Glenn M. Preminger

URETERAL STONES CLINICAL GUIDELINES PANEL SUMMARY REPORT ON THE MANAGEMENT OF URETERAL CALCULI

Purpose The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data.PURPOSE The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles related to ureteral calculi published from 1966 to January 1996. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative treatments of ureteral calculi. RESULTS The data indicate that up to 98% of stones less than 0.5 cm. in diameter, especially in the distal ureter, will pass spontaneously. Shock wave lithotripsy is recommended as first line treatment for most patients with stones 1 cm. or less in the proximal ureter. Shock wave lithotripsy and ureteroscopy are acceptable treatment choices for stones 1 cm. or less in the distal ureter. CONCLUSIONS Most ureteral stones will pass spontaneously. Those that do not can be removed by either shock wave lithotripsy or ureteroscopy. Traditional blind basket extraction, without fluoroscopic control and guide wires, is not recommended. Open surgery is appropriate as a salvage procedure or in certain unusual circumstances.

Laparoscopic Dismembered Pyeloplasty

As laparoscopic nephrectomy has become a viable ablative procedure for kidney removal, additional areas of reconstructive laparoscopic urological procedures are being investigated. We describe our early experience with laparoscopic pyeloplasty for the management of ureteropelvic junction obstruction. Technical highlights include initial placement of an internal ureteral stent, lateral insufflation, placement of 5, 10 mm. trocars, pyelotomy (or reduction pyeloplasty performed with articulating laparoscopic scissors, reapproximation of the ureteropelvic junction with a running 4-zero polyglactin suture, placement of a 7 mm. suction drain in the retroperitoneal space and reapproximation of the colon to the body wall with a hernia stapler. We have performed laparoscopic dismembered pyeloplasty in 5 patients with symptomatic ureteropelvic junction obstruction. Operating time ranged from 3 to 7 hours, with the majority of time devoted to laparoscopic suturing (1 to 3 hours). Hospital stay averaged 3 days and all patients returned to normal activity within 1 week. Followup averaged 12 months (range 9 to 17 months) with complete resolution of symptoms in all patients. We believe that this innovative reconstructive laparoscopic procedure can be used for treatment of complicated ureteropelvic junction obstruction as in patients with a large, redundant renal pelvis or crossing lower pole vessels.

LOWER POLE I: A PROSPECTIVE RANDOMIZED TRIAL OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL RESULTS

PURPOSE The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

2007 Guideline for the management of ureteral calculi.

TheAmericanUrologicalAssociationNephrolithiasis Clinical Guideline Panel was established in 1991. Since that time, the Panel has developed three guidelines on the management of nephrolithiasis, the most recent being a 2005 update of the original 1994 Report on the Management of Staghorn Calculi [1]. The European Association of Urology began their nephrolithiasis guideline project in 2000, yielding the publication of Guidelines on Urolithiasis, with updates in 2001 and 2006 [2]. While both documents provide useful recommendations on the management of ureteral calculi, changes in shock-wave lithotripsy technology, endoscope design, intracorporeal lithotripsy techniques, and laparoscopic expertise have burgeoned over the past five to ten years. Under the sage leadership of the late Dr. JosephW. Segura, the AUA Practice Guidelines Committee suggested to both the AUA and the EAU that they join efforts in developing the first set of internationally endorsed guidelines focusing on the changes introduced in ureteral stone management over the last decade. We therefore dedicate this report to the memory of Dr. Joseph W. Segura whose vision, integrity, and perseverance led to the establishment of the first international guideline project. This joint EAU/AUA Nephrolithiasis Guideline Panel (hereinafter the Panel) performed a systematic review of the English language literature published since 1997 and a comprehensively analyzed outcomes data from the identified studies. Based on their findings, the Panel concluded that when removal becomes necessary, SWL and ureteroscopy remain the two primary treatment modalities for the management of symptomatic ureteral calculi. Other treatments were reviewed, including medical expulsive therapy to facilitate spontaneous stone passage, percutaneous antegrade ureteroscopy, and laparoscopic and open surgical ureterolithotomy. In concurrence with the previously published guidelines of both organizations, open stone surgery is still considered a secondary treatment option. Blind basketing of ureteral calculi is not recommended. In addition, the Panel was able to provide some guidance e u r o p e a n u r o l og y 5 2 ( 2 0 0 7 ) 1 6 1 0 – 1 6 3 1

Nephrolithiasis Clinical Guidelines Panel Summary Report on the Management of Staghorn Calculi

The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommendations for managing struvite staghorn calculi are based on a comprehensive review of the treatment literature and meta-analysis of outcome data from the 110 pertinent articles containing viable, unduplicated data. The panel concluded that the 3 most significant outcome probabilities are those of being stone-free, undergoing secondary unplanned procedures and having associated complications. Panel guideline recommendations for most standard patients are that neither shock wave lithotripsy monotherapy nor open surgery should be a first-line treatment choice but that a combination of percutaneous stone removal and shock wave lithotripsy should be used.

Comparison of open and endourologic approaches to the obstructed ureteropelvic junction

OBJECTIVES To compare open pyeloplasty with three minimally invasive modalities: antegrade endopyelotomy, Acucise endopyelotomy (Applied Medical, Laguna Hills, Calif), and laparoscopic pyeloplasty. METHODS Forty-five adult patients with ureteropelvic junction obstruction were managed by one of the above four techniques. Success rates, analgesic use, length of hospital stay, recovery time, and complications were compared between each of the four groups. RESULTS Successful relief of obstruction was achieved in 100% of patients undergoing open and laparoscopic dismembered pyeloplasty, 78% undergoing Acucise endopyelotomy, and 77% undergoing antegrade percutaneous endopyelotomy. Acucise endopyelotomy results in shorter convalescence (1 week) than antegrade endopyelotomy (4.7 weeks), laparoscopic pyeloplasty (2.3 weeks) or open pyeloplasty (10.3 weeks). Complication rates appear to be similar among all groups. CONCLUSIONS Our limited data imply that Acucise endopyelotomy offers low morbidity with success rates comparable to antegrade pyeloplasty, whereas laparoscopic pyeloplasty is as effective as open pyeloplasty with diminished morbidity.

CRITICAL ANALYSIS OF SUPRACOSTAL ACCESS FOR PERCUTANEOUS RENAL SURGERY

PURPOSE Percutaneous renal surgery is currently performed for complex renal calculi as well as for various other endourological indications. In many patients an upper pole nephrostomy tract allows direct access to most of the intrarenal collecting system. Upper pole percutaneous access may be obtained via the supracostal or subcostal approach. The preferred route depends on the location and size of the specific stone or lesion. Previously others have cautioned against the supracostal approach above the 12th rib and many have discouraged an approach above the 11th rib due to concern about the increased risk of intrathoracic complications. We retrospectively assessed the morbidity associated with supracostal percutaneous renal surgery and compared and analyzed the morbidity of the supracostal and subcostal approaches. MATERIALS AND METHODS The records of all patients who underwent upper pole percutaneous renal surgery between November 1993 and July 1999 were retrospectively reviewed. A total of 240 patients underwent percutaneous renal procedures, including 225 for managing symptomatic renal or ureteral stones, that is nonstaghorn calculi in 157, staghorn calculi in 41, proximal ureteral calculi in 12, calculi within a caliceal diverticulum in 6, calculi associated with primary ureteropelvic junction obstruction in 5 and calculi associated with a retained ureteral stent in 4. An additional 15 procedures were done for ureteropelvic junction obstruction (7), intrarenal collecting system tumors (5), a caliceal diverticulum without stones (1), a retained ureteral stent (1) and a ureteral stricture (1). RESULTS A total of 300 nephrostomy tracts were placed to obtain access to the intrarenal collecting system via the supracostal approach in 98 (32.7%) cases and the subcostal approach in 202 (67.3%). Of the supracostal approaches 72 (73.5%) tracts were above the 12th and 26 (26.5%) were above the 11th rib. The overall complication rate irrespective of percutaneous approach was 8.3% (16.3% for supracostal and 4.5% for subcostal access). Complications included blood transfusion in 7 patients, intraoperative hemothorax/hydrothorax in 5, sepsis/bacteremia in 3, atrial fibrillation in 2, delayed nephropleural fistula in 2, renal artery pseudoaneurysm in 2, deep venous thrombosis/pulmonary embolus in 2, pneumothorax in 1 and subcapsular hematoma in 1. Seven of 8 intrathoracic complications (87.5%) developed in supracostal cases. CONCLUSIONS Percutaneous renal surgery remains an important option for managing complex renal calculi and other upper urinary tract lesions. In our experience it is generally associated with low morbidity. The supracostal approach is often preferred for obtaining intrarenal access to complex renal and proximal ureteral pathology. Because supracostal access tracts are associated with significantly higher intrathoracic and overall complication rates compared to subcostal access tracts, this approach must be used with caution when no other alternatives are available.

Long-Term Treatment of Calcium Nephrolithiasis with Potassium Citrate

The long-term effects of potassium citrate therapy (usually 20 mEq. 3 times daily during 1 to 4.33 years) were examined in 89 patients with hypocitraturic calcium nephrolithiasis or uric acid lithiasis, with or without calcium nephrolithiasis. Hypocitraturia caused by renal tubular acidosis or chronic diarrheal syndrome was associated with other metabolic abnormalities, such as hypercalciuria or hyperuricosuria, or occurred alone. Potassium citrate therapy caused a sustained increase in urinary pH and potassium, and restored urinary citrate to normal levels. No substantial or significant changes occurred in urinary uric acid, oxalate, sodium or phosphorus levels, or total volume. Owing to these physiological changes, uric acid solubility increased, urinary saturation of calcium oxalate decreased and the propensity for spontaneous nucleation of calcium oxalate was reduced to normal. Therefore, the physicochemical environment of urine following treatment became less conducive to the crystallization of calcium oxalate or uric acid, since it stimulated that of normal subjects without stones. Commensurate with the aforementioned physiological and physicochemical changes the treatment produced clinical improvement, since individual stone formation decreased in 97.8 per cent of the patients, remission was obtained in 79.8 per cent and the need for surgical treatment of newly formed stones was eliminated. In patients with relapse after other treatment, such as thiazide, the addition of potassium citrate induced clinical improvement. Thus, our study provides physiological, physicochemical and clinical validation for the use of potassium citrate in the treatment of hypocitraturic calcium nephrolithiasis and uric acid lithiasis with or without calcium nephrolithiasis.

DOSE A URETERAL ACCESS SHEATH FACILITATE URETEROSCOPY

PURPOSE Ureteral access sheaths were initially developed to facilitate difficult ureteroscopic access. However, to our knowledge no formal evaluations have been performed to assess the routine use of ureteral access sheaths. Therefore, we prospectively analyzed intraoperative time, symptomatic outcome, major complications, stone-free rate and overall costs related to the routine use of a new ureteral access sheath during standard ureteroscopic procedures. MATERIALS AND METHODS Patients undergoing 6.5Fr semirigid or 7.5Fr flexible ureteroscopy were prospectively randomized to unaided ureteroscopy with no access sheath or ureteroscopy via a 12-14Fr ureteral access sheath. Patients who required ureteral dilatation were randomized to the ureteral access sheath used as a dilator or a standard 18Fr ureteral balloon dilator. Patients were evaluated postoperatively on days 0, 1 and 6 with a questionnaire to assess pain, irritative symptoms and complications. The stone-free rate and long-term complications were determined by excretory urography or computerized tomography at 3 months. RESULTS Enrolled in the study were 59 consecutive patients, who underwent a total of 62 ureteroscopic procedures. Of the 47 patients (76%) who did not require ureteral dilatation 23 (49%) underwent ureteroscopy via the ureteral access sheath and 24 (51%) underwent unaided ureteroscopy. Seven of the 15 patients (28%) who required ureteral dilatation underwent access sheath dilatation, while balloon dilatation was performed in 8. There was no significant difference in postoperative symptoms, complication rate or stone-free status in the access sheath and nonaccess sheath groups in patients not requiring ureteral dilatation (p <0.05). A significant increase in postoperative symptoms was noted when the balloon was used as a dilator compared to the access sheath. Operative time and costs in all patients who underwent access sheath dilatation were less than in those in whom the access sheath was not used. In the 15 patients who required dilatation 71% of access sheath and 100% of balloon dilatations were successful. CONCLUSIONS Routine use of a ureteral access sheath appears to facilitate semirigid and flexible ureteroscopy by decreasing operative time and costs, allowing direct visualization of ureteroscope insertion with simple ureteral re-entry and assisting renal and ureteral access with minimal associated morbidity. A ureteral access sheath should be considered for routine ureteroscopic procedures.

Ureteral Access Sheath Provides Protection against Elevated Renal Pressures during Routine Flexible Ureteroscopic Stone Manipulation

BACKGROUND AND PURPOSE New-generation flexible ureteroscopes allow the management of proximal ureteral and intrarenal pathology with high success rates, including complete removal of ureteral and renal calculi. One problem is that the irrigation pressures generated within the collecting system can be significantly elevated, as evidenced by pyelovenous and pyelolymphatic backflow seen during retrograde pyelography. We sought to determine if the ureteral access sheath (UAS) can offer protection from high intrarenal pressures attained during routine ureteroscopic stone surgery. PATIENTS AND METHODS Five patients (average age 72.6 years) evaluated in the emergency department for obstructing calculi underwent percutaneous nephrostomy (PCN) tube placement to decompress their collecting systems. The indications for PCN tube placement were obstructive renal failure (N=1), urosepsis (N=2), and obstruction with uncontrolled pain and elevated white blood cell counts (N=2). Flexible ureteroscopy was subsequently performed with and without the aid of the UAS while pressures were measured via the nephrostomy tube connected to a pressure transducer. Pressures were recorded at baseline and in the distal, mid, and proximal ureter and renal pelvis, first without the UAS, and then with the UAS in place. RESULTS The average baseline pressure within the collecting system was 13.6 mm Hg. The mean intrarenal pressure with the ureteroscope in the distal ureter without the UAS was 60 mm Hg and with the UAS was 15 mm Hg. With the ureteroscope in the midureter, the pressures were 65.6 and 17.5 mm Hg, respectively; with the ureteroscope in the proximal ureter 79.2 and 24 mm Hg, and with the ureteroscope in the renal pelvis 94.4 and 40.6 mm Hg, respectively. All differences at each location were statistically significant (P<0.008). Compared with baseline, all pressures measured without the UAS were significantly greater, but only pressures recorded in the proximal ureter and renal pelvis after UAS insertion were significantly higher (P<0.03). CONCLUSIONS The irrigation pressures transmitted to the renal pelvis and subsequently to the parenchyma are significantly greater during routine URS without the use of the UAS. The access sheath is potentially protective against pyelovenous and pyelolymphatic backflow, with clinical implications for the ureteroscopic management of upper-tract transitional cell carcinoma, struvite stones, or calculi associated with urinary tract infection.