|Year : 2003 | Volume
| Issue : 1 | Page : 23-27
Management of proximal ureteral stones - comparison of outpatient ureterolithotripsy with in-situ shock wave lithotripsy (SWL)
Harbans Singh, Vipul Tandon, US Dwivedi, Mufti Mahmood, Arif Hamid, Gopi Kishore, PB Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
P B Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The aim of this study is to review the feasibility and effectiveness of ureteroscopy with intracorporeal lithotripsy under intravenous sedation on outpatient basis as a primary procedure in patients with proximal ureteral calculi and its comparison with in situ SWL.
Methods: From January 2000 to December 2001, 56 patients with proximal ureteral calculi underwent ureterolithotripsy and 32 patients underwent in situ shock wave lithotripsy (SWL). Ureterolithotripsy was performed with 8.0 Fr Wolf rigid ureteroscope and Swiss Lithoclast on daycare basis.
Results: In patients managed with ureterolithotripsy, stone was successfully reached and fragmented in 47(83.93%) patients. Complete stone fragmentation and spontaneous passage occurred in 40 (71.4%)patients with single session. Seven (12.5%) patients required more than one session for complete clearance. JJ stent was required in 13(23.2%) patients. One case of ureteral perforation was managed successfully with JJ stent. In SWL group, 28 (87.5%) patients became stone free at 3 months. Seventeen patients (53.2%) required retreatment and adjuvant procedure was done in 6 patients (18.7%).
Conclusions: Ureterolithotripsy and in situ SWL are equally effective for proximal ureteral stone. Ureterolithotripsy for proximal ureteral calculi has high success rate with low morbidity. It can be done safely with intravenous sedation and local anesthesia. Ureteroscopic stone removal can be considered as primary approach in patients with proximal ureteral calculi reserving SWL for those who can afford it.
Keywords: Ureteral calculus, ureteroscopy, SWL.
|How to cite this article:|
Singh H, Tandon V, Dwivedi U S, Mahmood M, Hamid A, Kishore G, Singh P B. Management of proximal ureteral stones - comparison of outpatient ureterolithotripsy with in-situ shock wave lithotripsy (SWL). Indian J Urol 2003;20:23-7
|How to cite this URL:|
Singh H, Tandon V, Dwivedi U S, Mahmood M, Hamid A, Kishore G, Singh P B. Management of proximal ureteral stones - comparison of outpatient ureterolithotripsy with in-situ shock wave lithotripsy (SWL). Indian J Urol [serial online] 2003 [cited 2020 Aug 11];20:23-7. Available from: http://www.indianjurol.com/text.asp?2003/20/1/23/37119
| Introduction|| |
Technological developments have drastically changed the management of ureteral calculi in last two decades. Extracorporeal shock wave lithotripsy (SWL) is considered standard therapy for most of the proximal ureteral calculi.  Ureteroscopy (URS) and intracorporeal lithotripsy is used as a salvage procedure. With the availability of flexible, semi rigid and small caliber ureterorenoscopes along with better energy sources, ureteroscopic removal has become more safe and successful.  Grasso M et al reported that ureteroscopic lithotripsy is by far the most expeditious and cost-effective means of clearing ureteral stone burden.  Recent reports have suggested that the ureteroscopy may be performed with intravenous sedation as an outpatient procedure further reducing the cost. , In developing countries cost is one of the major factors influencing the treatment. At our university hospital ureteroscopy costs about one third that of SWL. We managed proximal ureteral calculi with ureterolithotripsy or shock wave lithotripsy (SWL) and report our experience.
| Patients and Methods|| |
From January 2000 to December 2001, 56 patients underwent ureteroscopic stone removal and 32 underwent in-situ SWL. Preoperatively renal function test, urine culture, ultrasonography, and intravenous urogram were performed. In elderly patients ECG and X-ray chest were also done. All patients were treated on outpatient basis. They were informed thoroughly about the procedure particularly regarding the type of anesthesia and informed written consent was taken. The stone site was determined using the sectional anatomy of ureter proposed by Talati et al.  Section 1 extends from pelviureteric junction to lower margin of kidney, section 2 extends 2.0 cms distal to section 1 and section 3 extends to sacroiliac joint.
Patients with contraindications of SWL such as nonfunctioning kidney, bleeding diathesis and pregnancy were excluded from the study. The exclusion criteria for the ureterolithotripsy were previously failed ureteroscopy, active infection, bleeding diathesis and general health not fit for surgical procedure. There were no specific exclusion criteria pertaining to size, site and hydronephrosis in each group. Patients were explained about both of the procedures, anaesthesia requirements and the cost involved. Treatment modality was decided as per the choice of patients. As decision was based on patient's choice, controlled randomization was not possible.
For ureteroscopy, patients were called empty stomach on the day of procedure. They were given intravenous pentazocine (0.3mg/kg) and midazolam (0.05 mg/kg). If required, repeat dose of midazolam or tramadol was given during the procedure. All patients received one dose of prophylactic antibiotic.
Ureteroscopy was performed with 8.0/9.8 Fr Wolf rigid uretero-renoscope (425 mm working length) without need of intramural ureteral dilatation. We first pass guide wire (0.035 inch) with the help of cystoscope. Two to three cms of ureteric catheter is introduced into ureter through ureteroscope. Keeping the guide wire at 12 o'clock and ureteric catheter at 6 o'clock position ureteroscope is negotiated and advanced into the ureter with the help of pathfinder. Stones were fragmented to approximately 2mm fragments with the help of 0.8 mm probe of Lithoclast (pneumatic lithotripsy) at 2.5 bar pressure. Stones were fragmented either in ureter or in calyx if migrated to upper calyx. Procedure was abandoned if stone migrated to inaccessible calyx. After the procedure indwelling JJ stents were inserted only in cases of stone impaction, stone migration, severe ureteric edema and ureteric injury.
Patients acceptance of procedure was classified good if the patient did not complain of discomfort or pain; fair, if there was minimal discomfort and satisfactory, if patient experienced discomfort requiring repeat dose of analgesic or sedative.
Electrohydraulic extracorporeal shock wave lithotripter (Stonelith) is used for SWL at our center. Ureteric stones were treated in-situ at power ranging from 16-20KV under intravenous sedation. At each sitting 2400 to 3600 shock waves were given. Patients were called again after 14 days with x-ray KUB and further treatment was given accordingly.
| Results|| |
Till date we performed ureteroscopy and intracorporeal lithotripsy in 300 patients, of which 56 had proximal ureteral calculi. The 30 men were 20 years to 64 years (mean37 years) and 26 women were 22 years to 54 years (mean 34 years). Stone size varied from 6 mm to 25 mm (mean l lmm). There was mild (Grade 1) hydronephrosis in 33 patients, moderate (Grade 2) in 18 patients and severe (Grade 3) in 5 patients.
Mean procedure time was 36 minutes varying from 24 to 64 minutes. Analgesia was good in 40 patients (71.40%), fair in 10 patients (17.8%) and satisfactory in 4 patients (7.1%) and only 2 patients required termination of procedure because of discomfort. All procedures were done on outpatient basis and were sent home after 4 hours of procedure. One patient was hospitalized on the fifth day due to urosepsis and successfully treated with antibiotics.
Of 56 patients, 47(83.93%) stones could be reached and fragmented. Forty (71.4%) patients were stone free after one session of ureteroscopy whereas 7 patients required retreatment for residual fragment increasing success rate to 83.93%. In 6 patients stone could not be reached either due to ureteral tortuousity, stricture or acute kinks and curves. Indwelling JJ stent was inserted in only 13 patients (23.2%). In 3 patients stone migrated in to kidney, 2 were fragmented in the upper calyx whereas in third patient stone went into inferior calyx and was managed by SWL [Table - 1]. Stone migration occurred in I patient with grade 2 and in 2 patients with grade 3 hydronephrosis.
There was no serious complication and minor complications were limited to only 7 (12.5%) patients. Four patients had UTI and one of them required hospitalization for the management of urosepsis. Two patients had irritative voiding symptoms because of stent and became asymptomatic after stent removal. Ureteric perforation occurred only in one patient (1.7%) requiring no more than JJ stent. All patients underwent USG at 3 months and none of the patients had evidence of hydronephrosis ruling out ureteric stricture.
Thirty-two patients including 20 men and 12 women were treated with in situ extracorporeal lithotripsy. Mean age was 39 years ranging from 14 years to 64 years. Average stone size treated was 12mm varying from 7 mm to 24 mm. On average 4250 shock waves for 6-10mm, 7250 for 11-20 mm and 9000 for more than 20 mm stone were given. Twenty-eight patients (87.5%) had complete fragmentation and clearance with SWL. Out of these 28, 17 required retreatment. Six patients underwent URSL successfully owing to failed SWL or development of steinstrasse [Table - 2].
Twenty patients had mild (Grade 1), 8 moderate (Grade 2) and 4 patients had severe (Grade 3) hydronephrosis. There was no difference in stone clearance in these three groups [Table - 3].
Average cost in ureteroscopy group for each stone free patient was Rs 4,700 whereas it was Rs 11,000 for SWL patient.
| Discussion|| |
Since the advent of extracorporeal shock wave lithotripsy, ureteroscopy has been relegated to salvage treatment for proximal ureteral calculi except for large ones. Early ureteroscopic experience using large rigid ureteroscope showed a success rate of 52 - 80%., The development of flexible, semi rigid and small caliber rigid ureteroscope simultaneously with new smaller lithotripsy probes has made ureteroscopy in proximal ureter safe and effective. Minowada et al evaluated their experience treating mostly upper ureteral calculi in 63 patients using progressively smaller caliber ureteroscope [12.8, 10.5, 9.3 Fr], stone free rate improved as smaller endoscopes were used; 67% for the 12.8 Fr vs. 82% for 10.5 Fr and 85% for 9.3 Fr ureteroscope. 
Although laser lithotripsy had greatest impact on ureteroscopic lithotripsy but its cost and limited availability limits its widespread use. Using wide array of ureterorenoscopes, EHL, laser lithotripter, Erhard M et al reported success rate as high as 97%.  Others have also reported success rate of 83% to 95 % with laser lithotripters. ,
The lithoclast, a pneumatic lithotripter is relatively inexpensive, safe and cost of each treatment is minimal. Denstedt et al found it effective for fragmenting the hardest renal calculi.  The success rate of ureteric calculi fragmentation is 89% to 97% in most of studies.  Nutahara et al in their comparative study of lithoclast and pulse dye laser lithotripsy reported that success rate was 97% and 95% for lithoclast and candela 2000 MDL respectively.
Lithoclast required less operative time and postoperative analgesia.  Ather et al treated 437 patients of ureteric calculi including 170 proximal ureteral stones with ureteroscopy and ultrasonic/pneumatic lithotripsy and reported overall success rate of 80%.  Only 6 % patients required more than one session of ureteroscopy. We could successfully treat 73.2% patients with single sitting of ureteroscopy. Only 7(12.5%) patients required retreatment increasing success rate to 85.7 %. Majority of retreatments were required in stones larger than 2.0 cms.
The proximal retropulsion is the main disadvantage of Lithoclast. Hofbauer et al reported that 10.5 % stone were pushed up with Lithoclast compared to 14.7% with EHL.  In our study; only 3 (7.1 %) stone migrated to kidney. During the procedure, we used pathfinder very gently and judiciously to prevent proximal migration of stone. Fortunately in 2 patients stone migrated to upper calyx and were fragmented successfully. Female patients and patients with stone at distal part of upper ureter are better candidate for URSL whereas patients with gross dilatation of ureter proximal to small stone has high chance of stone migration hence should be considered for SWL.
Proponents of SWL as an initial therapy prefer it on the basis that it is less invasive than ureteroscopy, provide comparable results, avoid major regional and general anesthesia, and eliminate need of stenting after procedure and lower risk of complications. On the other hand ureteroscopy is more cost effective, rapid and in skilled hands complication rates are minimal. Most of in situ SWL series have reported stone-free rate of 56-97%, with 10-13% patients requiring retreatment and 15-25% needing adjuvant procedure. ,, Our stone-free rate with SWL was 87.5% and retreatment was required in 53.2%. Although male patients and stone in proximal part of upper ureter were comparatively more in SWL group,a significant number of similar patients were also managed with ureterolithotripsy. Stone-free rates were comparable in both the groups. Retreatment rate were lower in ureterolithotripsy group but 23.2% patients required JJ stenting whereas only 2 patients of SWL were stented after adjuvant URSL.
Recent reports suggest that the regional and general anesthesia can also be avoided for ureterolithotripsy. There have been several reports of ureteroscopy with IV sedation and local anesthesia. , Vogeli et al completed 133 of 161 ureteroscopy with intravenous sedation or local anesthesia and only 48% were confined to lower ureter.  All patients tolerated the procedure very well. Tolerance was good in 71.4% of our patients and in only two patients procedure was terminated. The safety of ureteroscopy as an outpatient procedure reported earlier also helps in reducing the cost of procedure.  We did the procedure on day care basis and all patients were discharged on the same day and were given oral analgesics. Only 1 of 56 patients required hospitalization for the treatment of urosepsis.
Stoller et al in their series of 156 patients including 51 with upper ureteric stones who underwent ureteroscopic stone removal reported that overall complication rate was 19% including sepsis, moderate hemorrhage and ureteral perforation.  Nineteen of 24 perforation occurred with the use of 12.5F ureteroscope and perforation rate was 31% in patients with proximal ureteral calculi. Schuster et al reported perforation rate of 4.7% but did not find any association of perforation with stone size, site and type of ureteroscope used.  In a review of 378 patients by Puppo et al 5 patients (1.3%) had ureteral perforation and concluded that this technique can represent good alternative to SWL in the treatment of obstructing stone or when patients ask for a one shot treatment.  Most of the recent reports showed that with the use of smaller caliber ureteroscope perforation rate is 0-5% and 1-3.5% patients develop ureteric stricture. ,, Ather et al reported that 12 (5.6%) of 214 patients of ureteral calculi had significant ureteral injury with the use of pneumatic lithotripsy whereas it was 13% with ultrasonic lithotripsy.  In our study only one patient (2.3%) had perforation and no one developed stricture until now.
| Conclusions|| |
For the management of proximal ureteral calculi, ureteroscopy and intracorporeal pneumatic lithotripsy can be performed successfully without any significant morbidity and complication. The success rates are comparable to SWL. Ureteroscopy can be safely performed under IV sedation and local anesthesia on day care basis. Any skilled and experienced urologist especially in developing country like ours should consider ureterolithotripsy for primary therapy of proximal ureteral calculi particularly in female patients, in patients with large stone and stone at distal part of proximal ureter reserving SWL for those who can financially afford it.
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[Table - 1], [Table - 2], [Table - 3]