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Complications of electrohydraulic lithotresis
COMPLICATIONS
OF ELECTROHYDRAULIC
LITHOTRESIS WILLIAM JOEL
M. PELANDER,
M. KAUFMAN,
M.D.
M.D.
From the Division of Urology, Department of Surgery, Saint Joseph Hospital, University of Colorado Medical Center and Colorado Permanente Medical Group (Kaiser), Denver, Colorado
ABSTRACT’ - The urologic literature reports excellent success with minimal complications utilizing electrohydraulic lithotresis for bladder calculi. Our recent experience with 10 patients suggests that small stones of struvitelcarbonate apatite composition can be fragmented easily, but larger stones, particularly of uric acid or oxalate composition, may be better handled by open cystolithotomy. complications developed in 3 of these Failure to disrupt stones occurred in 6 patients. Signi$cant patients, including breakage of the electrode tip in 2 and sepsis in another related to prolonged operative time.
Bladder calculi secondary to obstruction or infection may be removed by transurethral or open methods. While the transurethral approach has more appeal, it often involves significant difficulty and major complications. Previous reports using transurethral electrohydraulic disintegration of bladder calculi state that this technique is simple, widely applicable, and safe.‘-I1 Our recent experience with electrohydraulic lithotresis” in 10 patients suggests that this modality may be unsuccessful and associated with complications. Material
and Methods
During a recent nine-month period, 10 patients with bladder calculi underwent electrohydraulic lithotresis using principles and techniques described previously.4*5 The instrument used was the Litho-triptor EHL-21 in 9 cases and the Electrolithotriptor SDl-Stone Disintegrator-j in 1 patient. Surgery was performed by five different urologists. Individual
*~,ithotresis: drilling or boring of holes in a calculus. tCalculus Instruments, Westwood, New Jersey. ]Northgate Research Corporation, Plattsburgh, New York.
UBOLOCY
/
AUGUST
1980
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VOLUME
XVI.
NUMBER 2
patient data, stone composition and size, and success of operation are summarized in Table I. Unqualified success occurred in only 4 patients (Cases 1 to 4), all of whom had chronic urinary tract infection and predominantly struvite stones less than 2 cm. maximal diameter. In 3 patients (Cases 5 to 7), electrohydraulic lithotresis was unsuccessful, and open cystolithotomy was required. One patient with chronic Proteus urinary tract infection and 6 struvite/carbonate apatite stones (Fig. 1) underwent open lithotomy after three electrode tips wore down without fragmenting the stones. The other 2 failures occurred in patients with calcium oxalate and phosphate stones. In the former patient, a large stone was fragmented partially, but three electrode tips were used during one hour of operative time and no more electrodes were available to complete the procedure. No fragmentation was achieved of the calcium phosphate stone either electrohydraulitally or with Lowsley forceps even after it had been removed from the bladder. Three complications occurred with the lithotriptor. In Case 8 with prostatic obstruction and two large uric acid stones, four probes wore down without stone fragmentation. At subsequent cystolithotomy, severe trigonal inflammation and mucosal tearing were evident, and
155
an electrode tip was present in the bladder having separated from the probe without recognition. An almost pure calcium oxalate stone in Case 9 could not be shattered with two electrode tips; the first wore down, the second fragmented intravesically (Fig. 2). Both the probe tip and stone were extracted with the Lowsley lithotriptor, creating significant urethral trauma. Case 10 required ninety minutes to achieve only partial disruption of a large mixed uric acid/calcium oxalate stone. Three electrodes were worn down before cystolitholapaxy with the Lowsley lithotrite was performed with difficulty. In the recovery room septic shock developed, but the patient responded to intravenous antibiotics, fluids, corticosteroids, and vasopressors. Comment
:(E *
FIGURE 1.
Case 5. Six 1.5 to 3.5cm.
stones of not be fragmented
struvitelcarbonate apatite could using electrohydraulic procedure,
TABLE
Case No.
As
I.
Diagnosis*
1
35
1,2
2
19
1,2
3
56
1,2
4
79
1
5
75
1
6
76
3
7t 8
40 69
4 3
9 10
70 80
3 3
Summary
-_____
Since transurethral removal of bladder stones historically has been associated with difficulty and complications, reports of the ease and high success rates with the electrohydraulic approach were particularly welcome. More than 300 patients have been reported in the English literature from 1970 to 1977l-” with only 10 associated complications: 1 bladder wall perforation,’ 1 electrode tip which fragmented intravesically, 6 and 8 cases in which the stones
of individual
patients
and stone data
Stone Analysis --~ ____--__ Struvite 77%; carbonate apatite 20% Struvite 76%; carbonate apatite 21% Struvite 81%; carbonate apatite 10% Struvite 82%; carbonate apatite 18% Struvite 65%; carbonate apatite 30% Ca oxalate 91%; hydroxyl apatite 7% Ca phosphate 100% Uric acid 100%
Stone
Size
2 cm.
Successful ----Yes
Multiple
small
Yes
Multiple
small
Yes
2 cm.
Yes
6 1.5 to 3.5 cm.
No
3 cm.
No
2.5 cm. 2 cm. 4 cm. 2.5 cm. Unknown
No No
Ca oxalate 95% No Ca oxalate 58%; No uric acid 40% _______~ -__________ *f = Chronic urinary tract infection; 2 = neurogenic bladder, suprapubic cystostomy; 3 = benign prostatic hypertrophy; and 4 = urethral stricture. tpatient of H. E. Fauver, M.D., Fitzsimmons Army Medical Center.
156
UROLOGY
/
AUGUST 1980
i
VOLUME XVI, NUMBER 2
were too hard to fragment. Of these 8 cases the stone composition was reported in 3, and 2 were 100 per cent uric acid.’ Tidd” has demonstrated in animal models that paravesical air-filled bowel may rupture during electrohydraulic lithotresis, although no such instance has been reported in humans. Most authors agree that struvite, phosphate, and carbonate stones are relatively easy to fragment, while uric acid and oxalate stones can be difficult to disrupt, requiring an hour or more of operating time. 2,4-8 Eaton4 and Glenn5 have provided specific technical guidelines for disintegration of stones of different composition. Reuters states that stones of “hard” composition, especially if greater than 4cm. diameter, will generally require an hour or more to fragment. Mitchell and Kerr’ report that limitations on electrohydraulic lithotresis are few and include in addition to those mentioned above: urethra of inadequate caliber to accommodate the required cystoscopic equipment; bladder capacity less than 150 to 200 cc. (amount of irrigating fluid needed to perform the procedure); and stone in the ureter. The literature to the contrary, we have found electrohydraulic lithotresis successful in only 4 patients in whom struvite stones less than 2-cm. diameter shattered easily. The standard mechanical lithotrites probably would have served as well in these patients. The patient with larger struvite stones required open cystolithotomy when the available supply of electrodes became exhausted before satisfactory stone disruption. In our series, the electrohydraulic procedure failed in all 5 patients with other stone types calcium oxalate, and uric (calcium phosphate, acid) and in 3 of these patients significant trauma to the urethra and bladder was associated with the procedure. In 2 patients the probe tips fragmented before the stones did. An attempt with the Litho-triptor EHL-2 may be made in several situations; but if the bladder stone does not fragment quickly and easily, open cystolithotomy is simpler, safer, and more reliable.
FIGURE 2. Case 9. Attempted electrohydraulic lithotresis of 2.Scm. calcium oxalate stone resulted in separation of probe tip before
ACKNO\VLEDGILIENT. To Dr. D. Cox, and Dr. H. E. Fauvrr patients in this report.
/
AUGUST
1980
/
VOLUME
XVI.
NUMBER
hl. Crissey. for inclusion
Dr. H. of their
References 1. Alfthan 0, and Murtomaa M: Experiences with the clinical and experimental use of URAT-1 lithotriptor, Scand. J. Urol. Nephrol. 6: 23 (1972). 2. Angeloff A: Hydroelectrolithotripsy, J. Urol. 108: 867 (1972). 3. Bapat SS: Endoscopic removal of bladder stones in adults, Br. J. Urol. 49: 527 (1977). 4. Eaton JM: Electrohydraulic lithotripsy, J. Urol. 108: 865 (1972). 5. Glenn JF: Bladder stones: from lithotrity to ultrasound, Urol. Clin. North Am. 1: 375 (1974). 6. Mitchell ME, and Kerr WS: Experiences with the elrctmhydraulic disintegrator, J. Urol. 117: 159 (1977). 7. Raney AM: Electrohydraulic cystolithotripsy. Urology 7: 379 (1976). 8. Reuter HJ: Electronic lithotripsy: transurethral treatment of bladder stones in 50 cases, J. Urol. 104: 834 (1970). 9. Terhorst B: Treatment of bladder stones hy ultrasound, Urol. Int. 27: 458 (1972). 10. Tessler AN, and Kossow J: Electrohydraulic stone disintegration, Urology 5: 470 (1975). 11. Wallace DM: Cracking of vesical calculi by capacitor discharge, Br. J. Urol. 44: 262 (1972). 12. Tidd MJ: Hazards to bladder and intestinal tissues from intravesical underwater electrical discharges from a surgical electronic lithoclast, Ural. Res. 4: 49 (1976).
2045 Franklin Street Denver, Colorado 80205 (DR. KAUFMAN)
UROLOGY
M.
2
157
OF ELECTROHYDRAULIC
LITHOTRESIS WILLIAM JOEL
M. PELANDER,
M. KAUFMAN,
M.D.
M.D.
From the Division of Urology, Department of Surgery, Saint Joseph Hospital, University of Colorado Medical Center and Colorado Permanente Medical Group (Kaiser), Denver, Colorado
ABSTRACT’ - The urologic literature reports excellent success with minimal complications utilizing electrohydraulic lithotresis for bladder calculi. Our recent experience with 10 patients suggests that small stones of struvitelcarbonate apatite composition can be fragmented easily, but larger stones, particularly of uric acid or oxalate composition, may be better handled by open cystolithotomy. complications developed in 3 of these Failure to disrupt stones occurred in 6 patients. Signi$cant patients, including breakage of the electrode tip in 2 and sepsis in another related to prolonged operative time.
Bladder calculi secondary to obstruction or infection may be removed by transurethral or open methods. While the transurethral approach has more appeal, it often involves significant difficulty and major complications. Previous reports using transurethral electrohydraulic disintegration of bladder calculi state that this technique is simple, widely applicable, and safe.‘-I1 Our recent experience with electrohydraulic lithotresis” in 10 patients suggests that this modality may be unsuccessful and associated with complications. Material
and Methods
During a recent nine-month period, 10 patients with bladder calculi underwent electrohydraulic lithotresis using principles and techniques described previously.4*5 The instrument used was the Litho-triptor EHL-21 in 9 cases and the Electrolithotriptor SDl-Stone Disintegrator-j in 1 patient. Surgery was performed by five different urologists. Individual
*~,ithotresis: drilling or boring of holes in a calculus. tCalculus Instruments, Westwood, New Jersey. ]Northgate Research Corporation, Plattsburgh, New York.
UBOLOCY
/
AUGUST
1980
/
VOLUME
XVI.
NUMBER 2
patient data, stone composition and size, and success of operation are summarized in Table I. Unqualified success occurred in only 4 patients (Cases 1 to 4), all of whom had chronic urinary tract infection and predominantly struvite stones less than 2 cm. maximal diameter. In 3 patients (Cases 5 to 7), electrohydraulic lithotresis was unsuccessful, and open cystolithotomy was required. One patient with chronic Proteus urinary tract infection and 6 struvite/carbonate apatite stones (Fig. 1) underwent open lithotomy after three electrode tips wore down without fragmenting the stones. The other 2 failures occurred in patients with calcium oxalate and phosphate stones. In the former patient, a large stone was fragmented partially, but three electrode tips were used during one hour of operative time and no more electrodes were available to complete the procedure. No fragmentation was achieved of the calcium phosphate stone either electrohydraulitally or with Lowsley forceps even after it had been removed from the bladder. Three complications occurred with the lithotriptor. In Case 8 with prostatic obstruction and two large uric acid stones, four probes wore down without stone fragmentation. At subsequent cystolithotomy, severe trigonal inflammation and mucosal tearing were evident, and
155
an electrode tip was present in the bladder having separated from the probe without recognition. An almost pure calcium oxalate stone in Case 9 could not be shattered with two electrode tips; the first wore down, the second fragmented intravesically (Fig. 2). Both the probe tip and stone were extracted with the Lowsley lithotriptor, creating significant urethral trauma. Case 10 required ninety minutes to achieve only partial disruption of a large mixed uric acid/calcium oxalate stone. Three electrodes were worn down before cystolitholapaxy with the Lowsley lithotrite was performed with difficulty. In the recovery room septic shock developed, but the patient responded to intravenous antibiotics, fluids, corticosteroids, and vasopressors. Comment
:(E *
FIGURE 1.
Case 5. Six 1.5 to 3.5cm.
stones of not be fragmented
struvitelcarbonate apatite could using electrohydraulic procedure,
TABLE
Case No.
As
I.
Diagnosis*
1
35
1,2
2
19
1,2
3
56
1,2
4
79
1
5
75
1
6
76
3
7t 8
40 69
4 3
9 10
70 80
3 3
Summary
-_____
Since transurethral removal of bladder stones historically has been associated with difficulty and complications, reports of the ease and high success rates with the electrohydraulic approach were particularly welcome. More than 300 patients have been reported in the English literature from 1970 to 1977l-” with only 10 associated complications: 1 bladder wall perforation,’ 1 electrode tip which fragmented intravesically, 6 and 8 cases in which the stones
of individual
patients
and stone data
Stone Analysis --~ ____--__ Struvite 77%; carbonate apatite 20% Struvite 76%; carbonate apatite 21% Struvite 81%; carbonate apatite 10% Struvite 82%; carbonate apatite 18% Struvite 65%; carbonate apatite 30% Ca oxalate 91%; hydroxyl apatite 7% Ca phosphate 100% Uric acid 100%
Stone
Size
2 cm.
Successful ----Yes
Multiple
small
Yes
Multiple
small
Yes
2 cm.
Yes
6 1.5 to 3.5 cm.
No
3 cm.
No
2.5 cm. 2 cm. 4 cm. 2.5 cm. Unknown
No No
Ca oxalate 95% No Ca oxalate 58%; No uric acid 40% _______~ -__________ *f = Chronic urinary tract infection; 2 = neurogenic bladder, suprapubic cystostomy; 3 = benign prostatic hypertrophy; and 4 = urethral stricture. tpatient of H. E. Fauver, M.D., Fitzsimmons Army Medical Center.
156
UROLOGY
/
AUGUST 1980
i
VOLUME XVI, NUMBER 2
were too hard to fragment. Of these 8 cases the stone composition was reported in 3, and 2 were 100 per cent uric acid.’ Tidd” has demonstrated in animal models that paravesical air-filled bowel may rupture during electrohydraulic lithotresis, although no such instance has been reported in humans. Most authors agree that struvite, phosphate, and carbonate stones are relatively easy to fragment, while uric acid and oxalate stones can be difficult to disrupt, requiring an hour or more of operating time. 2,4-8 Eaton4 and Glenn5 have provided specific technical guidelines for disintegration of stones of different composition. Reuters states that stones of “hard” composition, especially if greater than 4cm. diameter, will generally require an hour or more to fragment. Mitchell and Kerr’ report that limitations on electrohydraulic lithotresis are few and include in addition to those mentioned above: urethra of inadequate caliber to accommodate the required cystoscopic equipment; bladder capacity less than 150 to 200 cc. (amount of irrigating fluid needed to perform the procedure); and stone in the ureter. The literature to the contrary, we have found electrohydraulic lithotresis successful in only 4 patients in whom struvite stones less than 2-cm. diameter shattered easily. The standard mechanical lithotrites probably would have served as well in these patients. The patient with larger struvite stones required open cystolithotomy when the available supply of electrodes became exhausted before satisfactory stone disruption. In our series, the electrohydraulic procedure failed in all 5 patients with other stone types calcium oxalate, and uric (calcium phosphate, acid) and in 3 of these patients significant trauma to the urethra and bladder was associated with the procedure. In 2 patients the probe tips fragmented before the stones did. An attempt with the Litho-triptor EHL-2 may be made in several situations; but if the bladder stone does not fragment quickly and easily, open cystolithotomy is simpler, safer, and more reliable.
FIGURE 2. Case 9. Attempted electrohydraulic lithotresis of 2.Scm. calcium oxalate stone resulted in separation of probe tip before
ACKNO\VLEDGILIENT. To Dr. D. Cox, and Dr. H. E. Fauvrr patients in this report.
/
AUGUST
1980
/
VOLUME
XVI.
NUMBER
hl. Crissey. for inclusion
Dr. H. of their
References 1. Alfthan 0, and Murtomaa M: Experiences with the clinical and experimental use of URAT-1 lithotriptor, Scand. J. Urol. Nephrol. 6: 23 (1972). 2. Angeloff A: Hydroelectrolithotripsy, J. Urol. 108: 867 (1972). 3. Bapat SS: Endoscopic removal of bladder stones in adults, Br. J. Urol. 49: 527 (1977). 4. Eaton JM: Electrohydraulic lithotripsy, J. Urol. 108: 865 (1972). 5. Glenn JF: Bladder stones: from lithotrity to ultrasound, Urol. Clin. North Am. 1: 375 (1974). 6. Mitchell ME, and Kerr WS: Experiences with the elrctmhydraulic disintegrator, J. Urol. 117: 159 (1977). 7. Raney AM: Electrohydraulic cystolithotripsy. Urology 7: 379 (1976). 8. Reuter HJ: Electronic lithotripsy: transurethral treatment of bladder stones in 50 cases, J. Urol. 104: 834 (1970). 9. Terhorst B: Treatment of bladder stones hy ultrasound, Urol. Int. 27: 458 (1972). 10. Tessler AN, and Kossow J: Electrohydraulic stone disintegration, Urology 5: 470 (1975). 11. Wallace DM: Cracking of vesical calculi by capacitor discharge, Br. J. Urol. 44: 262 (1972). 12. Tidd MJ: Hazards to bladder and intestinal tissues from intravesical underwater electrical discharges from a surgical electronic lithoclast, Ural. Res. 4: 49 (1976).
2045 Franklin Street Denver, Colorado 80205 (DR. KAUFMAN)
UROLOGY
M.
2
157