Stone Migration Research Articles

Pneumatic Lithotripsy Versus Laser Lithotripsy for Ureteral Stones.

Introduction: Several different modalities are available for ureteral stone fragmentation. From them pneumatic and holmium: yttrium-aluminum-garnet (Ho: YAG) lithotripsy have supportive outcomes. In this study we studied 250 subjects who had ureteroscopic pneumatic lithotripsy (PL) or laser lithotripsy (LL). Methods: Two-hundred fifty patients with ureteral stones underwent ureteroscopic lithotripsy (115 subjects in the PL group, 135 subjects in the LL group) from August 2010 to April 2016. The purpose of this investigation was to evaluate stone-free rate (SFR), mean operation time (MOT), mean hospital stay (MHS), stone migration and complications. Results: Two groups were similar in age, gender, mean size of stones, side of stone, and complications. There was a statistical difference in terms of SFR, stone migration and MHS in favor of the LL group (P ≤ 0.05, P ≤ 0.05 respectively), and MOT in favor of the PL group (P ≤ 0.05). Conclusion: Both the PL and LL techniques were effective and safe for ureteral stones, however a slightly higher SFR was found in the LL group.

Ureteroscopic lithotripsy in the Trendelenburg position for extracting obstructive upper ureteral obstruction stones: a prospective, randomized, comparative trial

Objective: To introduce a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi.Materials and methods: Between June 2014 and May 2017, 192 patients were enrolled in this study. Patients were randomly assigned to one of two groups: group A, ureteroscopic lithotripsy (URSL) in the Trendelenburg position; or group B, URSL in the standard position. Baseline information, including gender, age, body mass index (BMI), stone side, stone size and hydronephrosis grade, was collected and determined preoperatively. Stone-free rate (SFR) was evaluated 3 weeks after surgery and was defined by the absence of residual stones or the presence of residual stones <2 mm in diameter. Operation time, hospital stay, stone migration, operative complications and SFR were assessed and compared between the two groups.Results: There were no statistically significant differences in gender, age, BMI, stone side, stone size, serum creatinine or hydronephrosis grade between the two groups (all p > 0.05). There were no significant differences in the postoperative hospital stay or postoperative complications between the two groups (all p > 0.05), but the differences in operative time, stone migration and SFR between the two groups were statistically significant (p < 0.05).Conclusion: This study introduced a new position for ureteroscopic holmium laser lithotripsy for patients with upper ureteral calculi. The Trendelenburg position can improve the SFR and may provide an optional surgical method for treating upper ureteral calculi.

Dual usage of a stone basket: Stone capture and retropulsion prevention.

Stone migration during ureteroscopy (URS) for proximal ureteric calculi is a constant challenge. Several retropulsion prevention devices have been developed to optimize URS outcomes. Our technique involves capturing the stone within a four-wire Nitinol stone basket and then performing laser lithotripsy to dust the stone while it is engaged in the basket. The dusted fragments wash out with the irrigation fluid and once small enough, the remaining stone is removed intact. A retrospective chart review was performed of all proximal semi-rigid URS procedures for a solitary calculus (2000-2016). We compared our new technique introduced in 2010 to URS control procedures that did not use retropulsion prevention techniques or devices. One hundred and forty patients underwent URS for proximal ureteric calculi. Mean stone diameter was 9.3±3.4 mm, with similar impaction rate between both groups (44.1% vs. 43.1% control; p=n/s). The mean surgical procedure time was 53.3±17.9 minutes for the new technique and 65.2±29.2 minutes for the control group (p=0.005). Compared to the new technique, the control group had a higher rate of retropulsion (33.3% vs. 14.7%; p=0.01) and required flexible URS more often to exclude or remove residual fragments (24.1% vs. 59.1%; p=0.001). Using the new technique, stone-free rates were higher (79.1% vs. 69.4%; p=n/s) and there was a lower likelihood of leaving residual fragments both <3 mm and ≥3 mm (p=0.001). Our novel technique results in shorter operative times, lower retropulsion rates, and decreases postoperative residual stone fragments.

Evaluation the result of warm normal saline irrigation in ureteral endoscopic surgeries.

Transurethral lithotripsy (TUL) is a major modality for the endoscopic management of ureteral stones. Ureteral spasm makes access for ureters difficult, which causes impaction of the ureteroscope, ureteral dislodge, and a low success rate of endoscopic surgeries. This study described the outcomes of a new endoscopic surgical experience by use of 40-degree warm saline irrigation during TUL compaired with routine ambient air irrigation in TUL. In this randomized clinical trial from 2014 to 2015, 150 patients with ureteral stone with balanced randomization were divided into two parallel groups. Patients underwent TUL in the first group with 20-25 degree saline irrigation and in the second group with 40-degree saline irrigation. One surgical team with the same semi-rigid instrument performed all TULs and the other steps were similar in both groups. Complete stone fragmentation was measured as the primary outcome and the duration of procedure, retrograde stone migration and all and any intraoperative complications were the secondary measurements. While comparing warm saline irrigation with cold saline irrigation, the rate of access to upper ureter was 95% versus 72%, stone retropulsion frequency was 10.7% versus 30.7% and the stone-free rate was 96% versus 76% respectively (P < .05). There was no ureteroscope impaction and ureteral dislodge in both groups. Using warm saline irrigation in endoscopic surgeries results in better surgical outcomes including a lower ureteral spasm rate, greater ureteral muscle relaxation and better access to the upper ureteral zone, and a lower rate of complications, such as ureteroscope impaction, ureteral dislodge and stone retropulsion.

Первоначальный опыт клинического применения тулиевой контактной литотрипсии в трансуретральном доступе в лечении мочекаменной болезни

The choice of an effective and safe method of disintegration of stones in upper and lower urinary tract is very important in the context of continuous scientific and technological progress. In current clinical urological practice, various lithotriptors with rigid and flexible probes are used for contact disintegration of stones, having both advantages and disadvantages. This study aimed to analyze the first results of the clinical application of the native Tm: fiber Urolaz laser (STA IRE-Polyus, Russia) for contact transurethral lithotripsy. The study comprised 56 patients who underwent transurethral contact thulium laser lithotripsy for 68 stones of the upper and lower urinary tracts between April and September 2017. Forty-four patients had kidney and ureteral stones, and twelve patients had urinary bladder stones. Twenty-four kidney stones were removed by retrograde intrarenal surgery using ureteral casing, flexible ureteropyeloscope and thulium laser, 32 stones in various ureteral segments - by rigid contact thulium laser ureterolithotripsy and 12 bladder stones - by thulium laser cystolithotripsy. The size of the upper urinary tract stones varied from 0.6 to 1.8 cm, bladder stones measured from 1.1 to 3.5 cm. Also, experimental studies were carried out to investigate the effects of the fiber thulium and holmium laser on the stone displacement and temperature environment during lithotripsy. Full stone fragmentation was achieved in 100% of patients. 47.7% of patients required additional lithoextraction of fragments; there was no retrograde migration of large stones. The mean duration of stone disintegration was 19 minutes. Postoperatively, 15.9% of patients had an exacerbation of pyelonephritis, which was successfully managed by conservative measures. The mean postoperative hospital stay was 2.4+/-1.1 days. At follow-up examination 4-6 weeks after surgery, one patient was found to have a residual symptomatic ureteral stone, which required extracorporeal short-wave lithotripsy. The experimental study showed that fiber thulium laser lithotripsy produced much less propulsion of artificial stone than Holmium laser lithotripsy. With the use of therapeutic power, neither of the lasers resulted in "dangerous" rises of the washing fluid temperature during stone disintegration. Using the universal thulium laser system "Urolaz" provides a significant improvement in the effectiveness of endourologic upper urinary tract interventions and significantly reduces the likelihood of intraoperative trauma and postoperative complications, which contributes to improving the quality of specialized urological care.

Stone Cone® in ureteroscopic ballistic lithotripsy of proximal ureteral stones

Stone Cone® (Microvasive-Boston Scientific Corp, USA) is a device which prevents retrograde calculus migration during endoscopic ureterolithotripsy. We have studied the safety and efficacy of this device in endoscopic ureterolithotripsy with ballistic energy in proximal ureteral stones. MATERIALS AND METHODS. From 01/02/2006 to 01/02/2008 we carried out 36 ureterorenoscopies (URS) for proximal ureteral stones (average age: 46, range: 15-73). A ballistic energy was used for stones fragmentation. In 18 patients (Group A) we carried out URS with the aid of Stone Cone®, which was not used in the other 18 patients (Group B). Semirigid 8 Ch or 10 Ch Storz ureteroscope and ballistic lithotriptor Swiss Lithoclast Master EMS® were used. In cases of migration, edema, and ureteral damage, a ureteral stent was used. RESULTS. In Group B patients (URS performed without Stone Cone®) the migration of the whole stone, or of clinically significant fragments, occurred 8 times (45%). All of these patients underwent external shockwave lithotripsy (ESWL) at a center equipped with a lithotriptor. A ureteral stent was placed in 14 cases (78%). In Group A, the migration of a stone requiring ESWL treatment occurred only once (5%). The ureteral stent was placed 8 times (45%). We had no significant complications during the procedure. CONCLUSIONS. The Stone Cone® is a safe and easy-to-use device. The cost of this device can be balanced by the reduction of postoperative ESWL treatments for lithiasic fragments pushing up into the kidneys (p<0.01), and of ureteral stent applications at the end of the procedure (p<0.05).

Медикаментозная экспульсивная терапия камней мочеточника

In prospective, non-placebo controlled, non randomized investigation were included 98 patients with single stone of ureter. All patients were divided in two groups. The first one underwent standard therapy plus “Prolit Super Septo” (2 capsules 3 times a day), and the second one (n=65) - only standard therapy (drotaverin 40 mg 3 times a day). The total stone expulsions were statistically higher in mane group (85 % vs 66%, р=0.02). The mane trend of stone migration from proximal to distal part of ureter were higher too in first group (52% vs 32 %. р = 0,17). The possibility of stone expulsion ratio in two groups were 4,1:1,0.

Worldwide Use of Antiretropulsive Techniques: Observations from the Clinical Research Office of the Endourological Society Ureteroscopy Global Study.

Retropulsion, defined as unintended migration of a stone under the influence of the fragmentation device in ureteroscopy (URS) procedures, occurs in 2% to 60% of the cases. Antiretropulsive devices (ARDs) have been studied in experimental and small clinical studies. The current study aims at describing the worldwide usage of ARD and the outcomes related to their usage. The Clinical Research Office of the Endourological Society URS Global Study enrolled 11,885 patients who underwent URS and stone fragmentation for ureteral and/or renal stones. Of the 11,885 treated patients, 9877 were treated for ureteral stones, and data were available on stone migration and ARD use. Of all procedures, 14.5% were performed with the use of an ARD. Less stone migration (-2.0%; p = 0.050), higher stone-free rates (SFRs) (2.8%; p < 0.001), and shorter length of stay (-4.7%; p = 0.001) were observed in the antiretropulsive group. When an ARD is used during URS, less migration, higher SFRs, and shorter length of hospital stay are observed. This effect is independent from baseline differences and corrected for other treatment characteristics.

Transurethral contact ureterolithotripsy in gas (СО2) medium.

Transurethral intracorporeal lithotripsy is the modality of choice for the endoscopic disintegration of large, long-standing, radiolucent or high-density stones. Despite several advantages and proven benefits of contact ureterolithotripsy/ureterolithoextraction (CULT), the application of irrigation carries significant risks of untoward perioperative events including retrograde stone migration and postoperative pyelonephritis. We describe a new technique - endoscopic intracorporeal lithotripsy in the gas (СО2) medium. It is a prospective randomized, single blinded pilot study that included total of (n = 60) patients with urolithiasis who were allocated to either experimental or control group. Out of the total pool of patients, 30 underwent treatment with the new approach (experimental group) and other 30 (control group) had contact ureterolithotripsy in a standard of care 0.9% NaCL medium. We included patients >18 years old, with known symptomatic renal calculi disease who were eligible and scheduled for CULT and free from significant coexisting pathologies of urinary tract. No retrograde migration of the stone fragments into the kidney was reported in the experimental group [complications rate 0%, confidence interval (CI): 0-11.6%]. In the control group, complications were observed in eight cases (complications rate 26.7%, CI: 14.7-42.3%); retrograde migration was in five patients (16.6%), and acute pyelonephritis/exacerbation of chronic pyelonephritis was seen in three (10%) patients. There was not any acute pyelonephritis in the experimental group. Reliability of frequency differences - p = 0.0023 (χ2). The novel method of contact ureterolithotripsy is a safe and promising alternative to the conventional contact ureterolithotripsy in a fluid medium in a carefully selected patient population.

Factors predisposing to stone migration from the gallbladder into the common bile duct

AimEndoscopic retrograde cholangiopancreatography (ERCP), followed by laparoscopic cholecystectomy (LC), has an important role in the treatment of gallstone cholangitis. The aim of the present study was to investigate the optimal timing of LC, and factors that predispose early recurrence in patients who undergo ERCP for common bile duct (CBD) stones.Patients and MethodsA retrospective study was carried out for all patients who were treated conservatively in our hospital from 2006 to 2008. A total of 116 patients were followed up. Patients were divided into three groups: early recurrence, late recurrence and no recurrence. Risk factors evaluated included age, sex, number of stones, largest stone size, gallbladder wall thickness, CBD diameter, presence of stones in the gallbladder and CBD and the presence of pericholecystic fluid.Results CBD stone recurrence occurred in 29 patients (25 per cent). Fifteen patients had recurrent symptoms within 2.6 months. These patients were subsequently placed in the early recurrence group. Multivariate analysis showed that lager stone size [odds ratio (OR): 1.084, 95 per cent confidence interval (CI): 1.007–1.167, P = 0.033] is a significant risk factor for early recurrence, but older age is a protective factor (OR: 0.994, CI: 0.907–0.984, P = 0.006).ConclusionGallstone size is significantly associated with early CBD stone recurrence. Advancing age is protective against early recurrence. LC should be performed within 2.6 months after the first event.

The \u201cGuidewire-Coil\u201d-Technique to prevent retrograde stone migration of ureteric calculi during intracorporeal lithothripsy

BackgroundStone retropulsion represents a challenge for intracorporeal lithotripsy of ureteral calculi. The consequences are an increased duration and cost of surgery as well as decreased stone-free rates. The use of additional tools to prevent proximal stone migration entails further costs and risks for ureteral injuries. We present the simple technique of using a coil of the routinely used guidewire to prevent stone retropulsion.MethodsWe retrospectively evaluated all patients with mid-to-proximal ureteral stones in 2014, which were treated by ureteroscopic lithotripsy (Ho: YAG and/or pneumatic lithotripsy). The preoperative stone burden was routinely assessed using low dose CT scan (if available) and/or intravenous pyelogram.ResultsThe study population consisted of 55 patients with 61 mid-to-proximal calculi. Twentyseven patients underwent semirigid ureterorenoscopy using the “Guidewire-Coil-Technique”, the second group (n = 28) served as control group using the guidewire as usual. There has been a statistically significant reduction of accidental stone retropulsion (2/27 vs. 8/28, p < 0.05) as well as a decreased use of auxiliary procedures (p < 0.05) compared to the control group. No difference was observed in operative time. One ureteral injury in the control group required a prolonged ureteral stenting.ConclusionThe “Guidewire-Coil-Technique” is a simple and safe procedure that may help to prevent proximal calculus migration and therefore may increase stone-free rates without causing additional costs.

Role of Retroperitoneal Laproscopic Surgery in Ureteric Calculus - An Experience from Bundelkhand Region

Background: Urolithiasis is the aggregation of crystals in the urine, most commonly composed of calcium oxalate. Laparoscopic procedures have higher stone clearance in comparison of ESWL, URS and PCNL. Aims and objective: The aim of the current study was to analyze the feasibility of laparoscopic retroperitoneal surgery for management of urolithiasis and to investigate that the minimal invasive surgery is an alternative technique in current era of endoscopic procedure. Materials and Methods: A total of 52 patients with urolithiasis were enrolled and all were treated with laparoscopy. All stones were taken out after ureterotomy without fragmenting the stone. Results: 28 were male and 24 were female patients from 52 enrolled patients. Patient’s age was 31.4 ± 29.81 years of age. Out of 52 patients 28 had stone on right side and 24 were from left side. Size of the stone 16.2 ± 11.11 mm. Total operation time was 48 ± 19.08 min. Procedure was performed usually with 3 ports. Post-operative stay was 3 to 9 days. Proximal migration of stone, urinary leakage, ureteric stricture and conversion to open surgery were complications found during the study. Conclusion: Laparoscopic retroperitoneal surgery for urolithiasis is a safe and good alternative for open surgical procedure and can be performed at primary healthcare units.

Bilateral Same-Session Ureteroscopy for Treatment of Ureteral Calculi: A Systematic Review and Meta-Analysis.

The traditional procedure for the management of bilateral ureteral stones is staged ureteroscopic lithotripsy (URS). However, in recent years particularly, some urologists advocate same-session bilateral URS on the ground of success rates and minimal morbidity. This systematic review is to evaluate the efficacy and safety of same-session bilateral ureteroscopy for the treatment of ureteral calculi. We conducted a bibliographic search using MEDLINE (1980 to August 2015) and EMBASE (1980 to August 2015). Review articles and abstract data were excluded and only studies in English reporting on outcomes of bilateral URS were included in this meta-analysis. Two reviewers independently assessed the quality of each included studies and extracted data. STATA 12.0 was used for meta-analysis. In 11 studies, 431 patients were reportedly treated with bilateral URS. Most of the stone sizes were not larger than 20 mm. The mean stone-free rate is 96% for the distal ureter, 85% for the middle ureter, and 72% for the proximal ureter. The mean operative time ranged from 45 to 100 minutes with an average hospital stay from 2 to 4 days. The overall complications rates were 17%, with the incidence of postoperative fever 4%, postoperative pain 20%, and gross hematuria 4%. Other complications, including urosepsis, urinary tract infection, small mucosal laceration, stone migration, and ureteral perforation, accounted for 6% of overall complications. This meta-analysis found that bilateral same-session ureteroscopy could achieve a high overall stone-free rate. There might be a relatively higher complication incidence, but most of the complications are minor. For selected cases, bilateral URS could be safe and effective.

From Bouveretʼs Syndrome to Gallstone Ileus: The Journey of a Migrating Stone!

Bouveret's syndrome is an unusual cause of gastric outlet obstruction secondary to large gallstone impaction in the proximal duodenum after migration through a cholecystoduodenal fistula. Stone migration to the distal small intestine has been described after endoscopic or surgical fragmentation of the original impacted gallstone. Our case report is the 1st to our knowledge, to describe migration of the duodenal stone after oral administration of water soluble hyperosmolar contrast agent, used while performing an abdominal computed tomography imaging. This phenomenon occurred 48 hours after contrast intake and caused a distal jejunal gallstone ileus. 61 year old female with diabetes mellitus and hypertension presented with 5 day history of epigastric pain and postprandial vomiting. Physical examination revealed a soft abdomen with mild epigastric tenderness. Labs were significant for acute kidney injury. Abdominal CT scan following water soluble hyperosmolar radiocontrast administration showed a 3.5 cm intraluminal calculus at the level of the 3rd duodenal segment, diffuse pneumobilia and air containing gallbladder suggesting Bouveret's syndrome (Fig 1, arrow). An initial improvement was noted afterwards, followed by recurrence of symptoms 2 days later. A repeat abdominal CT showed migration of the duodenal stone and impaction at the distal jejunum with dilation of the proximal loops suggesting gallstone ileus (Fig 2,arrow). Subsequent jejunotomy and successful extraction of the stone (Fig 3) were performed with no postoperative complications.Figure 1Figure 2Figure 3Although over 300 cases of Bouveret's syndrome have been reported, it is unusual to see a migrating gallstone after seven days of obstruction. The rarity of stone migration and its timing after ingestion of the water soluble contrast raised the speculation of possible “iatrogenic” migration of the stone. Conventional hyperosmolar water soluble contrast media have pharmacologic effects including cholinesterase inhibition, release of histamine and in the gut, release of serotonin-like substance that enhances bowel motility. We believe that the hyperosmolar contrast agent played a role in inducing osmotic pressure, intestinal smooth muscle contraction and decreasing wall edema, which led to spontaneous disimpaction and migration of the stone forwards. We believe this presentation is unique and warrants a heightened clinical awareness in order to avoid delayed diagnosis and management.

Clinicopathological features of choledocholithiasis patients with high aminotransferase levels without cholangitis

Common bile duct (CBD) stones are generally associated with greater elevations of alkaline phosphatase and gamma-glutamyl transpeptidase levels than aspartate aminotransferase and alanine aminotransferase levels. However, some patients with CBD stones show markedly increased aminotransferase levels, sometimes leading to the misdiagnosis of liver disease. Therefore, the aim of this study was to investigate the clinicopathologic features of patients with CBD stones and high aminotransferase levels.This prospective cohort study included 882 patients diagnosed with CBD stones using endoscopic retrograde cholangiopancreatography (ERCP). Among these patients, 38 (4.3%) exhibited aminotransferase levels above 400 IU/L without cholangitis (gallstone hepatitis [GSH] group), and 116 (13.2%) exhibited normal aminotransferase levels (control group). We compared groups in terms of clinical features, laboratory test results, radiologic images, and ERCP findings such as CBD diameter, CBD stone diameter and number, and periampullary diverticulum. Liver biopsy was performed for patients in the GSH group.GSH patients were younger and more likely to have gallbladder stones than control patients, implying a higher incidence of gallbladder stone migration. Also, GSH patients experienced more severe, short-lasting abdominal pain. ERCP showed narrower CBDs in GSH patients than in control patients. Histological analysis of liver tissue from GSH patients showed no abnormalities except for mild inflammation.Compared with control patients, GSH patients were younger and showed more severe, short-lasting abdominal pain, which could be due to a sudden increase of CBD pressure resulting from the migration of gallstones through narrower CBDs. These clinical features could be helpful not only for the differential diagnosis of liver disease but also for investigating the underlying mechanisms of liver damage in obstructive jaundice. Moreover, we propose a new definition of “gallstone hepatitis” based on the specific clinicopathologic characteristics observed in our patients.

Digital SpyGlass Cholangioscopy Confirmed Common Bile Duct Stones Clearance Without Fluoroscopy

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for common bile duct stones (CBDS). In certain situations, fluoroscopy is prohibited or not available such as pregnant patient or critically ill patient in an intensive care unit. Although previous series reported the possibility of therapeutic ERCP without fluoroscopy, there is a need for confirmation of CBDS clearance otherwise biliary stenting is the only option. We prospectively evaluated the effectiveness of Digital SpyGlass (DS) cholangioscopy to facilitate CBDS removal without fluoroscopy. Methods: Between December 2015-June 2016, consecutive patients with suspected CBDS based on clinical presentations and/or imaging studies were recruited from our institute. Patients with stones > 15 mm, altered anatomy, and unstable medical condition were excluded. Following informed consent for the study, biliary cannulation with a papillotome using guide wire-assisted technique and sphincterotomy were performed without fluoroscopy. Successful biliarycannulation was confirmed by visible bile in the catheter during aspiration. After non-fluoroscopic CBDS removal (NCR) was successful by balloon extraction, a DS scope was applied into common duct to confirm complete CBDS clearance. If cholangioscopy still showed residual CBDS, another round of NCR was attempted. This process was repeated until there was no residual stone. The final occlusion cholangiogram (OC) under fluoroscopy was performed to confirm CBDS clearance. Results: Thirty eligible patients were enrolled (table 1). Without fluoroscopy, biliary cannulation was achieved in 97% (table 2). NCR was successful in 90%, which were confirmed with SpyGlass and OC. Two patients had failed cholangioscopy (failed standard cannulation requiring precut=1 and narrow CBD precluding SpyGlass insertion=1). Both DS and OC missed CBDS in 1 patient (3%). The reasons for missed CBDs clearance were dark bile obscuring the visibility, very small stone fragment, and over irrigation causing stone migration to intrahepatic duct. No patients had post procedure pancreatitis.Table 1: Baseline characteristics of patients who had Digital SpyGlass cholangioscopy performed in facilitating common bile duct stones removal without fluoroscopyTable 2: Clinical outcomes of patients who had Digital SpyGlass cholangioscopy performed in facilitatingcommon bile duct stones removal without fluoroscopyConclusion: DS cholangioscopy is feasible and safe to facilitate in CBDS removal without fluoroscopic guidance. Certain conditions may limit the effectiveness of this technique.Figure 1

Devices to help combat stone retropulsion during ureteroscopic lithotripsy in 2016

Proximal migration of stones during ureteroscopic lithotripsy is a common problem that faces many urologists and reduces stone-free rates, which translates into higher costs and longer operative times. In a bid to increase stone-free rates, there are several anti-retropulsion devices on the market, to help urologists during ureteroscopic lithotripsy. We previously reviewed these anti-retropulsion devices and wish to update what is currently available on the market.

Comparison of Holmium: YAG Laser and Pneumatic Lithotripsy in the Treatment of Ureteral Stones: An Update Meta-Analysis

Purpose: Holmium YAG laser lithotripsy (LL) and pneumatic lithotripsy (PL) are the most commonly used procedures in the treatment of ureteral calculi. In a previous meta-analysis examining the treatment effect of the 2 modalities, the authors highlighted the need for large sample size and high quality trials to provide more uncovered outcome. Recently, several randomized controlled trials (RCTs) evaluating the same issue with larger patient number and more complicated data have been published. Therefore, we conducted this meta-analysis to update and synthesize evidence on the efficacy and safety of the 2 procedures in the treatment of ureteral calculi. Methods: The relevant studies were identified by searching Medline, EMBASE and Cochrane Library Database from January 1990 to November 2015. RCTs assessing the efficacy and safety of Holmium YAG laser and PL for ureteral stones were included. Two reviewers independently screened studies and extracted data. Results: A total of 8 studies were identified including 1,555 patients. Compared with PL, Holmium YAG LL significantly reduced the mean operative time (weighted mean difference = -11.52, 95% CI -17.06 to -5.99, p < 0.0001) and increased the early stone-free rate (OR 2.69, 95% CI 1.91-3.78, p < 0.00001) and the delayed stone-free rate (OR 2.12, 95% CI 1.40-3.21, p = 0.0004). However, a higher postoperative ureteral stricture rate (OR 3.38, 95% CI 1.56-7.31, p = 0.002) was observed in LL group over PL group. There was no statistical significance in the ureteral perforation rate (OR 1.19, 95% CI 0.65-2.16, p = 0.58), the stone migration rate (OR 0.64, 95% CI 0.41-1.00, p = 0.05), the postoperative gross hematuria rate (OR 0.71, 95% CI 0.40-1.25, p = 0.23) and the postoperative fever rate (OR 0.73, 95% CI 0.50-1.09, p = 0.12). Conclusions: Our data reconfirmed that Holmium LL for ureteral stones can achieve shorter mean operative time, better early and delayed stone-free rate with larger sample size and more high quality studies. And further trials are unlikely to considerably alter this conclusion. In terms of higher risk of postoperative ureteral stricture in LL group over PL group observed in our review, more high quality, multicenter RCTs with long-term follow-up outcome are warranted to better assess this issue.

Transurethral Pneumatic Cystolithotripsy: A Novel Approach.

Various endoscopic instruments used in treating renal stones have been used in managing bladder calculi. Our aim is to evaluate the use of transurethral ureteroscopic pneumatic cystolithotripsy for the management of large bladder calculi. In a retrospective study conducted between May 2005 and July 2011, 53 patients with solitary bladder stones were subjected to our technique, transurethral ureteroscopic pneumatic cystolithotripsy. The mean patient age was 54.3 years. The mean stone size was 4.8 cm. Diagnostic cystoscopy was performed first. A semirigid ureteroscope with a pneumatic probe was introduced through the cystoscope sheath, and pneumatic lithotripsy was performed. The cystoscope sheath works as a draining channel, allowing bladder evacuation. The bladder collapses over the stone and, subsequently, prevents stone migration, which shortens the lithotripsy's duration. Stone immobilization allows the transmission of full pneumatic power to the stone. The stone fragments were removed through periodic bladder irrigation using an Ellick evacuation-irrigation system, and a 16F Foley catheter was placed at the end of the procedure. Our technique was effective in all cases, including stone-free bladders. No surgical complications were detected. The mean operative time was 83 ± 21.0 minutes, which is comparable to that of standard management. The mean duration of lithotripsy and evacuation was 29.7 ± 18.4 minutes. In the postoperative period, patients were followed up for 18 months, with no urethral stricture being reported in any case. The transurethral ureteroscopic pneumatic cystolithotripsy procedure is a safe technique for the management of large bladder calculi. It allows the bladder to collapse over the stone, leading to stone immobilization and, subsequently, decreasing lithotripsy duration. Our procedure is associated with a minimal chance of postoperative urethral injury because all stone fragments are evacuated through the cystoscope sheath, without contact with the urethral urothelium.

Gallstone ileus - the double challenge: case report and review of the literature

Gallstone ileus is a rare condition which occurs as an evolutive complication of biliary lithiasis. It occurs after stone migration from extrahepatic biliary tree to the digestive lumen, mostly through a biliary-enteric fistula. This condition involves repeated inflammatory relapses with the formation of local adhesions and generally requires a long evolution. The vast majority of patients with biliary ileus are third aged women who often have concomitant medical illnesses. Gallstone ileus surgery deals with the two components: bowel obstruction and biliary pole. Obstruction solving is approached as a surgical emergency and it requires an attitude adapted to the local situation. The attitude towards biliary surgery for gallstone ileus is a matter in debate. It could be one-stage surgery, elective surgery or expectancy and its choice is imposed by both local and general condition of the patient. We report the case of a middle-age woman whose first symptom of cholelithiasis was the gallstone ileus. Plain upright abdominal radiography revealed air-fluid levels with distended loops of the small bowel and pneumobilia. Laparotomy was decided and exploration revealed an impacted gallstone into the ileum and dense adhesions were found under the liver region. Enterolithotomy for gallstone removal was made. Postoperative evolution was uneventful with discharge on 7th day.