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Objective: We evaluated the feasibility and effectiveness of ureteroscopic lithotripsy for ureteral stones under local anesthesia without any sedation.
Methods: Prospectively, ureteroscopic lithotripsy under local anesthesia was performed in 100 patients (45 males and 55 females). A rigid endoscope (8.5 to 11.5 Fr) was used in all cases. Local anesthesia consists of lidocaine jelly in the bladder associated with a penile nerve block in males only, and without any intravenous analgesia. Ureteroscopy was done for stone fragmentation with a double-J catheter insertion in 13 patients. We compared the pain perception during ureteroscopy to that of cystoscopy performed during the same procedure, using a visual-analogue pain scale recorded by the patient.
Results: The overall success rate was 82%. The success rates of the upper, mid, and lower ureteral calculi were 71.4%, 72.7%, and 89%, respectively. The success rate was 100% in calculi less than 10 mm, and 80.3% in those more than 10 mm. Postoperatively, 1 patient developed pyelonephritis. We didn’t report any cases of ureteral perforation. The mean pain scale score was lower during the ureteroscopy (3.61 [2.2 to 8.5]) than in cystoscopy (4.52 [1.5 to 8] [p <0.001]). Almost all patients tolerated pain well during the procedure. The procedure was interrupted in only 5 patients and was performed later under spinal anesthesia. Postoperative pain was also tolerable in most patients, and only 8 patients required additional analgesics after the procedure.
Conclusion: Our findings suggest that most of the patients could tolerate the pain during a rigid ureteroscopic lithotripsy under local anesthesia. This procedure does not increase the risk of complications or compromises the results of treatment. Thus, it may be recommended in carefully selected and informed patients and performed with experienced hands.
Ahmed Shelbaia, Sherif Abd ELRahman, Ali Hussein
Submitted June 15, 2011 - Accepted for Publication Sept 12, 2011
KEYWORDS: Ureteroscopy; Local anesthesia; Stone; Lithotripsy; Pain
CORRESPONDENCE: Satâa Sallami, Department of Urology, La Rabta Hospital, University of Tunis, El Manar, Tunis, Tunisia ().
CITATION: UroToday Int J. 2011 Dec;4(6):art 77. http://dx.doi.org/10.3834/uij.1944-5784.2011.12.10
Endoscopic treatment of upper urinary tract stones is an important part of modern urology, allowing a mini-invasive and efficient diagnosis and treatment . Previously, the relatively large size and fragility of the instruments has generally necessitated the performance of ureteroscopy under general or regional anesthesia. Actually, with the improvement of technology, there is much progression in the endoscopic management of ureteral calculi. The relative ease, use, and experience with smaller and flexible instruments has indicated the routine use of local anesthesia for endoscopic procedures .
However, ureteroscopic lithotripsy under local anesthesia is rarely performed. This is mainly due to the fear and risk of ureteral injury caused by a patient’s painful sudden movement and the patient complaining of a painful procedure .
Recent reports [3,4] showed that the success rate of ureteroscopic lithotripsy under local anesthesia was comparable with that of general or spinal anesthesia, but only few reports mentioned the degree of pain associated with the procedure .
Our idea is that if, currently, it is recommended to perform cystoscopy under local anesthesia, and if there is no difference in the level of pain between the cystoscopy and the ureteroscopy, why don’t we perform ureteroscopy with lithotripsy under local anesthesia?
In this study, we evaluated the effectiveness, pain perception, and acceptance of local anesthesia in ureteroscopic lithotripsy.
PATIENTS AND METHODS
During a 3-year period (November 2006 to December 2009), 541 ureteroscopic procedures for ureteral stones were performed in our hospital. One hundred of them underwent ureteroscopic lithotripsy of ureteral stones under local anesthesia.
We designed a prospective study for comparing pain values during the introduction of the ureteroscope into the bladder, which mimics the cystoscopic procedure and ureteroscopic lithotripsy using a visual-analogue pain scale (VAS). Patients with large stones (transversal diameter >10 mm) were excluded from the study. One hundred patients were entered into the study.
We considered the upper ureter as the ureteral portion between the ureteropelvic junction and the upper border of the sacroiliac joint, the mid ureter as the portion of the ureter anterior to the sacroiliac joint, and the lower ureter as the section of the ureter between the distal edge of the sacroiliac joint and the ureterovesical junction.
The patient was informed of other available anesthetic options, and the risks and benefits associated with each anesthetic method. All procedures were done with informed patient consent and by a single operator.
All patients underwent ureteroscopy under local anesthesia and without any sedation.
Ten ml of 2% lidocaine, intravesical gel, through a 12 F silicone catheter inserted into the urethra, was used to anesthetize the bladder in all cases. In males, in addition with bladder anesthesia, 10 ml of lidocaine hydrochloride (40 mg/2 mL) was injected using a 26-gauge needle superficial to the fascia of the penile shaft at its base. The surgeon performed the dorsal penile nerve block and 5 minutes later, he started the endoscopic procedure.
Perioperative antibiotic prophylaxis consists of 1 g of cefotaxime given just before the endoscopic operation.
SEQUENCE OF URETEROSCOPY
Patients were placed in the dorso-lithotomy position with the legs suspended in stirrups.
Ureteroscopy was performed using an 8.5 Fr rigid ureteroscope (Storz, Germany). Along the working guide, a wire ureteroscope was inserted and we removed the working guide wire when calculi were found. Continuous irrigation with intermittent manual pumping of the irrigant was done to maintain a clear ureteroscopic view. Irrigation pressure was less than 70 cm of H2O. Pneumatic lithotripsy was used for fragmentation of the calculi. A trapping basket was used as necessary to extract calculi fragments. During the operation, patients were encouraged to view on the screen when explaining anatomy and procedures to them.
After each procedure, patients were asked to grade the discomfort and/or pain level experienced during the 2 procedures (cystoscopy then ureteroscopy and lithotripsy) using a 10-point linear VAS. Pain is considered mild when VAS <3, moderate when VAS >3 but <6, and was severe when VAS >6.
Pain during the introduction of the ureteroscope into the bladder was considered the referenced level. The pain score was compared according to operation time, the location, and the size of calculi.
Patients were discharged 2 to 3 hours postoperatively after a short follow-up. All patients underwent postoperative abdominal ultrasonography and plain X-rays at our institution. The patients were re-evaluated at 1 and 3 months postoperatively for any residual stones and other complications. Complications and outcomes were recorded.
Treatment success was defined as radiographic evidence of the complete disappearance of the stone within 1 month: totally stone free. Patients with residual ureteral calculi that had not passed spontaneously within 4 weeks required earlier management because of recurrent renal colic or the obstruction of the upper urinary tract.
The chi-squared test was used to evaluate the statistical significance of the difference in the variables with a 95% confidence interval. Data was analyzed using SPSS version 11.0 (SPSS Inc, Chicago, IL, USA). A “p” value of less than 0.05 was considered statistically significant.
There were 45 men and 55 women with a mean age of 49.6 years (range 18 to 85 years). Female mean-age was 47 years (18 to 75) and the male mean-age was 52.77 years (21 to 85). A history of urinary stones was reported in 43 patients:
|Extracorporeal wave lithotripsy (ESWL)||15|
|Percutaneous nephrolithotomy (PCNL)||4|
Patients presented with renal colic (n = 91), fever and flank pain (n = 5), and anuria (n = 4). Five of them had had nephrectomy and 1 had a single functioning kidney. The stone was in the left ureter (n = 58), right ureter (n = 41), and bilateral in one case. X-ray film (KUB) showed opaque calculi in all cases, and the intravenous pyelogram showed mild hydroureteronephrosis in 23 cases. The ultrasound showed moderate hydronephrosis in 82 patients.
Calculi were in the upper ureter in 8 cases, mid ureter in 11 cases, and lower ureter in 74 patients. It was a distal steinstrasse in 5 cases and double-stone location (in the upper and the lower ureter) in 2 cases.
The mean calculi size (stone length) was 10.8 mm (range 5 to 18). The stone size was between 5 and 10 mm in 73 patients and between 11 and 20 mm in 29 patients. The stone was unique in almost all cases (n = 84), and double (n = 11) and multiple in 6 cases (including 5 cases of steinstrasse). The stone location and size are listed in Table 1
The indications of ureteroscopy were obstructive ureteral stone (n = 91), pyelonephritis (n = 5), and anuria with renal failure (n = 4).
Ureteroscopy was done for stone fragmentation with a double J catheter insertion in 13 patients. The average duration of the operation was 21 minutes (range 13 to 34). This duration was 2.1 (2 to 3) and 18.2 (11 to 31) minutes, respectively, for the cystoscopic and the ureteroscopic procedures. We didn’t find a correlation between pain and duration of the procedure. No complications related to local anesthesia were encountered during the preoperative or postoperative period.
Mean pain score after local ureteroscopic lithotripsy was 3.61 (2.2 to 8.5) compared with 4.52 (1.5 to 8) after cystoscopy. The level of pain during cystoscopy was significantly higher than during ureteroscopy (p <0,001). The pain score was lower in female patients in both procedures (p <0.001). Pain during ureteroscopy was lower then pain during cystoscopy in females but the difference was not significant (p <0.07). This difference was significant in males (p = 0.04) (Table 2).
Calculi size and operation time did not correlate with pain score (p = 0.2 and p = 0.73, respectively). Pain values differ according to calculi location: the difference in pain values was significant in distal ureteral stones (p <0.001) but not in proximal ureteral stones (p = 0.06).
Almost all patients tolerated ureteroscopic lithotripsy under local anesthesia with minimal discomfort (n = 95). Only 5 patients required conversion to spinal anesthesia because of severe flank pain during the procedure. Failure during procedures was due to severe pain, especially during cystoscopy (3 males [>53 years] and 2 young females [<30 years]; [2 distal stones, 1 lumbar stone, and 2 cases of steinstrasse]).
Preoperatively, the urologist reported good fragmentation (n = 76), extraction by Dormia basket (n = 6), and partial fragmentation (n = 13) with stone migration upward in 2 cases. The mean hospital stay was 0.96 days. A trapping basket was used in 6 cases only and it was very useful in these cases. Postoperative pain was also tolerable in most patients and only 8 patients required additional analgesics after the procedure.
When questioned afterward, many patients had little recall of the procedure, and nearly all stated that they would undergo a similar procedure again if necessary in the future.
Intraoperative and postoperative complications occurred in only 5 cases: ureteral mucosa injury (n = 3), pyelonephritis (n = 1), and ureteral bleeding (n = 1). Infections were treated with suitable antimicrobial agents. Evolution was favorable in all these cases. None of these patients developed long-term complications.
The overall success rate of ureteroscopy under local anesthesia was 84.2% at 1 month postoperatively. The success rate was not significantly different between male and female patients: 78.5% and 88.7%, respectively (p = 0.29). The success rates of the upper, mid, and lower ureteral calculi were 66.7%, 72.7%, and 88%, respectively (out of 95 patients only). The success rate was 91.2% in calculi less than 10 mm and 66.7% in those more than 10 mm. The success rates don’t depend on the location and size of the calculi (p = 0.188 and p = 0.028, respectively).
ESWL was indicated in 3 patients and a second ureteroscopy under spinal anesthesia in 11 patients for residual stones. One patient eliminated the ureteral stone spontaneously after 6 weeks.
Endoscopy of the upper urinary tract has progressed these last 2 decades. The indications for ureteroscopy increased particularly in the treatment of ureteral stones in Tunisia. With the miniaturization of the ureteroscope and the use of small-caliber intracorporeal lithotripsy devices, ureteroscopy has become less traumatic and more effective [5,6].
The complication and pain associated with ureteroscopy have significantly decreased .
Ureteroscopies are usually performed under general or spinal anesthesia [5,6,7]. Although they are efficient, the complications associated with spinal or epidural anesthesia are not exceptional. They include orthostatic hypotension, prolonged motor or sensory blockage, headache, and urinary retention . Moreover, they can delay the discharge of the patient, thus developing more nosocomial infections . Therefore, more and more authors reported the achievement of this procedure under local anesthesia with or without sedation analgesia [1,9,10].
The advantages of local anesthesia include the prevention of complication associated with anesthesia, communication with the surgeon during the procedure, early mobilization, earlier return to work compared with those who undergo general anesthesia, and lower costs [2,8]. These advantages highlight the possibility of local ureteroscopic lithotripsy being performed as an outpatient procedure. The main criterions for selecting patients for this technique of anesthesia are the expected duration of the intervention and patient acceptance .
The main reason against performing ureteroscopic lithotripsy under local anesthesia has been the risk of ureteral wounds resulting from a patient’s jerky movements in response to pain during the procedure . However, Vogeli et al. noted the similar complication rates of ureteroscopic lithotripsy with and without general anesthesia . Deliveliotis et al  didn’t find a significant difference in the number of ureteral lesions between patients operated on under general anesthesia and those operated on under local anesthesia (4.8 and 5%, respectively). Furthermore, similar therapeutic results have been published .
In our procedure, we associated the intravesical injection of lidocaine and a penile block in males.
Two techniques have been advocated in penile blocks. The simplest of these is the subcutaneous ring block, which consists of injecting the local anesthetic superficial to the fascia of the penile shaft at its base, as described by Broadman et al. . Alternatively, local anesthetic can be injected deep into Buck’s fascia on either side of the dorsal midline . We prefer the second procedure of the penile block because of its ease and lower complication rate.
However, to establish local ureteroscopic lithotripsy as a treatment modality of ureteral calculi, there are several preceding conditions. First, the success rate of local ureteroscopic lithotripsy must be the same as that of ureteroscopic lithotripsy under general or spinal anesthesia. Second, the pain associated with local ureteroscopic lithotripsy must be tolerable and at least comparable to that of urologic procedures that are usually performed under local anesthesia, such as cystoscopy .
Several reports have shown the effectiveness of local ureteroscopic lithotripsy [3, 4]. The review of a published series on treatment with ureteroscopy using multiple types of ureteroscopes and intracorporeal lithotripsy devices reveals success rates ranging from 86 to 100% [14-16].
Rittenberg et al. were the first to report on 30 selected patients treated by ureteroscopic lithotripsy under local anesthesia and sedoanalgesia . Yalcinkaya et al. reported a success rate of 83% in their series with local ureteroscopic lithotripsy . A similar success rate (88%) was reported by Abdel-Razzak et al. . In the experience of Park et al , the overall calculi-free rate of local ureteroscopic lithotripsy was 93%.
In our experience, the overall success rate was 84.2%, which is consistent with the success rates in other reported series of ureteroscopic lithotripsy under general or spinal anesthesia. To our knowledge, this is the largest series of local ureteroscopic lithotripsy.
In our study, as reported by Park et al. , most of the patients tolerated the procedure very well and cooperated with the procedures without any significant movement. Our low overall complication rate of 5% was consistent with others reported. In carefully selected patients, this is a rapid and effective procedure . It is as effective and as safe as ureteroscopic lithotripsy under general or spinal anesthesia .
Although several reports have shown good results with local ureteroscopic lithotripsy, few have evaluated the pain associated with the procedure. Yalcinkaya et al. reported ‘‘minimal pain’’ in about 50% of patients, but the data was not compared with that of other procedures and was highly subjective .
We designed our study to evaluate the pain during local ureteroscopic lithotripsy in comparison with that during cystoscopy in the same patient. The main reason was that cystoscopy is the most common transurethral procedure performed under local anesthesia in Tunisia and throughout the world. Stein et al.  reported a pain score of 3.2 after rigid cystoscopy in male patients using similar linear analog self-assessment scales, a finding almost the same as our results.
Women have traditionally undergone cystoscopy and ureteral catheterization with relative ease and comfort without any or only under local anesthesia . The difference in the pain scale of the female patients (ureteroscopy versus cystoscopy) was very small . Experience in men with rigid cystoscopy has shown that this technique is relatively well tolerated with topical lidocaine anesthesia .
In our study, we demonstrate no significant difference in pain scales between the 2 procedures. Some patients initially felt anxiety about the procedure, but following our explanation of the whole procedure and the use of a monitor during the operation, we were able to reduce patient fear. We performed the operation successfully in cooperation with the patients. Only 5 of the procedures required termination due to patient discomfort or lack of cooperation.
Our series makes several important points: 1) ureteroscopic diagnosis and treatment can be accomplished under local anesthesia and without intravenous sedation analgesia in carefully selected patients, 2) this procedure has excellent efficacy on pain, even in men, 3) there are no specific side effects, 4) it does not increase the risk of complications intraoperatively, and 5) it can be performed in the office.
Our results are consistent with those already published in another prospective study .
This option should be exclusively reserved for a highly selected population of patients: planned ease and rapidity of the procedure (distal ureteral stone), females, patient preference, pregnancy, and medical contraindications to general anesthesia [1,11].
Endoscopic lithotripsy for ureteral stones is feasible under local anesthesia without increasing complication rates or compromising the results of the treatment. Most of the patients could tolerate the pain of the procedure. We suggest that ureteroscopic lithotripsy be performed effectively and safely under local anesthesia in carefully selected and informed patients.
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