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Ureteroscopic Stone Removal: Experience with Distal Ureteral Dilation to 24F
Calculi 776
777
BALLOON DILATION OF THE DISTAL URETER: OBSERVATIONS ON SAFETY, SIZE, AND LONG TERM EFFECTS. *Jeffrey D. Elbers, *James Palmer, St. Louis, MO; *William Wassynger, Santa Ana,CA (Presentation to be made by Mr. Elbers) The ability to perform ureterorenoscopy is directly related to the ease of ureteral dilation. In most cases, dilation is limited to 12F due to concerns of extravasation or secondary ureteral stricture. Based upon Dourmashkin's observations that the ureter could be dilated to large size, we elected to study the effect of balloon dilation of the distal ureter to 24F. Cystoscopy was performed in 7 anesthetized pigs weighing an average of 250 pounds. An 0.038 in. Bentson guidewire was passed up both ureters. Under fluoroscopic guidance, an 8 mm, 10 cm long linear extrusion balloon on a 7F shaft (American Edwards, Inc.), was passed over the guidewire into the distal ureter and inflated. After 10 minutes, the balloon was deflated and removed. In l animal, the balloon was left inflated for 50 minutes on both sides. No stents were placed. After 6 weeks, the pigs were evaluated with cystograms and antegrade ureterograms. Each renal unit was harvested intact and sections were made of the ureteral orifice, tunnel, uretero-vesical junction and midureter. One pig died intraoperatively. Two animals died 3 and 9 days postoperatively. In the former, death was associated with perirenal hematomas from a percutaneous nephrostomy. There was low grade reflux in one ureter. In the other pig, both distal ureters were obstructed; however, the balloon in this pig had been left inflated for 50 minutes in both ureters. Four pigs (3 test, I control) survived the 6 week study period. In only one test renal unit was there reflux (grade 1). None of the 6 week animals had a stricture. Histological examination revealed minor urothelial inflammation in only one of the test ureters. In sum, balloon dilation of the distal pig ureter to 24F is safe and effective provided the duration of inflation is brief (i.e. 10 min.). The clinical applicability of these findings is currently under study.
URETEROSCOPIC STONE REMOVAL: EXPERIENCE WITH DISTAL URETERAL DILATION TO 24F. *Todd J. Garvin, St. Louis,MO (Presentation to be made by Dr. Garvin) Ureteroscopy(UR) has become an accepted approach to ureteral stones. Complications such as ureteral perforation or late stricture formation are associated with maneuvering the ureteroscope and stone within the confines of a minimally dilated distal ureter. Previous laboratory work by us, had shown that balloon dilation of the distal ureter to 24F was safe. As such, we studied the effect of balloon dilation to 24F in 21 patients undergoing UR for distal (18) and middle (3) ureteral calculi. In each case, a 0.038 in. guidewire was passed up the ureter. Next, an 8 mm, 10 cm. long balloon, on a 7F shaft (American Edwards/Cook Urologic) was passed over the guidewire until its distal marker was alongside the calculus or its proximal marker was I cm. distal to the ureteral orifice. Slow inflation (0.5 cc/min.) of the dilating balloon, under pressure monitoring conditions, allowed successful dilation of the ureter in each patient. Stones were removed using a 4 prong grasping forceps (17 patients) or electrohydraulic lithotripsy (4 patients). In 10 patients, followup cystograms and urograms were obtained > 3 months after the procedure. Passage of the ureteroscope and successful stone retrieval was achieved in all patients. The mean pressure required for dilation to 24F was 9.4 atm. UR post dilation revealed minor mucosa! tears in 52% and extravasation in 19%. In the latter, an indwelling ureteral stent was placed for 2-4 weeks. Followup studies ( > 3 months) revealed no loss of renal function and no distal ureteral strictures. One patient had asymptomatic grade II reflux. Balloon dilation of the distal ureter to 24F facilitates UR and successful removal of ureteral calculi. Radiographic studies at 3 months further corroborate the safety of this technique.
778
179
COMPARATIVE EXPERIMENTAL STUDY ON THE DISINTEGRATING EFFECT OF THE TUNABLE DYE LASER AND ULTRASOUND ON STONES OF VARIOUS COMPOSITION *Gerhard J.Fuchs, UCLA Stone Center, Division of Urology, University of California, Los Angeles Most ureteral stones are amenable to ESWL therapy which as a non- or in conjunction with ureteral manipulation minimally invasive procedure has become the treatment of first choice. Large impacted stones which can not be manipulated are an indication for disintegration by other means. Recently a 2.5 Fr. wire probe and a 10.5 Fr. rigid ureteroscope has become available to us (Storz). This enabled us to break up all stones which were approached. The potential danger of this procedure includes ureteral damage from the ureteroscopy and thermal damage from the extensive use of the probe. The most innovative method of breaking up ureteral stones is the tunable dye Laser (Candela) which has now been introduced as an investigational device. The 250 micron Laser fiber takes up no place at all and i t can be guided to the stone using small caliber flexible ureteroscopes, such as the 7 Fr. or 9 Fr. flexible ureteroscope by Reichardt.In animal experiments the safety of this procedure has already been shown. A recent comparative study on the fragmenting effect of the wire probe ultrasound and the Laser lithotripter has proven the same disintegrating efficacy of both devices when used under water and on stones contained in a Penrose drain which was held under tension. In conjunction with suitable small caliber flexible instruments the use of the Laser lithotripter obviates the need of ureteral dilation. In the future it may also be used for kidney stones via a retrograde approach once steerable flexible instruments become available.
CLINICAL EXPERIENCE WITH WIRE PROBE ULTRASOUND URETEROLITHOTRIPSY UTILIZING A 10.5 OPERATING URETEROSCOPE. Andrei N. Lupu, UCLA Stone Center, Division of Urology, Univerisity of California, Los Angeles. Between September 1985 and August 1986 68 patients underwent ureterolithotripsy, utilizing a 10.5 french operating ureteroscope with a wire ultrasonic probe. On these 68 patients, 87 treatments for larger ureteral stones requiring disintegration were performed (64% for large solitary stones and 36% for management of Steinstrasse ). Indications were: Failed stone manipulation with or without ESWL for stones above the iliac crest; stones in the "stonecracker's nomansland" between the iliac crest and pelvic brim and large stones in the distal ureter which could not be manipulated. Of the stones treated, 9% were located in the upper third of the ureter, 8% in the mid ureter, and 83% in the lower third of the ureter. The operating time averaged 108 minutes (upper ureter) 140 minutes (mid ureter) and 116 minutes (lower ureter). successful stone disintegration was achieved in 99% of all cases, and the average stone free rate at a six week follow-up was 99%.
298A
777
BALLOON DILATION OF THE DISTAL URETER: OBSERVATIONS ON SAFETY, SIZE, AND LONG TERM EFFECTS. *Jeffrey D. Elbers, *James Palmer, St. Louis, MO; *William Wassynger, Santa Ana,CA (Presentation to be made by Mr. Elbers) The ability to perform ureterorenoscopy is directly related to the ease of ureteral dilation. In most cases, dilation is limited to 12F due to concerns of extravasation or secondary ureteral stricture. Based upon Dourmashkin's observations that the ureter could be dilated to large size, we elected to study the effect of balloon dilation of the distal ureter to 24F. Cystoscopy was performed in 7 anesthetized pigs weighing an average of 250 pounds. An 0.038 in. Bentson guidewire was passed up both ureters. Under fluoroscopic guidance, an 8 mm, 10 cm long linear extrusion balloon on a 7F shaft (American Edwards, Inc.), was passed over the guidewire into the distal ureter and inflated. After 10 minutes, the balloon was deflated and removed. In l animal, the balloon was left inflated for 50 minutes on both sides. No stents were placed. After 6 weeks, the pigs were evaluated with cystograms and antegrade ureterograms. Each renal unit was harvested intact and sections were made of the ureteral orifice, tunnel, uretero-vesical junction and midureter. One pig died intraoperatively. Two animals died 3 and 9 days postoperatively. In the former, death was associated with perirenal hematomas from a percutaneous nephrostomy. There was low grade reflux in one ureter. In the other pig, both distal ureters were obstructed; however, the balloon in this pig had been left inflated for 50 minutes in both ureters. Four pigs (3 test, I control) survived the 6 week study period. In only one test renal unit was there reflux (grade 1). None of the 6 week animals had a stricture. Histological examination revealed minor urothelial inflammation in only one of the test ureters. In sum, balloon dilation of the distal pig ureter to 24F is safe and effective provided the duration of inflation is brief (i.e. 10 min.). The clinical applicability of these findings is currently under study.
URETEROSCOPIC STONE REMOVAL: EXPERIENCE WITH DISTAL URETERAL DILATION TO 24F. *Todd J. Garvin, St. Louis,MO (Presentation to be made by Dr. Garvin) Ureteroscopy(UR) has become an accepted approach to ureteral stones. Complications such as ureteral perforation or late stricture formation are associated with maneuvering the ureteroscope and stone within the confines of a minimally dilated distal ureter. Previous laboratory work by us, had shown that balloon dilation of the distal ureter to 24F was safe. As such, we studied the effect of balloon dilation to 24F in 21 patients undergoing UR for distal (18) and middle (3) ureteral calculi. In each case, a 0.038 in. guidewire was passed up the ureter. Next, an 8 mm, 10 cm. long balloon, on a 7F shaft (American Edwards/Cook Urologic) was passed over the guidewire until its distal marker was alongside the calculus or its proximal marker was I cm. distal to the ureteral orifice. Slow inflation (0.5 cc/min.) of the dilating balloon, under pressure monitoring conditions, allowed successful dilation of the ureter in each patient. Stones were removed using a 4 prong grasping forceps (17 patients) or electrohydraulic lithotripsy (4 patients). In 10 patients, followup cystograms and urograms were obtained > 3 months after the procedure. Passage of the ureteroscope and successful stone retrieval was achieved in all patients. The mean pressure required for dilation to 24F was 9.4 atm. UR post dilation revealed minor mucosa! tears in 52% and extravasation in 19%. In the latter, an indwelling ureteral stent was placed for 2-4 weeks. Followup studies ( > 3 months) revealed no loss of renal function and no distal ureteral strictures. One patient had asymptomatic grade II reflux. Balloon dilation of the distal ureter to 24F facilitates UR and successful removal of ureteral calculi. Radiographic studies at 3 months further corroborate the safety of this technique.
778
179
COMPARATIVE EXPERIMENTAL STUDY ON THE DISINTEGRATING EFFECT OF THE TUNABLE DYE LASER AND ULTRASOUND ON STONES OF VARIOUS COMPOSITION *Gerhard J.Fuchs, UCLA Stone Center, Division of Urology, University of California, Los Angeles Most ureteral stones are amenable to ESWL therapy which as a non- or in conjunction with ureteral manipulation minimally invasive procedure has become the treatment of first choice. Large impacted stones which can not be manipulated are an indication for disintegration by other means. Recently a 2.5 Fr. wire probe and a 10.5 Fr. rigid ureteroscope has become available to us (Storz). This enabled us to break up all stones which were approached. The potential danger of this procedure includes ureteral damage from the ureteroscopy and thermal damage from the extensive use of the probe. The most innovative method of breaking up ureteral stones is the tunable dye Laser (Candela) which has now been introduced as an investigational device. The 250 micron Laser fiber takes up no place at all and i t can be guided to the stone using small caliber flexible ureteroscopes, such as the 7 Fr. or 9 Fr. flexible ureteroscope by Reichardt.In animal experiments the safety of this procedure has already been shown. A recent comparative study on the fragmenting effect of the wire probe ultrasound and the Laser lithotripter has proven the same disintegrating efficacy of both devices when used under water and on stones contained in a Penrose drain which was held under tension. In conjunction with suitable small caliber flexible instruments the use of the Laser lithotripter obviates the need of ureteral dilation. In the future it may also be used for kidney stones via a retrograde approach once steerable flexible instruments become available.
CLINICAL EXPERIENCE WITH WIRE PROBE ULTRASOUND URETEROLITHOTRIPSY UTILIZING A 10.5 OPERATING URETEROSCOPE. Andrei N. Lupu, UCLA Stone Center, Division of Urology, Univerisity of California, Los Angeles. Between September 1985 and August 1986 68 patients underwent ureterolithotripsy, utilizing a 10.5 french operating ureteroscope with a wire ultrasonic probe. On these 68 patients, 87 treatments for larger ureteral stones requiring disintegration were performed (64% for large solitary stones and 36% for management of Steinstrasse ). Indications were: Failed stone manipulation with or without ESWL for stones above the iliac crest; stones in the "stonecracker's nomansland" between the iliac crest and pelvic brim and large stones in the distal ureter which could not be manipulated. Of the stones treated, 9% were located in the upper third of the ureter, 8% in the mid ureter, and 83% in the lower third of the ureter. The operating time averaged 108 minutes (upper ureter) 140 minutes (mid ureter) and 116 minutes (lower ureter). successful stone disintegration was achieved in 99% of all cases, and the average stone free rate at a six week follow-up was 99%.
298A