Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs laser ureteroscopy. A comparison of costs, morbidity and effectiveness.

OBJECTIVES: To determine the efficacy and costs of extracorporeal shock-wave lithotripsy (ESWL) compared with ureteroscopy (URS) in the treatment of mid- and lower ureteric calculi. PATIENTS AND METHODS: The records of patients treated primarily by ESWL and URS were analysed retrospectively. Treatment with ESWL included 63 patients (42 men and 21 women, mean age 52 years, range 23-78, 19 mid- and 44 lower ureteric calculi). All patients received 4000 shock waves at a mean energy setting of 18.1 kV. URS was used in 105 patients, with a 7.2 F miniscope or the 7.1 F flexible scope. Stones were fragmented with a pulsed-dye laser lithotripter at 504 nm and a power of up to 130 mJ (mean 53 mJ) using a 200 or 320 microns fibre. All ureteroscopies were performed with the patient under general (n = 17) or spinal (n = 87) anaesthesia in a mean treatment duration of 34 min. Stones were located in the mid-ureter in 24 patients and in the lower ureter in 80. The outcome was assessed by stone-free rates, re-treatment rates, time to become stone-free, complication and costs. RESULTS: ESWL for mid- and lower ureteric calculi resulted in a success rate of 90% and 81%, respectively, compared with 96% and 99% for URS. However, patients treated with URS were stone-free within 2 days, whereas patients in the ESWL group required up to 4 months. The best results for ESWL were achieved with stones of < 50 mm2. The costs of URS were higher than those for ESWL. CONCLUSIONS: ESWL provides a noninvasive, simple and safe option for the management of mid- and lower ureteric calculi, provided that the stones are < 50 mm2; larger stones are best treated by URS.

The value of antibiotic prophylaxis during extracorporeal shock wave lithotripsy in the prevention of urinary tract infections in patients with urine proven sterile prior to treatment.

INTRODUCTION: There are controversies in the literature regarding the need for and duration of antibiotic prophylaxis in patients treated with extracorporeal shock wave lithotripsy (ESWL) who have a negative urine culture before treatment. In order to determine the efficacy of antibiotic prophylaxis in ESWL treatment of patients with proven sterile urine, a randomized trial was performed. METHODS: Patients were randomized for placebo and 1 or 7 days antibiotic prophylaxis (cefuroxime or ciprofloxacin), starting 30 min before ESWL. Post-ESWL studies (immediately and 2 and 6 weeks after ESWL) included patient history, urine culture and Gram stain. RESULTS: After 2 weeks 20% of the patients and after 6 weeks 23% of the patients had bacteriuria, but there was no statistical significance between patients treated with placebo or those receiving prophylactic treatment. Only 2-3% of the patients (in the prophylaxis and placebo group) had clinical and bacteriological signs of a urinary tract infection, either 2 or 6 weeks after ESWL, possibly caused by re-infection, however, since bacteria were found in none of the urine samples collected directly after ESWL. There was no beneficial effect of antibiotic prophylaxis, in the prevention of urinary tract infections in patients with a nephrostomy catheter or dilatation at the site of treatment. CONCLUSION: We conclude that in patients with urine proven sterile prior to ESWL there is no need for antibiotic prophylaxis.

Early urethral obstruction sequence: a lethal entity?

Early urethral obstruction sequence (EUOS) is characterized by severe bladder distension by the end of the first trimester of pregnancy, resulting in renal dysplasia or hydronephrosis, oligohydramnios and subsequent lung hypoplasia. We reviewed the outcome of 18 fetuses with suspected EUOS. The mean gestational age at the time of diagnosis was 15 weeks. In 1 fetus, a vesicoamniotic shunt was placed unsuccessfully. Pregnancy was terminated in 11 fetuses and 9 showed signs of pulmonary hypoplasia and severe renal disease on autopsy. In 3 cases, the autopsy material could be evaluated. Premature delivery occurred in 2 patients, and 5 chose to deliver at term. All 7 fetuses died soon after birth because of respiratory failure and lung hypoplasia; renal abnormalities were also found on autopsy. Since it is currently not clear whether prenatal intervention will prevent renal dysplasia and it is not known how early it should be done to prevent pulmonary hypoplasia, we believe that termination of pregnancy should be discussed when EUOS is suspected.

Anterograde percutaneous treatment of ureterointestinal strictures following urinary diversion.

OBJECTIVE: The incidence of ureterointestinal strictures following urinary diversion ranges from 4 to 8%. Traditionally, the treatment consists of open ureteral reimplantation. During the last decade, however, percutaneous techniques have gained increased interest for treatment of these strictures. We evaluated the outcome of anterograde percutaneous treatment of ureterointestinal strictures after urinary diversion. METHODS: Since 1985, we attempted treatment of 15 ureterointestinal strictures, either by percutaneous anterograde dilatation (n = 10) or cold-knife incision (n = 2). In 3 patients the stricture could not be passed with a guide wire, precluding percutaneous treatment. Anterograde dilatation was performed with semirigid fascial dilators in 6 patients and additionally with a Grüntzig balloon catheter in 4. Routinely, following a successful procedure, a 12-Fr multihole stent was left in place for 6 weeks. RESULTS: Restenosis was seen in 4 patients 2, 2, 19, and 36 months, respectively following the procedure. In 8 patients no stenosis developed so far (follow-up 8-96 months). Morbidity after the procedure consisted of fever after nephrostomy puncture in 1 patient and stent occlusion in another. Both were managed conservatively. CONCLUSION: Anterograde percutaneous treatment of ureterointestinal strictures after urinary diversion is a safe primary procedure with a permanent success rate in half of the patients (53%).

Treatment of stones in caliceal diverticula: extracorporeal shock wave lithotripsy versus percutaneous nephrolitholapaxy.

Stones in caliceal diverticula may cause symptoms for which treatment is indicated. Both extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolitholapaxy (PNL) are recommended. We have evaluated the results of ESWL treatment of stone-containing caliceal diverticula and compared these with the results obtained by percutaneous surgery. In the ESWL group, 15 patients were treated with an electromagnetic lithotriptor (Siemens Lithostar). After 3 months, plain abdominal X-rays revealed that only 2 patients were both stone-free and symptom-free. Of the 13 patients with residual fragments, 7 had no symptoms. The remaining 6 were treated by a lower pole resection (n = 3), a percutaneous procedure (n = 2) and long-term administration of antibiotics (n = 1). Sixteen patients were treated percutaneously. Puncture failed in 3 and they underwent a lumbotomy. In the remaining 13 patients the stones were reached by direct puncture (n = 12) or via an adjacent calix (n = 1). After 3 months, 10 patients were stone-free and had no symptoms. Morbidity consisted of post-operative bleeding (n = 3) and high fever (n = 1). It was concluded that caution should be exercised in the treatment of stone-containing caliceal diverticula. Only in symptomatic cases is treatment indicated and ESWL is the first choice. If ESWL fails (residual stones and persistent symptoms), PNL should be performed, although it is associated with a higher morbidity rate.

Efficacy of second generation lithotriptors: a multicenter comparative study of 2,206 extracorporeal shock wave lithotripsy treatments with the Siemens Lithostar, Dornier HM4, Wolf Piezolith 2300, Direx Tripter X-1 and Breakstone lithotriptors.

Extracorporeal shock wave lithotripsy (ESWL) has become the treatment of choice for urinary calculi. The good results of the first generation Dornier HM3 lithotriptor stimulated the development of second generation machines. A multicenter trial is presented involving the Siemens Lithostar, Dornier HM4, Wolf Piezolith 2300, Direx Tripter X-1 and Breakstone lithotriptor to compare the therapeutic efficacy of second generation machines. Treatment results were best for calculi less than 2 cm. in diameter. Although the second generation lithotriptors are comparable to each other, none of the machines provided a success rate comparable to that of the first generation unmodified Dornier HM3 lithotriptor. The 5 machines differed mainly in types of stones treated in relation to imaging system, use of anesthesia, use of auxiliary procedures and hospitalization but overall success rates were similar. We conclude that second generation ESWL is less effective than first generation ESWL.

The use of local anesthesia in second generation extracorporeal shock wave lithotripsy: eutectic mixture of local anesthetics.

Extracorporeal shock wave lithotripsy (ESWL&) can be painful. Of our population of patients treated with a Siemens Lithostar device 51.4% needed intravenous analgesia. A eutectic mixture of local anesthetics, a hydrophylic cream containing 25 mg. lidocaine and 25 mg. prilocaine per gm., proved to be effective for local analgesia. Therefore, we investigated its effectiveness during ESWL. With randomized, double-blind application the eutectic mixture of local anesthetics and placebo were evaluated in 83 patients according to the percentage of patients who required intravenous analgesia during ESWL. Of 40 patients treated with the eutectic mixture of local anesthetics 12 (30%) needed supplementary fentanyl citrate, compared to 23 of 43 (53%) placebo treated patients. Although there is no statistical significance (p = 0.32), the eutectic mixture of local anesthetics does decrease pain during ESWL and it should be particularly useful for patients in whom intravenous analgesia is contraindicated.

Extracorporeal shock wave lithotripsy for large renal calculi: the role of ureteral stents. A randomized trial.

Ureteral stents reduce complications after extracorporeal shock wave lithotripsy (ESWL*) and contribute to successful stone passage. However, some reports note complications that are attributed to indwelling ureteral stents. We randomized 64 patients with large renal calculi (stone burden more than 200 mm.2) for in situ treatment or treatment with a prophylactically inserted stent. We used a 6Ch round stent with single-coiled ends or a triangular shaped stent with double-coiled ends. Patients were treated with a Siemens Lithostar lithotriptor. After 3 months we evaluated the results of treatment and post-ESWL morbidity. Of the in situ group (23 patients) treatment complications consisted of fever in 3, pyelonephritis in 1 and steinstrasse in 3. After 3 months 8 patients (35%) were free of stones. Of the stented population (41 patients) treatment complications consisted of fever in 7, pyelonephritis in 1, steinstrasse in 6 and bladder discomfort in almost half of the patients. Stent calcification and stent migration were also seen in 7 and 10 patients, respectively. Calcified stents had been in situ longer than noncalcified stents. The round stents migrated and calcified more often than the more rigid triangular stents. After 3 months 18 of the stented patients were stone-free (44%). We conclude that ureteral stents do not reduce post-ESWL complications. They are clearly associated with morbidity and do not improve stone passage markedly. Therefore, patients with a stone burden of more than 200 mm.2 should be treated in situ without auxiliary stenting.

The effect of the extracorporeal shock wave lithotriptor on bone cement.

For the purpose of studying its applicability for acrylic cement removal during total hip revision surgery, experiments with an extracorporeal shock wave lithotriptor were carried out. High-energy shock waves (HESW) were focussed on discs of polymethylmethacrylate bone cement. The average discharge was 18.1 kV; the number of shock waves 0, 100, 250, 500, 1000, and 2000; the application rate was 85 shocks/min. Macroscopic or radiographic effects were not in evidence. Microscopically, typical lesions in a small concentric focal area with a diameter of 8.5 (+/- 2.5) mm were found. The individual lesions were smaller than 0.1 mm, and displayed characteristic shapes. The area porosity increased with the number of shocks. The maximal area porosity caused by the HESW, measured by quantitative microscopy, was 4% after 2000 shock waves. The lesions were also studied by scanning electron microscopy. It can be concluded that HESW causes only microscopic lesions on the frontal surface of discs of bone cement, and that these lesions are small compared to the pores normally present in bone cement, when applied clinically.

Extracorporeal shock-wave lithotripsy for small symptomatic renal calculi: is it effective?

Renal calculi with a diameter of less than 5 mm can pass spontaneously. However, some patients have small symptomatic renal calculi for more than 3 months. We evaluated the results of extracorporeal shock-wave lithotripsy in 38 patients with such stones. Patients presented with loin pain, hematuria, infection, or a combination of complaints. Average stone size was 18 mm2. After a wait of 3 months for spontaneous evacuation without success, all patients were treated with a Siemens Lithostar. Three months after treatment, 19 patients (50%) were completely free of stones, but 7 still had complaints; of the 19 patients with residual fragments, 8 (42%) were free of complaints. Both evacuation and resolution of complaints were achieved in only 12 of the 38 patients (32%). We conclude that one should be reluctant to treat small renal calculi, because spontaneous evacuation occurs in about 80% and the results of treatment are restricted.

[The treatment of kidney and ureteral stones using a second-generation kidney stone lithotriptor]. / De behandeling van nier- en ureterstenen met een niersteenvergruizer van de tweede generatie.

In January 1988 a Siemens Lithostar lithotriptor was installed in the Radboud University Hospital in Nijmegen. Over 1600 treatments have been performed since. The results of 582 treatments of the first 500 patients are discussed. After three months 51.3% of the patients were free of stones. After six months this percentage was 64.5 and in addition 25.4% of the patients were free of symptoms although residual particles were still present. In only 10.1% of the patients did the ESWL treatment not succeed. In over 50% of the cases treatment was performed on an outpatient basis. Among 90% of the patients in whom treatment was performed without auxiliary procedures only 50% needed i.v. sedation or analgesia. The other 50% did not need any form of sedation or analgesia. Major complications did not occur although 376 patients (75.2%) suffered from a short period of haematuria and many patients had a skin lesion. With the possibility of outpatient treatment, the use of less anaesthesia and a success rate of 89.9% (residual stones, less than 5 mm in diameter, which can be evacuated spontaneously) after six months, the Lithostar is an improvement in the treatment of urolithiasis.

[Fragmentation of sialoliths]. / Vergruizen van speekselstenen.

An in vitro experiment proved that a sialolith can be disintegrated, but that also serious damage is caused to the teeth and dental restorations. Therefore, no experiment was carried out on a patient, although it proved to be possible to position a patient on a lithothriptor in a way that the shock wave of the apparatus would hit the sialolith without passing the brain, eyeballs and laryngeal skeleton.

Removal of salivary stones with the aid of a lithotriptor.

The feasibility of removal of salivary calculi with the aid of high energy shock waves was investigated. The postulation was, that salivary stones can be fragmented and no harm will be done to the surrounding tissues. An in vitro experiment was done with a lithotriptor to test the effect on a salivary stone and an extracted upper molar containing an amalgam restoration. Also investigated was whether a patient can be positioned in a prone position on the lithotriptor. In the in vitro experiment, the salivary stone was fragmented very quickly, but the amalgam restoration also fragmented. The patient could be positioned in the correct position on the lithotriptor, but because of the expected damage to the dentition, the experiment was not carried out on the patient.

Replacement of the early-control IVU after ureteral reimplantation by ultrasonography.

Many intravenous urographies (IVU) are still made shortly after ureteral reimplantation as a routine procedure to evaluate the function of both kidneys and to exclude a severe distal ureteral obstruction known as a complication of the operation (Broaddus et al., 1978). By studying two groups of patients we present an evaluation of the use of this IVU and the possible replacement by ultrasonography (US). The first group consisted of 119 cases with 155 reimplanted ureters. All of the patients underwent an IVU within two weeks and again three months after the operation. The second group included 35 patients, who underwent 55 reimplantations: US of the kidneys was performed within two weeks and three months and also one year after operation. In the first group three patients needed a second reimplantation because of a developed distal ureteral stenosis after three months. The second IVU showed severe dilatation in all of them. In two patients of the second group we also saw an increase in dilatation during follow-up within three months, for which a ureteral reimplantation was indicated. There was not a single case in which the outcome of the early IVU or US gave rise to a serious change in postoperative management. Our conclusion is that the early postoperative IVU, should be replaced by US of the kidneys, the result of which should function as a baseline for further follow-up studies.