URETEROSCOPIC LITHOTRIPSY: A DAY-SURGERY PROCEDURE
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1 ISRA MEDICAL JOURNAL Volume Issue 2 Jun 2013 ORIGINAL ARTICLE URETEROSCOPIC LITHOTRIPSY: A DAY-SURGERY PROCEDURE Abdul Rasheed Shaikh, Mohamed Ali Sohail Memon, A Saboor Soomro, A. Hameed Bozdar ABSTRACT OBJECTIVE: To ascertain patient's safety and efficacy of ureterolithotripsy as a day-surgery procedure. STUDY DESIGN: An interventional study. PLACE AND DURATION: At Citi Medical Center Larkana, Ghulam Mohammed Mahar Medical College & Hospital Sukkur Peoples University of Medical & Health Sciences for Women Nawabshah between Dec: 2007 to Dec: METHODOLOGY: All the patients of either sex having ureteral stone less than 1. cm in diameter were selected on the basis of routine clinical examination, laboratory investigation like complete blood count and biochemistry, Ultra-sound and x-rays like intravenous urography (IVU) etc for ureteral lithotripsy. The Semi-rigid Ureteroscopic6.0 Fr with Swiss Lithoclast lithotripter was used. RESULTS: Our study comprises 320 selected patients. Male to female ratio was 1.6:1. Average age of patients was 30. year. The mean stone diameter was 1.2 cm. The stones were successfully disintegrated and completely pulverized in 9% (n=304) cases. In remaining %(n=16) cases, the procedure was deferred. Among them, ureteric catheter or JJ stent in 3% (n=9) and 2%(n=7) cases respectively had been left. Of them, former cases were due to failure of access to stone and ureteroscope did not negotiate at all and in later cases stone was presented in upper ureter and inadvertently floated up into the kidney (P< 0.0). The operative complications like simple mucosal injury occurred in 11%(n=3) and minor bleeding which did not cloud the field of vision occurred only in 13%(n=42) cases. The Mean operating time was 27(ranged from 22 to ) minutes. Postoperative complications like urinary tract infection (sepsis) with fever and persisting haematuria had occurs in.%(n=18) cases 9%(n=29) respectfully. The hospital stay was merely a day in all except 1% (n=47) cases who developed post-operative complications (P< 0.0). In 03 week follow-up, residual fragments were noted only in 6%(n=19) cases. These patients were managed conservatively except 2%(n=7) cases that underwent repeat ureteral catheterization for manipulation of fragments which were jammed together. remit CONCLUSION: Although, our study has documented high success rate and low morbidity with merely a day hospital stay but is dependent on many potentially modifiable and process-related factors KEY WORDS: Ureteral stone, Ureteroscope, Swiss Lithoclast INTRODUCTION With all the options of treatment, the method of choice should be minimal invasive and successful. The conservative Urolithiasis is known as the most common urological 1 method of treatment like expectant therapy with non-steroid ailment. A USA study reports that approximately 12% anti-inflammatory analgesic drugs and hydration or medicalperson of population will have stone disease at some point 2 expulsive therapy (MET) with an alpha 1-adrenoceptor in their lives. Primary stones have rarely formed in ureter. blocker (tamsulosin), has been used for facilitating They have formed in kidney and trapped during its spontaneous passage of smaller stones (04 to 08 mm passage through ureter where they produce more 3 diameter in size) has been recommended for certain group symptoms and complications. These, ureteral stones 6 of patients under restricted criteria. The open surgery account for 20% of urolithiasis, and 70% of them are (ureterolithotomy) or laparoscopic method of treatment are located in the lower third part of the ureter and are known 4 the popular options for very large impacted, and /or multiple as distal ureteral stones ureteral stones. These stones are difficult to manage with Various modalities of treatment for ureteral stone like 7 URS or ESWL alone. conservative, non-invasive extra-corporeal shock wave Among non-invasive and minimal invasive procedures like lithotripsy (ESWL), minimal invasive uretero-renoscopy ESWL and retrograde ureteroscopy (URS) with lithoclast are (URS), laparoscopic and surgical are being practiced. 7 the preferred methods. Undoubtedly, ESWL has become a most valuable asset to the urologist and greatly benefits patients who had renal stones. Its use for ureteral stone is 1 Professor GMC Sukkur 2 Associate Professor Nawab Shah 3 Assistant Professor GMC Sukkur 4 Senior Registrar GMC Sukkur Correspondence to: Dr. Abdul Saboor soomro Assistant Professor, GMC Sukkur soomrosaboor2007@yahoo.com 8-9 again limited. The endoscopic management for ureteral calculi with dormia basket is a rather challenging procedure but was popular in old days. From last 03 decades its use with or without fluoroscope had replaced with the advent of ureteroscope. Over the time, there have been many advances in ureteroscope design has taken place. These are modern up-dated small size caliber ureteroscope with better 130
2 10 optical visualization and have sufficient working channel ureteral orifice. Ureteroscopy has proceeded. Unless More over recently, another timely advance in progression difficulty was encountered in inserting the ureteroscope of endoscope with development of prototypes flexible through ureteral orifice then ureteral dilatation was ureteroscope has occurred. It lead to allow access to performed with balloon or ureteral catheter (-7 Fr) dilators. entire upper urinary tract and supposed to be a final Once ureteroscope was in the ureter, further it passed up to version which incorporated >3000 primary active stone carefully using a least amount of irrigation fluid ( deflection. Thus, today uretero-renoscopy continues to Glysine) consistent with good vision to prevent the float up of gain popularity with ever-increasing indication. Its use, the stone. For this purpose other precautions include intra- both for diagnostic as well as therapeutic purposes are venous frusamide infusion of 40mg with 00ml dextrose 6-10 well documented. Nowadays, worldwide trend has water and raising the operative table from cranial side was started to perform this procedure on an out-patient basis taken. The 0.8mm probe of Lithoclast was passed through and has been well suggested In our set-up, Majority of working channel of ureteroscope. The treatment procedure our patients comes either from rural or far-flung areas and was started and stone was pulverized under direct vision till they do not have access to advanced medical services. complete fragmentation has achieved. The fragments were T herefore, the objective of our study was to ascertain left in situ (smash & go).at the end of procedure, ureteral patient's safety and efficacy of ureterolithotripsy as a daycatheter was tied around the 18 or 16Fr Foley's catheter. catheter (4Fr) or JJ stent (4.7Fr) was left. The ureteral surgery procedure. These were removed after 18 hours where as JJ stent was METHODOLOGY kept for 06 week. The majority of patients were discharged on the following day after the procedure. All patients were This multicentral study was conducted at Citi Medical followed up routinely at weekly interval for 2-3 week. The Center Larkana, Ghulam Mohamed Mahar Medical KUB x-ray was advised to assess the outcome of the College & Hospital Sukkur and Peoples University of procedure. Medical & Health Sciences for Women Nawabshah The numerical data has analyzed, using a commercially between Dec: 2007 to Dec: All the patients, enrolled available SPSS version 11.. The analysis of variance from OPD of either sex having ureteral stone radiological (ANOVA) test, chi-square test or Fisher test when diameter less than 1. cm in size were selected prior to day appropriate was used to determine any statistical significant. of admission. Then, we evaluated and documented factors into 03 components: (1) Patient factors (e.g., RESULTS patient wellness); It based on complete history, clinical examination and investigation like urine analysis, Urine Our study comprises 320 selected patients. Among them culture, hemoglobin, complete blood count, bleeding 208(6%) were males and 112(3%) were female (Table - I). profile and Biochemistry like serum cretinine, Random Male to female ratio was 1.6:1. Their mean age was 30.year blood sugar, ultrasound, x-ray chest, ECG and (ranged from 16 to 8 years). The stone was presented in intravenous urography. The patients fulfilling our selection 19(61%) cases on right and 12(39%) cases on left side. requirement were admitted on the afternoon of the day of The further distribution of stone location at lower, Middle and procedure. Those patients, who were more than 40 year upper ureter was 183(7%), 102(32%) and 3(11%) age or found hypertensive, were further assessed by respectively (Figure - I). Mean stone diameter was 1.2 cm cardiologist and anesthetist. The patients, who were under Figure - 1: Distribution of stone location 12 years of age, having bleeding disorder or with major comorbidities included ischemic heart disease, un-controlled diabetic mellitus, chronic obstructive airway disease, obvious infection, pregnant women and those becomes unfit by cardiologist and anesthetist were postpone or excluded from the study. (2) Structural and process factors (e.g. Suitability in hospital bed and operating rooms schedule system); (3) evaluated the outcome and patient interviewed to confirmed the emotional and financial impact. The procedure was attempted under spinal or general anesthesia in modified lithotomic position. Preoperative broad spectrum Antibiotics coverage has given in all cases. A semi-rigid ureteroscope 6.0 Fr or 7.Fr (Karl Storz, Germany) and Swiss pneumonatic lithotripter (Lithoclast) were used. Preliminary check cystoscopy has done to assess the status of the lower urinary tract and (range 0.6 to1.6 cm). No significant difference was found in size between proximal and distal ureteral stones (P=NS). 131
3 ISRA MEDICAL JOURNAL Volume Issue 2 Jun As a contribution to the growing data for all size of Radiological Grade 1 and Grade-2 hydronephrosis and dilated ureter were presented only in 121(38%) and in stone with minimal stay at hospital, it is the need of time to 80(2%) cases respectively. In remaining 119(37%) evaluate surgical procedures at lesser stay and eventually it cases, the hydronephrosis and dilated ureter were not reflects on cost of patient and burden on hospital beds. presented. The ureteral dilatation with balloon ureteric In our series a total of 320 selected ureteroscopies were dilator or with ureteric catheter no: and 6 Fr was needed attempted. The stones were successfully pulverized in only in 9(18.%) cases versus 261(81.%) cases that did 304(9%) cases and in remaining 16(%) cases, the not require so. The stones were successfully disintegrated procedure was deferred. Of them, the failure of access to and completely fragmented in 304(9%) cases (Table - 2). stone had occurred in 09(3%) cases due to constricted lower Remaining 16(%) cases, the procedure was deferred. ureter and ureteroscope did not negotiate at all means. These cases were simply managed by inserting 04Fr ureteric catheter and were successfully treated by second attempt after 03-0 day. In remaining 07(2%) cases, stone was presented in upper ureter and after partial disintegration incidentally floated up into the kidney even we have applied all traditional measures i-e keeping the proximal part of patient body tilts with head up of operating table at 30 to 4 degree and using intravenous frusamide 40mg infusion. Therefore, only in these cases JJ stent had been left. More or less similar positive results were reported from many wellknown centers all around the globe (Table -II) and had been 4, 7, 14, 16-, documented in the international literature We did not come across with any major operative complications like profuse bleeding or ureteral perforation. It may be because of our up-to-date replacement of 06Fr semirigid ureteroscope and achievement of perfection in skill. There or thereabouts, this sort of favorable outcome was 4-9, Among them, ureteric catheter or JJ stent in 9(3%) and reported from many distinguished centers of the world 07(2%) cases respectively had been left. Of them, former 7 but is almost similar to Mugiya et al in 2006, who also did not cases were due to failure of access to stone and stumble upon any complication. Nonetheless, more recent 16 ureteroscope did not negotiate at all and in later cases studies published from our country by Adeel etal, 2011 and stone was presented in upper ureter and were easily Ikramullah etal, 2011, who were bump into with major floated up into the kidney (P< 0.0).The operative operative complications namely ureteral perforation and complications like simple mucosal injury occurred in ureteric wall avulsion in 2% and 1% of their cases 3(11%) and slight bleeding which did not cloud the field of respectively. The former complication may be justified on the vision occurred in 42(13%) cases. The Mean operating basis that both scholars were still using 9.Fr ureteroscope in time was 27(ranged from 22 to ) minutes. Postoperative the era where 6Fr one are easily available. However, for later complications like urinary tract infection (sepsis) with fever complication, we could not find any good reason because and mild persisting haematuria had occurred in 18(.%) this is the known complication of dormia basket therapy. Our cases 29(9%) respectfully. The hospital stay was merely a 16 study also disagree with methodology of former author that day in all (Pie - I) except 47(1%) cases who developed they have inserted JJ 6Fr stent all even in successful cases. post-operative complications. These patients stayed in Because this requires another endoscopic procedure for its hospital for 03 day (Pie - 1).Mean hospital stay was 1.28 removal, therefore, we routinely keep ureteral catheter which day. Statistically significant difference (P=NS) was not has tied with Foley's catheter. Moreover, it could be removed found in regard to hospital stay. In 02 week follow-up, effortlessly. In this context, we do agree with later author residual fragments were noted only in 19(6%) cases. who recommended JJ stent only in difficult and adverse These patients were managed conservatively except situation. We do also encountered with some anticipated 7(2%) cases that underwent repeat ureteral minor and insignificant operative complications like simple catheterization for manipulation of fragments which were mucosal injury and bleeding which did not cloud the field of jammed together. vision that had occurred only in 3(11%) and 42(13%) cases respectively. These were not creating any difficulty to go DISCUSSION through the procedure. The factor responsible was, unexpected striking of lithoclast probe with mucosa of ureter. The advent of new urological armamentarium has made These minor operative complications in present series are ureteroscopy (URS) a safe, efficacious and more popular 4-9, comparable and nearer to other studies. In this context, 6-10 procedure and its application has followed very fast. In 1 Knispel et al has recommended that the constant direct this context, we also presented our early experience in 132
4 effect on patient emotional satisfaction, as well as on perception of quality of care. Moreover, it confirms the financial impact. More recently, worldwide current trend is to perform the procedure on an out-patient basis has in progressed. Many studies justify its feasibility on the basis that the same day planned and unplanned re-admission rate was reported only as low as in 1.% and 3.6% cases respectively These authors concluded that successfully out-patient ureterolithotripsy may be performed only at well established medical institution having backup with developed infrastructure. The complications may be minimized by using flexible ureteroscope and Holmium Laser lithotripter. In our set-up, Majority of our patients comes either from rural or farflung areas and they do not have access to nearby advanced medical services. Hence, we do not perform this procedure on out-patient basis. We also have a belief that, this practice may only be suitable for local resident because of unappropriate infrastructure in our country which supposed to be the key for a successful out-patient service. Although, we recommend it as a primary first-line treatment modality for ureteral calculi but requires fully established equipped medical care centre with experts and trained staff for such a short stay surgery. CONCLUSION Although, our study has documented high success and low complication rates with merely a day indoor stay but is consistent with many potentially modifiable and process- related factors. It has not only positive effect on patient satisfaction but also reflects the cost-effectiveness vision must be maintained and no energy is applied until and unless there is contact between stone and probe to avoid the mucosal injury and bleeding during the procedure. The post operative recovery was uneventful in majority of our 273(8%) cases except 47(1%) cases who developed febrile urinary tract infection or persisting but self-remitting haematuria. These were resolved within 72 hours of conservative treatment. The hospital stay was merely a day in all except who developed sepsis and haematuria. The mean hospital stay was 03 day in these patients. In this context, our study contradicts with Ikramullah et al 2011, who reported 06 day mean hospital stay in their cases that developed complications. It may be reasonable on the basis that their patient went through major operative complications. This study dominated our former study presented in 2007 (Rasheed et al ) consisting with our early experience of ureteroscopy. In that series, we had achieved an 88% success rate with major operative complications. It was due to our initial learning phase and using rather larger diameter 7.Fr (Karl Storz, Germany) and 8. (Wolf, Germany) ureteroscope. Then, we replaced it with new up-to-date 6.0 Fr (Karl Storz, Germany) one. Furthermore improvement in our judgment and surgical skill led to even better results with insignificant operative complications. This has given us courage to deal our cases on day care basis. The initial results are not only very much encouraging and authenticate but also prove the positive REFERENCES 1. Ramello A, Vitale C, Marangella M. Epidemiology of nephrolithiasis. J Nephrol 2000;13: Rasheed SA, Nisar SA and Saiyal AR. Extra-corporeal Shock Wave Lithotripsy; Early Experience with Chinese Lithotriptor at Larkana. The Prof: 47 Medical J: 08 (01) 2001; Naqvi SA. Khalique M, Zafar MN and Rizvi SAH. Treatment of ureteric stones. Comparison of laser and pneumatic lithotripsy. BJU , Meng-yuan Z, Sen-tai D, jia-ju L, Yan-he L, Hui Z and Qing-hua X. Comparison of tamsulosin with extracorporeal shock wave lithotripsy in treating distal ureteral stones. Chin Med J 2009;122 (7): Rasheed SA, Qurban A, Fatah A, Iqbal M, Nisar A and Altaf H. Uretero lithotripsy with semi-rigid ureteroscope: An early experience with 100 cases. JSP (int:) 2007;12 (3) Bierkens AF, Handrikx AJ, De La, Rossete JJ, Stultiens GN, Beerlage GN, et al. Treatment of mid and lower ureteric calculi: Extracorporeal Shockwave Lithotripsy vs laser ureteroscopy. A comparison of cost, morbidity 133
5 ISRA MEDICAL JOURNAL Volume Issue 2 Jun 2013 and effectiveness. Br J Urol. 1998;81:31-. of mini ureteroscope: results in 143 patients. J Urol, 7. Mugiya S, Ozono S, Nagata M, Takayama T, Nagai H. 1996; 12(6): 13-. Retrograde endoscopic management of ureteral 16. Adeel A khan, Syed AH, Khan N, Syed Majeed MK and stones more than 2cm in size. Urology. 2006; 67: Sulaiman M. Safety and efficacy of ureteroscopic lithotripsy. JCPSP 2011, 21(10) Denstedt JD, Eberwein PM, Singh RR. The Swiss. Ikramullah, Wazir BG, Alam K, Islam M, Shah F and Lithoclast: a new device for intracorporeal lithotripsy. J Khan SA. Evaluation of safety and efficacy of Urol. 1992;148; ureteroscopic lithotripsy in management of ureteral 9. Turk TM, Jenkins AD. A comparison of ureteroscopy to calculi. Ann. Pak. Inst. Med. Sci Vol. 7(3) in situ extracorporeal shock wave lithotripsy for the 18. Ali A, Saleem M, Jamil M and Tabassum SA. Our treatment of distal ureteral calculi. J Urol 1999; experience with 100 cases of ureteric stones. The 161:4-6. Professional. 2000; 7(3) Luis Osorio, Estevao Lima, Jose Soares and et al. 19. Ather MH, Paryani J, Memon A and Suleman MN. A 10 Emergency ureteroscopic Management of ureteral years experience of managing ureteric calculi. Changing stones: Why not? Urology. 2007; 69: trends towards endourological intervention- Is there a 11. Wills TE, Burns JR. Ureteroscopy: an outpatient procedure? J Urol1994;11: Cheung MC, Lee F, Leung YL, Wong BB, Chu SM, Tam PC. Outpatient Ureteroscopy: predictive factors for postoperative events. Urology 2001;8: role for open surgery. Br J Urol Int: 2001; 88, AL-Busaidy S S, Prem A R, Medhat M and Bulushi AL Y H K. Ureteric calculi in children; Preliminary experience with holmium: YAG Laser lithotripsy. BJU (int:) 2004; 93(9) Fasihuddin Q, Hasan AT. Ureteroscopy (URS): an 21. Ghalayini IF, AL-Ghazo MA, Khader YS. Extracorporeal effective interventional and diagnostic modality. J Pak Shockwave lithotripsy versus ureteroscopy for distal Med Assoc. 2002; 2: ureter calculi: efficacy and patient satisfaction. Int Braz J 14. Park H, Park M, Park T. Two years experience with Urol ; 32(6): ureteral stones: extracorporial shock wave lithotripsy 22. Subhani GM, Javed SH, Iqbal Z and etal. Outcome of v ureterorenoscopic manipulation. J Endourol. 1998; Retrograde ureteroscopy for the Management of 13: Ureteric Calculi: Four Years Experience. A.P.M.C. 2009; 1. Knispel HH, Klan R, Heicappell R, Miller K. Pneumatic 3(1) lithotripsy applied through deflected working channel 134
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