Comparison of ureteroscopy (URS) complementary treatment after extracorporeal shock wave lithotripsy failure with primary URS lithotripsy with holmium laser treatment for proximal ureteral stones larger than10mm.

BACKGROUND: To compare ureteroscopy (URS) complementary treatment following extracorporeal shock wave lithotripsy (SWL) failure with primary URS lithotripsy for proximal ureteral stones > 10 mm, and try to find out acceptable number of SWL sessions followed by safe URS. METHODS: This was a retrospective study following approval from Medical Ethics Committee of People's Hospital of Chongqing Banan District. Patients (n = 340) who received URS in our hospital for stones > 10 mm from Jan 2015 to June 2020 were divided into two groups according to their previous SWL history. Group 1 consisted of 160 patients that underwent unsuccessful SWL before URS. Group 2 encompassed 180 patients without SWL before URS. Patient's operative outcomes were compared. A logistic regression and receiver operator characteristics (ROC) were used to identify the acceptable number of SWL sessions prior to URS, regarding the intra-operative complications of URS. RESULTS: The group 1 required more surgery time (41.38 ± 11.39 min vs. 36.43 ± 13.36 min, p = 0.01). At the same time, more intra-operative (68.1% VS 22.8%, p < 0.05) and post-operative (35% VS 18.0%, p = 0.001) complications occurred in group 1. Need more hospital stay in group 1 (2.7 ± 1.2 days vs 1.6 ± 1.1 days, p < 0.05). More patients in group 1 need further URS (16.3% VS 8.9%, p = 0.029). After second URS, the SFR of URS in two groups was insignificant differences (82.5% VS 88.9%, p > 0.05). The median (25-75%) of SWL sessions before URS was 2 (1-3) in group 1. According to the results of logistic regression analysis, patients suffered more SWL failure have an increased risk of complications during URS (OR = 1.995, 95% CI: 1.636-2.434). ROC showed that the optimal number of SWL session followed by URS were 0.5, with a sensitivity of 67.7% and specificity of 71.5%. Intra-operative complication rates of URS treatment were higher in patients who suffered > 1 SWL failure (72.6% vs 57.4%, p = 0.047). CONCLUSION: There was no acceptable number of SWL sessions that could be followed by URS with fewer intra-operative complications. Patients who underwent previous SWL were likely to suffer more intra-operative complications, the average operating time, hospitalization time, and needing further treatment, during URS treatment for proximal ureteral stones larger than 10 mm.

Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial.

BACKGROUND: Meta-analyses of previous randomised controlled trials concluded that the smooth muscle relaxant drugs tamsulosin and nifedipine assisted stone passage for people managed expectantly for ureteric colic, but emphasised the need for high-quality trials with wide inclusion criteria. We aimed to fulfil this need by testing effectiveness of these drugs in a standard clinical care setting. METHODS: For this multicentre, randomised, placebo-controlled trial, we recruited adults (aged 18-65 years) undergoing expectant management for a single ureteric stone identified by CT at 24 UK hospitals. Participants were randomly assigned by a remote randomisation system to tamsulosin 400 µg, nifedipine 30 mg, or placebo taken daily for up to 4 weeks, using an algorithm with centre, stone size (≤5 mm or >5 mm), and stone location (upper, mid, or lower ureter) as minimisation covariates. Participants, clinicians, and trial personnel were masked to treatment assignment. The primary outcome was the proportion of participants who did not need further intervention for stone clearance within 4 weeks of randomisation, analysed in a modified intention-to-treat population defined as all eligible patients for whom we had primary outcome data. This trial is registered with the European Clinical Trials Database, EudraCT number 2010-019469-26, and as an International Standard Randomised Controlled Trial, number 69423238. FINDINGS: Between Jan 11, 2011, and Dec 20, 2013, we randomly assigned 1167 participants, 1136 (97%) of whom were included in the primary analysis (17 were excluded because of ineligibility and 14 participants were lost to follow-up). 303 (80%) of 379 participants in the placebo group did not need further intervention by 4 weeks, compared with 307 (81%) of 378 in the tamsulosin group (adjusted risk difference 1·3% [95% CI -5·7 to 8·3]; p=0·73) and 304 (80%) of 379 in the nifedipine group (0·5% [-5·6 to 6·5]; p=0·88). No difference was noted between active treatment and placebo (p=0·78), or between tamsulosin and nifedipine (p=0·77). Serious adverse events were reported in three participants in the nifedipine group (one had right loin pain, diarrhoea, and vomiting; one had malaise, headache, and chest pain; and one had severe chest pain, difficulty breathing, and left arm pain) and in one participant in the placebo group (headache, dizziness, lightheadedness, and chronic abdominal pain). INTERPRETATION: Tamsulosin 400 µg and nifedipine 30 mg are not effective at decreasing the need for further treatment to achieve stone clearance in 4 weeks for patients with expectantly managed ureteric colic. FUNDING: UK National Institute for Health Research Health Technology Assessment Programme.

Ureteroscopy: the first-line treatment for distally located ureteral stones smaller than 10 mm.

PURPOSE: To compare the efficacy of different treatment strategies for distal ureteral stones smaller than 10 mm. MATERIAL AND METHODS: A total 127 patient were included in the study. Based on the treatment modality , patients were divided into three groups.Patients in group 1 only received conventional treatment including daily hydration of 2500 mL, ciprofloxacin, diclofenac sodium and a spasmolytic agent; group 2 patients received conventional treatment (daily hydration of 2500 mL, ciprofloxacin, diclofenac sodium and a spasmolytic agent) and tamsulosin 0.4 mg orally daily for 4 weeks; and group 3 patients underwent ureteroscopy. Patients were further subdivided into 2 categories based on maximum stone diameter: category A (less than 5 mm) and category B (5.0-9.9 mm). Following treatment, all groups were compared in terms of stone-free rate and time to expulsion. RESULTS: Following treatment, the stone-free rates for groups 1, 2 and 3 were 48.7%, 59.5% and 95.6%, respectively (P < .0001).The mean expulsion times for groups 1, 2 and 3 were 15.3 ± 5.33, 15.1 ± 5.5 and 1.95 ± 2.2 days, respectively (P < .001). Compared to the other treatments, the stone-free rate and mean expulsion time in the ureteroscopy group were significantly increased and decreased, respectively. CONCLUSION: There are several treatment options for distal ureteral stones. Based on our data,we conclude that ureterorenoscopy should be the standard of care for distal ureteral stones smaller than 10 mm.

[Comparison of low-power laser and ultrasound litotripsy in the management of middle-distal ureteral stones]. / Confronto tra la litotrissia laser a bassa potenza e mediante ultrasuoni nel trattamento endoscopico della calcolosi ureterale medio-distale.

OBJECTIVE: To compare the success rates and complications of ultrasound and low-power Holmium laser-assisted ureteroscopy (URS) in managing middle-distal ureteral stones. MATERIALS AND METHODS: We retrospectively analyzed the records of 90 patients with middle-distal ureteral stones who underwent ureteroscopic lithotripsy at our institution from May 2006 to April 2010. 45 patients were treated with ultrasound (mean size 6.7 mm), 45 patients with low-power Holmium laser (mean size 7.4 mm). The same ureteroscope (9.5/8ch rigid-Storz) was used to treat all the patients. Patients were monitored before the hospital discharge with abdominal radiograph and ultrasonography, and as outpatients after 3 months with abdominal radiograph, ultrasonography and urography in selected cases. RESULTS: We obtained a complete immediate fragmentation of stones in 27/45 (60%) patients with ultrasound, and in 36/45 (80%) patients after laser treatment. A proximal migration of stones was observed in 12/45 (26.8%) patients with ultrasound and 3/45 (6.6) with laser. We observed a ureteral perforation after laser treatment and no patient developed urosepsis. 6/45 (13.3%) patients who were treated with ultrasound underwent auxiliary therapy such as alkalizing therapy, 9/45 (20%) patients a second ureteroscopy, 9/45 (20%) a shockwave lithotripsy. No patient underwent an auxiliary shockwave treatment after laser, 6/45 (13.4%) patients underwent a second ureteroscopy. Operating time (20.33 vs 28.85 minutes) and hospitalization (3.6 vs 5.1 days) were shorter with laser if compared with ultrasound treatment. CONCLUSION: In our study the fragmentation rates of Holmium laser-assisted ureteroscopy were significantly better than with ultrasound in the middle-distal ureteral stones management. We did not have relevant complications using both procedures, and the need for auxiliary procedures was significantly less for Holmium laser-assisted ureteroscopy when compared with ultrasound.

Aplicación de la tecnología láser en el tratamiento de la litiasis ureteral / Application of laser technology in the treatment of ureteral lithiasis

Objetivo: Valorar las aportaciones del láser, fundamentalmente de holmio, en el tratamiento endourológico de la litiasis ureteral. Método: Analizamos la experiencia acumulada en 154 tratamientos endourológicos con láser holmio de litiasis ubicadas a nivel ureteral, realizado de forma continuada en nuestra Unidad desde junio 2005 a diciembre 2007. Resultados: Se consiguió la fragmentación litiásica en el 100% de los casos. El uso asociado de la pinza de rama larga al láser de holmio, nos permitió alcanzar tasas de ausencia de litiasis residual en el 91% de los pacientes. Conclusiones: El tratamiento de la litiasis ureteral se ha beneficiado de los procedimientos endoscópicos, siendo el láser de holmio la fuente de energía de elección en el momento actual. La tasa de fragmentation alcanzada fue del 100%. Las complicaciones fueron escasas y en ningún momento de importancia (AU)

Objectives: To evaluate the contribution of laser, mainly holmium laser, to the endourological treatment of ureteral lithiasis. Methods: We analyze our experience in 154 endourological treatments of ureteral lithiasis with holmium laser performed in our Unit from June 2005 to December 2007. Results: Stone fragmentation was achieved in 100% of the cases. The use of long jaw forceps associated with the holmium laser enabled us to reach a stone free rate of 91%. Conclusions: The treatment of ureteral lithiasis has benefit from the development of endoscopic procedures, being the holmium laser the energy source of choice nowadays. The fragmentation rate was 100%. Complications were rare and never important (AU)

Myth: nephrolithiasis and medical expulsive therapy.

There is a medical myth that ureteral stones larger than 5 mm will not pass spontaneously and require urological intervention for removal. Recent findings indicate that medical expulsive therapy can facilitate spontaneous passage for stones up to 10 mm. For the management of ureteral stones, we recommend administering tamsulosin and a corticosteroid (deflazacort or prednisone) along with the standard therapy of analgesics, antibiotics and hydration.

Effectiveness of nifedipine and deflazacort in the management of distal ureter stones.

OBJECTIVES: To evaluate the effectiveness of medical therapy during watchful waiting in patients with distal ureter stones. METHODS: Ninety-six patients with radiopaque stones located in the distal tract of the ureter and with stone sizes of 1 cm or smaller were involved in the study. The patients were randomly divided into two groups. Group A (n = 48) received oral treatment with 30 mg of deflazacort daily (maximum 10 days) plus 30 mg of slow-release nifedipine daily (maximum 4 weeks). Group B (n = 48) underwent a wait-and-watch approach. Both groups of patients were allowed to use diclofenac on demand. Statistical analyses were carried out using Student's t test, the chi-square test, and Fisher's exact test. RESULTS: The average stone size was 5.8 +/- 1.8 mm for group A and 5. 5 +/- 1.4 mm for group B. No statistically significant difference was found in stone size. Stone expulsion was observed in 38 (79%) of 48 patients in group A and in 17 (35%) of 48 patients in group B. The average expulsion time was 7 days (range 2 to 10) for group A and 20 days (range 10 to 28) for group B. A statistically significant difference was observed in both the expulsion rate and the expulsion time (P <0.05). The mean amount of sodium diclofenac used was 15 mg per patient for group A and 105 mg per patient for group B (P <0.05). CONCLUSIONS: The medical treatment proved to be effective and safe, as demonstrated by the increased stone expulsion rate, decreased expulsion time, and reduced need for analgesic therapy.

Higher urinary potassium is associated with decreased stone growth after shock wave lithotripsy.

PURPOSE: We correlated serum and urinary biochemical parameters with radiological evidence of stone growth after shock wave lithotripsy. MATERIALS AND METHODS: Biochemical parameters in serum and 24-hour urine collections of 359 patients were correlated with stone growth for 2 years after shock wave lithotripsy. Each patient underwent a minimum of 2 radiological studies at 3 and 12 months and plain abdominal x-ray at 24 months. The presence and size of stones were documented by a radiologist in blinded fashion. Stone growth was defined as measurable growth of a preexisting stone or new stone formation. RESULTS: A total of 209 patients remained stone-free or had no existing stone growth, while stone size decreased in 30. Of the remaining 120 patients with stone growth 72 had new growth and 48 had growth of preexisting stones. Urinary excretion of potassium was significantly higher in those without than with stone growth (mean 24-hour urine collection plus or minus standard deviation 62 +/- 27 versus 54 +/- 23 mmol., p = 0.009). The only parameter significantly associated with stone growth was urinary potassium. Linear regression revealed that for each 10 unit increase in urinary potassium there was a corresponding 2 mm. decrease in stone growth (p = 0.013). CONCLUSIONS: Our results indicate that increased urinary potassium excretion correlates with a decreased risk of stone growth up to 2 years after shock wave lithotripsy, implying that a high potassium diet may be beneficial for preventing stone growth. The effect of potassium supplementation on stone formation and growth must be investigated further.

A randomized trial comparing lithoclast with an electrokinetic lithotripter in the management of ureteric stones.

OBJECTIVE: To compare two in situ ballistic lithotripters, the lithoclast and the electrokinetic lithotripter (EKL), both of which can be used through the newer small-bore ureteroscopes, for their ease of use, robustness, fragmentation time, adequacy of fragmentation and stone-free rate. PATIENTS AND METHODS: Forty-six consecutive patients with ureteric stones refractory to treatment by extracorporeal shock wave lithotripsy were randomized to undergo fragmentation using the lithoclast (23 patients) or the EKL (23 patients). One patient was excluded from analysis in the EKL group. The adequacy of fragmentation was recorded, with the degree and significance of proximal migration for each device. After treatment patients were assessed by plain X-ray and the stone-free rate was determined. RESULTS: The mean (median) initial stone burdens in the lithoclast and EKL groups were 69 (50) mm2 and 72 (52) mm2, respectively. The respective mean (median) procedure duration and fragmentation time were 54 (50) min and 90 (49) s in the lithoclast group, and 50 (42.5) min and 87 (52.5) s in the EKL group; the differences were not statistically significant. In four (14%) patients of each group there was significant proximal migration of the stones. The stones were completely fragmented in 17 of 23 (74%) patients in the lithoclast group and 19 of 22 (86%) in the EKL group. There was no fragmentation in one patient in each group. In the lithoclast and EKL groups, 20 of 23 (87%) and 17 of 22 (77%) were rendered stone-free, respectively (P > 0.5). The equipment failed on two occasions in each group. CONCLUSION: In this randomized trial there was no significant difference in the stone-free rate, procedure duration, fragmentation time, proximal stone migration rate and equipment failure between these in situ ballistic lithotripters.

[A clinical study on spontaneous passage of ureteral stone--effect of urocalun and jumping exercise to ureteral stone].

The effects of Urocalun and jumping exercise upon the passage of calculi were studied. Urocalun was administered to 47 patients with ureteral stones in a dosage of 6 capsules per day and they did jumping rope skipping 50 times twice a day. The size of the calculi was grouped according to the report of Minami et al. Namely the 47 cases were divided into the following groups according to their radiographic shadow; 1) small group (not greater than 0.5 cm in diameter), 27 cases (57.4%); 2) middle-sized group (not greater than 1.0 x 0.6 cm), 11 cases (23.4%); 3) large group (larger than 1.0 x 0.6 cm), 9 cases (19.2%). As a result, the rate of spontaneous passage was 80.9% which was considerably higher than expected. There was spontaneous passage of calculus in 25 cases of small group (85.2%), in 8 cases of middle-sized group (72.7%) and in 7 cases of large group (77.8%). Especially in the large group the rate of passage was higher than described before. On the other hand the period of calculi passage was earlier than that in Minami's report. In the large group 6 of the 7 discharged stones (85.7%) were discharged within six months. Therefore, it must be observed for six months regardless of calculus size with combination therapy if possible. The effects of this prescription on the calculi passage were better than those described on other drugs and Urocalun independently. Then the strict combination therapy of the drug and the exercise was useful for the passage of calculi.

[Extracorporeal lithotripsy by shock waves. Initial results (322 cases)]. / Lithotritie extracorporelle par ondes de choc. Premiers résultats (322 patients).

Results of 322 patients treated with extracorporeal shock wave desintegration are reported (277 patients treated with the Dornier lithotripter, 45 patients treated with Solonithe using ultrasonic stone location). Lesions treated included 168 caliceal, 111 pyelic, 23 ureteral and 21 coralliform calculi. 45 patients presented multiple and 28 bilateral renal lithiasis. Stones were mainly between 10 and 20 mm in diameter (157 patients) but were less than 10 mm in size in 110 cases and more than 20 mm in 55. For poorly opaque stone, lithotripsy was performed after ultrasound localization with the Sonolithe apparatus. The Dornier machine was used to treat 277 patients during 308 sessions, equivalent to an 11% repeat rate. Fragmentation was excellent in 84% of cases after a single session, and 5% of stones could not be fragmented and required complementary therapy. Out of 200 patients reviewed after 3 months, only 8% had residual fragments (92% success rate), 5% having to undergo auxillary endoscopic manoeuvres: stenting ureteral catheter (4 cases); percutaneous nepholithotomy (3 cases); ureteroscopy (7 cases). Septic complications (6 patients) responded well to antibiotic treatment. Renal colic or pain was recorded in 25% of cases. One kidney was non-functional at 3 months due to distal ureteral obstruction without subsequent dilatation of the collecting system. Out of 45 patients treated with the Sonolithe, 3 (6.6%) were failures of fragmentation and 85% had satisfactory results. After a minimum follow up of 3 months, 20/22 patients were free of residual calculi, and there were no complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcium oxalate urinary calculi: clinical and chemical aspects.

In 117 male patients with proven calcium oxalate renal calculi, adults of all ages were affected. There was a low incidence of urinary tract obstruction and infection and a high incidence of recurrence and bilateral disease. The group of patients could not be characterized as to a specific abnormality of blood or urine. There were no differences between all patients, a subset with multiple stones and normals with regard to the mean urinary excretions of calcium, magnesium and oxalic acid. There were no differences between the frequency distribution of patients with high excretions of both calcium and oxalic acid or low excretions of both calcium and oxalic acid. Mean supersaturation ratios and the frequency distribution of supersaturation ratios in 31 stone patients were the same as in 32 normal men. The data suggest that the difference between calcium oxalate stone patients and normals lies in the process of initiation.