Percutaneous Antegrade Fiberoptic Ureterorenoscopic Treatment of Ureteral Calculi

0022-534 7 /90/1443-0628$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 144, September

Printed in U.S.A.

PERCUTANEOUS ANTEGRADE FIBEROPTIC URETERORENOSCOPIC TREATMENT OF URETERAL CALCULI W. B. C. BERKHOFF*

AND

F. MEIJER

From the Departments of Urology and Radiology, Zuiderzee Hospital, Lelystad, The Netherlands

ABSTRACT

Treatment of upper ureteral calculi can be accomplished by various endourological techniques and/or extracorporeal shock wave lithotripsy. Percutaneous fiberoptic treatment of upper ureteral stones provides an alternative especially suited as second line treatment in cases when extracorporeal shock wave lithotripsy failed. Usually, these patients will present with impacted ureteral stones. Our first experiences with 8 stones in 7 patients to date proved this technique to be safe and reliable, with no complications encountered on excretory urography 3 months postoperatively. (J. Ural., 144: 628-630, 1990) U reteral stones pass spontaneously in 80% of the cases. 1 The introduction in recent years of new endourological techniques and extracorporeal shock wave lithotripsy (ESWLt) has changed treatment of ureter al stone disease dramatically in the remaining 20% of the cases. In ureteral stones distal to the pelvic brim rigid transurethral ureterorenoscopy proved to be successful, with success rates of 94 to 97%. 2• 3 Treatment success rates are lower for stones in the upper ureter, where presently various alternatives of treatment are available combining ureterorenoscopic, percutaneous and ESWL techniques, including push-up methods with ESWL or percutaneous nephrolithotomy, stent placement with ESWL, in situ ESWL, transurethral rigid or flexible ureterorenoscopy, percutaneous flexible ureterorenoscopy, percutaneous chemolitholysis or an open operation. The introduction of fiberoptic ureterorenoscopes with an active deflectable tip has made it possible to use a percutaneous technique in selected cases, for example when a push-pull or push-bang technique fails.4 We present our first experiences with this technique and attempt to place it in the present algorithm for the management of ureteral calculi. PATIENTS AND METHODS

Fiberoptic endoscopy was developed in 1957. 5 The Olympus fiberoptic ureterorenoscope features an insertion tube diameter of 4.4 mm. and a 1. 7 mm. instrument channel, and it can be deflected upwards and downwards 160 and 60 degrees, respectively. The working length is 705 mm. Accessory devices consist of grasping forceps, wire stone baskets and electrohydraulic lithotripsy probes. Percutaneous flexible ureterorenoscopy is performed with the patient under regional anesthesia in the prone position. The procedure is begun with the cystoscopic placement of a 6 or 7F normal or occlusion balloon catheter just distal to the stone. Attempts are made to manipulate the ureteral stone back into the renal pelvis by retrograde fluid injection and direct catheter manipulation. If repositioning of the stone fails contrast material can be instilled through the catheter port to opacify the renal collecting system just before puncture. The catheter also is used to flush saline when vision through the flexible ureterorenoscope is hampered by the low flow of irrigant because of obstruction caused by an instrument in the instrument channel. The renal collecting system is reached through a lower or middle pole caliceal puncture. Generally, a guide wire is placed through the ureteropelvic junction down Accepted for publication February 26, 1990. * Requests for reprints: Department of Urology, Zuiderzee Hospital, Ziekenhuisweg 100, 8233 AA Lelystad, The Netherlands. t Dornier Medical Systems, Inc., Marietta, Georgia.

the ureter up to the ureteral stone. The flexible ureterorenoscope is introduced along the guide wire through a 30F Amplatz nephroscopy working sheath after acute tract dilation. The ureterorenoscope is manipulated under direct vision using a microchip television camera. The upper ureter is entered by advancing the endoscope. At times fluoroscopy may be used to determine the position of the ureterorenoscope. Once the stone is reached it can be basketed and/or disintegrated by electrohydraulic lithotripsy. Smaller particles can be allowed to pass spontaneously. After the procedure is completed a nephrostomy tube is positioned in the renal pelvis. The nephrostomy tube is clamped the next day. From March to November 1988, 7 patients underwent 8 procedures for the treatment of 8 upper ureteral stones. The patients underwent excretory urography (IVP) at 3 months postoperatively. RESULTS

All 7 patients were treated successfully with the described procedure (table 1). Of the stones 2 were removed with a Dormia basket, while electrohydraulic lithotripsy was used in 2 and a combination of both techniques was applied in the remainder. In the patient with 2 stones both calculi were situated in the right ureter. At the initial attempt, after removal of the upper stone, the nephrostomy tract was lost and, therefore, a secondary procedure was necessary 1 week later. Electrohydraulic lithotripsy proved to be a safe option when using the lowest voltage with the 1-shot mode. For impacted stones, when Dormia basketing fails, electrohydraulic lithotripsy can be used to engage the stone and sometimes to disintegrate the stone entirely into small particles for spontaneous passage. Average operating time, including initial ureteral stent placement, was 1 hour 40 minutes, with a range of 70 minutes to 2½ hours. In our series there was no need for postoperative internal ureteral stenting. Average hospital stay after the procedure was 4 days. There were no postoperative complications and the IVP at 3 months was unremarkable in all patients, showing no stone remnants or ureteral stricture formation. DISCUSSION

The developments in ESWL, ureterorenoscopy and percutaneous stone removal have altered treatment of ureter al stone disease markedly. Contrary to lower ureteral stones, which can be removed ureteroscopically with high reliability, the results of treatment of upper ureteral stones are less favorable. Tables 2 and 3 show the reported results of treatment of ureteral stones by transurethral rigid ureterorenoscopy and ESWL. 2 • 6 - 17 The algorithm in treatment of upper ureteral stones incorporates ESWL in situ with or without stent place-

PERCUTANEOUS FIBEROPTIC URETERORENOSCOPIC TREATMENT OF URETERAL CALCULI

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TABLE 1. Patient population Pt-Age-Sex No. (yrs.)

Location of Calculus

Size of Calculus (mm.)*

Postop. Hospital Stay (days)

1-33-M

L3

6X5

3

2-55-M

L3

10 X 6

4

3-26-F 4-60-M 5-32-M 6-24-F 7-54-M

L3 L4 L3 82 L3 + L4

10 X 7 6X3 10 X 6 7X6 11 X 6 11 X 10

3 5 4 5 4

Composition of Calculus

Technique Electrohydraulic lithotripsy + Dormia basket Electrohydraulic lithotripsy + Dormia basket Electrohydraulic lithotripsy Dormia basket Dormia basket Electrohydraulic lithotripsy Electrohydraulic lithotripsy (procedures 1 and 2) + Dormia basket

Calcium oxalate Calcium oxalate Not done Calcium oxalate Calcium oxalate Not done Calcium oxalate

* Radiographic measurement.

TABLE 2. Results of transurethral rigid ureteroscopic treatment of ureteral calculi Ureter Reference

Upper+ Mid No. (% success)

Lingeman and associates'

29 (52) primary, 10 (60) after ESWL

Keating and associates 7 Kahn8 Weinberg and associates• Seeger and associates 10 Daniels and associates" Flam and associates 12

Upper No. (% success)

Mid No. (% success)

Lower No. (% success) 77 (94) primary, 31 (94) after ESWL

12 (58) 37 (95) ante grade*

10 (50)

20 (100) antegrade,* 7 (71) retrograde 8 (62) 25 (80)

53 (98) retrograde 119 (83) 70 (99)

25 (68) 50 (68)

75 (83) 130 (82)

* Flexible technique. TABLE 3. Results of ESWL of upper ureteral calculi Reference Miiller and associates 13 Lingeman and associates• Graff and associates 14 Graff and associates" Fetner and associates 16 Tiselius and associates 17

In Situ No. (% success) 29 123 194 51 30

(62) (78.2) (70.6) (92.1) (83.3)

In Situ + Ureteral Catheter No. (% success) 19 (74) 47 (89.1) 22 (68.2) 53 (79.3) 16 (100)

ment or ESWL after manipulation of the stone as first line treatment. Failing ESWL, the next step would be a ureterorenoscopic procedure. Drawbacks to transurethral rigid ureterorenoscopy, especially for upper ureteral stones, include dilation and negotiation of the fixed intramural ureter, inability to traverse the iliac vessels, a small ureteral diameter, ureteral fixation secondary to a previous operation and floating of loose stones into the renal pelvis, where. they may be lost in the calices. For impacted stones ureteral edema below the point of impaction often blurs vision of the stone and makes treatment difficult. Transurethral flexible ureterorenoscopy has overcome some of these problems. 18 In ESWL of upper ureteral stones the most difficult to disintegrate satisfactorily are unstentable long impacted calculi, small lucent or poorly calcified stones and stones overlying the pelvic bone. In the latter case excellent results are still possible. 17 When a second line treatment is chosen for an upper ureteral stone a percutaneous approach may provide some advantage over a transurethral rigid procedure. Hydronephrosis, often present as a result of ureteral obstruction, facilitates the introduction and advancement of the flexible ureterorenoscope, and also promotes secure placement of an accessory device or an electrohydraulic probe. Impacted stones may not allow contrast medium to flow beyond the stone but this does not interfere with ultrasonographic approaches in entering the renal collecting system, since in these cases marked hydronephrosis usually is present. Placement of a postoperative ureteral stent in our series

Push-Bang No. (% success) 100 245 201 67 55

Push + Delayed Bang No. (% success)

(97) (95.9) (95.5) (86.3) (92.8)

56 (100)

proved not to be necessary. The situation may be comparable to in situ ESWL without stent placement. 19 Percutaneous treatment shows significant complications in 3.2% of the cases, 20 whereas with rigid transurethral ureterorenoscopy in the larger series major complications were encountered in 4.4%. 8 Therefore, a percutaneous approach does not harbor essentially greater morbidity. Results of larger series of transurethral flexible ureterorenoscopic treatment of upper ureteral stones are not yet available and, therefore, are not yet comparable to the results with a percutaneous flexible approach. Further experience with transurethral and percutaneous flexible ureterorenoscopy will provide additional information in regard to its proper role in second line treatment of upper ureteral stone disease. REFERENCES

1. O'Flynn, J. D.: The treatment of ureteric stones: report on 1120

patients. Brit. J. Urol., 52: 436, 1980. 2. Lingeman, J. E., Sonda, L. P., Kahnoski, R. J., Coury, T. A., Newman, D. M., Mosbaugh, P. G., Mertz, J. H. 0., Steele, R. E. and Frank, B.: Ureteral stone management: emerging concepts. J. Urol., 135: 1172, 1986. 3. Blute, M. L., Segura, J. W. and Patterson, D. E.: Ureteroscopy. J. Urol., 139: 510, 1988. 4. Coptcoat, M. J., Webb, D.R., Kellett, M. J., Whitfield, H. N. and Wickham, J. E. A.: The treatment of 100 consecutive patients with ureteral calculi in a British stone center. J. Urol., 137: 1122, 1987. 5. Hirschowitz, B. I.: The development and application of fiberoptic endoscopy. Cancer, 61: 1935, 1988.

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6. Lingeman, J. E., Shirrell, W. L., Newman, D. M., Mosbaugh, P. G., Steele, R. E. and Woods, J. R.: Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J. Urol., 138: 720, 1987. 7. Keating, M.A., Heney, N. M., Young, H. H., II, Kerr, W. S., Jr., O'Leary, M. P. and Dretler, S. P.: Ureterorenoscopy: the initial experience. J. Urol., 135: 689, 1986. 8. Kahn, R. I.: Endourological treatment of ureteral calculi. J. Urol., 135: 239, 1986. 9. Weinberg, J. J., Ansong, K. and Smith, A. D.: Complications of ureterorenoscopy in relation to experience: report of survey and author experience. J. Urol., 137: 384, 1987. 10. Seeger, A. R., Rittenberg, M. H. and Bagley, D. H.: Ureteropyeloscopic removal ofureteral calculi. J. Urol., 139: 1180, 1988. 11. Daniels, G. F., Jr., Garnett, J.E. and Carter, M. F.: Ureteroscopic results and complications: experience with 130 cases. J. Urol., 139: 710, 1988. 12. Flam, T. A., Malone, M. J. and Roth, R. A.: Complications of ureterorenoscopy. Urol. Clin. N. Amer., 15: 167, 1988. 13. Muller, S. C., van Haverbeke, J. van, El Seweifi, A. and Alken, P.: Der hohe Harnleiterstein-ein Problem trotz extrakorporaler Stosswellenlithotripsie. Akt. Urol., 16: 294, 1985. 14. Graff, J., Diederichs, W. and Schulze, H.: Long-term followup in 1,003 extracorporeal shock wave lithotripsy patients. J. Urol., 140: 479, 1988. 15. Graff, J., Pastor, J., Funke, P.-J., Mach, P. and Senge, Th.: Extracorporeal shock wave lithotripsy for ureteral stones: a retrospective analysis of 417 cases. J. Urol., 139: 513, 1988. 16. Fetner, C. D., Preminger, G. M., Seger, J. and Lea, T. A.: Treatment of ureteral calculi by extracorporeal shock wave lithotripsy at a multi-use center. J. Urol., 139: 1192, 1988. 17. Tiselius, H.-G., Pettersson, B. and Andersson, A.: Extracorporeal shock wave lithotripsy of stones in the mid ureter. J. Urol., 141: 280, 1989. 18. Aso, Y., Ohtawara, Y., Fukuta, K., Sudoko, H., Nakano, M., Ushiyama, T., Ohta, N., Suzuki, K. and Tajima, A.: Operative fiberoptic nephroureteroscopy: removal of upper ureteral and renal calculi. J. Urol., 137: 629, 1987. 19. Holden, D. and Rao, P. N.: Ureteral stones: the results of primary in situ extracorporeal shock wave lithotripsy. J. Urol., 142: 37, 1989. 20. Segura, J. W., Patterson, D. E., LeRoy, A. J., Williams, H. J., Jr., Barrett, D. M., Benson, R. C., Jr., May, G. R. and Bender, C. E.: Percutaneous removal of kidney stones: review of 1,000 cases. J. Urol., 134: 1077, 1985.

EDITORIAL COMMENTS The authors have presented a well documented series of patients among whom percutaneous removal of upper ureteral calculi was successful with a fiberoptic ureteronephroscope (13.2F) passed in an antegrade direction. However, I believe that ESWL is the most effective and safest first line of therapy. With ESWL the ureteral calculus is fragmented successfully and passed completely in 80 to 88% of the patients without or with manipulation, respectively. In the remaining 20% of the patients a retrograde ureteroscopic approach is indicated as the first line of salvage therapy. Multiple series, all with larger numbers of patients than reported herein, document the safety and efficacy (68 to 93% stone removal) of this minimally invasive approach (reference 11 in article).'· 2 Among the few patients in whom ureteroscopy fails to remove the stone the calculus usually will be transposed to the renal pelvis or bypassed with a guide wire and stent. For these patients repeat ESWL should be effective. As such, it would appear that less than 3% of all patients with a proximal ureteral calculus will probably require the more invasive, percutaneous approach described by the authors. Two other points are of importance. Retrograde ureteroscopy for

proximal ureteral calculi is becoming even more acceptable due to the development of smaller rigid (7.lF Candela miniscope) and flexible (8.5 to 10.8F) ureteroscopes capable of traversing the ureter with little or no ureteral dilation. The latter are far more effective than the 13.2F ureteroscope used in this study and are associated with high success rates (93 to 96%) even in the proximal ureter. 2 Also, the authors do not address the convalescence period or pain associated with a percutaneous approach, both of which are significant especially when compared to ESWL or retrograde ureteroscopy. Indeed, the latter 2 therapies usually are completed on an outpatient basis (versus a 4-day hospital stay in this series) and the convalescence is brief. Indeed, in 1 series comparing ESWL, ureteroscopy and percutaneous removal of proximal ureteral stones the need for pain medication was 3, 2 and 12 doses of pethidine and the duration of convalescence was 3, 10 and 14 days, respectively. As such, I believe that percutaneous removal of proximal ureteral stones is a maneuver that should be used only on the rare occasion when the less invasive and less morbid therapies of ESWL or retrograde ureteroscopy happen to fail. Ralph V. Clayman Division of Urology Washington University School of Medicine St. Louis, Missouri A variety of factors must be considered when one approaches the treatment of upper ureteral calculi. Some of these include the stone size, composition, type of ESWL device available and level of endoscopic experience of the urologist. A categorical approach to this type of problem is made difficult because of the number of factors involved. In situ ESWL certainly is the safest method to treat stones at this location. However, if one has access only to a lithotripsy device that uses ultrasound for localization lithotripsy may not be possible due to the difficulties in finding a ureteral stone with ultrasound. Alternatively, if one has a lithotripsy device that uses fluoroscopy for localization, treatment of ureteral stones is easier and results prove to be comparable to other methods of extraction. 1 Generally, success rates for transurethral ureteroscopic stone removal lessen as the stone location ascends the urinary tract. Flexible ureteroscopy combined with laser lithotripsy has made an impact in this area and will allow success rates to approach those achieved in the lower ureter. As indicated in this report percutaneous antegrade ureteroscopy with flexible endoscopes represents an option for treatment of these patients when combined with intraureteral lithotripsy-electrohydraulic or laser. Laser lithotripsy has the advantage for use on impacted stones, whereas electrohydraulic lithotripsy should be used with extreme caution on impacted stones because of higher potential for ureteral injury. Certainly, temporary internal stenting of the ureter is advisable regardless of the type of treatment used. Potential problems may occur with the percutaneous approach due to the nephrostomy puncture. However, these are minimized if one abides by careful technique. The best results of stone removal are achieved by those who are able to offer all methods of stone treatment to the patient and do not limit themselves to 1 of these routes of stone removal. By offering the options of ESWL, transurethral ureteroscopy and percutaneous methods along with the occasional open stone operation one will be able to treat best patients with upper ureteral calculi. Jeffrey L. Huffman Department of Urology Kenneth Norris Hospital Los Angeles, California 1. Liong, M. L., Clayman, R. V., Gittes, R. F., Lingeman, J. E., Huffman, J. L. and Lyon, E. S.: Treatment options for proximal ureteral urolithiasis: review and recommendations. J, Urol., 141: 504, 1989. 2. Bagley, D. H.: Removal of ureteral and renal calculi with the flexible ureteropyeloscope, J. Urol., part 2, 139: 188A, abstract 104, 1988.