Long-Term Results of Transurethral Lithotripsy with the Rigid Ureteroscope: Injury of Intramural Ureter

0022-5347 /89/1424-0958$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 142, October Printed in U.S.A.

LONG-TERM RESULTS OF TRANSURETHRAL LITHOTRIPSY WITH THE RIGID URETEROSCOPE: INJURY OF INTRAMURAL URETER YOSHINARI ONO,* SHINICHI OHSHIMA, TSUNEO KINUKAWA, OSAMU MATSUURA, SATOSHI HIRABAYASHI AND SHIN YAMADA From the Departments of Uro/,ogy, Komaki Shimin Hospital, Komaki, and Shakai Hoken Chukyo Hospital, Nagoya, Japan

ABSTRACT

We treated 208 patients with ureteral calculi via transurethral lithotripsy using the rigid ureteroscope between March 1985 and April 1988. A total of 220 ureteroscopic procedures was performed in 217 ureters. Complete removal was achieved after 180 procedures (81.8%) and incomplete removal was achieved after 9 (4.1%). In 31 cases (14.1%) the stone could not be removed because of various reasons. Ureteral disruption was observed in 1 case (0.5%), which was treated successfully with reconstruction. Ureteral perforation occurred in 15 cases (6.8%) and was treated successfully except for 1 patient (0.5%) in whom ureteral stricture was observed requiring reconstruction. From longterm followup of sequential excretory urography and voiding cystography, mild stricture at the vesical end of the ureter was noted in 3 of 86 ureters (3.5%) and vesicoureteral reflux was noted in 7 of 73 (9.6%). These results indicate that the injury to the intramural ureter might arise from the passage of the ureteroscope resulting in stricture and vesicoureteral reflux. (J. Ural., 142: 958-960, 1989) In recent years endoscopic procedures were used to manage ureteral calculi. 1- 10 Ureteral calculi are removed either through the transrenal route with the flexible ureteroscope or through the transurethral route with the rigid ureteroscope. The latter is an ideal procedure for surgical management of ureteral calculi, since nephrostomy is not necessary. 2- 4 However, it is well known that this procedure can cause some early complications, such as ureteral perforation and avulsion, 5 • 8 • 10- 14 and late complications, such as ureteral stricture. 11- 17 We performed sequential excretory urography (IVP) and random voiding cystography to evaluate late complications seen after prolonged followup. Our results are analyzed and reported. MATERIALS AND METHODS

We treated 208 patients with ureteral calculi via transurethral lithotripsy using the rigid ureteroscope between March 1985 and April 1988. There were 150 male and 58 female patients between 16 and 80 years old (mean age 42 ± 14 years, standard deviation). Of the procedures 135 were performed on the right ureter and 85 on the left ureter. A total of 220 procedures was performed on 217 ureters in 208 patients. Mean stone size was 10.0 ± 4.9 X 6.2 ± 2.2 mm. The calculi were in the proximal third of the ureter in 27 patients, the middle third in 48 and the distal third in 145. Operative metlwd. The patient was placed in the lithotomy position and epidural anesthesia was administered. An ll.5F ureteroscope was used. A 0.038-inch straight guide wire was passed beyond the stone cystoscopically and left in place throughout as a safety guide wire. A 0.038-inch round guide wire was used in the working channel of the ureteroscope as a guide by always advancing the tip several centimeters beyond the beak of the ureteroscope. The ureteroscope was inserted directly into the orifice and intramural ureter without prior manipulation, such as dilation or meatotomy, although such manipulations were performed when the orifice was obviously too small. In 6 procedures the orifice was incised 5 mm. at the roof with the resectoscope and in 3 sequential metallic bougie

dilation (8 to 12F) of the orifice and intramural ureter over a guide wire was performed. The ureteroscope was passed to the stone alongside the guide wire under direct vision. The stone was fragmentated under direct vision with ultrasonic lithotripsy (139 patients), electrohydraulic shock waves (2) or both procedures (11). The larger fragments were removed under direct vision via a stone basket or forceps. When perforation or laceration of the ureteral mucosa occurred, a ureteral catheter was placed for several days. A Double-J t catheter left in place for 2 to 8 weeks might be an alternative. The duration of the procedures ranged from 11 to 200 minutes (mean 75 ± 41 minutes). Complete removal of the calculi was defined as no residual calculi on a plain radiographic film and IVP 1 week postoperatively. Incomplete removal was defined as residual calculi shown on the radiographic films and removed by other procedures, including transurethral lithotripsy, percutaneous nephrolithotripsy, ureterolithotomy and extracorporeal shock wave lithotripsy (ESWL:j:). Sequential postoperative IVPs and random voiding cystogram. After the procedure an IVP was performed sequentially once every 4 weeks for the first 3 months and once every 6 months thereafter to estimate the obstructive change at the vesical end of the ureter. A total of 86 patients was observed for at least 6 months with a sequential IVP. Voiding cystography was performed in 102 patients to evaluate vesicoureteral reflux into the ureter. Before the procedure 19 voiding cystograms were performed in 19 of 72 patients and 83 voiding cystograms were performed at random during 1 to 18 months in all 72 patients. RESULTS

Removal of the calculi. Complete removal of the calculi was achieved in 180 procedures (81.8%) and removal was incomplete in 9 (4.1%). In 31 cases (14.1%) the calculi could not be removed for various reasons, including failure to insert the ureteroscope into the ureter in 5, failure to access the stone in 14, proximal migration of the stone in 1 and failure to disintegrate the stone in 1. The rate of complete removal was 63.0% in the proximal, 87.5% in the mid and 84.1% in the distal ureteral third.

Accepted for publication April 26, 1989. * Requests for reprints: Department of Urology, Komaki Shimin Hospital, 1-20 Johbushi, Komaki-shi, 485 Japan. 958

t Medical Engineering Corp., New York, New York.

:j: Dornier Medical Systems, Inc., Marietta, Georgia.

959

LONG-TERM RESULTS OF TRANSURETHRAL LITHOTRIPSY WITH RIGID URETEROSCOPE

Early complications. Ureteral disruption was observed in 1 case (0.5%). The ureter was completely transected 10 cm. proximal to the orifice by forceful manipulation of the ureteroscope. The stone was found 3 cm. proximal to the site of the disruption and was removed with end-to-end ureteroureterostomy performed to restore the urinary drainage system. Ureteral perforation from forceful manipulation of the ureteroscope, sonotrode, forceps or stone basket also was observed in 15 procedures (6.8%). The condition was managed by placement of a Double-J or ureteral catheter except in 1 patient who had a solitary left kidney. This patient was managed by open drainage and a temporary nephrostomy tube, since neither placement of a Double-J catheter nor a percutaneous nephrostomy catheter was successful. Of these patients 14 were treated successfully with no complications except 1 who had a ureteral stricture. Acute bacterial prostatitis was observed in 3 patients and was treated successfully by antibiotic therapy. Bleeding from the injured orifice was observed in 1 patient. Hemostasis was attained without endoscopic electrocoagulation. Late complications. Complete stricture was observed in 1 patient who was managed successfully by a psoas bladder hitch and ureteroneocystostomy 4 months after the procedure. The patient had a stone 10 cm. proximal to the orifice. Extensive ureteral perforation occurred 6 cm. proximal to the orifice because of forceful manipulation of the ureteroscope. The stone was removed via flexible and rigid ureteroscopy with percutaneous nephrostomy. A Double-J catheter was placed for 6 weeks. Moderate dilatation of the ureter was observed on the IVP 8 weeks postoperatively. However, the kidney was no longer seen on an IVP after 12 weeks. Antegrade pyelography showed complete obstruction at the site of the perforation and exploration was performed. Prolonged obstructive change at the vesical end of the ureter (at least 6 months postoperatively) on sequential IVPs was observed in 3 of 86 ureters (3.5%, table 1 and figure). Mild stricture at the vesical end remained for 22 to 34 months in 3 ureters in 3 patients. There was neither improvement nor deterioration in the degree of obstruction. The stricture did not occur in the site of the impacted stone. These patients have

undergone neither meatotomy nor dilation. The duration of the procedures ranged from 50 to 95 minutes (mean 72 ± 18 minutes). In 19 preoperative voiding cystograms (19 ureters in 19 patients) vesicoureteral reflex could not be found. There were 83 voiding cystograms performed 1 to 18 months postoperatively on 73 ureters in 72 patients and vesicoureteral reflux was observed in 7 ureters of 7 patients (9.6%, table 2). Of the 7 ureters 1 was confirmed to have no pre-existing disease, while 6 were not. Vesicoureteral reflux was confirmed by a subsequent voiding cystogram at 3 to 6-month intervals in each patient. One of the 7 patients underwent meatotomy during this procedure and the other 6 have not undergone meatotomy or dilation of the orifice. There were 6 male and 1 female patients. Duration of the procedures ranged from 26 to 120 minutes (mean 74 ± 35 minutes). However, patients with vesicoureteral reflux had no urinary tract infections. DISCUSSION

Transurethral lithotripsy with the rigid ureteroscope has been performed as an alternative to conventional surgical approaches for removal of ureteral calculi in recent years. The stone removal rate has been up to 80 to 90%, especially for calculi in the mid or distal third of the ureter. 5 • 10• 11• 13• 14 Most of the calculi in the mid or distal ureteral third are removed by this procedure due to some difficulties in removal of such calculi byESWL. However, this procedure sometimes resulted in ureteral injury due to the rigid and relatively large diameter ureteroscope. Early complications, such as ureteral avulsion and perforation, have been reported. 5 •8 • 10- 1• In our series ureteral disruption was observed in 1 case (0.5%) and ureteral perforation in 15 (6.8%). These figures are similar to those reported previously. 8 •11 • 13• 14 Recently, late complications, such as ureteral stricture, also were reported by some investigators. 11- 17 Ureteral stricture has been attributed to ureteral damage, including hemorrhage, collapse and tears during ureteroscopy, and its subsequent scarring. In our series complete stricture of the ureter also was

C

B

A

IVPs show mild obstruction at ureteral end in 3 patients. A, patient Y. I. 30 months postoperatively. B, patient T. M. 24 months postoperatively. C, patient 0. T. 18 months postoperatively. TABLE 1.

Patients with the stricture at the vesical end of the ureter

Pt.-Sex-Age

Ureter

Stone Location

Result

Manipulation at Insertion

Postop. Urinary Tract Infection

Dilatation on Pyeloureterogram

Duration (mos.)

YI-F-55 TM-F-55 OT-M-30

Lt. Lt. Rt.

Distal third Distal third Proximal third

Complete removal Complete removal Complete removal

No No No

No No No

Mild Mild Mild

34 26 22

960

ONO AND ASSOCIATES TABLE 2. Patients with vesicoureteral reflux Stone Pt.-Age-Sex

Result Ureter

Location

MS-49-M M0-42-F

Rt. LL

Distal third Mid third

Complete removal Failed access to the

EA-55-M TF-28-M YM-41-M SY-37-M SK-48-M

Rt. Lt. Lt. Rt. Lt.

Distal third Distal third Distal third Distal third Distal third

Complete removal Complete removal Complete removal Complete removal Complete removal

Manipulation at Insertion

Postop. Urinary Tract Infection

Vesicoureteral Reflux Preop.

No No

No No

Not examined Not examined

No Meatotomy No No No

No No No No No

Not Not Not Not No

Grade*

stone

examined examined examined examined

* According to Dwoskin, J.Y. and Perlmutter, A.O.: J. Ural., 109: 888, 1973.

observed in 1 patient 4 months postoperatively. In this patient we failed to access the stone because of ureteral narrowing and ureteral perforation during ureteroscopy. The obstructive change at the vesical end of the ureter and vesicoureteral reflux were observed on the long-term followup IVP and voiding cystogram in our series. Some investigators observed stricture at the site of the stone, 11 ' 17 and that stricture might be caused by the stone itself and/or by traumatic dislodgement of the calculus. Biester and Gillenwater observed stricture at the vesical end of the ureter caused by dilation of the orifice and intramural ureter. 15 In our patients neither meatotomy nor dilation was performed and the site of the stone was different from the vesical end. Vesicoureteral reflux possibly arose from this procedure, although the presence of vesicoureteral reflux was not evaluated preoperatively in all 73 ureters. The striking higher incidence of vesicoureteral reflux observed in our series compared to that in the age-matched population supports our assumption. Stackl and Marberger reported vesicoureteral reflux in 2 of their patients. 16 They dilated the ureteral orifice and intramural ureter. In our series 6 of 7 patients with vesicoureteral reflux received no manipulation, including meatotomy or dilation. Both complications might arise from damage of the intramural ureter, which was caused by passage of the ureteroscope alone. Since the lumen of the intramural ureter is comparatively narrow, this segment might be damaged frequently by passage of the ureteroscope. REFERENCES

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ureteral calculi using rigid ureteroscope. Urology, 20: 574, 1982. 4. Huffman, J. L., Bagley, D. H., Schoenberg, H. W. and Lyon, E. S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasoniclithotripsy. J. Urol., 130: 31, 1983. 5. Green, D. F. and Lytton, B.: Early experience with direct vision electrohydraulic lithotripsy ofureteral calculi. J. Urol., 133: 767, 1985. 6. Ford, T. F., Watson, G. M. and Wickham, J.E. A.: Transurethral ureteroscopic removal of ureteric stones. Brit. J. Urol., 55: 626, 1983. 7. Meagher, M. J.: Use of the ureteroscope in ureteral calculus manipulation. Med. J. Aust., 141: 233, 1984. 8. Kahn, R. I.: Endourological treatment of ureteral calculi. J. Urol., 135: 239, 1986. 9. Keating, M.A., Heney, N. M., Young, H. H., II., Kerr, W. S., Jr., O'Leary, M. P. and Dretler, S. P.: Ureteroscopy: the initial experience. J. Urol., 135: 689, 1986. 10. Ono, Y., Hirabayashi, S., Yamada, S., Ohshima, S., Kinukawa, T., Matsuura, 0., Katoh, N., Sugiyama, T. and Watanabe, J.: Transureteral lithotripsy-preliminary report. Jap. J. Urol., 78: 1917, 1987. 11. Carter, S. S. C., Cox, R. and Wickham, J. E. A.: Complications associated with ureteroscopy. Brit. J. Urol., 58: 625, 1986. 12. Lytton, B., Weiss, R. M. and Green, D. F.: Complications ofureteral endoscopy. J. Urol., 137: 649, 1987. 13. Schultz, A., Kristensen, J. K., Bilde, T. and Eldrup, J.: Ureteroscopy: results and complications. J. Urol., 137: 865, 1987. 14. Daniels, G. F., Jr., Garnett, J. E. and Carter, M. F.: Ureteroscopic results and complications: experience with 130 cases. J. Urol., 139: 710, 1988. 15. Biester, R. and Gillenwater, J. Y.: Complications following ureteroscopy. J. Urol., 136: 380, 1986. 16. Stack!, W. and Marberger, M.: Late sequelae of the management of ureteral calculi with the ureterorenoscope. J. Urol., 136: 386, 1986. 17. Kramolowsky, E. V.: Ureteral perforation during ureterorenoscopy: treatment and management. J. Urol., 138: 36, 1987.