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Entrapped stone basket managed by extracorporeal shock wave lithotripsy
ENTRAPPED STONE BASKET MANAGED BY EXTRACORPOREALSHOCK WAVE LITHOTRIPSY ALEXANDER S. CASS, M.B.B.S. JOHN E. HELLER, M.D. From the Midwest Urologic Stone Unit and Abbott Northwestern Hospital, Minneapolis, Minnesota
ABSTRACT-When pull on a stone basket enclosing a distal ureteral stone met marked resistance and endoscopic lithotripsy failed, extracorporeal shock wave lithotripsy was used to fragment the entrapped stone in the ureter and allowed successful removal of the basket with the enclosed fragments.
A major complication of stone removal by a stone basket is entrapment within the ureter, which can be managed by leaving the basket in place with application of gentle traction (continuous or intermittent), endoscopic fragmentation of the stone, ureteric meatotomy, or ureterolithotomy Recently extracorporeal shock wave lithotripsy (ESWL) was used after the basket, with its enclosed stone, was advanced into the renal pelvis prior to lithotripsy.’ We report a case in which ESWL was used to fragment the entrapped stone in the ureter. CASE REPORT A forty-five-year-old man had episodes of left flank pain for six months and experienced acute renal colic requiring admission to hospital. An excretory urogram showed a 1.0 cm stone in the distal left ureter with significant hydronephrosis and hydroureter above the stone. Next day, a 11.5 F Storz ureteroscope was passed over a guide wire after dilatation of the terminal ureter with a balloon catheter 4 cm long and 6 mm in diameter. The stone was visualized and engaged without difficulty in a 3 F four-wire Segura basket. Stone extraction was not possible due to marked resistance. Ultrasonic lithotripsy was performed through the ureteroscope, but only several small pieces of stone broke off after prolonged ultrasonic lithotripsy. The stone would not extract when the basket was pulled and could not be dislodged from the basket. The entrapped stone was pushed up several centimeters in the distal ureter and injected contrast Submitted: 3, 1993
544
October
7, 1993,
accepted
(with
revisions):
December
medium showed some extravasation from the distal ureter. The handle of the stone basket was cut off, ureteroscope removed, and, via a cystoscope, a 6 F catheter was passed over the safety guide wire into the renal pelvis. ESWL with a Medstone STS lithotriptor in the prone position was performed with 3,600 shocks at 24 kV. Stone fragmentation was satisfactory The stone basket was easily pulled out under fluoroscopic and cystoscopic observation. Multiple small stone fragments were inside the basket. A double pigtail ureteral stent was passed. The patient was discharged from hospital one day later. COMMENT When intervention is required for a distal ureteral calculus because of pain and/or obstruction, stone basket extraction via a ureteroscope is the treatment of choice for many urologists. A major complication of stone basket retrieval is entrapment within the ureter, which occurs in 1 percent of cases.2 Management of the entrapped stone basket within the ureter includes leaving the basket in place with application of gentle traction (continuous or intermittent), endoscopic ultrasonic fragmentation of the entrapped stone via the ureteroscope, ureteric meatotomy if the entrapped basket is visible in the ureteral meatus, or ureterolithotomy. Harrison et al3 reported 6 cases of entrapped stone basket using the Dormia basket in 201 patients. While two baskets were removed by gentle traction, 4 patients required ureterohthotomy. Recently Durano and Hanosh’ described the use of ESWL after the basket with stone within it was advanced into the renal pelvis prior to ESWL. UROLOGY
/ APRIL 1994
/ VOLUME~~,NUMBER~
With more cases of ureteral stones being treated by ESWL in situ, rather than manipulation into the kidney prior to ESWL (“push bang”), it was rewarding to find that the entrapped stone basket in the ureter could be managed by ESWL in the ureter, rather than requiring manipulation into the kidney. Ureteral stones have been given a higher number of shocks than renal stones of the same diameter because satisfactory fragmentation is easier to determine in the kidney than in the ureter. Unless there is a vertical spread of the ureteral fragments after ESWL, the ureteral wall compression can compact the fragments, with the appearance of no change in the stone. With the entrapped stone there must be some vertical spread of the fragments after ESWL to allow a reduction in the diameter of the surrounding basket, which will allow its extraction by subsequent pull. The maximum number of shocks to the entrapped stone may be necessary to achieve this result.
UROLOGY
/ APRIL 1994
I VOLUME
43, N~JMBER 4
ADDENDUM A second patient had a stone measuring 0.7 x 0.5 cm in the distal right ureter entrapped in a stone basket. Dr. N. Kader of Lacrosse, Wisconsin, applied 1,500 shocks at 24 kV with a Medstone, which fragmented the stone and allowed successful extraction. A. 5. (lass, M.B.B.S. .Dlvlsion of C:rology Hennepin County Medical Center 701 Put k Avenue South Minneapolis. Minnesota 5541.5 REFERENCES 1. Durano AC Jr, and Hanosh JJ: A new alternative treatment for entrapped stone basket in the distal ureter. J Urol 139: 116-117,1988. 2. Drach GW: Stone manipulation. Modern usage and occasional mishaps. Urology 12: 286-289, 1978. 3. Harrison GS, Davies GA, and Holdsworth PJ: Twelveyear experience using the Dormia basket for the extraction of ureteric stones. Eur Urol9: 93-96. 1983.
545
ABSTRACT-When pull on a stone basket enclosing a distal ureteral stone met marked resistance and endoscopic lithotripsy failed, extracorporeal shock wave lithotripsy was used to fragment the entrapped stone in the ureter and allowed successful removal of the basket with the enclosed fragments.
A major complication of stone removal by a stone basket is entrapment within the ureter, which can be managed by leaving the basket in place with application of gentle traction (continuous or intermittent), endoscopic fragmentation of the stone, ureteric meatotomy, or ureterolithotomy Recently extracorporeal shock wave lithotripsy (ESWL) was used after the basket, with its enclosed stone, was advanced into the renal pelvis prior to lithotripsy.’ We report a case in which ESWL was used to fragment the entrapped stone in the ureter. CASE REPORT A forty-five-year-old man had episodes of left flank pain for six months and experienced acute renal colic requiring admission to hospital. An excretory urogram showed a 1.0 cm stone in the distal left ureter with significant hydronephrosis and hydroureter above the stone. Next day, a 11.5 F Storz ureteroscope was passed over a guide wire after dilatation of the terminal ureter with a balloon catheter 4 cm long and 6 mm in diameter. The stone was visualized and engaged without difficulty in a 3 F four-wire Segura basket. Stone extraction was not possible due to marked resistance. Ultrasonic lithotripsy was performed through the ureteroscope, but only several small pieces of stone broke off after prolonged ultrasonic lithotripsy. The stone would not extract when the basket was pulled and could not be dislodged from the basket. The entrapped stone was pushed up several centimeters in the distal ureter and injected contrast Submitted: 3, 1993
544
October
7, 1993,
accepted
(with
revisions):
December
medium showed some extravasation from the distal ureter. The handle of the stone basket was cut off, ureteroscope removed, and, via a cystoscope, a 6 F catheter was passed over the safety guide wire into the renal pelvis. ESWL with a Medstone STS lithotriptor in the prone position was performed with 3,600 shocks at 24 kV. Stone fragmentation was satisfactory The stone basket was easily pulled out under fluoroscopic and cystoscopic observation. Multiple small stone fragments were inside the basket. A double pigtail ureteral stent was passed. The patient was discharged from hospital one day later. COMMENT When intervention is required for a distal ureteral calculus because of pain and/or obstruction, stone basket extraction via a ureteroscope is the treatment of choice for many urologists. A major complication of stone basket retrieval is entrapment within the ureter, which occurs in 1 percent of cases.2 Management of the entrapped stone basket within the ureter includes leaving the basket in place with application of gentle traction (continuous or intermittent), endoscopic ultrasonic fragmentation of the entrapped stone via the ureteroscope, ureteric meatotomy if the entrapped basket is visible in the ureteral meatus, or ureterolithotomy. Harrison et al3 reported 6 cases of entrapped stone basket using the Dormia basket in 201 patients. While two baskets were removed by gentle traction, 4 patients required ureterohthotomy. Recently Durano and Hanosh’ described the use of ESWL after the basket with stone within it was advanced into the renal pelvis prior to ESWL. UROLOGY
/ APRIL 1994
/ VOLUME~~,NUMBER~
With more cases of ureteral stones being treated by ESWL in situ, rather than manipulation into the kidney prior to ESWL (“push bang”), it was rewarding to find that the entrapped stone basket in the ureter could be managed by ESWL in the ureter, rather than requiring manipulation into the kidney. Ureteral stones have been given a higher number of shocks than renal stones of the same diameter because satisfactory fragmentation is easier to determine in the kidney than in the ureter. Unless there is a vertical spread of the ureteral fragments after ESWL, the ureteral wall compression can compact the fragments, with the appearance of no change in the stone. With the entrapped stone there must be some vertical spread of the fragments after ESWL to allow a reduction in the diameter of the surrounding basket, which will allow its extraction by subsequent pull. The maximum number of shocks to the entrapped stone may be necessary to achieve this result.
UROLOGY
/ APRIL 1994
I VOLUME
43, N~JMBER 4
ADDENDUM A second patient had a stone measuring 0.7 x 0.5 cm in the distal right ureter entrapped in a stone basket. Dr. N. Kader of Lacrosse, Wisconsin, applied 1,500 shocks at 24 kV with a Medstone, which fragmented the stone and allowed successful extraction. A. 5. (lass, M.B.B.S. .Dlvlsion of C:rology Hennepin County Medical Center 701 Put k Avenue South Minneapolis. Minnesota 5541.5 REFERENCES 1. Durano AC Jr, and Hanosh JJ: A new alternative treatment for entrapped stone basket in the distal ureter. J Urol 139: 116-117,1988. 2. Drach GW: Stone manipulation. Modern usage and occasional mishaps. Urology 12: 286-289, 1978. 3. Harrison GS, Davies GA, and Holdsworth PJ: Twelveyear experience using the Dormia basket for the extraction of ureteric stones. Eur Urol9: 93-96. 1983.
545