Journal of Endourology

The traditional treatment of symptomatic gallstones has, in the majority of cases, been a cholecystectomy. A small number of patients have had their gallstones dissolved with chenodeoxycholic acid or ursodeoxycholic acid, but approximately 50% of these developed recurrent stones when they stopped the medications. Currently, endoscopic lithotomy and extracorporeal shock wave lithotripsy (ESWL), which were developed for urinary stones, are being applied to biliary stones in various investigational protocols. Herein, we review some of the advantages, disadvantages, and limitations of the traditional and newer therapeutic alternatives.

Percutaneous cholecystolithotomy (PCCL) is a new therapeutic alternative for patients with gallstones. Herein, we describe the operative technique in detail and present our initial experience in eight patients. Seven patients had successful procedures, and one patient required a cholecystectomy because of the inability to access a small, contracted gallbladder.

Except in eight patients with very large staghorn stones, extracorporeal shock wave lithotripsy (ESWL) was used as primary treatment of 274 renal units in 250 patients. Because all patients were from our own county, where no percutaneous surgery was performed at the referring hospitals, the group was considered to represent an average profile of stone formers requiring surgery. The concrement size ranged from 2 mm to complete staghorn stones, and the results were analyzed in relation to ESWL types. The follow-up rate after 4 weeks was 100%, after 6 months 97%, and after 12 months 93%. In the whole group, 68% of the patients were stone-free after 6 months and 83% after 12 months. The patients who were stone free after 1 year had not been given more ESWL sessions or a higher energy than those who had residual fragments. The best results were recorded for ESWL types A, B, and F, whereas residual fragments were observed more commonly for ESWL types C, D, and E. Residual fragments were frequently found in patients with struvite and pure calcium phosphate stones. Most residual fragments were located in the lower caliceal system irrespective of the original location. The frequency of residual fragments increased with increasing number of stones in the kidney. A slower rate of fragment passage was observed in renal units with anatomic abnormalities or previous surgery. Auxiliary procedures were frequently required, but open or percutaneous surgery was necessary in only 13 patients, eight before and five after ESWL. Ureteral catheters were required in 70 (26%) and percutaneous nephrostomies in 21 (8%) of the renal units.

Among the first 1000 cases in a single extracorporeal Shockwave lithotripsy (ESWL) unit, there were 41 renal units (36 patients) with pretreatment stone burdens greater than 3.0 cm. These calculi were managed by initial percutaneous nephrolithotomy (PCN) followed by ESWL of residual fragments (Group I), primary ESWL with pretreatment ureteral stenting (Group II), or primary ESWL without stenting (Group III). The most common complication of PCN was sepsis, which occurred in 4 of the 12 cases. Results were analyzed at 3 months: greater than 95% stone removal was achieved in 10/12 (83%) in Group I,15/21 (71%) in Group II, and 7/8 (88%) in Group III. Retained ureteral stone fragments was the most common complication, occurring in 1 (8%) Group I, 7 (33%) Group II, and 5 (62%) Group III. Six of the seven patients in Group II had had their stents removed before the development of retained ureteral stone fragments, so the risk of this complication in the presence of a ureteral stent was actually 1 in 15 (6.6%). Of the nine cases with a residual stone burden exceeding 5% of the original, the fragments were located in the lower pole calices in 4 (44%). Our results indicate a similar stone clearance rate for stones greater than 3 cm by using either a PCN and ESWL combination or primary ESWL but a significantly higher incidence of Steinstrasse in cases treated by primary ESWL without ureteral stenting. Lower caliceal components of large stones are poorly cleared by ESWL monotherapy and hence better managed by PCN.

Seventy-six patients underwent simultaneous bilateral extracorporeal shock wave lithotripsy (ESWL) at our institution from March 1986 to June 1987. The average combined stone burden was 25 mm. Seventy-three patients (96%) had an ancillary procedure prior to ESWL. Three-month follow-up was available in 60 patients. Twenty-eight were stone free and 48 were either stone free or had insignificant fragments, for a success rate of 80%. There were 12 treatment failures, two-thirds of which were related to large stone burdens. There were no major and 10 minor complications. Six patients required subsequent procedures. Simultaneous bilateral ESWL is safe and effective for bilateral upper tract calculi. Failures can be expected when stone burden exceeds 1 cm per kidney or if one side has a stone burden 2 cm or larger.

Clear guidelines that address the appropriate use of prophylactic antibiotics in patients undergoing extracorporeal shock wave lithotripsy (ESWL) are not available. The purpose of this study was prospectively to evaluate the role of such antibiotics.

Fifty-two patients with sterile urine (tested 3 days prior to ESWL or stent placement and not receiving antibiotics) were randomly assigned (double-blind) to receive oral placebo or norfloxacin 400 mg every 12 hours beginning 48 hours prior to ESWL, with the last dose at 6 am on the morning of the procedure. Urine cultures obtained on the first postoperative day were considered to be significant if the pure colony count exceeded 10,000/ml. No patients had perioperative sepsis. Although statistical evaluation showed no difference between the 24 evaluable norfloxacin-treated and the 25 evaluable placebo-treated patients in the frequency of urinary infection (p = 0.28), two of the patients in the placebo group, both of whom had other manipulations at the time of ESWL, had significant bacteriuria the day after treatment, and one of them was rehospitalized 4 days after ESWL for febrile urinary infection. In contrast, all patients in the norfloxacin group had sterile urine postoperatively. Although the data suggest that antimicrobial prophylaxis is not necessary in ESWL patients with sterile urine preoperatively, it is our impression that patients with a significant history of urinary infection who will have manipulations during ESWL may well benefit from prophylactic antibiotics. Further study on a larger cohort of patients will be necessary to corroborate this belief.

The pulsed dye laser has been shown to be effective for the fragmentation of ureteral calculi, and with the widespread introduction of extracorporeal shock wave lithotripsy (ESWL), many ureteral stones also are being treated with this modality. In the last 12 months at the Ohio Kidney Stone Center, approximately 90% of patients with ureteral stones were receiving an invasive adjunctive procedure prior to or after ESWL, making a comparison of costs of treatment with and without ESWL appropriate. A comparison of costs in 20 patients revealed that the pulsed dye laser is more cost effective than ESWL using current techniques. The total cost for a standard 1-day hospitalization and ESWL is approximately $6000, whereas the total cost for laser lithotripsy with a 1-day hospital stay is approximately $3500. The ESWL facility charges (i.e., the technology cost) account for most of the difference. Newer ureteroscopic techniques and instrumentation should increase utilization of the pulsed dye laser for the treatment of ureteral stones.

Seven patients with nephrolithiasis in a horseshoe kidney were successfully treated with either extracorporeal shock wave lithotripsy, percutaneous nephrostolithotomy, or combined therapy. The embryologic origin of the horseshoe kidney with the rotation anomaly and the varied vascular supply is discussed, with special reference to the management of horseshoe kidney nephrolithiasis.

Selected cases of complete obliteration of the distal ureter may benefit from endoscopic recanalization. We describe our technique and clinical experience.

Common ureteral instruments (stone basket, ureteral catheter, balloon dilator, stent) and ureteroscopes have been equipped with a distal eye to enable them to track alongside a guidewire rather than over it, thereby enhancing the utility of the in situ guidewire for a variety of endourologic manipulations. These "guide-eyed" instruments have facilitated repetitive stone basket access past obstructions, have simplified sequential instrument placement, and have permitted simultaneous coordinated instrument placement during retrograde stone removal and stent insertion. The guide-eye feature has enhanced both the function and the access capability of common ureteral instruments.

The Terumo guidewire was used in 90 cases of percutaneous nephrolithotomy, 60 cases of transurethral retrieval or ureteral stones, and one case each of urethral stricture after mechanical instrumentation, stricture of the ureteroileal junction with a large ureteral stone, stricture of the ureteropelvic junction, and cystic dilatation of terminal seminal duct associated with hematospermia. This rigid-stem hydrophilic wire with a floppy terminal portion is superior to other types of guidewires in regard to flexibility, elasticity, coefficient of friction, and maneuverability.

A 4.7F polyurethane stent that can be passed through the 5F channel of a ureteroscope is described. The stent is 76 cm in length and has a memory curl at the distal end and at 26 cm; this allows the stent to be placed over a wire, under direct vision, through the ureteroscope. The ureteroscope may then be removed and the stent left in place. Cystoscopic scissors are used to cut the stent within the bladder, removing the distal 50 cm and leaving a retained 26-cm double-J ureteral stent. This technique is useful for placing a stent under direct vision above a false passage or for placing a stent once the ureteroscope has been negotiated above a difficult area of the ureter. For problem cases, using this stent under direct vision provides a degree of certainty not present when a stent is placed blindly over a guidewire.

Percutaneous nephrolithotomy is usually carried out with minimal morbidity and few perioperative complications. Despite the close proximity of the lung and bowel, injury to these adjacent organs is uncommon, and only nine cases of colon perforation have been documented. We report a case of percutaneous nephrolithotomy complicated by a small-bowel perforation. This appears to be the first published case of this complication.

The female Hanford strain of minipig proved to be an excellent endourologic model. Cystourethroscopy was possible in all 13 animals tested, with a rigid ureteroscope the optimum instrument. Ureteral catheterization was successful in 24 of 26 cases, and in all of these 24 cases, ureteral dilatation, ureteroscopy, and retrograde puncture were successful. The minipig upper tract is similar in size and anatomy to that of a 70-kg human. The greatest success with the least morbidity was obtained in animals weighing about 25 kg.

The Technomed Pulsolith laser represents a highly effective tool for the destruction of ureteral calculi, including those of calcium oxalate monohydrate. The small flexible fibers can be delivered with rigid or flexible ureteroscopes throughout the entire upper urinary tract.