Marshall L. Stoller, Maxwell V. Meng-Urinary Stone Disease

Подождите немного. Документ загружается.

578 Gettman and Segura

Table 2

Treatment of Proximal Ureteral Stones With Ureteroscopy

First Size of ureteroscope Modality of Stone-free LOS Second

author Year Patients (Fr) stone removal rate (days) Complications procedure

Grasso

(5)

1995 27 6.9, 7.5 Pulsed dye, EHL 96% (26/27) NR NR 4% (1/27)

Jung

(23)

1996 40 6.5 Alexandrite laser 68% (27/40) NR 5% (1/40) 28% (11/40)

Yang

(52)

1996 43 6.9 EHL 84% (36/43) 2.5 9% (4/43) 14% (6/43)

Erhard

(51)

1996 39 6.9–13 EHL, Ho:YAG, Pulsed dye

99% (38/39) NR NR 3% (1/39)

Harmon

(14)

1997 17 6–11.5 Intact, EHL, USL,

77% (13/17) NR NR NR

Yip

(31)

1998 18 8.5, 9.5 Ho:YAG 78% (14/18) NR NR 6% (1/18)

Park

(28)

1998 12 7.9–11.5 Intact, PL 75% (9/12) NR NR NR

Pearle

(29)

1998 51 6.9–8.5 Alexandrite laser 69% (35/51) NR NR NR

Kupeli

(25)

1998 15 9.5, 12.0 EHL, USL, PL 66% (10/15) NR 40% (6/15) NR

Grasso

(12)

1998 84 >8.0 Pulsed dye, EHL, Ho: YAG

97% (82/84) NR NR NR

Devarajan

(30)

1998 114 7.5 Ho: YAG 88% (77/114) NR NR 11% (12/114)

Puppo

(35)

1999 62 7.0–8.0 EHL, PL 99% (61/62) NR NR 26% (16/62)

Matsuoka

(40)

1999 40 NR Ho: YAG 80% (32/40) NR 5% (2/40) 15% (6/40)

Scarpa

(39)

1999 22 4.8–9.5 Ho:YAG 100% (22/22) NR 1% (2/150) 7% (10/150)

Maheshwari

(54)

1999 20 8.5 USL, PL 85% (17/20) 1-2 10% (2/20) 45% (9/20)

Hendrikx

(37)

1999 32 6.0–9.5 EHL, Pulsed dye 81% (26/32) 4.4 25% (22/87) NR

Tawfiek

(33)

1999 29 6.0–9.8 Intact, EHL, PL, Ho:YAG

97% (28/29) NR 0% (0/29) 3% (1/29)

Dretler

(56)

2000 29 6.9–7.5 Ho:YAG, EHL 90% (26/29) NR 0% (0/29) 10% (3/29)

Hollenbeck

(43)

2001 81 6.9, 7.5 Intact, Ho:YAG 78% (63/81) NR 17% (14/81) 9% (7/81)

Cheung

(45)

2001 42 6.5, 7.0 Intact, Ho:YAG 73% (32/44) NR 5% (2/44) 24% (10/42)

Yagisawa

(44)

2001 14 8.0 PL 86% (12/14) NR NR 14% (2/14)

Sofer

(3)

2002 194 7.5–10.5 Ho:YAG, EHL 97% (188/194) 99% Outpt. 4% (7/194) 6% (12/194)

Lam

(53)

2002 81 7.5 Ho:YAG, Intact 97% (30/31) 0 0% (0/81) 3% (1/31)

Desai

(46)

2002 24 7.0, 8.0 PL 100% (24/24) NR 0% (0/24) 0% (0/24)

TOTAL 1995-2002 1130 4.8–13.0 — 86% (928/1082)

— 7% (62/877) 11% (109/997)

USL, ultrasonic lithotripsy; EHL, electrohydraulic lithotripsy; PL, pneumatic lithotripsy; Outpt., outpatient.

578

Chapter 29 / Indications and Outcomes of Ureteroscopy 579

Studies comparing ureteroscopy to other treatment modalities have also attempted to

define optimal stone therapy in the proximal ureter; however the small numbers of

patients in many of the ureteroscopy treatment arms remain a limitation. Park et al.

retrospectively compared ureteroscopic stone extraction to shockwave lithotripsy with

a Dornier MPL9000 lithotripter (28). In their 2-yr experience, 301 patients were treated

with shockwave lithotripsy, but only 12 patients were treated with ureteroscopy. Stone-

free rates after a single session were 75% and 72% for ureteroscopy and shockwave

lithotripsy, respectively. Despite these results, the group recommended ureteroscopy

predominantly as salvage therapy for shockwave lithotripsy failures. Strohmaier and

associates also compared ureteroscopy to shockwave lithotripsy for treating patients

with proximal ureteral calculi (36). The stone-free rate for primary shockwave litho-

tripsy was 76%, whereas primary ureteroscopy was successful for the single patient

undergoing this treatment. Stones successfully treated with shockwave lithotripsy had

a mean diameter of 6.8 mm, whereas shockwave lithotripsy failures had a mean diameter

of 9.4 mm. All patients failing shockwave lithotripsy selected secondary treatment with

ureteroscopy and this secondary procedure was associated with an overall 97% stone-

free rate. These results again confirm the efficacy of ureteroscopy for salvage therapy

after failed shockwave lithotripsy. Grasso et al. compared the efficacy of ureteroscopy

(27 patients) to shockwave lithotripsy on a Siemens Lithostar lithotripter (27 patients)

for large proximal stones (5). Stone-free rates of 62% and 97% were achieved for shock-

wave lithotripsy and ureteroscopy, respectively. Importantly, combined retreatment and

auxiliary treatment rates were significantly higher for the shockwave lithotripsy cohort

when compared to the ureteroscopy cohort (37% vs 3.7%). In addition, treatment costs

were higher and postoperative visits were more common in the shockwave lithotripsy

group (5). Likewise, Lam et al. recently compared shockwave lithotripsy to Ho:YAG

lithotripsy in 67 patients with proximal ureteral stones. Among stones >1.0 cm in diam-

eter, the initial stone-free rate was 93% for ureteroscopy and 50% with shockwave

lithotripsy performed with a DoLi 50 lithotripter (53). For stones <1.0 cm in diameter,

the initial stone-free rates were 100% and 80% for ureteroscopy and shockwave litho-

tripsy, respectively. The researchers recommended shockwave lithotripsy as first-line

therapy for stones <1.0 cm because the procedure was less invasive. For stones >1.0 cm,

ureteroscopy was recommended as first-line treatment (53).

Based on the results of contemporary ureteroscopy series, the indications for

ureteroscopic treatment of proximal ureteral stones appear to be evolving. Similar to the

AUA guidelines published in 1997, we favor shockwave lithotripsy as first-line therapy

for most proximal ureteral stones <1.0 cm in diameter. Ureteroscopy appears indicated

as salvage therapy after failed shockwave lithotripsy for calculi <1 cm in diameter.

Based on series published since 1996, the authors tend to favor ureteroscopy as an

alternative to shockwave lithotripsy for proximal ureteral calculi >1 cm in diameter,

especially if a Dornier HM3 lithotripter is not available. In addition, ureteroscopy appears

advantageous for impacted proximal ureteral stones and as a treatment alternative for

obese patients that are not candidates for shockwave lithotripsy. Furthermore, uretero-

scopy appears more effective than shockwave lithotripsy for patients that present with

stones in more than one area of the collecting system.

URETEROSCOPIC MANAGEMENT OF RENAL CALCULI

Although technologic advances make all areas of the kidney accessible, indications

for ureteroscopic treatment of renal calculi remain debated. The current mainstays of

580 Gettman and Segura

therapy are shockwave lithotripsy and percutaneous nephrolithotomy; however ureter-

oscopy has been evaluated as an alternative to these treatment modalities. Because

shockwave lithotripsy is the least invasive treatment option for small renal stones, this

treatment modality has been preferable and effective, particularly when performed with

the Dornier HM3 lithotripter. For stone burdens >2.0 cm in diameter, a percutaneous

approach is classically selected. For larger diameter renal stones, a combination of

minimally invasive therapies is often required to achieve a stone-free state. In similar

fashion for ureteral stones, the AUA has also devised treatment guidelines for manage-

ment of staghorn calculi (57). Given the dramatic advances in minimally invasive tech-

niques, open surgery is rarely required for treating renal stones. The indications for

treatment of renal calculi, regardless of treatment approach, include urinary tract obstruc-

tion,an attempt to prevent the loss of renal function, renal colic, and an attempt to prevent

recurrent urinary tract infections. Selection of specific therapy traditionally has been

influenced by stone burden, stone configuration (i.e., staghorn vs nonstaghorn calculus),

individual patient characteristics (i.e., anatomy, underlying medical conditions), stone

composition, and to some degree patient preference. The relatively new ureteroscopic

treatment of renal calculi is increasingly reported and indications and outcomes can be

considered in relationship to stone configuration (staghorn vs nonstaghorn).

Nonstaghorn Renal Stones

Before the advent of small-caliber flexible ureteroscopes, the role of ureteroscopy in

the management of renal calculi was extremely limited. For the most part, ureteroscopic

removal of a renal stone was typically reserved for the incidental stone encountered

during diagnostic ureteroscopy. Although early reports described approx 50% success

rate for ureteroscopic treatment of renal calculi, the cumulative success rate for 13 series

(comprising 681 patients) published since 1996 was 84% (33) (Table 3). Among the

same series, the cumulative incidence of complications was 4.4% and the cumulative

incidence of secondary interventions was 17% (Table 3). To date, ureteroscopic treat-

ment of renal calculi has been most favored for patients with contraindications to other

minimally invasive treatments, but ureteroscopy is also increasingly used at some cen-

ters for standard patients and as an alternative to other treatments for lower-pole stones.

Recent series have effectively demonstrated the role of ureteroscopy in management

of renal stones. Using 1.9-Fr electrohydraulic lithotripsy probes and flexible uretero-

scopes, Elashry et al. reported a success rate of 92% when treating renal stones (58). In

another report published early in the era of Ho:YAG laser lithotripsy, Grasso reported

an 88.5% success rate among 26 patients following one treatment (59). In an expanded

series reported by Fabrizio et al., an overall success rate of 89% was noted among 100

patients undergoing Ho:YAG laser lithotripsy (4). In 68% of patients, laser lithotripsy

was selected because stones were located concurrently in multiple regions of the collect-

ing system. In addition, a stone burden of >6 mm in diameter was noted in 67% of

patients. Other indications for ureteroscopic treatment of renal calculi included patients

previously failing shockwave lithotripsy, obese patients, and patients with anatomic

abnormalities (4). In a recent report by Sofer et al, a similar success rate of 84% was

reported among 56 patients with renal calculi that were treated exclusively with the

Ho:YAG laser (3). In the era of Ho:YAG lithotripsy, ureteroscopy can also be used to

treat renal stones regardless of stone composition. In two small series, cystine stones

with diameter less than 3 cm have been effectively treated using ureteroscopic tech-

niques (61,63). In this manner, ureteroscopy appears to be indicated for patients that are

Chapter 29 / Indications and Outcomes of Ureteroscopy 581

Table 3

Treatment of Renal Stones With Ureteroscopy

First Scope Stone

Location (

) Stone type (

Stone LOS Complication Second

author Year Patients size removal modality Upper Mid Lower Pelvis Staghorn Nonstaghorn free rate (d) rate proc.

Elashry

(58)

1996 17 7.5–9.4 EHL 17 37 88% NR NR 12%

(15/17) (2/17)

Grasso

(59)

1996 29 7.5 Ho:YAG 7 2 20 3 26 88% NR NR 12%

(23/26) (3/26)

Grasso

(60)

1998 45 7.5 Ho:YAG; EHL 5 6 11 23 NR 76% NR 6% 35%

(34/45) (3/51) (18/51)

Grasso

(12)

1998 193 <8.0 Pulsed dye, EHL,

43 25 80 45 NR 79% NR NR NR

Ho: YAG (152/193)

Fabrizio

(4)

1998 100 7.5–9.8 EHL, Ho:YAG, 63 NR 98% 0.5 6% 0%

Intact Renal (other locations)=37

(98/100) (6/100) (0/100)

Rudnick

(61)

1999 5 NR EHL 1 5 2 5 50% 1 80% 50%

(4/8) (4/6) (3/6)

Tawfiek

(33)

1999 59 7.5–9.8 Intact, EHL, PL, 11 7 23 18 NR 88% NR NR NR

Ho:YAG (64/73)

Grasso

(62)

1999 79 7.5 Ho:YAG 90 22 68 76% NR 13% 31%

(90)

(53/70) (9/70) (22/70)

Kourambas

(63)

2000 3 7.5 Ho:YAG 1 2 2 3 66% 0 0% 0

(2/3) (0/3)

Hollenbeck

(64)

2001 72 6.9–7.5 Intact, Ho:YAG, 72 72 88% 83% 19% 13%

EHL (38/43) outpt. (14/72) (9/72)

Lee

(65)

2001 9 NR Ho:YAG 1 1 7 2 7 100% NR NR NR

(9/9)

Kourambas

(7)

2001 14 7.5 Ho:YAG NR NR 79% NR 0% NR

(11/14) (0/14)

Sofer

(3)

2002 56 7.5–10.5 Ho:YAG, EHL NR NR 84% 99% NR NR

(47/56) Outpt

TOTAL 1996– 681 7.5–10.5 — — — 84% — 4.4% 17%

2002 (698)

(550/657) (14/316) (57/342)

Proc., procedure; outpt., outpatient.

581

582 Gettman and Segura

not candidates for repeat percutaneous nephrolithotomy or for cystine stone patients that

fail shockwave lithotripsy.

Among the renal stones treated with ureteroscopic techniques, management of stones

located in the lower pole has generated significant interest. The mainstays of treatment

for lower-pole stones have been percutaneous removal and shockwave lithotripsy. Per-

cutaneous treatment of lower-pole stones assures the patient an almost certain treatment

success, yet the procedure is more invasive and can be associated with significant com-

plications. A percutaneous approach is also contraindicated in some patients with mul-

tiple medical problems or severe anatomic deformities. Although shockwave lithotripsy

is appealing, the overall success rates using this treatment modality for lower-pole stones

are only 50–80% (66). When stratified by stone size, shockwave lithotripsy is associated

with a stone free rate of 63–76% for stones <1.0 cm in diameter and 45–59% for stones

1.0–2.0 cm in diameter (64). The introduction of the flexible steerable ureteroscope

provides the chance to merge the higher success rates of percutaneous surgery with the

minimally invasiveness of shockwave lithotripsy. Nonetheless, ureteroscopic treatment

of lower-pole stones can be much more challenging than the other treatment options

despite the technologic advances in ureteroscopy.

Ureteroscopic treatment of lower-pole stones has been performed by directly treating

the stone in the lower pole or by displacing the stone to a more favorable location before

intracorporeal lithotripsy (67). Using either approach, initial success rates for uretero-

scopic treatment of lower-pole stones have been 76–88% (33, 58,62,64,67). In a recent

report comparing in situ treatment of lower-pole stones to treatment after displacement,

Schuster et al. found nonsignificant differences in success rates for stones <1.0 cm in

diameter (77% vs 89%). For stones >1.0 cm in diameter, however, the 29% success rate

associated with in situ stone treatment was significantly less than the 100% success rate

associated with treatment after stone displacement (68). In an early report using in situ

stone treatment, Elashry et al. used 1.9 Fr. EHL probes to achieve an 87% success rate

among 17 patients with 37 lower-pole stones at a mean follow-up of 8.7 mo (58). The

researchers suggested EHL was the only lithotrite with adequate flexibility to routinely

access the lower pole and was also the most cost-effective mode of intracorporeal lith-

otripsy. In other studies, however, efficacy of Ho:YAG lithotripsy has now also been

reported for lower-pole stones. Hollenbeck et al. evaluated ureteroscopic treatment for

60 patients undergoing 66 interventions for lower-pole stones <2.0 cm in diameter (mean

8.7 mm) (64). Using flexible ureteroscopy and intracorporeal lithotripsy when required,

the researchers noted a 79% stone-free rate after a single procedure and an 88% success

rate after a second procedure in four patients (64). Nonetheless, the researchers recom-

mended shockwave lithotripsy as first-line therapy for lower-pole stones <1.0 cm. For

patients failing initial shockwave lithotripsy, ureteroscopy was recommended as salvage

therapy. For stone diameters between 1.0 and 2.0 cm, ureteroscopy was favored as first-

line therapy because better results were achieved than historical results with shock-

wave lithotripsy, and ureteroscopy was less invasive than percutaneous nephrolitho-

tomy. Grasso and Ficazzola also investigated the results of ureteroscopic treatment of 90

lower-pole stones based on stone burden (62). They stratified results based on stone

diameter with groupings of <1.0 cm, 1.1–2.0 cm, and >2.0 cm in diameter and noted

fragmentation rates of 94%, 95%, and 45%, respectively. After a second treatment for

stones >2.0 cm in diameter, the success rate increased to 82% (62). A similar success

rate of 87% was also reported at 3 mo follow-up in a report by Tawfiek and Bagley for

23 lower-pole stone patients with a mean diameter of 7 mm (33).

Chapter 29 / Indications and Outcomes of Ureteroscopy 583

In addition to type of intracorporeal lithotripsy, patient anatomy has been another

factor considered in the treatment of lower-pole stones. For patients undergoing shock-

wave lithotripsy of lower-pole stones, Elbahnasy et al. previously evaluated the impact

of patient anatomy on successful stone clearance (69). Among the anatomic factors

considered, they noted an acute infundibulopelvic angle, a narrow infundibular width,

and a long lower-pole infundibular length as negative predictors of successful shockwave

lithotripsy treatment. Grasso and Ficazzola similarly studied the impact of anatomic

factors on ureteroscopic lithotripsy of lower-pole stones and noted an infundibular length

>3.0 cm and the presence of infundibular strictures as adverse predictors of outcome

(62). In their series, they reported a 21% failure rate secondary to inability to access the

lower-pole stone or inability to render the patient stone-free after fragmentation. As

such, when either of these anatomic factors were encountered preoperatively, the

researchers recommended percutaneous treatment of lower-pole stones rather than

ureteroscopic treatment (62).

Inability to ureteroscopically access the lower-pole stone with the intracorporeal

lithotrite or stone basket is a particularly vexing problem. Not uncommonly, the stone

can be accessed with the ureteroscope alone but decreased deflection of the ureteroscope

with the addition of the stone basket or lithotrite through the working channel precludes

adequate stone access. To overcome this limitation, Landman et al. recently recom-

mended the use of unsheathed nitinol baskets within the standard working channel of

commonly available flexible ureteroscopes to additionally improve active deflection by

approx 15–20° and to improve irrigant flow approx 2- to 30-fold when compared to

similar studies performed with sheathed nitinol baskets (70).

Whereas the results of prospective studies comparing ureteroscopic treatment of

lower-pole stones to other treatment modalities are currently unavailable, Albala et al.

have previously published the results of treating lower-pole stones with shockwave

lithotripsy and percutaneous nephrolithotomy (71). They noted that percutaneous neph-

rolithotomy provided superior results, regardless of stone burden. Specifically, the suc-

cess rates for stones <1.0 cm was 63% with shockwave lithotripsy compared to 100%

with percutaneous nephrolithotomy. For shockwave lithotripsy, the success rates were

23% for stones between 1.0 and 2.0 cm and 14% for stones >2.0 cm in diameter (71).

Based on retrospective data now available for lower-pole stones, outcomes data for ure-

teroscopy appears more comparable to percutaneous nephrolithotomy and the treatment

modality also appears more beneficial because it is less invasive.

In summary, the role of ureteroscopy in the management of nonstaghorn renal calculi

appears to be expanding. In 2006, ureteroscopic treatment of renal stones appears indi-

cated as a salvage therapy following failed shockwave lithotripsy and as first-line therapy

when the other commonly employed first-line treatment modalities are contraindicated.

Ureteroscopy also compares favorably to percutaneous nephrolithotomy from a stand-

point of treatment morbidity when considering treatment of obese patients in which

shockwave lithotripsy is contraindicated. Similar to recommendations for patients with

multiple ureteral stones, ureteroscopy is favored for patients with stones located concur-

rently in the kidney and ureter and for patients with anatomic abnormalities precluding

treatment with shockwave lithotripsy or percutaneous lithotripsy. Finally, ureteroscopic

treatment has emerged as a very effective intervention for select patients with lower-pole

stones. Although ureteroscopy is increasingly used for management of the standard renal

stone patient, additional outcomes data comparing ureteroscopy and the other treatment

options are warranted before ureteroscopic treatment of all renal stones becomes com-

584 Gettman and Segura

monplace. Likewise, the results of ongoing comparative studies will further clarify the

role of ureteroscopy in the management of lower-pole stones.

Staghorn Renal Calculi

Widespread enthusiasm is lacking for the primary management of staghorn calculi

with ureteroscopic techniques. Although ureteroscopic management of select patients

with staghorn calculi has been reported, the technique is challenging, often labor inten-

sive, and can be associated with a high incidence of ancillary treatments. When the AUA

treatment guidelines were published for staghorn stones in 1994, ureteroscopic manage-

ment was not considered in the treatment armamentarium for staghorn stones (57). In

general, first-line therapy for staghorn calculi remains percutaneous nephrolithotomy

followed by shockwave lithotripsy and/or repeat percutaneous nephrolithotomy. Based

on the AUA guidelines, neither open surgery nor shockwave lithotripsy alone should be

considered as first-line treatments for staghorn stones in the standard patient. For smaller

volume branched stones, the AUA guidelines recommended percutaneous nephrolitho-

tomy and shockwave lithotripsy as equally effective treatment options when the anatomy

was normal or near normal. Also, as an option, open surgery was considered appropriate

therapy when the stone could not be treated effectively by percutaneous nephrolitho-

tomy or shockwave lithotripsy. In addition, nephrectomy was considered a reasonable

option for a poorly functioning kidney bearing a staghorn stone. The recommended AUA

guidelines were also reported as the most cost-effective methods for treatment of stag-

horn stones in a previous investigation (57).

Advances of ureteroscopy have made ureteroscopic treatment of select patients with

large-volume branched calculi a technical possibility. In a limited clinical experience

published since 1994, successful ureteroscopic treatment of staghorn calculi has been

reported (59,60,72,73). Feasibility of ureteroscopically treating staghorn calculi also

appears to be increasing in the era of Ho:YAG lithotripsy. Grasso et al. treated a group

of 45 patients with minor staghorn calculi of noninfectious etiology and found a stone-

free rate of 76% after a single treatment (60). Following a second procedure in eight

patients with residual fragments, the investigators achieved a 91% stone-free rate. With

the ureteroscopic approach, second procedures were commonly performed for patients

with large branched calculi or stone burdens in excess of 3.0 cm to exclude the presence

of large residual fragments. In the series by Grasso et al. a second procedure was per-

formed in 15 patients and identified fragments in 53% (n = 8) (60). Among 25 patients

with a minimum follow-up of 6 mo, 15 patients (60%) were stone-free, 6 patients had

small fragments (24%), and 4 patients had stone regrowth (16%) The researchers recom-

mended ureteroscopic stone treatment only for patients with noninfectious stones. When

matrix stones were encountered, the group recommended a conversion to percutaneous

nephrolithotomy (60). In addition to ureteroscopic monotherapy of staghorn stones,

combination therapies incorporating ureteroscopy have also been reported (73). In one

of the earliest reports on ureteroscopic treatment of staghorn calculi, Dretler et al. used

staged therapy with primary pulsed dye laser lithotripsy and secondary shockwave lithot-

ripsy to treat eight patients with staghorn stone burdens (72). Although a mean of 2.8

procedures was performed for each patient and the mean length of hospitalization was

3.5 d, eventually 88% of the patients became stone-free (72). Likewise, in the era of

Ho:YAG laser lithotripsy, Mugiya et al. noted the combination of ureteroscopy and

shockwave lithotripsy resulted in a 61% stone-free rate for complete staghorn calculi and

an 80% stone-free rate for partial staghorn calculi (73).

Chapter 29 / Indications and Outcomes of Ureteroscopy 585

Although feasibility of ureteroscopic treatment of staghorn calculi represents a true

technical milestone in the management of renal stones, additional experience is required

to delineate the role of ureteroscopic stone treatment for staghorn calculi. At the present

time, ureteroscopic treatment of staghorn calculi appears warranted only for patients that

are not candidates for the traditional treatment modalities. Furthermore, ureteroscopic

treatment of minor staghorn calculi should not be performed for patients with matrix

stones or infectious stones. In reality, given the advances in anesthesia and the advances

in percutaneous treatment of renal calculi, treatment of staghorn calculi with

ureteroscopic techniques appears limited. Nonetheless, as additional experience and

technologic advances are incorporated into the ureteroscopic treatment of staghorn cal-

culi, indications for primary treatment of staghorn calculi in the standard patient may

ultimately increase. The authors still favor the staghorn calculi treatment guidelines as

previously published by the AUA (57).

CONCLUSIONS

The indications and outcomes for ureteroscopic management of ureteral and select

renal stones continue to increase and improve. Given the technologic advances, essen-

tially all areas of the collecting system can be accessed with the ureteroscope. In our

opinion, the strongest indication for ureteroscopic management of ureteral stones is for

patients with calculi located below the pelvic brim. For stones located above the pelvic

brim, ureteroscopy is an increasingly successful treatment, but may still remain less

advantageous to shockwave lithotripsy in many cases, especially when performed with

a Dornier HM3 lithotripter. In the kidney, the ureteroscopic indications for stone treat-

ment are even less established, but encouraging results have recently been reported for

stones especially located in the lower pole of the kidney.

The coexistence of multiple effective treatment modalities for management of ure-

teral calculi and renal calculi has created controversy. The battle for optimal treatment

of ureteral and renal calculi has been amplified with the increased use of ureteroscopy

secondary to improvements in ureteroscope design and instrumentation. Patient prefer-

ence, physician familiarity, and instrument availability are factors that may influence the

selection of stone treatment. Only prospective, randomized trials employing state of the

art technology and equivalent physician expertise will determine the optimal treatment

algorithms for ureteral and renal calculi and help resolve management controversies. In

reality, optimal treatment of ureteral and renal stones will likely continue to require one

of a number of minimally invasive therapeutic modalities that are tailored specifically

to the characteristics of the patient.

REFERENCES

1. Marshall VF. (1964) Fiberoptics in urology. J Urol 1964; 91: 110.

2. Goodman TM. Ureteroscopy with a pediatric cystoscope in adults. Urology 1977; 9: 394.

3. Lyon ES, Kyker JS, Schoenberg HW. Transurethral ureteroscopy in women: a ready addition to

the urological armamentarium. J Urol 1978; 119: 35–36.

4. Sofer M, Watterson JD, Wollin TA, Nott L, Razvi H, Denstedt JD. Holmium:YAG laser lithotripsy

for upper urinary tract calculi in 598 patients. J Urol 2002; 167: 31–34.

5. Fabrizio MD, Behari A, Bagley DH Ureteroscopic management of intrarenal calculi. J Urol 1998;

159: 1139–1143.

6. Grasso M, Beaghler M, Loisides P. The case for primary endoscopic management of upper urinary

tract calculi: II. Cost and outcome assessment of 112 primary ureteral calculi. Urology 1995; 45:

372–376.

586 Gettman and Segura

7. Biyani CS, Cornford PA, Powell CS. Ureteroscopic endopyelotomy with the holmium: YAG laser.

Eur Urol 2000; 38: 139–143.

8. Kourambas J, Delvecchio FC, Preminger GM. Low-power holmium laser for the management of

urinary tract calculi, strictures, and tumors. J Endourol 2001; 15: 529–532.

9. Elliott DS, Segura JW, Lightner D, Patterson DE, Blute ML. Is nephroureterectomy necessary in

all cases of upper tract transitional cell carcinoma? Long-term results of conservative endourologic

management of upper tract transitional cell carcinoma in individuals with a normal contralateral

kidney. Urology 2001; 58: 174–178.

10. Nakada SY, Elashry OM, Picus D, Clayman RV. Long-term outcome of flexible ureterorenoscopy

in the diagnosis and treatment of lateralizing essential hematuria. J Urol 1997; 157: 776–779.

11. Grasso M. Ureteropyeloscopic treatment of ureteral and intrarenal calculi. Urol Clin North Am

2000; 27: 623–631.

12. Grasso M, Bagley D. Small diameter, actively deflectable, flexible ureteropyeloscopy. J Urol

1998; 160: 1648–1654.

13. Elashry OM, Elbahnasy AM, Rao GS, Nakada SY, Clayman RV. Flexible ureteroscopy:

washington university experience with the 9.3F and 7.5F flexible ureteroscopes. J Urol 1997; 157:

2074–2080.

14. Harmon WJ, Sershon PD, Blute ML, Patterson DE, Segura JW. Ureteroscopy: current practice and

long-term complications J Urol 1997; 157:28–32.

15. Segura JW, Preminger GM, Assimos DG, Dretler SP, Lingeman JE, Macaluso JN, Jr. Ureteral

stones clinical guidelines panel summary report on the management of ureteral calculi. J Urol

1997; 158:1915–1921.

16. Ueno A, Kawamura T, Ogawa A, Takayasu H. Relation of spontaneous passage of calculi to size.

Urology 1977; 10: 544–546.

17. Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient

education. J Urol 1999; 162: 688–690.

18. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone

size and location as revealed by unenhanced helical CT. AJR 2002; 178: 101–103.

19. Blute ML, Segura JW, Patterson DE. Ureteroscopy. J Urol 1988; 139:510–512.

20. Keating MA, Heney NM, Young HH 2nd, Kerr WS Jr, O’Leary MP, Dretler SP. Ureteroscopy: the

initial experience. J Urol 1986; 135: 689–693.

21. Daniels GF Jr, Garnett JE, Carter MF. Ureteroscopic results and complications: experience with

130 cases. J Urol 1988; 139: 710–713.

22. Hosking DH, Bard RJ. Ureteroscopy with intravenous sedation for treatment of distal ureteral

calculi: a safe and effective alternative to shock wave lithotripsy. J Urol 1996; 156: 899–901.

23. Jung P, Wolff JM, Mattelaer P, Jakse G. Role of lasertripsy in the management of ureteral calculi:

experience with alexandrite laser system in 232 patients. J Endourol 1996; 10: 345–348.

24. Netto NR Jr., De Almeida Claro J, Esteves SC, Andrade EFM. Ureteroscopic stone removal in the

distal ureter. Why change? J Urol 1997; 157: 2081–2083.

25. Kupeli B, Biri H, Isen K, et al. Treatment of ureteral stones: comparison of extracorporeal shock

wave lithotripsy and endourologic alternatives. Eur Urol 1998; 34: 474–479.

26. Bierkens AF, Hendrikx AJM, De La Rosette JJ, et al. Treatment of mid and lower ureteric calculi:

extracorporeal shock–wave lithotrispy vs laser ureteroscopy. A comparison of costs, morbidity,

and effectiveness. Br J Urol 1998; 81: 31–35.

27. Eden CG, Mark IR, Gupta RR, Eastman J, Shrotri NC, Tiptaft RC. Intracorporeal or extracorpo-

real lithotripsy for distal ureteral calculi? Effect of stone size and multiplicity on success rate. J

Endourol 1998; 12: 307–312.

28. Park H, Park M, Park T. Two-year experience with ureteral stones: extracorporeal shockwave

lithotripsy v ureteroscopic manipulation. J Endourol 1998; 12: 501–504.

29. Pearle MS, Sech SM, Cobb CG, et al. Safety and efficacy of the Alexandrite laser for the treatment

of renal and ureteral calculi. Urology 1998; 51:33–38.

30. Devarajan R, Ashraf M, Beck RO, Lemberger RJ, Taylor MC. Holmium:YAG lasertripsy for

ureteric calculi: an experience of 300 procedures. Br J Urol 1998; 82: 342–347.

31. Yip KH, Lee CW, Tam PC. Holium laser lithotripsy for ureteral calculi: an outpatient procedure.

J Endourol 1998; 12: 241–246.

Chapter 29 / Indications and Outcomes of Ureteroscopy 587

32. Peschel R, Janetschek G, Bartsch G. Extracorporeal shock wave lithotripsy versus ureteroscopy

for distal ureteral calculi: a prospective randomized study. J Urol 1999; 162: 1909–1912.

33. Tawfiek ER, Bagley DH. Management of upper urinary tract calculi with ureteroscopic tech-

niques. Urology 1999; 53: 25–31.

34. Turk TM, Jenkins AD. A comparison of ureteroscopy to in situ extracorporeal shock wave lith-

otripsy for the treatment of distal ureteral calculi. J Urol 1999; 161:45–46.

35. Puppo P, Ricciotti G, Bozzo W, Introini C. Primary endoscopic treatment of ureteric calculi. Eur

Urol 1999; 36: 48–52.

36. Strohmaier WL, Schubert G, Rosenkranz T, Weigl A. Comparison of extracorporeal shock wave

lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study. Eur Urol

1999; 36: 376–379.

37. Hendrikx AJ, Strijbos WE, deKnijff DW, Kums JJ, Doesburg WH, Lemmens WA. Treatment for

extended-mid and distal ureteral stones: SWL or ureteroscopy? Results of a multicenter study. J

Endourol 1999; 13: 727–733.

38. Pardalidis NP, Kosmaoglou EV, Kapotis CG. Endoscopy vs. extracorporeal shockwave litho-

tripsy in the treatment of distal ureteral stones: ten years’ experience. J Endourol 1999; 13: 161–

164.

39. Scarpa RM, De Lisa A, Porru D, Usai E. Holmium:YAG laser lithotripsy. Eur Urol 1999; 35: 233–

238.

40. Matsuoka K, Iida S, Inoue M, et al. Endoscopic lithotrispy with the holmium:YAG laser. Lasers

Surg Med 1999; 25: 389–395.

41. Pearle MS, Nadler R, Bercowsky E, et al. Prospective randomized trial comparing shock wave

lithotripsy and ureteroscopy for management of distal ureteral calculi. J Urol 2001; 166: 1255–1260.

42. Delvecchio FC, Kuo RL, Preminger GM. Clinical efficacy of combined lithoclast and lithovac

stone removal during ureteroscopy. J Urol 2000; 164: 40–42.

43. Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS Jr. Comparison of outcomes of ureteroscopy

for ureteral calculi located above and below the pelvic brim. Urology 2001; 58: 351–356.

44. Yagisawa T, Kobayashi C, Ishikawa N, Kobayashi H, Toma H. Benefits of ureteroscopic pneu-

matic lithotripsy for the treatment of impacted ureteral stones. J Endourol 2001; 15: 697–699.

45. Cheung MC, Lee F, Yip SKH, Tam PC. Outpatient holmium laser lithitripsy using semirigid

ureteroscope: is the treatment outcome affected by stone load? Eur Urol 2001; 39: 702–708.

46. Desai MR, Patel SB, Desai MM, et al. The Dretler stone cone: a device to prevent ureteral stone

migration-the initial clinical experience. J Urol 2002; 167: 1985–1988.

47. Kuo RL, Aslan P, Fitzgerald KB, Preminger GM. Use of ureteroscopy and holmium:YAG laser

in patients with bleeding diatheses. Urology 1998; 52: 609–613.

48. Watterson JD, Girvan AR, Cook AJ, et al. Safety and efficacy of holmium:YAG laser lithotripsy

in patients with bleeding diathesis. J Urol 2002; 168: 442–445.

49. Lotan Y, Gettman MT, Roehrborn CG, Cadeddu JA, Pearle MS. Management of ureteral calculi:

a cost comparison and decision making analysis. J Urol 2002; 167: 1621–1629.

50. Anderson KR, Keetch DW, Albala DM, Chandhoke PS, McClennan BL, Clayman RV. Optimal

therapy for the distal ureteral stone: extracorporeal shock wave lithotropsy versus ureteroscopy.

J Urol 1994; 152: 62–65.

51. Erhard M, Salwen J, Bagley DH. Ureteroscopic removal of mid and proximal ureteral calculi. J

Urol 1996; 155: 38–42.

52. Yang SSD, Hong JS. Electrohydraulic lithotripsy of upper ureteral calculi with semirigid ureter-

oscope. J Endourol 1996; 10: 27–29.

53. Lam JS, Greene TD, Gupta M. Treatment of proximal ureteral calculi: holmium:YAG laser lith-

otripsy versus extracorporeal shock wave lithotripsy. J Urol 2002; 167: 1972–1976.

54. Maheshwari PN, Oswal AT, Andankar M, Nanjappa KM, Bansal M. Is antegrade ureteroscopy

better than retrograde ureteroscopy for impacted large upper ureteral calculi? J Endourol 1999; 13:

441–444.

55. Pace KT, Weir MJ, Tariq N, Honey RJ. Low success rate of repeat shock wave lithotripsy for

ureteral stones after failed initial treatment. J Urol 2000; 164: 1905–1907.

56. Dretler SP. Ureteroscopy for proximal ureteral calculi: prevention of stone migration. J Endourol

2000; 14: 565–567.