Update of Management of Ureteral Stones

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1 Update of Management of Ureteral Stones Demetrius H. Bagley Jr, MD The Nathan Lewis Hatfield Professor of Urology Professor of Radiology Thomas Jefferson University Philadelphia, Pennsylvania Ureteral Calculi Spontaneous passage Medical Expulsive Therapy Dissolution ESWL Ureteroscopic Retrieval Lithotripsy PCN Laparoscopic Spontaneous Passage of Ureteral Calculi Symptoms Infection Obstruction Size of calculus Location of calculus Duration Social Factors Anatomy of Ureter 2 Divisions upper or proximal lower or distal 3 Divisions proximal mid distal

2 Duration of Passage Calculi Time 25% of 4-6 mm 2.8 weeks (av) 35% of 5.5 mm (3-10mm) 4 weeks (range) 95% 2-4 mm 40 d. 58% <6 mm prox ureter 4 weeks 92% <6 mm dist ureter 4 weeks 25% >6-10 mm prox ureter 4 weeks 59% 6-10 mm dist ureter 4 weeks 99% <6 mm 4 mos. 79% 6-10 mm 4 mos. 25% >10 mm 4 mos. Spontaneous Passage- References Ueno A. et al. Urol 10: 544, 1977 Morse & Resnick J Urol 145: 263, 1991 Hubner et al. Eur Urol 24: 173, 1993 Kinder et al. BJU 60: 506, 1987 Spontaneous Passage (%) of Ureteral Calculi* Location 5 mm 5-10 mm Proximal Distal Spontaneous Passage of Ureteral Calculi < 4 mm Follow if possible 4-6 mm Attempt to follow 6-10 mm Consider following *AUA Guidelines 1997

3 Medical Expulsive Therapy Treatment with medicine to facilitate stone passage MET Medicines Used Glucogon Steroids Ca Channel Blockers α Blockers MET Meta Analysis* 9% more treated with nifedipine passed stones than controls (N.S.) 29% more treated with α blockers passed stones than controls (<0.05) *AUA Guidelines 2007 MET Efficacy of 3 Different αblockers* Spontaneous Passage Control 53.6 Tamsulosin 79.3 Terozosin 78.6 Doxazosin 75.9 Also time to pass pain episodes analgesic dosage *Yilmaz et al. J Urol 173: 2010, 2005

4 Alfuzosin Stone Expulsion Therapy for Distal Calculi: A Double-Blind, Placebo Controlled Study* Placebo Treatment P Spontaneous passage Time to pass Size on CT Size by calipers Pain from base Opiod meds Medical Expulsive Therapy* Patient with new <10 mm ureteral stone - may be offered medical therapy to facilitate stone passage - should be counseled on risks of MET including drug side effects - should be informed that it is off label use *Pedro et al. J Urol 179: 2244, 2008 *AUA Guidelines 2007 Selection of Patient for Passage or MET* - Well controlled pain - No clinical evidence of sepsis - Adequate renal functional reserve - Should be followed with imaging for - stone position - hydronephrosis Indications for Ureteral Stone Treatment* Stone removal is indicated in the presence of persistent obstruction failure of stone progression, or in the presence of increasing or unremitting colic *AUA Guidelines 2007 *AUA Guidelines 2007

5 Ureteral Stone Treatment* - SWL and ureter are acceptable firstline treatments - Routine stenting not recommended as part of SWL - Stenting optional after ureteroscopy *AUA Guidelines 2007 Rigid Ureteroscopes Tip 6+ 9F Channel 1 or 2 min 2.3F Length ~33 35 ~41-43 Actively Deflectable Flexible Ureteroscopes Company Outer Size (F) Channel Deflection Circon-ACMI & 180 o & 330 o Olympus & 270 o Storz 7.5/ & 270 o Wolf 7.5/ & 170 o 210 & 270 o

6 Passing Flexible Ureteroscopes Effect of Size Size Failed Total % Flexible Ureteroscopes Improved durability Increased deflection But, size Hudson RG et al. BJU Int. 2005;95(7): Video Ureteroscope CMOS or CCD chip Size Image Durability Convenience

7 Nitinol Baskets No tip Kink-proof Flexible Releasing Stone Basket Function Engage calculus Release calculus Basket Feature Improving Release of Stone Nitinol No tip Fewer wires Larger diameter Articulation

8 Distal Ureteral Calculi* Uretero ESWL #Patients 12,933 20,885 Stent 75% 13% Stone-free Re-treat Anesthesia 94% sp 86% sedation or gen Complications Hosp. Stay Cost 4,336* 7,560* *USD *Adapted from Gutierrez-Aceves J. In: Segura et al, eds. 1st International Consultation on Stone Disease Distal Ureteral Calculi Uretero ESWL Retreatment (%) 5.6 ( ) 17.3( ) 1 Ancillary Procedure (%) Stone clearance (d) Adapted from Gutierrez-Aceves J. In: Segura et al, eds. 1st International Consultation on Stone Disease Bierkens AF et al. Br J Urol. 1998;81(1): Effect of Stone Size Stone-free SWL Uretero Single Stone 0-4 mm mm mm mm mm 0 -- Eden CG et al. J Endourol. 1998;12(4):

9 Distal Ureteral Calculi Success Complications % % Chow et al. J Urol. 2003;170(1): ESWL Treatment of Upper Ureteral Calculi* Litho Stone-free (%) 3 mo Proximal Mid HM MFL HM-4 & MPL Piezolith & LTO Lithostar Modulith *Adapted from Gutierrez-Aceves J. In: Segura et al, eds. 1st International Consultation on Stone Disease

10 Upper Ureteral Calculi-ESWL* Litho Stent ReRx Complic. HM MFL HM-4 & MPL Piezolith LTO Lithostar Modulith NR *Adapted from Gutierrez-Aceves J. In: Segura et al, eds. 1st International Consultation on Stone Disease Endoscope Rigid 10F Lithotriptor US 3F EHL Removal of Ureteral Calculi With Rigid Ureteroscopes Success Rate (%)* Group Lingeman Seeger Chaussy Blute Weinberg Kostakopoulous Stoller & #Pts. Site Prox Ureter Mid Ureter Upper (prox & mid) Distal Ureter *Adapted from Zeltser I et al. In: Moore RG et al, eds. Minimally Invasive Urological Surgery. London, England: Informa Healthcare; 2005: Endoscope 10F Flexible Lithotriptor 3F EHL 60mJ pulsed dye laser

11 Removal of Ureteral Calculi With Flexible Ureteroscopy Success/Total/Patients Bagley* Kavoussi* Higashihara* % Success Site Renal 22/ Proximal 18/ ureter Above pelvic brim 40/42 12/16 14/16 89 Mid ureter 16/22 4/ Distal ureter 6/13 5/ *3F EHL or 60mJ pulsed dye laser available *Adapted from Zeltser I et al. In: Moore RG et al, eds. Minimally Invasive Urological Surgery. London, England: Informa Healthcare; 2005: Endoscope 7F Rigid 7.5F Flexible Lithotriptor EHL >140mJ pulsed dye laser Ureteroscopic Removal of Upper Ureteral Calculi in a Single Procedure Location Erhard Grasso Boline Success & Bagley 1 et al 2 & Belis 3 % Proximal 26/28 25/27 ns 92.7 Mid 42/45 14/15 ns 93.3 Upper 68/73 39/42 28/ Endoscope 7F Rigid 7.5F Flexible Lithotriptor Holmium Laser 1. Erhard M et al. J Urol. 1996;155(1): Grasso M, Bagley D. Urology. 1994;43(4): Boline GB, Belis JA. J Endourol. 1994;8(5):

12 Treatment of Ureteral Calculi With Ureteroscopic Ho:Laser Lithotripsy Success (%) Location Grasso & Tawfiek & Devarajan Chalik 98 1 Bagley 98 2 et al 98 3 Proximal Mid Distal SWL VS. Semirigid Ureter for Proximal Ureteral Calculi* 43 Matched Pairs SWL Uretero Success (P=0.8) Retreatment (P<0.01) Auxiliary Proc (NS) Complication *Youssef et al. Urol 73: 1184, Grasso M, Chalik Y. J Clin Laser Med Surg. 1998;16(1): Tawfiek ER, Bagley DH. Urology. 1999;53(1): Devarajan R et al. Br J Urol. 1998;82(3): Stone-free rates for SWL and URS in the overall population AUA Guidelines J Urol 178: 2418, 2007 Table 5: Complications Occurrence Rates with SWL and URS Overall Population* SWL URS Groups/ Med/95% Groups/ Med/95% Patients CI Patients CI DISTAL URETER Sepsis 6 3% 7 2% 2019 (2-5%) 1954 (1-4%) Steinstrasse 1 4% 26 (0-17%) Stricture 2 (0%) 16 (1%) 609 (0-1%) 1911 (1-2%) Ureteral Injury 1 (1%) 23 (3%) 45 (0-5%) 4529 (3-4%) UTI 3 4% 3 4% 87 (1-12%) 458 (2-7%) *AUA Guidelines J Urol 178: 2418, 2007

13 Table 5: Complications Occurrence Rates with SWL and URS Overall Population* SWL URS Groups/ Med/95% Groups/ Med/95% Patients CI Patients CI MID URETER Sepsis 2 5% 4 4% 396 (0-20) 199 (1-11%) Steinstrasse 1 8% 37 (2-20%) Stricture 1 1% 7 4% 43 (0-6%) 326 (2-7%) Ureteral Injury 10 6% 514 (3-8%) UTI 1 6% 1 2% 37 (1-16%) 63 (0-7%) *AUA Guidelines J Urol 178: 2418, 2007 Table 5: Complications Occurrence Rates with SWL and URS Overall Population* SWL URS Groups/ Med/95% Groups/ Med/95% Patients CI Patients CI PROXIMAL URETER Sepsis 5 3% 8 4% 704 (2-4%) 360 (2-6%) Steinstrasse 3 5% 1 0% 235 (2-10%) 109 (0-2%) Stricture 2 2% 8 2% 124 (0-8%) 987 (1-5%) Ureteral Injury 2 2% 10 6% 124 (0-8%) 1005 (3-9%) UTI 5 4% 2 4% 360 (2-7%) 224 (1-8%) *AUA Guidelines J Urol 178: 2418, 2007 ESWL for Upper Ureteral Calculi Later generation machines are less successful Retreatment ranges from 12.5 to 48% Complications range from 2.3 to 21% Upper Ureteral Calculi: Ureteroscopic Treatment Instrument-dependent Can be very successful Invasive One procedure

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