly-FURS retrograde intrarenal surgery combined with ultrasound guided all seeing needle Microperc, the patients stone sized more than 2 mm and located in the lower-pole calyx were retrospectively reviewed. Multiple stones were found in 37 cases and solitary stones in 26. Male patients used 70cm Poly-FURS, and the female 42cm.The clinical data including the operation time, the amount of bleeding, the stone free rate(SFR), the incidence of postoperative complications.&#x0D; Results: The operation time was 30~60min, mean 45min, FURS lithotripsy time was 20~35min, ultrasound guided all seeing needle puncture time was 3~5min, and lithotripsy time was 8~12min. 48 cases mainly lithotripsy with FURS and 15cases with micro-Percutaneous nephrolithotomy(micro-perc), 3 cases of fever as postoperative complications, 2 cases of pain; In non blood transfusion patients. The postoperative hospital stay was 2~3 days, with an average of 2 days. Postoperative residual stones were observed in 3 cases(SFR 95.2%) and treated with ESWL after 2 weeks. The stone clearance rate was 98.4% (62/63)after one month.&#x0D; Conclusion: The results of our study demonstrated that Poly- FURS retrograde intrarenal surgery combined with ultrasound guided all seeing needle Microperc had a significant effect on the success rate of lower Pole Renal Calculi larger than 2cm.