Urinary stone disease: Great progress with promise for the future.

Urinary calculus disease has been a scourge on mankind since ancient times. Research in the field has been hampered by lack of funds and the lack of cachet with the public such as seen with cancer or heart disease. In recent years there have been marked changes led by urologists in the diagnosis, treatment and long-term management of calculi

Ureteroscopic lithotripsy.

There is a wide array of endoscopic lithotriptors presently available. Each of these has its own advantages and disadvantages. No single lithotriptor is suitable for all applications and none can meet the goal of fragmenting all calculi while remaining harmless to tissue

Ureteroscopic treatment of larger renal calculi (\u3e2 cm).

OBJECTIVES: To evaluate the current status of ureteroscopic lithotripsy (UL) for treating renal calculi of \u3e2 cm, as advances in flexible ureteroscope design, accessory instrumentation and lithotrites have revolutionised the treatment of urinary calculi. While previously reserved for ureteric and small renal calculi, UL has gained an increasing role in the selective management of larger renal stone burdens. METHODS: We searched the available databases, including PubMed, Google Scholar, and Scopus, for relevant reports in English, and the article bibliographies to identify additional relevant articles. Keywords included ureteroscopy, lithotripsy, renal calculi, and calculi \u3e2 cm. Retrieved articles were reviewed to consider the number of patients, mean stone size, success rates, indications and complications. RESULTS: In all, nine studies (417 patients) were eligible for inclusion. After one, two or three procedures the mean (range) success rates were 68.2 (23-84)%, 87.1 (79-91)% and 94.4 (90.1-96.7)%, respectively. Overall, the success rate was \u3e90% with a mean of 1.2-2.3 procedures per patient. The overall complication rate was 10.3%, including six (1.4%) intraoperative and 37 (8.9%) postoperative complications, most of which were minor. The most common indications for UL were a failed previous treatment (46%), comorbidities (18.2%), and technical and anatomical factors (12.3%). CONCLUSIONS: UL is safe and effective for treating large renal calculi. While several procedures might be required for total stone clearance, UL should be considered a standard approach in the urologist\u27s options treating renal calculi of \u3e2 cm

Ureteroscopic laser treatment of upper urinary tract neoplasms.

BACKGROUND: Endoscopic management of upper urinary tract transitional cell carcinoma has assumed an important role in diagnosis and treatment. The introduction of small diameter rigid and flexible ureteroscopes has permitted access to the upper tract. Biopsy techniques have been developed for accurate diagnosis, and the addition of lasers has given the urologists an excellent tool for treatment. METHODS: Medical literature available relative to the endoscopic laser treatment of upper tract neoplasms has been reviewed. RESULTS: Ureteroscopic treatment has been characterized by good success with high recurrence rates, both in the upper tract and in the bladder. Bladder recurrence rates are similar to those seen after surgical treatment of upper tract tumors. Surveillance has been ureteroscopic since the other diagnostic options are inadequate. The holmium and neodymium:YAG lasers are the devices most commonly used now for the endoscopic treatment of upper tract tumors. CONCLUSION: Ureteroscopic treatment of upper tract neoplasms usually with ablation and resection using the neodymium and holmium: YAG lasers is a current acceptable procedure. This should be considered as one of the options in tumor treatment

Fluoroscopic placement of double-pigtail ureteral stents.

Purpose: Double-pigtail ureteral stent is placed cystoscopically after ureteroscopy. We describe a technique for fluoroscopic placement of ureteral stents and demonstrate its use in a non-randomized prospective study.Materials and methods: Double-pigtail stents were placed either fluoroscopically or cystoscopically in 121 consecutive patients. In the fluoroscopic method, the stent was placed over a guide wire using a stent pusher without the use of cystoscopy. Conversely, stents were placed through the working channel of the cystoscope under vision. The procedure, stent length, width, type, method, ureteral dilation, and use of a retrieval string were noted.Results: A wide range of stent sizes were used. The success with fluoroscopic placement of double-pigtail ureteral stents was 100% (89 of 89 cases). No stents migrated or required replacement. Stents were placed after ureteroscopic laser lithotripsy (53/89) and ureteroscopic tumor treatment (22/89). Cystoscopic visualization was used in 32 additional procedures requiring precise control (15 ureteral strictures and nine retrograde endopyelotomy).Conclusions: The fluoroscopic placement of ureteral stents is a safe and simple technique with a very high success rate. We have used cystoscopic placement only after incisional procedures such as retrograde endopyelotomy, stricture or ureterotomy

Prevention of stone migration with the Accordion during endoscopic ureteral lithotripsy.

BACKGROUND AND PURPOSE: Endoscopic lithotripsy is often prolonged secondary to the retrograde migration of calculous fragments. Various balloons, baskets, and other devices have been used to prevent this migration. Our purpose is to analyze the effect of the Accordion(®) on stone migration and overall efficiency during lithotripsy. PATIENTS AND METHODS: We prospectively evaluated 21 patients with a total of 23 distal ureteral stones. Patients underwent lithotripsy using an endoscopic impact lithotriptor. The Accordion was randomly used in 11 of these 21 patients. Data were collected regarding stone migration, stone size, stone ablation, ureteral clearing, and lengths of time for various stages of each procedure. RESULTS: Patients who were treated with the Accordion device experienced significantly less retrograde migration during fragmentation (P=0.0064). When stone volume was taken into account (but not on a per stone basis), ablation and ureteral clearing were also expedited, and fewer lithotripter hits and basket sweeps were needed. CONCLUSION: The Accordion device is effective in preventing the migration of stone fragments during endoscopic ureteral lithotripsy. Our data suggest that this device may also increase efficiency of the fragmentation and clearance of ureteral calculi

Ureteroscopic biopsy of upper tract urothelial carcinoma and role of urinary biomarkers

Ureteroscopic biopsy is an integral part of diagnosis of urothelial carcinoma of the upper urinary tract. It can be a technical challenge, but diagnostic rates have improved remarkably with refinements in surgical technique and specimen processing. Cytology aids with diagnosis and other urinary biomarkers continue to evolve, which may help further stratify patients for treatment. The current literature on the ureteroscopic biopsy and role of urinary biomarkers is reviewed and summarized below

The minimally invasive treatment of ureteropelvic junction obstruction: a review of our experience during the last decade.

PURPOSE: The minimally invasive treatment of ureteropelvic junction obstruction has evolved during the last decade from endoscopic to laparoscopic and robotic. We review our 10-year experience with ureteropelvic junction obstruction, and report on our experience and followup. MATERIALS AND METHODS: We reviewed all patients treated during the last 10 years. There were 294 procedures performed with complete records on 273 patients including 128 retrograde endopyelotomies, 116 laparoscopic pyeloplasties and 29 robotic pyeloplasties. Technique for each procedure is reviewed. Statistical analysis was performed on all results. Variables evaluated were gender, age (younger than 41 vs 41 years or older), side (right or left), presence of crossing vessels, presence of a high insertion, primary or secondary procedure and whether prior endopyelotomy or pyeloplasty had been performed. RESULTS: Mean followup for endopyelotomy, laparoscopic pyeloplasty and robotic pyeloplasty was 20, 20 and 19 months, respectively, with success rates of 60.2%, 88.8% and 100%, respectively. On univariable analysis only the presence of crossing vessels or a high insertion was significant for laparoscopic pyeloplasty. On multivariable analysis age was significant for endopyelotomy and the presence of crossing vessels was significant for pyeloplasty. On Kaplan-Meier analysis failures were noted to occur after 5 years in both groups. CONCLUSIONS: Laparoscopic pyeloplasty and robotic pyeloplasty are superior minimally invasive treatments for ureteropelvic junction obstruction. However, endopyelotomy can be used for select patients. Because of late failures patients who undergo either of these procedures should receive long-term followup

Urolithiasis location and size and the association with microhematuria and stone-related symptoms.

PURPOSE: To conduct a study to assess the association between calculus location and size and the incidence of both microhematuria and symptoms of urolithiasis in a urology office environment. PATIENTS AND METHODS: After Institutional Review Board approval, a prospective study was conducted with data from 100 consecutive patients who presented to our office with documented urolithiasis. The location (caliceal, pelvic, or ureteral) and size ( RESULTS: A total of 111 stones were found in the study population resulting in a 45.9% incidence of microhematuria. In patients with renal pelvic and ureteral stones, 67.6% demonstrated microhematuria vs 36.4% with caliceal stones, P=0.0035. For stones ≥ 8 mm, 62.5% were positive for microhematuria vs 29.1% of stones \u3c8 \u3emm, P=0.0006. Ureteral or renal pelvic stones caused the most symptoms (70.6%) compared with caliceal stones (16.9%), P=0.0001. In those patients who reported pain associated with urolithiasis, 65.6% had concomitant microhematuria vs 36.8% in those without pain, P=0.0097. CONCLUSIONS: Urinary calculus location and size are associated with the incidence of microhematuria and stone-related symptoms. Pain related to urolithiasis may be a positive predictor for the presence of microhematuria

Hand problems among endourologists.

BACKGROUND AND PURPOSE: Endourology has evolved rapidly for the management of both benign and malignant disease of the upper urinary tract. Limited data exist, however, on the occupational hazards posed by complex endourologic procedures. The aim of this study was to determine the prevalence and possible causes of hand problems among endourologists who routinely perform flexible ureteroscopy compared with controls. MATERIALS AND METHODS: An online computer survey targeted members of the Endourological Society and psychiatrists in academic and community settings. A total of 600 endourologists and 578 psychiatrists were contacted by e-mail. Invited physicians were queried regarding their practice settings and symptoms of hand pain, neuropathy, and/or discomfort. RESULTS: Survey responses were obtained from 122 (20.3%) endourologists and 74 (12.8%) psychiatrists. Of endourologists, 61% were in an academic setting and 70% devoted their practice to endourology. Endourologists were in practice for a mean 13 years, performing 4.5 ureteroscopic cases per week with a mean operative time of 50 minutes. Hand/wrist problems were reported by 39 (32%) endourologists compared with 14 (19%) psychiatrists (P=0.0486, relative risk [RR]=1.69). Surgeons who preferred counterintuitive ureteroscope deflection were significantly more likely to have problems (56%) compared with intuitive users (27%) (RR 2.07, P=0.0139) or those with no preference (26%) (RR 2.15, P=0.0451). Overall, most respondents (85%) with hand/wrist problems needed either medical or surgical intervention. CONCLUSIONS: Hand and wrist problems are very common among endourologists. Future studies are needed to develop more ergonomic platforms and thereby reduce the endourologist\u27s exposure to these occupational hazards