Urolithiasis (2014) 42:1–7 DOI 10.1007/s00240-013-0635-y

REVIEW

Current status of ureteroscopy for stone disease in pregnancy Hiro Ishii • Omar M. Aboumarzouk Bhaskar K. Somani



Received: 5 November 2013 / Accepted: 16 December 2013 / Published online: 29 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013

Abstract Ureteroscopic management of urolithiasis in pregnancy has been on the rise. Technological advancements such as the development of the semi-rigid or flexible ureteroscope, improvements in the design of baskets used for retrieval and the availability of laser have enabled atraumatic fragmentation of stones. We did a systematic review of literature from January 1990 to December 2012. Data were analysed separately for the time period from January 1990 to June 2010 (Period 1) and for last 2.5 years from July 2010 to December 2012 (Period 2). Inclusion criteria were all English language articles with at least three patients reported. Data were extracted on the outcomes and complications reported in the literature. A total of 271 procedures (116 in period 1, 155 in period 2) across 21 studies were reported in the last 22 years. General anaesthesia was used in 38 % (44/116) in period 1 and in 64 % (99/155) in period 2. The average stone size (7.6 mm) and stone-free rate (SFR) (85 %) were similar in both time periods. Fluoroscopy was used in 20 % (23/116) and 24 % (38/155) in period 1 and 2, respectively. There were fewer complications in period 1 (n = 9) than period 2 (n = 25). These complications were divided into obstetric (n = 5) and non-obstetric complications (n = 29). There were no maternal or foetal deaths during the 22 years. Stone treatment using ureteroscopic techniques in pregnancy can achieve a high success rate. Evidence suggests a

H. Ishii  B. K. Somani (&) Department of Urology, University Hospital of Southampton NHS Foundation Trust, SO16 6YD Southampton, UK e-mail: [email protected] O. M. Aboumarzouk Department of Urology, Academic Unit, University Hospital of Wales, Heath Park, Wales, CF14 4XW Cardiff, UK

rise in the risk of complications with increasing number of these procedures in pregnancy. Keywords Pregnancy  Urolithiasis  Laser  Ureteroscopy  Stones  Complications

Introduction The presence of urolithiasis during pregnancy is rare and the literature reports a wide range of incidence rates; ranging from 1 in 1,500 to 1 in 200 [1–5]. Compared to the lifetime risk of developing urolithiasis in the non-pregnant population (1–10 %) [3], the risks during pregnancy are much lower, ranging between 0.03 and 0.53 % [6, 7]. The diagnosis of urolithiasis in pregnancy is usually made after the first trimester [8, 9] when the disease becomes symptomatic [10–13]. Urolithiasis is the second most common cause of abdominal pain in the pregnant patient after urinary tract infections (UTI), but is the most common cause of nonobstetric reason for hospital admission [12]. During pregnancy, the body undergoes a series of anatomical and physiological changes that may be associated with an increased likelihood of stone formation. The ureters dilate as early as the first trimester and remain dilated throughout pregnancy [14, 15]. This allows the migration of any renal stones down into the ureters, leading to obstruction and/or pain. As well as migration, the dilated ureters can lead to urinary stasis, thereby facilitating the aggregation of urinary crystals [12]. There is also an increase in glomerular filtration rate during pregnancy by 30–50 % [16]. This increased glomerular filtration rate (GFR) results in more sodium, calcium and uric acid filtered by the kidneys. This, with the

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anatomical changes further increases the likelihood or urinary crystal formation. However, this increase in GFR does also increase the urinary excretion of citrate, glycoproteins and magnesium, which have been documented to inhibit stone formation both in vivo and in vitro [15]. The physiological hydronephrosis caused by the enlarged uterus during pregnancy causes diagnosis of intramural obstruction of the ureter difficult. With distal ureteric stones, where the obstruction may be below the pelvic brim and knowing that pregnancy-related hydronephrosis does not tend to go this low, the diagnosis is easier than with proximal or mid ureteric stones. The presence of stones that reside in the urinary tract can lead to renal colic, infection and obstruction, which pose significant risks to both mother and child. When managing a pregnant patient with urolithiasis, conservative management is favoured where possible. This is due to the fact that 70–80 % of stones have been shown to pass spontaneously [17–20]. The mainstay of conservative management is for rehydration, anti-emetics, analgesia and antibiotics if an infection is suspected. In the remaining 20–30 %, surgical intervention is required. The indications for surgical intervention are for those that do not improve with conservative measures, such as infected hydronephrosis with declining renal function or urosepsis [1, 2, 8, 21–24]. Traditionally, surgical intervention in pregnant women with renal colic has consisted of temporising measures; ureteral stenting or percutaneous nephrostomy. However, both options are poorly tolerated, as there is the need for multiple exchanges of the stents or tubes, as these are rapidly encrusted in crystals throughout pregnancy [25]. With the advancements in technology and endourological techniques, ureteroscopy (URS) has become safer with ever improving results as the first line management in ureteric stones in pregnancy.

Materials and methods Search strategy The search involved finding relevant studies from MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, Google Scholar and individual urological journals between January 1990 and December 2012. The terms used in the search included the following: ‘ureteroscopy’, ‘pregnancy’, ‘calculi’, ‘stones’, ‘laser’, ‘laser therapy’ and ‘urolithiasis’. Boolean operators (AND, OR) were used to refine the search. Only papers written in the English language were considered for inclusion. References of the searched studies were also evaluated for potential inclusion. Authors of the relevant studies were contacted to verify data if unclear or unavailable.

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The inclusion criteria for patient population were all pregnant women in all stages of their pregnancy, who were 16 years or older and underwent URS for stone disease. The terms used in the search included the following: ‘ureteroscopy’, ‘pregnancy’, ‘stones’, ‘calculi’, ‘laser’ and ‘laser therapy’. Boolean operators (AND, OR) were used to refine the search. The outcomes measured were the safety and adverse effects of each of these treatments, graded by the Clavien criteria. As well as urological complications, and obstetric complications were also analysed. Efficacy was defined as stone-free rate (SFR) and the need for additional procedures. The included studies had to report upon at least three pregnant patients with ureteric calculi and their surgical intervention with associated outcomes as outlined above. Studies published between January 1990 and June 2010 have been analysed as a systematic review [12] in November 2012. This cohort of studies has been termed as ‘period 10 . The more recent studies published during the period of July 2010 and December 2012 have been termed grouped together and termed ‘period 2’. The results from two cohorts of studies have been compared against each other to see if there have been any improvements or differences in outcomes between the two periods of review and to determine the reason for this. Evidence level of included studies The levels of evidence and recommendation were based on the Centre for Evidence Based Medicine [13]. Data extraction Studies fitting into the inclusion criteria were analysed for the following variables: period of study, country of origin, stone size and location, population demographics (age and gestation), type of anaesthetic used, number and type of procedure performed, method of stone extraction, use of stents (pre- and post-operatively), use of fluoroscopy, SFRs, urological, obstetric and other complications and hospital stay length. This systematic review assesses the outcomes of URS in the management of stone disease during pregnancy between January 1990 and December 2012 (Fig. 1). Due to the steep rise in the number of URS procedures during pregnancy, the results of the data from the last 30 months have been compared to the data set collected up to June 2010 (Table 1).

Results A total of six studies reported on URS in pregnant women that fit the inclusion criteria between July 2010 and December 2012 (Tables 2, 3). All were retrospective case

Urolithiasis (2014) 42:1–7

3

Fig. 1 Outcomes of literature search (January 1990– December 2012)

Table 1 Summary of study information from period 1 (January 1990–June 2010) Year of publication (n)

Country of publication (n)

Journal of publication (n)

1992

1

Brazil

3

BJU

2

1995

1

Canada

2

Int Br J

1

1, 2 and 3

3

1996

2

Italy

1

J Chin Med Assoc

1

1, 3

3

1998

2

Norway

1

J Endourol

3

2

1

2002

3

Pakistan

1

J Urol

5

2, 3

4

2004

1

Saudi Arabia

1

Kaohsiung J Med Sci

1

3

3

2006

1

Sweden

1

Urology

2

2007

1

Taiwan

2

2009

2

Turkey

1

2010

1

USA

2

series. A total of 155 procedures were performed over the six studies. The mean age of this population was 26.7 years (range 18.6–38). The majority of the patients in the studies were in their second or third trimester of pregnancy. Pre-operative imaging methods showed that the majority of patients underwent ultrasound examination (n = 127, 82 %), the next most used imaging modality was low dose computerised tomography (n = 23, 14.8 %) and finally, magnetic resonance imaging was utilised in five patients (3.2 %). The majority of patients underwent their procedure under general anaesthetic (63.9 %), whilst the others either had it under local anaesthetic or sedation (5.1 %), spinal or epidural (31 %) anaesthesia. Stone location was documented in all, but one study. The stones were located in the proximal (28), mid (17) and distal ureter (66). Stone sizes were documented in four out the six studies (average size 7.60 mm, range 3–25 mm). There were 36 rigid URSs (23.2 %), 94 semi-rigid URSs (60.6 %), 8 flexible URSs (5.2 %) and 17 cases where a rigid and flexible URS was used (11.0 %). Peri-operative

Av age range (years)

Trimester (n)

20.54–34.45

1, 2

1

fluoroscopy was used in 38 patients (24.5 %). The most common method of stone extraction was by pneumatic lithotripsy (n = 96, 62 %), the next most common method being basket retrieval (n = 37, 23.8 %). The other two methods of stone extraction were laser lithotripsy (n = 17, 11 %) and stone forceps (n = 4, 2.6 %). 113 stents (72.9 %) were inserted at the end of the procedure. The SFR was reported in four out of the six studies. From these four studies, the mean SFR after first procedure was calculated at 84.65 % (72.7–92.6 %). In total, there were 25 (16.1 %) cases of complications (Table 3). Four of those were obstetric complications including one with premature uterine contractions, one premature delivery, one preterm labour followed by caesarean section and one preterm labour that was then carried to full term. Urological complications included seven ureteric perforations, seven post-operative UTIs, three cases of stent pain, two cases of dysuria and a case each of sepsis and stent migration and expulsion. There were no maternal or foetal deaths reported in any of the studies.

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Urolithiasis (2014) 42:1–7

Table 2 Summary of study information and patient demographics from period 2 (July 2010–December 2012) Author

Year

Country

Journal

Level of evidence

Age range

Trimester

Elgamasy [26]

2010

Egypt

BJUI

4

18–38

Polat [27]

2011

Turkey

Urol Res

4

19–34

2, 3 2, 3

Bozkurt [28]

2011

Turkey

Urol Res

4

20–39

2, 3

Isen [29]

2012

Turkey

J Urol

4

19–42

1, 2, 3

Hoscan [30]

2012

Turkey

J Urol

4

17–37

1, 2, 3

Johnson [31]

2012

USA

J Urol

4

27

1, 2, 3

Table 3 Comparison of the number of complications between the two review periods Complications

Period 1 (n) (January 1990– June 2010)

Premature uterine contraction

1

Period 2 (n) (July 2010– December 2012) 1

Premature delivery

1

Preterm labour followed by caesarean section

1

Preterm labour carried to full term

1

Migration of JJ stent outside external urethral orifice

1

Ureteric perforation

1

Post-operative UTI

5

7 7

Stent induced bladder irritation

3

Dysuria

2

Post-operative sepsis

1

Prolonged admission due to pain

2

In comparison, the previous cohort of studies [12] (January 1990–June 2010) had 15 papers with a total of 116 patients, a mean age of 28 years (range 16–41) and the majority of these patients were in their second or third trimester (Tables 4, 5). Stone-free status was reported as 100 out of the 116 patients, making that a SFR of 86 %. There were a total of nine complications (7.8 %) reported in this cohort (Table 3). There were five UTIs, two cases of stent pain, and a case each of premature uterine contraction and ureteric perforation.

Discussion This review is the biggest review of the outcomes of ureteroscopy and stone fragmentation in pregnancy. There were 271 patients with an average age of 27 years. The majority of these patients were in their second or third trimester. The most number of studies came from Turkey (n = 5), followed by Brazil and USA with three each. There were two studies each from Canada and Taiwan

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whilst Egypt, Italy, Norway, Pakistan, Saudi Arabia and Sweden produced a study each. The traditional management of urolithiasis in pregnancy has been the use of ureteral stenting or the insertion of a percutaneous nephrostomy (PCN) tube. However, these are merely temporising measures and are not without their complications. The stents are prone to increased rates of encrustation, requiring changes every 4–6 weeks, they have been reported to migrate if sited early on during the pregnancy and they have been reported to cause irritation and pain. PCN tubes have similar complications to ureteral stents; a significant proportion of patients requires the removal of the tube due to pain, fever or drainage obstruction. With these risks and the temporary nature of the procedures coupled with the technological advancements as well as increased skill level, URS in pregnancy for stone disease is becoming more common. In the last 3 years patient demographics, mean stone burden has remained stable compared to the period before (Table 5). Although USS has been shown to be the imaging modality of choice there seems to be an emergence of LDCT more recently. Similarly more patients are now having a general anaesthesia now compared previously. More fluoroscopy time and increased stent use in period 2 possibly reflects an increased complexity of stones over time. Although the stone-free rates are fairly similar, the complication rate seems to have increased with time; 7.8 % of cases reporting a form of complication during period 1, compared to 16.1 % of cases with complications in period 2. When specifically looking at the complications, there seemed to be a higher incidence of pneumatic lithotripsy used in period 2 suggesting that perhaps laser fragmentation might be better for stone fragmentation in pregnancy. Neither review period reported any foetal or maternal deaths. As with the previous review [12], there are inherent limitations of this current review. The limitations have not changed; lack of numbers in the literature, leading to case series being published and not well-designed randomised trials or comparative studies, the lack of well-defined inclusion criteria for the studies, performance bias due to level of expertise and experience of surgeon not being known and finally publication bias. However, the results

Rigid 9.5F 15

Flexi 8 Rigid 21 Both 17

Semirigid 9.5Fr 16

Semirigid 9.5Fr 32

8/9.8 Fr Wolf semirigid 12

Elgamasy [26]

Johnson [31]

Polat [27]

Bozkurt [28]

Isen [29]

USS

USS

USS

LDCT 23 USS 18 MRI 5

USS

Imaging

Epidural 12

Spinal 22 GA 7 LA 3

GA 16

GA 32 LA/ sedation 5 Epidural/ spinal 9

GA 10 Spinal 5

Anaesthetic

2 10

Mid third Lower third

5 found on URS, 6 passed spont

5 20

10

Lower third Prox

9

Mid third

Distal

8

Upper third

5 6

Prox Distal

Not mentioned

2

Upper third

Stone location

9.5 Fr semirigid 34

USS

GA 34

8 6 20

Prox Mid Distal

7 mm (4–13)

8 mm (6–10)— for the 25 seen on USS

8 mm (5–19)

N/A

7.8 mm (3–25)

N/A

Stone size (mm)

No

No

No

No

8/46 USS

38/46

No

Fluoroscopy

Pneumatic lithotripter

Pneumatic lithotripter 10*

Stone forceps 2 Laser lithotripsy 17 Pneumatic lithotripsy 8

Pneumatic lithoclast

Lithotripsy 24 Basket 37

Dormia basket/ pneumatic lithotripter 12 Stone king forceps 2 No stones 1

Method

16/34 (47 %)

3/12 (25 %)

19/ 32(59.4 %)

16 post op (100 %)

44/46 (96 %)

15 (100 %)

Stent

85.3

NA

92.6

72.7

88

NA

SFR (%)

Ureteric oedema/mild ureteric perforations 5 UTI 3 Stent induced bladder irritation 3 Premature uterine contraction 1

Nil

2 peri-op perforations 4 post op UTIs 2 post op dysuria 1 post op sepsis

Nil

Preterm labour in recovery ? C section Preterm labour \24 h post op—tocolytic Rx and rest, carried to full term

1 premature delivery. 1 migration of JJ stent outside external urethral orifice and removed w/o complication

Complications

Obstetric care OPA— clinical assessment, USS and urine culture

Dip, urine MC&S and USS every month until delivery.Post-partum XR KUB and noncontrast CT/IVU on all

15/7 post op and/or postpartum—USS and JJ stent removed

Obstetric care, OPA FU—clinical assessment, USS and urine culture

Nil

1/12 post-partum USS and JJ stent removed

Follow-up pattern

URS Ureteroscopy, Rigid Rigid ureteroscopy, Flexi Flexible ureteroscopy, Semi-rigid Semi-rigid ureteroscopy, USS Ultrasound scan, LDCT Low dose CT, GA General anaesthesia, LA Local anaesthesia, PCN Percutaneous nephrostomy, SFR Stone-free rate

Hoscan [30]

*1 patient had PCN initially, then went onto have URS

URS

Author

Table 4 Management and outcomes of patients in the studies included between July 2010 and December 2012

Urolithiasis (2014) 42:1–7 5

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64 (55 %)

The authors declare that they have no conflict

References

B = July 2010–December 2012

USS Ultrasound scan, IVU Intravenous urogram, LDCT Low dose CT, GA General anaesthesia, LA Local anaesthesia, EHL Electrohydraulic lithotripsy

23 LDCT

1

11

XR KUB

NA

17 Rigid ? flexible

4 USS ? Limited IVU 3 Flexible

8 4 Rigid ? semi

Conflict of interest of interest.

A = January 1990–June 2010

8 10

15 Unknown

LA/sedation

5 13

2 MRI

4 Mini

17

16 21

66 46 Distal

17 9 Mid 48 47 Spinal/ epidural 4 IVU 94 47 Semi-rigid

The evidence from this systematic review suggests that URS as the first line surgical management in ureteric stone disease in pregnancy is still a safe and effective procedure. An increase in the number of cases performed and a rise in the complication rates possibly reflect the fact that as more procedures are undertaken there is a potential rise in the complexity of these cases. To further improve efficacy and reduce complication rates, URS in pregnancy should be performed in high volume centres by experienced endourological surgeons with the help of obstetric colleagues.

Laser lithotripsy

Lithoclast

4 1

1 EHL

6 USL

Forceps

6 Displaced

80

37

2

55

Pneumatic

20 Holmium laser

Basket

7 38 (24.5 %) 7.58 26.7 28 99 127 36 62 Rigid

A

B

USS

81

A

B

GA

44

A

B

A

B

Prox

31

28

7.60

23 (19.8 %)

Pulse dye laser

A B A A

B

B

A

Method of stone extraction (n) Fluoroscopy (n) Average stone size (mm) Position of stones (n) Mean age (years) Anaesthesia (n) Pre-op imaging (n) URS type (n)

Table 5 Comparison of variables between the two cohorts

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XR KUB ? USS

A

86 113 (72.9 %)

A

Conclusion

B B

from this review are in keeping with the previous review and are promising. The results of this systematic review show, that despite limitations, URS is an effective procedure, achieving an average SFR of 85.3 % over 271 cases between January 1990 and December 2012.

B

Stent use (n)

84.65

Urolithiasis (2014) 42:1–7

SFR (%)

6

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Current status of ureteroscopy for stone disease in pregnancy.

Ureteroscopic management of urolithiasis in pregnancy has been on the rise. Technological advancements such as the development of the semi-rigid or fl...
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