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S164 URETEROSCOPIC MANAGEMENT OF STONES IN THE UPPER URINARY TRACT
of PCNL, and fourth period was our experienced period with joining a pediatric urologist. The stone-free rates were determined according to the periods. Results: The mean age of the children was 7.50 years (range 9 months to 17 years). There were 495 renal, 228 ureteral, 21 bladder, 11 urethral stones and the remaining 13 had stones in multiple locations. Of 783 procedures performed for the treatment of urolithiasis in children, 75.9% were open surgery during first period (1987-1992), this rate was 29.7% during second period (1993-1998), 6.1% during third period (1999-2004) and 0.2% during fourth period (2005-2010). The number of children who underwent urinary stone treatment increased significantly (p=0.001) and the age of the children at the time of surgery decreased (9.09 to 6.08) (p=0.001) with time. The stone-free rates were not changed during the periods. Conclusions: The majority of stones in children can be managed using endourological procedures with the advances in technology. Also, technologic advances and improved surgical skills have greatly reduced the number of children requiring open surgery. Endourological treatments have become our current management method for pediatric urolithiasis treatment. Open surgery is mainly used for children with complex urinary calculi disease presented with anatomic abnormalities.
S163
Predictive factors and the management of steinstrasse after shock wave lithotripsy in pediatric urolithiasis-a multivariate analysis study
Onal B., Citgez S., Tansu N., Demirdag C., Dogan C., Gonul B., Demirkesen O., Obek C., Erozenci A. University of Istanbul Cerrahpasa Medical Faculty, Dept. of Urology, Istanbul, Turkey Introduction & Objectives: To define the predictive factors for the formation of steinstrasse (SS) after shock wave lithotripsy (SWL), and to determine the treatment strategies for this complication in pediatric urolithiasis. Material & Methods: We retrospectively reviewed the data of 341 renal units (RUs) treated with SWL for urolithiasis. The location of the stones, stone burden, auxiliary procedures, the energy level and number of shock waves were recorded. Statistical analysis was performed to detect the predictive factors for the formation of SS. In addition, the management of children with SS was evaluated. Results: The mean age of the children was 8.31 years (range 1-17). Episodes of SS developed in 26 RUs (7.6%). Twenty (77%) of RUs were localized in the lower, 5 (19%) in the upper ureter, and one (4%) in multiple locations of the ureter. Stone burden was the only statistically significant factor predicting the formation of SS on logistic regression (p=0.001). Seventeen RUs (65.4%) were successfully managed by repeat SWL monotherapy, 4 (15.4%) were managed by URS after failure SWL treatment, 1 (3.8%) was managed by URS monotherapy and 4 were followed (15.4%) by conservative management with antispasmodic drug plus hydration therapy. The mean SWL session was 1.72. Conclusions: SS development in children after SWL treatment was similar with the adult series. Our results suggest that stone burden is a significant predictive factor for the development of SS after SWL in pediatric urolithiasis. The majority of children with SS could be easily and safely treated by repeat SWL.
S164
Ureteroscopic management of stones in the upper urinary tract
Hinev A.I., Chankov P.K., Kosev P.A., Anakievski D. "St. Marina" University Hospital, Clinic of Urology, Varna, Bulgaria Introduction & Objectives: The aim of this study was to investigate the impact and outcome of rigid ureteroscopic lithotripsy (RUL) of stones, located in the upper urinary tract (UUT). Material & Methods: Since 2012 a total of 383 patients with UUT stones were treated by RUL at our institution. 182 of these patients were males and 201 females. Their age ranged from 13 to 83 years (mean 49.8 years). Prior to URL, 123 (32.1%) of the patients had undergone one or more sessions of extracorporeal shock wave lithotripsy. Stone size varied from 3 to 17 mm (mean 6.2 mm). Stone location included the kidney /n=16/, and all three segments of the ureter (proximal /n=80/, mid /n=105/ and distal /n=182/). 182 of the stones were on the left; 193 - on the right, and 8 were bilateral. 41 of the stones were impacted, and stayed unchanged in the same location for at least 2 months. URL was a preliminary planned procedure in 311 cases, while in 72 cases patients were admitted and treated in emergency. Results: RUL was successfully implemented in 372 (97.1%) of the cases. Larger stones were fragmented by ultrasound lithotripsy (239 cases); pneumatic lithotripsy (26 cases), or by a combination of both these methods (14 cases). Smaller stones were extracted mechanically, without lithotripsy (93 cases). Double J stent, or a temporary ureteral catheter were inserted in 92 and 122 cases, respectively, while in 158 cases URL was performed without stenting of the ureter. Most patients were discharged on the first day after the procedure. The stone-free rate on the first postoperative day was 69% for renal; 78% for proximal ureteric; 82% for midureteric, and 97% for distal ureteric stones. The stone-free rates were significantly
higher in distal and nonimpacted stones, but were independent of stone size, stone composition, and the degree of hydronephrosis. The presence of intraoperative complications correlated with stone location and patient gender, being significantly higher (p < 0.01) in proximal stones and in male patients. Conclusions: In experienced hands, RUL is an excellent method to manage urinary stones, located in the UUT, as it is characterized by high efficacy, low cost and minimal morbidity.
S165
Ultrasound guided percutaneous pneumatic lithotripsy in classic lumbotomy position
Radojevic V., Kenic U., Aleksic Dj., Jeremic N., Markovic V., Tomovic S. CHC Zvezdara, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: The aim of this article is to present our experiences in ultrasound guided percutaneous lithotripsy in lumbotomy position. Material & Methods: We performed this procedure on 48 patients, in period from September 2008 to June 2012, with massive renal calculosis. In 6 patients this procedure was performed as a primary procedure, in 12 patients this procedure was performed as secondary procedure many years after open surgery, and in the rest of patients after previosly failed combined retrograde intrarenal lithotripsy and ESWL. 40 patients were in standard lumbotomy position and 8 patients were in modified supine positionUltrasound guided approach was utilized due to restriction of use of x-ray apparatus, for technical reasons, in our department Prior to the procedure, we placed ureteral catheter Ch 5 for arteficial dilatation of pyelocaliceal system and for protective drainage during postoperative care Introducing the puncture needle through dilatated calices, was followed by placement of guidewire and telescopic dilatators (Olympus) in 45 patients, or ballon dilatator (COOK) in 3 patients, to make a working chanell. After that we introduced Amplatz and finally nefroscope Ch 28 (Olympus). Lithotripsies were performed with pneumatic lithotriptor (Swiss lithoclast), using Lithovac aspiration in 40 cases or Olympus LUS-2® ultrasonic lithtripter in 8 cases. The average duration of the procedure was about 130 minutes. Results: Complete disintegration of stone and extraction of fragments was achieved in 30 patients, in 15 patients we had partial disintegration and extraction and in 3 patients we could not reach calices and calculi. In 1 patient procedure was performed in two steps and complete disintegration of stone was achieved. In patients with partial disintegration and extraction retrograde endorenal lithotripsy and/or ESWL were performed later. The requirement for blood tranfusions was needed in 7 patients. One patient with complete disintegration of stone needed conversion to the open procedure with nephrectomy due to excessive bleeding. In 4 patients procedure was complicated with penetration of irrigation fluid in intraperitoneal space, which was evacuated by puncture needle. One patient had pulmonary embolism two weeks after the operation. In other 42 patients the procedure did well without immediate or late complications. None of the patients suffered from peritoneal and bowel injury during intervention. In all patients aspiration drain Ch 16 was left as a nephrostomy tube. Conclusions: In the beggining of utilization of ultrasound guided PCNL we used both lumbotomy and modified supine position Lately, we choose lumbotomy position as it offers greater maneuver space for manipulation with ulrasound probe, puncture needle, guidewire, neprhoscope and lithotriptor. Besides, this position turned out to be safer due to gravitation which moves bowel away from puncture line.
S166
Internal urethrotomy combined with antegrade flexible cystoscopy for management of obliterative urethral stricture
Hosseini J., Mazloomfard M.M., Mokhtarpour H. Infertility and Reproductive Health Research Center, Shaheed Beheshti University of Medical Science, Dept. of Reconstructive Urology, Tehran, Iran Introduction & Objectives: We studied the safety and efficacy of flexible cystoscopyguided internal urethrotomy in the management of obliterative urethral strictures. Material & Methods: Forty-three flexible cystoscopy-guided internal urethrotomies were performed between 2006 and 2009. The indication for the procedure was nearly blinded bulbar or membranous urethral strictures not longer than 1 cm that would not allow passage of guide wire. Candidates were those who refused or were unable to undergo urtheroplasty. By monitoring any impression of the urethrotome on the monitor through the flexible cystoscope, we were able to do under-vision urethrotomy. All of the patients were started clean intermittent catheterization afterwards which was tapered over the following 6 months. Follow-up continued for 24 months after the last internal urethrotomy. Results: Seventeen patients were younger than 65 years with a history of failed posterior urethroplasty, and 26 were older than 65 with poor cardiopulmonary conditions who had bulbar urethral stricture following straddle or iatrogenic injuries. Urethral stricture stabilized in 16 patients (37.2%) with a single session of urethrotomy and in 17 (39.5%) with 2 urethrotomies. Overall, urethral stricture stabilized in 76.7% of patients with 1 or 2 internal urethrotomies within 24 months
Eur Urol Suppl 2012;11(4):173
S163
Predictive factors and the management of steinstrasse after shock wave lithotripsy in pediatric urolithiasis-a multivariate analysis study
Onal B., Citgez S., Tansu N., Demirdag C., Dogan C., Gonul B., Demirkesen O., Obek C., Erozenci A. University of Istanbul Cerrahpasa Medical Faculty, Dept. of Urology, Istanbul, Turkey Introduction & Objectives: To define the predictive factors for the formation of steinstrasse (SS) after shock wave lithotripsy (SWL), and to determine the treatment strategies for this complication in pediatric urolithiasis. Material & Methods: We retrospectively reviewed the data of 341 renal units (RUs) treated with SWL for urolithiasis. The location of the stones, stone burden, auxiliary procedures, the energy level and number of shock waves were recorded. Statistical analysis was performed to detect the predictive factors for the formation of SS. In addition, the management of children with SS was evaluated. Results: The mean age of the children was 8.31 years (range 1-17). Episodes of SS developed in 26 RUs (7.6%). Twenty (77%) of RUs were localized in the lower, 5 (19%) in the upper ureter, and one (4%) in multiple locations of the ureter. Stone burden was the only statistically significant factor predicting the formation of SS on logistic regression (p=0.001). Seventeen RUs (65.4%) were successfully managed by repeat SWL monotherapy, 4 (15.4%) were managed by URS after failure SWL treatment, 1 (3.8%) was managed by URS monotherapy and 4 were followed (15.4%) by conservative management with antispasmodic drug plus hydration therapy. The mean SWL session was 1.72. Conclusions: SS development in children after SWL treatment was similar with the adult series. Our results suggest that stone burden is a significant predictive factor for the development of SS after SWL in pediatric urolithiasis. The majority of children with SS could be easily and safely treated by repeat SWL.
S164
Ureteroscopic management of stones in the upper urinary tract
Hinev A.I., Chankov P.K., Kosev P.A., Anakievski D. "St. Marina" University Hospital, Clinic of Urology, Varna, Bulgaria Introduction & Objectives: The aim of this study was to investigate the impact and outcome of rigid ureteroscopic lithotripsy (RUL) of stones, located in the upper urinary tract (UUT). Material & Methods: Since 2012 a total of 383 patients with UUT stones were treated by RUL at our institution. 182 of these patients were males and 201 females. Their age ranged from 13 to 83 years (mean 49.8 years). Prior to URL, 123 (32.1%) of the patients had undergone one or more sessions of extracorporeal shock wave lithotripsy. Stone size varied from 3 to 17 mm (mean 6.2 mm). Stone location included the kidney /n=16/, and all three segments of the ureter (proximal /n=80/, mid /n=105/ and distal /n=182/). 182 of the stones were on the left; 193 - on the right, and 8 were bilateral. 41 of the stones were impacted, and stayed unchanged in the same location for at least 2 months. URL was a preliminary planned procedure in 311 cases, while in 72 cases patients were admitted and treated in emergency. Results: RUL was successfully implemented in 372 (97.1%) of the cases. Larger stones were fragmented by ultrasound lithotripsy (239 cases); pneumatic lithotripsy (26 cases), or by a combination of both these methods (14 cases). Smaller stones were extracted mechanically, without lithotripsy (93 cases). Double J stent, or a temporary ureteral catheter were inserted in 92 and 122 cases, respectively, while in 158 cases URL was performed without stenting of the ureter. Most patients were discharged on the first day after the procedure. The stone-free rate on the first postoperative day was 69% for renal; 78% for proximal ureteric; 82% for midureteric, and 97% for distal ureteric stones. The stone-free rates were significantly
higher in distal and nonimpacted stones, but were independent of stone size, stone composition, and the degree of hydronephrosis. The presence of intraoperative complications correlated with stone location and patient gender, being significantly higher (p < 0.01) in proximal stones and in male patients. Conclusions: In experienced hands, RUL is an excellent method to manage urinary stones, located in the UUT, as it is characterized by high efficacy, low cost and minimal morbidity.
S165
Ultrasound guided percutaneous pneumatic lithotripsy in classic lumbotomy position
Radojevic V., Kenic U., Aleksic Dj., Jeremic N., Markovic V., Tomovic S. CHC Zvezdara, Dept. of Urology, Belgrade, Serbia Introduction & Objectives: The aim of this article is to present our experiences in ultrasound guided percutaneous lithotripsy in lumbotomy position. Material & Methods: We performed this procedure on 48 patients, in period from September 2008 to June 2012, with massive renal calculosis. In 6 patients this procedure was performed as a primary procedure, in 12 patients this procedure was performed as secondary procedure many years after open surgery, and in the rest of patients after previosly failed combined retrograde intrarenal lithotripsy and ESWL. 40 patients were in standard lumbotomy position and 8 patients were in modified supine positionUltrasound guided approach was utilized due to restriction of use of x-ray apparatus, for technical reasons, in our department Prior to the procedure, we placed ureteral catheter Ch 5 for arteficial dilatation of pyelocaliceal system and for protective drainage during postoperative care Introducing the puncture needle through dilatated calices, was followed by placement of guidewire and telescopic dilatators (Olympus) in 45 patients, or ballon dilatator (COOK) in 3 patients, to make a working chanell. After that we introduced Amplatz and finally nefroscope Ch 28 (Olympus). Lithotripsies were performed with pneumatic lithotriptor (Swiss lithoclast), using Lithovac aspiration in 40 cases or Olympus LUS-2® ultrasonic lithtripter in 8 cases. The average duration of the procedure was about 130 minutes. Results: Complete disintegration of stone and extraction of fragments was achieved in 30 patients, in 15 patients we had partial disintegration and extraction and in 3 patients we could not reach calices and calculi. In 1 patient procedure was performed in two steps and complete disintegration of stone was achieved. In patients with partial disintegration and extraction retrograde endorenal lithotripsy and/or ESWL were performed later. The requirement for blood tranfusions was needed in 7 patients. One patient with complete disintegration of stone needed conversion to the open procedure with nephrectomy due to excessive bleeding. In 4 patients procedure was complicated with penetration of irrigation fluid in intraperitoneal space, which was evacuated by puncture needle. One patient had pulmonary embolism two weeks after the operation. In other 42 patients the procedure did well without immediate or late complications. None of the patients suffered from peritoneal and bowel injury during intervention. In all patients aspiration drain Ch 16 was left as a nephrostomy tube. Conclusions: In the beggining of utilization of ultrasound guided PCNL we used both lumbotomy and modified supine position Lately, we choose lumbotomy position as it offers greater maneuver space for manipulation with ulrasound probe, puncture needle, guidewire, neprhoscope and lithotriptor. Besides, this position turned out to be safer due to gravitation which moves bowel away from puncture line.
S166
Internal urethrotomy combined with antegrade flexible cystoscopy for management of obliterative urethral stricture
Hosseini J., Mazloomfard M.M., Mokhtarpour H. Infertility and Reproductive Health Research Center, Shaheed Beheshti University of Medical Science, Dept. of Reconstructive Urology, Tehran, Iran Introduction & Objectives: We studied the safety and efficacy of flexible cystoscopyguided internal urethrotomy in the management of obliterative urethral strictures. Material & Methods: Forty-three flexible cystoscopy-guided internal urethrotomies were performed between 2006 and 2009. The indication for the procedure was nearly blinded bulbar or membranous urethral strictures not longer than 1 cm that would not allow passage of guide wire. Candidates were those who refused or were unable to undergo urtheroplasty. By monitoring any impression of the urethrotome on the monitor through the flexible cystoscope, we were able to do under-vision urethrotomy. All of the patients were started clean intermittent catheterization afterwards which was tapered over the following 6 months. Follow-up continued for 24 months after the last internal urethrotomy. Results: Seventeen patients were younger than 65 years with a history of failed posterior urethroplasty, and 26 were older than 65 with poor cardiopulmonary conditions who had bulbar urethral stricture following straddle or iatrogenic injuries. Urethral stricture stabilized in 16 patients (37.2%) with a single session of urethrotomy and in 17 (39.5%) with 2 urethrotomies. Overall, urethral stricture stabilized in 76.7% of patients with 1 or 2 internal urethrotomies within 24 months
Eur Urol Suppl 2012;11(4):173