Reply by the Author

Re: Khairy-Salem et al.: Semirigid Ureteroscopy in Management of Large Proximal Ureteral Calculi: Is There Still a Role in Developing Countries? (Urology 2011;77:1064-1069) TO THE EDITOR:

We read with interest the experience of Khairy-Salem et al and the Editorial Comment on the study. We wish to share with our readers our own experience in semirigid upper tract ureteroscopy for calculi gathered over the past 20 years. Regarding the relative unsuitability of the male urinary tract for upper tract ureteroscopy, 2 instances come prominently to our minds. In lean young males, the reason could be the paucity of periureteral fat restricting stretch and leading to rigid lower ureters. A large prostatic median lobe in the appropriate age group is another. Notwithstanding these situations, we have been able to reach the calculus ⬎90% of the time. Over the past 5 years, we have almost entirely switched to the 6-7.5 semirigid ureteroscope. We also use ureteroscopy and pneumatic lithoclast fragmentation as a primary modality for small renal pelvic and upper caliceal calculi. We do not perform ureteral meatal dilation because the extraction of multiple small upper ureteral or renal fragments using multiple excursions of the ureteroscope is neither necessary nor advisable. Therefore, we place a stent in all patients after the procedure. A vexing problem we have observed using this narrow ureteroscope is the blurring of vision owing to a decrease in water pressure when the lithoclast probe is in place. This is especially discomforting in the presence of bleeding or turbidity after initial stone fragmentation attempts and necessitates the use of a larger ureteroscope. In our experience, upward migration of the calculus is the rule rather than the exception, and the calculus usually finds its way into the lower calyx, from which it is almost impossible to dislodge even with appropriate patient positioning and “thumping” over the flank. Therefore, at the onset, we place the patient in a steep Trendelenburg position with a contralateral tilt, to allow a controlled migration of the stone into the upper calyx for accessibility. A larger pelvic calculus can usually be aligned using abdominal pressure. We do not perform retrograde contrast studies. We do not pass the guidewire beyond the calculus but rather let its floppy tip project a few centimeters beyond the ureteroscope, using it as a “pathfinder” up to the calculus. Regarding the extraction of calculi ⬍10 mm without fragmentation, the danger of using a Dormia is well known. The authors reported safe and easier extraction using stone forceps, but our experience has been different. The use of stone forceps effectively increases the width of the “extractor-stone” assembly much beyond UROLOGY 79 (4), 2012

Figure 1. (A) Dormia basket conforms to shape and size of calculus, while distal ends of jaws of stone forceps extend beyond the stone width. (B) Shoulder of ureteroscope avulsing vesicoureteral junction.

that of a “Dormia-stone” assembly (Fig. 1A). Any tug on the assembly could lead to mucosal maceration and avulsion with difficulty in re-entry or stenting (as opposed to total avulsion with a Dormia). Finally a word of caution using the larger caliber ureteroscopes. The ureteroscope has a couple of “shoulders” at regular intervals as its diameter increases proximally. If one faces “tightness” when the ureteroscope tip reaches the upper ureter, it is impossible to ascertain whether the problem originates at the tip of the ureteroscope or the intramural ureteral segment. The graduated shouldering is likely to make one complacent and to believe that the ureteroscope will find its way up with a reasonable degree of force. We have once faced the horrifying situation of the most proximal shoulder of the ureteroscope avulsing the ureter at its entry point into the bladder (Fig. 1B)— and once was enough! Sunil P. Shenoy, M.S., D.N.B., M.Ch., D.N.B. Prashanth K. Marla, M.Ch. Division of Urology AJ Institute of Medical Sciences Kuntikana, Mangalore, Karnataka, India M.B. Hanumanthappa, M.S. Department of Surgery AJ Institute of Medical Sciences Kuntikana, Mangalore, Karnataka, India

Reply by the Author TO THE EDITOR:

Having read the letter to the editor, I have found it to describe the problems faced during semirigid ureteroscopy 971

for upper ureteral stones with a high degree of clinical expertise. I do agree with the authors regarding the relative unsuitability of the male urinary tract for upper tract ureteroscopy. However, we have found that sometimes dilation of the intramural ureter can help, not only in the extraction of larger stone fragments, but also in patients with a rigid lower ureter. This is usually possible in the vast majority of young males, albeit a few patients will have nondilatable lower ureters. In patients with prominent adenoma, we usually proceed to direct ureteroscopy without the use of any cystoscopy sheath to facilitate the ascent of the scope to the upper ureter. However, we do not agree with the routine stenting of patients to avoid pneumatic fragmentation or multiple excursions of the ureteroscope because stenting overburdens patients both medically because they will have to undergo another procedure (no matter how simple it might be) and financially, especially in developing countries. We agree that these narrow ureteroscopes result in poorer vision owing to the decrease in water pressure. We have usually solved this by increasing the irrigant pressure using a blood pressure cuff or increasing further the height of the irrigant solution, when the lithoclast probe is in place. We also routinely place our patient in a steep Trendelenburg position to prevent upward calculus migration. Although we have not tried the contralateral tilt to direct the stones into the upper calix rather than the lower, it seems to be a very worthwhile idea to adopt. Not performing routine retrograde contrast studies is quite logical to not dislodge the stone. However, I would strongly insist on attempting to pass a floppy tip guidewire beyond the calculus and, if this fails, I would consider in that case performing a retrograde study or passing a guidewire under vision beside the stone. My rationale in that case would be that having a guidewire in the upper tract provides a safeguard to stenting and aborting the procedure in the case of any mishap. We believe that although the extractor-stone assembly increases the stone width, careful and gentle manipulation allows one to deliver the stone through the narrow terminal part of the ureter, avoiding the blindly directed pull on the Dormia basket. Finally, we strongly agree with the word of caution provided by the authors regarding the fact that one never knows with graduated ureteroscopes what is the exact site of tightness. We similarly stress that endoscopy does not require any degree of force and that the trick is in the smoothness of the procedure. Mohamed El Ghoneimy, M.D. Department of Urology Cairo University Cairo, Egypt 972

Re: Kreshover et al.: Predictors for Negative Ureteroscopy in the Management of Upper Urinary Tract Stone Disease (Urology 2011;78:748-752) TO THE EDITOR:

We carefully read the article by Kreshover et al,1 which deals with a common issue that all urologists face in their everyday practice. Ureterorenoscopies that are performed to manage stones may not reveal any findings, particularly in small distal stones, although the patient has already been diagnosed with urolithiasis using sensitive imaging modalities, mainly computed tomography (CT).1 However, we would like to make a couple of points that, in our opinion, require further discussion, as they suggest limitations of the present study. First, as the authors mention in their Comment section, the fact that they do not use kidneys-ureters-bladder x-rays (KUB) for the follow-up of patients with urolithiasis could have been a predisposing factor for useless, negative ureterorenoscopies. They also report that small or radiolucent stones would not be eligible candidates for such follow-up schedules. We suggest that these types of stones, when defined in the pelvicalyceal system (46.3% of cases in the current study) could be followed up using ultrasound.2 In experienced areas, this imaging modality can detect even small calculi. Although it is characterized by some limitations when compared to CT,3 it can achieve rather high accuracy levels, especially when combined with KUB.4 Even properly trained urologists could play this role in their outpatient clinics, provided that ultrasound machines are available.5 Second, it seems that the waiting list is long enough in some tertiary referral centers. Surpisingly, in the present study, it is reported that some patients have been waiting for more than 1 year. We believe that the authors would have distinguished the stone location and size, as well as the patients’ pain, in correlation with the waiting period. Moreover, it would have been prudent to follow the status of renal units periodically, particularly in patients with ureteric stones. This could been achieved in 2 ways: by assessing the grade of hydronephrosis and renal cortex, and by evaluating the ureteric “jet” in ureteric orifices on bladder ultrasound scans. The latter has been reported to offer the opportunity of estimating divided renal function, as well.6 Georgios Papadopoulos, M.D., Ph.D. Georgios Megas, M.D. Dimitrios Moshonas, M.D. Konstantinos Doumas, M.D., Ph.D. Urology Department Athens General Hospital “G. Gennimatas” Athens, Greece UROLOGY 79 (4), 2012