No abstract

Either transurethral ureteroscopy (URS) or extracorporeal shock wave lithotripsy (ESWL) was the primary method of intervention in two series of patients presenting consecutively with stones located in the ureter distal to the radiological marking of the sacroiliac joint. Of 65 patients treated by URS, successful evacuation of the major part of the stone was achieved in 97% in one or two sessions. Of those subsequently attending for review, 93% proved stone-free but 3% required surgery for serious complications. In the ESWL series of 53 patients, successful stone fragmentation was recorded in 94%, with 2 patients requiring a supplementary endourological or surgical procedure. No significant complications were related to ESWL and 90% of those followed up after successful ESWL proved stone-free at 6 weeks. In uncomplicated cases, the mean procedure time for ESWL was one-third of that required for URS and the hospital stay one-half. It is suggested that ESWL should be the primary method of intervention in patients with distal ureteric stone, with URS reserved for the small number that prove refractory to such treatment.

Large bladder calculi are often outside the range of treatment with conventional endoscopic lithotrites because of either anatomic factors or the mechanical limits of available instruments. Alternative methods of cystolithotripsy: ultrasonic, electrohydraulic, or laser, can prove time-consuming or even hazardous, so that open surgery is often the most expeditious option. We report our experience using Dornier HM3 extracorporeal shockwave lithotripsy (SWL) for initial bladder stone reduction preparatory to transurethral litholapaxy and definitive treatment of any underlying obstructive pathology. Primary cystolitholapaxy was judged impractical in these 24 patients (21 adults and 3 children) presenting 31 large bladder stones (mean size 35.6 mm). In all patients, primary transpelvic SWL was followed immediately by endoscopic evacuation of stone debris or cystolitholapaxy. In addition, 10 of the 24 patients (42%) underwent a definitive endoscopic operation for treatment of an underlying obstructive lesion at either the same or a follow-on session. Morbidity was minimal, and the mean hospital stay after the initial SWL treatment was 3.5 days. In our experience, Dornier SWL has proved invaluable in enabling cystolitholapaxy of very large bladder calculi that would otherwise require protracted and difficult endoscopic manipulation or open surgery.

The clinical and aetiological pattern in 85 stone-forming children presenting to an integrated nephrourological service in Riyadh is reviewed. All patients were below the age of 15 years, the male to female ratio being 2:1. Only 2 children presented with bladder calculi. The remaining all had upper tract stones and, in 12 cases, these were bilateral. Of 34 calculi recovered for analysis, one-third was predominantly calcium oxalate and a further third was composed of uric acid or urate. Four patients had cysteine stones and the remaining 7 presented mixed calcium stones, 6 (17.6%) being struvite and infection-related. Of the 85 patients 55 were treated successfully with extracorporeal shock wave lithotripsy, 16 underwent surgery and 7 had their stones removed by endourological procedures. In the remaining 7 children, stones dissolved or were passed spontaneously during medical therapy. Nine children (10.6%) showed a primary metabolic defect leading to their stone formation, 10 (11.8%) had a predisposing anatomical anomaly and 15 (17.6%) presented with urinary tract infection. Of the remaining 51 patients (60%) with idiopathic disease, 6 showed hypercalciuria on investigation and 2 children may have formed their stones due to prolonged recumbency.

In a study of 115 ureters showing chronic bilharzial changes, 4 main patterns of ureteropathy are defined. Type A is benign, shows mild fusiform dilatation localised to the distal ureteric segment and requires no surgery. Type B presents with distal ureteric stricture, without extensive fibrosis, is rare, and shows good results following resection and ureterovesical reimplantation. Type C shows extensive bilharzial changes without stricture and is difficult to evaluate unless fluoroscopy is added to standard urographic investigation. If peristaltic dysfunction is severe, these ureters will require placement with an ileal segment. Type D ureteropathy presents with fixed tortuosity, mainly in the upper ureteric segment, and conservative surgery, involving freeing and straightening the entire ureter, has shown good results. Staging the presenting ureteropathy has proved valuable in evaluation and follow-up.

In an unselected, consecutive series of patients, ureteroscopy was carried out for removal or manipulation of stones in 48 patients and for evaluation of suspected ureteric tumours in two. A success rate of 92% was achieved. The use of an intra-ureteric safety guide wire, indwelling throughout the procedure, facilitated ureteroscopic manipulation, minimised complications, reduced the need for subsequent open surgery and has been a prerequisite for our comparatively aggressive approach to ureteric disorders. The procedure may be time-consuming but prolonged manipulation within the ureter seems to carry little morbidity.

The power and nociceptive intensity of shock waves generated by the Dornier HM3 extracorporeal shock wave lithotripter (ESWL) are voltage dependent and suited to algesimetry in a controllable voltage range of 8-30 kV. Fidelity of the HM3 as an algesimeter was tested by: (1) In vitro measurements of shock pressure at voltages between 14 and 30 kV were recorded by a force transducer at the point of clinical focus. (2) Unanaesthetized volunteer (n = 5) assessment and VAS pain scores of shocks in the range of 10-24 kV, yielding highly significant correlations between blinded randomized shock voltage (r = 0.88), and VAS scores (r = 0.84). (3) Voltage-tolerance curves generated from 33 ASA class 1 or 2 patients undergoing ESWL treatment under epidural analgesia with 0.125% bupivacaine, fortified with a bolus epidural dose of 100 micrograms fentanyl if pain arose during treatment. Voltage tolerance was increased by 50% after an epidural bolus of 100 micrograms fentanyl (P less than 0.001). The respiratory consequences of epidural fentanyl were assessed by changes of respiratory rate and rhythm recorded from capnographic tracings of expired carbon dioxide. This study indicates that the Dornier HM3 system provides a valuable opportunity to conduct precise, quantitative measurements of induced deep truncal pain, as well as the effectiveness and respiratory cost of analgesic interventions directly applicable to the safe management of acute pain.

We report on 8 azotemic patients with anuria or progressive oliguria owing to bilateral uric acid lithiasis. In 7 patients the precipitating cause of acute obstructive renal insufficiency was choking of at least 1 distal ureter with numerous small uric acid stones. In 6 of these ureters contrast retrograde ureterography showed relief of obstruction, which was believed to be owing to the stone dissolution properties of the contrast medium used. In situ alkalization via nephrostomy catheters achieved dissolution of obstructing stones in 3 tracts and systemic alkalization dissolved the stones in 3 others. An operation was necessary in 4 cases of large calculi, all of which showed some radiodensity, either because of super added calcification or phosphatic incrustation, rendering dissolution unfeasible. Methods of management of the obstructed tract caused by uric acid stone disease are evaluated and discussed.