S. Bapat

Comparison of Holmium Laser and Pneumatic Lithotripsy in Managing Upper-Ureteral Stones

OBJECTIVE To compare the success rates and complications of Lithoclast and holmium laser-assisted ureterorenoscopy (URS) in managing upper-ureteral stones. MATERIAL AND METHODS We retrospectively analyzed the records of 394 patients with upper-ureteral stone who underwent ureteroscopic lithotripsy at our institution from January 2000 to December 2005. In 193 patients (mean stone size 12.3 mm), pneumatic lithotripsy was used; in 201 patients (mean stone size 11.5 mm), laser lithotripsy was performed. Patients were monitored as outpatients at 2 weeks, at 3 months, and then annually with a kidneys, ureters, and bladder radiograph and ultrasonography. Patients with migrated stones or incomplete clearance underwent an auxiliary procedure such as shockwave lithotripsy (SWL) or repeated URS. Follow-up ranged from 6 to 24 months. RESULTS Fragmentation of stones to fine pieces that pass eventually was assessed at 2 weeks. This did not include proximal migration of a stone or fragments that required auxiliary treatment. This occurred in 166/193 (86.01%) patients in the Lithoclast group and in 195/201 (97.01%) in the laser group. Ureteral perforations were nine in the Lithoclast group and six in the laser group. Auxiliary procedures included SWL (27/193 [13.98%] patients in the Lithoclast group and 4/201 [1.99%] patients in the laser group) or repeated URS (two in the Lithoclast group). Urosepsis after URS occurred in 11/193 patients in the Lithoclast group and 5/201 patients in the laser group. CONCLUSION In our study, the fragmentation rates of holmium laser-assisted ureteroscopy were significantly better in the upper ureter. The complications and the need for auxiliary procedures were significantly less for holmium laser-assisted ureteroscopy when compared with pneumatic lithotripsy.

Is stenting required before retrograde intrarenal surgery with access sheath.

Background: Flexible ureterorenoscopies continue to assume an increasing role in the armamentarium of the endourologist. In many centers around the world, prior stenting is carried out before retrograde intrarenal surgery (RIRS) to passively dilate the ureter, which facilitates passage of a flexible ureteroscope with or without an access sheath. In our series, the first stage of passive dilatation with prior stenting was totally avoided without compromising the success of the procedure. Materials and Methods: From January 2004 to December 2007, 54 patients with 55 renal units underwent RIRS. The patients were between 28 and 65 years old. All patients had renal stones ranging in size from 8 mm to 22 mm. The mean serum creatinine level was 1.1 mg%. The lower ureter was dilated under ‘C - arm’ fluoroscopy guidance up to 14 FR. An access sheath of 10/12 Fr was passed over the working guide wire. RIRS (7.5/9.3 Fr) was introduced into the access sheath. The stones were fragmented using a holmium laser. The mean operating time was 85 mins (45-130 mins). Results: In 52 out of 55 renal units (94.5%), a flexible ureteroscope could be passed successfully into the kidney through an access sheath. In 3 of the cases (5.4%), the lower ureter could not be dilated. In these patients, the procedure was staged after passing a 6/26 JJ stent. An X-ray KUB was done at the 3-month follow-up visit. A total of 50 renal units (94.3%) were stone free at the 3-month follow-up visit. Conclusion: In a majority of the cases, RIRS could be accomplished successfully during the first sitting. Single stage RIRS did not alter the subsequent stone clearance or increase the incidence of morbidity or complications.

Shock wave lithotripsy as a primary modality for treating upper ureteric stones: A 10-year experience.

Aims and Objectives: Shock wave lithotripsy (SWL) has been recommended as a first-line treatment for upper ureteric calculi in several studies with a success rate of 80-90%. Our aim is to present our retrospective data of treatment of upper ureteric stones with SWL as primary modality over a 10-year period and evaluate the factors affecting fragmentation and clearance. Materials and Methods: From February 1997 to March 2007, 846 patients with upper ureteric stones were treated with SWL as the primary modality. Age: 9-69 years, 546 males and 300 females, stone size: 7-22 mm. Pyuria in 132/846 with clinical infection 40/132, pre-SWL JJ stenting: 40/846 and anesthesia in 41/846 patients. Duration of symptoms: < 4 weeks- 780/846, >4 weeks- 66/846. Stone size: < 1 cm- 513/846, >1 cm-333/846. Workup: X-Ray KUB, Urine and Uro-USG. Intravenous urogram (IVU): 130/846. Intraoperative (C-arm) fluoroscopic imaging was used. Presentation: colic-801/846, incidental-45/846. Criteria for clearance: symptomatic relief, X-ray and USG confirmation. Results: Clearance rate: < 1cm- 95.91% (492/513), >1 cm- 85.29% (284/333). Overall clearance rate: 91.73% (776/846). No clearance: 70/846 (8.27 %). In these, 59/70 underwent ureteroscopy, 8/70 percutaneous nephrolithotomy and 3/70 open ureterolithotomy for clearance. Post SWL complications were seen in 25 (3%) cases with septicemia in nine and stein strasse in 16 cases. Duration of symptoms < 4 weeks - 93.7% success (731/780), >4 weeks – 68.1% (45/66). Non-stented – 92% (744/806) success. Stented group–80% (32/40). Conclusions: Best results with SWL as monotherapy for upper ureteric stones are achieved when stones are less than 1 cm in size, of short duration history and without indwelling stents. Overall success rate – 91.73%.

Preputial skin free graft as dorsal onlay urethroplasty: Our experience of 73 patients.

Objective: To present the outcome of dorsal onlay urethroplasty in 73 patients for stricture urethra over a period of eight years. Materials and Methods: Seventy-three patients of stricture urethra have undergone dorsal onlay urethroplasty from July 1998 to February 2006. Age distribution: 14-58 years. Etiology: Trauma 20/73 (27.39%), Balanitis Xerotica Obliterans 2/73 (2.73%), Iatrogenic 26/73(35.61%), Infection 3/73 (4.10%), Idiopathic 22/73 (30.13%). Site: Penobulbar-25/73, bulbar-38/73, membranous-8/73 and long length-2/73. Suprapubic catheter was inserted preoperatively: 21/73 patients. Preputial / distal penile skin was used in all patients. Buccal mucosa was not used in any patient. Hospitalization was for four to five days. Catheter was removed after 21 days. All patients had their first endoscopic checkup after three months. Subsequently they were followed up by uroflometry. Routine imaging of urethra for follow-up was not carried out. Results: 63/73 (86.30%) patients had satisfactory outcome not requiring any further treatment, 8/73 (10.95%) developed anastomotic stricture (3/8-optical internal urethrotomy, 5/8 dilatation alone). 2/73 (2.75%) developed external meatal stenosis. None had urinary fistula and required repeat urethroplasty. Follow-up ranged from three months to eight years. Conclusion: Dorsal onlay urethroplasty using preputial/distal penile skin is a satisfactory procedure. Preputial/distal penile skin is devoid of hair and fat and hence an ideal graft material. Even in circumscribed patients distal penile skin can be harvested. Long-term follow-up is required in judging results of patients with stricture urethra.

Comparison of fluid absorption during transurethral resection of prostate and Holmium-Yag laser enucleation of benign adenoma of prostate using breath ethanol concentration

Objective: We conducted a study to detect, quantify and compare irrigation fluid absorption in transurethral resection of the prostate (TURP) and Holmium laser enucleation of the prostate (HoLEP), using BEC. Materials and Methods: The study included 50 patients of lower urinary tract symptoms, secondary to benign enlargement of prostate. The patients were nonrandomly allocated to undergo TURP and HoLEP. Twenty-six patients underwent TURP and the remaining 24 underwent HoLEP. Sterile water tagged with 1% ethanol w/v was used for irrigation. Absorption was detected and quantified every 10min by BEC levels. Data was analyzed using standard nomograms. Results: In HoLEP, 14/24 had no fluid absorption. The remaining 10/24 showed fluid absorption ranging from 95 ml to 300 ml. In TURP, all had fluid absorption ranging from 250-980 ml. Three TURP patients developed overt symptoms, while none did in the HoLEP group. Conclusions: Fluid absorption observed in our study in the HoLEP group was lower than in the TURP group.

Removal of migrated metallic prostatic stent by holmium laser

A 90-year-old male with prostatic hyperplasia with a history of ischemic heart disease and right-sided hemiplegia had undergone a Urolume stent placement because of acute urinary retention 9 months earliar. The stent had migrated into the bladder causing dysuria and a poor stream of urine. We fragmented the prostatic stent by Holmium (HO: YAG) laser followed by a laser prostatectomy. After the procedure, the patient voided satisfactorily.

Use of Kuntz Laser Carrier and Sachse Urethrotome Sheath in Percutaneous Nephrolithotomy: A Point of Technique

OBJECTIVE Percutaneous nephrolithotomy (PCNL) is an established minimally invasive modality for treating large renal stones. Even with newer crushing modalities, difficulties are encountered during intrarenal manipulation of complex pelvicalyceal anatomy. We are presenting a modified technique to overcome this difficulty by using Kuntz laser carrier and Sachse urethrotome sheath. MATERIALS AND METHODS This study was carried out from January 2000 to December 2005 in 294 renal units in 288 patients (age range, 20-70 years; mean age, 43 years; male:female = 211:77) on whom PCNL was performed with Holmium laser. From January 2000 to December 2002, 96 PCNL (group I) were performed by passing laser fiber through 26F nephroscope. From January 2003 to December 2005, in 197 PCNL (group II) after initial inspection with 26F nephroscope, laser stone fragmentation was performed using Kuntz laser carrier and Hopkins II telescope. This assembly was passed through 21F Sachse urethrotome sheath. In all patients, puncture and dilatation with insertion of 30F Amplatz sheath was carried out under Image Intensifier. LISA SPHINX Holmium laser (80 watts) was used in all cases; energy used was 20 to 40 watts. All stones were radio-opaque and well viewed on X-ray and fluoroscopically. RESULTS Overall stone clearance in group I was 87/96 (90.63%) and in group II was 185/197 (93.91%). Additional punctures were needed: 21/96 (21.88%) in group I and 19/197 (9.64%) in group II. Need for blood transfusion was 5/96 (5.20%) in group I and 2/197 (1.01%) in group II. Mean operating time was almost same for group I and group II. Mean stone size was 2644.70 +/- 587.07 mm(2) for group I and 2680.56 +/- 674.98 mm(2) for group II. CONCLUSION With Kuntz laser carrier passed through Sachse sheath, precise delivery of laser energy is possible. Smaller sheath aids in increased intrarenal maneuverability; precise infundibulotomy helps in better stone clearance. Thus, requirement of additional punctures and blood transfusion rate being less in group II has been proven to be statistically significant.