Management Of Proximal Ureteral Calculi Research Articles

Comparison Between Extracorporeal Shock Wave Lithotripsy and Ureteroscopic Lithotripsy for Treating Large Proximal Ureteral Stones: A Meta-analysis

To compare extracorporeal shock wave lithotripsy (ESWL) and ureteroscopic lithotripsy (URSL) in terms of efficacy, complications, and overall efficiency in the management of proximal ureteral calculi. ESWL and URSL are the 2 most common modalities for treating ureteral stones. Previous studies and meta-analyses suggest that for stones<10mm, ESWL is safer and of comparable efficacy compared with URSL. However, the choice between one modality over the other for the treatment of stones >10mm is not as clear. The literature was reviewed in the databases, and resulting reports were screened for relevance. This process yielded 10 articles, which were analyzed in terms of the initial stone-free rate (primary outcome measure) compared between the 2 treatment modalities. Pretreatment rate, operation time, auxiliary procedure rate, and complication rate constituted secondary measures in the analysis. A statistically higher initial stone-free rate was demonstrated for URSL compared with ESWL (odds ratio [OR]= 0.349; 95% confidence interval [CI]= 0.183-0.666; P= .001). ESWL showed a statistically higher retreatment rate compared with URSL (OR= 7.192; 95% CI= 4.934-10.482; P<.001). The 2 treatment modalities did not show statistically significant differences in mean operating time (OR= 10.35; 95% CI=-0.29 to 20.99; P= .056), auxiliary procedure rate (OR= 1.043; 95% CI= 0.415-2.616; P= .929), or in the complication rate (OR= 0.78; 95% CI= 0.304-1.984; P= .598). For treating large (>10mm) proximate ureteral stones, URSL tends to be more effective than ESWL, yet without adding significant risk.

Invasive Management of Proximal Ureteral Calculi During Pregnancy

To review our experience with invasive management of proximal ureteral calculi during pregnancy when conservative treatment fails. From February 2006 to September 2012, a total of 87 pregnant women received invasive management for proximal ureteral calculi in our center. Invasive management included the following: double-J stent insertion, percutaneous nephrostomy (PCN), and ureteroscopic lithotripsy (URSL). The medical records of these patients were reviewed retrospectively. Of the 87 patients, 4 patients received PCN; 19 patients received cystoscopic double-J stent insertion, whereas 2 patients (10.5%) failed in guide wire inserting and switched to ureteroscopic aid; a total of 64 patients received URSL with holmium laser, in which 52 patients (81.2%) had complete fragmentation of calculi; in 9 patients (14.1%), stone fragments retrograde migrated to the renal pelvis; in 3 patients (4.7%), the stone could not be reached because of serious ureteral tortuosity. One patient (1.6%) patient had a threatened abortion, but this problem was resolved immediately using conservative treatment. All patients completed the full term of pregnancy, and no serious obstetric or urologic complications were observed. For pregnant patients with proximal ureteral calculi, double-J stent insertion, PCN, and URSL all are effective and safe options when conservative treatment fails. They should be chosen on the basis of different patient's condition. However, patient's postoperative tolerance was poor for double-J stent insertion and PCN; URSL (especially with holmium laser lithotripsy) is more effective and should be considered as the preferred choice.

E73 Emergency management of proximal ureteral calculi: Comparative evaluation of two different approaches

E73 Emergency management of proximal ureteral calculi: Comparative evaluation of two different approaches

Editorial Comment

The main objective of the treatment of ureteral stones is to achieve the immediate relief of the symptoms, decompression of the urinary tract, and stone disintegration/expulsion, with an acceptable rate of complications. Shock wave lithotripsy (SWL), retrograde lithotripsy, and medical expulsive treatment are each valuable options. At present, no high-quality, randomized study has been published showing the superiority of 1 treatment over the other 2. Given the particular clinical setting, it is unlikely such a study will ever be performed. In contrast, retrospective and prospective series have undoubtedly shown that each approach is safe. 1 Parsons J.K. Hergan L.A. Sakamoto K. et al. Efficacy of alfa-blockers for the treatment of ureteral stones. J Urol. 2007; 177: 983-987 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar , 2 Seitz C. Tanovic E. Kikic Z. et al. Impact of stone size, location, composition, impactation, and hydronephrosis on the efficacy of holmium:YAG laser ureterolithotripsy. Eur Urol. 2007; 52: 1751-1757 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar , 3 Salem H.K. A prospective randomized study comparing shock wave lithotripsy and semirigid ureteroscopy for the management of proximal ureteral calculi. Urology. 2009; 74: 1216-1221 Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar The authors describe a large retrospective experience of immediate versus delayed ureteroscopic treatment of ureteral stones. The latter group was treated first with appropriate medical treatment that failed to be effective. The results of the ureteroscopic procedures were similar. The main difference is practical and obvious. The delayed group surely experienced more pain, a later return to daily activities, and required more medical treatment. Nevertheless, it should be underlined that the report was not a comparison between immediate ureteroscopic treatment and medical expulsive therapy, because the patients who experienced successful medical treatment were not included in the analysis. Therefore, according to the authors, the main conclusion that can be drawn is that ureteroscopic lithotripsy is a safe option, even when performed immediately after the first colic attack, with results comparable to those for treatment delayed until expectant therapy has failed. In conclusion, when ureteral stones are complicated by hydronephrosis and/or fever or when the colic cannot be controlled by drugs, emergency ureteroscopic treatment can (and I believe should) be adopted. In most settings, emergency treatment means within 24 hours, a reasonable compromise, allowing time for a correct evaluation of the general condition of the patient. Patients with only 1 colic attack controlled by drugs and without hydronephrosis do not require hospitalization; thus, emergency ureteroscopic treatment could result in unnecessary overtreatment. One might finally debate in these cases the usefulness of emergency SWL (if available). Theoretically, SWL could improve the chance of spontaneous resolution, even if the fragmentation is partial. However, SWL of ureteral stones is not always easy, and, after colic, the visualization of the stone is even more difficult owing to intestinal meteorism, such that it would probably end as a fruitless attempt, with considerable cost. Emergency Ureteroscopic Removal of Ureteral Calculi After First Colic Attack: Is There Any Advantage?UrologyVol. 78Issue 3PreviewTo comparatively evaluate the efficacy of ureteroscopic stone treatment immediately after the first colic attack and in an electively planned manner. Full-Text PDF ReplyUrologyVol. 78Issue 3PreviewObstructing ureteral calculi have been the most common cause of severe colic pain evaluated and treated in an emergent manner. Regarding the management alternatives, because of its noninvasive and practical nature, shock wave lithotripsy is currently the preferred therapeutic option and can be performed after the onset of renal colic to relieve stones and related problems.1-5 However, although the success rates are high in the management of proximal ureteral calculi, these rates tend to decrease in distal stones and for those treated in an emergency setting. Full-Text PDF

Does tamsulosin change the management of proximally located ureteral stones?

The objective of this study is to assess the efficacy of an alpha-1 adrenergic receptor blocking agent on the spontaneous passage of proximal ureteral calculi < or =10 mm. 92 patients having single radio-opaque proximal ureteral stone < or =10 mm were randomized into two groups. Group 1 patients (n = 50) were followed with classical conservative approach and patients in Group 2 (n = 42) additionally received tamsulosin, 0.4 mg/day during 4 weeks follow-up. The stone passage rates, stone expulsion time, VAS score, change in colic episodes, and hospital re-admission rates for colicky pain were compared. The patients were furthermore stratified according to stone diameters <5 and 5-10 mm. The data of these subgroups were also compared. Stone expulsion rates showed statistically significant difference between tamsulosin receivers and non-receivers (35.7 vs 30%, p = 0.04). Time to stone expulsion period was also shortened in those receiving tamsulosin (8.4 +/- 3.3 vs 11.6 +/- 4.1 days, p = 0.015). Likewise, the mean VAS score and renal colic episodes during follow-up period were significantly diminished in Group 2 patients (4.5 +/- 2.3 vs 8.8 +/- 2.9, p < 0.01 and 66.6 vs 36%, p = 0.001, respectively). Among the stones <5 mm, tamsulosin receiving patients had higher spontaneous passage rate (71.4 vs 50%, p < 0.001). The prominent effect of tamsulosin on the 5-10 mm stones was the relocation of the stones to a more distal part of ureter (39.3 vs 18.7%, p = 0.001). Administration of tamsulosin in the medical management of proximal ureteral calculi can facilitate the spontaneous passage rate in the stone <5 mm and the relocation of the stones between 5 and 10 mm to more distal part of the ureter.

Reply

We read with great interest the comments given by Dr. Dorit and Dr. Glenn regarding our article, as they have raised 2 points. A Prospective Randomized Study Comparing Shock Wave Lithotripsy and Semirigid Ureteroscopy for the Management of Proximal Ureteral CalculiUrologyVol. 74Issue 6PreviewTo 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. Full-Text PDF Editorial CommentUrologyVol. 74Issue 6PreviewIn this prospective randomized study, the authors compare shock wave lithotripsy (SWL) and ureteroscopy (URS) for the management of proximal ureteral calculi > 1 cm. Both groups were comparable in terms of stone size, patient's age, and sex. SWL was associated with more postoperative office and emergency room (ER) visits for pain management, and had a higher percentage of complications (using the Calvien grading system), as compared with URS. URS was associated with higher stone-free rates (SFR) and found to be superior in treating calcium oxalate monohydrate stones. Full-Text PDF

Editorial Comment

In this prospective randomized study, the authors compare shock wave lithotripsy (SWL) and ureteroscopy (URS) for the management of proximal ureteral calculi > 1 cm. Both groups were comparable in terms of stone size, patient's age, and sex. SWL was associated with more postoperative office and emergency room (ER) visits for pain management, and had a higher percentage of complications (using the Calvien grading system), as compared with URS. URS was associated with higher stone-free rates (SFR) and found to be superior in treating calcium oxalate monohydrate stones. Overall, URS scored higher in terms of the efficiency quotient (EQ) for stones ≥ 1 cm as compared with SWL. Finally, the mean total cost for SWL was significantly higher as compared with URS when taking into account additional office and ER visits as well as auxiliary procedures needed for the management of residual stones after SWL. A Prospective Randomized Study Comparing Shock Wave Lithotripsy and Semirigid Ureteroscopy for the Management of Proximal Ureteral CalculiUrologyVol. 74Issue 6PreviewTo 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. Full-Text PDF ReplyUrologyVol. 74Issue 6PreviewWe read with great interest the comments given by Dr. Dorit and Dr. Glenn regarding our article, as they have raised 2 points. Full-Text PDF

Treatment of Proximal Ureteral Calculi: Holmium:Yag Laser Ureterolithotripsy Versus Extracorporeal Shock Wave Lithotripsy

We compared the safety and efficacy of ureteroscopy with intracorporeal holmium:YAG laser lithotripsy and extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for proximal ureteral calculi. A total of 67 patients underwent 81 primary procedures, including in situ ESWL with a DoLi 50 lithotriptor (Dornier Medical Systems, Inc.) or ureteroscopy combined with holmium:YAG laser lithotripsy for proximal ureteral calculi. Of the primary procedures 81 involved proximal ureteral calculi, including 35 done for calculi 1 cm. or greater. The initial stone-free rate in patients with calculi 1 cm. or greater was 93% for ureteroscopy combined with holmium:YAG laser lithotripsy and 50% for in situ ESWL. The efficiency quotient for treating proximal ureteral calculi 1 cm. or greater was calculated as 0.76 for ureteroscopic lithotripsy and 0.43 for ESWL. For proximal ureteral calculi less than 1 cm. the initial stone-free rate was 100% and 80% for ureteroscopic laser lithotripsy and ESWL, respectively. The efficiency quotient was calculated as 0.81 for ureteroscopic lithotripsy and 0.72 for ESWL for treating proximal ureteral calculi less than 1 cm. There were no major complications in either group and all procedures were performed on an outpatient basis. Our study demonstrates that ureteroscopy combined with holmium:YAG laser lithotripsy is an acceptable treatment modality for all proximal ureteral calculi and excellent results are achieved for calculi 1 cm. or larger. Although the stone-free rate was better for smaller stones with ureteroscopic laser lithotripsy, efficiency quotients were similar. Therefore, ESWL should remain first line therapy for proximal ureteral calculi less than 1 cm. because of less morbidity, and a lesser anesthesia and analgesic requirement.

The Dretler Stone Cone: A Device to Prevent Ureteral Stone Migration—The Initial Clinical Experience

Retrograde stone migration during ureteroscopic lithotripsy occurs in 5% to 40% of proximal and distal ureteral stone cases. This migration increases morbidity and the need for auxiliary procedures. The Dretler stone cone (Medsource, Norwell, Massachusetts) is a novel device to prevent proximal stone migration and facilitate fragment extraction during ureteroscopic lithotripsy. We assessed the safety and efficacy of the Dretler stone cone in the clinical setting and compared it prospectively with a conventional flat wire basket during ureteroscopy for ureteral calculi. To our knowledge we report the initial clinical use of the Dretler stone cone in 50 consecutive patients with ureteral calculi undergoing ureteroscopic extraction. Calculi were situated above the sacroiliac joint in 24 cases, over the sacroiliac joint in 15 and below the sacroiliac joint in 11. Pneumatic lithotripsy was done in 42 cases. In the remaining 8 cases ureteroscopic (3) or fluoroscopic (5) intact stone extraction was performed. The later 23 cases using the Dretler stone cone were prospectively compared with 20 of ureteroscopic intracorporeal lithotripsy using a standard flat wire basket. The Dretler stone cone was successfully placed in all 50 cases. In 41 patients it was placed via cystoscopy under fluoroscopic guidance, while 9 impacted stones required ureteroscopic placement. Six patients in whom the Dretler stone cone was used had residual fragments less than 3 mm. No patient required auxiliary procedures. In the prospective trial no patients in Dretler stone cone group had residual fragments greater than 3 mm. or required auxiliary procedures. However, in the flat wire basket group residual stones greater than 3 mm. were present in 6 cases (30%, p <0.001), while auxiliary procedures were required in 4 (20%, p <0.01). The Dretler stone cone represents a new generation of basketry that minimizes proximal ureteral stone migration and allows safe extraction of fragments during ureteroscopic lithotripsy. In our experience it is associated with a lower incidence of significant residual fragments and fewer auxiliary procedures than conventional flat wire baskets.

DOSE A URETERAL ACCESS SHEATH FACILITATE URETEROSCOPY?

Ureteral access sheaths were initially developed to facilitate difficult ureteroscopic access. However, to our knowledge no formal evaluations have been performed to assess the routine use of ureteral access sheaths. Therefore, we prospectively analyzed intraoperative time, symptomatic outcome, major complications, stone-free rate and overall costs related to the routine use of a new ureteral access sheath during standard ureteroscopic procedures. Patients undergoing 6.5Fr semirigid or 7.5Fr flexible ureteroscopy were prospectively randomized to unaided ureteroscopy with no access sheath or ureteroscopy via a 12-14Fr ureteral access sheath. Patients who required ureteral dilatation were randomized to the ureteral access sheath used as a dilator or a standard 18Fr ureteral balloon dilator. Patients were evaluated postoperatively on days 0, 1 and 6 with a questionnaire to assess pain, irritative symptoms and complications. The stone-free rate and long-term complications were determined by excretory urography or computerized tomography at 3 months. Enrolled in the study were 59 consecutive patients, who underwent a total of 62 ureteroscopic procedures. Of the 47 patients (76%) who did not require ureteral dilatation 23 (49%) underwent ureteroscopy via the ureteral access sheath and 24 (51%) underwent unaided ureteroscopy. Seven of the 15 patients (28%) who required ureteral dilatation underwent access sheath dilatation, while balloon dilatation was performed in 8. There was no significant difference in postoperative symptoms, complication rate or stone-free status in the access sheath and nonaccess sheath groups in patients not requiring ureteral dilatation (p <0.05). A significant increase in postoperative symptoms was noted when the balloon was used as a dilator compared to the access sheath. Operative time and costs in all patients who underwent access sheath dilatation were less than in those in whom the access sheath was not used. In the 15 patients who required dilatation 71% of access sheath and 100% of balloon dilatations were successful. Routine use of a ureteral access sheath appears to facilitate semirigid and flexible ureteroscopy by decreasing operative time and costs, allowing direct visualization of ureteroscope insertion with simple ureteral re-entry and assisting renal and ureteral access with minimal associated morbidity. A ureteral access sheath should be considered for routine ureteroscopic procedures.