Proximal Ureteral Stones Research Articles

Effect of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones.

The aim of this study is to evaluate the impact of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones smaller than 15mm. One hundred thirty-two patients with proximal ureteral or renal pelvic stones <15mm who were treated by a SWL and forty controls were enrolled in the study. State-trait anxiety inventory (STAI) was used to assess anxiety of the controls and patients (before every SWL session). Pains of the patients were measured by a visual analog scale (VAS) at three times (T) of the sessions (T11 at 11 kV, T15 at 15 kV and T end of treatment). The mean STAI scores of the patients at the first SWL session and controls were 40.61±8.71 and 36.11±8.18, respectively (p<0.05). There was statistically positive moderate relationship between STAI and VAS scores at the first SWL session. The mean size of stone in men and women were 11.16±2.88 and 11.00±3.41, respectively (p=0.88). In the first session, the mean STAI and VAS scores of the men were significantly lower than the women. The stone-free rate (SFR) of SWL was 72.7% in this study. The SFR of SWL in the men and women were 78 and 64%, respectively (p<0.05). Our data showed that the severity of anxiety and pain in the women were higher than the men. SFR of SWL in the men was higher than the women. The severity of anxiety and pain in the patients may affect SFR of SWL.

PD47-11 PREDICTORS OF EMERGENCY DEPARTMENT REVISITS FOR URETERAL STONES

You have accessJournal of UrologyStone Disease: Epidemiology & Evaluation II1 Apr 2016PD47-11 PREDICTORS OF EMERGENCY DEPARTMENT REVISITS FOR URETERAL STONES Vishnu Ganesan, Christopher Loftus, Bryan Hinck, Daniel Greene, Yaw Nyame, Sri Sivalingam, and Manoj Monga Vishnu GanesanVishnu Ganesan More articles by this author , Christopher LoftusChristopher Loftus More articles by this author , Bryan HinckBryan Hinck More articles by this author , Daniel GreeneDaniel Greene More articles by this author , Yaw NyameYaw Nyame More articles by this author , Sri SivalingamSri Sivalingam More articles by this author , and Manoj MongaManoj Monga More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2699AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Patients with ureteral stones frequently present to the emergency department (ED) when they first become symptomatic. A proportion of these patients end up returning to the ED. Our objective was to identify predictors among patient characteristics, stone parameters, and management approaches associated with an increased risk of ED revisits. METHODS We analyzed all emergency department visits in the Cleveland Clinic health care network with an ICD-9 diagnosis of nephrolithiasis and a computed tomography (CT) scan between 2010 and 2013. CT scans were independently reviewed to confirm stone size and location and degree of hydronephrosis. The primary outcome was the occurrence of a second ED visit within 30 days of the initial visit for reasons related to the stone. Patient presenting characteristics and stone parameters were recorded. Comparisons among the various factors were computed using a T-test test for numerical data and Fisher exact test for categorical data. A multivariable analysis using logistic regression was used to identify predictive factors for revisit. RESULTS We reviewed the records of 1414 patient > 18 years of age who presented to the ED with a diagnosis of ureteral stones confirmed by CT. Of these, 161 (11%) patients had a revisit to the ED within 30 days. There were no differences in gender, stone size, degree of hydronephrosis, use of alpha blockers, or serum WBC and creatinine between the patients who returned to the ED and those who did not (Table 1). Patients who returned to the ED were more likely to have proximal stones, be < 30 years old, have higher VAS pain score on presentation, and been treated with IV narcotics in their initial visit. On multivariable analysis, presence of a proximal ureteral stone and age < 30 remained independent predictors for a revisit to the ED (Table 2). CONCLUSIONS Patients who present with proximal ureter stones or age less than 30 were strongly associated with return visits to the ED within 30 days. Consideration may be given for early follow-up or intervention. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1174 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Vishnu Ganesan More articles by this author Christopher Loftus More articles by this author Bryan Hinck More articles by this author Daniel Greene More articles by this author Yaw Nyame More articles by this author Sri Sivalingam More articles by this author Manoj Monga More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP51-01 SIXTY-DAY OUTCOMES AFTER SURGICAL VS. MEDICAL TREATMENT OF ACUTE RENAL COLIC

You have accessJournal of UrologyStone Disease: Surgical Therapy V1 Apr 2016MP51-01 SIXTY-DAY OUTCOMES AFTER SURGICAL VS. MEDICAL TREATMENT OF ACUTE RENAL COLIC Taylor Remondini, Samir Sami, Bryce Weber, Dean Wong, Anthony Cook, and Grant Innes Taylor RemondiniTaylor Remondini More articles by this author , Samir SamiSamir Sami More articles by this author , Bryce WeberBryce Weber More articles by this author , Dean WongDean Wong More articles by this author , Anthony CookAnthony Cook More articles by this author , and Grant InnesGrant Innes More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.456AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal colic is a common condition, affecting up to 10% of the population. Recent research suggests that medical expulsive therapy may be less effective in successful passage rates. Therefore we wish to evaluate a large cohort of renal colic patients in a high intervention setting to determine their characteristics and health care burden. METHODS This multicenter administrative database study retrospectively reviewed the all Calgary patients with an ED diagnosis of renal colic between Jan 1, 2014 and Dec 31, 2014. Demographics were captured from the regional ED database, tests and treatments from the order entry database, and ED revisits, admissions and interventions from the discharge abstract database. RESULTS 3104 renal colic visits were studied at 4 hospitals, including 921 (30%) with an index surgical intervention and 2183 (70%) managed medically. 1850 (54%) had confirmed ureteric stones and of these 752 (41%) had surgery at index visit with an additional 137 (8%) having surgery with in 60 days. Patients were more likely to have surgery if had a proximal ureteric stone (P<0.001, OR 2.2), stone larger than 5 mm (P<0.001, OR 4.4), or hydronephrosis (p<0.001, OR 2.3). Within 60 days surgical patients had higher need for readmission (p<0.001, OR 2.2) and emergency visits (p<0.001, OR 1.8). The presence of a proximal stone at index visit was the main risk factor for surgical patients requiring further ED visits, and readmission (p<0.001, OR 1.2). Medically managed patients had a trend toward more surgical procedures (p=0.06, OR 0.74) in the following sixty days and the main risk factor being the presence of a proximal stone (p<0.001, OR 2.9) at index visit. CONCLUSIONS Patients who undergo early surgical intervention for acute renal colic have more hospital visits and less surgical procedures in the following 60-days than medically treated patients; however, outcome differences are driven by stone location. Stone size and the presence of hydronephrosis were deciding factors in need for surgery yet did not lead to more ED visits, admissions or procedures post index visit. Yet proximal stones not only were more likely to have index surgery but also had more ED visits, and admissions post initial procedure. Similarly if a proximal stone is managed medically it is also more likely to require a procedure with in 60 days possibly just delaying the issues with surgery in this cohort. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e681 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Taylor Remondini More articles by this author Samir Sami More articles by this author Bryce Weber More articles by this author Dean Wong More articles by this author Anthony Cook More articles by this author Grant Innes More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

462 Computed tomography-based novel prediction model for the outcome of SWL in proximal ureteral stone

INTRODUCTION AND OBJECTIVES: Variations in morphology and internal structure of urinary calculi may cause differences in stone fragility. Stone heterogeneity index (SHI), a proxy of such variations, was defined as the standard deviation of a Hounsfield unit (HU) on noncontrast computed tomography (NCCT). As shown in Fig. 1, because the composition of urinary stones can vary even though they have a similar MSD, we postulated that a heterogeneous stone may be more fragile than a homogeneous stone. Herein, we defined the stone heterogeneity index (SHI) as the standard deviation of stone density on NCCT, and investigated whether SHI can be a novel predictor for SWL outcomes in patients with ureteral stones. METHODS: Medical records were obtained from the consecutive database of 1,519 patients who underwent the first session of SWL for urinary stones between Nov 2005 and Dec 2013. Ultimately, 604 patients with radiopaque ureteral stones were eligible for this study. Stone related variables including stone size, mean stone density (MSD), skin-to-stone distance, and SHI were obtained on NCCT. Patients were classified into the low and high SHI groups using mean SHI and compared. RESULTS: One-session success rate in the high SHI group was better than in the low SHI group (74.3% vs. 63.9%, P1⁄40.008). Multivariate logistic regression analyses revealed that smaller stone size (Odds ratio [OR] 0.889, 95% Confidence Interval [CI]: 0.841-0.937, P<0.001), lower MSD (OR 0.995, 95% CI: 0.994-0.996, P<0.001), and higher SHI (OR 1.011, 95% CI: 1.008-1.014, P<0.001) were independent predictors of one-session success. Similarly, stone size, MSD, and SHI also had an independent impact on one-session stone-free status (Table 1). CONCLUSIONS: The radiologic heterogeneity of urinary stones or SHI was an independent predictor for SWL success in patients with ureteral calculi and a useful clinical parameter for stone fragility.

1132 A randomized controlled trial comparing flexible ureteroscopy, semirigid ureteroscopy (URS) and extracorporeal shockwaves lithotripsy (SWL) for treatment of 0.5-1cm proximal ureteric stones

1132 A randomized controlled trial comparing flexible ureteroscopy, semirigid ureteroscopy (URS) and extracorporeal shockwaves lithotripsy (SWL) for treatment of 0.5-1cm proximal ureteric stones

455 Emergency extracorporeal shockwave lithotripsy (eESWL) for acute renal colic due to ureteral stones

independent predictor for SWL success. The prediction model based on the logistic regression analysis was as follow: SWL success 1⁄4 1 / (1 + exp (-10.165 + 0.279 x (BMI) + 0.334 x (diameter) + 1.040 (perinephric edema)) having AUC of 0.881. In the prediction model based on these parameters, the score of 0, 1, 2, and 3 correlated with SWL success rate of 98.5%, 65.7%, 31.4%, and 0% respectively. CONCLUSIONS: BMI, stone diameter, and perinpehric edema are independent predictor for SWL outcome and prediction model based on these parameters can facilitate decision-making for SWL in proximal ureteral stone.

Evaluating Ureteral Wall Injuries with Endoscopic Grading System and Analysis of the Predisposing Factors.

To analyze the predictive factors for intraoperative ureteral wall injury due to semirigid ureteroscopy (URS) used in the treatment of ureteral calculi. The data of 437 patients who had URS due to ureteral stones were prospectively analyzed. The ureteral wall injuries that occurred during URS were reviewed endoscopically at the end of surgery and divided into two groups as low grade (grades 0 and 1) and high grade (grades 2, 3, and 4) according to classification of ureteral wall injuries. Those two groups were compared for patient and stone characteristics and perioperative findings. Ureteral wall injury was seen in 133 (30.4%) patients after surgery. According to the endoscopic classification of the lesions after URS, grades 0, 1, 2, and 3 injury were seen in 69.5%, 16.4%, 11.2%, and 2.7% of the patients, respectively. There were no grade 4 injuries in our series. Two groups showed statistically significant differences for the location (prox- vs distal and mid-ureter) and size of the stone (9.9 mm vs 14.03 mm), presence of preoperatively urinary tract infection (UTI) (12% vs 50.8%), needed balloon dilatation (9.8% vs 36.1%), duration of surgery (33.6 min vs 43.3 min), and surgical success rate (90% vs 76%) (p = 0.01, for all). Stone size, location, duration of surgery, and presence of preoperative infection were determined as independent prognostic factors for mucosal injury. The ureteral wall injury grading system may be used for standardized reporting of ureteral lesions after ureteroscopy. Big, proximal ureteral stone, longer operation time, and presence of UTI are the risk factors for ureteral wall injury during URS.

İKİ CM’DEN KÜÇÜK PROKSİMAL ÜRETER TAŞLARININ FLEKSİBLE ÜRETERORENOSKOPİ İLE TEDAVİSİ

Ozet: Gunumuzde distal ureter taslarinin ilk basamak tedavisi rijid ureterenoskopidir. Ancak proksimal ureter taslarinin standart tedavisi halen tartismalidir. Son yillarda proksimal ureter taslarinda fleksibl ureterenoskopinin basari ile uygulanabilecegi literaturde yerini almaktadir. Bu calismada klinigimizde proksimal ureter taslarina uygulanan fleksibl ureterenoskopi sonuclari sunulmaktadir. Calismaya hastane kayitlari incelenen ve tum datalarina ulasilabilen 28 hasta dahil edildi. Tum hastalara preoperatif idrar kulturleri yapildi. Preoperatif diversiyonu olmayan hastalarin ureter orifislerine balon dilatasyon yapildi. Kilavuz tel uzerinden ilerletilen fleksibl ureterenoskop (Olympus URF-P5) esliginde sisteme girildi ve cerrahin tercihine gore farkli guc ayarlarinda ayni holmiyum lazer esliginde tas kirma islemi gerceklestirildi. Islem sonrasi hastalar direkt uriner sistem grafisi, ultrasonografi, intravenoz pyelografi gerektiginde bilgisayarli tomografi ile degerlendirildi. Hastalarin ortalama yasi 41 (22-84); 15’i (%53,6) erkek ve 13’u (%46,4) kadindi. 25 tas radyoopak, 1 tas semi-opak, 2 tas non-opak olmak uzere 16’si sag toplayici sisteme 12’si sol toplayici sisteme girisim yapildi. 13 (%53,6) hastaya islem oncesi swl uygulanmisti. Ortalama tas boyutu 105mm2 (49-400 mm2)’di. 11 (%39,3) hastada islem oncesi djs bulunmaktaydi. Ortalama ameliyat suresi 45 dakikaydi (35-80). Islem sirasinda 18 hastada (%64,3) anklave tas oldugu goruldu. Postoperatif 4 hastada (%14,3) diversiyon kullanilmazken yine 4 hastaya (%14,3) ureter kateteri konuldu ve birinci gun cekildi. 20 hastaya (%71,4) djs yerlestirildi. Islem sonrasi degerlendirmelerde tum hastalarda rezidu tas saptanmadi. Iki hastada (%7,1) erken donemde uriner enfeksiyon gozlenirken baska komplikasyona rastlanilmadi. Fleksibl ureterenoskopi, anklave taslar da dahil olmak uzere proksimal ureter taslarinda yuksek basari ve minimum komplikasyon orani ile uygulanabilir bir yontemdir. Anahtar Kelimeler: Ureterolitiazis, fleksible ureterenoskopi TREATMENT OF PROXIMAL URETER STONES LESS THAN TWO CENTIMETERS WITH FLEXIBLE URETERENOSCOPY Abstract: The first-line treatment of distal ureteral Stones is rigid ureterenoscopy. However, standard treatment of proximal ureteral stones is still controversial. In recent years, proximal ureteral stones can be managed with flexible ureterenoscopy (F-URS) successfully. This study presents results of F-URS due to the proximal ureteral stones in our clinic. 28 patients with accessible to all data were included in the study. Preoperative urine cultures were performed for all patients. Balloon dilatation of the ureteral orifice was done for patients without urinary diversion. Flexible ureterenoscope (Olympus URF- P5) was introduced over the wire and with different power settings of laser was applied according to the surgeon's preference. After the procedure, patients were evaluated x ray graphy, intravenous urography, ultrasonography and computed tomography when necessary. The average age of patients was 41 (22-84). 15 of patients (53.6%) were male and 13 of patients (46.4%) were female. 25 of stones were radiopaque, 1stone was semi-opaque, and 2 of stones were non-opaque while 16 of access was made on the patients’ right ureter and 12 of access was made on the patients’ left ureter. SWL was performed in 13 patients (%53,6) before the procedure. Mean stone size was 105mm2 (49-400 mm2). Eleven patients (%39,3) had double j stent before the procedure. Mean operative time was 45 minutes (35-80). During the operation, in 18 patients (64.3%) it was found to be completely obstructive stone. Postoperatively diversion was not use for 4 patients (14.3%), ureteral catheter placement was used for 4 patients (14.3%), which were pulled out on the first day. Double j stent was the choice of diversion on 20 patients (71.4%). There were no residual stones in all patients after the evaluation process. Urinary tract infection was the complication in two patients (7.1%) while other complications were not observed. Flexible ureterenoscopy is a reliable method with a high success rate and minimal complications in proximal ureteral stones. Key words: Ureter stone, Flexible ureterenoscopy

Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2–4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

Large proximal ureteral stones: Ideal treatment modality?

Background and Purpose:Ideal treatment modality for patients with large impacted proximal ureteral stone remains controversial. We compared laparoscopic transperitoneal ureterolithotomy (Lap-TPUL) and semirigid ureteroscopy for large proximal ureteric stones to evaluate their efficacy and safety.Patients and Methods:From November 2012 to December 2014, we enrolled 122 patients with large (≥1.5 cm) proximal ureteral stone in the study. Patients were randomly divided into two groups: Group A (60 patients), retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; Group B (62 patients), transperitoneal LU (Lap-TPUL).Results:The overall stone-free rate was 71.6% and 93.5% for Group A and Group B respectively (P = 0.008). Auxiliary procedure rate was higher in Group A than in Group B (27.3% vs. 5.6%). The complication rate was 11.2% in Group B versus 25% in Group A. Mean procedure time was higher in laparoscopy group as compared to ureterorenoscopy (URS) groups (84.07 ± 16.80 vs. 62.82 ± 12.71 min). Hospital stay was 4.16 ± 0.67 days in laparoscopy group and 1.18 ± 0.38 days in URS group (P < 0.0001).Conclusion:Laparoscopic transperitoneal ureterolithotomy is a minimally invasive, safe and effective treatment modality and should be recommended to all patients of impacted large proximal stones, which are not amenable to URS or extracorporeal shock-wave lithotripsy or as a primary modality of choice especially if patient is otherwise candidate for open surgery.

Management of upper ureteral stones exceeding 15 mm in diameter: Shock wave lithotripsy versus semirigid ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy.

Objectives:We conducted a retrospective study to evaluate the efficacy and outcome of shock wave lithotripsy versus semirigid ureteroscopy in the management of the proximal ureteral stones of diameter exceeding 15 mm.Methods:During the 2009−2014 study period, 147 patients presenting with the proximal ureteral stones exceeding 15 mm in diameter were treated. Both shock wave lithotripsy and ureteroscopy with laser lithotripsy were offered for our patients. A 6/8.9 Fr semirigid ureteroscope was used in conjunction with a holmium:yttrium–aluminum–garnet laser. The stone-free rate was assessed at 2 weeks and 3 months post-treatment. All patients were evaluated for stone-free status, operation time, hospital stay, perioperative complications, and auxiliary procedures.Results:Of the 147 patients who took part in this study, 66 (45%) had undergone shock wave lithotripsy and 81 (55%) underwent ureteroscopy. At the 3-month follow-up, the overall stone-free rate in the shock wave lithotripsy group was 39/66 (59%) compared to 70/81 (86.4%) in the ureteroscopic laser lithotripsy group. Ureteroscopic laser lithotripsy achieved a highly significant stone-free rate (p = 0.0002), and the mean operative time, auxiliary procedures, and postoperative complication rates were comparable between the two groups.Conclusion:In terms of the management of proximal ureteral stones exceeding 15 mm in diameter, ureteroscopy achieved a greater stone-free rate and is considered the first-line of management. Shock wave lithotripsy achieved lower stone-free rate, and it could be used in selected cases.

Retrograde versus Antegrade Approach for the Management of Large Proximal Ureteral Stones.

Objective. To evaluate and compare the efficacy and safety of retrograde versus antegrade ureteroscopic lithotripsy for the treatment of large proximal ureteral stones. Patients and Methods. We retrospectively analyzed the medical records of patients with proximal ureteral stones >15 mm, treated in our institution from January 2011 to January 2016. Intraoperative parameters, postoperative outcomes, and complications were recorded and compared between the two techniques. Results. Our analysis included 57 patients. Thirty-four patients (59.6%) underwent retrograde and 23 patients (40.4%) underwent antegrade ureteroscopy. There was no significant difference in patients' demographics and stone characteristics between the groups. Stone-free rate was significantly higher (p = 0.033) in the antegrade group (100%) compared to retrograde one (82.4%). Fluoroscopy time, procedure duration, and length of hospitalization were significantly (p < 0.001) lower in retrograde approach. On the other hand, the need for postoperative stenting was significantly lower in the antegrade group (p < 0.001). No difference was found between the groups (p = 0.745) regarding postoperative complications. Conclusions. Antegrade ureteroscopy is an efficient and safe option for the management of large proximal ureteral stones. It may achieve high stone-free rates compared to retrograde ureteroscopy with the drawback of longer operative time, fluoroscopy time, and length of hospitalization.

Flexible ureteroscopy versus laparoscopy for the treatment of patients who initially presented with obstructive pyelonephritis.

Objective:To compare the safety and effectiveness of flexible ureteroscopy (F-URS) with transperitoneal laparoscopic ureterolithotomy (TPLU) in cases of obstructive pyelonephritis secondary to large proximal ureteral stones.Methods:A series of 42 patients presenting with obstructive pyelonephritis due to proximal ureteral stones larger than 1.5 cm were included from April 2006 to February 2015 in this comparative study. After drainage of pyonephrosis and resolution of sepsis, 22 patients treated with TPLU (Group I), and 20 patients were treated with F-URS (Group II). Preoperative patient and stone characteristics, procedure-related parameters and clinical outcomes were assessed for each group.Results:It was seen that both methods were effective in the treatment of large proximal ureteral stones. However TPLU provided a higher stone- free rate (100% vs 80%. p=0.043) and lower retreatment rate. There was no difference between the groups for the operative time and complication rate. On the other hand, patients treated with F-URS had less postoperative pain (p=0.008), a shorter hospital stay (p<0.001) and a faster return to daily activities (p<0.001).Conclusions:The results of our study show that both F-URS and TPLU are safe and effective surgical procedures for treatment of large proximal ureteral stones after controlling obstructive pyelonephritis. However, TPLU has a higher stone-free rate with comparable operating time and complication rate as compared to F-URS. On the other hand F-URS has the advantages of less postoperative pain, shorter hospital stay and faster return to daily activities.

RE: Semi-rigid ureteroscopy - Proximal versus distal ureteral stone.

I read with great interest the article “Semi‑rigid ureteroscopy: Proximal versus distal ureteral stone” by Alameddine et al.[1] This article highlights important findings regarding common endourology procedure which is ureteroscopy. Since development of semi‑rigid ureteroscope, various studies had been done to evaluate the safety and efficacy of ureteroscopy. In this study, the authors found that stone‑free rate was comparable between proximal (89%) and distal (98.2%) ureteric stone with insignificant difference in complication rate. This study was retrospective in nature which had some limitations. The limitation found in this study was the selection of ureteroscope size. The authors stated that the ureteroscope size used ranged between 8 and 11 French.[1] These ranges were including almost all sizes of available ureteroscopes. Whereas, in other study by Molina Escudero et al., the ureteroscope size used was only 7 French.[2] These created a bias in this study. Without precise selection of the ureteroscope size, the author concluded that the use of smaller caliber semi‑rigid ureteroscopy combined with holmium‑yttrium‑aluminum‑garnet laser for proximal ureteral calculi is safe.[1] In my opinion, the conclusion made by the authors was not proved by this study.

Impaction of ureteral stones into the ureteral wall: Is it possible to predict?

To determine the possible predictive value of certain acute phase reactants CRP and ESR as well as radiologic parameters on the degree of impaction in ureteral stones. A total of 80 adult patients with a single opaque proximal ureteral stone were evaluated. A non-contrast CT was performed in all cases and all possible radiologic predictive parameters calculated. Additionally, to outline the degree of impaction at the stone site, two serum acute phase reactants namely CRP and ESR levels were also assessed. Patients were divided into two groups as follows; Group 1 (n:42) patients with normal CRP levels and Group 2 (n:38) patients with elevated levels of CRP. The data obtained in the subgroups were first comparatively evaluated with radiological parameters and the possible correlation between CRP values and these parameters was well evaluated. While the serum CRP levels were normal in 42 cases, they were elevated in 38 cases. Evaluation of the data from CRP subgroups and radiologic parameters showed that elevated levels of serum CRP were closely related with mean values of ureteral wall thickness (UWT) as well as mean level of hydronephrosis with a statistically significant difference. Additionally, a correlation analysis between serum CRP levels and all other parameters mentioned above demonstrated a statistically significant correlation between UWT, degree of hydronephrosis and serum ESR values. Evaluation of serum CRP and ESR values could let us to predict the UWT, a parameter which is closely related with the degree of stone impaction.

Ureteroscopy for treatment of obstructing ureteral calculi in pregnant women: Single center experience

ObjectivesTo evaluate our experiences with ureteroscopic treatment of ureteral calculi in pregnancy. Patients and methodsBetween April 2006 and October 2013, 41 pregnant women with persistent renal colics and/or hematuria refractory to conservative measures were treated with ureteroscopy. The patients’ mean age was 23 (range 19–37) years. Most of the patients (56.1%) presented in the 2nd trimester.Loin pain and colic were the most common presenting symptoms (90.2%). Twenty-seven patients (65.9%) had an obstruction on the right side. All patients underwent ureteroscopy under epidural anesthesia. ResultsUreteroscopy revealed the presence of ureteric stones in 36 of the 41 cases. The stone size ranged from 5 to 16 (mean 8.9) mm. Distal ureteric stones were found in 29 patients. The pneumatic lithoclast was used for stone fragmentation in 22 of them (75.9%), while the stone was directly extracted in 4 patients. In 3 patients the stone migrated proximally and was not accessible any more. Proximal ureteric stones were detected in 7 of the remaining 12 cases. When attempting to manipulate these stones, they migrated more proximally and became unreachable. In the last 5 patients the entire ureter was free of stones; they only had edema at the ureteric orifice. A long lasting JJ stent was left until the end of the pregnancy in all cases with migrated inaccessible stones. In all patients successfully treated, a JJ stent with dangle extraction strings was left for two weeks. Minor urologic complications were encountered in the form of mild dysuria in 12 cases (29.2%) and mild hematuria in 5 cases (12.2%). All patients completed their pregnancy until full term without any serious obstetric complications requiring intervention. ConclusionUreteroscopy is a safe and effective therapeutic option for the treatment of obstructing ureteral stones in pregnancy with stone-free and complication rates comparable to the non-pregnant population.

79 Comparative outcomes flexible ureteroscopy versus transperitoneal laparoscopic ureterolithotomy for the treatment of proximal ureteral stones >15 mm in patients who initially presented with urosepsis

79 Comparative outcomes flexible ureteroscopy versus transperitoneal laparoscopic ureterolithotomy for the treatment of proximal ureteral stones >15 mm in patients who initially presented with urosepsis

80 The success of treatment for proximal ureteral stone in ureteroscopic stone treatment

80 The success of treatment for proximal ureteral stone in ureteroscopic stone treatment

Ureteroscopy in proximal ureteral stones after shock wave lithotripsy failure: Is it safe and efficient or dangerous?

We assessed the effectiveness of ureteroscopy (URS) in proximal ureteral stones performed after shock wave lithotripsy (SWL) failure, and determined outcomes in terms of success rate, complications, and operation time. We analyzed data of patients with previous unsuccessful SWL (Group I) and the ones that did not have SWL or URS before (Group II) for proximal ureteral stones between December 2007 and August 2014. Group I included 346 patients who underwent complementary URS and Group II 209 patients who underwent primary URS. Success rates, operation time and complications were compared between groups. Success rates of complementary and primary URS were 78.9% and 80.9%, respectively. The difference in success rates was not statistically significant between groups (p = 0.57). The complication rates of complementary URS was 12.1%, and 9.5% in primary URS (p = 0.49). No statistically significant differences were noted in terms of gender, age, stone size and side, or lithotripter type between groups. The mean operation time and need for balloon dilatation were higher in complementary URS group compared to the primary URS group, and the difference was statistically significant (p < 0.05). Complementary URS may be used safely after SWL failure in proximal ureteral stones. Its success rate and morbidities are similar to primary URS, except for longer operation time and an increased need for balloon dilatation.

RETROPERITONEAL VS TRANSPERITONEAL LAPAROSCOPIC URETEROLITHOTOMY

Objective: To compare retroperitoneal versus transperitoneal laparoscopic ureterolithotomy in effectivity, pain scale and early complications. Material &amp; methods: In this prospective comparison study from January 2013 to June 2014, 32 patients with proximal and mid ureteral stones underwent retroperitoneal laparoscopic ureterolithotomy or transperitoneal laparoscopic ureterolithotomy. The randomization occured on consecutive sampling on a 1 : 1 basis. Group 1 and 2 consisted of patients who underwent retroperitoneal laparoscopic ureterolithotomy and transperitoneal laparoscopic ureterolithotomy, respectively. Demographic and clinical variable, operative time, length of stay, ureteral suturing, pain scale according to visual analog scale (VAS) and early complications data were collected and analyzed. Statistical analysis was performed with SPSS® version 17.0 using student T-test and Mann-Whitney U tests with p value &lt; 0.05 considered statistically significant. Results:VAS on day 1 between the 2 groups was statistically significant, and was higher in group 2 (p &lt; 0.05). According to the Clavien-Dindo classification of surgical complication all the patients were in grade 1 classification. The differences in operative time, length of stay, ureteral suturing, visual pain analog score on day 3, and early complications between the 2 groups were not statistically significant.Conclusion: Transperitoneal laparoscopic ureterolithotomy is significantly associated with pain than retroperitoneal laparoscopic ureterolithotomy in first day after surgery. Successful stone removal remains the same in both groups.