Marc Beaghler

The case for primary endoscopic management of upper urinary tract calculi: II. Cost and outcome assessment of 112 primary ureteral calculi.

OBJECTIVES To compare extracorporeal shock-wave lithotripsy (ESWL) with endoscopic lithotripsy to establish the more efficacious and cost-effective treatment for ureteral calculi. METHODS The records of 112 patients with primary ureteral calculi treated at one center with either ESWL or endoscopic lithotripsy were retrospectively reviewed. Follow-up data at 1 and 3 months were obtained in all patients. Success was defined as complete clearance of a stone burden in the endoscopy group. In the ESWL group patients with a residual, asymptomatic 2-mm fragment were also considered successful treatments. The number of auxiliary procedures, retreatments, postoperative office visits, and imaging studies required before a patient was considered stone free was defined. The impact of these variables on global costs was carefully reviewed. RESULTS Patients with ureteral calculi primarily treated with ESWL or ureteroscopic lithotripsy had stone-free rates after a single session of 45% versus 95% at 1-month follow-up, and 62% versus 97% at 3-month follow-up. Retreatment and auxiliary procedure rates were significantly higher in the ESWL group (31% versus 3%). The mean number of postoperative visits and imaging studies until a patient was stone free was also higher in the ESWL group (2.07 versus 1.13). Operative treatment costs were similar for both modalities, but overall costs weighed heavily against ESWL. CONCLUSIONS ESWL remains the treatment of choice for moderately sized, uncomplicated renal calculi. In skilled hands, ureteroscopic lithotripsy is by far the most expeditious and cost-effective means of clearing a ureteral stone burden.

The case for primary endoscopic management of upper urinary tract calculi: I. A critical review of 121 extracorporeal shock-wave lithotripsy failures

OBJECTIVES To define those patients with upper urinary tract calculi who are more likely to have an unsuccessful outcome from extracorporeal shock-wave lithotripsy (ESWL). METHODS A critical prospective analysis of 121 patients, referred to two university centers after ESWL had been exhausted as a treatment modality for upper urinary tract calculi, was performed. Patients were subdivided into the following groups: failure to clear fragments, failure to fragment, difficulty in calculus localization, and failure due to inherent upper urinary tract obstruction. Other important variables include the type of extracorporeal lithotriptor used, number of treatment sittings before referral, calculus location, calculus composition, patient body habitus, and the imaging leading to and associated with extracorporeal therapy. RESULTS Large renal calculi (mean, 22.2 mm) and those within dependent or obstructed portions of the collecting system were frequently referred for endoscopic management after failed ESWL. Steinstrasse can be an extremely morbid complication from ESWL and in this series was associated with irreversible loss of renal function and ureteral stricture disease. Extracorporeal lithotripsy of infectious calculi can be associated with severe septic complication. Inadequate preoperative and intraoperative imaging and morbid obesity were also associated with failure. Second- and third-generation lithotriptors were represented in greater numbers than the Dornier HM-3 in this group of ESWL failures. CONCLUSIONS ESWL remains the treatment of choice for moderately sized, uncomplicated renal calculi. Large calculi, those within obstructed or dependent portions of the collecting system, and those composed of calcium oxalate monohydrate, frequently fail ESWL. Training in the more technically challenging aspects of endoscopic lithotripsy must be encouraged.

Inability to pass a urethral catheter: The bedside role of the flexible cystoscope

An all too common cause of urologic consultation is the inability to place a urethral catheter. Often other health care providers have unsuccessfully attempted catheter placement. Urethral false passages, perforations, and edema are common sequelae. Diseases such as urethral strictures, bladder neck contractures, and prostate cancer are often the underlying etiologies for failed catheterization. Traditionally, the use of filiforms and followers or the placement of a suprapubic tube is required to drain the lower urinary tract. Bedside flexible endoscopy was performed in this series not only to define the area and etiology of urethral obstruction, but also to facilitate catheter placement. Fifty-four patients were studied prospectively. Initial endoscopic assessment was based on bedside flexible cystoscopy. Most procedures were performed under topical lidocaine anesthetic. Under direct vision a 0.038 inch standard guide wire was directed through the area or areas of obstruction. Strictures, fibrosis, and false passages were dilated using a series of graduated Nottingham dilators over the guide wire. A Council-tipped urethral catheter was then placed over the guide wire to assure bladder drainage. In 52 of the 54 patients urethral obstructions were dilated and drainage catheters were placed into the bladder. No complications were encountered. This technique is simple, it avoids suprapubic puncture, and it minimizes unneeded trips to the operating room.

EXAMINING THE OBSTRUCTED URETER WITH INTRALUMINAL SONOGRAPHY

PURPOSE Intraluminal sonography was used to define, differentiate and direct better treatment of obstructing ureteral lesions. MATERIALS AND METHODS A total of 63 patients with a history of ureteral obstruction and suspected stricture were accrued for evaluation. All patients underwent retrograde contrast imaging, ureteroscopy and intraluminal sonography as part of a diagnostic algorithm. Specific sonographic criteria to differentiate lesions and stricture types were developed. Associated complicating variables defined on sonography included foreign bodies, submucosal stone fragments, ureteral wall fibrosis, mass lesions and adjacent vasculature. Endoscopic treatment was then performed with ultrasound guidance if technically feasible. RESULTS A total of 63 ureters were evaluated with the preoperative diagnosis of ureteral stricture disease. All ureters were narrowed on contrast imaging in the segment where a stricture was suspected. On sonography 24 ureters (36%) had wall fibrosis with normal periureteral tissues. In general these strictures did well with endoscopic incision. Of the 67 ureters 13 (19%) were thickened or had edematous walls with normal architecture and without fibrosis. These patients all did well with expectant therapy. In contrast, 7 ureters (10%) were obstructed by segmental retroperitoneal fibrosis which did not respond to minimally invasive therapies. In addition, 8 ureters (12%) were obstructed by ureteral wall scarring and periureteral fibrosis, and required open surgical intervention. Ten ureteral strictures had adjacent vasculature, and endoscopic incisions under ultrasound guidance were directed safely away from these structures without associated morbidity. Calculi, stone fragments and foreign bodies embedded in the ureteral wall with associated inflammation were defined with sonography and responded to endoscopic therapies. The intraluminal sonographic diagnosis of ureteral endometriosis was made in 6 patients with a range of lesions from bright, hyperechoic blood filled cysts to an inhomogeneous fluid filled scar involving the wall and periureteral tissues. Primary ureteral carcinoma was also demonstrated in 2 patients after other diagnostic techniques failed. In 1 of these patients intraluminal sonography directed biopsies diagnosed submucosal tumor. Finally, 1 patient had a small periureteral urinoma on intraluminal sonography which was missed on other imaging studies. CONCLUSIONS Intraluminal sonography is useful in patients with ureteral obstruction of unclear etiology as well as for selecting patients who may benefit from minimally invasive therapies and safely directing these treatments.

ENDOSCOPIC URETEROURETEROSTOMY: LONG-TERM FOLLOWUP USING A NEW TECHNIQUE

PURPOSE We describe a new technique using a single ureteroscope and fluoroscopy for reestablishing ureteral continuity. MATERIALS AND METHODS Nine patients with obliterated ureteral segments (1 bilateral) were referred for treatment, of whom 3 had concurrent ureterovaginal fistulas. Mechanism of injury included open pelvic surgery in 9 ureteral segments and ureteroscopy in 1. Ureteral continuity was reestablished using a technique combining ureteroscopy and a fluoroscopically guided antegrade snare. The affected ureteral segment was then dilated and stented using a 14/7 reversed endopyelotomy stent. RESULTS Ureteral continuity was reestablished in all 10 consecutive attempts with this technique. At a mean followup of 16 months (range 6 to 33) all patients were stent-free without radiological evidence of obstruction. All 3 patients with fistulas were dry. In 3 patients ureteral strictures developed and required balloon dilation. Balloon dilation failed in 1 case and ultimately ureteral reimplantation was required. CONCLUSIONS Ureteral continuity can be safely and effectively reestablished using a single ureteroscope. As a minimally invasive technique, endoscopic ureteroureterostomy should be considered before open surgical reconstruction.

Flexible cystoscopic bladder biopsies: A technique for outpatient evaluation of the lower urinary tract urothelium

Routine urothelial biopsies of the lower urinary tract are obtained using the cold cup biopsy technique. This procedure is most often performed in the surgical suite and requires rigid endoscopic access and the use of biopsy forceps and Bugbee electrodes to obtain tissue for histologic examination. A new single-step biopsy forceps has been used through the flexible cystoscope. Using a 16 F actively deflectable, flexible cystoscope and the 5.4 F Therma Jaw Hot Urologic Forceps, bladder biopsies were obtained in 27 patients for a variety of indications. This biopsy forceps allows simultaneous tissue sampling and electrocoagulation of the biopsy site, thus eliminating the need for exchange of instruments through the flexible cystoscope. Tissue samples are somewhat protected from thermal changes during coagulation through the use of a Faraday cage. Biopsies were frequently obtained in an outpatient setting, requiring only local topical anesthesia (2% lidocaine jelly). Carcinoma in situ, transitional cell carcinoma, acute and chronic inflammation, and normal bladder mucosa were differentiated histologically. Using this technique, lower urinary tract urothelial mapping can be performed safely in the office with minimal patient discomfort.