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1832 OUTCOMES FOLLOWING SECONDARY TREATMENT USING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
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THE JOURNAL OF UROLOGY姞
June 2010 (Group 2). We excluded all patients with pre-operative positive urine cultures, pre-operative antibiotics, urinary diversion, who underwent concomitant percutaneous nephrolithotomy, were prestented or had strings attached to the ureteral stents for stent removal. All patients in both groups received a first generation cephalosporin or fluoroquinolone at the time of initial intervention (based on allergies and renal function). Group 1 received a fluoroquinolone for one week postoperatively and the stent was removed within 5–7 days. Group 2 received a first generation cephalosporin antibiotic peri-stent removal only. The patients rarely required a change in the antibiotic regimen. Our primary endpoint was symptomatic urinary tract infection (UTI). Other factors evaluated were baseline demographics, renal function, degree of preoperative hydronephrosis, and stone composition. RESULTS: After the exclusion criteria, Group 1 had 48 patients, Group 2 had 49. There was no statistical difference in the incidence of symptomatic UTI between the two groups; each group had one UTI (approximately 2% risk) (p⫽0.988). There were no cases of re-admission, pyelonephritis, UTI, surgical re-intervention, or C difficile. The UTI in Group 1 was secondary to E coli and in Group 2, Staphylococcus species – both were treated with oral antibiotics. There were two cases that developed asymptomatic funguria/bacteriuria in Group 1(Candida/E coli) and none in Group 2. There were no other statistically significant findings with regards to all other parameters that were evaluated. CONCLUSIONS: The use of peri-stent removal antibiotic prophylaxis is sufficient in preventing symptomatic UTIs in patienst that have undergone therapeutic ureteroscopic treatment for urolithiasis. The judicious use of antibiotics in uncomplicated cases may help in lowering the incidence of resistant organisms and other complications related to the use of widespread antibiotics. Future prospective studies are warranted to corroborate our findings and further identify cases where antibiotic use can be limited. Source of Funding: None
1830 URETEROSCOPIC LITHOTRIPSY FOR DISTAL URETERAL CALCULI: COMPARATIVE EVALUATION OF THREE DIFFERENT LITHOTRIPTORS Jose Salvado*, Ivan Saez, Alvaro Saavedra, Alvaro Zuniga, Arturo Dell’oro, Javier Dominguez, Santiago, Chile INTRODUCTION AND OBJECTIVES: We report the results of a randomized controlled trial (RCT) comparing three different lithotriptors using semirigid ureteroscopy for distal ureteral stones. METHODS: Between June 2009 and August 2010 sixty-nine patients undergoing ureteroscopy were randomized to three groups: LithoClast classic (Group 1), Holmium Laser (Group 2) and StoneBreakerTM (Group 3). A 7,5 Fr semirigid ureteroscope was used in all procedures. The primary outcome was differences in fragmentation time. Secondary outcomes were stone free rates, intraoperative complications, stone up migration, hospital stay, analgesic requirement and need for auxiliary procedures. Patients were followed at 15 days, 30 days and 3 months. The stone free status was defined with noncontrast CT performed at first control. Univariate and multivariate analysis were performed to determine clinical and surgical factors that have direct impact on the success of ureteroscopy. Chi - square test and ANCOVA tests were used for statistical comparisons. RESULTS: There were no differences between sociodemographic variables. Average stone size was 7,17 ⫾ 2,04 mm in Group 1; 7,89 ⫾ 2,73 mm in Group 2 and 7,79 ⫾ 2,97 mm in Group 3 (p ⫽ 0,79). Fragmentation time were similar between lithotriptors; 27,12 ⫾ 4,07 minutes in Lithoclast group; 21,78 ⫾ 2,81 minutes in Laser group and 27,14 ⫾ 4,71 minutes in StoneBreaker group (p ⫽ 0,74). Stone free rates were 96 ⫾ 11,18% (group 1), 96,9 ⫾ 8% (group 2) and 96,9 ⫾ 8,4% (group 3) (p ⫽ 0,1). No difference was observed in stone up migration, postoperative Double J stent placement or auxiliary procedures. Stone size and the placement of a second working wire were associated with shorter fragmentation time (p⬍0,01).
Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011
CONCLUSIONS: The three lithotripsy devices evaluated behaved similarly in terms of the ability to fragment stones, and were equally effective for distal ureteral stones. Adequate fragmentation and fragment removal are mainly dependant on stone size and surgical technique (use of auxiliary wire). Source of Funding: None
1831 ROBOTIC FLEXIBLE URETERORENOSCOPIC SURGERY, FIRST PRESENTATION OF THE NEW ROBOT Remzi Saglam*, Ahmet Sinan Kabakci, Erhan Koruk, Zafer Tokatli, Ankara, Turkey INTRODUCTION AND OBJECTIVES: Flexible Uretero Renoscopic Laser Surgery (FURLAS) or Retrograde Intra Renal Surgery (RIRS) has been a widely used method. While precision is essential for the treatment, sometimes it is a time-consuming, difficult and tiresome method. Flexible devices are too fragile especially for the new beginners. However, the new robot is perfect for precision, eases learning, makes the operation less challenging for the user, and prevents the equipment from being damaged. Thanks to this robot, the doctors can sit and operate distant to the patient which enables them not to be exposed to radiation. The robot is also not tiresome for the doctors. METHODS: The robot consists of two parts. The first part is the operating unit which stands near the patient, over the specially designed trolley. It can move up and down and to and fro, has some parts holding the camera not to move together with the hand piece. The hand piece holder of the flexible unit has adaptors for different types of flexible ureterorenoscopes (FURS) and provides a 270 degree rotation of the FURS. There is a movement mechanism for the deflection, rotating together with FURS. Another micromotor moves the laser fiber to and fro. The second part is a “control unit”, on the control table there are two monitors, one for endoscopy, another for fluoroscopic image. Computers and electronics are placed under the table. After connection of the FURS to the operating unit and inserting the flexible tip through the access sheet, it is possible to control every movement by remote control from the control unit, going forward into the kidney, rotating and deflecting the tip into the desired position. Pressing one button makes the tip stand in an exactly straight position; this prevents any possible damage in the equipment during fiber insertion. It is possible to adjust the water flow-rate by controlling the pump. This robot has been used in the treatment of 8 intrarenal stones and the easiness, preciseness and shortness of the operations was observed. RESULTS: The robotic use of the FURS provides precise fragmentation of the stone in a short time; maneuvers of the tip were easier than the manual use. It was not tiresome for the doctor. CONCLUSIONS: The robotic use of FURS is very easy to use, not tiring, and easy to learn, prevents damage of the FURS, and makes the operation shorter. The process of the improvement to see the position of the tip on the monitor, and to provide a memory to return to the previous position still maintains. Source of Funding: Support of Elmed Lithotripsy SystemsTurkey
1832 OUTCOMES FOLLOWING SECONDARY TREATMENT USING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Adam Stewart*, Wesley White, Frederick Klein, Knoxville, TN INTRODUCTION AND OBJECTIVES: Conventional treatment of renal and upper ureteral calculi includes ureteroscopy (URS) and Extracorporeal Shock Wave Lithotripsy (ESWL). Although initial treatment success rates with ESWL approach 90%, select patients will require a second treatment. URS is often employed in this scenario
Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011
despite limited data regarding treatment success following repeat ESWL. We present outcomes following re-treatment of stones using ESWL in a large observational cohort of patients. METHODS: A retrospective review was performed to determine the efficacy and perioperative outcomes following secondary treatment of renal and ureteral calculi using ESWL. Following initial treatment with ESWL, patients who were defined as treatment failures were offered repeat ESWL or URS. Patients who underwent secondary treatment with ESWL were followed postoperatively and routine aftercare was performed. Post-treatment imaging included KUB or non-contrast CT at 30 days. Aftercare reports were completed and catalogued in a prospectively maintained database. Success was defined as the absence of stones or the presence of fragments less than 4mm. RESULTS: Between 1/1/2000 and 12/31/2009, 14,313 patients underwent 22,463 treatments for renal or ureteral calculi by ESWL. Mean stone size was 9.04mm. Success rate with initial treatment was 91%. A total of 617 patients underwent secondary treatment with ESWL. Mean stone size was 1.24cm. Success was achieved in 75% of patients. Among patients that underwent repeat treatment, success rates were highest among patients with a stone size less than 1cm. Stone location did not appear to impact secondary treatment outcomes. CONCLUSIONS: Based on our large, single-center experience, secondary treatment with ESWL continues to offer a high overall success rate. Although URS should be strongly considered following initial treatment failure, patients who request or are better suited for ESWL can be offered repeat treatment with a high level of confidence. Source of Funding: None
1833 THE MANAGEMENT OF PROXIMAL URETERAL CALCULI > 10 MM: STONE VOLUME IS THE BEST INDICATOR OF SHOCK WAVE LITHOTRIPSY, FLEXIBLE URETEROSCOPY AND RETROPERITONEOSCOPIC URETEROLITHOTOMY Tetsutaro Hayashi*, Hiroshima, Japan; Keisuke Goto, Kure, Japan; Kiyotaka Oka, Yoji Inoue, Mutsuo Hayashi, Hiroshima, Japan INTRODUCTION AND OBJECTIVES: Treatment options for proximal ureteral calculi ⱖ 10 mm include shock wave lithotripsy (SWL), flexible ureteroscopy (URS) and retroperitoneoscopic ureterolithotomy (RPLU). As the ideal treatment and the indication of these treatments remain unclear, we conducted a retrospective study comparing the success and complication rates of these three treatments to establish the indication of each treatment for analyzing preoperative parameters. METHODS: Patients who were treated by SWL (n⫽202), URS (n⫽39) and RPUL (n⫽33) from a single institution were enrolled. Treatment failure was estimated based on predictors, i.e., body mass index, distance from skin to stone, stone length, dimension, volume, mean stone CT number and hydronephrosis grade of SWL and URS. RESULTS: For stones ⱖ 10 mm, the stone-free rate for SWL, URS and RPUL was 71%, 77% and 100%, respectively (p⬍0.01, Wilcoxon test); most cases of SWL and URS required re-treatment. The complication rate for SWL, URS and RPUL was 2%, 7% and 15%, respectively (p⬍0.01). Although SWL is less invasive, it had poorer efficacy, while RPUL had better efficacy although it is more invasive. Therefore, URS should be limited to difficult cases of SWL, and RPUL should be limited to difficult cases of URS. Univariate analysis revealed length (p⫽0.0016), dimension (p⫽0.0093), volume (p⫽0.0284), mean CT number (p⫽0.027) and hydronephrosis grading (p⫽0.0429) to be significant predictors of SWL failure, while length (p⫽0.0039), dimension (p⫽0.0092), and volume (p⫽0.0169) to be significant predictors for URS failure. Multivariate analysis revealed dimension (p⫽0.0383) and volume (p⫽0.0338) to be independent predictors of SWL failure, while volume (p⫽0.0225) to be an independent predictor of URS failure. Bifurcation of SWL and URS was respectively 500 mm3 and 1200 mm3, as determined by statistical analysis. CONCLUSIONS: Stone volume was the best indicator of SWL, URS and RPUL in the management of proximal ureteral calculi ⱖ 10 mm.
THE JOURNAL OF UROLOGY姞
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Source of Funding: None
1834 THE IMPACT OF EARLY SHOCK WAVE LITHOTRIPSY ON THE CLINICAL OUTCOMES OF UPPER URETERAL CALCULI Hong Yong Choi*, Hee Young Park, Joon Seok Kwon, Sung Yul Park, Hong Sang Moon, Yong Tae Kim, Tchun Yong Lee, Seoul, Korea, Republic of INTRODUCTION AND OBJECTIVES: Shockwave lithotripsy (SWL) is a representative non-invasive modality in treating ureteral stone. The aim of this study was conducted to compare between early (⬍72 hours) versus late (¡Y´72 hours) SWL after attack of an initial flank pain and assessed the effects on clinical outcome. METHODS: The study population was comprised of 336 patients with upper ureteral stone who underwent SWL from January, 2005 to April, 2010. All patients underwent KUB, intravenous pyelography (IVP) or computed tomography (CT) to evaluate the upper ureteral stone. SWL was performed with electrohydroulic SDS-5000 plus (Comed, Gwangju, Korea). The presence of remnant stones was evaluated with KUB, IVP or CT at two weeks after the procedure. In cases of remnant stones, additional SWL was performed at fortnightly intervals. The study population was divided into two groups; Group 1 (n⫽132): SWL was performed within 72 hours of onset of colicky pain; Group 2 (n⫽204): SWL was performed after 72 hours of onset of pain. Age, sex, stone size, presence of hydronephrosis, final stone-free rate, time to stone clearance, the number of session performed, rate of stone clearance after three months were evaluated. In addition, auxiliary procedures such as ureteral stent insertion or ureteroscopic removal of tone (URS) were also analyzed. RESULTS: The mean age was 45.4iA`15.0 years in Group 1 vs. 48.5¡A`14.0 years in Group 2 (p⫽0.338). The mean body mass index was 24.3¡A`3.2 kg/m2 in Group 1 vs. 24.5¡A`3.0 kg/m2 in Group 2 (p⫽0.824), showing no statistical significance. The mean size of upper ureteral stone did not significantly differ between the two groups; 0.72¡A`0.32 cm vs. 0.78¡A`0.41 cm (p⫽0.570). Also, there was no statistical significance regarding the presence of hydronephrosis prior to SWL between the two groups; 92 patients (69.7%) in Group 1 vs. 147 patients (72.1%) in Group 2 (p⫽0.642). The success rate was 82.6% and 80.4%, respectively (p⫽0.618), showing no statistical difference. However, the mean time taken for stone clearance was shorter in Group 1 (15.15¡A`26.11 days) when compared to Group 2 (22.65¡A`35.42 days) (p⫽0.037). The number of session required was significantly lesser in Group 1 than Group 2 (1.79¡A`1.03 vs. 2.11¡A`1.37, p⫽0.022). The rate of stone clearance after three months was no significantly different between the two groups; 78.0% in Group 1 vs. 76% in Group 2 (p⫽0.665). Auxiliary procedure rate did not differ significantly between the two groups (15.9% vs. 17.1%, p⫽0.765).
THE JOURNAL OF UROLOGY姞
June 2010 (Group 2). We excluded all patients with pre-operative positive urine cultures, pre-operative antibiotics, urinary diversion, who underwent concomitant percutaneous nephrolithotomy, were prestented or had strings attached to the ureteral stents for stent removal. All patients in both groups received a first generation cephalosporin or fluoroquinolone at the time of initial intervention (based on allergies and renal function). Group 1 received a fluoroquinolone for one week postoperatively and the stent was removed within 5–7 days. Group 2 received a first generation cephalosporin antibiotic peri-stent removal only. The patients rarely required a change in the antibiotic regimen. Our primary endpoint was symptomatic urinary tract infection (UTI). Other factors evaluated were baseline demographics, renal function, degree of preoperative hydronephrosis, and stone composition. RESULTS: After the exclusion criteria, Group 1 had 48 patients, Group 2 had 49. There was no statistical difference in the incidence of symptomatic UTI between the two groups; each group had one UTI (approximately 2% risk) (p⫽0.988). There were no cases of re-admission, pyelonephritis, UTI, surgical re-intervention, or C difficile. The UTI in Group 1 was secondary to E coli and in Group 2, Staphylococcus species – both were treated with oral antibiotics. There were two cases that developed asymptomatic funguria/bacteriuria in Group 1(Candida/E coli) and none in Group 2. There were no other statistically significant findings with regards to all other parameters that were evaluated. CONCLUSIONS: The use of peri-stent removal antibiotic prophylaxis is sufficient in preventing symptomatic UTIs in patienst that have undergone therapeutic ureteroscopic treatment for urolithiasis. The judicious use of antibiotics in uncomplicated cases may help in lowering the incidence of resistant organisms and other complications related to the use of widespread antibiotics. Future prospective studies are warranted to corroborate our findings and further identify cases where antibiotic use can be limited. Source of Funding: None
1830 URETEROSCOPIC LITHOTRIPSY FOR DISTAL URETERAL CALCULI: COMPARATIVE EVALUATION OF THREE DIFFERENT LITHOTRIPTORS Jose Salvado*, Ivan Saez, Alvaro Saavedra, Alvaro Zuniga, Arturo Dell’oro, Javier Dominguez, Santiago, Chile INTRODUCTION AND OBJECTIVES: We report the results of a randomized controlled trial (RCT) comparing three different lithotriptors using semirigid ureteroscopy for distal ureteral stones. METHODS: Between June 2009 and August 2010 sixty-nine patients undergoing ureteroscopy were randomized to three groups: LithoClast classic (Group 1), Holmium Laser (Group 2) and StoneBreakerTM (Group 3). A 7,5 Fr semirigid ureteroscope was used in all procedures. The primary outcome was differences in fragmentation time. Secondary outcomes were stone free rates, intraoperative complications, stone up migration, hospital stay, analgesic requirement and need for auxiliary procedures. Patients were followed at 15 days, 30 days and 3 months. The stone free status was defined with noncontrast CT performed at first control. Univariate and multivariate analysis were performed to determine clinical and surgical factors that have direct impact on the success of ureteroscopy. Chi - square test and ANCOVA tests were used for statistical comparisons. RESULTS: There were no differences between sociodemographic variables. Average stone size was 7,17 ⫾ 2,04 mm in Group 1; 7,89 ⫾ 2,73 mm in Group 2 and 7,79 ⫾ 2,97 mm in Group 3 (p ⫽ 0,79). Fragmentation time were similar between lithotriptors; 27,12 ⫾ 4,07 minutes in Lithoclast group; 21,78 ⫾ 2,81 minutes in Laser group and 27,14 ⫾ 4,71 minutes in StoneBreaker group (p ⫽ 0,74). Stone free rates were 96 ⫾ 11,18% (group 1), 96,9 ⫾ 8% (group 2) and 96,9 ⫾ 8,4% (group 3) (p ⫽ 0,1). No difference was observed in stone up migration, postoperative Double J stent placement or auxiliary procedures. Stone size and the placement of a second working wire were associated with shorter fragmentation time (p⬍0,01).
Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011
CONCLUSIONS: The three lithotripsy devices evaluated behaved similarly in terms of the ability to fragment stones, and were equally effective for distal ureteral stones. Adequate fragmentation and fragment removal are mainly dependant on stone size and surgical technique (use of auxiliary wire). Source of Funding: None
1831 ROBOTIC FLEXIBLE URETERORENOSCOPIC SURGERY, FIRST PRESENTATION OF THE NEW ROBOT Remzi Saglam*, Ahmet Sinan Kabakci, Erhan Koruk, Zafer Tokatli, Ankara, Turkey INTRODUCTION AND OBJECTIVES: Flexible Uretero Renoscopic Laser Surgery (FURLAS) or Retrograde Intra Renal Surgery (RIRS) has been a widely used method. While precision is essential for the treatment, sometimes it is a time-consuming, difficult and tiresome method. Flexible devices are too fragile especially for the new beginners. However, the new robot is perfect for precision, eases learning, makes the operation less challenging for the user, and prevents the equipment from being damaged. Thanks to this robot, the doctors can sit and operate distant to the patient which enables them not to be exposed to radiation. The robot is also not tiresome for the doctors. METHODS: The robot consists of two parts. The first part is the operating unit which stands near the patient, over the specially designed trolley. It can move up and down and to and fro, has some parts holding the camera not to move together with the hand piece. The hand piece holder of the flexible unit has adaptors for different types of flexible ureterorenoscopes (FURS) and provides a 270 degree rotation of the FURS. There is a movement mechanism for the deflection, rotating together with FURS. Another micromotor moves the laser fiber to and fro. The second part is a “control unit”, on the control table there are two monitors, one for endoscopy, another for fluoroscopic image. Computers and electronics are placed under the table. After connection of the FURS to the operating unit and inserting the flexible tip through the access sheet, it is possible to control every movement by remote control from the control unit, going forward into the kidney, rotating and deflecting the tip into the desired position. Pressing one button makes the tip stand in an exactly straight position; this prevents any possible damage in the equipment during fiber insertion. It is possible to adjust the water flow-rate by controlling the pump. This robot has been used in the treatment of 8 intrarenal stones and the easiness, preciseness and shortness of the operations was observed. RESULTS: The robotic use of the FURS provides precise fragmentation of the stone in a short time; maneuvers of the tip were easier than the manual use. It was not tiresome for the doctor. CONCLUSIONS: The robotic use of FURS is very easy to use, not tiring, and easy to learn, prevents damage of the FURS, and makes the operation shorter. The process of the improvement to see the position of the tip on the monitor, and to provide a memory to return to the previous position still maintains. Source of Funding: Support of Elmed Lithotripsy SystemsTurkey
1832 OUTCOMES FOLLOWING SECONDARY TREATMENT USING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Adam Stewart*, Wesley White, Frederick Klein, Knoxville, TN INTRODUCTION AND OBJECTIVES: Conventional treatment of renal and upper ureteral calculi includes ureteroscopy (URS) and Extracorporeal Shock Wave Lithotripsy (ESWL). Although initial treatment success rates with ESWL approach 90%, select patients will require a second treatment. URS is often employed in this scenario
Vol. 185, No. 4S, Supplement, Tuesday, May 17, 2011
despite limited data regarding treatment success following repeat ESWL. We present outcomes following re-treatment of stones using ESWL in a large observational cohort of patients. METHODS: A retrospective review was performed to determine the efficacy and perioperative outcomes following secondary treatment of renal and ureteral calculi using ESWL. Following initial treatment with ESWL, patients who were defined as treatment failures were offered repeat ESWL or URS. Patients who underwent secondary treatment with ESWL were followed postoperatively and routine aftercare was performed. Post-treatment imaging included KUB or non-contrast CT at 30 days. Aftercare reports were completed and catalogued in a prospectively maintained database. Success was defined as the absence of stones or the presence of fragments less than 4mm. RESULTS: Between 1/1/2000 and 12/31/2009, 14,313 patients underwent 22,463 treatments for renal or ureteral calculi by ESWL. Mean stone size was 9.04mm. Success rate with initial treatment was 91%. A total of 617 patients underwent secondary treatment with ESWL. Mean stone size was 1.24cm. Success was achieved in 75% of patients. Among patients that underwent repeat treatment, success rates were highest among patients with a stone size less than 1cm. Stone location did not appear to impact secondary treatment outcomes. CONCLUSIONS: Based on our large, single-center experience, secondary treatment with ESWL continues to offer a high overall success rate. Although URS should be strongly considered following initial treatment failure, patients who request or are better suited for ESWL can be offered repeat treatment with a high level of confidence. Source of Funding: None
1833 THE MANAGEMENT OF PROXIMAL URETERAL CALCULI > 10 MM: STONE VOLUME IS THE BEST INDICATOR OF SHOCK WAVE LITHOTRIPSY, FLEXIBLE URETEROSCOPY AND RETROPERITONEOSCOPIC URETEROLITHOTOMY Tetsutaro Hayashi*, Hiroshima, Japan; Keisuke Goto, Kure, Japan; Kiyotaka Oka, Yoji Inoue, Mutsuo Hayashi, Hiroshima, Japan INTRODUCTION AND OBJECTIVES: Treatment options for proximal ureteral calculi ⱖ 10 mm include shock wave lithotripsy (SWL), flexible ureteroscopy (URS) and retroperitoneoscopic ureterolithotomy (RPLU). As the ideal treatment and the indication of these treatments remain unclear, we conducted a retrospective study comparing the success and complication rates of these three treatments to establish the indication of each treatment for analyzing preoperative parameters. METHODS: Patients who were treated by SWL (n⫽202), URS (n⫽39) and RPUL (n⫽33) from a single institution were enrolled. Treatment failure was estimated based on predictors, i.e., body mass index, distance from skin to stone, stone length, dimension, volume, mean stone CT number and hydronephrosis grade of SWL and URS. RESULTS: For stones ⱖ 10 mm, the stone-free rate for SWL, URS and RPUL was 71%, 77% and 100%, respectively (p⬍0.01, Wilcoxon test); most cases of SWL and URS required re-treatment. The complication rate for SWL, URS and RPUL was 2%, 7% and 15%, respectively (p⬍0.01). Although SWL is less invasive, it had poorer efficacy, while RPUL had better efficacy although it is more invasive. Therefore, URS should be limited to difficult cases of SWL, and RPUL should be limited to difficult cases of URS. Univariate analysis revealed length (p⫽0.0016), dimension (p⫽0.0093), volume (p⫽0.0284), mean CT number (p⫽0.027) and hydronephrosis grading (p⫽0.0429) to be significant predictors of SWL failure, while length (p⫽0.0039), dimension (p⫽0.0092), and volume (p⫽0.0169) to be significant predictors for URS failure. Multivariate analysis revealed dimension (p⫽0.0383) and volume (p⫽0.0338) to be independent predictors of SWL failure, while volume (p⫽0.0225) to be an independent predictor of URS failure. Bifurcation of SWL and URS was respectively 500 mm3 and 1200 mm3, as determined by statistical analysis. CONCLUSIONS: Stone volume was the best indicator of SWL, URS and RPUL in the management of proximal ureteral calculi ⱖ 10 mm.
THE JOURNAL OF UROLOGY姞
e735
Source of Funding: None
1834 THE IMPACT OF EARLY SHOCK WAVE LITHOTRIPSY ON THE CLINICAL OUTCOMES OF UPPER URETERAL CALCULI Hong Yong Choi*, Hee Young Park, Joon Seok Kwon, Sung Yul Park, Hong Sang Moon, Yong Tae Kim, Tchun Yong Lee, Seoul, Korea, Republic of INTRODUCTION AND OBJECTIVES: Shockwave lithotripsy (SWL) is a representative non-invasive modality in treating ureteral stone. The aim of this study was conducted to compare between early (⬍72 hours) versus late (¡Y´72 hours) SWL after attack of an initial flank pain and assessed the effects on clinical outcome. METHODS: The study population was comprised of 336 patients with upper ureteral stone who underwent SWL from January, 2005 to April, 2010. All patients underwent KUB, intravenous pyelography (IVP) or computed tomography (CT) to evaluate the upper ureteral stone. SWL was performed with electrohydroulic SDS-5000 plus (Comed, Gwangju, Korea). The presence of remnant stones was evaluated with KUB, IVP or CT at two weeks after the procedure. In cases of remnant stones, additional SWL was performed at fortnightly intervals. The study population was divided into two groups; Group 1 (n⫽132): SWL was performed within 72 hours of onset of colicky pain; Group 2 (n⫽204): SWL was performed after 72 hours of onset of pain. Age, sex, stone size, presence of hydronephrosis, final stone-free rate, time to stone clearance, the number of session performed, rate of stone clearance after three months were evaluated. In addition, auxiliary procedures such as ureteral stent insertion or ureteroscopic removal of tone (URS) were also analyzed. RESULTS: The mean age was 45.4iA`15.0 years in Group 1 vs. 48.5¡A`14.0 years in Group 2 (p⫽0.338). The mean body mass index was 24.3¡A`3.2 kg/m2 in Group 1 vs. 24.5¡A`3.0 kg/m2 in Group 2 (p⫽0.824), showing no statistical significance. The mean size of upper ureteral stone did not significantly differ between the two groups; 0.72¡A`0.32 cm vs. 0.78¡A`0.41 cm (p⫽0.570). Also, there was no statistical significance regarding the presence of hydronephrosis prior to SWL between the two groups; 92 patients (69.7%) in Group 1 vs. 147 patients (72.1%) in Group 2 (p⫽0.642). The success rate was 82.6% and 80.4%, respectively (p⫽0.618), showing no statistical difference. However, the mean time taken for stone clearance was shorter in Group 1 (15.15¡A`26.11 days) when compared to Group 2 (22.65¡A`35.42 days) (p⫽0.037). The number of session required was significantly lesser in Group 1 than Group 2 (1.79¡A`1.03 vs. 2.11¡A`1.37, p⫽0.022). The rate of stone clearance after three months was no significantly different between the two groups; 78.0% in Group 1 vs. 76% in Group 2 (p⫽0.665). Auxiliary procedure rate did not differ significantly between the two groups (15.9% vs. 17.1%, p⫽0.765).