Surgical Management Of Stones Research Articles

Editorial Commentary.

No AccessUrology PracticeClinical Research23 Jan 2023Editorial CommentaryThis article comments on the following:Stent Omission in Prestented Patients Undergoing Ureteroscopy Decreases Unplanned Health Care Utilization Kristin G. Baldea Kristin G. BaldeaKristin G. Baldea * E-mail Address: [email protected] Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1097/UPJ.0000000000000376.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Commentary." Urology Practice, Publish Ahead of Print, pp. – Reference 1. Surgical management of stones: American Urological Association/Endourological Society guideline, part II. J Urol.2016; 196(4):1161–1169. Link, Google Scholar © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesUrology Practice23 Jan 2023Stent Omission in Prestented Patients Undergoing Ureteroscopy Decreases Unplanned Health Care Utilization Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristin G. Baldea Department of Urology, Loyola University Medical Center, Maywood, Illinois * E-mail Address: [email protected] More articles by this author Expand All Advertisement PDF downloadLoading ...

URINARY STONES IN A CONTINENT CATHETERIZABLE POUCH: A CASE REPORT

Changes in anatomy, as well as other metabolic factors, often result in the urinary tract infection and urolithiasis in patients after urinary diversion. The surgical management of stones in patients after urinary diversion is challenging. We report the case of a 21-year-old female presenting with fever. This patient had earlier undergone the creation of a continent urinary reservoir with appendicular catheterizable stoma for a failed exstrophy repair. We report the management of urinary stones occurring in this patient.

Pediatric Ureteroscopy.

In recent years, the incidence of nephrolithiasis in the pediatric population appears to be increasing. 1 This has placed a new emphasis on surgical management of stones in children. In the past, extracorporeal shockwave lithotripsy was the preferred management technique for stones in children. 2 More recently, though, advances in endoscopy have allowed ureteroscopy to be adapted to the pediatric population and this approach has become more frequently utilized not just for lower ureteral calculi but also for proximal ureteral and renal stones.

British Association of Urological Surgeons standards for management of acute ureteric colic

These guidelines have been developed by the British Association of Urological Surgeons to give a framework to clinicians, based primarily in the UK, for the management of patients presenting acutely with ureteric colic. They have been developed by consensus with reference to the American Urological Association/Endourological Society guidelines on the surgical management of stones and the European Association of Urology guidelines on urolithiasis, and adapted to the logistics of those practicing within the National Health Service. Grades of recommendation and levels of evidence are based upon the system adopted by the European Association of Urology.

Surgical and Metabolic Management of Urolithiasis Following Bladder Reconstruction

Urolithiasis occurs in up to 52 % of patients who undergo urinary diversion for any cause. The anatomic and metabolic alterations that occur at the time of bladder reconstruction with intestinal segments results in significant risk factors for stone formation unique to this patient population. Furthermore, the risk of urinary tract colonization with urease-producing bacteria further enhances their risk of urolithiasis. While primary prevention is paramount, surgical management is often necessary to remove stones that develop in patients with urinary diversion. In this review, we discuss the particular risk factors associated with urolithiasis in patients with urinary diversion, as well as medical and behavioral interventions to minimize risk of stones and to prevent recurrent stone formation. We also discuss the particular intricacies of surgical management of stones in both the upper and lower urinary tracts in patients with all types of diversions and provide an evidence-based approach to treatment of urolithiasis in this complex patient population.

Surgical management of urolithiasis in spinal cord injury patients.

Urolithiasis is a common condition in patients with spinal cord injury (SCI). Surgical management of stones in this population is more challenging and associated with lower clearance rates than the general population. The rate of complications - specifically infectious complications - is also high due to the chronic bacterial colonization. Shock wave lithotripsy (SWL) has a low clearance rate of 44-73 %. Percutaneous nephrolithotripsy is indicated for larger nephrolithiasis, but multiple procedures may be required to clear the stones. Ureteroscopy has been associated with low success rates because of difficulty in obtaining ureteral access. Historically, bladder stones were managed with open surgery or SWL. Recently, good results have been reported with the combination of endoscopic and laparoscopic techniques. Surgical management of urolithiasis in patients with SCI should be performed in high-volume centers in light of the technical challenges and higher rate of perioperative complications.

Surgical Management of Stones: New Technology

In recent years, the surgical treatment of kidney stone disease has undergone tremendous advances, many of which were possible only as a result of improvements in surgical technology. Rigid intracorporeal lithotrites, the mainstay of percutaneous nephrolithotomy, are now available as combination ultrasonic and ballistic devices. These combination devices have been reported to clear a stone burden with much greater efficiency than devices that operate by either ultrasonic or ballistic energy alone. The laser is the most commonly used flexible lithotrite; advances in laser lithotripsy have led to improvements in the currently utilized Holmium laser platform, as well as the development of novel laser platforms such as Thulium and Erbium devices. Our understanding of shock wave lithotripsy (SWL) has been improved over recent years as a consequence of basic science investigations. It is now recognized that there are certain maneuvers with SWL that the treating physician can do that will increase the likelihood of a successful outcome while minimizing the likelihood of adverse treatment-related events.

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.

PASSIVE DILATION BY URETERAL STENTING BEFORE URETEROSCOPY: ELIMINATING THE NEED FOR ACTIVE DILATION

We sought to evaluate the use of passive dilation by stenting of ureteral orifices that were inaccessible at initial cystoscopic evaluation in children before a ureteroscopic procedure. We evaluated all patients younger than 18 years undergoing a ureteroscopic procedure in whom the ureteral orifice could not be accessed endoscopically by a ureteroscope. A total of 26 children (14 boys and 12 girls) 7.3 to 14.1 years old (median age 10.3 years) underwent 28 passive dilations of initially inaccessible ureters. Stents remained indwelling for 2 to 8 weeks (median 3). All patients underwent successful ureteroscopy with a semirigid and/or flexible ureteroscope after preoperative stent placement. No patient required active dilation of the ureteral orifice at ureteroscopy. There were no complications from stent placement before the ureteroscopic procedures. No patient had a urinary tract infection or bladder spasms requiring anticholinergic therapy from stent insertion and/or early stent removal. Our study shows that passive dilation of the ureteral orifice in preparation for ureteroscopy is a straightforward, successful and beneficial technique in children, with no associated complications.

The Surgical Management of Stones in Patients With Urinary Diversions

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population.Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible.Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

The surgical management of stones in patients with urinary diversions.

Stones in patients with urinary diversions present unique challenges. Anatomical knowledge of the type of diversion is essential to adequately and safely treat the patient. We will review the anatomical differences between the forms of diversion and helpful maneuvers for successful management of urinary lithiasis in this patient population. Urology has recently seen a shift toward continent diversion with the most common forms being continent-cutaneous or orthotopic reservoirs. In patients with these forms of diversions, stone management is challenging. In continent cutaneous diversion, for example, trauma to the continence mechanism during stone manipulation can occur. Recently, percutaneous pouch access to facilitate the treatment of upper/lower tract stones has become popular. In patients with upper tract stones, knowledge of ureteral anatomy is essential. There is controversy not only on non-refluxing versus refluxing anastomoses, but also on the mechanism of formation of non-refluxing anastomoses. At the same time, some stone centers have gone back to attempting retrograde management of upper tract stones. In some types of anastomoses, however, this is not possible. Percutaneous pouch access for large stone burden has become the treatment of choice for most urologists. Percutaneous access may involve placement of an Amplatz sheath or laparoscopic trocars into the pouch, allowing for stone entrapment or intracorporeal lithotripsy. With upper tract stones, retrograde management can be attempted in the setting of a refluxing-ureteral-anastomosis. Laparoscopic management of stones may be on the rise, however, like open stone surgery, the indications are narrow.

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal shockwave therapy for urolithiasis with renal insufficiency.

Management of urolithiasis with renal insufficiency poses a multidimensional nephrourological situation. Sixty-two patients of potentially reversible calculus obstructive nephropathy and azotemia were treated with extracorporeal shockwave lithotripsy (ESWL) on the Sieman's Lithostar. These patients were treated under sedoanalgesia after the initial therapeutic ureteral stenting. Satisfactory fragmentation was achieved in all the patients. The incidence of major complications was 3.2% with an 85% stone-free rate at 6 months. Pre- and post-ESWL hemodialysis was required in 14 and 3 patients, respectively. All patients had variable levels of improvement in the renal function. Proper selection of cases is mandatory for satisfactory outcome. The combination of ureteral stenting followed by phased ESWL represents an attractive alternative to traditional surgical management of stones with renal insufficiency.