Need For Ureteral Dilatation Research Articles

Effect of preoperative alpha-blockers on ureteroscopy outcomes: A meta-analysis of randomised trials.

This work aims to determine the efficacy and safety of preoperative alpha-blocker therapy on ureteroscopy (URS) outcomes. In this systematic review and meta-analysis of randomised trials of URS with or without preoperative alpha-blocker therapy, outcomes included the need for ureteral dilatation, stone access failure, procedure time, residual stone rate, hospital stay, and complications. Residual stone rates were reported with and without adjustments for spontaneous stone passage, medication noncompliance, or adverse events leading to patient withdrawal. Data were analysed using random-effects meta-analysis and meta-regression. Certainty of evidence was assessed using the GRADE criteria. Among 15 randomised trials with 1653 patients, URS was effective and safe with a stone-free rate of 81.2% and rare (2.3%) serious complications. The addition of preoperative alpha-blockers reduced the need for ureteral dilatation (risk ratio [RR] = 0.48; 95% CI = 0.30 to 0.75; p = 0.002), access failure rate (RR = 0.36; 95% CI = 0.23 to 0.57; p < 0.001), procedure time (mean difference [MD] = -6min; 95% CI = -8 to -3; p < 0.001), risk of residual stone in the primary (RR = 0.44; 95% CI = 0.33 to 0.66; p < 0.001) and adjusted (RR = 0.52; 95% CI = 0.40 to 0.68; p < 0.001) analyses, hospital stay (MD = -0.3days; 95% CI = -0.4 to -0.1; p < 0.001), and complication rate (RR = 0.46; 95% CI = 0.35 to 0.59; p < 0.001). Alpha-blockers increased ejaculatory dysfunction risk and were less effective for renal/proximal ureter stones. The certainty of evidence was high or moderate for all outcomes. The main limitation of the review was inconsistency in residual stone assessment methods. While URS is an effective and safe treatment for stone disease, preoperative alpha-blocker therapy is well tolerated and can further improve patient outcomes.

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.

Effective ureteral access sheath insertion during flexible ureteroscopy: Influence of the ureteral orifice configuration.

We sought to determine the possible predictors for effective insertion of the ureteral access sheath (UAS) during flexible ureteroscopy (fURS) in virgin ureters and their impact on postoperative ureteral wall injury and the procedural outcome. A retrospective review of prospectively collected data was performed for all consecutive patients scheduled for fURS of virgin ureters at two tertiary care centers between 2018 and 2020. Demographics, stone characteristics, and perioperative data, including the configuration of the ureteral orifice (UO) over introductory guidewire insertion, were collected. Multivariate logistic regression was used to detect possible predictors of successful UAS insertion. In total, 128 patients who underwent primary fURS were included, with a mean age of 43.3±12.3 years and a stone burden of 12.3±6.9 mm. One hundred and ten patients (85.9%) achieved successful ureteral access insertion, including 81 (63.3%) without ureteral dilatation and 35 with dilation, of which 29 (22.7%) had a successful UAS afterward, while six failed. Total patients who underwent ureteral orifice dilatation were 35. 29 had a successful UAS afterward, while 6 failed. Patients who underwent successful UAS placement into virgin ureters were significantly older and had a lower body mass index (BMI). A tent-shaped UO over the guidewire led to successful UAS insertion. In multivariate regression analysis, cases with BMI <30 kg/m2 (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.28-7.03) and those with a tent-shaped UO over the introductory guidewire (OR 6.60, 95% CI 3.8-7.2) maintained their significance to predict successful UAS insertion into virgin ureters. Nine patients (8.2%) had ureteral mucosal injuries, and the overall stone-free rate was 78.2%. Patients with normal BMIs and tent-shaped UOs over the introductory guidewires are more likely to achieve primary UAS insertion without the need for ureteral dilation.

A Single-Center Prospective Comparative Study of Two Single-Use Flexible Ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China).

Introduction and Objective: Single-use flexible ureteroscopes have the benefit of decreasing infection transmission, avoiding sterilization need, and no maintenance cost. Primary objective was to compare in vivo performance and surgical outcomes with two single-use ureteroscopes: LithoVue (Boston Scientific, USA) and Uscope PU3022a (Zhuhai Pusen, China) with secondary objective being to compare in vivo vision by independent endourologist blinded to ureteroscope manufacturer. Materials and Methods: Fifty patients undergoing retrograde intrarenal surgery with <2 cm renal stones were prospectively allocated: Group 1 (25 patients) for LithoVue and group 2 (25 patients) for Uscope. Pre-, intra-, and postoperative parameters were evaluated. Vision of both ureteroscopes with and without accessory was evaluated by an independent endourologist, blinded to the make of the ureteroscope. Stone clearance was assessed with kidney, ureter, and bladder radiograph (KUB) and ultrasonography KUB at 1 month. Student's t-test for quantitative and chi-square for categorical data was used. Results: Pre- and intraoperative parameters such as need for ureteral dilatation (p > 0.05), ureteral access-sheath size (p = 0.78), accessibility to pelvicaliceal system (p > 0.05), and maneuverability (p > 0.05) were comparable in both groups. Lower-pole access was possible in all cases of LithoVue and slightly difficult in three cases of Uscope (p > 0.5). Intraoperative vision was hazy in four cases of LithoVue and eight cases of Uscope (p = 0.32) during lasing along with three cases of Uscope with accessory (p = 0.24). Blinded endourologist reported more cases of hazy vision with or without accessory or lasing in Uscope arm (p > 0.05). One device had malfunction in LithoVue arm. Complete stone clearance was achieved in all cases at 1 month. Conclusions: We conclude that performance of these two single-use ureteroscopes, LithoVue and Uscope, is comparable in clinical settings with similar clinical outcomes and complications.

Comparison of Silodosin, Tadalafil and Combinations Prior to Ureteroscopic Management of Ureteral Stones

The present paper, aims to assess and compare the therapeutic efficacies of silodosin, Tadalafil, and their combination for the negotiation of large semi-arid ureteroscopic through ureteric orifice during ureteral stone management. During endoscopy, the patients in groups A, B, and C exhibited wider ureteric orifice than the patients of group D. About 70.6%, 60.6%, 62.9% and 32.4% of patients belonging to groups A, B, C, and D, respectively, exhibited easy negotiation. Significantly lower proportions of patients in groups A, B, and C (35.3%, 39.4%, and 28.6%, respectively) exhibited the need for ureteral dilation compared to those in group D (61.8%). In addition, the duration of surgery for groups A, B, and C was less than that for group D. Preoperative silodosin and Tadalafil administration in patients undergoing ureteroscopic for ureteral stones improves the access of large size duretero scope and reduced the need for ureteral dilatation with less surgical duration and minimal adverse events.

Extracorporeal Shock Wave Lithotripsy in Prepubertal Children: 22-Year Experience at a Single Institution With a Single Lithotriptor

The sophistication of percutaneous nephrolithotomy and ureteroscopy challenges the efficacy of ESWL for urolithiasis in prepubertal patients. We evaluated our long-term experience with ESWL in these patients and determined its efficiency. We retrospectively reviewed the charts of all prepubertal patients who underwent ESWL. We evaluated the need for tubing, the 3-month stone-free rate, the need for additional ESWL, and the effect of stone size and location, and cystinuria on the 3-month stone-free rate. Between 1986 and 2008, 119 males and 97 females with a mean age of 6.6 years who had urolithiasis underwent ESWL using the Dornier HM3 lithotriptor. We treated 157 children with renal calculi with an average +/- SD diameter of 14.9 +/- 8.9 mm, of whom 66 (42%) required a tube in the urinary system. The 3-month stone-free rate was 80% and 31 patients (19.7%) needed an additional procedure. Stone location did not affect the stone-free rate but stone size did. We treated 59 patients for ureteral stones with an average stone length of 9.5 +/- 4.8 mm, of whom 41 (69%) required tube insertion. The 3-month stone-free rate was 78% and 13 patients (22%) needed an additional procedure. The 3-month stone-free rate did not depend on stone location or size. The rate was 37.5% in patients with cystinuria and 82.5% in all others (p <0.0001). Six patients (2.8%) had complications. The 3-month stone-free rate after ESWL in prepubertal patients is 80% and 20% of patients require additional procedures. ESWL is most effective for kidney stones less than 11 mm. ESWL has inferior results for cystine stones compared to other calculi. Complications are rare.

When is Prior Ureteral Stent Placement Necessary to Access the Upper Urinary Tract in Prepubertal Children?

We studied the possibility that age, height, weight and body mass index could be used to predict the likelihood of successful ureteroscopic access to the upper urinary tract without previous stent placement in prepubertal children. We retrospectively reviewed all ureteroscopic procedures for upper tract calculi in prepubertal children from 2003 to 2007. We compared age, height, weight and body mass index in patients who underwent successful primary flexible ureteroscopic access and in those who required initial stent placement to perform ureteroscopy. Successful primary ureteroscopic access to the upper tract was achieved in 18 of 30 patients (60%). There was no difference in mean age (9.9 vs 9.5 years, p = 0.8), height (132 vs 128 cm, p = 0.6), weight (37 vs 36 kg, p = 0.86) or body mass index (19.3 vs 20.5 kg/m(2), p = 0.55) between patients with successful vs unsuccessful upper tract access. Locations that prevented access to the upper urinary tract were evenly distributed among the ureteral orifice, iliac vessels and ureteropelvic junction. Age, height, weight and body mass index could not predict the likelihood of successful ureteroscopic access to the upper tract. Placement of a ureteral stent for passive ureteral dilation is not necessary for successful ureteroscopic access to the renal pelvis in prepubertal children. An initial attempt at ureteroscopy, with placement of a ureteral stent if upper tract access is unsuccessful, decreases the number of procedures while maintaining a low complication rate.

Experience with ureteroscopic holmium laser lithotripsy in children

The purpose of the study was to evaluate the outcome of ureteroscopic holmium laser lithotripsy (UHLL) in children, taking into consideration different stone locations. Records of 15 children with ureteral calculi managed with UHLL were reviewed. All patients were evaluated with history, clinical, radiological and laboratory assessment prior to treatment. All patients were managed on an outpatient basis. After stone disintegration, if sizable fragments remained, they were retrieved using grasping forceps or stone basket extraction. Patient records were reviewed for age, sex, stone laterality, location, number and size, need for ureteral dilation, stenting and residual fragment extraction. Of the 15 children, 11 were female and 4 were male. Mean age was 8.5 years (age range 2-15 years). There was no significant difference in stone laterality (eight left and seven right ureteral stones). Main presenting symptoms were renal colic, hematuria and urinary tract infection or a combination of these symptoms. The 15 children harbored 15 ureteral stones (range 5-11 mm, mean 7.8 mm) and underwent 15 UHLL procedures. Ureteral dilation was performed in 14 patients using balloon dilators. Stone retrieval was done in all patients. DJ stents were placed at the conclusion of the procedure in 11 patients. Complete stone clearance was achieved at the end of the procedure in all patients (success rate 100%). No complications were encountered during or after the procedure. This study confirms the effectiveness and safety of ureteroscopy and holmium laser in the treatment of ureteral stones in children regardless of stone location.

Semi-rigid ureterorenoscopy in children without ureteral dilatation

We aimed to retrospectively review the efficiency of ureterorenoscopy (URS) applied without ureteral dilatation for evaluating pediatric ureteral pathologies. The files of pediatric patients hospitalized in our clinic between January 2000 and June 2006 due to ureteral stone disease were reviewed and evaluated retrospectively. The ages, medical histories, physical examination results, preoperative routine blood and urinary tests, and culture results were recorded. Ureteral orifice dilatation was not needed in any of the patients. Due to the risk of mucosal trauma and edema development in the ureteral orifice and intramural ureter, 3F and 4F catheters were applied in all patients following the ureterorenoscopy. These catheters were removed 24 h after the procedure. The files of 54 pediatric patients with a mean age of 8.5 years (range 1-16 years) were evaluated retrospectively. While diagnostic URS was applied in 12 (22.2%) of the patients, ureteral calculi were determined in 42 (77.8%) patients and the stones were fragmented by pneumatic lithotripter. Twenty-five of the stones were localized in the lower ureter, 16 in the mid-ureter, and 3 in upper ureter. The mean stone size was found to be 7.1 mm (range 4-12). None of the stones migrated to the proximal region. In 2 patients open ureterolithotomy was applied; stones were localized in the upper ureter in both of these patients. Ureterorenoscopy can be successfully and safely applied without the need for ureteral dilatation in ureteral pathologies of children.

Ureteroscopy in children: Is there a need for ureteral dilation and postoperative stenting?

Introduction Ureteroscopic stone manipulation and extraction is the standard of care for distal stone disease in the adult population. Recently, with refinements in instrumentation, these standards have been applied in pediatrics. Here, we investigate the role of ureteral dilation and the need for postoperative stenting after ureteroscopy. Materials and methods Twenty-nine children (21 male, eight female) with a mean age of 11.0 (2.5–17.5) years underwent 34 ureterscopic procedures (21 right, 13 left) to address ureteral stones in 27 (23 distal, 3 mid and 1 proximal), surveillance of the upper tract in six and a retained stent in one. Active ureteral dilation was not required in any of these patients. A Wolfe 4.5-F or 6.5-F tapered semi-rigid ureterescope was passed alongside a previously placed guidewire to access the upper collecting system. Proximal ureteral surveillance was performed after completion of the procedure; all but two patients had a diagnostic ureterogram. Four patients had preoperative placement of a JJ stent. Postoperative stents were placed in six patients, two had stents placed preoperatively for infection associated with either autonomic dysreflexia or stone impaction, two for extravasation or perforation, one for edema and one for subsequent ESWL. Results Mean follow up after ureteroscopy was 16.2 (0.3–48) months. Of the 27 procedures for stone disease, 15 (55%) stones required laser litholipaxy and 12 (45%) were managed with stone basket extraction. The overall re-treatment rate for stone disease was 4%. Diagnostic ureteroscopy was normal in six procedures. None of the procedures managed without a post-ureteroscopy stent required subsequent intervention. Conclusion Ureteroscopy is a safe, effective method to manage ureteral stones. Refinements in instrumentation allow its application to the pediatric population. Ureteroscopy including laser lithotripsy can be performed without ureteral dilation or postoperative stenting.

796: Ureteroscopy in Children: Is there a Need for Ureteral Dilation and Post-Operative Stenting?

796: Ureteroscopy in Children: Is there a Need for Ureteral Dilation and Post-Operative Stenting?

Reply by the authors

The percutaneous approach remains our first choice for the management of complex renal and upper ureteral pathologic findings. Yet, when a retrograde approach is indicated, a ureteral access sheath greatly aids flexible ureteroscopy by decreasing the need for ureteral dilation and facilitating withdrawal and re-entry of the endoscope during the management of stones, strictures, or tumors. Previous studies have demonstrated that routine use of the ureteral access sheath makes upper tract endoscopy faster and less expensive.1 The current report provides additional evidence to support previously performed studies, which validate the safety of the access sheath.2

Semirigid Ureteroscopy: A New Genre

The semirigid ureteroscope has a diameter of 7.2F for the distal 11cm. and gradually enlarges to 11.9F at the proximal portion. We inserted the device in the ureter of 50 consecutive patients without the need for ureteral dilation. The instrument has 2, 0.025-inch channels (2.1F) for wires (0.025), irrigation or 250μ. laser fibers. Flexible optical fibers and a metal sheath allow for handling as with a rigid instrument, with 2 inches of flexure at the tip without loss of vision. The instrument was inserted successfully in 26 of 27 female patients (lower ureter in 13 of 13, mid ureter in 4 of 4 and upper ureter in 9 of 10), and 14 of 23 male patients (lower ureter in 8 of 10, mid ureter in 4 of 8 and upper ureter in 2 of 5). The semirigid ureteroscope may be used for laser fragmentation of ureteral calculi in almost all female patients and in some male patients. It may be used in strictured and otherwise impassable ureters, for placement of guide wires in the intramural tunnel and to examine the entire ureter atraumatically in most female and some male patients. The device has been designed specifically for laser lithotripsy, and its development expands the indications and facility with which this technology may be used.