The outcome of extracorporeal shockwave lithotripsy for renal pelvic stone with and without JJ stent--a comparative study.

OBJECTIVE: To compare the outcome of Extra corporeal shockwave lithotripsy for a renal pelvic stone with and without JJ stent. METHODS: A comparative cross sectional study was carried out at Sindh Institute of Urology and Transplantation from January 2007 to January 2008. Eighty patients with renal pelvic stone measuring 2cm +/- 2mm were selected for treatment with Extra Corporeal Shockwave Lithotripsy (ESWL). All of these patients were adults with normal renal function and had unilateral renal stones with negative urine cultures. Patients with renal failure and children were excluded. They were divided into two groups of 40 each. Group A patients underwent ESWL without a JJ stent and in Group B a JJ stent was placed before ESWL. SLX F2 electromagnetic ESWL machine was used to impart shock waves. 3000 shockwaves were given in a session. Both the groups were compared for renal colic, steinstrasse, fever, lower urinary tract symptoms (LUTS) emergency room visits and hospital admissions, stone clearance, number of ESWL sessions, auxilliary procedures, (percutaneous nephrostomy or ureterorenoscopy) and cost. RESULTS: Ureteric colic occurred in 13 (32.5%) patients in group A and in 3 (7.5%) patient in group B. Steinstrasse developed in 4 (10%) patients with out JJ stent and in 3 (7.5%) patients with JJ stent. Fever was encountered in 1 (2.5%) patient in group A and in 3 (7.5%) patient in group B. Mean emergency room visits were 2.1 per patient in group A and 0.7 per patient in group B. Stone clearance occurred in 33 (82.5%) patients in group A and 31 (77.5%) in group B. In group B lower urinary tract symptoms were found in 50% versus 20% in group A. Auxillary procedure was performed in one (2.5%) patient each in both groups. CONCLUSION: Pre ESWL JJ stenting for a 2 cm +/- 2 mm renal stone was not beneficial in terms of steinstrasse, fever, stone clearance and number of ESWL sessions. However ureteric colic was significantly less in the stented group. Lower urinary tract symptoms (LUTS) was also significantly high in the patients having a JJ stent. The cost of the treatment doubled in the stented group which is an important factor in our country. JJ stenting does not prove to be a cost effective procedure when compared to the reduction in complications.

Comparison of holmium: Yag laser and pneumatic lithoclast in percutaneous nephrolithotomy.

OBJECTIVE: To compare holmium Yag laser with lithoclast in patients with renal stones undergoing percutaneous nephrolithotomy (PCNL). METHODS: A comparative cross sectional study was performed on 60 patients undergoing PCNL. Patients with a 2.5 cm stone in renal pelvis, having preoperative negative urine culture, no coagulopathy and fit for general anaesthesia were included, pregnant females were excluded. They were randomly divided into 2 groups of 30 cases each depending on the energy source used. Group A included cases of PCNL subjected to laser treatment and group B had patients undergoing PCNL with pneumatic lithoclast. For each group duration of procedure, any per operative or postoperative complication, residual stone, duration of hospital stay and cost of each procedure were recorded. RESULTS: The average operative time was 125.7 +/- 31.1 minutes in group A and 98.5 +/- 18.7 minutes in group B (P = 0.0001). The overall complication rate was similar in both groups being 13.3% in group A and 23.3% in group B. Residual stone was observed in 17% cases in group A and 13% cases in group B (P = 0.5). The mean postoperative hospital stay was 3.17 +/- 1.6 days in group A and 4 +/- 2.3 days in group B (P = 0.4). Cost analysis showed that the initial capital cost of equipment was 40,000 Euro in laser and 24,000 Euro in pneumatic lithoclast. However because of reuse of fiber the per procedure cost was 60 Euro in laser and 50 Euro in lithoclast group. CONCLUSION: In our experience we found that Holmium: YAG laser and pneumatic lithoclast are both effective and safe lithotriptors for percutaneous stone removal. More operating time was required in laser, more complications encountered with pneumatic lithoclast and a high initial cost of laser. However with increasing experience with laser, more promising results are expected with this new technology. The cost can be compensated by using it in other procedures especially at a public sector hospital.