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PubMed2005

Therapeutic options for proximal ureter stone: extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium:yttrium-aluminum-garnet laser lithotripsy.

OBJECTIVES: To compare the safety and cost-effectiveness of ureterorenoscopic holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy (URSL) with extracorporeal shock wave lithotripsy (ESWL) for proximal ureteral stones. METHODS: This investigation assessed 220 patients with upper ureteral stones. Those in the ESWL group were treated on an outpatient basis using the Medispec Econolith 2000 (Medispec, Germantown, MD) under intravenous sedation. URSL was performed with a 6/7.5F semirigid tapered ureterorenoscope and holmium:YAG laser under spinal anesthesia on an inpatient basis. A successful outcome was defined as the patient being stone free on radiography 1 month after treatment. The stone size, success rate, postoperative complications, and cost were evaluated in each group. RESULTS: A total of 220 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. The mean stone burden +/- SD was 58.7 +/- 3.1 mm2 in the ESWL group and 108.4 +/- 10.0 mm2 in the URSL group (P = 0.000). The accessibility of the semirigid ureterorenoscope for upper ureteral stones was 98.1% (101 of 103), and the stone-free rate achieved after one treatment was 83.2% (84 of 101). The initial stone-free rate of in situ ESWL was 63.9% (76 of 119). Significantly, the initial stone-free rate of the URSL group was superior to that of the ESWL group (P = 0.001). The average cost in the URSL group appeared to be lower than that in the ESWL group (P = 0.000). CONCLUSIONS: The results of this study have demonstrated that URSL achieved excellent results for upper ureter calculi. In terms of cost and effectiveness, this procedure should be the first-line therapy for proximal ureter stones.

Costs and Cost Analysis↗
PubMed2003

Retrograde intrarenal lithotripsy outcome after failure of shock wave lithotripsy.

PURPOSE: We report our experience with retrograde intrarenal lithotripsy (RIRL) for renal stones not alleviated by shock wave lithotripsy (SWL). MATERIALS AND METHODS: A total of 28 females and 53 males with a mean age of 53 years (range 18 to 86) were studied. They had been treated with a mean of 3.2 previous SWLs. Mean stone size was 9.2 mm (range 4 to 22) and the mean number of stones per patient was 1.27 (range 1 to 5) for a total of 103 stones overall. In 70 patients there was 1 stone. Rigid and flexible ureteroscopes were used in 8 and 67 cases, respectively, while a combined approach was used in 6. A holmium:YAG laser was used for fragmentation in 52 patients. Success was defined as stone-free status or residual fragments less than 3 mm. RESULTS: The overall success rate was 67%. RIRL yielded a 46% stone-free rate. Of the 44 patients 17 (39%) had residual stones less than 3 mm, while 13 required ancillary procedures. There were no residual ureteral stones. Original stone size correlated inversely with the success rate. Most failures involved lower pole stones, in that laser fiber deflection prevented reaching them in 9 cases. The procedure was interrupted due to extravasation or bleeding in 5 patients and 6 had postoperative urinary tract infections (16% overall complication rate). CONCLUSIONS: RIRL effectively and safely alleviated upper tract stones unresponsive to earlier SWL. It can be considered salvage therapy in such cases. RIRL is well suited for treating stones less than 2 cm with better stone-free rates than SWL in the same circumstances. Residual stones were more likely in lower pole cases.

Adolescent↗
PubMed2004

Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal ureteral stones.

PURPOSE: Management of large impacted upper ureteral calculi remains challenging for urologists. These calculi are frequently associated with obstructive uropathy and deteriorated renal function. Extracorporeal shock wave lithotripsy (SWL) is the least invasive treatment but its success rate is decreased for large impacted upper ureteral calculi. According to the American Urological Association guidelines on ureteral stones published in 1997, the appropriateness of ureteroscopy decreases when stone size exceeds 1 cm. However, the application of advanced ureteroscopy and techniques has increased the success rate of treating proximal ureter calculi. In this study we compared the safety and efficacy of ureterorenoscopic holmium:YAG laser lithotripsy (URSL) with SWL for large impacted proximal ureteral stones. MATERIALS AND METHODS: This study evaluated 82 patients with large impacted upper ureteral stones. Two patients were excluded from study owing to conversion to open surgery. SWL and URSL were performed in 41 and 39 patients, respectively. Those in the SWL group were treated on an outpatient basis with Medispec Econolith 2000 (Medispec, Germantown, Maryland) under intravenous sedation. The URSL was performed with a 6/7.5Fr semirigid tapered ureterorenoscope and holmium:YAG laser with the patient under spinal anesthesia on an inpatient basis. Successful outcome was defined as the patient being stone-free on radiography 1 month after treatment. Stone size, success rate, postoperative complications and cost were analyzed in each group. RESULTS: A total of 80 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. Mean stone size +/- SD was 1.28 +/- 0.04 cm in the SWL group and 1.51 +/- 0.05 cm in URSL group (p = 0.0009). Accessibility of the semirigid ureterorenoscope for impacted upper ureteral stones was 95.1% (39 of 41) and the stone-free rate achieved after 1 sitting was 92% (36 of 39). The initial stone-free rate of in situ SWL was 61% (25 of 41). Notably, the initial stone-free rate in the URSL group was better than that of the SWL group (p = 0.003). The efficiency quotient was 0.53 for URSL and 0.59 for SWL. The average cost in the URSL group appears to be lower than in the SWL group. Both groups were free of major complications. CONCLUSIONS: This study demonstrated that URSL achieved excellent results for upper ureteral calculi greater than 1 cm. Thus, this procedure should be considered first line therapy for large proximal ureteral stones.

Equipment Design↗
PubMed1997

Fluoroscopically guided laser lithotripsy versus extracorporeal shock wave lithotripsy for retained bile duct stones: a prospective randomised study.

BACKGROUND AND AIMS: To compare extracorporeal shock wave lithotripsy (ESWL) and laser induced shock wave lithotripsy (LISL) of retained bile duct stones to stone free rate, number of therapeutic sessions, and costs. PATIENTS: Thirty four patients were randomly assigned to either ESWL or LISL therapy. The main reasons for failure of standard endoscopy were due to stone impaction (n = 12), biliary stricture (n = 8), or large stone diameter (n = 14). METHODS: An extracorporeal piezoelectic lithotripter with ultrasonic guidance and a rhodamine 6G laser with an integrated stone tissue detection system were used. LISL was performed exclusively under radiological control. RESULTS: Using the initial methods complete stone fragmentation was achieved in nine of 17 patients (52.4%) of the ESWL group and in 14 of 17 patients (82.4%) in the LISL group, or combined with additional fragmentation techniques 31 of the 34 patients (91.2%) were stone free at the end of treatment. In comparison LISL tended to be more efficient in clearing the bile ducts (p = 0.07, NS). Significantly less fragmentation sessions (1.29 v 2.82; p = 0.0001) and less additional endoscopic sessions (0.65 v 1.6; p = 0.002) were necessary in the LISL group. There were no major complications in either procedure. CONCLUSIONS: Compared with ESWL, fluoroscopically guided LISL achieves stone disintegration more rapidly and with significantly less treatment sessions, which leads to a significant reduction in cost.

Adult↗
PubMed1998

Outpatient treatment of middle and lower ureteric stones: extracorporeal shock wave lithotripsy versus ureteroscopic laser lithotripsy.

The aim of this retrospective study was to evaluate the efficacy of ureteroscopic lithotripsy (URSL) and extracorporeal shock wave lithotripsy (ESWL) in the treatment of middle and lower ureteric stones. From January 1996 to March 1997, 61 patients treated by URSL and 49 patients treated by ESWL were studied, both were conducted as outpatient procedures. URSL using Holmium laser and semirigid ureteroscope (Fr.8.5) performed under general anaesthesia had single session stone clearance rates of 100% and 95% for middle and lower stones respectively. There were 6 complications including 5 readmissions (2 febrile episodes, 2 severe pain spells, and 1 stent migration) and 1 stricture formation. ESWL using the Dornier MFL 5000 lithotriptor had a single session success rate of 51% and overall success rate of 78% after retreatment (retreatment rate 35%). No significant complication or readmission was noted. Seventy-two per cent of patients required intravenous fentanyl for pain control. The efficiency quotients calculated for the URSL group and the ESWL group were 97% and 58% respectively. In summary, in the treatment of middle and lower ureteric calculi, ESWL carries reasonable success rate, especially with retreatment; and minimal morbidity. On the other hand, URSL is highly effective in rapidly clearing the stones, a low risk of complication is noted. Both can be conducted as an outpatient treatment modality.

Adult↗
PubMed1995

Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones. A prospective randomized trial.

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2006

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopic lithotripsy for management of large upper third ureteral stones.

OBJECTIVES: To conduct a prospective and randomized trial to compare the efficiency quotient and cost-effectiveness index of shock wave lithotripsy (SWL) and ureteroscopic lithotripsy (URSL) for the treatment of large upper third ureteral stones. METHODS: A total of 35 male patients and 7 female patients with a solitary, radiopaque upper ureteral stone, 15 mm or more in diameter, who underwent SWL or URSL were enrolled in this study. The mean patient age was 53.1 +/- 14.5 years. The endpoint of the study was for the patient to be stone free or to have insignificant residual stone (3 mm or less) within the kidney. RESULTS: The mean stone length +/- SD was 17.9 +/- 3.9 cm in the SWL group and 18.5 +/- 2.9 cm in the URSL group (P > 0.05). The efficiency quotient for SWL and URSL was 0.61 and 0.63, respectively. The cost-effectiveness index, treatment time, pain score, and hospital stay were greater in the URSL group. However, the degree of hydronephrosis significantly influenced the success rate of SWL. All patients with severe hydronephrosis in the SWL group needed auxiliary surgical procedures to become stone free. CONCLUSIONS: The efficiency quotients of SWL and URSL were comparable in the treatment of large upper third ureteral stones. However, SWL should not be recommended as the first-line treatment option for the management of upper third ureteral stones larger than 1.5 cm with severe hydronephrosis. Understanding the cost-effectiveness, success rate, pain score, and patient satisfaction score for the two different approaches constitutes the indispensable requisites for choosing the optimal first-line therapeutic strategy.

Cost-Benefit Analysis↗
PubMed2002

Extracorporeal shock wave lithotripsy of pancreatic duct stones using the Healthtronics LithoTron lithotriptor and the Dornier HM3 lithotripsy machine.

PURPOSE: Pancreatic duct stones, which are most often a result of alcohol induced chronic pancreatitis, can lead to chronic abdominal pain, pseudocysts, and exocrine and endocrine failure of the pancreas. Others have reported success using extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for pancreatic stones. We report our experience with pancreatic ESWL using the LithoTron (Healthtronics, Marietta, Georgia) and HM3 (Dornier) lithotripsy machines. MATERIALS AND METHODS: We performed pancreatic ESWL in 23 patients in 4 years, including in 12 with the LithoTron and in 11 with the HM3. After ESWL endoscopic retrograde cholangio-pancreatography (ERCP) was performed in all cases. Stone-free status was defined as no stone fragments visualized or the elimination of all post-ESWL stones by ERCP. RESULTS: Stone-free status was documented in 83% and 82% of patients treated with the LithoTron and HM3, respectively, and 2 per group later required open surgical intervention. There were no changes in pancreatic enzymes and no cases of sepsis or fever after ERCP. CONCLUSIONS: In association with post-procedure ERCP pancreatic ESWL is an effective and safe procedure that enables patients with obstructing pancreatic duct stones recalcitrant to primary endoscopic extraction to avoid a potentially morbid open procedure. The HM3 and LithoTron have comparable efficacy and safety. This modality is particularly effective for a stone aggregate of less than 20 mm., while a larger stone burden of greater than 20 mm. in aggregate and multiple stones are clear risk factors for treatment failure.

Adult↗
PubMed2003

Prospective study of the effects of shock wave lithotripsy on renal function: role of post-shock wave lithotripsy obstruction.

OBJECTIVES: To examine the effects of transient post-shock wave lithotripsy (SWL) obstruction on renal function after SWL application for treatment of renal stones in nonobstructed kidneys. METHODS: One hundred consecutive patients with unilateral renal stones were treated by SWL monotherapy. They had a normal laboratory profile and no or controlled urinary tract infection. The urinary tract was radiologically normal. Technetium-99m mercaptoacetyltriglycine and Doppler ultrasonography were performed for all cases a few days before and 1 week and 3 months after SWL. Renal uptake, time to peak clearance, split renal function, effective renal plasma flow, and resistive index were obtained. Patients were stratified into two groups. Group 1 consisted of patients with normal kidneys before SWL and unobstructed kidneys after SWL (n = 84). Group 2 consisted of patients with normal kidneys before SWL that were obstructed 1 week after SWL (n = 16). RESULTS: In group 1, there was a gradual increase in the effective renal plasma flow that became significant after 3 months, up to 114% of the pretreatment levels (P = 0.008). The glomerular filtration rate was stable 1 week after SWL and had increased significantly after 3 months, up to 110% of the pretreatment levels (P = 0.006). In group 2, there was marked deterioration of the effective renal plasma flow and glomerular flow rate to 50.5% (P = 0.002) and 45.8% (P = 0.001), respectively, of the pretreatment levels. These levels returned to the basal levels after 3 months. No significant changes occurred in the resistive index in both groups. CONCLUSIONS: Extracorporeal shock wave lithotripsy has no deleterious effects on the renal function. Post-SWL obstruction, although transient, has a major effect on the renal function on the treated side and must be managed urgently.

Adult↗
PubMed1988

Endotoxemia in patients who underwent ultrasonic lithotripsy and extracorporeal shock wave lithotripsy.

The authors conducted limulus tests of assay blood endotoxin in order to study the fever which often develops after ultrasonic lithotripsy (USL) and extracorporeal shock wave lithotripsy (ESWL). Assays of endotoxin were also conducted after transurethral resection (TUR) and other operations as a basis for comparison. Endotoxemia was observed in 18 among 28 patients (64.3%) who underwent USL, in 8 among 34 patients (23.5%) who underwent ESWL, in 1 among 14 patients (7.1%) who underwent TUR and in 1 among 11 patients (9.1%) who underwent other operations. The incidence of endotoxemia was significantly higher (p less than 0.01 by chi 2 test) in patients who had undergone USL than in those who had undergone ESWL, TUR or other operations.

Endotoxins↗
PubMed2001

[Percutaneous kidney lithotripsy. Clinical course, indications, and current methodology in our Lithotripsy Unit].

OBJECTIVE: To review the history, development, indications and current methods of percutaneous renal lithotripsy. METHODS: The history and development of PNL is briefly reviewed. Its indications are analyzed, starting with large calculi and covering all the indications over the last 15 years of development of this technique and its current use. The PNL technique currently performed in our Lithotripsy Unit is described step by step. Technical details, equipment, instruments, complications and solutions are discussed. RESULTS/CONCLUSIONS: In our view, PNL continues to be the technique of choice for most of the calculi that are more than 2 cm in size. It is fundamental for the new generation of urologists to be familiar with all endourologic techniques since current technological advancements will allow us to perform procedures throughout the urinary tract using endoscopic methods.

Equipment Design↗
PubMed2003

Treatment of lower urethral calculi with extracorporeal shock-wave lithotripsy and pneumatic ureteroscopic lithotripsy: a comparison of effectiveness and complications.

OBJECTIVE: To determine the efficacy and incidence of complications of extracorporeal shock-wave lithotripsy (ESWL) compared with pneumatic ureteroscopic lithotripsy (URSL) in the treatment of lower uretheral calculi. METHODS: From August 1997 to June 1999, 210 patients with lower ureteric calculi were treated with ESWL and the other 180 with URSL. The stones were fragmented with pneumatic lithotripter. The outcome was assessed by evacuation, retreatment and complication rates. RESULTS: ESWL for lower ureteric calculi resulted in a stone evacuation rate of 78.1%, compared with 93.3% for URSL (P < 0.05). ESWL had a retreatment rate of 11.9% and a perforation rate of 0, while URSL caused perforation of ureters in 3.3% of patients and a refreatment of 2.2%. CONCLUSION: For the management of lower ureteric calculi, ESWL provides a non-invasive, simple and safe option, and URSL has a higher stone evacuation rate but causes ureter perforation more frequently than ESWL does. Both ESWL and URSL have their respective advantages. It is recommended, however, that URSL be extensively developed for better treatment efficacy, given that the operator has an adequate technical background.

Adolescent↗
PubMed2004

Percutaneous ultrasonic lithotripsy (PUL) after shock wave lithotripsy (SWL) failure.

OBJECTIVE: Shock wave lithotripsy (SWL) is an attractive initial treatment for nephrolithiasis. Unfortunately, a significant number of stones are resistant to SWL therapy and require subsequent percutaneous ultrasonic lithotripsy (PUL) for definitive treatment. Our objective was to determine if previous SWL had adverse effects on PUL success and if there were differences between the patients undergoing primary PUL and those undergoing PUL after SWL failure. MATERIALS AND METHODS: In 2001, 108 PULs were performed at our institution, of which 40 (37%) were performed after SWL failure. Stone location, anesthesia time, stone composition and size, and complication rates were compared between patients who had PUL alone and those who underwent PUL after SWL failure. Anesthesia time was considered a reflection of technical difficulty of the case. RESULTS: Stone composition differed between the SWL failure and primary PUL groups. Cystine stones were found to be more common in the ESWL failure group and calcium oxalate monohydrate stones more common in the primary PUL group. There was not a statistically significant difference in stone size, anesthesia time or complication rates, between the PUL alone and PUL after SWL failure groups. CONCLUSION: PUL remains a reliable and safe treatment of nephrolithiasis. Prior SWL does not affect efficacy, technical difficulty, or postoperative complications of subsequent PUL. Based on our data, prior SWL should not be considered a negative factor in PUL outcomes. Stone composition should be considered a prognostic indicator of SWL failure and alert the surgeon that primary PUL may be indicated.

Adolescent↗
PubMed1991

Successful removal of massive intragastric gallstones by endoscopic electrohydraulic lithotripsy and mechanical lithotripsy.

We describe a case of massive gallstones discharged into the stomach through a cholecystoduodenal fistula and the successful removal of these stones by endoscopic electrohydraulic lithotripsy (EEHL) and endoscopic mechanical lithotripsy (EML) for the prevention of gallstone ileus. A 60-yr-old woman was admitted with epigastric pain and nausea. Upper gastrointestinal tract examination demonstrated backflow of contrast medium from the duodenal bulb into the gallbladder. Endoscopic examination revealed a large fistula on the anterior wall of the duodenal bulb, and two brown stones (about 3 cm in diameter) were found in the stomach. To prevent gallstone ileus, removal of these stones was attempted. They were broken into pieces by EEHL, then crushed into smaller pieces by EML and removed orally. Chemical analysis showed the composition of the gallstones to be at least 98% cholesterol. The patient was discharged one month after removal of the gallstones and has remained asymptomatic.

Biliary Fistula↗
PubMed1990

[Analgesia in extracorporeal shock wave lithotripsy. Experience with a lithotripsy apparatus made in Czechoslovakia].

The authors describe their experience with the use of analgesia during lithotripsy by an extracorporeal impulse wave (LERV). They made a total of 253 lithotripsies in various indications in a total of 150 patients. Most frequently ataracoanalgesia was administered (a combination of diazepam and phentanyl), however, administration of midazolam (Dormicum) is also adequate. This is due among others to the favourable physical properties of the impulse waves generated by the apparatus used. In the discussion the authors give a brief account of the causes of painfulness of LERV, based on contemporary ideas and experience.

Analgesia↗
PubMed1989

[The treatment of coralliform kidney calculosis with extracorporeal lithotripsy, percutaneous lithotripsy and ureteroscopy].

Experience is recorded with the combined treatment of 53 patients with coralliform renal calculosis. Combined application of bypass lithotripsy (BLT), percutaneous lithotripsy (PLT) and ureterorenoscopy (URS) is an alternative to open surgical intervention. Depending on the size, form and position of the calculus, the degree of destruction of the residual concrements, combined therapy was applied, as follows: 17 patients--PLT and BLT, 7 patients--PLT, BLT and URS, 7 patients--URS and BLT, 13 patients--BLT and URS, 8 patients--BLT and URS. Very good results were obtained--complete cure in 51 patients (96.2 per cent), which encourage the authors to recommend the three methods for routine application in the treatment of coralliform renal calculosis.

Adolescent↗