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RESEARCH ARTICLE
Year : 2003  |  Volume : 20  |  Issue : 1  |  Page : 23-27
 

Management of proximal ureteral stones - comparison of outpatient ureterolithotripsy with in-situ shock wave lithotripsy (SWL)


Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Correspondence Address:
P B Singh
Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221 005
India
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Source of Support: None, Conflict of Interest: None


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   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 2019 Aug 26];20:23-7. Available from: http://www.indianjurol.com/text.asp?2003/20/1/23/37119



   Introduction Top


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. [1] 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. [2] Grasso M et al re­ported that ureteroscopic lithotripsy is by far the most ex­peditious and cost-effective means of clearing ureteral stone burden. [3] Recent reports have suggested that the ureteroscopy may be performed with intravenous sedation as an outpa­tient procedure further reducing the cost. [4],[5] 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 Top


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. [6] 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 Top


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 Top


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%.[2],[7] 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. [8]

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%. [2] Others have also reported success rate of 83% to 95 % with laser lithotripters. [9],[10]

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. [11] The success rate of ureteric calculi frag­mentation is 89% to 97% in most of studies. [12] 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. [13] 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%. [14] 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. [12] 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. [15],[16],[17] 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. [4],[5] Vogeli et al completed 133 of 161 ureteroscopy with intravenous sedation or local anes­thesia and only 48% were confined to lower ureter. [4] 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. [5] 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. [18] 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. [19] 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. [20] 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. [18],[19],[20] 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. [14] In our study only one patient (2.3%) had perforation and no one developed stricture until now.


   Conclusions Top


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.

 
   References Top

1.Segura JW. The role of percutaneous surgery in renal and ureteral stone removal. J Urol 1989; 141(3) Part 2:780-1.  Back to cited text no. 1    
2.Erhard M. Salwen J. Bagley DH. Ureteroscopic removal of mid and proximal ureteral calculi. J Urol 1996: 155(1): 38-42.  Back to cited text no. 2    
3.Grasso M. Beaghler M, Loisides P. The case of primary endoscopic management of upper urinary tract calculi: cost and outcome assessment of 112 primary ureteral calculi. Urology 1995; 45(3): 372­-376.  Back to cited text no. 3    
4.Vogeli TA. Mellin HE. Hopf B. Ackermann R. Ureteroscopy under local anesthesia with or without intravenous analgesia. Br J Urol 1993: 72: 161-4.  Back to cited text no. 4    
5.Wills TE, Burns JR. Ureteroscopy: an outpatient procedure? J Urol 1994: 151:1185-7.  Back to cited text no. 5    
6.Talati J, Khan LA. Noordzij JW, Mohammad N. Memon A. Hotiana MZ. The scope and place of ultrasound monitored extra corporeal shock wave lithotripsy in a multimodality setting and the effects of experimental audit evoked changes on the management of ureteric calculi. Br J Urol 1994; 73: 480-486.  Back to cited text no. 6    
7.Dretler SP, Keating MA, Riley J. An algorithm for the management of ureteral calculi. J Urol 1986: 136:1190-3.  Back to cited text no. 7    
8.Minowada S. Higashihara E, Kameyama S. Oshi M, Homma Y. Aso Y. Advantage of smaller caliber fiberscope and learning curve on transurethral lithotripsy. J Urol 1992: 147:1243-4.  Back to cited text no. 8    
9.Grasso M. Bagley DH. Flexible ureteroscopic lithotripsy using pulsed dye laser. J Endourol 1990; 4:155-160.  Back to cited text no. 9    
10.Benizri E, Wodey J. Amiel J, Toubol J. Comparison of tw . pulsed lasers for lithotripsy of ureteral calculi: report of 154 patients. J Urol 1993: 150:1803-1805.  Back to cited text no. 10    
11.Denstedt JD, Eberwein PM, Singh RR. The Swiss lithoclast: a new device for intracorporeal lithotripsy. J Urol 1992: 148:1088-1190.  Back to cited text no. 11    
12.Hotbauer J. Hobarth K. Marberger M. EHL versus pneumatic dis­integration in the treatment of ureteral stones: a randomized pro­spective trial. J Urol 1995; 153:623-5.  Back to cited text no. 12    
13.Nutahara K. Kato M. Miyata A. Murata A. Okegawa T. Miura 1. Kojima M. Higashihara E. Comparative study of pulsed dye laser and pneumatic lithotripters for transurethral ureterolithotripsy. : Int J Urol 2000 May: 7(5): 172-5.  Back to cited text no. 13    
14.Ather MH. Paryani J. Memon A. Sulaiman MN. 10-year experi­ence of managing ureteric calculi: Changing trends towards endourological interventions - is there a role for open surgery? BJU international 2001: 88:173-7.  Back to cited text no. 14    
15.Rassweiler J, LuTz K. Gumpinger R. Eisenberger F. Efficacy of in situ extracorporeal shock wave lithotripsy for upper ureteral cal­culi. Fur Urol 1986: 12: 377-386.  Back to cited text no. 15    
16.Danuser H. Ackermann DK, Marth DC, Studer UE, Zingg EJ. Ex­tracorporeal shock wave lithotripsy in situ or after push up for up­per ureteral calculi: a prospective randomized trial J Urol 1993: 150 (3): 824-6.  Back to cited text no. 16    
17.Ehreth JT. Drach GW, Arnett ML. Barnett RB, Govan D, Lingeman J, Loening SA, Newman DM, Tudor JM, Saada S. Extracorporeal shock wave lithotripsy: multicenter study of kidney and upper ure­ter versus middle and lower ureter treatment. J Urol 1994: 152: 1379-1385.  Back to cited text no. 17    
18.Stoller ML, Wolf JS Jr, Hofmann R. Marc B. Ureteroscopy without routine balloon dilatation: an outcome assessment J Urol 1992: 147:1238-1242.  Back to cited text no. 18    
19.Schuster TG. Hollenbeck BK, Faerber GJ, Wolf JS. Complication of ureteroscopy: analysis of predictive factors. J Urol 2001: 166: 538-540.  Back to cited text no. 19    
20.Puppo P. Ricciotti G, Bozzo W, Introini C. Primary endoscopic treat­ment of ureteric calculi. A review of 378 cases. Eur Urol 1999: 36:48-52.  Back to cited text no. 20    



 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    Conclusions
    References
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