Retrospective comparative study of rigid and flexible ureteroscopy for treatment of proximal ureteral stones

ABSTRACT Background: We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS). Subjects and methods: Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications. Results: The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusıon: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.

Shock Wave Lithotripsy in Ureteral Stones: Evaluation of Patient and Stone Related Predictive Factors

ABSTRACTPurpose:To evaluate the patient and stone related factors which may influence the final outcome of SWL in the management of ureteral stones.Materials and Methods:Between October 2011 and October 2013, a total of 204 adult patients undergoing SWL for single ureteral stone sizing 5 to 15 mm were included into the study program. The impact of both patient (age, sex, BMI,) and stone related factors (laterality, location, longest diameter and density as CT HU) along with BUN and lastly SSD (skin to stone distance) on fragmentation were analysed by univariate and multivariate analyses. Results: Stone free rates for proximal and distal ureteral stones were 68.8% and 72.7%, respectively with no statistically significant difference between two groups (p=0.7). According to univariate and multivariate analyses, while higher BMI (mean: 26.8 and 28.1, p=0.048) and stone density values (mean: 702 HU and 930 HU, p<0.0001) were detected as statistically significant independent predictors of treatment failure for proximal ureteral stones, the only statistically significant predicting parameter for the success rates of SWL in distal ureteral stones was the higher SSD value (median: 114 and 90, p=0.012).Conclusions:Our findings have clearly shown that while higher BMI and increased stone attenuation values detected by NCCT were significant factors influencing the final outcome of SWL treatment in proximal ureteral stones; opposite to the literature, high SSD was the only independent predictor of success for the SWL treatment of distal ureteral stones.

Extracorporeal shock wave lithotripsy in the treatment of renal and ureteral stones / Litotripsia extracorpórea no tratamento de cálculos renais e ureterais

The use of certain technical principles and the selection of favorable cases can optimize the results of extracorporeal shock wave lithotripsy (ESWL). The aim of this study is to review how ESWL works, its indications and contraindications, predictive factors for success, and its complications. A search was conducted on the Pubmed® database between January 1984 and October 2013 using "shock wave lithotripsy" and "stone" as key-words. Only articles with a high level of evidence, in English, and conducted in humans, such as clinical trials or review/meta-analysis, were included. To optimize the search for the ESWL results, several technical factors including type of lithotripsy device, energy and frequency of pulses, coupling of the patient to the lithotriptor, location of the calculus, and type of anesthesia should be taken into consideration. Other factors related to the patient, stone size and density, skin to stone distance, anatomy of the excretory path, and kidney anomalies are also important. Antibiotic prophylaxis is not necessary, and routine double J stent placement before the procedure is not routinely recommended. Alpha-blockers, particularly tamsulosin, are useful for stones >10mm. Minor complications may occur following ESWL, which generally respond well to clinical interventions. The relationship between ESWL and hypertension/diabetes is not well established.

A utilização de certos princípios técnicos e a seleção de casos favoráveis podem otimizar os resultados da litotripsia extracorpórea por ondas de choques (LECO). O objetivo deste trabalho é revisar os princípios de funcionamento da LECO, suas indicações e contraindicações, fatores preditivos de sucesso e suas complicações. Realizou-se uma pesquisa na base de dados do Pubmed® entre janeiro/1984 e outubro/2013 utilizando como palavras chaves shock wave lithotripsy e stone. Apenas artigos com bom nível de evidência, de língua inglesa, em seres humanos, do tipo clinical trials ou de revisão/metanálise foram incluídos. Na busca pela otimização dos resultados da LECO, diversos fatores técnicos, como o tipo de aparelho de litotripsia, energia e frequência dos pulsos, acoplamento do paciente ao litotridor, localização do cálculo e tipo de anestesia, devem ser levados em consideração. Fatores relacionados ao doente e ao cálculo, como seu tamanho, densidade, distância pele-cálculo, anatomia da via excretora e anomalias renais, também são importantes. A profilaxia com antibiótico não é necessária, e a passagem de duplo J de rotina não é recomendada. A prescrição de alfabloqueadores, particularmente a tansulosina, é benéfica em cálculos > 10 mm. Complicações menores podem ocorrer após LECO e geralmente respondem bem a condutas clínicas. A relação entre LECO e o surgimento de hipertensão e diabetes não está comprovada.

Ureteral stricture formation after ureteroscope treatment of impacted calculi: A prospective study

PURPOSE: Urinary calculi is a familiar disease. A well-known complication of endourological treatment for impacted ureteral stones is the formation of ureteral strictures, which has been reported to occur in 14.2% to 24% of cases. MATERIALS AND METHODS: This was a prospective study. Ureterotripsy treatment was used on patients with impacted ureteral stones. Then, after 3 months and 6 months, the condition of these patients was assessed by means of a kidney-ureter-bladder (KUB) ultrasound. If the KUB ultrasound indicated moderate to serious hydronephrosis, the patient was further assessed by means of a computed tomography intravenous urogram or retrograde pyelogram to confirm the occurrence of ureteral strictures. RESULTS: Of the 77 patients who participated in the study, 5 developed ureteral strictures. Thus, the stricture rate was 7.8%. An analysis of the intraoperative risk factors including perforation of the ureter, damage to the mucous membrane, and residual stone impacted within the ureter mucosa revealed that none of these factors contributed significantly to the formation of the ureteric strictures. The stone-related risk factors that were taken into consideration were stone size, stone impaction site, and duration of impaction. These stone factors also did not contribute significantly to the formation of the ureteral strictures. CONCLUSIONS: This prospective study failed to identify any predictable factors for ureteral stricture formation. It is proposed that all patients undergo a simple postoperative KUB ultrasound screening 3 months after undergoing endoscopic treatment for impacted ureteral stones.

A meta-analysis of the efficacy of ureteroscopic lithotripsy and extracorporeal shock wave lithotripsy on ureteral calculi

PURPOSE: To re-evaluated the clinic efficacy of ureteroscopic lithotripsy (URS) and extracorporeal shock wave lithotripsy (ESWL) on ureteral calculi with Cochrane systematic reviews in this paper. METHODS: We searched clinical randomized controlled trials and prospective controlled trials in databases such as Cochrane library, Medline, Springer, Elsevier Science Direct, PubMed. Pooled estimate of risk ratios (RRs), standard mean difference (SMD) with 95% confidence intervals (CIs) were used as measure of effect sizes. Summary effect estimates were also stratified by sample size, study design and study region. The overall effect sizes were derived using a random-effects model or fixed-effects model when appreciated, and meta-analysis were conducted with software RewMan 5.0. RESULTS: The meta-analysis suggested that there were significant differences of post-treatment stone free rate, repeat treatment rate, patients' satisfaction, incidence of postoperative complications, operation time and hospital stays between ESWL treatment cases and URS treatment cases. But in the sample sizes analysis, there were no significant differences of the post-treatment stone free rate and repeat treatment rate when the sample sizes were less than 100. CONCLUSIONS: Compared to the ureteroscopic lithotripsy treatment, extracorporeal shock wave lithotripsy treatment provided a significantly lower post-treatment stone free rate, but it also obviously brought out less postoperative complications, shorter operation time and hospital stays. .

Outcomes of intracorporeal lithotripsy of upper tract stones is not affected by BMI and skin-to-stone distance (SSD) in obese and morbid patients

Purpose The purpose of this study is to determine if body mass index (BMI) and stone skin distance (SSD) affect stone free rate (SFR) in obese and morbid obese patients who underwent flexible URS for proximal ureteral or renal stones < 20 mm. Materials and Methods A retrospective chart review was performed of consecutive patients that underwent flexible URS. Inclusion criteria were: proximal ureteral stones and renal stones less than 20 mm in the preoperative computed tomography (CT). SFR were then compared according to SSD and BMI. Results A total of 153 patients were eligible for this analysis, 49 (32.02%) with SSD < 10 cm and 104 (67.97%) with SSD ≥ 10 cm. The mean stone size was 10.5 ± 6.4 mm. The overall SFR in our study was 82.4%. The SFR for the SSD < 10 and ≥ 10 were 79.6% and 83.7% respectively (p = 0.698) and for BMI < 30, ≥ 30 and < 40 and ≥ 40 were 82.9%, 81.7% and 90.9% respectively. Regression analysis showed no affect between BMI or SSD regarding SFR. Conclusion Ureteroscopy should be considered as a first-line of treatment for renal/proximal stones in obese and morbid obese patients. URS may be preferable to SWL in obese patients independently of the SSD, BMI or the location of proximal stones. .

Withdraw of the Ureteroscope Causes Fragmented Ureter Stones to Disperse

Introduction Ureteroscopy has improved from the first use of ureteroscope in the 1970's. Although the success rate increased in the last years, (1) new treatment techniques are being developed for impacted and large proximal ureter stones (2). Pneumatic lithotripsy has high efficiency with low complication rates (2). However, in case of steinstrasse and large (> 1 cm) ureter stones, fragmented small stones may obstruct insertion of a ureteroscope after initial lithotripsy. In order to triumph over this issue, multiple ureteroscopic passages and manipulations needed for extraction of these small stones by forceps or basket catheters. The overall incidence of stricture was found upto 14.2% when the fragments were removed with a grasping forceps or a basket (3). We present our technique to disperse small fragmented stones in order to contact non-fragmented rest stone. Materials and Methods Ureteral lithotripsy was performed with an 8-9.8F semirigid ureteroscope using a pneumatic lithotripter (Swiss LithoClast, EMS, Nyon, Switzerland). The stone was fragmented into small pieces as small as 2-3 mm. by pneumatic lithotripter. Eventually, these fragmented stones interfered with vision and the lithotripter to get in touch with the rest stone. After fragmenting distal part of the large stone, the ureteroscope was pulled back out of ureter. While pulling back, the operating channel was closed and irrigation fluid was flowing in order not to decrease pressure behind the stones. Simultaneously, a person tilted the operating table to about 30° in reverse Trendelenburg position. When the ureteroscope was out of ureteral orifice, the operating channel was opened and irrigation fluid was stopped. This maneuver aided decreasing pressure in the bladder more rapidly in addition to feeding tube. Stone dust and antegrade fluid flow were easily seen out of the ureteral orifice. Ureteroscope was re-inserted after 30-60 seconds. While reaching the ...

Impacted Anterior Urethral Calculus Complicated by a Stone-containing Diverticulum in an Elderly Man: Outcome of Transurethral Lithotripsy without Resection of the Diverticulum

Introduction The prevalence of lower urinary tract symptoms (LUTS) is about 20% in men aged 40 or above. Other than benign prostatic hyperplasia (BPH), urethral diverticulum or calculus is not uncommon for LUTS in men. Surgical treatment is often recommended for urethral diverticulum or calculus, but treatment for an impacted urethral calculus complicated by a stone-containing diverticulum is challenging. Materials and Methods An 82-year-old man had the persistence of LUTS despite having undergone transurethral resection of prostate for BPH. Regardless of treatment with broad spectrum antibiotics and an α-blocker, LUTS and post-void residual urine volume (100 mL) did not improve although repeated urinalysis showed reduction of WBCs from 100 to 10 per high power field. Further radiology revealed multiple urethral calculi and the stone configuration suggested the existence of a diverticulum. He was successfully treated without resecting the urethral diverticulum; and a new generation of ultrasound lithotripsy (EMS, Nyon, Switzerland) through a 22F offset rigid Storz nephroscope (Karl Storz, Tuttingen, Germany) was used to fragment the stones. Results The operative time was 30 minutes and the stones were cleanly removed. The patient was discharged after 48 hours with no immediate complications and free of LUTS during a 2 years follow-up. Conclusions When the diverticulum is the result of a dilatation behind a calculus, removal of the calculus is all that is necessary. Compared with open surgery, ultrasound lithotripsy is less invasive with little harm to urethral mucosa; and more efficient as it absorbs stone fragments while crushing stones. .

Comparative study on ureteroscopic lithotripsy and laparoscopic ureterolithotomy for treatment of unilateral upper ureteral stones / Estudo comparativo entre litotripsia e ureterolitotomia laparoscópica no tratamento de cálculos unilaterais altos

PURPOSE: To compare the curative effects of ureteroscopic lithotripsy and laparoscopic ureterolithotomy for unilateral upper ureteral stones, and to explore optimal surgical indications and skills. METHODS: Fifty cases of unilateral upper ureteral stones were randomly divided into two groups: one group underwent ureteroscopic holmium laser lithotripsy under epidural or lumbar anesthesia (n=25), and another group underwent laparoscopic ureterolithotomy under general anesthesia (n=25). Double-J stent was routinely indwelled in both groups. Operating time, postoperative hospitalization time, stone clearance rate and perioperative complications were compared. RESULTS: Operation was successfully performed in all 50 cases, and no open surgery was converted in any case. In the ureteroscopy and laparoscopy groups, the mean operating time was 49.0±10.7 min and 41.8±8.0 min (t=2.68, P=0.00999), respectively, their hospitalization time was 2.8±1.3 days vs. 2.9±0.8 days (t =-0.40, P=0.69413), and stone clearance rate was 88.0 percent (22/25) vs. 100 percent (25/25). Stone moved to the renal pelvis in three cases in the ureteroscopy group, and residual stones were removed by extracorporeal shock-wave lithotripsy (ESWL). All patients were followed up for more than three months, and no serious complications such as ureterostenosis occurred. CONCLUSIONS: Laparoscopic ureterolithotomy has a higher stone clearance rate and shorter operation time compared with ureteroscopic lithotripsy. Laparoscopic ureterolithotomy is one safe and effective treatment on unilateral upper ureteral stones.

OBJETIVO: Comparar os efeitos curativos da litotripsia ureteroscópica e a ureterolitotomia laparoscópica para cálculos unilaterais altos e pesquisar as indicações e resultados. MÉTODOS: Cinquenta casos de cálculos unilaterais altos foram distribuídos aleatoriamente em dois grupos: um grupo submetido a litotripsia ureteroscópica com laser holmium sob anestesia epidural ou lombar (n=25) e outro grupo submetido a ureterolitotomia laparoscópica sob anestesia geral (n=25). Duplo-J stent foi rotineiramente instalado em ambos os grupos. Comparou-se o tempo operatório, tempo de hospitalização pós-operatória, nível de desaparecimento dos cálculos e complicações pós-operatórias. RESULTADOS: Atos operatórios nos 50 casos sem ocorrências e nenhum ato convertido. Nos grupos por ureteroscopia e laparoscopia, o tempo operatório médio foi 49,0±10,7 minutos e 41,8±8,0 minutos (t=2,68, P=0,00999) respectivamente, tempo de hospitalização foi 2,8±1,3 dias vs. 2,9±0,8 dias (t=0,40, P=0,69413) e o nível de desaparecimento dos cálculos foi 88.0 por cento (22/25) vs. 100 por cento (25/25). Cálculo deslocado para pelve renal em três casos no grupo ureteroscópico e cálculos residuais foram removidos por litotripsia por onda de choque extracorpóreo (ESWL). Todos pacientes foram seguidos por mais de três meses e não ocorreram complicações sérias como estenoses ureterais. CONCLUSÕES: A ureterolitotomia laparoscópica teve maior nível desaparecimento dos cálculos e tempo operatório menor comparado à litotripsia ureteroscópica A ureterolitotomia laparoscópica é um tratamento seguro e efetivo para cálculos ureterais unilaterais altos.

Single-session ureteroscopic pneumatic lithotripsy for the management of bilateral ureteric stones

PURPOSE: In nowadays there is no consensus on single-session ureteroscopic lithotripsy (URSL) for the management of bilateral ureteric stones. The aim of this study was to evaluate efficacy and safety of single-session URSL in patients with bilateral ureteric stones. MATERIALS AND METHODS: 41 patients who have undergone bilateral single-session URSL were evaluted in this study. A 8/9.8 Fr Wolf semi-rigid ureteroscope was used for the procedures, and the stones were fragmented with pneumatic lithotripter. RESULTS: A high stone-free rate was achieved (90.2%) after single endoscopic procedure with a retreatment rate of 9.8%. The procedure was most successful for distal ureteric stones with a 96.2% stone-free rate followed by middle ureteric stones with a 81.8% stone-free rate while the least success was achieved for proximal ureteric stones with a 77.7% stone-free rate (p < 0.05). A greater stone-free rate was obtained in those with stones less than 10 mm (93.7%) than in those with stones larger than 10 mm (77.7%) (p < 0.05). Ureteral perforation occurred in only one patient (2.4 %). No long-term complication was observed in any patient. CONCLUSIONS: Bilateral single-session URSL can be performed effectively and safely with a low complication rate in patients with bilateral ureteric stones. It can reduce the need of anaesthetics and hospital stay.

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

OBJECTIVE: Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital. MATERIALS AND METHODS: Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients. RESULTS: Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i.e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers. CONCLUSION: Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Steinstrasse predictive factors and outcomes after extracorporeal shockwave lithotripsy

PURPOSE: Urinary stone disease is a common medical problem. Extracorporeal shockwave lithotripsy (SWL) has been applied with high success and low complication rates. Steinstrasse (SS) is a possible complication after SWL. The aim of the present study was to prospectively evaluate the factors and outcomes associated with SS after SWL. MATERIALS AND METHODS: We have prospectively evaluated 265 SWL sessions (2005-2009). Two lithotriptors were used randomly: Siemens Lithostar and Dornier Compact S. All patients had imaging exams after 30 and 90 days or according to symptoms. RESULTS: SS was observed in 14 (5.3 percent) out of 265 SWL procedures (n = 175 patients, 51.5 percent women/48.5 percent men, mean ± SD age = 46.3 ± 15.5 years). SS was more common after SWL for pelviureteral calculi rather than caliceal stones (p = 0.036). There was a trend toward more occurrences of SS after SWL for larger stone area (> 200 mm², p = 0.072). Preoperative ureteral stent didn't prevent SS. SWL machine, intensity, number of pulses and frequency were not associated with SS formation. Post-SWL pain, fever and gravel elimination were factors associated with SS (p = 0.021; p = 0.011; p = 0.078). When SS occurred, treatment modalities included Medical Expulsive Therapy (MET), ureteroscopy and SWL. CONCLUSIONS: Steinstrasse is an uncommon event after SWL and seems to occur more frequently with larger pelviureteral stones. Impaction of stones is more frequent in the middle ureter. All patients should be followed after SWL, but SS should be specially suspected if there is macroscopic gravel elimination, flank pain and/or fever. When SS occurs, treatment should be promptly introduced, including medical expulsive therapy, surgical approach or SWL in selected cases. Further prospective studies are awaited to evaluated preventive measures for SS occurrence.

Tamsulosin in the expulsion of distal ureteral calculi

The purpose of the work is to evaluate the effectiveness of Tamsulosin for patients with distal ureteral calculi with respect to its effect on stone expulsion and time to stone expulsion. This prospective randomized controlled study included a total of 70 patients with distal ureteral calculi, who presented to the outpatient clinic of El-Sahel Teaching Hospital between March 2009 and May 2011. Their age range was between 19-65 years in the Tamsulosin group and 20 - 68 years in the control group. Selection criteria included a ureteral calculus located in the distal ureter [Juxtavesical or Intramural], single, size less than 1 cm with no or minimal ipsilateral hydronephrosis and normal contralateral kidney. Patients with solitary kidney, renal insufficiency and high grade obstruction, were excluded. All patients were initially assessed by appropriate physical examination followed by plain UT and I.V.U to locate site and size of the calculus. Urinary tract ultrasound was done to exclude solitary kidney or high grade obstruction and for follow up of patients during the study. Renal functions in the form of blood urea and serum creatinine, were done. Patients with ipsilateral ureteral surgical manipulation, serious medical conditions,pregnancy and those receiving calcium channel blockers or corticosteroids, were excluded. A written informed consent was signed by all patients included in the study. The patients were randomlly categorized into 2 groups, each group consists of 35 patients: Group I [Control Group] included 35 patients who were given oral sodium diclofenac 50 mg twice/day for 10 days. Group II [Tamsulosin group] included 35 patients, who were given Tamsulosin 0.4 mg once/day for 28 days or until stone expulsion [whoever is nearer] in addition to oral sodium diclofenac 50 mg twice/day for 10 days. All patients in both groups were instructed to drink a minimum of 2 liters of water every day and for follow up including number of pain episodes, serum creatinine, KUB and urinary ultrasound. The primary endpoint of the study was the determination of the stone passage time, episodes of renal colic, need for analgesia, drug adverse effects, stone size and distal ureteral stone site whether Juxtavesical or Intramural. Sex distribution was 24 males and 11 females in group 1 [control group] compared to 22 males and 13 females in group 2 [Tamsulosin group]. Age ranges were 20 - 68 years [mean 41.2 +/- 10.55 years] and 19 - 65 years [mean 39.3 +/- 10.67years] for groups 1 and 2 respectively. Stone sizes ranged bet ween 4-10 mm in both groups [mean of 5.3 +/- 1.24 and 5.8 +/- 1.58 mm in groups 1 and 2 respectively].In both groups, no significant statistical differences,were noted as regards patients age,sex distribution or laterality [P= 0.453, P= 0.615 and P= 0.461 respectively]. The overall stone expulsion rate was 60% and 94.3% in groups 1 and 2 respectively. For stones < 6 mm, expulsion rates were 76.2% and 95.7% in groups 1 and 2 respectively. For stones 7-10 mm, the expulsion rates were 35.7% and 91.7% in groups 1 and 2 respectively.The improvements percentages in stone expulsion attained were 37.5% and 120% for stones < 6mm and 7-10 mm respectively. Episodes of renal colic were reported in 26 patients [74.3%] in the control group versus 8 patients [22.9%] in the Tamsulosin group [P< 0.001]. Tamsulosin is an effective and safe therapy for uncomplicated distal ureteral calculi as it improves stone passage rates,shortens passage time,decreases analgesia requirements and decreases the need for intervention. Moreover, these results allowed home management without hospitalization and allowed the patient to almost regularly perform everyday activities. Tamsulosin augments stone passage rates for all stone sizes especially for larger stones than smaller ones.Moreover,Tamsulosin shortens the time of stone passage especially for smaller stones than larger ones

Comparison between two shock wave regimens using frequencies of 60 and 90 impulses per minute for urinary stones

PURPOSE: Two different regimens of SWL delivery for treating urinary stones were compared. METHODS: Patients with urinary stones were randomly divided into two groups, one of which received 3000 shocks at a rate of 60 impulses per minute and the other of which received 4000 shocks at 90 impulses per minute. Success was defined as stone-free status or the detection of residual fragments of less than or equal to 3 mm three months after treatment. Partial fragmentation was considered to have occurred if a significant reduction in the stone burden was observed but residual fragments of 3mm or greater remained. RESULTS: A total of 143 procedures were performed with 3000 impulses at a rate of 60 impulses per minute, and 156 procedures were performed with 4000 impulses at 90 impulses per minute. The stone-free rate was 53.1 percent for patients treated with the first regimen and 54.8 percent for those treated with the second one (p = 0.603). The stone-free rate for stones smaller than 10 mm was 60 percent for patients treated with 60 impulses per minute and 58.6 percent for those treated with 90 impulses per minute. For stones bigger than 10 mm, stone-free rates were 34.2 percent and 45.7 percent, respectively (p = 0.483). Complications occurred in 2.3 percent of patients treated with 60 impulses per minute and 3.3 percent of patients treated with 90 impulses per minute. CONCLUSION: No significant differences in the stone-free and complication rates were observed by reducing the total number of impulses from 4000 to 3000 and the frequency from 90 to 60 impulses per minute.

Extracorporeal shock wave lithotripsy; outcome in pediatric urolithiasis

[1] To determine the efficacy of extra-corporeal shock wave lithotripsy with reference to stone size, site and radiodensity in children. [2] To determine acute early complications during and following extra-corporeal shock wave lithotripsy in children. Analytical case series study. Fifty patients of either sex below the age fourteen [14 years] having renal, ureteric and bladder stones between 5-20 mm in size along with their long axis presented to department of urology Shaikh Zayed Hospital Lahore during the period of one year extending from 02-02-2008 to 02-02-2009 were included in this study. Children with serum creatinine level greater than or equal to 3mg/dl, obstruction distal to the stone, patient with active bleeding disorders, uncorrected hypertension, patient unfit for general anaesthesia, untreated urinary tract infection and patients with gross anatomical anomaly were excluded from study. All the patients were given shock waves under intravenous sedation or general anaesthesia in a standard manner on out door basis. All the children were evaluated for stone clearance and early complications at first 24-72 hours. At the end of three months ESWL treatment was considered successful, if the patients were stone free or had residual fragments 4 mm or less in size. Out of the fifty patients, 40 [80%] were males and 10 [20%] females with male to female ratio of 4.1. The age range of patients was 2-14 years [mean +/- SD 9.24 +/- 3.48 years]. Thirty three patients [66%] had renal stones, 7 [14%] ureteric and 10 patients [20%] had bladder stones. Single successful treatment session was noted in 22 patients [44%], 18 patients [36%] received two sessions and 10 patients [20%] required three sessions for successful stone fragmentation. Seventeen patients did not show stone clearance even after three sessions within three months follow-up. Twenty one patients [42%] felt pain after lithotripsy session, and they were given injectable analgesia and the pain settled, haematuria in 17 patients [34%], impacted stone in five [10%], ureteric colic and urinary tract infection in three, three cases respectively and only one case developed steinstrasse. Twenty patients [40%] developed minor complications of anaesthesia, like nausea, vomiting which relieved with injectable antiemetics

Is there any role for alpha-blockers to treate lower urinary tract symptomatology after ureteral stenting?

Internal ureteral stents are associated with lower urinary tract symptomatology and can cause significant patient morbidity. This study aimed to evaluate the role of alpha-blockers as a treatment for stent-related symptoms. Sixty patients were scheduled for ureteral stenting after retrieval of lower ureteric stones. Thirty patients received Tamsulosin 0.4mg capsule daily postoperative and the other 30 patients did not received Tamsulosin. No significant difference was obtained between the groups with regard to age, sex, or postoperative haernaturea. Also, no statistically significant difference as regard suprapubic discomfort in the 2 groups on day 0, 1 and 6 [p 0.04], as well in urinary frequency, urgency or dysuria between the groups on the postoperative day-1. The irritative symptoms significantly reduced in both groups on day 6 [p<0.001]. Tamsulosin has no significant effect on stented patients in terms of bladder pain relief and irritative bladder symptoms

Impact of obesity on ureteroscopic laser lithotripsy of urinary tract calculi

Purpose: The treatment of urinary tract stones in obese patients may differ from the treatment of non-obese patients and their success rate varies. Our objective was to compare ureteroscopic treatment outcomes of ureteral and renal stones, stratified for stone size and location, between overweight, obese and non-obese patients. Materials and Methods: Charts were reviewed for 500 consecutive patients presenting at our institution for renal and ureteral stones. A total of 107 patients underwent flexible or semi-rigid ureteroscopy with Ho:YAG laser lithotripsy and met criteria for review and analysis. Results: Overall, initial stone-free rates were 91 percent, 97 percent, and 94 percent in normal, overweight and obese individuals respectively. When compared to non-obese patients, there were no significant differences (p value = 0.26; 0.50). For renal and proximal ureteral stones, the stone-free rate in overweight and obese individuals was 94 percent in both groups; and a stone-free rate of 100 percent was found for distal stones, also in both groups. Conclusions: Ureteroscopic treatment of stones in obese and overweight patients is an acceptable treatment modality, with success rates similar to non-obese patients.

prospective randomized trial comparing non-stented versus routine stented ureteroscopic holmium laser lithotripsy

To determine whether post-operative ureteral stenting is necessary after ureteroscopic lithotripsy for the treatment of middle and distal ureteral calculi. The trial was carried out in the Department of Urology of West China Hospital, Sichuan University, Chengdu, China, between May 2005 and May 2006. A total of 110 patients underwent uncomplicated ureteroscopic lithotripsy. After the procedure, patients were randomized to a non-stented [n=55], or stented [n=55] group. The stent was routinely placed for 3 weeks. Outcome measures included operative time, visual analog scale, postoperative analgesic requirements, complications, and the stone-free rate. The incidence of hematuria was higher and the operative time was longer in the stented group compared to the non-stented group. At 48 hours post-operatively, the symptoms of flank pain and abdominal pain were significantly greater in the stented group. There was no statistical difference in the 2 groups, in terms of irritative symptom, analgesic use, and complications. The stone-free rate was almost 100% in both groups. Uncomplicated ureteroscopic lithotripsy can be safely performed without the placement of a ureteral stent. Patients without stents had less operative time, pain and hematuria