Extracorporeal shock wave lithotripsy (ESWL) for treatment of ureteral calculi has gained wide popularity because of its non-invasive and ambulatory nature. The success rate using the Dornier MFL 5000 is about 77%, but retreatment is often required and stone clearance is gradual. Ureteroscopic lithotripsy (URSL) used to be performed as an in-patient procedure. With the introduction of Holmium laser and establishment of day surgery service, out-patient URSL carries a success rate of 93% and offers immediate stone clearance. It is an attractive alternative for low surgical risk patients as a primary treatment modality.published_or_final_versio

Lee, FCW

Leung, YL

Tam, PC

Yip, KH

HKU Scholars Hub

Title Management of ureteric calculi: the pendulum swingsAuthor(s) Yip, KH; Lee, FCW; Tam, PC; Leung, YLCitation Hong Kong Practitioner, 1997, v. 19 n. 11, p. 583-590Issued Date 1997URL http://hdl.handle.net/10722/45391Rights Creative Commons: Attribution 3.0 Hong Kong LicenseManagement Of Ureteric Calculi:The Pendulum SwingsK H Yip, FRCS(Edin)F Lee,* FRCS (Edin), FRACSP C Tam, FRCS(Edin)(Urol), FRACSY L Leung, FRCS(Edin)Department of SurgeryQueen Mary HospitalSummaryExtracorporeal shock wave lithotripsy (ESWL) for treatment of ureteral calculi has gained wide popularitybecause of its non-invasive and ambulatory nature. The success rate using the Dornier MFL 5000 is about 77%,but retreatment is often required and stone clearance is gradual. Ureteroscopic lithotripsy (URSL) used to beperformed as an in-patient procedure. With the introduction of Holmium laser and establishment of day surgeryservice, out-patient URSL carries a success rate of 93% and offers immediate stone clearance. It is an attractivealternative for low surgical risk patients as a primary treatment modality. (HK Pract 1997;19:583-590)URSL&J5 -MFLIntroductionThe introduction of extracorpo-real shock wave lithotripsy (ESWL)has revolutionized the treatment ofurinary stone disease.1 Its use has beenextended to in situ treatment of uretericstones with reasonable success rates.2-3Essentially, it is a non-invasive therapywhich can be performed on an out-patient basis (Table 1). However, thefragmented stone takes time to pass,for a period of up to three months.Retreatment is also frequently requiredto enhance the success rate. And thereremains some stones which fail theESWL therapy and where endoscopicprocedure would be indicated.4-6 On* Address for correspondence; Dr Francis Lee, Consultant Surgeon & Director, Day Surgery Centre, Tung Walt Hospital, Centenary Building, 12 Po YauStreet, Sheung Wan, Hong Kong.583Ureteric CalculiUPDATE ARTICLETable 1: Available treatment modalities for ureteric calculi inorder o f invasiveness • • • • • ' : • • • / > • • • ' 'NatureConservativeNon-invasiveMinimally invasiveModality AnaesthesiaAwait spontaneous passage not applicableExtracorporeal shock wave lithotripsy IV sedationUreteroscopic lithotripsyPercutaneous nephrolithotripsySA/GAGAMinimally invasive, Ureteroscopic manipulation, followed by SA/GAcombined modality Extracorporeal shock wave lithotripsyMinimal access surgery Laparoscopic ureterolithotomyInvasive Open ureterolithotomyGAGAIV = intravenous; SA = spinal anaesthesia; GA = general anaesthesiathe other hand, there has been majortechnological advances for intracor-poreal l i tho t r ipsy inc lud ing thedevelopment of small calibre semi-rigid ureteroscopes, and powerful yetsafe lithotripsy mechanism such asHolmium laser.7-11 In fact, out-patientUreteroscopic lithotripsy has beenpractised worldwide and regarded as aviable alternative treatment modalityto ESWL, in view of its ambulatoryna ture and min imal associatedmorbidity.12'13 This treatment modalitymeets the increasing demand for ahighly successful therapy for uretericcalculi which can offer rapid stoneclearance with minimal morbidity.Extracorporeal shock wavelithotripsyThe high success rate of ESWLfor renal stones leaves very little roomfor controversy. With the advance intechnology, including localizationmodalities and shock wave deliverysystems, the use of in situ ESWL (nooperative manipulation of stone) hasbeen extended to the treatment ofureteric calculi at all levels. TheDornier MFL 5000 was the f i r s tlithotriptor introduced to the publicservice in 1991. The machine deliversa spark-induced shock wave focusedby an ellipsoid. Its variable powergenerator can deliver a wide range ofshock wave energies enabling thefragmentation of stones under minimalanalgesia. A dual stone localizationsystem ( fluoroscopy and ultrasono-graphy) is available and the unit 'sdesign as a multi-purpose table allowsits various urological procedures to beperformed. In the year 1996, two morelithotriptors were installed in otherpublic hospitals under the HospitalAuthority, the waiting time for electivetreatment has since been reduceddramatically.ESWL success ratesThe Dornie r MFL 5000lithotriptor was introduced into themarket in 1988. Watson and associatesfirst reported a success rate of 72% forsingle session treatment and 81% forretreatment using this model in 1993.14In the year 1994, Ehreth and associatesreported success rates of 67% for renaland upper ureteric calculi and 83% formiddle and lower ureteric stonesrespectively.15 In this institute, wereported a success rate of 77%(retreatment rate 16%) based on ourinitial review of 124 patients.16 Sixtytwo percent of pa t ien ts requiredintravenous injection of sedatives oropiod analgesia for pain control duringthe procedure.In another review of 251 patientssuffering from ureteric stones from1991 to 1994 where 184 patientsreceived ESWL, an overall success rateof 77% was again noted.17 An averageof 1.23 sessions was required for eachpatient. Stone size was found to affectthe outcome significantly: for stones ofsize <10mm, the success rate was86%; whereas for stones > 10 mm insize, a success rate of 66% wasrecorded. It must be noted, that only70% of the patients received ESWL asthe primary treatment. The commonreasons for choosing other modalitiesincluded bilateral ureteric calculi,presence of major obstruction, giantstone size and anticipated difficultstone localization for ESWL. Thus,while many patients benefit fromESWL as an ambulatory and non-invasive treatment for their uretericcalculi, there are a significant numberof others who will require endoscopicintervent ion either as a pr imary(Continued on page 587)584Hong Kong Practitioner 19 (11) November 1997UPDATE ARTICLEtherapeutic option or as an auxiliaryprocedure to failed ESWL.Out-patient ureteroscopiclaser lithotripsyIn this hospital and many otherhospitals in Hong Kong, ureteroscopiclithotripsy used to be performed as in-patient procedures. In a previous studycomparing URSL and ESWL, wereported a mean hospital stay of 3.7days for patients undergoing URSL.18At the time of the study, the intracor-poreal lithotripsy mechanism waslimited to ultrasonic lithotriptor andelectrohydraulic lithotriptor, whichcould result in inadvertent perforationof the ureter. It was most natural thatmore patients opted for ESWL despitea much longer waiting time for theprocedure during the study period. Infact, our treatment guidelines in 1995were to offer ESWL as primarytreatment modality for most patients.The frequency of various treatmentmodalities employed by our institutionin the 90's are shown in Figure 1.Since 1996, the Holmium: YAG laserhas been available in our institution. Inthe same year, the Day Surgery Centrewas opened, and ureteroscopiclithotripsy (URSL) was arranged as anout-patient procedure. The logisticsfor arrangement of out-patient URSL isshown in Table 2.Figure 1: Number of patients undergoing various treatment modalities for ureteric calculi in the 90'sU)e.SJI"o^mEz160140120100806040200 191OpenURSL• ESWL• DSURSL• LAP192 93 94Year95OPEN = UreterolithotomyURSL = Ureteroscopic lithotripsyESWL = Extracorporeal Shockwave lithotripsyDSURSL = Day surgery ureteroscopic lithotripsyLAP = Laparoscopic ureterolithotomyTable 2: Ambulatory ureteroscopic lithotripsy logisticsConsent to out-patient ureteroscopic laser lithotripsyAttendance at pre-operative assessment clinic to be seen by urologist and anaesthetistOperation performed in the morning session to allow ample time for recoveryPatient accompanied by adult upon discharge, responsible adult to take care of patient subsequentlyAccess telephone number for inquiries • . : ; . : . : : • :Telephone follow up on post-operative day 1 and day 3 : . : :;587Ureteric CalculiUPDATE ARTICLEHolmium: YAG laserThe Holmium: YAG laser (VersaPulse select; Coherent, Palo Alto, CA)produces light of wavelength 2124 nm,which is delivered in a pulsatilemanner and has tissue penetration ofless than 0.5mm. The Holmiumdevice is a true thermal laser and actsby superheating water, thus creating amicroscopic vaporization bubble at thetip of a quartz fibre. The bubblecollapse as well as surface ablationproduce erosion plus mechanicaldisruption powerful enough tovaporize and fragment all types ofcalculi, while its thermal effect can belocalized to an area a few millimetersfrom the fibre tip as long as continuousirrigation is applied. The risk ofintra-luminal trauma is thereforevery low. In short, it allows powerfulstone fragmentation in a very safemanner.7-11URSL resultsErhard and Bagley reported theirpreliminary results of the urologicalapplications of the Holmium laser in1995, laser lithotripsy was commentedto be highly successful and extremelysafe.9 In the same year, Matsuoka etal reported a success rate of 87% in 38procedures.10 In 1996, Glasso reporteda remarkably high success rate of 97%in 34 patients." In this institution,from January 1996 to March 1997, 48male and 36 female with mean age of47.9 ( range, 21-76), and ASA(American Society of Anaesthetist)status I or II underwent ureteroscopiclithotripsy under general anaesthesiafor their ureteric calculi usingHolmium laser and semi - r ig idureteroscopes as an ou t -pa t i en tprocedure. Twenty-one upper, 18middle and 45 lower ureteric stoneswere treated, the mean stone burdenmeasured 12.0 mm (5-45). The meanoperative time was 60 minutes (15-150). Complete c learance wasachieved in 78 patients (92.9%). Allpatients were discharged on the day ofoperation. The complication rate was7.1% (6/84). This i n c l u d e d 5unscheduled readmissions (fever - 2patients; pain - 2 patients; stentmigration - 1 patient) and 1 strictureformation which resolved w i t hendoscopic intervention.Reasons for high success rate1. The breakthrough was largelyrelated to the instalment of theHolmium: YAG laser, which canprovide unsurpassed stone frag-mentation in an extremely safeand controlled manner.19 TheHolmium laser can be used witha smal l ca l ib re semi-r igidureteroscope, which fur therTable 3: Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopic laser lithotripsy (URSL) - abrief comparisonPatient selectionClearance of stoneall patientsgradual, up to 3 monthsURSLlow surgical risk patientsimmediate(in lower if stone > 10 mm of 12 mm (range 5 - 45}. not regarded as faiFollow until clearance588Hong Kong Practitioner 19 (11) November 1997UPDATE ARTICLEKey messages1. Extracerporeal shock wave lithotripsy (ESWL) is suitable for treatment of most ureteric stones with areasonable success rate. However, retreatment is often necessary and stone clearance is slow,2. With the use of newer semi-rigid ureteroscopes and laser device, Ureteroscopic lithotripsy (URSL) providesa higher success rate with immediate stone clearance. In selected patients it can be performed on a day basisWith minimal morbidity. : • ' • . . . .reduces the trauma to the ureterduring the ureteroscopic manipu-lation. Thus, once the infra-structure of The Day SurgeryCentre was established, we havebeen much more liberal to offerout-patient URSL to our patientswho have a low surgical risk, asan alternative treatment to ESWL.2. The f ib re -op t i c semi- r ig idureteroseopes are easy to handleand allow very good vision. Theyhave been refined to allow directaccess of the ureter without theneed of pre-operat ive stentinsertion or balloon dilatationimmediately prior to the ureteros-copy. They are also rather durableand allow certain degree of torquethus enhancing access to theupper ureter even in malepatients. URSL can therefore beoffered to all levels of stones,irrespective of the gender.3. The liberal use of in ternalstenting has also been significantin allowing the procedure to beconducted as an out-patientprocedure. The current stentinsertion rate of 77% is muchhigher than our previous stentinsertion rate of 47%, where manyof which were in fact externalstents that had necessitated in-hospital stay post-operatively.The ava i lab i l i ty of f lexiblecystoscopes has also renderedremoval of an internal stent asimple procedure that causesm i n i m a l discomfort, if any.Erhard et al reported similarexperience of switching fromexternal stents to internal stentsand promoting the procedure tobe conducted on out-patientbasis.20URSL as an out-patient procedureKelly demonstrated in his seriesthat laser l i tho t r ipsy could beperformed in a significant number ofpatients as a day case procedure.21 Inhis series, 6.7% of his patients requiredadmission on the day of surgery,including three patients admitted forpain control and one patient admittedfollowing perforation of the ureter.Boline had 90% of his patientsdischarged the same day, 96% within23 hours while 4% required hospitaladmission.13 All our patients weredischarged on the day of surgery, ourreadmission rate of 6.0% is acceptablein a day surgery setting. Our resultshave led to a major revision of thepolicy in this institution. In 1995,ureteroscopic lithotripsy wasperformed as an in-patient procedure,and in the years 1996 and 1997,ureteroscopic lithotripsy became anout-patient procedure in the DaySurgery Centre in about 40% and 70%of cases respectively.RecommendationsWith these results, we would notbe hesitant to recommend ureteros-copic laser lithotripsy even in thosepatients whose stones had beenpreviously considered by us to bedifficult for ureteroscopic lithotripsy.URSL using the Holmium laser is ah ighly s u c c e s s f u l o u t - p a t i e n tprocedure, associated with a lowcomplication rate and recommended asan ambulatory, minimally invasivetreatment alternative in low riskpatients (Table 3). While we considerURSL as at t ract ive a t reatmentmodality as ESWL, it is important thatpatients should be allowed a freechoice of the treatment options.AcknowledgementsOur thanks go to the nursing staffof the Day Surgery Centre, Tung Wah589Ureteric CalculiUPDATE ARTICLEHospital and the Lithotriptor Unit,Queen Mary Hospital for compilingthe data as well as Ms Joanne Li forthe secretarial work. •References1. Schmiedt E, Chaussy C. Extracorporeal shockwave lithotripsy of kidney and ureteric stones.Urol lnt 1984;39:193-1982. Dreller SP. Ureteral stone disease. Options formanagement. Urol Clin North Am 1990;17:217-2303. Cass AS. Comparison of f i r s t generat ion( D o r n i e r HM3) and second g e n e r a t i o n(Medstone STS) lilholriptors: treatment resultswi th 13864 renal and ureleral ca lcul i . J Urol1995:153:588-5924. Francesca F, Grasso M, L u c c h e l l i M, et al.Cost-efficacy comparison of extracorporealshock wave l i thot r ipsy and endoscopic laserlithotripsy in distal ureteric stones. J Endourol1993:7: 289-291.5. Hofbauer J, Tuerk C, Hobarth K, et al. ESWLin s i tu or ureteroscopy for ureter ic stones?World J Urol 1993:11:54-58.Preminger GM. Editorial: Technique versustechnology: What is the most appropriatemethod for the removal of ureteral calculi? JUrol 1994;152:66-67.Sayer J, Johnson DE, Price RE, DM. Ureterallithotripsy wi th the holmium: YAG laser. JLaser Surg Med 1993:11:61-65.Bagley D, Erhard M. Use of the Holmium laserin the upper urinary tract. Techniques inUrology 1995:1:25-30.E r h a r d MJ and Bag ley DH. U r o l o g i capplications of the holmium laser: preliminaryexperience. J Endourol 1995:9:383-386.Matsuoka K, Iida S, Nakanami M, et al.Holmium: Yt t r ium-a luminum-garne t laser forendoscopic lithotripsy. Urology 1995;45:947-952.Grasso M. Experience with the holmium laseras an endoscopic l i thotr i te . Urology 1996;48:199-206.W i l l s TE, B u r n s JR. Ure t e roscopy : Anoutpatient procedure? J Urol 1994:151:1185-1187B o l i n e G B a n d B e l i s J A . O u t p a t i e n tfragmentat ion of ureteral calcul i w i th mini-ureteroscopes and laser lithotripsy. J Endourol1994:8:341-343.Watson RB, James AN. Extracorporeal shockwave lithotripsy for ureteric calculi wi th theDornier MFL5000 lithotriptor at a multi-usercentre. Br J Urol 1993:72:683-687.15. Ehreth JT, Drach GW, Arnet t NL, et al.E x t r a c o r p o r e a l shock wave l i t h o t r i p s y :Multicenter study of kidney and upper ureterversus middle and lower ureter treatments. JUrol 1994:152:1379-1385.16. Yip KH, Tam PC, Chow WM, et al. In-situextracorporeal shock wave lithotripsy of uretericstones with the Dornier MFL 5000. Asian JSurg 1995:18:78-81.17. Yip KH, Tam PC, Lee CWF, et al. The efficacyof extracorporeal shock wave lithotripsy in thetreatment of ureteric stones. HKMJ 1995;1:110-11418. Yip KH, Tam PC. Lee F. A Prospective studycomparing the efficacy of ureleroscopy and in-situ extracorporeal shock wave lithotripsy in thetreatment of lower ureteric stones. Asian JSurgery 1996:19:313-318.19. Winfield HN. Editorial: Endourology-1996. JUrol 1996:155:56-57.20. Erhard M, Salwen J, Bagley DH. Ureteroscopicremoval of mid and proximal ureteral calculi. JUrol 1996:155:38-42.21. Kelly JD, Johnson SR, Kernoham RM, et al.Day case lasertripsy for ureteric calculi. J OneDay Surgery 1996;Summer: 17-19.N E X T I S S U E1. The Effect Of A Two Phase Clinical Audit On GPs' Knowledge, Attitude And Practice OfCardiovascular Disease And Cancer Prevention. A Study In Two Divisions Of General PracticeIn Australia.2. Dystonia - An Update Review3. Management Of Alcoholism And Drug Disorders4. Melatonin Use In Sleep Disorders590

Management of ureteric calculi: the pendulum swings

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Management of ureteric calculi: the pendulum swings

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