|Year : 2021 | Volume
| Issue : 2 | Page : 108-111
Evaluation of ureterorenoscopy with semirigid ureteroscope and laser lithotripsy as a treatment modality for upper ureteric stones less than 20 mm
Ravi Batra, Pooja Batra, Shreyak Garg, Sneha Yadav
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
|Date of Submission||31-Aug-2021|
|Date of Acceptance||21-Dec-2021|
|Date of Web Publication||10-Feb-2022|
Dr. Ravi Batra
Department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Technological developments over the past two decades have revolutionized the treatment of ureteric stones. With the emergence of flexible, small-diameter ureteroscopy, the paradigm of ureteral stone treatment has shifted to ureteroscopy. The success rate is close to 95%, but it has its own complications. Objective: The objective of this study is to assess the effectiveness of ureterorenoscopy (URS) with semirigid ureteroscope and laser lithotripsy in the treatment of upper ureteric stones of size less than 20 mm and its associated complications. Methods: This is a prospective cohort study designed to assess the effectiveness of URS for the treatment of upper ureteric calculi. We present data from 57 patients who received URS as their primary treatment at our center and were followed up for at least 3 months. Results: We found that when stone size was less than 10 mm, the stone-free rate was 80% (28/35), while when stone size was in the 10.1–20 mm range, the stone-free rate increased to 90.9% (20/22). Stones were found in 41/48 patients (85.41%) with symptoms lasting less than a month. Only 7/9 patients (77.77%) were stone-free in the group with symptoms lasting more than a month. A total of 28.1% of patients encountered complications among which proximal migration of the stone was the most common (12.3%). Mean procedure time was 40.37 min. Conclusion: This study shows that URS had a higher stone-free rate when treating stones of size ranging from 10.1 to 20 mm. In upper ureteric stones ranging in size from 10.1 to 20 mm, we strongly advise using URS as the primary treatment option.
Keywords: Laser lithotripsy, stone-free, ureteric stone, ureterorenoscopy
|How to cite this article:|
Batra R, Batra P, Garg S, Yadav S. Evaluation of ureterorenoscopy with semirigid ureteroscope and laser lithotripsy as a treatment modality for upper ureteric stones less than 20 mm. J Mahatma Gandhi Inst Med Sci 2021;26:108-11
|How to cite this URL:|
Batra R, Batra P, Garg S, Yadav S. Evaluation of ureterorenoscopy with semirigid ureteroscope and laser lithotripsy as a treatment modality for upper ureteric stones less than 20 mm. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2023 Jan 28];26:108-11. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/108/337438
| Introduction|| |
Technological developments over the past two decades have revolutionized the treatment of ureteric stones. Historically, ureterolithotomy and stone basket manipulation were the pillars of treatment. The primary goal of any ureteric calculi procedure is the complete removal of the stone. Failure to meet this goal can be because of different factors associated with patient, stone, and technique used. As a result, many elements influence a patient's stone clearance rate. The transformation from the era of stone baskets, forceps, and electrohydraulic lithotripsy to laser and lithoclast has changed the way ureteric calculi are treated.
Introduction of ureteroscopes in the late 1970s opened a rare insight into the live anatomy of ureter. Initially, however, because of the size constraints and rigidity of the instrument, the use of endoscopes was confined to the distal ureter. Refinement of the technology in the 1990s with the use of fiber optic instruments has totally replaced large rigid ureteroscopes with semirigid and flexible ureteroscopes. With the advent of small-caliber and flexible ureteroscopes, the paradigm of treatment of upper ureteric stones has shifted toward ureteroscopy with success rates approaching 95%. However, this is not without its share of complications. In our study, we present the utility of ureterorenoscopy (URS) with semirigid ureteroscope and laser lithotripsy in the treatment of upper ureteric stones of size less than 20 mm and its associated complications.
| Methods|| |
This is a prospective cohort study designed to assess the effectiveness of URS for the treatment of upper ureteric calculi. We present the data from 57 patients who received URS as the primary treatment at our center and were followed up for at least 3 months. Written consent statement was obtained. All patients received a complete medical history and clinical evaluation. Reference laboratory tests included complete blood count, kidney function tests, plasma glucose levels, coagulation characteristics, urine culture, and sensitivity. If urine culture showed signs of infection, appropriate antibiotics were administered before surgery. X-ray kidney, ureter, and bladder (KUB) was used as the main diagnostic method for profiling stones, and the highest dimension was defined as the stone size. Other tests included abdominal/pelvic ultrasound and intravenous pyelography. This study only included patients with a single radiopaque stone with a diameter of less than 20 mm in the upper ureter and excluded patients with stones greater than 20 mm, patients with translucent stones, patients with stones located outside the upper ureter, or patients with abnormal ureteral stones, such as congenital ureteric abnormalities. This study also excluded patients who were morbidly obese or had renal insufficiency.
The patient was placed in the lithotomy position on the fluoroscopic table while under general or spinal anesthesia. Cystoscopy was performed after cleaning and draping. The appropriate ureteral opening was identified, and a guidewire was inserted under fluoroscopic guidance. The intramural ureter was dilated using Nottingham dilator to 12 French size (Fr). An 8 Fr polyvinyl chloride Nelaton catheter was placed into the urinary bladder for the prevention of overdistension of bladder. Ureteroscopic intracorporeal lithotripsy was performed using 6/7.5 Fr semirigid ureterorenoscope (Karl Storz, Germany). Holmium: yttrium aluminum garnet laser (100 W Sphinx) and a 365 μ laser fiber were used for the lithotripsy. The laser energy was set at 0.8–1.5 J, and the frequency was between 10 and 20 Hz. The end point of procedure was set as state at which the stone was fragmented up to twice the size of the laser fiber. Any complications that occurred during the procedure were documented. In patients with a large stone burden, intraluminal mucosal edema, or a severely impacted stone, a double J stent was inserted. If patients were asymptomatic, they were discharged the next morning. After receiving an X-ray KUB to confirm the stone-free status, the stent was removed as an outpatient procedure under local anesthesia after 2–3 weeks.
The treatment success was determined by confirmation of stone-free condition on plain X-ray KUB 4 weeks after the initial treatment. Ethics clearance was obtained from the institutional ethics committee. Informed written consent was taken from all the study participants for voluntary participation.
The frequency distribution of the various qualitative characteristics is shown as n (% of cases), while the distribution of several quantitative characteristics is shown as the mean ± standard deviation. Fisher's exact probability test was applied to test the significance of the difference in categorical variables between two groups. Statistics Package of the Social Sciences (SPSS Version 21.0; Chicago, IL, USA) was used for statistical analysis.
| Results|| |
Most of the study participants were aged between 31 and 60 years. Men accounted for 63.2% of the cases, while women accounted for 36.8%. The most common symptom was pain affecting 80.7% of patients, followed by hematuria which was present in 14% of patients, and in 5.3% of patients, the stones were incidentally detected. In 84.2% (48/76), patients had the symptoms for less than 1 month, while symptoms of more than 1 month duration were recorded in 15.8% (9/57) of the patients. Right-sided stones were accounted for in 64.9% (37/57) of the patients, while 35.1% (20/57) of the patients had stones in the left upper ureter. We found that 35/57 patients had stones of less than 10 mm in size, while 38.6% (22/57) of patients had stones that were 10.1–20 mm in size [Table 1].
Of the 57 patients who underwent URS, 84.2% (48/57) of the patients were stone-free; however, in only 15.8% (9/57) of the patients, URS was unsuccessful.
A subgroup analysis was carried out which showed that, in the group of stone size less than 10 mm, the stone-free rate was 80% (28/35), while in the group with 10.1–20 mm stone size, the stone-free rate increased to 90.9% (20/22). P value by Fisher's exact test is 0.4582. As a result, there was no statistically significant difference in the stone-free status between the two URS subgroups when the stone size is considered.
Stones were found in 41/48 patients (85.41%) with symptoms lasting less than a month. Only 7/9 patients (77.77%) were stone-free in the group with symptoms lasting more than a month. P value by Fisher's exact test is 0.6225. As a result, based on symptoms duration, there was no significant difference in stone-free status between the two URS subgroups [Table 2].
|Table 2: Stone-free rate according to stone size and duration of symptoms|
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A total of 16/57 (28.1%) patients encountered complications. Among the study patients who underwent URS and developed complications, maximum patients had proximal migration of the stone in 12.3% (7/57), 3.5% (2/57) of patients each had hematuria, difficulty in accessing the stone, and development of mucosal injury, whereas 5.3% (3/57) of patients developed fever [Table 3].
The procedure time for URS, including anesthesia, ranged from 20 to 75 min in our study, with the mean procedure duration being 40.37 min.
| Discussion|| |
With the emergence of small-diameter, flexible, semi-rigid ureteroscopes and enhanced instruments, such as holmium laser, URS has become a safer and effective method for treating stones within the ureter. “Overall stone-free rates are remarkably high at 81%–94% depending on stone location, with the vast majority of patients rendered stone-free in a single procedure. Moreover, impacted ureteral calculi are better managed by URS. When URS was used as the treatment modality for upper ureteric stones less than 20 mm, many authors have outlined a stone-free rate ranging from 80% to 100%.,,, Stone-free rates and associated complications are important parameters that can be used to assess outcomes.
In this study, of the 57 patients who underwent URS with laser lithotripsy, 84.2% (48/57) of the patients were stone-free, while only 15.8% (9/57) of the patients were found to be unsuccessful. Several authors in their studies have reported stone-free rates ranging from 80% to 100%. Our study shows comparable stone-free rate for the URS group [Table 4].
Our study shows that the proportion of stone-free patients in the subgroup of stone size less than 10 mm was 80%, and the proportion of stone-free patients in the subgroup with stone size ranging from 10.1 to 20 mm was 90.9%. In our opinion, this was probably because larger stones were more impacted and hence proximal migration was less, so procedure could be completed in toto. However, other authors report that the stone-free rate of the 10 mm stone size subgroup is slightly higher than that of our study, ranging from 87.7% to 91.4%. However, when the stone-free rate was compared in the subgroup with stone sizes ranging from 10.1 to 20 mm, our study fared favorably [Table 5].
|Table 5: Stone-free rates according to size of stone after ureterorenoscopy|
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The complication rate reported in the present study is 28.1%. It is higher than what was reported by Taie et al. but compares favorably with the observations of Parker et al. and Mursi et al. [Table 6].
In the present study, proximal migration of stone was the most common complication, which occurred in 12.3% of the patients in the URS group. Other authors have reported lower incidence of proximal migration of stone. Such patients with proximal migrations of stone were considered for extracorporeal shockwave lithotripsy. In our study, there was no incidence of ureteric perforation while other authors have reported some incidence of ureteric perforation ranging from 1% to 3.2%. There was a marginally increased incidence of fever as a complication in our study, while other complications were far lower in contrast to other studies [Table 7].
| Conclusion|| |
With the development of flexible, small-diameter ureteroscopes and enhanced instruments such as holmium laser, URS has evolved as a potent tool in the hands of urologists for efficacious treatment of stones within the ureter. Stone-free rates achieved are as high as 81%–94%, and more often, this procedure requires just a single sitting. When treating stones between 10.1 and 20 mm, URS had a higher stone-free rate in our study. In upper ureteric stones ranging in size from 10.1 to 20 mm, we strongly advise using URS as the primary treatment option.
We would like to acknowledge the Department of Surgery for their cooperation and full support in conducting this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Padhye AS, Yadav PB, Mahajan PM, Bhave AA, Kshirsagar YB, Sovani YB, et al.
Shock wave lithotripsy as a primary modality for treating upper ureteric stones: A 10-year experience. Indian J Urol 2008;24:486-9.
] [Full text]
Wu CF, Shee JJ, Lin WY, Lin CL, Chen CS. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium: YAG laser lithotripsy for treating large proximal ureteral stones. J Urol 2004;172:1899-902.
Skolarikos A. Management of residual stone fragments. In: Smith's Textbook of Endourology. UK: John Wiley & Sons, Ltd.; 2012. p. 662-74.
Elganainy E, Hameed DA, Elgammal M, Abd-Elsayed AA, Shalaby M. Experience with impacted upper ureteral stones; should we abandon using semirigid ureteroscopes and pneumatic lithoclast? Int Arch Med 2009;2:13.
Fong YK, Ho SH, Peh OH, Ng FC, Lim PH, Quek PL, et al.
Extracorporeal shockwave lithotripsy and intracorporeal lithotripsy for proximal ureteric calculi – A comparative assessment of efficacy and safety. Ann Acad Med Singap 2004;33:80-3.
Stewart GD, Bariol SV, Moussa SA, Smith G, Tolley DA. Matched pair analysis of ureteroscopy vs. shock wave lithotripsy for the treatment of upper ureteric calculi. Int J Clin Pract 2007;61:784-8.
Khalil M. Management of impacted proximal ureteral stone: Extracorporeal shock wave lithotripsy versus ureteroscopy with holmium: YAG laser lithotripsy. Urol Ann 2013;5:88-92.
] [Full text]
Parker BD, Frederick RW, Reilly TP, Lowry PS, Bird ET. Efficiency and cost of treating proximal ureteral stones: Shock wave lithotripsy versus ureteroscopy plus holmium: yttrium-aluminum-garnet laser. Urology 2004;64:1102-6.
Kumar V, Kumar V, Yadav AK, Iyengar S, Bhalla A, Sharma N, et al.
Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India. PLoS Negl Trop Dis 2014;8:e2605.
Kijvikai K, Haleblian GE, Preminger GM, de la Rosette J. Shock wave lithotripsy or ureteroscopy for the management of proximal ureteral calculi: An old discussion revisited. J Urol 2007;178:1157-63.
Taie K, Jasemi M, Khazaeli D, Fatholahi A. Prevalence and management of complications of ureteroscopy: A seven-year experience with introduction of a new maneuver to prevent ureteral avulsion. Urol J 2012;9:356-60.
Mursi K, Elsheemy MS, Morsi HA, Ali Ghaleb AK, Abdel-Razzak OM. Semi-rigid ureteroscopy for ureteric and renal pelvic calculi: Predictive factors for complications and success. Arab J Urol 2013;11:136-41.
Latif AM. Ureteroscopic holmium lasertripsy for treatment of impacted ureteral calculi. Afr J Urol 2007;13:262-6.
Ahn ST, Kim JH, Park JY, Moon du G, Bae JH. Acute postoperative pain after ureteroscopic removal of stone: Incidence and risk factors. Korean J Urol 2012;53:34-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]