991 DAY CASE RIGID AND FLEXIBLE URETERORENOSCOPY

989



990

Ureteroscopy vs. conservative treatment of distal ureteral calculi: results of a randomized study

Epidemiological characteristics and ureteroscopic treatment of large ureteral stones

Nigro F., Benedetto G., Ferrarese P., Abatangelo G., Scremin E., Bratti E., Tasca A.

Sofer M., Greenstein A., Keren Paz G., Ben Chaim J., Chen J., Matzkin H.

San Bortolo Hospital, Urology, Vicenza, Italy

Tel-Aviv Sourasky Medical Center, Urology, Tel-Aviv, Israel

Introduction & Objectives: The aim of this study is to compare the cost-effectiveness of two different treatment strategies, namely observation and ureteroscopy (URS), for hospitalised patients with symptomatic distal ureteral calculi.

Introduction & Objectives: To define epidemiological characteristics of ureteral stones ≥ 2 cm and to assess the effectiveness of their ureteroscopic treatment.

Material & Methods: Inclusion criteria: age > 18 year old, symptomatic monolateral distal ureteral stone <1 cm in diameter. Exclusion criteria: urinary tract infection, hydronephrosis (renal pelvis diameter >2 cm), urinary malformation, pregnancy, diabetes, pre-existing medical conditions, previous expulsion of urinary stones, episodes of hypotension, previous abdominal surgery. Conservative treatment (20 patients, group “A”): methylprednisolone 8 mg/d (max 10 days) and tamsulosin 0,4 mg/d (max 28 days) after resolution of acute symptoms with sodium diclofenac. Endoscopic treatment (20 patients, group “B”): loco-regional anesthaesia, transurethral approach using a semirigid instrument, stone removal and/or lithotripsy, stenting of the treated upper tract (optional). Cross-over to group B is determined by the onset of psychologic or pharmacologic intolerance as well as by the appearance of urinary tract infection, hydronephrosis or untreatable pain. Results: Stone dimension was statistically homogeneous for the two groups (5.4/6.3mm, A/B). Group A: length of therapy: 7,2 days, spontaneous expulsion rate: 75% (15 patients), cross over to group B: 25% (5 patients), average hospitalisation: 4,3 days. Group B: average hospitalisation 3,2 days (p n.s.). One complication was observed in 1 patient of group B: injury of the ureteral wall, that was successful treated with a JJ catheter for 30 days. The cost for each patient (treatment, clinical and radiological monitoring, hospitalisation) was 1480 and 1520 Euro for the group A and B, respectively (p n.s.). Conclusions: Our results appear to show similar costs for both groups. In reality, for the 5 patients who were shifted from group A to group B the final cost should include even the cost of the invasive treatment. In the conservative group, the cost is strictly related to hospitalisation. The URS approach eliminates the stone in a short time and appears to be potentially preferable for patients who are not willing to accept the economic damage deriving from loss of working hours and/or in whom the stone episode has a consistent impact on quality of life.

Day case rigid and flexible ureterorenoscopy

991

Wiseman O., Longhorn S., Philp T., Choong S.

Material & Methods: A cohort of 625 consecutive patients with ureteral calculi, of them 69 (11%) with stones ≥2 cm and 556 (89%) with stones <2 cm comprised the study group. Data regarding demographics, clinical presentation, intraoperative aspects, stone free rate, hospitalization and complications were statistically analyzed. Results: The average stone burden was 23 mm (range 20-40 mm) in the large stones group and 8 mm (range 2-18 mm) in the small stones group. There was a significant association between large stones and advanced age (60±17 vs 49±18 years) (p<0.001). Patients with large stones were typically asymptomatic or presented with vague flank pain and/or urinary tract infections (UTI). Preoperative drainage to treat acute situations was needed in 51 (74%) cases of large stones (48 stents; 3 nephrostomy tubes) and 291 (52%) of small stones (285 stents; 6 nephrostomy tubes) (p<0.001). Large stones were located mostly in the proximal ureter (p<0.001). Impaction was found in 20% and 7% of large and small stones, respectively (p<0.01). The average operating time was 43 and 77 minutes for small and large stones groups respectively (p<0.001). Operating time was associated with failure and complications (odds ratio: 1.039 and 1.024 respectively). Average hospital stay was 1.4 and 1.1 days for large and small stones groups, respectively (p<0.05). Overall there were 16 (2.6%) intraoperative minor perforations, of them 6 (9%) in the large and 10 (18%) in the small stone group (p<0.01). Postoperatively, 7 (10%) and 23 (4%) patients developed UTIs in the large and small stones group, respectively (p<0.05). Two (0.4%) patients with small stones were subsequently treated endoscopically for ureteral stricture. Stone free rate was 90% for large stones and 96% for small stones (p<0.05). Conclusions: Large ureteral stones (≥2 cm) are diagnosed in significantly older population, presents with vague symptoms, are predominantly located in the upper ureter and are associated with more secondary infections and impactions than small ureteral stones. In spite of these challenging circumstances, it appears that ureteroscopy is a highly effective and safe modality for treating large ureteral calculi.



992

Single-center experience of 5549 ureteroscopies. Comparative analysis of safety and efficacy of two large series of candela and holmium laser lithotripsy

UCLH Hospitals NHS Trust, Urology, London, United Kingdom

Budía A., Broseta E., Boronat F., Oliver F., Pontones J.L., Jiménez-Cruz F.

Introduction & Objectives: The possibility of performing ureteroscopy (urs) as a day case was reported almost 30 years ago, but despite this it is not routinely performed in the UK. We set out to evaluate the outcome after day case rigid and flexible urs for stone disease in our hospital.

La Fe University Hospital, Urology, Valencia, Spain

Material & Methods: All patients undergoing therapeutic rigid or flexible urs for the treatment of stone disease were evaluated prospectively over a 5 month period. 27 patients underwent rigid urs (mean age 38yrs, range 21-55 yrs) and 41 flexible urs (mean age 46 yrs, range 24-83 yrs). Patients who had their procedures as a day case were contacted subsequently and any complications noted. Results: 41% of rigid urs and 39% of flexible urs were performed as a day case. Of the patients who underwent rigid urs, 8 had lower, 2 mid and one an upper ureteric stone, all of which were treated with intracorporeal lithotripsy. All of the patients who underwent flexible urs had intrarenal stones treated +/- basketed. Over 80% of patients who had a rigid urs has a JJ stent, while only 50% of those who had a flexible procedure did so. There was only one complication for all patients in both groups. This was in a 47 year old lady who had undergone flexible urs and basket stone extraction who was readmitted for pain on the day of discharge. This was found to be due to an upper ureteric perforation undetected at the time of flexible urs and was managed conservatively. Patients who were not treated as day cases were kept in hospital for social reasons, due to pain, or simply because they did not expect to be discharged home on the same day, as same day discharge has only recently been implemented in our hospital (total 14 patients in the rigid urs group, 23 in the flexible urs group), and all were discharged on the following day. Two patients in each group were kept in hospital for greater than 1 day, due to one each of post-operative retention of urine, renal failure in a patient with a single kidney, post-operative sepsis and for medical investigation of severe anaemia in a non-compliant patient. The latter three of these could have been predicted pre-operatively. Conclusions: Day case therapeutic rigid and flexible ureteroscopy in the management of upper tract stones is safe and well tolerated, and ought to be increasingly used in the management of patients with suitable upper tract stones. In the majority of patients the expectation ought to be that their procedure be carried out as a day case and we are currently implementing this in our hospital.

Eur Urol Suppl 2007;6(2):270

Introduction & Objectives: Ureteroscopy is nowadays the most widely used technique for upper urinarytract pathology and specially for lithiasis. Our goal is to compare two large series of consecutive patients treated with lithotripsy either with Candela® pulsed-dye laser or Dornier MedTech® holmium laser in a whole series of 5549 ureteroscopies. Material & Methods: Between April 1991 and August 2006, 5257 patients aged 6 to 78 years underwent retrograde ureteroscopy (5549 procedures) under video and fluoroscopic assistance. We used semirigid ureteroscopes (8/9.8F Wolf, 8F Olympus, 8F Candela, 10F Storz) and flexible ureteroscopes (8F Olympus, 8F Candela, 10F Storz) for 338 diagnostic and 5211 therapeutic procedures. The main indication for ureteroscopy was upper urinary-tract lithiasis (4439 cases). An initial series of 3750 cases were treated with pulsed-dye laser followed by a series of 689 cases with a holmium laser. After a calculation of the effect size (alpha-error 0,05 and power 95%), a total of 1000 cases were selected from the initial series of 3750 pulseddye laser to match with the series of 689 holmium laser procedures according to size homogeneity, location and composition of stone. The mean follow-up period was 3 months (range 1-6 months). Results: Both series were comparable in terms of location, size of the stone and type of anesthesia. The procedures were performed under general anesthesia in 950 cases and in an outpatient basis with mild sedation in 739. The total success-percentage (stone-free rate after 3 months) of the series according to the location, type of anesthesia and main source of energy are shown in the next table. Location

Pelvic Iliac Lumbar Steinstrasse Renal pelvis

Mild Sedation Mild sedation Mild sedation General anesthesia Pulsed.dye Holmium p Pulsed.dye laser Laser laser N Stone-free N stone-free N Stone-free (%) (%) (%) 344 (82) 113 (98,3) < 0,05 220 (87,3) 38 (52,7) 24 (100) < 0,05 50 (69,4) 23 (58,9) 30 (90,9) < 0,05 60 (64,5) 12 (63,1) 7 (87,5) 0,2 17 (54,8) 7 (100)

Caliceal Total

2 (100) 417 (75,8)

183 (96,8)

General anesthesia Holmium Laser N stone-free (%) 246 (98,4) 88 (93,6) 95 (89,6) 34 (85) 9 (100)

General anesthesia p

< 0,05 < 0,05 < 0,05 < 0,05

1 (100) < 0,05

346 (76,9)

473 (94,6)

< 0,05

In the anesthesia group the rate of intraoperative complications was slightly better for holmium laser (4,8%) versus pulsed-dye laser (14,8%). The main complication for both series was impossible access to the calculi. Other complications were ureteral perforation (0,6%), guide-wire breakage (0,6%) and severe bleeding (0,8%). Conclusions: Ureteroscopy is a safe and ideal procedure for ureteral stones. Dornier MedTech Holmium laser lithotripsy had significant better results than Candela laser lithotripsy with minimum morbidity.