Clinical and imaging parameters were assessed for stone size, the number of sessions required, stone-free rate, stone-free period and complications. They defined a large stone as greater than or equal to 1.3 cm. Preoperative imaging included intravenous pyelogram or noncontrast CT. Postoperative imaging included KUB or KUB with ultrasound, usually at a 1-week postop and at 3 months. All patients underwent laser lithotripsy with Holmium: YAG laser, 365-micron laser fiber. Settings used include 1200-1500mJ, 12-15Hz, for power of 15-25 watts. While stone impaction varies in the literature, they defined impaction as failure to pass a retrograde guidewire beyond the stone. The surgical strategy was described as strategic fragmentation to treat impacted stones that did not permit the passage of a guidewire. The fragmentation is initiated at the central part of the stone, creating a lumen to allow passage of the guidewire. After a safety wire was established, they would then continue to fragment the stone. They utilized a combination approach of fragmentation and dusting.
They identified 465 patients who underwent ureteroscopy and laser lithotripsy. 35 of these patients had large ureteral stones (>1.3cm). The mean stone size was 1.8 cm. All patients had a double J stent placed. They noted that 29 patients (82.9%) were stone free at 1 month and 31 patients (88.6%) were stone free at 3 months. 4 patients required another treatment. There were 4 complications reported: 2 patients had steinstrasse, 2 patients had prolonged hematuria. There was no ureteric perforation, sepsis, or mortality.
There are a number of treatment strategies for large impact ureteral stones including ureteroscopy, antegrade ureteroscopy, percutaneous nephrolithotomy (PCNL), combined approach, laparoscopic ureterolithotomy, and percutaneous ureterolitholapaxy. They concluded that ureteroscopy and laser lithotripsy can be a first-line treatment for large impact ureteral stones up to 2cm in size. These strategies and approaches are especially important in areas of high stone recurrence, dubbed the stone belt regions.
Presented by: Syed Mahmud, FCPS, FEBU, Head of Urology, Lifecare Hospital (Abu Dhabi Campus), Abu Dhabi, United Arab Emirates
Written by: Pengbo Jiang, MD Department of Urology, University of California, Irvine, at the 37th World Congress of Endourology (WCE) – October 29th-November 2nd, Abu Dhabi, United Arab Emirates