Ureteral Stone Manipulation Before Extracorporeal Shock Wave Lithotripsy

Abstract

We randomized 75 patients with solitary ureteral calculi that could not be dislodged by ureteral catheterization to receive instillation of saline, 2 per cent lidocaine viscous solution or dilute surgical lubricant before repeat stone manipulation with ureteral catheters. Of the stones irrigated with saline 76 per cent were returned to the pelvis along with 60 per cent of the lidocaine group and 48 per cent of the surgical lubricant treated stones. There was no statistical significance among the 3 groups. The success rates for upper, mid and lower ureteral stones were 80, 54 and 30 per cent, respectively. Of stones 0.5 cm. or less and between 0.6 and 1.0 cm. 77 and 72 per cent, respectively, were manipulated successfully but only 38 per cent of the stones larger than 1.0 cm. could be dislodged. Extracorporeal shock wave lithotripsy was successful in treating pelvic and ureteral stones, although higher kilovolt settings and additional shocks were necessary to fragment the ureteral stones completely. Percutaneous nephrostomy or ureteral meatotomy was required in 10 per cent of the patients with impacted ureteral stones following in situ extracorporeal shock wave lithotripsy but in only 4 per cent of the patients with stones successfully returned to the pelvis. Of the ureteral stones 17 per cent were treated with repeat extracorporeal shock wave lithotripsy. No patient with pelvic stones required repeat treatment. Retrograde manipulation of ureteral stones is an effective adjunctive procedure before extracorporeal shock wave lithotripsy.

Management and Follow-Up of Impacted Ureteral Stones

“…There is a decreased ESWL efficacy in such cases. During ureteroscopy, the difficulty and many times inability to pass a guide wire by the stone reduces the safety margin and increases the possibility of injury and subsequent stricture [4]. In our cases we failed to pass a guide wire in as much as 14 of the 30 patients that underwent ureteroscopy.…”

“…Ureteroscopic techniques present higher success rates since stones can be basketed, fragmented or pushed up to the kidney for ESWL [1,2]. Open or laparoscopic ureterolithotomy is still necessary in some cases of obstinate ureteral stones when less-invasive methods fail [3,4].…”

ESWL of Stones in the Mid-Ureter

“…ESWL has proven to be effective for stented ureteral stones [6,7], It is argued that the decreased efficacy of ESWL for ureteric stones is due to a lack of adequate expansion chamber around the stone [8], Therefore, inva sive techniques to dislodge, fragment and extract the ure teral calculus are given first priority [9], Impacted radiodense stones at any level of the ureter exceeding 1.5 cmunstentable by definition -should even be treated by ure terolithotomy [8], Conversely, ESWL is considered as an alternative only after failure of invasive standard tech niques [10].…”

Management of Ureteral Stones by Extracorporeal Shock Wave Lithotripsy

“…It must be mentioned that we did not perform preoperative ure teral catheter manipulation because it is less important compared to the postoperative interventions like percu taneous nephrostomy, ureteroscopy or open surgery. Whereas other groups managed dislodge the stones into the renal pelvis in 76 and 86% of the patients [Evans et al, 1988;Lingeman et al, 1986, respectively], we were successful in only 51%. We found the success rate of stone repositioning into the kidney to be dependent on duration in ureter and transverse stone diameter.…”