Ultrasonic Lithotripsy Research Articles

STONE GRANULOMA CAUSES URETEROPELVIC JUNCTION OBSTRUCTION AFTER PERCUTANEOUS NEPHROLITHOTOMY AND ANTEGRADE ENDOPYELOTOMY

Stone granuloma is a rare cause of ureteral obstruction. To our knowledge only 1 case of secondary ureteropelvic junction obstruction following percutaneous nephrolithotomy and ultrasonic lithotripsy has been reported in the literature. It has been postulated that perforation with migration of stone fragments into the ureteral wall may be a mechanism for this occurrence. We report a case of recurrent ureteropelvic junction obstruction due to stone granuloma after simultaneous percutaneous nephrolithotomy and antegrade cold knife endopyelotomy.

PERCUTANEOUS MANAGEMENT OF RENAL CALCULI: EXPERIENCE WITH PERCUTANEOUS NEPHROLITHOTOMY IN 60 CHILDREN

We report our experience with percutaneous nephrolithotomy in a pediatric population in which primary as well as recurrent stone episodes are frequent and the need for less invasive procedures is imperative. Percutaneous nephrolithotomy was performed in 60 children 3 to 13 years old (average age 6), including 44 boys (73.3%) and 16 girls (26.7%). There was a single obstructing renal calculus in 43 patients, while 17 had multiple calculi. The procedure was performed in 1 stage in 49 patients, and it was staged with preliminary nephrostomy in 11 who presented with calculous anuria and elevated serum creatinine. Normal saline was used as an irrigant and perioperatively serum electrolytes were measured to monitor fluid absorption in 18 patients. Stones were extracted intact from 40 patients (66.6%) and ultrasonic lithotripsy was performed in 20 (33.3%). Of the 60 patients 50 (83.3%) were rendered stone-free at 1 session. Incomplete stone clearance at 1 session was due to intraoperative bleeding requiring blood transfusion, extravasation, multiple stones that were inaccessible via 1 tract, displacement of stone fragments into an inaccessible calix and insignificant residual fragments less than 3 mm. in 2 cases each. During followup of 3 months to 6 years (average 1 year) no late complications were noted. Percutaneous nephrolithotomy is a safe and relatively efficacious mode of managing pediatric renal calculi. Although higher success rates are achieved in adults, caution should be exercised in children, in whom diligent attempts at stone clearance in 1 session may be made at the expense of safety.

UNENHANCED COMPUTERIZED AXIAL TOMOGRAPHY TO DETECT RETAINED CALCULI AFTER PERCUTANEOUS ULTRASONIC LITHOTRIPSY

Purpose We report our experience with unenhanced computerized axial tomography (CT) after percutaneous ultrasonic lithotripsy in patients thought to be at high risk for retained calculi. Materials and Methods CT was obtained in 121 patients (124 kidneys) within 12 to 36 hours of percutaneous ultrasonic lithotripsy for staghorn or large nonstaghorn renal calculi. Cases were grouped according to the CT findings as no retained calculi, insignificant retained calculi (fragments 1 to 3 mm.), retained calculi amenable to shock wave lithotripsy and retained fragments requiring second look percutaneous ultrasonic lithotripsy or flexible nephroscopy. Results No calculi were seen in 73 kidneys (59%) and retained calculi were identified in 51 (41%). Shock wave lithotripsy was used to treat 8 patients and another percutaneous ultrasonic lithotripsy or flexible nephroscopy was performed in 23 to remove retained stones. Insignificant calculi were noted in the remaining 21 patients. Conclusions We believe that postoperative unenhanced CT is superior to plain renal tomography and is the best method to determine if a patient is stone-free after percutaneous ultrasonic lithotripsy. It helps to locate precisely those stones requiring a second percutaneous ultrasonic lithotripsy or nephroscopic extraction. An unenhanced renal CT devoid of calculi obviates routine postoperative second look flexible nephroscopy. We encourage others to consider this technique to define more accurately kidney stone status after percutaneous ultrasonic lithotripsy for large staghorn calculi or in any patient at high risk for retained calculi after percutaneous ultrasonic lithotripsy.

Endoscopy vs. extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones: ten years' experience.

The lower third is the location of the great majority of ureteral stones. Treatment of these stones remains controversial: in situ extracorporeal shockwave lithotripsy (SWL) vs. ureteroscopy (URS). During the last decade, 633 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar electromagnetic lithotripter) in 395 patients and URS (with 11.5F instrument and ultrasonic lithotripsy) in 228 patients. The patients' age and stone size were similar in the two groups. All SWL therapies were performed on an outpatient basis. The overall success rate was 99% for SWL, and the efficiency quotient (EQ) was 92.4%. The treatment was more effective for <10 mm calculi. In the URS group, there was a 92% overall success rate with an EQ at 91.2%. Compared with SWL, URS was more time consuming, at least for the initial cases; often required intravenous sedation; entailed routine placement of a ureteral stent; and more often led to hospitalization. On the other hand, stone clearance was rapid after URS, although most of the SWL patients were stone free at the end of 6 weeks. The cost was similar in the two groups. We believe that multiple factors should be considered when deciding the most appropriate approach to distal ureteral calculi. In situ SWL provides optimal first-line treatment for calculi < 10 mm, whereas URS is better reserved for stones >10 mm.

Treatment of Ureteral Stones: Comparison of Extracorporeal Shock Wave Lithotripsy and Endourologic Alternatives

Aim of the Study: The aim of the study is to compare the effectiveness of ESWL and ureteroscopic lithotripsy with pneumatic, ultrasonic and electrohydraulic modalities in patients with ureteral stones. Patients and Method: In this study, 1,970 patients with ureteral stones were evaluated. ESWL and ureteroscopic lithotripsies were performed in 1,580 and 484 patients, respectively. The ESWL group was treated with a Siemens Lithostar plus. Ureteroscopic lithotripsy was performed with pneumatic lithotripsy (PL), ultrasonic lithotripsy (USL) and electrohydraulic lithotripsy (EHL) in 140 (28.9%), 311 (64.3%) and 33 (6.8%) patients, respectively. 94 patients underwent both because of unsuccessful ESWL therapy. Results: In the ESWL group, the stone-free rate was 49.9% and the fragmentation rate 71.0%. These values were: 95.0 and 97.1% for PL; 88.1 and 89.4% for USL; 90.9 and 93.9% for EHL, respectively. Ureteroscopic lithotripsy has been found more effective than ESWL in the treatment of middle and lower ureteral calculi (p < 0.001) and PL has the greatest success rate within these endoscopic groups. Conclusion: ESWL therapy can be the first-line therapy in upper ureteral stones keeping the other modalities for unfragmented stones. However, ureteroscopic lithotripsy is the most effective treatment choice in lower ureteral stones no matter which kind of energy used and PL is the most effective and less complicated among the other types.

Combined spinal-epidural anesthesia for urological and lower extremity vascular procedures

Certain urological and vascular surgical procedures lend themselves to combined spinal-epidural anesthesia. Ultrasonic lithotripsy often requires significant analgesia and sedation. In appropriate patients this goal can be achieved using intrathecal sufentanil 10 μg. Placing an epidural catheter at the time of spinal injection provides a way to provide additional analgesia if needed. Epidural anesthesia and analgesia may improve outcome in patients undergoing lower extremity peripheral vascular surgery. Combined spinal-epidural anesthesia rapidly provides excellent surgical conditions plus the benefits of postoperative epidural analgesia. In these patients, begin with an intrathecal injection of 12 to 15 mg hyperbaric bupivacaine. One hour later, carefully dose the epidural catheter with 0.5% bupivacaine. Provide postoperative analgesia with an infusion of 0.1% bupivacaine plus 0.01% morphine at 8 to 10 mL/hr.

Large Impacted Intrahepatic Bile Duct Stones: Usefulness of Ultrasonic Lithotripsy

Large Impacted Intrahepatic Bile Duct Stones: Usefulness of Ultrasonic Lithotripsy

A modification of standard percutaneous nephrolithotripsy technique for the morbidly obese patient

Objectives Urolithiasis in the morbidly obese patient presents several unique challenges to the urologist, and its treatment often requires creativity and innovation. We present a new modification of standard percutaneous nephrolithotripsy (PNL) technique, which is very helpful in overcoming some of the problems that are encountered when performing PNL in this group of patients. Methods We present 5 patients in whom this new technique has been used. Each had either failed prior extracorporeal shock-wave lithotripsy (ESWL) therapy or their size and abdominal girth precluded use of ESWL technology. All 5 patients underwent PNL. The radiographically measured skin-to-stone distances (determined by computed tomography or ultrasonography or both) exceeded the lengths of the standard percutaneous access sheaths and the 26 F rigid nephroscope. Thus larger and longer Amplatz access sheaths and a 30 F gynecologic laparoscope were used to reach the stones. Standard ultrasonic lithotripsy was then performed, and extralong bronchoscopic grasping forceps were used to remove stone fragments. Results All 5 patients were rendered stone-free using this technique. There was no significant perioperative morbidity. Conclusions For this very challenging group of patients, the use of larger and longer access sheaths and the gynecologic laparoscope have been very effective additions to the urologists' armamentarium in the treatment of urolithiasis.

Laser lithotripsy: A preliminary study on its application for sialolithiasis

The present study has established that a flashlamp pumped coumarin dye laser is capable of fragmenting salivary calculi. The refinement of spectroscopic feed-back techniques will allow laser lithotripsy to complement ultrasonic lithotripsy in the non surgical management of salivary calculi.

Minimally invasive endourologic management of calculi in continent urinary reservoirs

This study was done to determine whether minimally invasive endourologic management of calculi in continent reservoirs can be done effectively without compromise of urinary continence. Four patients with continent urinary diversions (1 Indiana pouch and 3 Kock pouches) were managed with trans-stomal pouchoscopic ultrasonic lithotripsy (n = 2), prone position extracorporeal shock wave lithotripsy (n = 1), or a “sandwich” combination of these (n = 1) for stone burdens up to 20 cm 2. Total hospital stay ranged from one to four (mean = 2.6) days. All 4 patients were initially rendered stone free, and, with follow-up as long as twenty-five months, only 1 has had a recurrence. No patient experienced stomal leakage or other complications. This study suggests that minimally invasive endourologic management of calculi in continent urinary reservoirs can be done safely and effectively to obviate the need for more invasive percutaneous approaches or open surgery, even for some patients with large stone burdens.

Trattamento endoscopico della calcolosi ureterale

Non-invasive techniques have revolutionized the treatment of ureteral stones. We report the success rate and the complication rate of ureteral calculosis treatment with ureterorenoscopy. From November 1990 to April 1994 we have treated 121 patients with URS. In all cases we have used a 12.5 F. “Wolf” rigid ureteroscope. 85 patients (70.2%) were treated with ultrasonic lithotripsy; 36 (29.7%) with a Dormia basket; and in 16 cases a combined treatment of both procedures was employed. Complete stone removal was obtained in 96 patients (79.3%) but six of these required further endoscopic treatment. The complication rate was 7.4 per cent (9 patients) and two patients (1.6%) needed open surgery. In our experience ureteroscopy is a good approach to the treatment of ureteral stones.

Endoscopic Lithotripsy for Urinary Calculi: Treatment Alternatives

or many years, “open” procedures were the treatment of choice for almost all calF culi too large to be expelled spontaneously. Extracorporeal shock wave lithotripsy (ESWL), which fragments calculi without incisions, and endoscopic procedures such as percutaneous nep hros toli thot rip s y and rig id ureteroscopy with ultrasonic lithotripsy gradually have made open procedures obsolete.’ Endoscopy continues to be a viable treatment alternative for fragmenting calculi because of the advances in flexible ureteroscopic technology. Many of the recent advances involve newer, smaller accessory instruments (eg, fulgurating probes as small as 1.6 Fr) for use with endoscopes. One of these accessory instruments is the small, “hair-like’’ fiber of the pulsed dye laser, which often is used in conjunction with flexible endoscopes. Additionally, baskets, graspers, and snares now come in a myriad of shapes and in sizes as small as 1.7 Fr. Flexible ureteroscopes also have evolved and now have increased deflecting capabilities that allow urologists to inspect the entire ureter

How to Irrigate a Nephrostomy Tube

kidney stones, surgery may be the only remaining option. In percutaneous nephrolithotomy, for instance, the surgeon removes small stones through a nephroscope inserted through a percutaneous tract to the kidney. In percutaneous ultrasonic lithotripsy, larger stones, broken up by ultrasound, are removed via the nephroscope or are excreted in the urine. Or, calculi are removed by special loops or basket catheters inserted into the ureter

The treatment of female urethral diverticulum with calculus through ultrasonic lithotripsy

A case report is presented of a large urethral diverticulum with calculus. We proposed the use of transurethral ultrasonic lithotripsy, followed by conventional surgical reconstruction 3 months later, when the condition had improved. The patient was completely cured.

Improved Bladder Stone Fragmentation with a Newly Designed Net: Studies in ex Vivo Porcine Model

We have designed and made a net to secure bladder stones that will facilitate their fragmentation. Ex vivo porcine bladders were used for experimental trials with artificial calculi fragmented with electrohydraulic and ultrasonic lithotripters with and without the net. The duration and number of electrohydraulic shocks were significantly reduced with the net: mean of 2 v 11 minutes; 17 v 59 shocks. The duration of ultrasonic lithotripsy also was reduced significantly with the net: 2 v 13 minutes. The net facilitates stone fragmentation by acting as a sieve to retain large particles for further fragmentation while letting smaller particles pass through. It also increases efficiency by holding the stone fragments closer and surrounding the lithotripter probe, where they absorb the shock wave or energy maximally. In addition, the net may reduce bladder injury by keeping stones and fragments and the lithotripter probe away from the mucosa.

Anatomical bases of percutaneous surgery for calculi in horseshoe kidney.

Horseshoe kidney is a renal fusion which combines three anatomic abnormalities: ectopia, malrotation and vascular changes. These anomalies can be recognised separately to varying degrees in unfused kidneys. Necessary modifications of the standard technique for percutaneous nephrolithotomy (PNL) are directly deducible from analysis of the anatomic data of the imaging of horseshoe kidneys. We report our experience with 5 patients (7 kidneys) who underwent PNL for calculi in horseshoe kidneys. The percutaneous approach was performed under ultrasound and fluoroscopic monitoring. In situ disintegration by ultrasonic lithotripsy and nephrostomy drainage were necessary in all cases. Modifications of the standard PNL procedure are related to the anatomic changes. The lower abdominal position of a horseshoe kidney necessitates upper or middle calyceal puncture, while the malrotation necessitates a more posterior puncture. Monitoring of the puncture needle by fluoroscopy as it is advanced postero-anteriorly is more difficult and the risk of the surgeon's hand entering the radiation path is increased. The renal pelvis is deep and a long endoscope may be required. Aberrant segmental vessels may create potential hazards. The majority of problems in location can be avoided by use of an ultrasonically guided needle. Percutaneous nephrolithotomy is the treatment of choice for calculi in horseshoe kidneys for the following reasons: the high incidence of recurrent lithiasis in horseshoe kidney and the complexity of repeated surgical approaches diminish the acceptable results of open surgery; difficulties in focussing on the calculi and drainage problems militate against the success of extracorporeal shock wave lithotripsy (ESWL); PNL has a good success rate and the least morbidity.

パルスダイレーザーによる総胆管結石の破砕経験および臨床的検討

The development of EST and percutaneous transhepatic catheterization techniques and recent improvements in fiberoptic cholangioscopy have allowed for non-surgical removal of biliary stones. Several centers have reported success in bile stone fragmentation and removal via percutaneously or via transcapillary using various techniques (mechanical stone extraction, ultrasonic lithotripsy, electrohydrauric lithotripsy, Nd:YAG laser). However, some reports have suggested the possibility of bile duct damage being associated with EHL or Nd:YAG laser treatment.In our hospital, almost all CBD stones were extracted using a basket catheter or mechanical lithotripter. But 3% of the patients have undergone EHL (guided by PTCS or POCS). In this report, 2 patients with intrahepatic bile duct stones and 6 with large common bile duct stones were treated successfully with a pulsed dye laser. Lithotripsy was performed under direct vision by cholangioscopy (4 cases) and peroral cholangioscopy (4 cases). Practically speaking, the PTCS procedure was easier than POCS for guiding pulsed laser lithotripsy. There were no serious complications. All stones were satisfactorily fragmented in one session of pulsed laser lithotripsy, except one case (with intrahepatic bile duct stones combined with CBD stones).Pulsed dye laser will make endoscopic lithotripsy safer, more effective and less time consuming.

Percutaneous Lithotripsy for Retained Biliary Calculi

Retained ductal stones after biliary surgery present challenging management problems. We have used urologic endoscopic techniques, including electrohydraulic and ultrasonic lithotripsy, to extract retained biliary duct calculi with minimal morbidity in three particularly difficult cases. Until other specialists gain the skills needed for such extractions, urologists can provide valuable assistance in the management of retained biliary calculi.

Endopyelotomy: Review of Results and Complications

Percutaneous endopyelotomy augmented by balloon dilation was performed on 27 of 40 patients for the treatment of symptomatic, primary ureteropelvic junction obstruction. Percutaneous ultrasonic lithotripsy was performed simultaneously on 12 of 27 patients (44%) for associated calculi. After endopyelotomy 24 of 27 patients became asymptomatic (clinical success rate 89%). Three clinically improved patients demonstrated only radiographic stability, while radiographic improvement was documented in 21 of 27 (radiographic success rate 78%). Adjuvant percutaneous ultrasonic lithotripsy was successful from the standpoint of stone removal in all patients and no increased morbidity could be identified.Of 27 patients 3 (11%) suffered major complications and are considered failures. Reasons for failure varied and are discussed. Included is a patient who at nephrostography and stent capping became septic and subsequently died. To decrease the risk of sepsis perioperative antibiotics to include at the time of nephrostomy tube capping are recommended. Angiography was performed in 19 of 40 patients to rule out an accessory crossing vessel at the ureteropelvic junction, and such a vessel was found in 6. From analysis of presenting excretory urograms (IVPs) we conclude that a crossing vessel cannot predictably be identified on an IVP.

Device and technique for transurethral ultrasonic lithotripsy using a flexible ureteroscope

First Page