Agnes Yost

Clinical Implications of Clinically Insignificant Stone Fragments After Extracorporeal Shock Wave Lithotripsy

PURPOSE We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention. RESULTS Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8%), 26 (16.3%), 67 (41.9%) and 29 (18.1%) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9%) remained asymptomatic while 69 (43.1%) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years). CONCLUSIONS While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significantly number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.

Treatment of Caliceal Diverticular Calculi with Extracorporeal Shock Wave Lithotripsy: Patient Selection and Extended Followup

We treated 19 selected patients with calculi in 21 caliceal diverticula with extracorporeal shock wave lithotripsy (ESWL). By limiting this treatment to patients with relatively small (less than 1.5 cm.) calculi associated with a radiographically patent diverticular neck, a stone-free state was initially achieved in 11 patients (58%). Of 14 patients with flank pain before ESWL 12 (86%) were rendered symptom-free or markedly improved, often independent of a stone-free state. Extended followup in 13 patients for 12 to 49 months (mean 23.8 months) after ESWL revealed recurrent stones or stone growth in only 1. Although pain relief has remained constant for those initially rendered symptom-free, recurrent infection has been documented in 6 (67%) of 9 patients with infection before ESWL. We conclude that ESWL for selected patients with calculi in caliceal diverticula can achieve a relatively high initial stone-free rate and that recurrent stones may not be inevitable. Treatment in this setting also may provide long-term symptomatic relief that is often independent of a stone-free state. However, recurrent infection is not unusual, especially when associated with residual calculi. Considering the relatively noninvasive nature of this approach, ESWL should be considered an acceptable form of primary management for selected patients with calculi in caliceal diverticula.

Management of failed primary intervention for ureteropelvic junction obstruction: 12-year, single-center experience

OBJECTIVES To compare contemporary endourologic and open surgical management of failed primary intervention for ureteropelvic junction obstruction, specifically in regard to immediate and long-term results and complications. METHODS Since 1989, 48 patients have undergone management of failed primary intervention for ureteropelvic junction obstruction. Of these, 42 patients (21 females and 21 males; age range 16 to 68 years, mean age 34.9) underwent follow-up evaluations. These 42 patients constitute the present study group. The mode of secondary intervention was determined by individual upper tract anatomy, concurrent medical conditions, and informed patient preference. Secondary intervention included open operative repair (n = 20) or percutaneous (n = 11), ureteroscopic (n = 5), or retrograde cautery wire balloon (n = 6) endopyelotomy. Success was defined as symptomatic relief and improved calicectasis on radiographic evaluation at latest follow-up. RESULTS Follow-up ranged from 6 to 148 months (mean 47.7). Endourologic intervention was associated with a mean hospital stay of 2.3 nights and a complication rate of 13.6%. The long-term success rate of these endoscopic approaches was 59.1% overall, including a 71.4% success rate after a failed open operative procedure and a 37.5% success rate after a failed endourologic procedure. In contrast, open operative salvage was associated with a mean stay of 4.3 nights and a 15% complication rate. The success of open operative salvage was 95% overall, including 94.1% after failed endourologic intervention and 100% after failed open operative intervention. CONCLUSIONS Endourologic intervention for failed primary management of ureteropelvic junction obstruction is associated with a short hospital stay and low rate of complications. Such intervention provides acceptable success rates in the setting of prior failed open operative intervention. However, when endourologic salvage was used for prior failed endourologic intervention, the success rates were limited. This suggests that intrinsic factors such as crossing vessels or periureteral fibrosis may play a role in limiting the utility of such procedures in this setting. In contrast, open operative salvage after any prior failed intervention for ureteropelvic junction obstruction provides excellent functional results without any increase in morbidity, with, in this contemporary series, an acceptably short hospital stay. These data should help urologists and patients make well-informed treatment decisions.

Ureteroscopic Laser Endopyelotomy: A Single-Center Experience

PURPOSE We review our experience with ureteroscopic endopyelotomy using a holmium laser for correction of ureteropelvic junction (UPJ) obstruction in order to further define the immediate and long-term results and complications. PATIENTS AND METHODS From 1999 to 2002, 11 men and 34 women (mean age 42 years) underwent 46 ureteroscopic holmium laser endopyelotomy procedures for treatment of primary (N=40) or secondary (N=5) UPJ obstruction. The inclusion criteria were a short (<2-cm) obstruction and absence of ipsilateral renal calculi. Demographic, intraoperative, and postoperative measures were obtained from a prospectively designed and updated database. The endopyelotomy was performed under direct vision using a semirigid (N=40) or flexible (N=5) ureteroscope with a laser setting of 1 J at 10 Hz. Radiographic confirmation of obstruction and the results of intervention was obtained by combinations of intravenous and diuretic urography, diuretic renography, ultrasonography, and CT. The first postoperative and latest radiographic follow-up studies were compared with the preoperative studies to determine whether the obstruction was resolved, unchanged, or worsened. Success was defined as symptomatic relief and radiographic resolution. RESULTS The mean operative time was 65 minutes (range 10-153 minutes). There were no intraoperative complications, although 5 patients (11.1%) experienced postoperative complications consisting of subcapsular hematoma, pyelonephritis, sepsis, urinary retention, or dysrhythmia. Forty-two patients (93%) had a hospital stay of <23 hours. Stents were removed 3 to 8 weeks (mean 5 weeks) postoperatively. The mean length of follow-up was 23.2 months (range 5-43 months). Symptoms were resolved in 65.4% of patients, improved in 7.7%, unchanged in 11.5%, and worse in 15.4%. Radiographically, at latest follow-up, the obstruction was resolved in 73.1% of patients, unchanged in 23.1%, and worse in 3.8%. Primary UPJ obstruction was associated with a symptomatic success rate of 68% compared with only 50% for secondary UPJ obstruction. CONCLUSIONS Ureteroscopic laser endopyelotomy is a minimally invasive, short-stay outpatient procedure associated with a 65.4% symptomatic and 73.1% radiographic success rate. In contrast to the findings in previous reports of results of retrograde or antegrade endopyelotomy, patients treated for primary UPJ obstruction experienced higher rates of success than those with secondary obstruction.

Extracorporeal Shock Wave Lithotripsy in Patients with Bleeding Diatheses

Five patients with known bleeding diatheses were treated with extracorporeal shock wave lithotripsy. Specific therapy was administered before extracorporeal shock wave lithotripsy to reverse the bleeding disorder. After treatment each patient was monitored with serial hemoglobin determinations and renal ultrasonography. The course during and after lithotripsy was uneventful in all patients. We conclude that extracorporeal shock wave lithotripsy is a viable option for patients with significant bleeding diatheses provided that specific therapy to reverse the coagulopathic condition is available and used before treatment.

EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY: A COMPARATIVE STUDY OF ELECTROHYDRAULIC AND ELECTROMAGNETIC UNITS

PURPOSE We determined the results of shock wave lithotripsy with a newer electromagnetic lithotriptor and compared them with those in a contemporary series of cases managed by an electrohydraulic lithotriptor using identical treatment and followup criteria at a single center. MATERIALS AND METHODS Between 1995 and 1999, 356 patients (375 renal units, 483 upper urinary tract stones) meeting study inclusion criteria were treated with an MFL 5000 electrohydraulic shock wave lithotripsy unit (Dornier Medical Systems, Inc., Marietta, Georgia). From 1999 to 2000, 173 patients (175 renal units; 218 upper urinary tract stones) meeting identical study inclusion criteria were treated using an electromagnetic Modulith SLX shock wave lithotripsy unit (Karl Storz Lithotripsy, Atlanta, Georgia). In each group stone-free results were determined by plain abdominal x-ray and renal ultrasound 1 month after lithotripsy and efficiency quotients were developed. Baseline patient and stone characteristics were compared by the Wilcoxon rank sum and Fisher exact tests. All variables significant at p <0.05 were included in subsequent outcome analysis using multivariate logistic regression. RESULTS Baseline characteristics were equivalent, including patient age, gender, stone number and location, although patients treated with the electrohydraulic unit had a significantly larger median stone burden (103 versus 71 mm.2, p = 0.015). Multivariate regression analysis demonstrated a higher stone-free rate in the electrohydraulic group (77% versus 67%, p = 0.01) but also a higher rate of total adjunctive measures (56% versus 47%, p = 0.04). Consequently the efficiency quotients were comparable for the electrohydraulic and electromagnetic lithotripsy units (0.45 and 0.42, respectively, p = 0.43). CONCLUSIONS Electrohydraulic lithotripsy resulted in a higher stone-free rate at 1 month, although it was associated with a higher rate of auxiliary measures. Ultimately the efficiency quotients were equivalent, implying that these 2 contemporary energy sources are acceptable. According to single center treatment and followup criteria they are equally efficacious.

Scrotal hematoma resulting from extracorporeal shock wave lithotripsy for a distal ureteral calculus.

We performed extracorporeal shock wave lithotripsy with a Dornier HM3 lithotriptor to treat a distal ureteral calculus. Although the procedure resulted in successful stone fragmentation, the patient incurred a large scrotal hematoma. We propose a mechanism for this previously unreported complication of shock wave lithotripsy and discuss recommendations for its prevention.