Ureteroscopic Management Research Articles

What Is the Cost of Maintaining a Kidney in Upper-Tract Transitional-Cell Carcinoma? An Objective Analysis of Cost and Survival

For many years, the gold standard in upper urinary tract transitional-cell carcinoma (UT-TCC) management has been nephroureterectomy with excision of the bladder cuff. Advances in endourologic instrumentation have allowed urologists to manage this malignancy. The feasibility and success of conservative measures for UT-TCC have been widely published, but there has not been an objective cost analysis performed to date. Our goal was to examine the direct costs of renal-sparing conservative measures v nephroureterectomy and subsequent chronic kidney disease (CKD) or end-stage renal disease (ESRD). Secondary analysis includes a discussion of survival and quality-of-life issues for both treatment cohorts. Retrospective review of a cohort of patients treated at our institution with renal-sparing ureteroscopic management of UT-TCC who were followed for a minimum of 2 years. The costs per case were based on equipment, anesthesia, surgeon fees, pathologic evaluation fees, and hospital stay. ESRD and CKD costs were estimated based on published reports. From 1996 to 2006, 254 patients were evaluated and treated for UT-TCC at our institution. A cohort of 57 patients was examined who had a minimum follow-up period of 2 years. Renal preservation in our series approached 81%, with cancer-specific survival of 94.7%. Assuming a worst-case scenario of a solitary kidney with recurrences at each follow-up for 5 years v nephroureterectomy and dialysis for the same period, an estimated $252,272 U.S. dollars would be saved. This savings would cover the expenses of five cadaveric renal transplantations. Conservative endoscopic management of UT-TCC in our experience should be the gold standard management for low-grade and superficial-stage disease. From a cost perspective, renal-sparing UT-TCC management is effective in reducing ESRD health care expenses.

Compare the outcome of ureteroscopic lithotripsy with ureteroscopic management after failed extracorporeal shock wave lithotripsy for ureteral calculi

To compare the efficacy and complication of ureteroscopic lithotripsy and ureteroscopic management for ureteral calculi after failed extracorporeal shock wave lithotripsy (ESWL). One hundred and thirty-six cases with ureteral calculi after failed ESWL and 189 cases with ureteral calculi were treated with ureteroscopic lithotripsy (URSL). Clinical data of two groups were analyzed retrospectively. The mean operating time and therapeutic time in ESWL-URSL group was longer than that in URSL group, while the rate of polypi hyperplasia and open-surgery in ESWL-URSL group was 34.6%, 5.88% versus 28.3%, 1.59% in URSL group. There is no significant statistical difference in stone-free rate between two groups. Ureteroscopic management can be preferred for the patients with disadvantage of ESWL in some condition.

Ureteroscopic management of distal ureteral stones in children: holmium: YAG laser vs. pneumatic lithotripsy

Aim: In this retrospective study, we aimed to compare the treatment results of pneumatic and holmium laser-assisted ureteroscopy in managing distal ureteral calculi in children. Materials and methods: The study group included a total of 36 children (23 boys, 13 girls) who underwent ureteroscopy between June 1998 and April 2008 due to distal ureteral calculi. Pneumatic lithotripsy was performed in 11 children and holmium:YAG laser lithotripsy in 25. Results: Their ages ranged from 18 months to 14 years (mean: 8.5 ± 3.5 years). The overall success rate for the holmium:YAG laser lithotripsy (100%) was higher than that of pneumatic lithotripsy (81.8%), but the difference was insignificant (P = 0.087). The complication rate was higher in pneumatic lithotripsy than in holmium:YAG laser lithotripsy (36.4% versus 4%, P = 0.023). Treatment time and hospital stay were shorter in the holmium:YAG laser lithotripsy group than in the pneumatic lithotripsy group (32.4 min versus 42.3 min, P = 0.041; 17.4 h versus 33.6 h, P = 0.013, respectively). Conclusion: This study showed that the success rate for holmium:YAG laser lithotripsy was almost identical with that achieved by pneumatic lithotripsy in the treatment of distal ureteral stones; ureteroscopic holmium:YAG laser lithotripsy had significant clinical advantages over pneumatic lithotripsy in terms of operative time, and hospitalization duration, stent requirements, and complication rates.

Clinical Trials of the Surgical Management of Urolithiasis: Current Status and Future Needs

We reviewed the literature on the surgical treatment of urolithiasis. All prospective, randomized trials on the surgical treatment of stone disease were reviewed. Percutaneous nephrolithotomy (PNL) is superior to shockwave lithotripsy (SWL) or open surgery in the treatment of staghorn calculi. For ureteral stones, ureteroscopy appears to result in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. For lower pole renal calculi, PNL results in a higher stone-free rate and lower need for retreatment compared with SWL but has a higher complication rate and increased hospital stay. Most areas of surgical stone treatment have been addressed by a randomized controlled trial; however, most trials were of poor quality. Trials tend to focus only on radiologic outcomes. No study to date has been able to show a measurable quality of life benefit to patients, possibly because no condition-specific quality of life instruments have been developed. In addition, economic impact, both direct and indirect, has been rarely characterized. The surgical treatment of kidney stones is poorly researched. Future trials should be performed with adequate funding and patient-focused outcomes.

Percutaneous nephrolithotomy for the treatment of lower pole renal calculi

Percutaneous nephrolithotomy for the treatment of lower pole renal calculi

Ureteroscopic management of lower ureteric calculi: a 15‐year single‐centre experience

To review our 15-year experience with ureteroscopic treatment of distal ureteric calculi and to determine the impact of improved technology and techniques on the efficacy, success and complications of the procedure. We retrospectively reviewed the medical records of 4512 patients who underwent 5133 ureteroscopic procedures for the treatment of distal ureteric calculi at our institution from January 1991 to December 2005. The patient and stone characteristics, treatment variables and clinical outcomes were assessed. Factors such as type of ureteroscope, procedure duration, procedure success, complication rate and hospital stay were evaluated. Data obtained from a cohort of patients that underwent the procedure from 1991 to 1995 (group 1) were statistical compared with those obtained from a cohort of patients from 1996 to 2005 (group 2). Logistic regression analysis was used to identify associated factors with the major complications of ureteroscopy. Overall, the stone-free rate after the procedure was 94.6%, the mean (sd; range) operative duration was 43 (15.0; 25-120) min, the intraoperative complication rate was 6.67%, the postoperative complication rate was 9.9%, and the mean (sd) hospital stay was 1.7 (1.1) days. The clinical and radiological follow-up (mean 36.8 months) for 71.3% of eligible patients detected only 12 ureteric strictures (0.23%). On comparing group 1 with group 2, the overall success of ureteroscopic stone extraction improved from 85.7% to 97.3% (P < 0.001), significant ureteric perforation decreased from 3.3% to 0.5% (P = 0.05), ureteric avulsion decreased from 1.3 to 0.1% (P < 0.05), ureteric stricture decreased from 0.7% to 0.1% (P < 0.007), the mean (sd) procedure time significantly decreased from 75 (42.9) min to 36.5 (12.5) min (P < 0.001), and the mean hospital stay significantly decreased from 2.5 (1.6) days to 0.5 (1.2) days, with a trend toward outpatient treatment. Logistic regression analysis showed a significant association of the major ureteroscopic complications with increased operative duration, type of ureteroscope used, stone impaction, stone size and surgeon experience. The present series shows the high success rate, with minor complications, that can be achieved with ureteroscopic treatment of distal ureteric calculi. Improvements in ureteroscope design, accessories, technique and experience have led to a significant increase in the success rate and decrease in the complication rate.

Pediatric Ureteroscopic Management of Intrarenal Calculi

Data addressing ureteroscopic management of intrarenal calculi in prepubertal children are limited. We reviewed our experience from January 2002 through December 2007. We retrospectively reviewed ureteroscopic procedures for intrarenal calculi in children younger than 14 years. Stone-free status was determined with postoperative imaging. Multiple logistic regression analysis was used to assess the influence of preoperative factors on initial stone-free status and the need for additional procedures. Intrarenal calculi were managed ureteroscopically in 52 kidneys in 50 children with a mean age of 7.9 years (range 1.2 to 13.6). Mean stone size was 8 mm (range 1 to 16). Stone-free rate after a single ureteroscopic procedure was 50% (25 of 50 patients) on initial postoperative imaging and 58% (29 of 50) with extended followup. Initial stone-free status was dependent on preoperative stone size (p = 0.005) but not stone location. Additional stone procedures were required in 18 upper tracts. Younger patient age (p = 0.04) and larger preoperative stone size (p = 0.002) were associated with the need for additional procedures. Additional procedures were required in more than half of the stones 6 mm or larger but in no stone smaller than 6 mm. Ureteroscopy is a safe method for the treatment of intrarenal calculi in the prepubertal population. Our ureteroscopic stone-free rate for intrarenal stones is lower than that reported for ureteral stones. Parents should be informed that additional procedures will likely be required, especially in younger patients and those with stones larger than 6 mm.

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.

Is Endoscopic Management Suitable for Long Ureteral Fibroepithelial Polyps?

Fibroepithelial polyps of the ureter are rare benign tumors that have traditionally been managed by open exploration and resection. Endoscopic resection have been regarded as the gold standard for small lesions, while the management modality for long lesions is still controversial. We review our experience with ureteroscopic management of long (>6 cm) ureteral fibroepithelial polyps by holmium: yttrium-aluminum-garnet (YAG) laser resection. Five patients with a long ureteral fibroepithelial polyp underwent ureteroscopic resection using a holmium:YAG laser. Endoscopic management was successful in all five patients, and no major complications resulted from the approach. The average length of stay was 3 days (range 2-5 d). The mean length of the lesions were 11 cm (range 6-16 cm). The ureteral stent was removed at 6 weeks. No recurrences were seen during a mean followup of 24.2 months (range 3-51 mos). One ureteral stricture developed at 3 months, and the patient underwent endoscopic treatment by holmium:YAG laser. Endoscopic management of long ureteral fibroepithelial polyps is an acceptable modality with minimal morbidity and durable treatment results. The holmium:YAG laser offers the advantages of facilitating the use of a small-caliber fiber or flexible ureteroscope and allows safe destruction of the stalk and efficient removal of the entire polyp.

Ureteral calculi in children: what is best as a minimally invasive modality?

Minimally invasive treatment of ureteral calculi in children is a challenging topic. In an evidence-based review, we evaluated the efficacy and safety of extracorporeal shock wave lithotripsy (SWL) and ureteroscopic modalities for this group of patients. In this study, we performed a comprehensive systematic review on articles appeared in the PubMed from 1998 to March 2008. We selected all papers addressing SWL or ureteroscopic management of the ureteral calculi in children and determined the level of evidence of the presenting data. Thirty-nine articles were reviewed and 24 with valid information on SWL or ureteroscopic management of the pediatric ureteral calculi were analyzed. Six articles (25%) were randomized controlled trials and 18 (75%) were retrospective case-controls or case series. The following data were extracted from the 24 articles: in SWL groups, overall success rate was 84.1% (range, 71% to 100%) for the upper ureteral calculi and 76.2% (range, 19% to 91%) for the lower ureteral calculi. Only 61% of the patients had only 1 treatment course, while 8% and 31% of the cases required 2 and more than 2 sessions of treatment, respectively. With ureteroscopic management, the overall success rates were 93.2% (range, 81% to 100%) and 74.4% (range, 20% to 100%) in the lower and upper ureteral calculi, respectively. The main limitations of the series on minimally invasive treatment of pediatric ureteral calculi are lack of powerful randomized controlled trials or prospective data and insufficient patient numbers. Therefore, it is difficult to draw absolute conclusions about successful treatment based on current knowledge.

Ureteroscopic management of upper tract transitional cell carcinoma and ureteropelvic obstruction

Introduction:Technological advances have increased the application of the endoscopic management of upper tract transitional cell carcinoma (TCC) and ureteropelvic junction obstruction (UPJO).Materials and Methods:Published, peer-reviewed articles on endoscopic treatment of upper tract TCC and UPJO were identified using the MEDLINE database.Results:Although nephroureterectomy remains the gold standard for upper tract TCC treatment, low-grade, low-stage and small tumors, especially in patients with solitary kidneys or poor renal function can be managed with encouraging success rates, despite the considerable recurrence rate. Endoscopic alternatives to pyeloplasty for UPJO can be used especially in cases with absence of crossing vessels, stricture length less than 1.5 cm, severe hydronephrosis and renal function less than 30%.Conclusion:Proper patient selection is critical for the successful endoscopic management of treatment of upper tract TCC and UPJO.

Prestenting Improves Ureteroscopic Stone-Free Rates

Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease. A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups. Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (17/36, 47%) or infection (13/36, 37%). Strict stone-free rates after ureteroscopic treatment were 47% in the 79 procedures without previous stents, compared with 67% in the 36 procedures with prestenting (P < 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54% v 78%, respectively (P < 0.02). Complications were not significantly different in the two groups (P = 0.70). Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases.

Is Ureteroscopy First Line Treatment for Pediatric Stone Disease?

We report our current outcomes for ureteroscopic management of pediatric stone disease. We carried out a retrospective review of all ureteroscopic procedures for kidney or ureteral calculi performed between 2001 and 2005. Stone location and size, preoperative and postoperative stenting, intraoperative dilation, use of ureteral access sheath, stone-free rates and complications were noted. A total of 100 patients (58% female, mean age 13.2 years) underwent 115 procedures. Stones were located in the renal pelvis in 6% of patients, upper pole in 10%, mid ureter in 11%, lower pole in 17%, proximal ureter in 19% and distal ureter in 37%. Mean stone size was 8.3 mm (median 7.0), with a mean of 1.5 stones per patient. Preoperative stenting was used in 54% of patients, and a stent was placed postoperatively in 76%. Ureteral coaxial dilators and ureteral access sheaths were used in 70% and 24% of patients, respectively. There were no major intraoperative complications, although 5 patients required stent placement for ureteral perforation or extravasation. One patient had a ureteral stricture requiring ureteral reimplantation. Mean followup was 10.1 months (median 2.6). Stone-free rate was 91% on followup ultrasound, abdominal radiography or computerized tomography. Seven patients required staged ureteroscopic procedures to achieve stone-free status. While the number of percutaneous nephrolithotomy and shock wave lithotripsy cases remained stable, the number of ureteroscopic cases increased 7-fold during this period. Improved ureteroscopic access to stones throughout the pediatric urinary tract and stone-free rates that are comparable to the adult population have led to the adoption of ureteroscopy as first line therapy in children at our institution.

936: The Ureteroscopic Management of Lower Pole Stones in a Pediatric Population

936: The Ureteroscopic Management of Lower Pole Stones in a Pediatric Population

“Blind Coning”—Using the Stone Cone for Removal of Intramural Ureteral Calculi

To describe the otherwise heretical technique of "blind" nonureteroscopic extraction of calculi from the intramural ureter using a 7-mm-diameter tapered coil called the "Stone Cone." After bypassing the stone and deploying the Stone Cone, slow traction was exerted. The Stone Cone's 5, 6, and 7-mm diameter coils and unique rotary action dilated the tunnel distal to the calculus and the 2, 3, and 4-mm stiffer coils caught the calculus and propelled it out of the transiently dilated intramural ureter. A safety feature is that the coils of the Stone Cone will unwind at greater than 0.2-lb tension. Unlike the baskets, if a pressure greater than this is encountered, the Stone Cone will release the stone, preventing entrapment. In selected cases, use of the Blind-Cone to remove an intramural calculus can be a rapid, effective, and safe alternative to ureteroscopic management.

Ureteroscopic Management of Patients with Upper Tract Transitional Cell Carcinoma

Objectives This paper reviews the indications, technique, and treatment outcomes for the ureteroscopic management of upper tract transitional cell carcinomas (UTTCCs). Methods The author reports on his experience and reviews of the most recent data published in the literature. Results The expanding experience with minimally invasive techniques to treat UTTCCs has demonstrated its safety and efficacy in selected patients. Diagnostic accuracy can be enhanced and pathologic confirmation of tumour grade and stage can be regularly obtained. In selected patients with unique, small tumours with low grade and low stage, the results of endoscopic management are encouraging. Patients with a functional solitary kidney, bilateral disease, or renal insufficiency can also be considered for conservative treatment. The patient must be willing to and capable of undergoing vigilant and frequent endoscopies during the follow-up. However, conservative management remains controversial in a patient with low-grade/low-stage disease and a normal contralateral kidney. Conclusions Ureteroscopic management of UTTCC is feasible and safe using, preferably, laser fulguration.

Emergency Ureteroscopic Management of Ureteral Stones: Why Not?

Objectives To describe a single-center experience in the emergency ureteroscopic management of ureteral stones. Methods We retrospectively considered the data from 144 patients (mean age 49.6 years, range 23 to 82) who had had obstructive ureteral stones and had undergone emergency ureteroscopy with stone retrieval. Intracorporeal pneumatic lithotripsy was performed when necessary. At the end of the procedure, a ureteral catheter was systematically left in place in 100 patients (69.4%) and removed within 24 hours. In the remaining 44 patients, a double- J stent was preferred and was removed within 30 days, depending on the clinical course. Stone-free status was defined as the complete absence of fragments at 1 month of follow-up. Results The calculi were more frequently localized in the distal ureter than in the proximal one (90.3% versus 9.7%, respectively). The overall mean stone diameter was 9.1 mm (range 5 to 20). The overall stone-free rate was 92.4%. A greater stone-free rate was obtained in those with stones less than 10 mm (95.8%) than in those with stones larger than 10 mm (89%, P = 0.002). Similarly, a significantly better outcome occurred for those with stones located in the distal ureter (94.6%) than for those with stones in the proximal one (71.4%, P = 0.004). The overall complication rate was 4.2%. The mean hospital stay was 2.5 days (range 1 to 7). Conclusions In our experience, emergency ureteroscopy in cases of obstructive ureteral stones proved to be safe and effective. It has the main advantage of offering both immediate relief from pain and stone fragmentation. Additional extensive studies are warranted to corroborate these findings.

Combined Electrohydraulic and Holmium:YAG Laser Ureteroscopic Nephrolithotripsy of Large (Greater Than 4 cm) Renal Calculi

Percutaneous nephrolithotripsy is standard treatment for renal calculi larger than 2 cm. Modern flexible ureteroscopes and accessories using the complimentary effects of electrohydraulic lithotripsy and holmium:YAG laser lithotrites can treat large (greater than 4 cm) branched renal calculi in a minimally invasive fashion with similar or superior results. This report is an assessment of the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of large (greater than 4 cm) branched renal calculi in the community setting. A total of 16 patients with 17 branched renal calculi ranging from 41 to 97 mm (mean 65) in length and 560 to 2,425 mm2 (mean 1,169) in area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (body mass index greater than 30) was present in 81% and 38% were morbidly obese (body mass index greater than 40). An infectious etiology was present in 81% and hard stone components were present in 94%. All patients presented with hematuria, pain and/or recurrent urinary tract infection. Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly electrohydraulic lithotripsy. Laser drilling was used (in 4) to weaken hard stones before electrohydraulic lithotripsy. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation. All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 15 of 17 renal units (88%) with a mean of 2.4 stages and 36 of 40 (90%) procedures performed on an outpatient basis. Operative time averaged 49 minutes per stage and 115 minutes per calculus. There were 3 patients admitted for fever and 1 patient (90 years old) admitted for pneumonia 3 days postoperatively. There were also 3 patients with calculi larger than 75 mm who required ureteroscopic management of steinstrasse. Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with percutaneous nephrolithotripsy.

UP-02.91: Treatment of distal ureteric stones: Comparing Dornier S II lithotriptor versus semi-rigid ureteroscopy

Advances in ureteroscopy (URS) and ongoing development in extracorporeal shock wave lithotripsy (ESWL) have resulted in a change in the balance of the use of these treatment modalities in the management of ureteric stones. We report our experience with a modern Lithotriptor set (Dornier S II) we have recently installed and compare treatment outcomes with our previous ureteroscopic management of similar stones.

MP-19.03: Retroperitoneoscopy for treatment of ureteral stones

Recent advances in ureteroscopic management of ureteral stones with laser lithotripsy and in situ extracorporeal shockwave has made open surgery infrequent. But patients with large impacted proximal ureteral stones still may be a challenge for urologists. Laparoscopic technique has opened up a therapeutic option for the management of such cases.