Impacted Ureteral Stones Research Articles

The double wire technique: an alternative method for difficult ureteroscopic access

We read with great interest the study report by Ji et al. (Urol Res, doi: 10.1007/s00240-012-0476-0 , 2012) about the impact of the intentional ureteral stenting on the success rate of calculus extraction by second ureteroscopy, when the initial ureteroscopy failed. Actually, sometimes ureteral stone treatment pose challenging problems for the urologists. This study has filled an important gap on this field. If flexible ureteroscopy and laser lithotripter are not available pre-existing stent may improve the success rate of a subsequent ureteroscopy for impacted ureteral stones. Because, post-stent ureteroscopy has the advantage of working through a dilated ureter. We would like to add some additional comments and suggestions in addition to the authors' discussion, which is noteworthy in several respects.

Outcomes of Ureteroscopy for the Management of Impacted Ureteral Calculi With Different Localizations

To assess the effectiveness of Holmium:yttrium-aluminum-garnet lithotripsy for the treatment of impacted ureteral stones with different localizations. In this retrospective study, between January 2010 and October 2011, 105 patients underwent Ho:YAG laser lithotripsy for impacted ureteral stones with different localizations. Ninety patients (85.7%) had single ureteral stone and 15 (14.3%) had multiple stones. Single stone mean and multiple stone burden were 11.9 ± 4.6 mm and 23.8 ± 8.5 mm, respectively. Intraoperative and postoperative complications were grouped according to the modified Clavien grading system. Success rates with regard to stone localization after single endoscopic session for single stones were 95.7%, 88.8%, and 81.8% for lower, middle, and upper ureter, respectively. The stone clearance rate was reclassified as lower (below the iliac crest) and upper, the stone clearance rate was highest in the lower ureteral stones (55 of 57 patients, 96.5% vs 27 of 33 patients, 81.8%; P = .047). Operation time and the success rate were the only statistically significant parameters effecting the complications (P = .001 and P = .012). According to the Clavien classification system, the overall complication rate was 27.5% in our study. The distribution of 44 complications in 27 patients; grade I, II, IIIa, IIIb, and IVa was 17 (16.2%), 6 (5.7%), 7 (6.7%), 13 (12.4%), and 1 (0.9%), respectively. Complications are more common in patients with longer operation time and unsuccessful intervention. Ureterorenoscopy (URS) using Ho:YAG laser lithotripsy can be an effective and safely performed technique in impacted stones with different localizations and considered as the first-line approach at single setting.

1826 STUDY OF SILENT OBSTRUCTION AFTER URETEROSCOPIC MANAGEMENT OF IMPACTED URETERAL STONES

You have accessJournal of UrologyStone Disease: New Technology/SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20121826 STUDY OF SILENT OBSTRUCTION AFTER URETEROSCOPIC MANAGEMENT OF IMPACTED URETERAL STONES Soichi Mugiya, Masao Nagata, Hiroshi Furuse, and Seiichiro Ozono Soichi MugiyaSoichi Mugiya Hamamatsu, Japan More articles by this author , Masao NagataMasao Nagata Hamamatsu, Japan More articles by this author , Hiroshi FuruseHiroshi Furuse Hamamatsu, Japan More articles by this author , and Seiichiro OzonoSeiichiro Ozono Hamamatsu, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1914AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Improved endoscope and advanced devices have significantly decreased the incidence of complications during ureteroscopy (URS). Despite recent reports suggesting that routine postoperative imaging may not be necessary in all individuals after URS silent obstruction may develop in some, ultimately resulting in renal damage. We evaluated the incidence and factors associated with postoperative abnormal imaging without symptoms after URS for impacted ureteral stones. METHODS We retrospectively reviewed the records of 377 patients who underwent URS for impacted ureteral stones at our institution. Our URS procedure using a small-caliber ureteroscope and a holmium: YAG laser has been reported previously (J. Urol. 171: 89, 2004). All of the patients routinely underwent IVP in order to assess for obstruction or delayed excretion at 1 month after URS. Abnormal imaging was defined when postoperative imaging did not show improvement of hydronephrosis. Patient characteristics as well as endoscopic findings were reviewed to identify factors associated with abnormal post-URS imaging. RESULTS Of the 377 patients 19 (5%) revealed abnormal postoperative imaging without symptoms. All 19 patients underwent secondary ureteroscopy in order to assess and alleviate obstruction. 19 patients with a mean age of 59 years were included. Mean diameter of the initial target stone was 14 mm (range 2-23) with stone location being 13 proximal, 5 distal, and one mid ureter. Mean duration of impaction was 31 months (range 2-84). Second URS revealed obstruction due to ureteral stricture in 16, complete ureteral occlusion in 2 and ureteral tortuosity in 1. Second URS detected a severe ureteral stricture related to laser therapy distal to the successfully treated stone. The obstruction eventually resolved with endoscopic balloon dilation in 17 out of 19 patients. 2 patients ultimately received ureteroureterostomy and 2 were lost to follow-up. Among these 19 patients, initial URS revealed inflammatory ureteral polyps associated with the calculi in 9 and ureteral stricture in 6. Stone location, stone size, operative time, duration of impaction and stone composition were not associated with abnormal post-URS imaging. CONCLUSIONS Our analysis suggests that silent obstruction remains a potentially significant complication after URS for long-term impacted ureteral stones which are frequently associated with ureteral polyps and strictures. Therefore, we recommend that routine postoperative imaging should be performed after URS to avoid the potential complications of unrecognized ureteral obstruction. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e737-e738 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Soichi Mugiya Hamamatsu, Japan More articles by this author Masao Nagata Hamamatsu, Japan More articles by this author Hiroshi Furuse Hamamatsu, Japan More articles by this author Seiichiro Ozono Hamamatsu, Japan More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

2197 FLUORO-LESS URETEROSCOPY: MINIMIZING INTRAOPERATIVE RADIATION DURING URETEROSCOPIC PROCEDURES

You have accessJournal of UrologyImaging/Radiology: Uroradiology II1 Apr 20122197 FLUORO-LESS URETEROSCOPY: MINIMIZING INTRAOPERATIVE RADIATION DURING URETEROSCOPIC PROCEDURES Ryan Hsi and Jonathan Harper Ryan HsiRyan Hsi Seattle, WA More articles by this author and Jonathan HarperJonathan Harper Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2371AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Fluoroscopy usage during endoscopic procedures exposes the patient and operating room staff to ionizing radiation. Little is known regarding the average range of exposure during these cases. Mean fluoroscopy usage time during ureteroscopy reported from recent literature is between 15-183 seconds. The purpose of this study was to determine if a minimalist approach to fluoroscopy usage during ureteroscopy could reduce overall intraoperative fluoroscopy time. METHODS Over a 9 month period, fluoroscopy usage for all cases involving retrograde ureteroscopy for a single surgeon was prospectively recorded. A protocol was developed to access the ureter with the ureteroscope without fluoroscopy usage, and minimize radiation at every step (Figure 1). A retrospective chart review was then performed on patient factors and intraoperative events. Figure 1. Utilization of fluoroscopy during specific steps in ureteroscopy. Step Protocol Prior to procedure Surgeon controlled fluoroscopy pedal Scout film Unnecessary; C-arm positioned based on external visual cues Retrograde pyelogram Unnecessary unless difficult access to upper urinary tract Initial wire placement Place under tactile guidance or directly through ureteroscope Ureteroscopic access Place under tactile guidance to mid ureter over wire or drive directly into ureter Stent placement Single-tap pedal to visualize proximal stent curl, visualize distal curl cystoscopically RESULTS Fluoroscopy usage during ureteroscopic cases was utilized on 109 renal units in 73 consecutive patients. The indications for ureteroscopy included the treatment of stones (84%), diagnosis and/or biopsy (15%), and laser incision of infundibular stenosis (1%). Of the 102 renal units with fluoroscopic usage data, total mean and median fluoroscopy time was 2.8 and 1.0 seconds (0-31 seconds), respectively. Excluding fluoroscopy usage to confirm ureteral stent placement, 72% of all cases did not require any fluoroscopy time, and 82% required 2 seconds or less. For the last 44 consecutive renal units, total mean and median radiation dose was estimated at 0.5 mGy and 0.4 mGy (0.0-2.3 mGy), respectively. The most common reasons for utilization of fluoroscopy during ureteroscopy included aberrant anatomy, severely impacted ureteral stone, or difficult navigation due to a tight ureter. There were no intraoperative complications. CONCLUSIONS The reduced fluoroscopy protocol resulted in minimal fluoroscopy time and radiation exposure, significantly lower than reported in the literature. Fluoro-less ureteroscopy is safe and feasible in the majority of ureteroscopic cases and lessens exposure to patients and staff. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e886 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Hsi Seattle, WA More articles by this author Jonathan Harper Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

E100 Retrograde ureteroscopic approach for impacted proximal ureteral stones – experience on 200 cases

E100 Retrograde ureteroscopic approach for impacted proximal ureteral stones – experience on 200 cases

E102 Endoscopie management of impacted ureteral stones – risks and results

E102 Endoscopie management of impacted ureteral stones – risks and results

E131 Minimum Incision Endoscopie Surgery (MIES) lithotomy for the treatment of the large impacted ureteral stones or the complicated renal stones

E131 Minimum Incision Endoscopie Surgery (MIES) lithotomy for the treatment of the large impacted ureteral stones or the complicated renal stones

Evaluation of pneumatic versus holmium:YAG laser lithotripsy for impacted ureteral stones

We prospectively analyzed and compared the effectiveness and complications of pneumatic lithotripter with a holmium:yttrium-aluminum-garnet (Ho:YAG) laser for the ureterorenoscopic management of impacted ureteral stones. From January 2006 to January 2008, we performed retrograde endoscopic treatment in 288 patients with ureteral stones in our clinic. The patients with impacted stones were randomized into two groups according to the lithotripter used to fragment the stone: pneumatic (n = 40) and laser (n = 40). The preoperative, operative, and post-operative follow-up findings were analyzed and compared. The average stone size was similar in both groups (118.8 ± 58.3 mm(2) vs. 110.7 ± 54.4 mm(2)). The calculi were located in the distal ureter in most of the patients in both groups (65% in pneumatic group and 52.5% in laser group). The operation time was significantly diminished in the laser group (P = 0.001). The stone-free rates after a single ureteroscopic procedure were 80 and 97.5% in the pneumatic and laser groups, respectively (P = 0.03). Auxiliary treatments were needed in seven patients in the pneumatic group, while only one patient in the laser group (P = 0.05) needed this treatment. After the additional procedures, a 100% success rate was achieved in both groups. The rate of double J stent insertion was significantly higher in the pneumatic group (P = 0.01). In the pneumatic group, four cases of stone up-migration and one case of post-operative stricture were seen, whereas only one case of stone up-migration was noted in the laser group. Our comparative study has shown that the use of Ho:YAG as an intracorporeal lithotripter during ureteroscopic management of impacted ureteral stones is highly efficient with high success rates, regardless of the stone location.

1690 ROUTINE POSTOPERATIVE IMAGING IS IMPORTANT AFTER URETEROSCOPIC MANAGEMENT OF IMPACTED URETERAL STONES

INTRODUCTION AND OBJECTIVES: Improved endoscope and advanced intracorporeal lithotripsy devices have significantly decreased the incidence of complications during ureteroscopy (URS). Despite recent reports suggesting that routine postoperative imaging may not be necessary in all individuals after URS silent obstruction may develop in some, ultimately resulting in renal damage (Weizer AZ, et al. J Urol 168: 46–50, 2002.) We evaluated the incidence and factors associated with postoperative abnormal imaging and assessed the need for routine postoperative imaging after URS. METHODS: We retrospectively reviewed the records of 323 patients who underwent URS for impacted ureteral stones at our institution. Our URS procedure using a small-caliber ureteroscope and a holmium: YAG laser has been reported previously (J. Urol. 171: 89–91, 2004). All of the patients routinely underwent IVP in order to assess for obstruction or delayed excretion at 1 month after URS. Abnormal imaging was defined when postoperative imaging did not show improvement of hydronephrosis. RESULTS: Of the 323 patients 16 (5%) revealed abnormal postoperative imaging without symptoms. All 16 patients underwent secondary ureteroscopy in order to assess and alleviate obstruction. 16 patients with a mean age of 56 years were included. Mean diameter of the initial target stone was 15 mm (range 2–23) with stone location being 11 upper ureter and 5 lower ureter. Mean duration of impaction was 30 months (range 2–72). Second URS revealed obstruction due to ureteral stricture in 13, complete ureteral occlusion in 2 and ureteral tortuosity in 1. Second URS detected a severe ureteral stricture related to laser therapy distal to the successfully treated stone. The obstruction eventually resolved with endoscopic balloon dilation in 14 out of 16 patients. 2 patients ultimately received ureteroureterostomy and 2 were lost to follow-up. Among these 16 patients, initial URS revealed inflammatory ureteral polyps associated with the calculi in 8 and ureteral stricture in 4. Stone location, stone size, operative time, duration of impaction and stone composition were not associated with abnormal post-URS imaging. CONCLUSIONS: Our analysis suggests that silent obstruction remains a potentially significant complication after URS for long-term impacted ureteral stones which are frequently associated with ureteral polyps and strictures. Therefore, we recommend that routine postoperative imaging should be performed after URS to avoid the potential complications of unrecognized ureteral obstruction.

Experiences in Laparoscopic Removal of Upper Ureteral Stones: Multicenter Analysis of Cases, Based on the TurkUroLap Group

Laparoscopic surgery for ureteral stones was restricted to special cases-those with large or impacted ureteral stones. We present special cases of patients who underwent laparoscopic ureterolithotomy at various clinics in Turkey. Forty-one patients were included in the study from five urology clinics in which laparoscopic surgery was being performed. After a disease-specific history and physical examination, age and sex were recorded. The mean patient age was 41.8 years (30 men and 11 women). Urinalysis, determination of creatinine level, intravenous urography, and ultrasonography were performed. The parameters of stone size, presence of hydronephrosis, previous shockwave lithotripsy, previous ureteroscopic stone therapy, type of laparoscopic approach, operative time, ureteral incision, insertion of a Double-J stent, amount of drainage, hospitalization period, and perioperative complications were evaluated. Mean ureteral stone size was 22 mm. The retroperitoneoscopic approach was preferred in 35 (85.3%) patients, while the transperitoneal approach was used in 6 (14.7%) patients. Grade I hydronephrosis was detected in 4 patients, grade 2 in 22 patients, and grade 3 in 12 patients. In six patients, a history of shockwave lithotripsy was confirmed. The ureteral wall was incised with a cold knife in 5, scissors in 16, J-hook in 3, and a monopolar or bipolar dissector in 17 patients. In six patients, a Double-J stent was inserted, while in one patient, the operation was converted to an open procedure. The mean operative time was 124 minutes. The mean amount of drainage was 220 ml. Mean hospitalization time was 4.8 days. In five (12.5%) of seven patients, persistent drainage was a major complication that was managed by insertion of a Double-J stent. All patients were discharged stone free. Increased hospitalization and operative time can be related to the large stone sizes and prolonged urine leakage. In our opinion, however, the overall success of laparoscopic ureterolithotomy makes it a feasible and effective procedure, especially for stones that could not be managed easily with ureteroscopic stone therapy.

Is Stent Placement Necessary After Uncomplicated Ureteroscopy for Removal of Impacted Ureteral Stones?

Ureteral stent placement after ureteroscopic lithotripsy has some advantages and disadvantages. In this randomized study, the necessity of ureteral stent placement after uncomplicated ureteroscopy for impacted ureteral stones was assessed. Between 2005 and 2007, 60 evaluable patients were equally randomized to groups with and without stents. Patients underwent ureteroscopic pneumatic lithotripsy for ureteral stones. The operation was completed with or without stent placement according to the randomization order. Excretory urography was performed 3 months after the procedure. All stents were cystoscopically removed at the third postoperative week. Sociodemographic and clinical variables (age, sex, stone location, stone size, operative time, hospital stay, narcotic and nonnarcotic analgesic use), and postoperative complications (fever, pain delaying discharge, emergency department visit, urinary retention, stent-related irritative symptoms) were evaluated. Mean stone size was not significantly different in both groups. Mean operative time was significantly longer in the stent group: 30.5 +/- 9.6 vs 43.7 +/- 11.6 minutes. On the operation day and until postoperative day (POD) 5, narcotic (P = 0.004) and nonnarcotic analgesic (P = not significant) use was more frequent in the no-stent group. At POD 5 and later, although narcotic and nonnarcotic analgesic use were frequently necessary in the stent group, both were almost unnecessary in the no-stent patients. Stent-related irritative symptoms were overwhelmingly higher (10% vs 93%) in the stent group. Discharge was delayed (23% vs 10%) and unplanned emergency department visits (20% vs 10%) were exercised almost two times more commonly in the no-stent group. Stone-free rates were identical (n = 29/30; 97%) in both groups. Routine placement of a ureteral stent is not mandatory in patients without complications after ureteroscopic lithotripsy for impacted ureteral stones. Stent placement can be argued and agreed with the patients preoperatively in the light of the data presented above.

1452 TRANSPERITONEAL LAPAROSCOPIC URETEROLITHTOMY 800 CASES: A 10-YEAR SINGLE-CENTER EXPERIENCE

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal I1 Apr 20101452 TRANSPERITONEAL LAPAROSCOPIC URETEROLITHTOMY 800 CASES: A 10-YEAR SINGLE-CENTER EXPERIENCE Gonghui Li, Damin Yu, Xinde Li, Xuefang Rui, and Guoqing Ding Gonghui LiGonghui Li More articles by this author , Damin YuDamin Yu More articles by this author , Xinde LiXinde Li More articles by this author , Xuefang RuiXuefang Rui More articles by this author , and Guoqing DingGuoqing Ding More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1166AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES we report our 10-year experience in performing transperitoneal laparoscopic ureterolithtomy on 800 patients to determine its indication,safety and effectacy and advantages in the current era of minimally invasive surgery. METHODS We performed 800 transperitoneal laparoscopic ureterolithotomy during the past 10 years. Main indication was large (1.5 to 3.5 cm), impacted stone. Other indications were failed ESWL and a failed attempt at ureteroscopy. RESULTS There were no major complications. The stone was successfully removed in all 800 patients, 9 patients.needed the combination of flexible cystscopy. The operative time ranged from 32 to 185 minutes (mean 65). No intra-operative complication was encountered and no patient required a blood transfusion. Average duration of hospi-tal stay was 2-4 days. During follow-up 3 months later IVU revealed normal ureter in all cases. CONCLUSIONS In selected patients with large, hard, impacted ureteral stones, laparoscopic ureterolithotomy is a reason-able treatment option. It is a minimally invasive and maximally effective procedure and is an economically viable option where laparoscopic instruments are easily available. We recommend laparoscopy for large ureteral stone (1.5 cm and above). Hangzhou, People's Republic of China© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e559-e560 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gonghui Li More articles by this author Damin Yu More articles by this author Xinde Li More articles by this author Xuefang Rui More articles by this author Guoqing Ding More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transumbilical Laparoendoscopic Single-Site Ureterolithotomy for Large Impacted Ureteral Stones: Initial Experiences

PurposeWe presented our initial clinical experiences with transumbilical laparoendoscopic single-site (LESS) ureterolithotomy for large, impacted ureteral stones.Materials and MethodsBetween March 2009 and November 2009, seven LESS ureterolithotomies were performed at our institute. During the operation, we made a single 2 cm incision at the umbilicus and a homemade port by using a small wound retractor (Alexis®, Applied Medical, Rancho Santa Margarita, USA), a surgical glove, and conventional trocars. The operation was performed in the same manner as conventional laparoscopic surgery. The mean maximal stone diameter was 21.9 mm (range, 16.0-27.0 mm). There were six cases of upper ureteral stones and one case of a mid-ureteral stone. Perioperative and postoperative parameters were evaluated.ResultsThe mean operative time was 197.1 min (range, 150-270 min). No transfusions were required. The mean postoperative hospital stay was 3.3 days (range, 2-6 days). The mean pain intensity on a visual analogue scale (VAS) on postoperative day 2 was 26 mm (range, 0-80 mm), and the mean cosmetic VAS at 6 weeks after the operation was 0 mm. The mean time for patients to return to their baseline activities was 4.0 days (range, 3-7 days). In six cases, all stones were completely removed on the basis of postoperative radiologic evaluation. There were no cases of major complications, including internal organ injury, urinary leakage, or urinary tract infection.ConclusionsTransumbilical LESS ureterolithotomy can be considered as an alternative treatment option with minimal invasiveness and good effectiveness for large, impacted ureteral stones.

MP-07.13: Extraperitoneal Laparoscopic Ureterolithotomy for Impacted Ureteral Stone: Surgical Technique and Results

Since the introduction of laparoscopy in urology, transperitoneal and lumboscopic approaches have been developed to treat a wide variety of pathologies. Considering its reduced perioperative morbidity, the extraperitoneal laparoscopic (lumboscopic) extraction of impacted ureteral stones is a good alternative to traditional open surgery for cases that have failed endoscopic management or extracorporeal shock wave lithotripsy (ESWL). We report our initial experience in a consecutive series of patients that underwent lumboscopic extraction of impacted mid-ureteral stones refractory to first line treatments.

S112 Comparative evaluation of pneumatic versus holmium: YAG laser lithotripsy for impacted ureteral stones

S112 Comparative evaluation of pneumatic versus holmium: YAG laser lithotripsy for impacted ureteral stones

Extracorporeal shock wave lithotripsy as a first-line therapy for ureteral calculi with impaired renal function due to hydronephrosis

In their recent article on extracorporeal shock wave litho-tripsy (ESWL) as a first-line single therapy for obstructiveureteral stones, Chiara and colleagues indicated that ESWLis an effective therapy for obstructive ureteral calculi,varying degrees of hydronephrosis, and impaired renalfunction [1]. The present article adds further support to thefeasibility and safety of ESWL for calculus clearance andrecovery of renal function [1]. It is evident that ESWL hasbecome standardized and can guarantee acceptable peri-operative morbidity, yielding reproducible results fortreatment of ureteral calculi. Although some authors con-sider that ESWL is clearly indicated in the presence ofhydronephrosis, others consider hydronephrosis to be anindicator of successful outcome after ESWL. Consistentwith the findings of Chiara et al., El-Assmy et al. [2] foundthat the degree of urinary obstruction caused by calculusdid not affect the success of calculus clearance. However, atendency for repeat treatment and a prolonged period forstone clearance were associated with the degree of hydro-nephrosis [2]. Chang et al. conducted a prospective,randomized study of patients with hydronephrosis whosestones were located above the level of L5 [3]. Theyreported that hydronephrosis had a major impact on theoutcome of ESWL, because more stone-free patients werefound among those with mild, than among those withsevere, hydronephrosis, and ancillary procedures wereneeded in 16.9% of all patients [3]. Although ESWL hascertain limitations, its indications are expanding and nowinclude all types of urinary tract calculi. Deliveliotis et al.evaluated the use of ESWL in patients with impactedureteral stones that had remained in the same location for atleast 2 months, and found that 85.7% were rendered stone-free without the need for an open procedure, concludingthat ESWL should be attempted as an initial approach forthe treatment of impacted stones [4]. The use of ESWL,which is minimally invasive compared any other surgicalmethod known currently, should be promoted wheneverpossible for patients with ureteral stones.References

Combined Removal of Stones with Resection of Concurrent Pathologic Ureter May Be a Preferred Treatment for Impacted Ureteral Stones with Stricture Lesions

We investigated ureteral lesions associated with impacted stones and compared the long-term outcomes after ureteroscopic lithotripsy (URSL) with a holmium laser with open ureterolithotomy, resection of concurrent pathologic ureter, and ureteroureterostomy (OUU) for patients with impacted ureteral stone. Between January 2004 and December 2007, 86 patients with impacted ureteral stones were treated with URSL (61) or OUU (25) because of tortuous ureter or failed access to stones. The stone size, location, impaction, ureteral lesions, and long-term outcomes were recorded. Mean stone size for the URSL group and the OUU group was 11.8 +/- 2.6 mm and 15.3 +/- 4.2 mm, respectively (P = 0.078). The impaction duration was 8.5 +/- 1.1 months for the URSL group and 17.2 +/- 3.8 months for the OUU group (P < 0.001). Endoscopic observation revealed two types of ureteral lesions that were defined as villous or polypoid protrusion (type 1) and edematous hemispheric lesions (type 2). Stone-free rates for the URSL group and the OUU group were 91.8% and 100%, respectively (P = 0.140). URSL was associated with a higher incidence of stricture (26.2% v 4.0%; P = 0.019) and worse recovery of hydronephrosis (P < 0.001). Stricture occurred more frequently in patients with type II lesions in the URSL group (P = 0.022). Stone recurrence for the URSL group and the OUU group were 13.1% and 4%, respectively (P = 0.210). Chronically impacted stones are frequently associated with ureteral polyp or stricture lesions. Our results reveal that combined removal of stones with resection of the pathologic ureter may achieve better long-term outcomes for patients with impacted stones with stricture lesions.

Success of Laser Endoureterotomy of Ureteral Strictures Associated with Ureteral Stones Is Related to Stone Impaction

Since the holmium:yttrium-aluminum-garnet (Ho:YAG) laser is the flexible lithotrite of choice for ureteral stones, its application to ureteral strictures associated with ureteral calculi is convenient. The results of Ho:YAG laser endoureterotomy in this specific setting have not been defined. We report our experience with Ho:YAG laser endoureterotomy of ureteral strictures associated with ureteral stone treatment, with or without a history of stone impaction. We reviewed the medical records of 13 patients with ureteral stricture related to stone treatment, with (n = 9) or without (n = 4) a history of impacted ureteral stones, who were managed with Ho:YAG laser endoureterotomy. Follow-up was obtained with radiographic imaging and renal scans. The overall success rate was 62%, with a mean follow-up of 21 months in successful cases and a mean recurrence time of 1.6 months in failures. Outcome was not associated with length or location of the stricture. Among the nine strictures associated with impacted stones, treatment was successful in only 5 (56%). Of the four strictures that occurred after stone removal but without history of impaction, the success rate was 75%. Success was also greater for strictures managed with post-procedure stents >or=8 Fr (75%), compared to stents <or=7 Fr. (56%). Our results suggest that laser endoureterotomy of ureteral strictures due to ureteral stone treatment without a history of impaction is associated with a reasonable success rate (75%), but that laser endoureterotomy for strictures related to impacted stones is associated with a success rate of only 56%. Larger caliber stents might be preferred in this setting.

Acute renal failure due to bilateral ureteral stone impaction in an HIV-positive patient

A 51-year-old HIV-positive man treated with atazanavir for 9 months presented with anuria following right flank pain. Laboratory examination indicated renal insufficiency, and abdominopelvic computed tomography scanning showed bilateral hydroureteronephrosis, but no stones were visualized. Endoscopic procedures were performed to investigate the causes of ureteral obstruction and, if possible, to insert Double-J stents in the ureters. A yellowish stone composed of pure atazanavir was found at the right ureteral orifice, and retrograde pyelography revealed a filling defect in the left ureter found to be caused by an atazanavir stone. The patient's renal function recovered after removal of these stones.

Ostiolitholapaxy

The authors developed a new, minimally invasive technique for the removal of impacted iuxtavesical ureteral stones, using nephroscope and a grasping forceps. They named this technique ostiolitholapaxy. The authors present their detailed technique and results. Between 1. 1. 1995 and 31. 12. 2006 48 operations were performed. In 41 cases the stones were removed successfully. In seven unsuccessful cases the stones were extracted by ureteroscopy. The authors worked up 41 successful cases presenting the steps and technical details of the procedure. Average stone size was 5,2 (3-12) mm. Male and female ratio was 23/18. In 19 patients local and in 22 patients spinal anaesthesia was performed. Among the patients who underwent local anaesthesia there were 13 (68,4%) female and 6 (31,6%) male patients. Average operating time was 8,5 (3,5-35) minutes. Mean follow-up time was 95,3 (2-143) months. The success rate of the procedure was 85,41%. There were no intraoperative complications. In the mentioned period no ureteral stricture and/or reflux-uropathy has developed. Due to the simplicity, efficacy of this technique and the fact that it can be performed even in local anaesthesia, this procedure can be useful in case of small symptomatic iuxtavesical stones as a quick and safe stone removal intervention.