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PubMed1993

Extracorporeal shock wave lithotripsy in situ or after push-up for upper ureteral calculi: a prospective randomized trial.

A total of 110 patients with upper ureteral calculi was admitted to a prospective trial and randomly allocated to 2 groups: 1 group treated with in situ extracorporeal shock wave lithotripsy (ESWL) and 1 group treated with ureteral manipulation before ESWL. All patients had solitary upper ureteral calculi without urinary infection. The stones had to be smaller than 1 cm. and located more than 2 cm. lateral to the spine. ESWL was performed with the Dornier HM3 lithotriptor. One patient in the in situ ESWL group had to be treated twice because disintegration of the stone was insufficient after the initial treatment session. All other patients underwent only 1 treatment session. Because 16 patients were lost to followup, 94 were evaluable for the analysis of immediate and long-term results. For disintegration of the stones in situ ESWL needed significantly more shock waves (1,844 +/- 639 versus 1,297 +/- 473, p < 0.001) and a higher voltage (19.5 +/- 1.4 versus 18.7 +/- 0.9 kv., p < 0.001). There were no severe complications in either treatment group. At 3 months 44 of 46 patients (96%) after in situ ESWL and 45 of 48 (94%) after ureteral manipulation before ESWL were free of stones. In view of these results it is suggested that uncomplicated upper ureteral calculi (as defined previously) should be treated first with in situ ESWL, thus, avoiding an invasive procedure.

Adult↗
PubMed1993

Ureteroscopic treatment of lower ureteral calculi in the era of extracorporeal shock wave lithotripsy: from a developing country point of view.

In a series of 229 lower ureteral calculi manipulated with either extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy the stone clearance rate 7 days after treatment was 40.6% and 90%, respectively. Only 17 of 32 patients (53.1%) treated with ESWL were rendered stone-free at 4-week followup. In addition to concern about stone clearance, other medical and social factors, and the availability of health insurance coverage must be considered. Since the differences of living standards between highly developed and developing countries are great, the selection of ESWL or ureteroscopy as primary treatment of lower ureteral calculi must be based on the socioeconomical status of a specific country. Because ESWL devices are not readily available in most developing countries and ureteroscopy is cost-effective, highly efficacious (greater than 92%) and involves minimal morbidity (less than 10%) for calculi removal in experienced hands, we recommend ureteroscopy as the treatment of choice for lower ureteral stones, with ESWL as the alternative, in developing countries.

Adult↗
PubMed1992

Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy.

Percutaneous nephrostolithotomy with or without extracorporeal shock wave lithotripsy (ESWL) has been extensively used in the management of staghorn calculi, with stone-free rates varying from 23 to 86%. Explanations for the variability of such results include differences in stone burden, differences in percutaneous techniques and an overreliance on ESWL. The results and changing trends in the relative roles of percutaneous nephrostolithotomy and ESWL in the management of staghorn calculi at the Methodist Hospital of Indiana were examined. We reviewed 343 cases of staghorn calculi (partial and complete) with adequate followup data, which were managed with initial percutaneous nephrostolithotomy. Cases were divided into 2 groups: group 1 (252 cases) from 1984 to 1987 when access was performed by a radiologist and group 2 (91 cases) from 1988 to 1990 when access was performed by a urologist. Although stones in group 2 tended to be larger, a decreasing dependence on ESWL was noted (64.7% in group 1 compared to 35.2% in group 2, p less than 0.001). Despite the larger stone size in group 2, stone-free rates were similar (83.3% in group 1, 86.8% in group 2). In groups 1 and 2 percutaneous nephrostolithotomy alone achieved stone-free rates of 91% and 91.5%, respectively. The stone-free rate with the combination approach was 79.1% and 78.1% in groups 1 and 2, respectively. Technical refinements with percutaneous nephrostolithotomy in group 2 include accurate and carefully selected accesses (superior pole in 36.3%) for best approach to the stone, multiple accesses (13.3%) and improved skills in flexible nephroscopy. Blood transfusion has not been required in group 2 compared with 11.1% in group 1. Mean hospital stay was 12.4 days in group 1 and 10.3 days in group 2 (percutaneous nephrostolithotomy alone, 7.2 days). With careful attention to percutaneous nephrostolithotomy techniques, complex renal stones can be successfully managed endourologically, reducing the need for combination ESWL. Complications previously associated with percutaneous nephrostolithotomy have decreased.

Combined Modality Therapy↗
PubMed1992

Extracorporeal shock wave lithotripsy of radiolucent urinary calculi using the Siemens Lithostar Plus.

Between October 1989 and June 1991, 1,250 patients with urinary calculi were treated at our institution using the Siemens Lithostar. A total of 17 patients (1.37%) with radiolucent or slightly opaque calculi underwent lithotripsy with the Lithostar Plus, which has an overhead electromagnetic generator module and a localization system composed of a real-time on-line 3.5 mHz. ultrasound transducer. The stones were located in the calices in 52.9% of the cases, renal pelvis in 17.7%, ureter in 23.5% and bladder in 5.9%. Followup consisted of a nephrotomogram or ultrasound 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 76.4% of the cases after 3 months. Retreatment was necessary in 23.5% of the cases. All treatments were performed without anesthesia and hospitalization. Complications were present in 11.8%; perirenal hematoma was noted in 1 patient but this resolved spontaneously within a few days and the same occurred in 1 patient with renal pain. Extracorporeal shock wave lithotripsy using the Lithostar Plus proved to be an effective noninvasive procedure to treat radiolucent and slightly opaque urinary calculi. However, since the Lithostar Plus has a higher power setting, care must be taken to avoid damage with the use of high energy.

Adult↗
PubMed1992

Treatment strategy for piezoelectric shock wave lithotripsy of upper ureteral calculi.

In situ piezoelectric lithotripsy monotherapy for upper ureteral stones is an attractive option because it can be conducted on an outpatient basis. Difficulty in calculus localization with ultrasound is the limiting factor. We reviewed our experience with 99 patients treated for upper ureteral calculi with the EDAP LT.01 lithotriptor. For stones above the lower renal border we achieved a 53% stone-free rate compared to 25% for calculi below the lower renal border. In situ piezoelectric lithotripsy of upper ureteral calculi may be considered for stones above the lower renal border.

Adolescent↗
PubMed1991

Treatment options for ureteral calculi: endourology or extracorporeal shock wave lithotripsy.

Two therapeutic methods, endourology and extracorporeal shock wave lithotripsy (ESWL), can be used in the treatment of ureteral calculi. In a retrospective analysis during a 2-year period 236 patients treated with endourological procedures and 71 who underwent ESWL with a Siemens Lithostar were analyzed as to the success rate, effectiveness quotient, complication rate and hospitalization. The mean stone size was 1.12 cm. in the endourology group and 1.03 cm. in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated endourologically and without retreatment. In the ESWL group success was obtained in 90.1%, with an 11.2% retreatment rate. The retreatment rate was higher (25.0%) for calculi in the mid ureter. The group treated endourologically had a better success rate and no retreatment was necessary. On the other hand, the group treated with ESWL had a shorter hospitalization and a lower complication rate. Followup ranged from 11 to 60 months (mean 48 months) in the endourology group and 7 to 29 months (mean 11 months) in the ESWL group. These observations showed that in situ ESWL therapy with the Siemens Lithostar device is the method of choice for upper ureteral stones. Lower ureteral calculi should be treated endoscopically. Mid ureteral stones larger than 1 cm. had better results with endoscopic procedures and those smaller than 1 cm. had better results with ESWL.

Adolescent↗
PubMed1991

Extracorporeal shock wave lithotripsy in combination with transurethral surgery for management of large bladder calculi and moderate outlet obstruction.

In 5 men evaluated for symptoms of obstructive voiding flexible cystoscopy revealed large or multiple bladder calculi along with small to moderate prostatic enlargement. All patients had successful localization and fragmentation of calculi with the Dornier HM3 lithotriptor. Of these patients 4 underwent transurethral resection or incision of the prostate under the same epidural anesthesia for moderate prostatic obstruction without complication and 1 subsequently required suprapubic prostatectomy of a gland with a large middle lobe that made a transurethral operation difficult. Extracorporeal shock wave lithotripsy should be considered for the primary management of large or hard bladder calculi and it is of particular value in combination with a transurethral operation for patients with small to moderate prostatic obstruction.

Combined Modality Therapy↗
PubMed1991

Retrograde nephrostolithotomy in management of complex renal calculi.

From October 1986 to July 1990 we evaluated 22 patients with complex renal calculi in 25 kidneys for initial therapy using retrograde percutaneous nephrostolithotomy. In 3 patients we could not attain renal access in a retrograde fashion. In the remaining patients residual fragments after percutaneous nephrostolithotomy were treated with a combination of extracorporeal shock wave lithotripsy (ESWL), chemolysis and retrieval of small calculi with a flexible nephroscope. Successful treatments were achieved in 6 of the 22 kidneys (27%) using percutaneous nephrostolithotomy alone and in 17 (77%) using all modalities. Retrograde and antegrade percutaneous nephrostolithotomy in conjunction with ESWL, chemolysis and flexible nephroscopy in the treatment of patients with complex calculi yield comparable success rates. However, retrograde percutaneous nephrostolithotomy can be performed without the aid of an interventional radiologist and it provides easy access to the nondilated collecting system.

Adult↗
PubMed1991

Endoscopic laser lithotripsy: safe, effective therapy for ureteral calculi.

At our lithotripsy department more than 400 patients with renal or ureteral calculi have been treated with a pulse-dye laser for stone disease. We review our experience during an 11-month period when a total of 223 patients was treated. Of these patients 204 whose ureteral calculi were treated by laser lithotripsy are available for followup. The data in this series demonstrate that a miniaturized ureteroscopic system is of paramount importance in laser lithotripsy, allowing access into the ureter without dilation in the majority of patients (165 of 204). Lack of dilation is associated with a decrease in pain and postoperative hospitalization. Satisfactory stone fragmentation was accomplished in 198 of 204 procedures in this series with use of the laser alone. A low complication rate was observed. Endoscopic laser lithotripsy is a safe, reliable and cost-effective method of therapy for ureteral calculi in a community hospital setting.

Endoscopes↗
PubMed1989

Extracorporeal shock wave lithotripsy treatment of calculi in horseshoe kidneys.

From June 1985 to November 1986, 17 patients with calculi in horseshoe kidneys presented to our hospital for evaluation and possible treatment with extracorporeal shock wave lithotripsy. Of these patients 14 were treated with extracorporeal shock wave lithotripsy; the calculi in 2 could not be localized and focused at the F2 focal point, and 1 was asymptomatic and has been followed conservatively. Four patients required repeat extracorporeal shock wave lithotripsy. Adjunctive procedures included preoperative retrograde catheter placement (5 patients), postoperative percutaneous nephrostolithotomy (1), ureteroscopy for ureteral fragments (2) and placement of a double pigtail stent (1). Of 14 patients 11 (79 per cent) have been rendered free of fragments with extracorporeal shock wave lithotripsy and adjunctive measures as needed. We conclude that most patients with calculi in a horseshoe kidney can be managed primarily with extracorporeal shock wave lithotripsy.

Adult↗
PubMed1988

Bladder calculi in women after urethrovesical suspension.

There have been a number of reports recently on vesical calculi in women with a history of gynecological procedures. Within 1 year we encountered 2 patients with vesical calculi after vesicourethral suspension performed with concomitant hysterectomy. These calculi formed on a retained intravesical suture and a monofilament knitted polypropylene pledget, and they produced interesting pathological and radiographic findings.

Adult↗
PubMed1987

Extracorporeal shock wave lithotripsy of caliceal diverticula calculi.

We reviewed 10 patients with calculi in caliceal diverticula to determine whether they could be treated successfully by extracorporeal shock wave lithotripsy. Of the patients 7 required 1 and 3 required 2 treatment attempts to fragment the calculi completely. After a minimum followup of 3 months (mean 5.9 months) 2 patients (20 per cent) had passed successfully all of the stone fragments, while 3 (30 per cent) had passed more than half and 5 (50 per cent) had passed less than half of the fragments. Of the 8 patients with residual fragments only 3 had persistent symptoms indicating that symptom relief is not dependent on complete stone removal. The possibility of producing a satisfactory result (70 per cent free of symptoms) and the low morbidity of extracorporeal shock wave lithotripsy suggest that this treatment may be appropriate for calculi in caliceal diverticula.

Adult↗
PubMed1987

Kinetics of dissolution of calcium oxalate calculi with calcium-chelating irrigating solutions.

Dissolution of calcium oxalate urinary calculi was studied in vitro. Rate constants were calculated by measuring the concentration of calcium in solution during dissolution. Various irrigating agents, including ethylenediaminetetraacetic acid (EDTA) and other calcium-chelating substances, were tested at different concentrations and pH values. EDTA was the most effective agent in dissolving calcium oxalate calculi. When EDTA was used, the rate of dissolution depended on both concentration and pH. At a pH of 7.5 or 10.0, the rate of dissolution increased progressively with the EDTA concentration. At each concentration tested, dissolution was faster at a pH of 10.0 than at a pH of 7.5. Calculated rate constants were extrapolated to determine whether in vivo irrigation with EDTA solutions is clinically practical. Even at an EDTA concentration of 0.03 M at a pH of 7.5, a two mm. calculus could be dissolved within 48 hr. Although dissolution of calcium oxalate calculi is not a practical first-line treatment, it might be a useful adjunct to percutaneous stone removal or extracorporeal shock wave lithotripsy.

Calcium Oxalate↗
PubMed1986

In vitro dissolution of cystine urinary calculi.

Dissolution of cystine urinary calculi was studied in vitro. Sodium hydroxide, acetylcysteine and tris(hydroxymethyl)aminomethane (tromethamine) were tested for effectiveness in dissolving cystine calculi. Calculi were mounted in a dissolution apparatus. Dissolution rates were calculated from the amount of cystine released into solution per unit time and were compared with linear regression techniques. Calculated dissolution rates of all the irrigating agents tested were similar at a pH of 7.5 and were significantly different at pH 10.0. The most effective agent in the promotion of cystine dissolution was 2 per cent acetylcysteine. Sprague-Dawley rats were used to test the effect of 2 per cent acetylcysteine, 0.3 molar tromethamine and 2 per cent acetylcysteine mixed with 0.3 molar tromethamine on the urothelium. A nephrostomy tube was placed in the left kidney of each rat. The kidneys were irrigated for 3 days with either 2 per cent acetylcysteine, 0.3 molar tromethamine or 2 per cent acetylcysteine mixed with 0.3 molar tromethamine. The rats then were sacrificed at various intervals after infusion. Irrigation with 2 per cent acetylcysteine at a pH of 10 caused an acute inflammatory response at 3 days that was healed almost completely in 4 weeks. The addition of tromethamine to the acetylcysteine did not prevent the inflammatory response.

Acetylcysteine↗
PubMed1986

Methodology for endoscopic treatment of ureteral calculi.

The records of 27 patients undergoing endoscopic treatment of ureteral calculi were reviewed. The percutaneous nephrostomy approach was used for calculi located above the iliac vessels, while the transurethral approach was used for those below the iliac vessels. The success rates achieved for these calculi were 82.3 and 90.0 per cent, respectively. Endoscopic treatment has proved to be safe and effective in patients with ureteral stones.

Adult↗
PubMed1985

Ureolytic Citrobacter freundii infection of the urine as a cause of dissolution of cystine renal calculi.

We report a case of cystinuria with staghorn renal lithiasis in a solitary right kidney and chronic renal failure. Right nephropyelolithotomy was performed and although 29 renal calculi were extracted many stones remained in situ. A permanent nephrostomy was left in the kidney. Several months later the urine was infected chronically with a ureolytic Citrobacter freundii bacteria and urinary pH oscillated between 8.0 and 9.2. Spontaneous dissolution of the cystine calculi was observed and many tiny fragments of cystine were expulsed through the nephrostomy, following which renal function improved. Despite the conditions favoring struvite calculi, formation did not occur.

Citrobacter↗
PubMed1984

Dissolution kinetics of uric acid calculi.

Dissolution of uric acid calculi was studied in vitro. Calculated rate constants were then applied to an in vivo situation. The time required for complete dissolution of a uric acid calculus in a patient on oral alkali therapy can be estimated. Sodium bicarbonate, acetylcysteine, [tris(hydroxymethyl)aminomethane] and [tris(hydroxymethyl)aminomethane]-E were tested for relative effectiveness in dissolving uric acid calculi in vitro. In patients who require irrigation for dissolution of uric acid calculi [tris(hydroxymethyl)-aminomethane] is the preferred agent.

Acetylcysteine↗
PubMed1983

Bladder calculi enveloped by extensive cystitis glandularis: case report.

We report a case of 2 large calculi encased within a 15 gm. tumor of cystitis cystica and cystitis glandularis. The patient presented with acute right epididymitis. An excretory urogram showed 2 bladder calculi. Cystoscopy revealed a mass around the stones resembling adenocarcinoma of the bladder base. Transurethral resection of the tumor and cystolitholapaxy were performed. The final diagnosis was bladder calculi within a mass of cystitis cystica and cystitis glandularis. A review of the literature failed to reveal a similar case.

Adult↗