Management Of Ureteral Stones Research Articles

Day surgery urolithiasis management: efficacy and safety of ureteroscopy and laser lithotripsy in a district general hospital setting

Introduction: Incidence of urolithiasis is rising worldwide and increasingly Ureteroscopy (URS) coupled with laser fragmentation is being used safely within the day surgery setting for ureteral and renal stone management. This study is to explore whether URS guided lithotripsy could be delivered effectively as a day surgery procedure. Method: Retrospective analysis of 118 day surgery patients who underwent URS guided laser lithotripsy for ureteric and renal calculi between November 2017 and April 2019. All patients underwent ureteric stenting during acute admission prior to the URS guided lithotripsy. Outcomes were compared against European Association of Urology (EAU) guidelines on the best clinical practice in use of URS in urolithiasis. Results: Of the 118 patients who underwent URS and laser fragmentation, mean age was 54 years with 2:1 male:female ratio. 56% were ureteric (67% upper, 8% middle and 25% distal ureter), 44% renal stones. Mean stone size was 9.7mm, with 58% ‹1cm, 38% 1-2cm and 4% ›2cm. 90.6% of patients following URS guided stone fragmentation were stone-free. The complication rate was 8.5% (n = 10), Clavien-dindo 3 in 4 patients and Clavien-dindo 4 in 1 patient. Conclusion: This study demonstrated that URS guided stone fragmentation can safely deliver high stone free and low complication rates within day surgery setting.

Comparison of minimally invasive percutaneous nephrolithotomy and ureteroscopy in the management of impacted proximal ureteral stones

Introduction and objective: Management of large impacted proximal ureteral stones is often challenging due to the presence of mucosal edema, inflammation and angulations of the ureter and other factors which impede stone access, visibility and lithotripsy and can lead to different types of complications. The objective of our study is to compare the efficacy and safety of minimally invasive percutaneous nephrolithotripsy (mini-PCNL) and ureteroscopy (URS) in the treatment of impacted proximal ureteral stones. Material and methods: The medical records of 345 patients with impacted proximal ureteral stones 10-20 mm, treated between January 2016 – November 2022 were retrospectively reviewed. 178 patients (51.6%) underwent mini-PCNL, and 167 (48.4%) – URS. Data on patients’ preoperative characteristics, stone-free rates, operating times, intra- and postoperative complications were compared. Results: Patients’ preoperative characteristics were comparable between the two groups, except for mean stone surface and stone size, which were significantly higher in the mini-PCNL group (respectively, 137.87±44.32mm2 vs 80.94±29.66mm2, p=0.000; and 15.03±2.43 vs 12.02±2.22mm, p=0.000). The stone free rate after single procedure was 94.9% for mini-PCNL and 89,3% in the URS group (p=0,116). Four patients (2.3%) in the mini-PCNL group had significant hemorrhage necessitating selective renovasography and angioembolization of AV fistula. 21 (12.5%) patients had stones showing upward migration during the URS procedure and 3 (1.8%) had partial perforation of the ureteral wall. Hemoglobin drop was significantly higher in mini-PNL group (13.58±12.79g/l vs 4.69±5.72g/l, p=0,000). Mean operative time was significantly longer in the URS group, despite the smaller size of the stones (respectively, 41.41±13.62min vs. 30.67±10.34min, p=0,000). There were statistically significant difference of the necessity of auxiliary procedures in the URS group (respectively, 78 patients (46,4%) vs 6 patients (3.6%), p=0.000). Conclusions: For an impacted, proximal ureteral stone mini-PNL had better stone-free rates, shorter operative time and low percentage of auxiliary procedure and hospitalizations. However, URS had the advantages of less invasiveness procedure and shorter postoperative hospital stay.

Efficacy and safety of retrograde ureteroscopy for the treatment of impacted proximal ureteral stones larger than 10 mm

Introduction and objective: Optimal management of large impacted proximal ureteral stones remains controversial. Retrograde ureteroscopy in these cases may be challenging due to the presence of mucosal edema and inflammation, tortuousity and unusual angulations of the ureter. The objective of this study is to evaluate the efficacy and safety of retrograde ureteroscopy (URS) for the treatment of impacted proximal ureteral stones larger than 10 mm. Material and methods: A prospectively collected database of 143 patients, who underwent retrograde ureteroscopy for impacted proximal ureteral stones ≥ 10 mm between January 2016 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates, complications and auxiliary procedures was analyzed. Results: Patients’ mean age was 54.2±13.4 years, and male-to-female ratio – 67.8%/32.2%. Mean stone length was 14.2±5.4 mm and mean stone width – 9.6±2.9 mm. 26 (18.2%) patients were on preoperative anticoagulation therapy, which could not be discontinued. 26 patients (18.2%) had preoperative drainage with ureteral stent JJ, and 7 (4.9%) – with percutaneous nephrostomy. Stone-free rate after single procedure was 88.8%. Mean operative time was 44.2±15.4 min. There were no cases of failed endoscopic access to the stone. Flexible ureteroscopy was performed in 34 (23.8%) cases. Postoperative drainage was ureteral stent JJ in 71 (49.7%) patients and ureteral catheter for 24 h – in 33 (23.1%). Most common postoperative complications were fever in 5 (3.5%) and postoperative renal colic – in 5 (3.5%) patients. 8 patients (5.6%) underwent SWL for treatment of residual fragments and 2 (1.4%) – retrograde intrarenal surgery. Conclusions: The results from this study demonstrate that retrograde ureteroscopy is an effective and safe treatment modality for impacted proximal ureteral stones ≥ 10 mm. Its high stone-free rate and low complication rate make retrograde URS a suitable first-line treatment for anticoagulated patients with impacted proximal ureteral stones, who are at increased risk of complications from the antegrade approach

Comparison between Intracorporeal Pneumatic Lithotripsy and Extracorporeal Shock Wave Lithotripsy (ESWL) in terms of efficacy and Safety for Management of Proximal Ureteric Stones

Objective: To compare efficacy and safety of intracorporeal pneumatic lithotripsy versus extracorporeal shock wave lithotripsy (ESWL) in patients of upper ureteric stones having stone size from 10 to 15 mm. Study Design: Randomized control trial Setting: Study was done at department of Urology, Nishtar Hospital Multan. The duration of the study was from January 2021 to January 2022. Methodology: 140 patients were divided into two groups randomly. In group A ureterorenoscopy (URS) with Pneumatic Lithotripsy was used for proximal ureteric stones management. URS was performed under general anesthesia. In group B, ESWL was done for the management of proximal ureteric stones identified by ultrasound and fluoroscopy. SPSS version 23 was used for data analysis. Results: In this study In Intracorporeal Pneumatic Lithotripsy group the stone cleared in 90% patients and in ESWL group the stone cleared in 78.6% patients (p-value=0.595). In Intracorporeal Pneumatic Lithotripsy group the pain was present in 14.3% patients and in ESWL group the pain was present in 18.6% patients (p-value=0.494). In Intracorporeal Pneumatic Lithotripsy group the bleeding was noted in 25.7% patients and in ESWL group the bleeding was noted in 40.0% patients (p-value=0.072). Conclusion: This study concluded that intracorporeal pneumatic lithotripsy is a good alternate of ESWL for the management of upper ureteric stones (having size from 10 to 15mm). Keywords: Urolithiasis, Intracorporeal Pneumatic Lithotripsy, Extracorporeal Shock Wave Lithotripsy, Ureteric Stone

The use of tamsulosin in the treatment of 10–15 mm lower ureteral stones in adults: a double-blinded randomized controlled trial

BackgroundThe discovery of alpha-adrenergic receptors in the ureteral smooth muscle cells led to a thorough investigation of the therapeutic potential of alpha-blockers for ureteral calculi. Tamsulosin is a selective blocker of alpha-1A and alpha-1B adrenoceptors. It significantly improved the expulsion of distal ureteral stones measuring 3–10 mm in most randomized trials. To the best of our knowledge, tamsulosin was not tested before in the management of ureteral stones 10–15 mm. Hence, the present study aimed at estimation of the efficacy of tamsulosin in the expulsion of lower ureteral stones 10–15 mm in length compared to placebo in adult patients (primary goal) and the need for ureteral dilatation at scheduled ureteroscopy.MethodsBetween November 2017 and November 2019, 80 patients with distal ureteral stones 10–15 mm were divided into two equal groups. One group received tamsulosin 0.4 mg/day and the other received a placebo. Patients were followed-up for 8 weeks.ResultsSix patients of the tamsulosin group (15%) passed their stones spontaneously compared to none of the placebo group (p = 0.026). Two of the 6 patients who passed the ureteral stones developed urinary retention and required endoscopic treatment of urethral stones. So, the adjusted spontaneous ureteral stone passage ratios for the tamsulosin and the control groups were 10 and 0%, respectively (p = 0.12). Overall, 37.5% reported adverse effects in the tamsulosin group, and 30% in the placebo group (p = 0.7). The most common adverse effect reported in both groups was dizziness, which occurred more frequently with tamsulosin (25%) than placebo (22.5%) (p = 0.9). We noticed increased ejaculatory dysfunction among men in the tamsulosin group versus placebo group [17.9% vs. 3.5% (p = 0.1)]. Among patients who needed ureteroscopy, ureteral dilatation was always needed in the control group versus 85.3% of the tamsulosin group (p = 0.015). Although 23.5% of the treatment group didn’t need stents after ureteroscopy compared to only 12.5% of the control group, this difference was not statistically significant (p = 0.2).ConclusionsAlthough tamsulosin significantly increased spontaneous passage of 10–15 mm lower ureteral stones in adults, it did not decrease the need for operative intervention. Preoperative tamsulosin significantly facilitated ureteral dilations during ureteroscopic management.

The Efficiency of Extracorporeal Shock Wave Lithotripsy (ESWL) in the Treatment of Distal Ureteral Stones: An Unjustly Forgotten Option?

IntroductionThe optimal management of distal ureteral stones remains a matter of debate since current guidelines favor ureteroscopy over extracorporeal shock wave lithotripsy (ESWL). We aimed to evaluate the efficiency of ESWL for distal ureteral stones and to identify factors that affect treatment outcomes.Materials and methodsThe retrospective study included records of 115 patients with distal ureteral stones, 5 mm to 18 mm in size, undergoing 223 ESWL sessions as an outpatient procedure. Early fragmentation and three-month follow-up stone-free rate (SFR) was assessed through radiographic imaging. Treatment was successful if there were no residual fragments or they were ≤4 mm, three months after the last session.ResultsThe mean ±standard deviation (range) stone size was 9.68 ±3.10 (5.00-18.0) mm. The mean body mass index (BMI) was 24.3 ±2.67 (18.4-29.8) kg/m² with a significant correlation between BMI and stone size (r2 =0.324, p <0.001). Patients underwent ESWL an average of 1.7 ±1.36 times (1-5), while 68 patients (59.1%) became stone-free after one session. The overall SFR was 82.6%; for patients with stone sizes ≤10 mm and >10 mm, it was 99% and 9.4%, respectively. Cumulative SFR after the second session was 77%. In 20 (17%) patients the treatment was a failure. Complications occurred in 10.4%, while auxiliary procedures were needed in 8.7% of cases, both significantly affected by the stone size (p <0.001). The efficiency quotient (EQ) was 0.76. Treatment outcome was significantly different depending on stone size, BMI, number of sessions, complications, and auxiliary procedures (p <0.001, p =0.022, p <0.001, p <0.001, p <0.001, respectively). Univariate regression analysis identified stone size and BMI as significant predictors of treatment outcome (odds ratio (OR) 3.84, 95% confidence interval (CI): 2.31-8.97, p =0.001, and OR 1.25, 95% CI: 1.04-1.54, p =0.024, respectively).ConclusionsExtracorporeal shock wave lithotripsy continues to be a safe and effective option for managing simple calculi in distal ureters with a diameter of ≤10 mm. The stone size and BMI remain significant predictors of treatment outcome.

685 Management of Patients Presenting Acutely with Suspected Ureteric Colic

Abstract Aim To assess how patients presenting with suspected ureteric colic are managed compared to NICE guidance (renal and ureteric stones, QS195 July 2020). Also, to review the incidence of ureteric stones occurring in all referrals received in a hospital where patients are referred prior to imaging confirmation of stones. Method The dataset was formed by retrospective handover screening during a three-month period in 2019 prior to the impact of COVID-19 with any patient included who was referred to urology with a suspected ureteric calculus, generating 149 cases. Demographic information, imaging modality and treatment were recorded as well as comparisons to five NICE quality statements on the management of ureteric stones. Results Of the 149 referrals 88 were male with a median age of 45 years. Ureteric stones were found in 61/149 of referrals with 99/149 receiving CT scan first line whilst the remainder were initially imaged using ultrasound. Forty referrals were received for women under the age of 50 with only 3/40 having a ureteric stone. Pick-up rate of ureteric stones was higher in older and male patients. CT within 24 hours of referral was achieved in 82.8% and 69.9% were given appropriate analgesia. In patients in which it was necessary primary treatment occurred within 48 hours in 45.4% of patients. Conclusions Less than half of referrals received had a ureteric stone with particularly low pick-up rates in young women. A large proportion of patients having ultrasound first line had subsequent CT imaging. Adherence to NICE quality standards was comparable to other centres.

Cost-utility analysis of shockwave lithotripsy vs ureteroscopic stone treatment in adults.

To assess the cost-effectiveness, resource use implications, quality-adjusted life-years (QALYs) and cost per QALY of care pathways starting with either extracorporeal shockwave lithotripsy (SWL) or with ureteroscopic retrieval (ureteroscopy [URS]) for the management of ureteric stones. Data on quality of life and resource use for 613 patients, collected prospectively in the Therapeutic Interventions for Stones of the Ureter (TISU) randomized controlled trial (ISRCTN 92289221), were used to assess the cost-effectiveness of two care pathways, SWL and URS. A health provider (UK National Health Service) perspective was adopted to estimate the costs of the interventions and subsequent resource use. Quality-of-life data were calculated using a generic instrument, the EuroQol EQ-5D-3L. Results are expressed as incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. The mean QALY difference (SWL vs URS) was -0.021 (95% confidence interval [CI] -0.033 to -0.010) and the mean cost difference was -£809 (95% CI -£1061 to -£551). The QALY difference translated into approximately 10 more healthy days over the 6-month period for the patients on the URS care pathway. The probabaility that SWL is cost-effective is 79% at a society's willingness to pay (WTP) threshold for 1 QALY of £30,000 and 98% at a WTP threshold of £20,000. The SWL pathway results in lower QALYs than URS but costs less. The incremental cost per QALY is £39 118 cost saving per QALY lost, with a 79% probability that SWL would be considered cost-effective at a WTP threshold for 1 QALY of £30 000 and 98% at a WTP threshold of £20 000. Decision-makers need to determine if costs saved justify the loss in QALYs.

Predicting urine culture results in candidates for lithotripsy.

Urological guidelines assert that "urine culture should be obtained" before surgical management of ureteral or kidney stones. Thus, many surgeries are delayed by 1-3 days until the results of urine culture are available. During this time, the patient frequently experience pain and possible kidney damage. We investigated the hypothesis that it is possible to predict the results of urine culture in candidates for surgical intervention using parameters that are accessible immediately upon admission. A database of 1000 patients who underwent either percutaneous nephrolithotomy (PCNL) or ureteroscopy/retrograde intrarenal surgery was analyzed. Eleven parameters potentially related to urinary infections and accessible to the clinician at the emergency department were correlated with the preoperative urine culture results. Of the patients, 234 (23.4 %) had positive cultures. On multivariate analysis, only sex, hydronephrosis grade, and history of previous nephrolithotomy were significantly associated with a positive preoperative urine culture. The risk of a positive culture can be easily determined from a simple table or an Excel-based calculator. This risk could be as low as 0.45% for a man without a history of PCNL and no hydronephrosis (4% in a woman with similar parameters) or as high as 79.5% in a man with a history of PCNL and hydronephrosis (85% in a woman with similar parameters). The risk of preoperative positive urine culture can be predicted using 3 parameters that are accessible upon admission. In low-risk cases, prompt surgical treatment can be provided, eliminating the anticipation time for urine culture results.

Alpha-Blocker Prescribing Trends for Ureteral Stones: A Single-Centre Study.

PurposeRecommendations for alpha-blockers have shifted in the conservative management of ureteral stones. It is unknown whether real-life practices regarding alpha-blocker prescriptions reflect updates in evidence. This study aimed to characterise alpha-blocker prescriptions for conservatively managed ureteral stones and relate this to recent literature.MethodsThis was a retrospective audit, 01/01/2014 to 01/01/2019, of emergency acute renal colic presentations. Patients were included if they had a confirmed ureteral stone and were conservatively managed. The rates of alpha-blocker prescriptions were analysed using interrupted time-series analyses. May 2015 was selected as the cut-point to analyse before and after trend lines. Results were stratified by stone size and location. Tamsulosin and prazosin prescriptions were also compared.ResultsThis study included 2163 presentations: 70.4% were stones ≤5 mm and 61.4% were proximal stones. Altogether, 24.7% of presentations were prescribed alpha-blockers. There was a fall in alpha-blocker prescription rates from before to after May 2015, regardless of stone size or location (p < 0.001). Since May 2015, however, there was a monthly rate increase of 0.5% for patients with stones >5mm.ConclusionThis study demonstrated a significant shift in rates of alpha-blocker prescriptions, possibly related to the influence of updates in available high-quality evidence.

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

ObjectiveTo evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy (npPCNL) for the management of large proximal ureteral stones. MethodsWe 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. ResultsTwenty-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%. ConclusionThe 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.

Tamsulosin versus Fluid Therapy in Management of Ureteric Stone: A Comparative Study

Introduction: Almost all ureteric stone migrates from kidney. The drugs commonly used to assist in the passage of bigger calculi include alpha-blockers, calcium channel antagonists, phosphodiesterase inhibitors, corticosteroids. Tamsulosin is an alpha-1 adrenergic receptor antagonist known to augment the stone expulsion rate.&#x0D; Aims: To evaluate the efficacy of Tamsulosin versus fluid therapy in management of urolithiasis.&#x0D; Methods: The study was carried out on 100 patients (divided into 2 groups) at Nepalgunj Medical college Hospital Nepalgunj from May 2020 to April 2021,between 18-50 years of age of either sex, presenting with a symptomatic urinary calculus as demonstrated on imaging. Group 1 received 0.4mg of tablet tamsulosin once daily for 4 weeks, whereas Group 2 fluid therapy for a period of 4 weeks or until expulsion of stone.&#x0D; Results: Group A reflected 88% (40 patients) expulsion rate, whereas Group B reflected 72.0% (36 patients) expulsion rate. There was a statistically significant difference in the expulsion rate amongst both the groups. 92.0% (46 patients) subjects in Group A demonstrated stone expulsion within 4 weeks, mean time being 8 days. In comparison only 70.0% (35 patients) subjects in Group B demonstrated stone expulsion within 4 weeks, mean time being 14 days.Use of tablet diclofenec 100mg was lower in Group A in comparison to Group B.&#x0D; Conclusion: Tamsulosin is a safe and effective pharmacological agent in management of ureteric stones as it known to increase overall stone expulsion rate, reduced stone expulsion time, decrease acute attacks by acting as a spasmolytic, and fewer pain episodes. It may be considered as a conservative therapeutic option before more invasive procedures like ureteroscopic removal or Extracorporeal shock wave lithotripsy.

The role of inflammatory serum markers and ureteral wall thickness on spontaneous passage of ureteral stone < 10 mm: A prospective cohort study

IntroductionUreteral stone is a worldwide disease and accounts for 20% of all urolithiasis. There is a widespread discussion on the preferred initial treatment method, whether medical or surgical, and each has its pros and cons. In this study, we aimed to assess the role of both ureteral wall thickness around the stone and inflammatory markers in guiding the decision-making process. MethodsIn this prospective study, 161 patients who presented with ureteric colic and were diagnosed with ureteral stone with NCCT were included. UWT around the stone was measured, and the NLR and PLR were calculated. The patients were given a single daily dose of tamsulosin 0.4 mg for 4 weeks with weekly follow-up to determine SSP or failure. ResultsOf the 161 patients with a mean age 40.12 ± 12.36 SD, 55.9% had a spontaneous stone passage. Receiver operating characteristics showed a cut off value of 2.45 mm UWT of non SSP patients with an 83% sensitivity and 86% specificity. Moreover, there was a significant correlation between higher NLR, PLR and increased UWT (Pearson correlation of 0.314 and 0.426 respectively). The combined higher NLR, PLR and increased UWT were associated with failure of SSP (p-value <0.001). ConclusionMany factors play a role in decision making for management of ureteral stones. Our study concludes that patients with high NLR, PLR, and UWT around the stone have lesser chance of SSP using MET. Their rise can be used as predictors to decide early intervention.

Acute extracorporeal shockwave lithotripsy for ureteric stones - 7-years' experience from a busy district general hospital.

To demonstrate the efficacy and cost-effectiveness of acute extracorporeal shockwave lithotripsy (ESWL) for ureteric stones we present our experience of ESWL in 530 ureteric stone cases, in the largest UK series we are aware of to date. ESWL is underutilised in ureteric stone management. The Getting It Right First Time (GIRFT) report showed just four units nationally treated >10% of acute ureteric stones with ESWL. Despite guideline recommendations as a first-line treatment option, few large volume studies have been published. Retrospective review of prospectively collected data between December 2012 and February 2020 was performed. Data relating to patient demographics, stone characteristics, skin-to-stone distance, and treatment failure were collected. Cost analysis was conducted by the Trust's surgical financial manager. Multivariable analyses were performed to assess for predictors of ESWL success. A success rate of 68% (95% confidence interval 64%-72%) at 6 weeks was observed (n = 530). The median (interquartile range) number of treatment sessions was 2 (1, 2). Stone diameter was observed to be a predictor of ESWL success. The small number of stones treated of >13 mm or >1250 HU had an ~50% chance of successful treatment. Acute ureteric ESWL was less costly than acute ureterorenoscopy, consistent with findings from previous NHS studies. Acute ESWL is a safe, reliable, and financially viable treatment option for a wider spectrum of patients than reflected in international guidelines based on our large, heterogenous series. In the coronavirus disease 2019 (COVID-19) era, with theatre access reduced and concerns over aerosol generating procedures, acute ESWL remains an attractive first-line treatment option.

Predictors of successful emergency shock wave lithotripsy for acute renal colic

The role of emergency shockwave lithotripsy (SWL) in persistent pain control in patients with ureteral stones is not well established. The aim of this study is to evaluate efficacy as well as the predicting variables for successful early SWL patients with symptomatic ureteral stones. Eighty-six patients with a persistent renal colic secondary to single ureteral stone (6–12 mm) were prospectively enrolled in this study. SWL was performed within 24 h of the onset of flank pain. Pain control and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Seven patients required post-SWL ureteroscopy and ureteral stent placement for uncontrolled pain. The overall 3-month stone-free rate after SWL monotherapy was 83.7%. On multivariate analysis, predictors for pain relief after emergency SWL were lower Hounsfield (HU) stone density, mild hydronephrosis (HN) at presentation and presentation during the first colic episode. Lower HU stone density was the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis. In conclusion, early SWL is feasible and effective in management of ureteral stones presented by renal colic with low HU.

Intravesical aminophylline instillation as an alternative for balloon dilatation prior to semi-rigid ureteroscopic management of distal ureteral stones

PurposeIn a randomized controlled trial, we evaluated the effect of intravesical aminophylline instillation (IVAI) on intraureteral pressure of lower ureter and its use as an alternative to balloon dilatation after failure of advancing semi-rigid ureteroscope through the ureteric orifice without endodilatation.MethodsOur study included 83 patients with juxta-vesical distal ureteral calculi requiring endodilatation after unsuccessfully introducing the semi-rigid ureteroscope through the ureteric orifice. Patients were randomized into two groups: group A (study group) included 41 patients, where IVAI was used to dilate the ureter and facilitate ureteroscopy (the intraureteral pressure was measured using a pressure transducer connected to an invasive pressure monitor before and 5 min after IVAI), whereas group B (control group) included 42 patients, where balloon dilatation was used prior to ureteroscopy. Perioperative surgical outcomes of ureteroscopy were evaluated in both groups.ResultsA statistically significant decrease in mean intraureteral pressure of intravesical ureter was found after IVAI from 12.34 mmHg ± 1.94 before injection to 8.46 mmHg ± 1.94 after injection (P < 0.001). Ureteral injuries, postoperative pain and hematuria were statistically significantly less among the study group compared to the control group (P < 0.05). We did not find statistically significant differences in operative time, need for DJ ureteral stenting or stone-free rate between both groups and no perioperative side effects were associated with IVAI.ConclusionIn ureteroscopic management of distal ureteral stones, intravesical aminophylline instillation is safe, inexpensive and effective in reducing intraureteral pressure and achieves comparable outcomes to balloon dilatation with less ureteral injuries, postoperative pain and hematuria.

Comprehensive endoscopic management of impacted ureteral stones: Literature review and expert opinions.

Treatment of urolithiasis, a benign disease, requires high efficacy and safety. Endoscopic treatment of impacted ureteral stones remains a challenging procedure for urologists, despite recent remarkable advances in surgical technology in treatment of urolithiasis. The success rate of endoscopic treatment in patients with impacted stones is reported to be lower than that in patients with nonimpacted stones. Moreover, the presence of stone impaction is associated with high rates of intraoperative and postoperative complications. The best management for patients with impacted ureteral stones should therefore be devised based on the latest knowledge and techniques. The present review focuses on the preoperative prediction of stone impaction, the safest and most effective endoscopic surgical procedures, and the most appropriate management for postoperative ureteral strictures. We overview comprehensive endoscopic management for impacted ureteral stones based on literature review and expert opinions.

The impact of the COVID-19 pandemic on the primary definitive management of ureteric stones

Objective: To assess the management pathways of ureteric stones within our department and any impact on this as a result of the pandemic. Patients and methods: Retrospective data were collected at two different time points defined as ‘pre-COVID-19’, during April and May 2019, and ‘peri-COVID-19’, during April and May 2020 of all patients with ureteric stones. Results: Similar patient numbers presented with ureteric stones pre-COVID-19 (63) and during the pandemic (75). Pre-COVID-19, 31 patients were admitted, of which 48% had primary ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL). The average time to theatre was 1.2 days. During the pandemic, there were 34 admissions with 56% of these patients receiving primary URS/PCNL. The average time to theatre was 1.5 days. Of the patients referred to the virtual stone clinic, pre-COVID-19, 38% were listed for urgent-elective surgery which was performed at an average of 62 days. During the pandemic, 49% were listed for surgery, waiting 144 days for their procedure. Conclusion: Patients who underwent primary surgery during their first admission had their definitive treatment quicker during the pandemic. However, patients listed for elective procedures waited longer in the peri-COVID-19 period. Level of evidence: (Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009)): 2c

Cost-Effectiveness Analysis of Ureteroscopy vs. Extracorporeal Shockwave Lithotripsy in the Management of Distal Ureteral Stones in Adults Using Propensity Score Matching Analysis

Urolithiasis is an important public health issue with a substantial health burden and considerable global economic consequences [1-3]. Although urolithiasis is rarely fatal, it does have a profound impact on the quality of life.

Prospective, Randomized Comparison of Dual-Lumen vs Single-Lumen Flexible Ureteroscopes in Proximal Ureteral and Renal Stone Management.

Introduction: We sought to compare the safety, efficacy, efficiency, and surgeon experience during upper urinary tract stone management with single-lumen (SLFU) vs dual-lumen flexible ureteroscopes (DLFU). Materials and Methods: Seventy-nine patients with proximal ureteral or renal stone burden <2 cm were randomized to a SLFU or DLFU. We recorded times for ureteroscopy (URS), laser lithotripsy, stone basketing, as well as intraoperative and postoperative complications. The rate of stone clearance and stone free status were calculated using CT imaging. Surgeons completed a survey after each procedure rating various metrics regarding ureteroscope performance. Results: Thirty-five patients from the single-lumen group and 44 patients from the dual-lumen group had comparable median URS time (37 vs 35 minutes, p = 0.984) and basketing time (12 vs 19 minutes; p = 0.584). Median lithotripsy time was decreased in the dual-lumen group (single: 6 vs dual: 2 minutes, p = 0.017). The stone clearance rate was superior in the dual-lumen group (single: 3.7 vs dual: 7.1 mm3/min, p = 0.025). The absolute stone-free rate (SFR) was superior for the dual-lumen group (single: 26% vs dual: 48%, p = 0.045). No differences in intraoperative (single: 0% vs dual: 2%; p = 0.375) and postoperative complications (single: 7% vs dual: 11%, p = 0.474) were observed. Surgeons' ratings of the dual-lumen ureteroscope was superior for visibility, comfort, ease of use, and overall performance. Conclusions: The use of the dual-lumen ureteroscope in patients with renal and proximal ureteral stones <2 cm provided shorter lithotripsy time, higher stone clearance rates, improved SFR, and superior surgeon ratings when compared with SLFUs.