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A Critical Review of Stone Manipulation: A 5-Year Study
VVilliams &
Co.
A CRITICAL REVIEW OF STONE MANIPULATION: A 5-YEAR STUDY FRANK B. IVIAHON, JR.*
AND
RAUL F. WATERS
From the Department of Surgery, Section of Urology, University of Wisconsin Medical School and Saint Mary's Hospital J\!J.edical Center, Madison, Wisconsin
In 1902 Young reported the first successful stone manipulation-the extraction of a distal ureteral calculus with a catheter. 1 Since then manipulation has been important in the management of ureteral calculi. We report herein a determination of the rate of incidence, success and morbidity to stone manipulation.
There was a 67 per cent success rate in patients with radiopaque calculi between 5 and 11 mm. in diameteL There was a 63 per cent success rate in patients who had manipulations on the day of hospitalization. Major postoperative complications occurred in 10.5 per cent of the patients. One patient had a cardiac arrest and died 2 days postoperatively and 2.5 per cent of the patients required repeat manipulations. Ureterolithotomy was subsequently performed in 5 per cent of the patients. There was radiographic evidence of ureteral perforation in 2 per cent of the patients: 1 required stenting, 1 required ureterolithotomy and 2 were discharged from the hospital. One of these patients returned 4 months later with a lower ureteral stricture and secondary hydronephrosis. She subsequently had a successful ureteral reimplantation. Another patient with hydronephrosis secondary to ureteral stricture was treated with ""'""'""''',., dilation of the stricture, Many patients had minor postoperative com27 per cent had fever and 54 per cent pa·in (requiring more than 2 hyperdermic injections). An ileus requiring a nasogastric tube developed in 1 case. Another patient had postoperative ventricular premature contractions which necessitated 19 days of hospitalization. Fever developed in 21 per cent of the 61 patients who did not receive postoperative antibiotics and in 24 per cent of the 132 patients who dido Of the 136 patients without ureteral catheters 49 per cent had pain and 25 per cent had fever. Of the 57 patients with postoperative ureteral catheters 68 per cent had pain and 33 per cent had fever.
MATERIALS AND METHODS
The charts of all patients (428) admitted to this hospital because of renal and/or ureteral calculi between January 1965 and December 1969 were reviewed. Of those patients 28 per cent had spontaneous passage of uretera! calculi and 45 per cent underwent stone manipulations. We report herein a review of the 193 cases of stone manipulation. RESULTS
were between 12 and 74 years old between 20 and 60. The ratio of men to women was 2.7 to 1. Hovvever, in the 20 to group there was an equal ratio of men to women, Of the patients 29 per cent had a history of renal or ureteral calculi and 4 per cent a temperature exceeding lOOF before treatmenL The average white blood count was 10,800 (normal 5,000 to 10,000 cells per cu. mm.). Excretory urograms (IVPs) were available for review in 175 cases: 85 per cent showed hydrone14 per cent revealed renal calculi with ipsilateral ureteral 65 per cent showed u.reteral calculi with an average diameter of 4,3 mm, and 6 per cent demonstrated renal anomalies. All were performed after administration of general anesthesia, All calculi were in the lower third of the ureter. The Dormia stone basket was most
DISCUSSION
sex,
data and IVP our similar to those r<>1,m·t;,r1 ever, there are few reports on the success or of stone and James reported a 45 per cent in 76 patients.• Their
and the average total 57 per cent vvere success49 per cent of the non-opaque caJcuH were
extracted but 65 per cent of the calculi had successful
with
Accepted for publication April 6, 1973. Read at annual meeting of North Central Section, American Urological Association, Detroit, Michigan, September 2:-25, 1971. * Current address: Guthrie Clinic, Ltd., Guthrie Square, Sayre, Pennsylvania 18840. 1 Young, H. H.: Treatment of calculus in the lower end of the ureter in the male. Amer. Med., 4: 209, 1902.
2 Fox, Pyrah, L. N. and Raper, F. P.: Management of ureteric a review of 292 cases. Brit. J. Urol., 37: 660, 1965. 'Sandegard, E.: Prognosis of stone in the ureter. Acta Chir. Scand., suppl. 219, pp. 1-67, 1956. 'Nourse, M. H.: The management of ureteral stones. J.A.M.A., 198: 1270, 1966. 'Fetter, T. R., Zimskind, P. D., Graham, R.H. and Brodie, D. E.: Statistical analysis of patients with ureteral calculi. J.A.M.A., 186: 21, 1963. 'Kittredge, W. E. and James, D.: Management of ureteral calculi. J. Ural., 72: 342, 1954.
387
388
MAHON AND WATERS
complications were 7 repeat manipulations, 10 ureterolithotomies, 2 nephrectomies, 1 ureteral perforation and 1 broken ureteral stone basket tip. Prince and Scardino reported a 65 per cent success rate in 298 cases of stone manipulation. 7 Complications included 1 death, 1 nephrectomy, 2 surgical removals of wedged stone baskets, 1 ruptured ureter and 19 repeat manipulations. Of their patients 9.4 per cent required subsequent ureterolithotomy. Furlow and Bucchiere reported 84 per cent success in 45 patients with radiopaque calculi. 8 The complications wP-re 2 cases of renal colic secondary to blood clots, 1 case of bacteremia, 1 of acute pyelonephritis and 1 of ureteral perforation. Of these patients, 9 per cent required subsequent ureterolithotomy and 1 nephrectomy was performed. Our patients receiving antibiotics had a higher incidence of fever than those who did not. The antibiotics may have caused postoperative fever in some cases. The low percentage (6 per cent) of positive urine cultures in our patients with ureteral stones has been reported previously.• Thus, in the absence of a positive urine culture or impending sepsis, we do not believe that the routine use of antibiotics is indicated in cases of ureteral calculi. 7 Prince, C. L. and Scardino, P. L.: A statistical analysis of ureteral calculi. J. Ural., 83: 561, 1960. "Furlow, W. L. and Bucchiere, J. J., Jr.: The surgical fate of ureteral calculi. Lithotomy or manipulation? Minn. Med., 51: 339, 1968. • Wax, S. H. and Frank, I. N.: A retrospective study of upper urinary tract calculi. J. Urol., 94: 28, 1965.
Other authors have emphasized the importance of ureteral catheter insertion after stone manipulation. 10 • 11 Alyea left a ureteral catheter indwelling 24 to 72 hours, depending on the trauma and color of the urine. 10 The renal pelvis was irrigated with 0.5 per cent mercurochrome sulfadiazine every 6 hours. Thompson and Kibler reported that "pain will almost never be experienced if 2 catheters are left inlying in the ureter after manipulation". 11 An alarming postoperative fever developed in only 2.7 per cent of their cases. The high incidence of pain and fever in our patients with ureteral catheters may be because catheters were more frequently inserted after traumatic manipulations. We also noted that patients frequently experienced pain when the ureteral catheters became plugged with blood clots. SUMMARY
A retrospective study of 193 consecutive stone manipulations performed during a 5-year period is reported herein. No patient required subsequent nephrectomy. The mortality rate was 0.5 per cent and 5 per cent of the patients required subsequent ureterolithotomy. We believe that antibiotics are not required in the uncomplicated management of most stone manipulations. 10 Alyea, E. P.: Cystoscopic removal of large ureteral calculi. J. Urol., 40:83, 1938. "Thompson, G. J. and Kibler, J.M.: Treatment of ureteral calculus, with particular reference to transurethral manipulation. J .A.M.A., 114: 6, 1940.
Co.
A CRITICAL REVIEW OF STONE MANIPULATION: A 5-YEAR STUDY FRANK B. IVIAHON, JR.*
AND
RAUL F. WATERS
From the Department of Surgery, Section of Urology, University of Wisconsin Medical School and Saint Mary's Hospital J\!J.edical Center, Madison, Wisconsin
In 1902 Young reported the first successful stone manipulation-the extraction of a distal ureteral calculus with a catheter. 1 Since then manipulation has been important in the management of ureteral calculi. We report herein a determination of the rate of incidence, success and morbidity to stone manipulation.
There was a 67 per cent success rate in patients with radiopaque calculi between 5 and 11 mm. in diameteL There was a 63 per cent success rate in patients who had manipulations on the day of hospitalization. Major postoperative complications occurred in 10.5 per cent of the patients. One patient had a cardiac arrest and died 2 days postoperatively and 2.5 per cent of the patients required repeat manipulations. Ureterolithotomy was subsequently performed in 5 per cent of the patients. There was radiographic evidence of ureteral perforation in 2 per cent of the patients: 1 required stenting, 1 required ureterolithotomy and 2 were discharged from the hospital. One of these patients returned 4 months later with a lower ureteral stricture and secondary hydronephrosis. She subsequently had a successful ureteral reimplantation. Another patient with hydronephrosis secondary to ureteral stricture was treated with ""'""'""''',., dilation of the stricture, Many patients had minor postoperative com27 per cent had fever and 54 per cent pa·in (requiring more than 2 hyperdermic injections). An ileus requiring a nasogastric tube developed in 1 case. Another patient had postoperative ventricular premature contractions which necessitated 19 days of hospitalization. Fever developed in 21 per cent of the 61 patients who did not receive postoperative antibiotics and in 24 per cent of the 132 patients who dido Of the 136 patients without ureteral catheters 49 per cent had pain and 25 per cent had fever. Of the 57 patients with postoperative ureteral catheters 68 per cent had pain and 33 per cent had fever.
MATERIALS AND METHODS
The charts of all patients (428) admitted to this hospital because of renal and/or ureteral calculi between January 1965 and December 1969 were reviewed. Of those patients 28 per cent had spontaneous passage of uretera! calculi and 45 per cent underwent stone manipulations. We report herein a review of the 193 cases of stone manipulation. RESULTS
were between 12 and 74 years old between 20 and 60. The ratio of men to women was 2.7 to 1. Hovvever, in the 20 to group there was an equal ratio of men to women, Of the patients 29 per cent had a history of renal or ureteral calculi and 4 per cent a temperature exceeding lOOF before treatmenL The average white blood count was 10,800 (normal 5,000 to 10,000 cells per cu. mm.). Excretory urograms (IVPs) were available for review in 175 cases: 85 per cent showed hydrone14 per cent revealed renal calculi with ipsilateral ureteral 65 per cent showed u.reteral calculi with an average diameter of 4,3 mm, and 6 per cent demonstrated renal anomalies. All were performed after administration of general anesthesia, All calculi were in the lower third of the ureter. The Dormia stone basket was most
DISCUSSION
sex,
data and IVP our similar to those r<>1,m·t;,r1 ever, there are few reports on the success or of stone and James reported a 45 per cent in 76 patients.• Their
and the average total 57 per cent vvere success49 per cent of the non-opaque caJcuH were
extracted but 65 per cent of the calculi had successful
with
Accepted for publication April 6, 1973. Read at annual meeting of North Central Section, American Urological Association, Detroit, Michigan, September 2:-25, 1971. * Current address: Guthrie Clinic, Ltd., Guthrie Square, Sayre, Pennsylvania 18840. 1 Young, H. H.: Treatment of calculus in the lower end of the ureter in the male. Amer. Med., 4: 209, 1902.
2 Fox, Pyrah, L. N. and Raper, F. P.: Management of ureteric a review of 292 cases. Brit. J. Urol., 37: 660, 1965. 'Sandegard, E.: Prognosis of stone in the ureter. Acta Chir. Scand., suppl. 219, pp. 1-67, 1956. 'Nourse, M. H.: The management of ureteral stones. J.A.M.A., 198: 1270, 1966. 'Fetter, T. R., Zimskind, P. D., Graham, R.H. and Brodie, D. E.: Statistical analysis of patients with ureteral calculi. J.A.M.A., 186: 21, 1963. 'Kittredge, W. E. and James, D.: Management of ureteral calculi. J. Ural., 72: 342, 1954.
387
388
MAHON AND WATERS
complications were 7 repeat manipulations, 10 ureterolithotomies, 2 nephrectomies, 1 ureteral perforation and 1 broken ureteral stone basket tip. Prince and Scardino reported a 65 per cent success rate in 298 cases of stone manipulation. 7 Complications included 1 death, 1 nephrectomy, 2 surgical removals of wedged stone baskets, 1 ruptured ureter and 19 repeat manipulations. Of their patients 9.4 per cent required subsequent ureterolithotomy. Furlow and Bucchiere reported 84 per cent success in 45 patients with radiopaque calculi. 8 The complications wP-re 2 cases of renal colic secondary to blood clots, 1 case of bacteremia, 1 of acute pyelonephritis and 1 of ureteral perforation. Of these patients, 9 per cent required subsequent ureterolithotomy and 1 nephrectomy was performed. Our patients receiving antibiotics had a higher incidence of fever than those who did not. The antibiotics may have caused postoperative fever in some cases. The low percentage (6 per cent) of positive urine cultures in our patients with ureteral stones has been reported previously.• Thus, in the absence of a positive urine culture or impending sepsis, we do not believe that the routine use of antibiotics is indicated in cases of ureteral calculi. 7 Prince, C. L. and Scardino, P. L.: A statistical analysis of ureteral calculi. J. Ural., 83: 561, 1960. "Furlow, W. L. and Bucchiere, J. J., Jr.: The surgical fate of ureteral calculi. Lithotomy or manipulation? Minn. Med., 51: 339, 1968. • Wax, S. H. and Frank, I. N.: A retrospective study of upper urinary tract calculi. J. Urol., 94: 28, 1965.
Other authors have emphasized the importance of ureteral catheter insertion after stone manipulation. 10 • 11 Alyea left a ureteral catheter indwelling 24 to 72 hours, depending on the trauma and color of the urine. 10 The renal pelvis was irrigated with 0.5 per cent mercurochrome sulfadiazine every 6 hours. Thompson and Kibler reported that "pain will almost never be experienced if 2 catheters are left inlying in the ureter after manipulation". 11 An alarming postoperative fever developed in only 2.7 per cent of their cases. The high incidence of pain and fever in our patients with ureteral catheters may be because catheters were more frequently inserted after traumatic manipulations. We also noted that patients frequently experienced pain when the ureteral catheters became plugged with blood clots. SUMMARY
A retrospective study of 193 consecutive stone manipulations performed during a 5-year period is reported herein. No patient required subsequent nephrectomy. The mortality rate was 0.5 per cent and 5 per cent of the patients required subsequent ureterolithotomy. We believe that antibiotics are not required in the uncomplicated management of most stone manipulations. 10 Alyea, E. P.: Cystoscopic removal of large ureteral calculi. J. Urol., 40:83, 1938. "Thompson, G. J. and Kibler, J.M.: Treatment of ureteral calculus, with particular reference to transurethral manipulation. J .A.M.A., 114: 6, 1940.