|
STONE
DISEASE
doi: 10.1590/S1677-553820100002000014
Percutaneous
nephrolithotomy for proximal ureteral calculi with severe hydronephrosis:
assessment of different lithotriptors
Zhu Z, Xi Q, Wang S, Liu J, Ye Z, Yu X, Bai J, Li C
Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan, China
J Endourol. 2010; 24: 201-5
-
Purpose:
We compared the efficacy and safety of percutaneous nephrolithotomy
(PCNL) with different intracorporeal lithotriptors for proximal ureteral
stones in patients with severe hydronephrosis.
Patients and Methods: We retrospectively analyzed the records of 192
patients with proximal ureteral calculi and severe hydronephrosis
who underwent PCNL between February 2003 and December 2007. Calculi
were fragmented with a pneumatic lithotriptor in 44 patients (group
1), Swiss Lithoclast Master in 54 (group 2), low-power holmium:yttrium-aluminum-garnet
(YAG) laser in 56 (group 3) and high-power holmium:YAG laser in 38
(group 4). Patients were assessed about 12 months postoperatively
with intravenous urography and ultrasonography for late complications.
Stone size, operative time, stone-free rate, and follow-up were analyzed
in each group.
Results: Mean stone size for different groups were 16.2 +/- 2.8 mm,
16.6 +/- 2.1 mm, 16.0 +/- 2.7 mm, and 16.4 +/- 1.1 mm, respectively.
Average operative time for different groups were 118 +/- 17 minutes,
81 +/- 10 minutes, 85 +/- 14 minutes, 110 +/- 16 minutes, respectively.
Group 2 and group 3 showed superior outcomes of shorter operative
time (P = 0.000). The overall stone-free rate was 86.5%. As stratified
by lithotriptors, the stone-free rate was 81.8% in group 1, 92.9%
in group 2, 88.9% in group 3, and 78.9% in group 4 (P = 0.190). No
significant difference was found among the groups in terms of blood
loss and postoperative hospital stay. Repeated PCNL or shockwave lithotripsy
was necessary as an auxiliary procedure in 26 patients. The overall
complication rate was 18.2%; most complications were minor and insignificant.
During the follow-up, ureteral stricture developed in 10 patients
and new renal stones developed in 4 patients.
Conclusions: PCNL combined with Swiss Lithoclast Master or low-power
holmium:YAG laser is the preferred endourologic modality for the management
of proximal ureteral calculi in patients with severe hydronephrosis.
- Editorial
Comment
The authors
do not comment on their use of basket devices for fragment removal.
They comment that one deterrent to pneumatic lithotripsy is the large
fragments that are formed, requiring “time-consuming”
extraction. Indeed, the absence of a nephrostomy sheath in their surgical
technique suggests that active fragment extraction is not performed.
As such, this may impact their findings of higher efficacy for lithotripters
that either form smaller fragments (low-energy HO:YAG) or actively
extract stone fragments (ultrasonic component of the Lithoclast).
The finding of a higher ureteral stricture rate with High-energy HO:YAG
is an important contribution to the literature.
The authors do not report their selection of calyx for percutaneous
access; one would anticipate a high percentage of upper and middle
calyces to facilitate access to the proximal ureter with a rigid nephroscope.
For centers selecting a lower calyceal access and the use of a flexible
endoscope, the low-energy HO:YAG would come out on top.
Dr.
Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com
|