A flexible approach to surgical treatment of proximal ureteric stones

117 OUR

EXPERIENCE

WITH

ENCRUSTED

URETERIC

Bultitude M.F., Glass J.M.. Tiptaft R.C.. DasGupta Guy’s and St. Thomas’ Hospital,

STUDY

E\‘ALUATING

THE

SAFETY

P. Traxer O., Chibclcan C., Roland E.. Tllgui M.. Vigncau J.D., Gattegno B.. Thibault P.H.

IJrology. London, United Kingdom

INTRODUCTION & OBJECTIVES: Ureteric stents are commonly used to relieve or prevent ureteric obstruction. usually from urolithiasis. There use is associated with a number of complications including pain, frequency. urgency and hacmaturia. However one of the most serious complications is stent encrustation, which can lead to stent failure with consequent obstruction and renal impairment. It also poses a challenging problem for removal to the urologist. Current published series consist of only a handful of cases and concentrdtc on massive encrustations only.

We have treated a total of 47 stuck encrusted stents in 38 patients at Guys Hospital since 1999. The majority were tertiar) rcfcrrals.

MATERIAL

118 PROSPECTIVE RANDOMISED OF FIVE URETERIC STENTS

STENTS

& METHODS:

RESULTS: Mean length of time the stcnts had been in-aim was 6.1 months (range 2 18). 35 of these stents had been in for six months or less. 33 of 3X patients had their stents Inserted for stone disease. 24 stcnts had encrustations at the upper end; 5 at the lower and IX required treatment to both upper and lower parts. Multi-modality treatments were used: I Open (after fatled endoscopic procedures)/ 6 Percutaneous nephrolithotomy (PCNL) (3 after failed endoscopic procedures)/ 20 Ureteroscopy (rigid or flexible with EHL. lithoclast or Iloln~iun~ laser as appropriate)! 11 Storz Lithotripsy and ureteroscopy/ 2 Star/ Lithotripsy and cytoscopy! 6 CystolithopaxyI I Failed removal (unfit for PC‘NL/ open). Mean number of procedures per patient was 2.4.

CONCLUSIONS: Encrustation is a serious complication of the use of uretcric stents and many procedures are often required to remove the stent. Storz lithotripsy in combination with cystoscopyi ureteroscopy is used primarily, resorting to PCNL if these fail. Often patients require insertlon of a 2nd stent alongside the original. Patients with a large amount of encrustation or large concurrent stone load may primarily require PCNL. Open removal is reserved for cases when the above procedures fail. The common assumption is that stents only become stuck if left in for too long. Hence the current recomrncndaGon that stents should be changed every 6 months. From this data. 75”/ of stents encrusted within that time and as a result we would recommend that stems in stone-farmers should be changed every 3 months. This again highlights the Importance of stent registries.

(‘.. Basticn P.. Doublet

tlbpital Tenon. Urology, Paris. France INTRODUCTION & OBJECTIVES: [Jreleric stems arc widely used to drain obstructed urinary tracts. They are particularly useful in the cast of obstruction by stones. The objective of this randomiscd. pmspective study was to evaluate rhc safety of 5 types of uretcl-ic \tents. MATERIAL & METHODS: In the initial phase of the study, 64 patients with ureteric obstruction due to stones, requiring placement of a ureteric stcnt (Mardi\ Boston Scientific Microvasiv&) completed a questionnaire studying the safety of the stent, based on visual analoguc scales evaluating the general impression, voiding symptoms (burning & urgency, frequency, dysuria, haematuria), lumbar and suprapubic pain. Analgesic consumption has rccordcd. The qucstionnairc was completed on removal of the stent. The MardismK stem represented the reference stent (used in our daily activity). Subsequently. another 36 patients \+ith uretcric obstruction due to stones \vere randomised and trcatcd with one of the following four stcnts: Por@s K VorG. Micro\ asi\ch Percuflex, Cook k Multi-length. Angiomcdn Purotlcu and completed the same questionnaire on I-cmocal of the stenl. The global safety of 100 stents \tas calculated and the specific safety of each stcnt \vas compared to that of the reference stent. RESULTS: In the total population of 100 patients, 60% reported bladder pain, 58”/u reported lumbar pain (75 “0 reported bladder pain and/or lumbar pain). 62O;, reported haematuria. 29% reported dyauria and X2% reported urgency. 46% 01 patients had to USC minor analgesics. Frequency was constantly obscrvcd regardless of the Qent with a mean of I4 micturitions (5 6) per day. Analysis of the specific safety of each stcnt did not show any stent to he superior to the reference stent. Ureteric stent? arc rclatibely poorly tolerated due to the symptoms they Induce. mamly frcquencq and reno-vcalcal pain. This study failed to demonstrate the superiority of any one stent In relation to the othcrb in terms of safety.

CONCI,USIONS:

119 URETERAL STENTING AFTER URETEROSCOPY FOR URETER STONES: A PROSPECTIVE RANDOMISED STUDY ASSESSING SYMPTOMS AND COMPLICATIONS

120 A FLEXIBLE APPROACH TO PROXIMAL. URETERIC STONES

SURGICAL

TREATMENT

OF

Jeong H.‘. Kwak C’.‘. I long S.‘, Lee S.’ ‘Seoul Municipal Boramae IHospital, Urology, Seoul. South National University Hospital, Urology, Seoul. South Korea

Kol-ca.

Seoul

INTRODUCTION & OBJECTIVES: The placement of uretcral stent following ureteroscopy (URS) with stone extraction is a routine and many patient\ complain pain and urinary symptoms in the postoperative period. In order to decrease the frequency of stenting. we conducted a comparison 01 patients with and without stenting after URS for urctcral calculi. MATERIAL & METHODS: A total of 45 patients wtth urctcral calcull. amendable to ureteroscoplc management wcrc prospcctivcly randomized into a stented (23 patients) or a nonstented (22 patients) group. Standard urcteroscoplc basketing and lithotripsy was performed with ureteroscope (8.5Fr) with or without ureteral dilatation and postoperative symptom questionnaires wcrc obtained from each patient. Radiographic follow-up to assess stone-free rate and evidence of obstruction was performed 18 all patients. RESULTS: There was no statistically significant difference in age, stone sir.e, operation time, and hospital stay between a stented or nonstentcd group (p>O.OS). Furthermore there was no statistical difference in flank pain and urinary symptoms (p>O.O5), except hematuria between 2 groups. The hematuria was more severe and long standing in the stented group (p=O.OOl). CONCLUSIONS: Uncomplicated urcteroscopy for calculi removal can safely be performed without the placement of postoperative stent and considering its complication and side effect, we do not believe that the routine placement of ureteral stents after uncomplicated

ureteroscopy

European

2 (2003) No. 1, pp. 32

Urology

Supplements

for the stone iy necessary.

MA’I‘ERlAL & METHODS: Between January 1995 and Augu,l 2002, 105 percutaneous renal access procedures were performed at our centre: 353 by a single urgeon. 74 of these punctures were made to facilitate an antegradc appl-each to calculi m the proximal weter m 59 men and I5 woman. Age range 21- X2 years. 55 calculi were in upper khird ureter and 15 m middle third. 4 pattents had stone> formed on the upper end of an mdwelling stent. 41 stones were on the left and 33 on the right. Sire varied from 6.15 mm. 27 patients had an indwelhng ureteric stcnt. 29 had a percutaneous nephrostomy m situ. 1X had neither. RESULTS: 35 panents under\\ent a planned antegrade percu~aneow retrieval of proximal uretcric calculi. It wab succeshful in 34/35 cases (97.2”4,). 34 cares v,cre mitully approached ureteroxopically and then converted to an antegrade percutaneous approach to remove the stone. 25 calculi were located m the upper ureter and Y m the middle ureter. 29.‘34 patients were plcoperati~ely counselled for such convcrcton & had their stone? removed percutaneously in one stage after faded uretemacopy (URS). .Average operative time for the percutaneous procedure was 45 mmutes lmtlal LJRS was performed usmg a llexlble ureteroscope ( I I ca\es) or semi rigld ureteroscope (I 8 cases). 5/34 patients underwent percutaneous removal of stones at a separate stage after failed altempts at ureteroxoplc retric\al. for lack of prior cowent. Pet-cutaneous stone extractmn was successful in 33134 (97%) patients. A combmation of factors vi7. stone position, access to the stone and ditficultics with an indwelling stent led to intraoperative change ofplan. No significant complications were noted. Average hoqxtal stay was 4.5 days (median 4) 5 patients underwent percutaneous and endoccopic surgery at the same sitting for stones in the upper ureter/pelvi-calyceal system a?, well as the lower ureter. CONCLUSIONS: Management of calculi in the proximal ureter can be tailored to an mdiwdual case. There are advantages to the percutaneous approach in certain situations. Pre-operatwe counselling therefore has an Important role in the management of difficult stones m the proximal ureter. A one-stage approach improves efficiency of treatment by reducing the number of aeconda~y procedures thereby shortcning the patient journey to stone free status, without significant complicatmns or excessive additional operatwe time. In order to provide such flexibility, Independent ofa radmlogist, it is important that percutaneous renal access skills become an essential part of training of an endow&gist with an interest in stone disease