Üstünol Karaoğlan

Treatment of Ureteral Stones: Comparison of Extracorporeal Shock Wave Lithotripsy and Endourologic Alternatives

Aim of the Study: The aim of the study is to compare the effectiveness of ESWL and ureteroscopic lithotripsy with pneumatic, ultrasonic and electrohydraulic modalities in patients with ureteral stones. Patients and Method: In this study, 1,970 patients with ureteral stones were evaluated. ESWL and ureteroscopic lithotripsies were performed in 1,580 and 484 patients, respectively. The ESWL group was treated with a Siemens Lithostar plus. Ureteroscopic lithotripsy was performed with pneumatic lithotripsy (PL), ultrasonic lithotripsy (USL) and electrohydraulic lithotripsy (EHL) in 140 (28.9%), 311 (64.3%) and 33 (6.8%) patients, respectively. 94 patients underwent both because of unsuccessful ESWL therapy. Results: In the ESWL group, the stone-free rate was 49.9% and the fragmentation rate 71.0%. These values were: 95.0 and 97.1% for PL; 88.1 and 89.4% for USL; 90.9 and 93.9% for EHL, respectively. Ureteroscopic lithotripsy has been found more effective than ESWL in the treatment of middle and lower ureteral calculi (p < 0.001) and PL has the greatest success rate within these endoscopic groups. Conclusion: ESWL therapy can be the first-line therapy in upper ureteral stones keeping the other modalities for unfragmented stones. However, ureteroscopic lithotripsy is the most effective treatment choice in lower ureteral stones no matter which kind of energy used and PL is the most effective and less complicated among the other types.

Stones in anomalous kidneys : Results of treatment by shock wave lithotripsy in 150 patients

Objective:  To determine the efficacy of shock wave lithotripsy (SWL) in anomalous kidneys.

Management of Ureteral Stones with Pneumatic Lithotripsy: Report of 500 Patients

PURPOSE To evaluate the results of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of ureteral stones. PATIENTS AND METHODS We reviewed, retrospectively, the records of 500 patients (366 male, 134 female) with ureteral calculi treated by PL with the Swiss Lithoclast. Of these patients, 124 (24.8%) were treated primarily and 376 (75.2%) were treated secondarily after unsuccessful extracorporeal shockwave lithotripsy (SWL). The results were evaluated 3 months after treatment by excretory urography, ultrasonography, or both. RESULTS The over-all stone-free and fragmentation rates were 94.6% and 96.8%, respectively. These values were 97.1% and 98.5% for stones <or=10 mm and 83.7% and 89.1% for stones >10 mm, respectively. The main complications were stone migration (2.0%), urosepsis (3.0%), and ureteral perforation (1.4%). CONCLUSIONS While SWL is generally excepted as a first-line treatment option in ureteral stones because of its noninvasive nature, in situ lithotripsy, and especially PL, has higher success rates with minimal morbidity. Thus, PL seems to be a good alternative in patients in whom SWL was unsuccessful or not indicated and in patients who need early stone removal.

The Impact of Radiological Anatomy in Clearance of Lower Calyceal Stones after Shock Wave Lithotripsy in Paediatric Patients

OBJECTIVE To determine the factors affecting stone clearance after extracorporeal shock wave lithotripsy (ESWL) in children with lower calyceal stones. MATERIALS AND METHODS Lower pole stone clearance was reviewed in 34 patients aged between 2 and 16 years (23 boys and 11 girls) treated with ESWL between 1989 and 2001 in our clinic. Renal anatomy was determined on standard intravenous urograms. The lower infundibulopelvic angle (IPA) was measured by two different methods based either on measuring the angle between vertical pelvis axis and vertical axis of lower infundibulum or finding the angle between the ureteropelvic axis and vertical axis of lower infundibulum. RESULTS The mean age of the patients was 12.1+/-4.16 (2-16) years. The mean stone burden was found as 96.93+/-87.13 mm(2) and the mean shock wave number per session and power as 2631.4+/-593.1 and 17.57+/-1.1 kV, respectively. The stone-free rate was 55.9%. Fifteen (44.1%) cases had residual fragments retained in lower calices after lithotripsy and are still followed. The stone clearance was found to be unrelated to stone burden and infundibulum width (p=0.44 and p=0.34, respectively). However, a significant difference was present between mean lower pole infundibular length (p=0.0032) and lower IPA measurements according to both methods between stone-free cases and others. The most remarkable factor that had a significant influence on stone clearance was an acutely oriented infundibulum defined according to IPA-ureteropelvic axis angle determination method (p=0.00001) followed by Sampaios pelvic axis method (p=0.0001). Only 1 (5%) patient was stone-free under 40 degrees and 1 (6%) case with an angle of 45 degrees had residual fragments in the former method. Similarly none of the cases had residual fragments over 90 degrees for Sampaios method and 90% of the stone-free cases had a more obtuse angle. Thus, we determined that a cut-off point of 40 degrees for the IPA-ureteropelvic axis method and 90 degrees for Sampaios method was most useful to determine the clearance of lower pole fragments. CONCLUSION The factors affecting stone clearance in paediatric patients are similar to adults.

Extracorporeal Shock Wave Lithotripsy for Lower Caliceal Calculi

Objective: The aim of the study is to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL) therapy for isolated lower caliceal calculi. Patients and Methods: We analyzed 165 patients who were treated with the Siemens Lithostar Plus on an outpatient basis between March 1993 and August 1997. The age of patients ranged from 17 to 70 (mean 39.11) years. The stone size varied from 4 to 42 mm, and patients who had stones larger than 21 mm had a double-J stent inserted prior to treatment. Results: The overall stone-free rate at 3 months was 53.33%; whereas it was 61.79, 48.27, and 27.27% according to the stone size, ≤10, 11–20 and ≥21 mm, respectively. Complications were rare, including 2 pyelonephritis, 2 subcapsular hematoma formation, 24 renal colics and 8 stone streets, which were managed by ureteral stenting or additional ESWL and resulted in complete stone clearance. Conclusion: ESWL therapy is a reasonable and effective method for small lower caliceal stones, but due to its relatively low stone-free and high complication rates, percutaneous nephrolithotripsy or open surgery should be considered for stones larger than 21 mm.

What is the optimal treatment for lower ureteral stones larger than 1cm

Purpose : To compare the treatment options for lower ureteral stones larger than 1 cm.

An Unusual Cause of Urinothorax

Urinothorax is a rare complication of blunt renal trauma, ureteral instrumentation or ureteral surgery. A leakage from the urinary tract causes urinoma, a retroperitoneal collection of fluid, which can lead to urinothorax. We report a patient with solitary kidney who underwent extracorporeal shock wave lithotripsy (ESWL) for nephrolithiasis. Four days after ESWL, she had right-sided pleural effusion which demonstrated as urinothorax. Urinoma occurring after ESWL, as in our case, is a situation that has not been reported before as a cause of urinothorax. Urinothorax should be taken into consideration in patients with pleural effusion who recently underwent ESWL.

Value of Ultrasonography and Helical Computed Tomography in the Diagnosis of Stone-Free Patients after Extracorporeal Shock Wave Lithotripsy (USG and Helical CT after SWL)

Aim: To define the value of different radiologic modalities in determining the patients who believed to be stone-free after extracorporeal shock wave lithotripsy (SWL) with plain abdominal X-ray, by evaluating the same patients with ultrasonography (USG) and helical computed tomography (CT). Patients and methods: Between March 2002 and February 2003, 76 patients with urolithiazis who were treated with SWL and considered to be stone-free with plain abdominal X-ray, were evaluated with USG and helical CT. The results were compared for the accuracy of the stone-free diagnosis. Results: Residual stones were detected in 9 (11.8%) with USG and in 17 (22.3%) with CT of 76 patients who were thought to be stone-free with plain abdominal X-ray alone. Conclusions: Although plain abdominal X-ray has been accepted as the first line diagnostic tool in the follow-up after SWL with its cheap and practical use, helical CT was found to be more valuable in diagnosis of residual stone fragments which has not been found in plain abdominal X-ray. If we take these considerations which can change our clinical approach and patient follow-up into account, we believe that the routine use of helical CT can give more accurate information in patient controls after SWL.

Significance of Lower-Pole Pelvicaliceal Anatomy on Stone Clearance after Shockwave Lithotripsy in Nonobstructive Isolated Renal Pelvic Stones

PURPOSE To investigate the probable effect of lower-pole pelvicaliceal anatomy on stone clearance after shockwave lithotripsy (SWL) in patients with nonobstructive renal pelvic stones. PATIENTS AND METHODS The clinical records of patients with isolated renal pelvic stones who underwent SWL between 1996 and 2005 were reviewed. After excluding patients with obstruction leading to dilatation, major anatomic abnormalities, noncalcium stones, metabolic abnormalities, history of recurrent stone disease, multiple stones, and previous renal surgery, 153 patients were enrolled in the study. Lower pole infundibulopelvic angle (IPA) and infundibular length and width were measured from intravenous urography. Patients were classified into three groups according to stone burden (group 1, <100 mm(2); group 2, 101-200 mm(2); group 3, 201-400 mm(2)). RESULTS The mean stone size was 142.08+/-86.3 mm(2). Overall stone-free rate was 53.6%. Localization of clinically significant or insignificant residual fragments was in the lower calix, renal pelvis, and both in 50 (32.6%), 29 (18.9%), and 8 (5.2%) patients, respectively. There was no statistically significant difference in pelvicaliceal anatomic features except narrower IPA (P=0.02) in group 1 patients with residual stones. CONCLUSION The falling of stone fragments to the lower calix in spite of the ureter whether clinically significant or not after SWL of pelvic stones initially seems to be related to stone burden rather than lower caliceal anatomy. However, existence of a more narrow IPA in group 1 patients with residual fragments led us to believe that lower-pole IPA can play a role in stone clearance, especially for smaller stones, probably because of smaller residual fragment size or the more mobile nature of the primary stone.

Pelvicalyceal stone load: a factor affecting the outcome of extracorporeal shockwave lithotripsy for renal pelvic calculi

Objectives To determine the effect of variations in pelvicalyceal volume on the results of extracorporeal shock wave lithotripsy (ESWL) and the relationship of stone load to estimated pelvicalyceal volume in patients with renal pelvic stones.