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Abstract:

Background:
During recent years, considerable efforts have been expended in to the management
of urinary stone. Here we present our experience on ureteric stone removal
without any lithotripsy interventions. A new dimension of the present study
is provided by combination direct vision under ureteroscope with basket en-
trapping.

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Material & methods: The medical data of our adult patients with
?10 mm stone size, were reviewed. They received primary stone extraction under
direct ureteroscopic vision without lithotripsy during a 2-year period. All
patients were examined at our out-patient clinic
during regular visits for a six months follow up period.

Result:
We obtained 92.7% successful rate. This finding is about 69 patients of both
sexes who ranged from 18y to 68y. Totally the operative procedure was
associated with a 14.4 % complication. These results were obtained in 25.3 ±
10.4 min operative time.

Conclusion: Ureteral
stone extraction requires considerable caution and may be associated with some
complications. Stone extraction under direct ureteroscope guidance facilitates
this procedure, especially in the distal stones. It seems this combination may
be helpful in precise cases.

Keywords: urinary stone , direct vision ureteroscopy, basket
en- trapping

 

Introduction:

Urinary stone disease is a major health
problem that affects 2-3 % of the population. Today, several endourologic
options, such as Ureteroscopic Lithotripsy, Shock Wave Lithotripsy (SWL),
Laparoscopic Lithotomy, and Percutaneous Nephrolithotomy, are available for
treating this problem 1-5. Each type of these treatments is associated with related
benefits and risks 6-9. For example retropulsion during endoscopic
lithotripsy occurs in 5 to 40 percent of the cases 4.

Progress in ureteroscopic technology, specially
advances in small semi rigid and flexible ureteroscopes lead to prevent
needless interventions and enable urologists to remove the stone. There are
many varieties of tools that help better stone ureteroscopic removal such as
baskets, forceps and graspers 10-11. The ureteroscopic removal of the stone
with a basket is a mechanical approach that can perhaps be used instead of
different lithotripsy techniques.

Here we present our experience on ureteric stone
removal without any lithotripsy interventions. We combined direct vision
under ureteroscope with basket en- trapping. To our knowledge, this is
a first report of Iranian ureteroscopic stone removal that just applying this
mechanical approach under direct vision.

 

Methods:

The medical data of our patients, who received
primary stone extraction under direct ureteroscopic vision without lithotripsy
during a 2-year period, were reviewed. They were adult patients with ?10 mm
stone size without renal anatomical anomalies who did not suffer from all spectrums of urinary
tract infection (UTI)
(active/ chronic/ recurrent). Also, someone who had experienced any previous
lithotripsy management was excluded. This study was reviewed and approved by
the Research Committee of AJA University of Medical Sciences, Tehran, Iran
(Code No. 84/91/408).

Preoperative Evaluation: The preoperative evaluation that included
detailed history, physical examination, routine laboratory tests together
with plain x-ray of the kidneys, ureters and bladder in addition to excretory urography
(IVP), ultrasound or computerized tomography (CT) was carried out in all
patients.

The stone status and size were evaluated
postoperatively. All of the patients also received the same
prophylactic IV antibiotics.

Operative procedure: The operations were performed under general
or spinal anesthesia in a lithotomic position regarding
the vital functions’ management. The procedure was performed by using
a 7.5/8 Fr. ureteroscope (brand??).Then
a safety guide wire (0.038 inch, brand ??) was introduced to the ureter.  Removing the stone was done by insertion
extractor basket in to working channel under direct vision. Then stones can be
en- trapped in the basket . Synchronic pressurized washing
liquid created a pressure mechanism that can be pushed the calculi. When
the stone is trapped in a basket, it may be failing to pass
through distal of the ureter. However, at this time,
ureteroscopic manipulation with the upward movement may be introduced
to obtain a relatively dilatation. In case of need, double J stent would be
embedded post-operatively, remaining for up to two weeks. All patients were
discharged on the first day after the operation without complications.

Inter/Postoperative evaluation: Also stone residual fragments and ureteral
status were assessed at interoperation and then 3 to 6 months after discharge.

Follow up:
All patients were examined at our out-patient clinic during regular visits
for a six months follow up period.

Assessment of procedure outcome: The operative procedure
was considered successful if complete stone-free status
was achieved and no particular complaints were mentioned by
including all months of follow-up.

Analysis:
All statistical analyses were performed using SPSS
(15.0v.)

 

Results

Here we report the results of
ureteral stone extraction in 69 patients of both sexes who ranged from 18y
to 68y. Also, stone size ranged from 3-10 mm.

We perform basket stone extraction under
direct ureteroscopic vision for 64 patients (n=64/69). Stone was located in the
proximal, middle and distal of ureter, respectively in 8 (12.5 %), 17 (26.6%)
and 39 (60.9 %) cases. Totally basketing under direct ureteroscopic vision
without lithotripsy associated with a 14.4 % complication: 4.7 % (n=3) ureteral
mucosa rupture during ureteroscopy and 10.9 % (n=7) post ureteroscopy .Also,
ureteral mucosa rupture was managed by embedding double J stent.  In all of them, the stent was removed within
two weeks and IVP was performed. Also, ureteral constrictions and/or contrast
extravasations was
not observed in any of them. The post ureteroscopy complications included 2.9%
(n=2) UTI & 7.2 % (n=5) irritative symptoms which were related to stent
placement and improved after stent removal.

Also pneumatic lithotripsy was done for five
patients (n=5/69). In these patients, stone was located in the upper (n=3) and
middle of (n=2) the ureter.

Study population at 6 months follow-up
did not report any complications and no patients have attended another
institution with pain, sepsis, etc.

 For
stones ? 5 mm, the success rate was 98.5% and for stones > 5 mm, this rate
was 94.2%. These results were obtained in 25.3 ± 10.4 min operative time.

 

 

Discussion

In light of the experienced surgeon, we
obtained 92.7% successful rate.  This
finding is too good. Present result of stone- free rate is almost 11 % higher
than Castro et al. outcome. They used semirigid ureteroscopy for all stone
locations and reported 83.8% stone-free rates. They have seen no significantly
difference in stone-free rates between semirigid and flexible ureteroscopes
procedures (83.8% vs 85.5%). Although, they analyzed large population who
received ureteroscopy (9681 patients), but interestingly, they achieved
different result from the 2007 American Urological Association (AUA) Guidelines
on the Management of Ureteral Calculi data. Access to the proximal ureter is
one of important factor to increase stone-free rates.  In this regard using flexible ureteroscopy
was suggested by AUA as a better option compared with rigid or semirigid
ureteroscopes because of a 10% more stone-free rates (87% vs.77%)12-13. 

Another point of our approach to ureteral
stone management was prevention of needless intervention or complications,
which were related to lithotripsy. Lithotripsy techniques such as shock wave
lithotripsy (SWL) or holmium-YAG laser lithotripsy, usually accompanied by significant
risk of high complications such as ureteral perforation or stricture
development or ureteral stricture rate or ureteral dilation. Moreover, in cases
with high body mass index, SWL setting is difficult 6,8-9. Although long-term
practice decrease subsequent complications, but ureteroscopy help decrease
inter lithotripsy traumas. Here we avoid any stone manipulation and stone just
was en-trapped in the basket under direct ureteroscopy view. Karadag et al, analyzing the data of 124 patients,
reported 63.4% (40/63) and 86.8% (53/61) successful rate for initial stone free
status in groups 1 and 2, respectively. Their groups were defined as
patients who were preformed semirigid (S-URS) or flexible ureterorenoscopic
(F-URS) lithotripsy with holmium: YAG laser, respectively. The reoperation
was required in 14/124 (11.3%) of cases which may arise from the mean
stone size The average stone size was 12.5 mm and reoperation was required
in cases that had rest stones or stones > 4 mm in radiologic evaluations 10.

Although topic of stone free status is complex
and influenced by some agents, there is also published treatment trials to
guide the usefulness of N-Trap® basket in combination with semirigid URS. These
empirical literatures support the higher success rate achievement. For
example Liu et al, reported significantly higher stone-free rate in group of
patients who were treated by semi-rigid ureteroscope with the aid of stone
basket (n= 135; 93.2%) compared with that of patients without the aid of the
basket (n=52; 51.6%)14. In the present study we used only basket entrapping
under direct ureteroscope vision for all of our patients (n=64), this procedure
accompanied with totally 100 % successful rate without any lithotripsy
requested. Wherever Liu and colleagues used holmium: YAG laser lithotripsy for
their patients 14. Although, due to the risk of incidence of
complications such as avulsion, pneumatic lithotripsy was
used for five patients (n=5/69, 7.2%).

The next advantage is
reduction operating time. In our series the operating time
was 25.3 ±10.4 min while Karadag et al. have reported higher rate: 64.71 ±
16.11 min for Semirigid URS and 84.06 ± 16.7 min for Flexible URS 10.  It seems that this outcome achieved not only with
direct vision under ureterorenoscope but also with a single – step procedure. Also, in this study  JJ stent was used for only  3 patients (4.3%). Although there is a old
view point about necessity of stent therapy as a routine part of the
postoperative care, but this was in agreement with Elashry et al.15. 

Conclusion:

Combination basket en- trapping with direct
vision under ureteroscope is generally looked on as being more satisfactory
than the blind use of many varieties of tools such as baskets, forceps and
graspers , because it avoids  the related
risks such as retropulsion. This approach forms the basis to creation of a safe
model, one that contains direct vision in all of the ureteric stone
removal.

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