STONE DISEASE

Combined retrograde flexible ureteroscopic lithotripsy with holmium YAG laser for renal calculi associated with ipsilateral ureteral stones
Cocuzza M, Colombo JR Jr, Ganpule A, Turna B, Cocuzza A, Dhawan D, Santos B, Mazzucchi E, Srougi M, Desai M, Desai M
Department of Urology, University of Sao Paulo (USP), Sao Paulo, Brazil
J Endourol. 2009; 23: 253-7

• Purpose: The purpose of this study was to evaluate the effectiveness of combined ureteroscopic holmium YAG lithotripsy for renal calculi associated with ipsilateral ureteral stones.
• Materials and Methods: Between August 2002 and March 2007, retrograde flexible ureteroscopic stone treatment was attempted in 351 cases. Indication for treatment was concurrent symptomatic ureteral stones in 63 patients (group I). Additional operative time and perioperative complication rates were compared to a group of 39 patients submitted to ureteroscopic treatment for ureteral calculi exclusively (group II).
• Results: Mean ureteral stone size was 8.0 ± 2.6 mm and 8.1 ± 3.4 mm for groups I and II, respectively. Mean operative time for group I was 67.9 ± 29.5 minutes and for group 2 was 49.3 ± 13.2 minutes (p < 0.001). Flexible ureteroscopic therapy for renal calculi increased 18 minutes in the mean operative time. The overall complication rate was 3.1% and 2.5% for groups I and II, respectively (p = 0.87). Mean renal stone size was 10.7 ± 6.4 mm, overall stone free rate in group I was 81%. However, considering only patients with renal stones smaller than 15 mm, the stone free rate was 88%. Successful treatment occurred in 81% of patients presenting lower pole stones, but only 76% of patients with multiple renal stones became stone free. As expected, stone free rate showed a significant negative correlation with renal stone size (p = 0.03; r = -0.36). Logistic regression model indicated an independent association of renal stones smaller than 15 mm and stone free rate (OR = 13.5; p = 0.01).
• Conclusion: Combined ureteroscopic treatment for ureteral and ipsilateral renal calculi is a safe and attractive option for patients presenting for symptomatic ureteral stone and ipsilateral renal calculi smaller than 15 mm.
  
  
• Editorial Comment
  The authors are to be commended for the high stone-free rate obtained with the stringent criteria based on CT scan imaging. One might consider that it could be difficult to standardize instrumentation and technique across three continents and across a 5-year time period - this may impact the interpretation of results especially if a larger bulk of the flexible ureteroscopies were conducted in the later portion of the study period when the authors had more experience and better instrumentation. It would be helpful for the authors to define their criteria for using a ureteral access sheath - it is our practice to use it routinely during intrarenal stone extraction to improve stone frees rates and minimizes the risk of ureteral injury.
  The authors importantly define the upper limit of stone size to tackle ureteroscopically - 15 mm. Beyond this size one must inform patients of the risk of requiring staged ureteroscopies to render stone-free. Another important consideration is that all patients were stented after the surgery. As 60% of these patients had distal ureteral calculi, they could have been offered the alternative of no stent if intrarenal calculi were not treated at the same setting. Often patients who have had significant stent discomfort in the past will elect to leave the intrarenal stone untreated so as to avoid the ureteral stent.

Dr. Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com