Gustavo Caserta Lemos

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.

Renal calculi in lower pole calices: what is the best method of treatment?

Percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy (ESWL*) can be used in the treatment of lower pole caliceal calculi. In a retrospective analysis these 2 therapies were compared for treatment of solitary lower pole caliceal calculi to evaluate morbidity. During a 2-year period 23 patients treated with percutaneous nephrolithotomy and 24 who underwent ESWL with the Siemens Lithostar were analyzed in regard to the success rate, effectiveness quotient, complication rate, length of hospitalization and disability period. Followup consisted of ultrasound and/or a plain film of the kidneys, ureters and bladder 1 day and 1 to 3 months postoperatively. A nephrotomogram was included in the ESWL group. Complete removal of all stone fragments was achieved in 93.6% of the patients treated percutaneously without retreatment. In the ESWL group the success rate was 79.2% with a 41.6% retreatment rate. On the other hand, the ESWL group had a shorter hospitalization and an earlier return to normal physical activities. Among the patients who underwent a percutaneous operation 13% had complications compared to 4.1% in the ESWL group. The recurrence rate was higher in the former group (13% within a median of 18 months, compared to 8.3% within a median of 11 months in the ESWL group). The mean stone diameter was 1.42 cm. in the percutaneous group and 1.22 cm. in the ESWL group. Stone composition was similar in both groups. Since ESWL is an effective noninvasive procedure without the need for routine anesthesia and hospitalization, and with prompt return of the patient to a normal life it must be considered the method of choice for lower caliceal stones less than 2 cm. in diameter. However, percutaneous nephrolithotomy will continue to have a primary role in the management of larger stones.

In Situ Extracorporeal Shock Wave Lithotripsy for Ureteral Calculi

We reviewed our experience with in situ extracorporeal shock wave lithotripsy for ureteral stones in 30 patients. The Siemens Lithostar unit was used for stone disintegration and no attempts were made to manipulate the calculi back into the kidney. During the study period 15 patients presented with upper, 9 with mid and 6 with lower ureteral calculi. The mean stone size was 5 x 12 mm. The success rates in stone removal, hospitalization, anesthesia, average number of shocks and kilovolts used were analyzed. Complete removal of all calculous material was obtained in 86.6% of the patients after 3 months. Followup consisted of a plain film of the kidneys, ureters and bladder, and eventually renal ultrasound 1 day and 1 to 3 months postoperatively. Routinely, patients were treated without hospitalization, while 3 had persistent stone fragments and required hospitalization for auxiliary endourological procedures. The average hospital stay for these patients was 1.6 days. Of the 30 patients 13 (43.4%) were treated without anesthesia, 9 (30.0%) received intravenous sedation and 8 (26.6%) had epidural anesthesia. Patients received 3,000 to 6,000 shock waves per session (median 4,000) at 14.0 to 19.0 kv. (median 18.1 kv.), and in 76.9% the treatment was completed after 1 session. Patients who needed more than 1 session received 3,000 to 4,000 shock waves (median 3,000) at 15.0 to 19.0 kv. (median 17.8 kv.) per additional session. Minor complications, such as hematuria, were observed in 33.3% of the patients for less than 24 hours. A small erythematous area usually was present on the abdominal wall at the shock wave entrance site and temporary ileus was noted in 2 patients. In situ extracorporeal shock wave lithotripsy with the Siemens Lithostar device is an effective method for treatment of ureteral stones in all parts of the ureter due to the ease of patient positioning.

Endourological Management of Ureteral Strictures

We reviewed the records of 20 patients (21 ureters) treated during the last 5 years for ureteral stricture disease. The causes of stricture formation included ureterolithotripsy in 47.7% of the patients, open ureterolithotomy in 9.5%, other urological procedures in 23.8%, general surgical and gynecological procedures in 9.5% and miscellaneous factors in 9.5%. A total of 20 patients (21 ureters) underwent endourological treatment with balloon dilation (19) or balloon dilation and internal ureterotomy (2), with good results in 57.1% and a mean followup of 24 months. Of the 9 patients who failed endourological management 3 underwent successful open repair, 3 underwent nephrectomy, and 3 had a relatively large ureteral lumen and became asymptomatic, receiving no further treatment. The interval between injury and treatment was not a decisive factor. The length of ureteral stricture assumes the most significant parameter to predict success in the treatment of ureteral stricture. There were no intraoperative or postoperative complications. The association of balloon dilation and incision by special endoureterotomy scissors is a potentially useful technique.

COLON PERFORATION FOLLOWING PERCUTANEOUS NEPHROLITHOTOMY

Between February 1984 and 1986, 285 patients underwent percutaneous nephrostomy placement followed by track dilation and calculi removal. Although percutaneous colonic perforation is rare, we report a case consequent to this procedure. The patient had a good outcome after surgical management of the damaged colon. This report considers the anatomic aspects for percutaneous nephrostomy placement as well as the auxiliary methods used in diagnosis of lesions of the colon.

Adjunct controlled inversion therapy following extracorporeal shock wave lithotripsy for lower pole caliceal stones.

The lower calix is responsible for a significant number of kidneys with residual stone fragments after extracorporeal shock wave lithotripsy (ESWL*). To compare the effectiveness of controlled inversion therapy as an adjunctive method to the elimination of calculous fragments, 42 patients who had undergone treatment for lower caliceal stones with a Siemens Lithostar lithotriptor were reviewed. Of the patients 25 had no adjunctive therapy and 17 underwent controlled inversion therapy. The success rate, effectiveness quotient and complication rate were analyzed. Followup consisted of ultrasound and a nephrotomogram 1 day and 1 to 3 months postoperatively. Complete removal of all stone fragments was achieved in 84% of the patients without an adjunctive maneuver and in 64.7% of those treated with controlled inversion therapy. The effectiveness quotient was 72.4% and 35.5%, respectively. The group treated without adjunctive therapy had fewer retreatment sessions and a lower complication rate. There were no complications related to the controlled inversion therapy and patient acceptance was generally enthusiastic. We conclude that controlled inversion therapy did not improve the results of ESWL for lower pole caliceal calculi.

A Comparison of Treatment Methods for the Prophylaxis of Recurrent Superficial Bladder Tumors

We assigned 55 patients with superficial transitional cell carcinoma of the bladder by rotation to 1 of 3 treatment categories. Group 1 patients were treated by transurethral resection alone, group 2 by transurethral resection followed by topical thiotepa and group 3 by transurethral resection followed by orally administered bacillus Calmette-Guerin. Recurrent bladder tumors developed subsequently in 80 per cent of the patients in group 1, 42.9 per cent in group 2 and 6.2 per cent in group 3.

Internal Urethrotomy as a Complementary Method After Urethroplasties for Posterior Urethral Stenosis

Failure of the treatment of posterior urethral stenosis ranges from 10 to 30 per cent. Strictures secondary to pull-through or transpubic urethroplasty are difficult to manage. The management of these strictures is reviewed in 21 children and 84 adults. Of the 105 patients 69 had been treated previously by a perineal pull-through technique and 36 by transpubic urethroplasty. A total of 18 patients (10 in the transpubic and 8 in the pull-through groups) whose results were fair or poor underwent internal urethrotomy with the Sachse knife as a complementary treatment after posterior urethroplasty. Internal urethrotomy provided good results in 8 patients (80 per cent) in the transpubic group and 5 (62.5 per cent) in the pull-through group. None of the patients was incontinent and there was no symptomatic urinary infection postoperatively.

Extracorporeal shock-wave lithotripsy with Lithostar lithotriptor.

Initial experience of extracorporeal shock-wave lithotripsy (ESWL) using the Lithostar lithotriptor is reported; 193 patients underwent 248 treatments for 210 stones. A total of 139 renal calculi (126 patients) and 71 ureteral stones (67 patients) were analyzed. Treatments were performed without anesthesia in 65 calculi (27.6%), with intravenous sedation in 91 (42.5%), and under epidural anesthesia in 34 calculi (29.9%). A three-month follow-up showed a success rate of 88.0 percent for renal calculi and 95.5 percent for ureteral calculi treated in situ. Renal stone fragmentation was achieved with a mean of 4,890 shocks at 17.4 kV and ureteral calculi were fragmented with a mean number of 4,798 shocks at a mean of 18.3 kV. Auxiliary procedures after ESWL were required in 2 patients with renal stones and in 1 with ureteral calculi. A comparison between stone size and number of shock waves required to achieve stone fragmentation revealed a linear relationship. Hospitalization was not necessary in 84.4 percent of renal calculi and 89.6 percent of ureteral calculi. Retreatments were necessary in 22 (15.8%) of the renal calculi (18 had 2 sessions, 3 had 3 sessions, and 1 had 4 sessions). Of the ureteral calculi, 8 (11.3%) underwent retreatment (6 had 2 sessions, 1 had 3 sessions, and 1 had 4 sessions). The low morbidity with a large number of patients treated on an outpatient basis, minimizing the need for anesthesia, demonstrated a favorable initial successful experience with the Lithostar.

Bacillus Calmette-Guerin Immunotherapy of Infiltrating Bladder Cancer

Oral administration of bacillus Calmette-Guerin was used to treat 10 patients with muscle invasive transitional cell carcinoma of the bladder. The treatment induced tumor regression in 7 patients (70 per cent), including 1 who died without evidence of recurrent tumor. Skin test reactivity was correlated with response to treatment. Only 1 patient had marked skin test reactivity at the time of tumor recurrence. Our data demonstrated that patients with invasive bladder cancer may derive benefit from immunotherapy.