[The prostate cancer in the community of Madrid in 2000 I.- Incidence]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. I--Incidencia.

OBJECTIVE: To know the incidence in the year 2000 of prostate cancer in the Autonomous Community of Madrid and its breakdown by Health Areas. MATERIAL AND METHOD: Study of histologically confirmed prostate cancer case reports and retrospective data acquisition for 2000 in the Autonomous Community of Madrid, both from Public and Private Health Care hospitals. RESULTS: Gross incidence of prostate cancer in the Autonomous Community of Madrid was 100.4 cases per 100,000 males. The incidence adjusted for the Spanish, European and Worldwide population was 120.1, 103.5 and 68.6 cases per 100,000 males, respectively. Mean age at diagnosis was 70 +/- 7.8 (40-94) years, median of 70 years. The age group with higher incidence was 70 to 79 years. CONCLUSIONS: The incidence of prostate cancer in the Autonomous Community of Madrid is lower than that in the US but higher than in most countries or regions in the EU. The different way of using PSA testing in the Health Areas of the Autonomous Community may explain the differences seen in terms of incidence by Area.

[The prostate cancer in the community of Madrid in 2000. II Presentation and diagnosis]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. II--Presentación y diagnóstico.

OBJECTIVE: To know the presentation form, diagnostic method and clinical stage at the time of diagnosis in subjects with prostate cancer (PC) in the Autonomous Community of Madrid in 2000. MATERIAL AND METHOD: Data from 1745 patients with histologically confirmed prostate cancer obtained from 15 Hospitals participating in the study was analysed. The variables studied were: associated disease, reason for visiting the hospital, digital rectal examination (DRE), PSA, diagnostic method, graded Gleason score, tests performed in the tumoral extension study and tumour staging. The qualitative variables are given in percentages of the overall number and the quantitative variables are expressed as the median, standard deviation, maximum and minimum values and 25%, 50% (median) and 75% percentiles. RESULTS: 67% cases had an associated disease. In most (75%) patients the reason for visiting the hospital was prostatic syndrome. DRE revealed that 42.7% has no tumour. At the time of diagnosis half the patients had PSA levels lower than or equal to 11 ng/ml. Transrectal ultrasound-guided biopsy was used for diagnosis in 93% subjects. The most commonly reported Gleason scores were 6 (31.3%) and 7 (28.7%). In 75% subjects the disease was considered to be clinically limited to the prostate, in 12.5% locally advanced and in 12.5% metastatic. CONCLUSIONS: Most patients came to the hospital because of symptoms not related to PC. Transrectal ultrasound-guided biopsy is confirmed as the choice technique for PC diagnosis. When a comparison is made to historical series in our Autonomous Community a pattern of earlier diagnosis can be seen.

[Prostate cancer in the Community of Madrid in the year 2000. III. Study of tumor extent]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. III--Estudio de extensión tumoral.

OBJECTIVE: To identify a potential relationship between two variables, risk of metastasis and use of imaging techniques, in an extension study in prostate cancer patients diagnosed in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: 1,127 patients with available data on the tumour extension study were analysed. Performance and non performance of bone scans and CTs were correlated to risk variables for developing metastasis as described in the literature (PSA, Gleason and stage) and to therapy administered. RESULTS: The proportion of patients with risk variables for metastasis when bone scans were performed was between 7% to 14% greater than in patients with no variables. No differences were seen for CTs based on risk variables. With matching risk variables, more imaging techniques were used in patients receiving radiotherapy that in those managed with prostatectomy. CONCLUSION: Based on current recommendations imaging techniques were used in excess in the extension study in patients with no risk variables for metastasis. Conduct of a further study in the Autonomous Community seems advisable to confirm the likelihood of implementing such recommendations considering our prevalence of metastatic disease.

[Prostate cancer in the Community of Madrid in the year 2000. IV. Treatment]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. IV Tratamiento.

OBJECTIVE: To know the therapeutic options used in patients diagnosed with prostate cancer in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: The study was conducted on 1,745 patients referred by hospitals taking part in the study. Data on treatment used was available for 1,104 (63%) patients. Treatment modality was correlated to clinical stage and patient age. RESULTS: Most frequent choice was hormone therapy (35%) followed by radical prostatectomy (34%) and radiotherapy (25%). Prostatectomy was most commonly used in patients with localised (42.3%) disease while hormone therapy was preferred for locally advanced (45.6%) or disseminated (94%) disease. There are significant differences in therapeutic indications between the various Health areas participating in the survey. Median age of patients with localised and locally advanced disease was lower in patients managed with prostatectomy (65 and 64 years, respectively) than in those managed with radiotherapy (70 and 69 years, respectively). CONCLUSION: The therapeutic modality indicated by urologists in the Madrid Autonomous Community for managing patients with prostate cancer generally meets with literature recommendations.

[Bellini's duct carcinoma]. / Carcinoma de los conductos de Bellini.

Two new cases of uncommon Bellini's duct carcinoma are described. The existing literature is reviewed, discussing the clinical manifestations, diagnosis, treatment and embryological aspects, which differentiate from clear cell carcinoma.

[Giant cyst of the seminal vesicle associated with ipsilateral renal agenesis]. / Quiste gigante de vesícula seminal asociado con agenesia renal ipsilateral.

Cyst of the seminal vesicles represent a rare but illustrative type of embryologic malformation whose etiology is associated with an abnormal development of the mesonephric or Wolffian duct. Frequently these malformations are associated with an abnormal development of the ipsilateral upper urinary tract. The initial evaluation of the majority of cases is performed with abdominal or transrectal ultrasound. Considering the possible need of other diagnostic procedures to confirm the diagnosis, ultrasonography is safe in the majority of cases. The treatment of these urologic malformations should be restricted to symptomatic cases and usually consists of vesiculectomy, with of without, removal of the displastic or histoplastic kidney. We present a case of a right mesonephric duct malformation with a giant seminal vesicle associated with ipsilateral kidney agenesis and severe oligozoospermia, that presented with sporadic episodes of hemospermia and urinary complaints.

Carcinoma de los conductos de Bellini / Bellini's duct carcinoma

Se describen dos nuevos casos del carcinoma de conductos de Bellini, neoplasia renal muy poco frecuente, y se revisa la literatura existente. Comentamos los aspectos clínicos, diagnósticos, terapéuticos y embriológicos que lo diferencian del carcinoma de células claras (AU)

Quiste gigante de vesícula seminal asociado con agenesia renal ipsilateral / Giant cyst of the seminal vesicle associated to ipsilateral renal agenesis

Los quistes de las vesículas seminales representan un raro pero ilustrativo tipo de malformación embriológica, su etiología se relaciona con un mal desarrollo del conducto mesonéfrico o wolffiano. A menudo, se combinan con anormalidades del tracto urinario superior ipsilateral. En la mayoría de los casos, la evaluación inicial se realiza con la ecografía abdominal o transrectal. Aunque otros procedimientos diagnósticos pueden ser necesarios para confirmar el diagnóstico, el ultrasonido es bastante seguro en la mayoría de los casos. El tratamiento de tales malformaciones estará restringido a los casos sintomáticos y usualmente consiste en vesiculectomía con o sin extirpación del riñón displásico o hipoplásico.Presentamos un caso de malformación de conducto mesonéfrico derecho compuesta de quiste gigante de vesícula seminal asociado con agenesia renal ipsilateral y oligozoospermia severa, que debutó con episodios de hemospermia esporádicos y clínica miccional. (AU)

Cirugía de la litiasis renoureteral. Indicaciones actuales / Open surgery for kidney and ureteral stone. Current indications

INTRODUCCIÓN: Toda reflexión sobre litiasis renoureteral y su terapéutica se centra actualmente en la LEOC (Litotricia Extracorpórea por Ondas de Choque), como tratamiento único o asociado a otras técnicas. En ciertos casos la endourología y la litotricia de contacto, se consideran como primera alternativa. La retroperitoneoscopia es otra opción en aquellos centros donde se desarrolla. El abandono de la cirugía abierta es muy manifiesto a favor de las nuevas alternativas, sobre todo en aquellos centros con litotritor extracorpóreo. Los buenos resultados que se obtienen con las técnicas alternativas y la comodidad que el paciente vive, han hecho que el número de casos que se someten anualmente a cirugía abierta sea mínimo. MATERIAL Y MÉTODOS: La Unidad de Litiasis-Litotricia de la Fundación "Jiménez Díaz" (FJD), que realiza LEOC (Modulith SL 20, Storz (r) ), analiza 54 pacientes operados en los últimos años (1990-200), con el fin de concluir en los motivos de la indicación quirúrgica. No se incluye la nefrectomía por lesión renal terminal post-litiásica (pionefrosis, pielonefritis xantogranulomatosa,...).RESULTADOS: La cirugía abierta realizada ha sido la tradicional según el caso: pielotomía (simple o ampliada, ñ infundibulotomía), nefrotomía anatrófica, ureterolitectomía,..., y corrección de aquellas anomalías u obstrucciones asociadas a la patología litiásica (hidro-nefrosis congénita, ureterocele,...). DISCUSIÓN: Actualmente existen casos de litiasis difíciles de solucionar incluso con cirugía abierta. Es la litiasis renal compleja. Sin duda la cirugía es la alternativa más eficaz y resolutiva. Si la LEOC, la URS (Ureterorenoscopia) o la NPL (Nefrolitotomía percutánea) fracasan, y la litiasis es sintomática, debe ser operada. Ante situaciones críticas (complicaciones de estos métodos, se requiere una solución eficaz y urgente, siendo la cirugía tradicional la única alternativa. CONCLUSIONES: La cirugía abierta se indica hoy ante casos de litiasis renal compleja y litiasis renoureteral complicada. El aprendizaje quirúrgico debe ir paralelo al endoscópico, laparoscópico o extracorpóreo. La cirugía abierta será la primera alternativa terapéutica en algún caso. En situación de urgencia clínica, se deben tomar decisiones quirúrgicas, que deberán ser realizadas con la destreza y precisión que se merecen (AU)

[Surgery of renoureteral lithiasis. Current indications]. / Cirugía de la litiasis renoureteral. Indicaciones actuales.

INTRODUCTION: Today, the issue about kidney and ureteral stone and their management is based on ESWL (Extracorporeal Shock Wave Lithotripsy) like singly or as a part of combination therapy. In some cases, endoscopic procedures (URS, PNL) with contact lithotripsy, is the first-line treatment. Retroperitoneoscopic is a therapeutical option in some hospitals. Open stone surgery is now drastically reducing and the endoscopic and extracorporeal methods are increasing, overcoat ESWL in those hospitals who has an own lithotripter. The optimal results of non-invasive procedures, and the ESWL advantages for the patients (outpatient and anesthesia-free treatment, decreased morbidity,...), has caused limited annual indications of open surgery for stone disease even a complete disappearance in many center. MATERIALS AND METHODS: The Stone and Lithotripsy Unit of "Jiménez Díaz" Foundation (FJD) (Madrid), who has an own lithotipter (Modulith SL 20, STORZ) make an evaluation of 54 patients treated with open surgery (1990-2000) in order to reflect on the indications. Nephrectomy for serious paremquimal lithiasic lesions (complicated pyelonefhritis, xantogranulomatosis....) is not included. RESULTS: The open surgery techniques for stone diseases were the classic according to every case: pielolithotomy (simple or extended +/- infundibulolithotomy), anatrophic nephrotomy, ureterolithotomy,.... At the same time it should be resolved those anomalous structures or obstruction associated to the stone disease (congenital hydroneprosis, ureterocele,...). DISCUSSION: Now days are difficult cases of stone diseases to be managed for any methods included open surgery. It's the renal complex stone. Of course, surgery is the best option, the more effectively choice. When endoscopic procedures (URS, NPL) fall and the stone is synthomatic must be operated. When they are serious situation (septic shock, complications derived from the others methods,...). It's necessary an urgent and effectively treatment and it's the open surgery. CONCLUSION: Open surgery is actually indicated for the complex renal stone and the complicated ureteral stone. So, the training on open surgery should be at the same time on the endoscopic, laparoscopic or extracorporeal. Open surgery will be the first-line treatment in some case. Open surgery should be considered in those urgent situation and will be done with skill and precision.

[Treatment of ureteral lithiasis with shock waves]. / Tratamiento de la litiasis ureteral con ondas de choque.

OBJECTIVE: To present our results with ESWL in situ in the treatment of ureteral lithiasis. Distal ureter calculi can be managed by ESWL or URS. For complex ureteral calculi associated with ureteral malformations, failed ESWL or complications other procedures are utilized (URS) and open surgery has its indications. METHODS: From October 1990 to December 2000 the Lithiasis-Lithotripsy Unit of the FJD has performed 2,500 ESWL in situ for ureteral calculi without endoscopic or percutaneous procedures (double-J or PN). The calculus was located in the lumbar ureter in 45%, sacro-iliac in 11% and renal pelvis in 44%. 67% were males and 33% females (mean age 48 and 42 years, respectively). Stone size was 5-20 mm in 88% of the cases; 1.5% had bilateral involvement, 1.7% multiple and 1.5% had a solitary kidney. 15% had renal colic when the procedure was performed. IVP was performed during ESWL for ureteral uric acid stones. RESULTS: The overall success rate was 95%; 97% for stones in the lumbar ureter and 89% for stones in the distal ureter. Repeat-ESWL rate was 1.10. Renal colic resolved during ESWL, although stone fragmentation was partial. Hematuria is common post-ESWL and irritative voiding symptoms on passage of stone fragments. Post-ESWL colic was observed in 20% of the cases but were managed without difficulty with medication. There were 3 cases of severe complications (0.12%), colon perforation, severe renal hematoma and peritonitis. Septic obstruction was found in 1.5% that required catheterization or nephrostomy. Radiologic and asymptomatic Steinstrasse was observed in 10% of the cases. CONCLUSIONS: ESWL in situ is the treatment of choice in ureteral lithiasis and has been demonstrated by many groups. The size and degree of stone impaction have a negative influence on the results. Resistance to fragmentation, which is basically determined by stone chemical composition, influence the results. Monohydrate calcium oxalate stones have been found to be the most resistant. Previous insertion of a catheter (double-J or nephrostomy) does not enhance the results. It appears to be useful during an episode of renal colic. Distal ureteral calculi can be treated by ESWL and URS. If a lithotriptor is available, ESWL without endoscopic procedures is the first choice.

Leoc eficaz, inmediata o de urgencia: ¡una atractiva alternativa estratégica a considerar en el tratamiento del cólico renal! / Effective inmediate or emergency swel: an attractive strategic alternative for the management of renal colic

INTRODUCCIÓN: El cólico renal originado por la obstrucción ureteral aguda, motivada por impacto litiásico, provoca una inten-sa elevación de la presión intracavitaria. El tratamiento farmacológico clásico (analgésicos, antiinflamatorios y espasmolíticos) es sintomático y temporal pudiendo aparecer de nuevo el dolor al mantenerse la obstrucción. La opción terapéutica etiopatogénica vs la sintomática sería el tratamiento definitivo. MATERIAL Y MÉTODOS: En la Unidad de Litiasis-Litotricia de la FJD desde sus comienzos, se indica LEOC "in situ" inmediata o de urgencia, durante el cólico renal junto al tratamiento farmacológico habitual, una vez identificado el cálculo ureteral con precisión. De un total de 2.100 casos de Litiasis Ureteral tratados (1991-1999) se han atendido en situación de cólico renal el 15 por ciento. RESULTADOS: El cólico renal se soluciona en todos los casos (100 por ciento) aunque la fragmentación resulte parcial y/o precise una segunda LEOC diferida sobre restos litiásicos. El dolor no vuelve a aparecer como sucede cuando cede el efecto de la analgesia ya que la obstrucción ha sido resuelta. DISCUSIÓN: La colocación de un catéter ureteral o una nefrostomía con fines analgésicos para realizar una LEOC diferida del cálculo ureteral, que ha originado la obstrucción ureteral aguda y el cólico renal, no mejoran los resultados de la LEOC. Existen razones físicas que apoyan la práctica de LEOC "in situ" inmediata o de urgencia durante el cólico renal. El cálculo obstructivo al ser fragmentado, junto al edema ureteral que se origina, permite el paso de la orina. Al desaparecer la obstrucción desaparece la hiperpresión intracavitaria y así el dolor de manera definitiva. CONCLUSIONES: La LEOC inmediata, "in situ" o de urgencia en el caso del cálculo ureteral obstructivo, durante el cólico renal es una atractiva alternativa estratégica de tratamiento a considerar sobre todo en aquellos centros donde exista la posibilidad de realizarla, con la misma disponibilidad que cualquier otra actuación urológica (AU)

[Efficient, immediate or emergency ESWL: an attractive strategic alternative to be considered in the treatment of renal colic!]. / LEOC eficaz, inmediata o de urgencia: una atractiva alternativa estratégica a considerar en el tratamiento del cólico renal!

INTRODUCTION: Renal colic due to acute ureteral obstruction caused by lithiasic impact results in severe rise of intracavitary pressure. Traditional drug therapy (painkillers, anti-inflammatories, spasmolytics) is symptomatic and provisional, and pain can reappear when obstruction is maintained. A pathoetiological approach would be the ultimate therapy vs the symptomatic one. MATERIAL AND METHODS: From the beginning, the approach used at the Lithiasis-Lithotrity Unit at the FJD, once the ureteral stone is accurately identified during a renal colic, is that of immediate or emergency "in situ" SWEL together with the usual drug therapy. 15% of 2100 cases of ureteral lithiasis treated (1991-1999) were renal colic. RESULTS: Renal colic can be resolved in all cases (100%) even when fragmentation may be partial and/or require a second deferred SWEL on remnants of the first lithiasis. When obstruction has been resolved, pain does not reappear as it happens with the effects of analgesics. DISCUSSION: Placement of a ureteral catheter or nephrostomy for analgesia in order to perform deferred SWEL of the ureteral stone origin of the acute ureteral obstruction and the renal colic, do not improve SWEL results. There are physical reasons to support the practice of immediate or emergency "in situ" SWEL during a renal colic. Fragmentation of the obstructive stone together with the resulting ureteral oedema allow urine passage. Intracavitary pressure and pain disappear when the obstruction is withdrawn. CONCLUSIONS: Immediate, "in situ" or emergency SWEL in cases of obstructive ureteral stones during a renal colic, is an attractive strategic alternative for drug therapy that should be considered mainly in institutions with means to perform the procedure.

[ESWL-resistant lithiasis]. / La litiasis resistente a LEOC.

INTRODUCTION: To the extent in which the "lithotripter" improves technically. SWEL experts provide different explanations to the failures of this technique. It will depend on the type of "lithotripter" as well as the calculus and its features (size, number, location, composition, obstruction, impact, absence of expansion chamber, presence of ureteral catheter, ...). Not all facts in SWEL have a clear explanation today. Physically, the "cavitation" phenomena (shock, rebound, negative pressure, explosion, heat, ...) explain almost anything that takes place during SWEL. Certainly, the type of lithotripter has some influence, but the calculus fragility, determined by the chemical composition and the crystalline architecture, could be more determinant. MATERIAL AND METHOD: From a total series of 6,500 SWEL procedures performed in the Lithiasis-Lithotrity Unit at the "Jiménez Díaz" Foundation (JD) (January 1991-July 1998), 20 cases considered as failures after multiple SWELs were analyzed. Also the actual diagnostic tests (X-rays, helicoid CAT, densitometry, ...) were studied to establish a pre-SWEL chemical recognition of the calculi that may determine the behaviour of each case prior to treatment. RESULTS: After multiple SWELs (average 5 sessions) negative results were obtained in 65% cases. These cases were resolved with surgery (38%), ureterorenoscopy and ultrasound lithotrity (23%) or watchful wait in absence of signs and symptoms (39%). 57% were calcium phosphate calculi, 29% calcium oxalate monohydrate (COM) and 14% hypercalciuria calculi. CONCLUSIONS: SWEL resistant cases, either unresolved or undergoing multiple SWELs, demonstrate the existence of calculi that cannot be broken by SWEL, although no coincident or similar reasons can be established in all cases. Calcium phosphate dihydrate (brushite) and calcium oxalate monohydrate (COM) together with cystine are the most difficult to destroy with current shockwaves. Helicoid CAT could recognise chemically each case prior to SWEL, since it basically differentiates the most frequent ones, uric acid, struvite and calcium oxalate.

[Lithiasis of the distal ureter: ESWL or URS]. / La litiasis del uréter distal: LEOC o URS.

UNLABELLED: A nephritic colic is the clinical picture that evidences the presence of ureteral stones, the natural evolution being their spontaneous passing. Stones in the distal ureter are self-eliminated in about 71-80% cases. The adoption of a "watchful wait" involves an uncertain occupational and medical evolution since, although in some cases the stones will pass with no problems, in other instances they can result in severe, life threatening situations for the patient's health (intractable pain, anuria or sepsis). When a decision is made to treat the condition, there are two choices available: "in situ" SWEL (extracorporeal lithotrity), or URS (ureterorenoscopy), long-standing conflicting techniques each with its own advantages and disadvantages, which should now be considered complementary. SWEL's major disadvantage is the number of repetitions required and the long wait, sometimes even months, until the last fragment is passed. The greater strength of URS is that it can be resolutive in just one episode (95% cases), thus avoiding the obstruction problems that can arise after SWEL. In the Lithiasis-Lithotrity Unit of FJD, SWEL is the first therapeutical option for the treatment of stones in the distal ureter. SWEL and URS are equally likely to be performed although SWEL is the initial choice for efficiency reasons that are explained. We achieve 93.6% positive results with a 1.82% re-SWEL rate (retreatment), 0.60 coefficient of efficiency (EQ) and 0.69 modified coefficient of efficiency (EQM) (Chart). No serious complications were recorded. Morbidity is variable with little clinical significance. CONCLUSION: Distal ureter lithiasis can be treated with either URS and SWEL, both considered "different and complementary". The choice in each particular case and within each hospital will depend on availability of means to perform one or the other, equipment's efficiency, skill of the urologist, patient's preference and cost of each treatment.

[Strategy changes in the treatment of ureteral lithiasis and nephritic colic]. / Cambios de estrategia en el tratamiento de la litiasis ureteral y del cólico nefritico.

Since lithotripters were first introduced to the clinical practice in 1980, extracorporeal shock wave lithotrite (ESWL) has been universally recognized as the first choice to resolve urinary tract lithiasis, ureteral calculi being the most susceptible lithiasic site for controversy. The urologist approach to the lithiasic patient has changed mainly as compared to that of ureteral calculi. These profound changes translate an undeniable advance of the extracorporeal procedures versus those of endourology, basically based on ESWL low morbidity. In those cases when lithiasis is found in a situation of nephritic colic, there is a real therapeutical chance with ESWL, thus leading to drug therapy losing its major role. We present 768 patients with ureteral lithiasis (1991-1994), 20-25% of which were examined for a nephritic colic. Once the colic situation is overcome in all instances, 35% will require a new lithotrite for complete lithiasic resolution. Overall, our rate of successful ureteral lithiasis resolution is 97% (30% need repeated session).

[Renal cystic carcinoma: report of five cases]. / Carcinoma renal quístico: presentación de cinco casos.

Of 204 renal adenocarcinomas seen in the Urology Service at the Hospital "12 de Octubre", from January 1974 to December 1992, we found five cases (2.5%) of cystic renal carcinoma in patients with an average age of 51.8 years (range 35-69), with a female vs male ratio of 3:2, and a right-sided vs left sided ratio of 4:1. The article describes the signs and symptoms, diagnostic methods used, treatment and subsequent evolution of our series, and includes a revision of the published literature.

[Ambulatory ureteral lithotripsy with "Modulith SL-20"]. / Litotricia ureteral ambulatoria con el "Modulith SL-20".

Analysis of our experience in 'in situ' ambulatory shockwave extracorporeal lithofragmentation of ureteral stones in 104 patients seen in the Lithotrity Unit, Urology Service, Fundación "Jiménez Díaz". Using Modulith SL 20, a third generation lithotripter, 'in situ' disintegration was achieved in 82.69% of cases, 51.92% of which were fragmented in a single lithotrity session. As a first choice, no ureteral handling was used in any of the patients prior to lithotrity. In 9.62% of patients it was necessary to place a 'double J' by-pass catheter, due to the disease presenting with a septic picture. The patient's position was either dorsal or ventral decubitus depending on the lithiatic site, while location and focusing of the stones was done radiologically. All patients were treated ambulatory without hospitalization. Only 18% was given oral or i.v. anaesthesia. Fursemide 40 mg was administered to all patients shortly before starting the session. Each patient received an average of 3,200 shockwaves per session (14-18 Kv, average 16 Kv). Haematuria was the single and modest side effect that happened during the 24 hours following lithofragmentation in 30% of patients, while 20% reported slight discomfort at the time of eliminating the gritted stones. We conclude stating that 'in situ' shockwave extracorporeal lithotrity of ureteral stones with Modulith SL 20 allows for elective disintegration of ureteral stones in whatever location they are found, due to the patient's easy positioning. The simple location and focusing of ureteral stones has allowed us to treat and solve some cases of ureteral lithiasis at the precise moment of the nephritic colic painful emergency, thus speeding up and facilitating the resolution of the condition. Our results and our strategy imply a new change of direction in the management of these lithiasis, as opposed to the well established and historical doctrines in existence regarding stones with ureteral location.