Original Paper Urol Int 1992;49:167-170

M. Ruckdeschel E. Bauer W. Schneider J.E. Altwein

ESW L of Stones in the Mid-Ureter

Department of Urology, Krankenhaus der Barmherzigen Brüder München, BRD



ESWL in situ Ureteric stones Sedoanalgesia Noninvasive ESWL

Two hundred and twenty patients with a ureteric calculus were treated by in situ ESWL; in 60 of these the stone was located in the mid-ureter. Treatment was given without anesthesia or with sedoanalgesia only. Complete or partial stone clearance at the time of discharge from hospital was achieved in 95% irrespective of the site of the stone and there were no complications. It is sug­ gested that in situ ESWL is effective in the treatment of stones in mid ureter as well as those in upper and lower ureter.

ESWL has universally been accepted as a standard method for the removal of concrements in the urinary tract. Whereas the success rate is high for stones situated in the kidney, the reported rate of success with ureteric stones has been variable [1-3] and the optimal treatment for stones in the mid-ureter (i.e. stones overlying the pel­ vic bone) is still controversial. At the moment, the options available are open operation, ureteroscopy (retrograde or antegrade, with or without laser disintegration), use of Zeiss-loop, push-bang, in situ ESWL after passing a cathe­ ter bypassing the stone and in situ ESWL alone without any form of manipulation. In situ ESWL alone is ob­ viously the least invasive of all the options and herein we describe our experience with this method of treating ure­ teric stones.

Patients and Methods Between June 1987 and November 1989, 1,010 patients were subjected to ESWL using Siemens ‘Lithostar’, a lithotriptor using the electromagnetic technique of shock-wave (SW) generation. A SW is generated when an electrical impulse moves on a metallic membrane

Received: September 30,1991 Accepted: April 6. 1992

housed in a ‘shock tube’. The SW is focused by an acoustic lens and is transmitted to the body surface by means of a water cushion. The stone localisation is guided with biplanar fluoroscopy where also hard copy radiographs during treatment are possible. The Lithostar was introduced in 1986 [4]. Two hundred and twenty (22%) of the 1,010 patients had a ure­ teric calculus either alone or in combination with ipsilateral pyelocaliceal stones. There were 157 (71 %) males and 63 (29 %) females with a mean age of 48 years for males (range 10-75 years) and 49 years for females (range 11-81 years). Seventy-five (34%) stones were located in the upper ureter, 60 (27%) in the mid-ureter and 85 (39%) in the lower ureter; 112(51%) stones were in the right ureter and 108 (49 %) were in the left. The range and mean size of stones at all localisations is shown in table 1 (size is the largest single diameter as measured on X-ray). The prerequisites for carrying out in situ ESWL irrespective of the size and location were as follows: (1) the calculus should be visi­ ble on 2 planes, including cases when i.v. contrast and other support­ ing manipulations were used to aid localisation; (2) no urinary infec­ tion; (3) absence of severe obstruction (greater E II) determined by ultrasound, according to the classification of Emmett [5]; (4) satisfac­ tory renal function as indicated by serum creatinine, urea, sodium, potassium and also by recent renography; (5) that the height and weight of the patient were not extreme; gross obesity or anorexia interfere with proper stone localisation due to the fixed focus at max­ imum energy of the lithostar. In patients with acute fever and/or obstruction, a percutaneous nephrostomy tube or a double-J stent was inserted to relieve the obstruction prior to lithotripsy. After relief of obstruction or after

Dr. mcd. M. Ruckdeschel Department of Urology Krankenhaus der Barmherzigen Brüder Romanstrasse 93 D-W-8000 München 19 (FRG)

© 1992 S. Karger AG, Basel 0042-1138/92/0493-0167 $2.75/0

Downloaded by: Univ. of California Santa Barbara - 3/5/2018 10:44:25 AM


Table 1. Data of patients, stone size. ESWL-sessions and results of the in-situ-ESWL Upper ureter Patients Stone size, mm Mean Range Fragmentation After 1 session After 2 sessions After 3 sessions Failed fragmentation Number of SW needed Mean Range Stone free Fragmentation in situ at hospital discharge Successful treatment, %



8.1 ±0.5 2-20 66 9 4(5.3%)

8.8 ±0.4 3-20 47 1 1 3(5%)

Lower ureter 85 8.9 ±0.7 2-45 70 14 1 4(4.7%)

3.320 800-8.400 49(65%)

3.900 1.400-8.800 39(65%)

3.730 800-7.000 60(70%)

22(29%) 94

18(30%) 95

21 (25%) 95


Two hundred and fifty-nine treatments were given to the 220 patients; 183 patients (83%) received one treat­ ment, 35 (16%) received two treatments and 2 (1%) received 3 treatments. The number of sessions and results are shwon in table 1. Most of the patients could tolerate the maximum power of 19kV and needed 4,000 SW (range 800-4.000) before fissures could be discerned in the stones. There was no relationship between the loca­ tion of the stone and the number of shocks required to fragment it (table 1). Auxiliary procedures were required in 65 (29.5%) - percutaneous nephrostomy in 14 (6.4%), double-J stent in 22 (10%), Zeiss loop in 21 (9.55%) and ureteral catheter in 8 (3.6%) cases. Intravenous contrast to aid localisation was used in 14 cases. 3 being in the midpart of the ureter. The duration of hospitalization ranged from an ambu­ latory status in 12 cases to 23 days in the case of an 81year-old septic patient, most patients being hospitalized for 4-8 days (mean hospitalization period 7 days; see table 1). In 46 patients (21%). an additional treatment before ESWL was indicated in consequence of compli­ cated stones, causing a delay of stone treatment of 1-14 days (average 5.2 days). Complete fragmentation was achieved in 209 (95%) of cases. One hundred and forty-eight (67%) were stone free at the time of discharge from hospital and an additional 61 (28%) passed fragments while in hospital and were expected to pass the remaining fragments without addi-


ESWL of Stones in the Mid-Ureter

Downloaded by: Univ. of California Santa Barbara - 3/5/2018 10:44:25 AM

reduction of fever the stones of these patients were treated by in situ ESWL; push and smash was not carried out. If fever and/or obstruc­ tion occurred after ESWL auxiliary measures were carried out. Intra­ venous contrast (johexol 647 mg/ml, 75 ml) was used if the stones were nonopaque. The treatment was done usually in the supine position beginning with a low SW energy (13 kV); after 600-800 SW 19 kV was applied and given until fissures appeared on the calculus or until 4,000 SW were reached. Auxiliary means were limited to stasis, fever or diffi­ culties in stone positioning, e.g. focussing being possible in one plane only. Sedoanalgesia (10m l lidocaine 10 mg/ml s.c. or diazepam 10 mg i.v.) was routinely used for placement of a nephrostomy but only if necessary for placement of a double-J stent, a ureteral catheter or a Zeiss loop. If the stone did not disintegrate after one ESWL session, a second ESWL in high lying stones was undertaken. For stones in a lower position, a Zeiss loop was placed to guide the second ESWL. An attem pt was made to remove the stone with this loop - if successful the case was excluded from this study. If this attempt failed, the Zeiss loop was left in situ to aid localisation, especially if the stone was overlying the pelvic bone. In the mid-ureter no attempt was made to withdraw the loop. With a well-placed loop, a ‘chamber effect’ by the surrounding urine is thought to aid fragmentation of the stone. The results of ESWL were reviewed by X-ray 2 days after treat­ ment to check for fragmentation and ultrasound scanning of the kid­ ney was undertaken to exclude stasis before the patient was dis­ charged from hospital. ESWL was given without any form of anesthesia except at the request of the patient or if the clinician giving treatment felt that it was required. If necessary sedoanalgesia which consisted of piritramide 15 mg or pethidine 100 mg and diazepam 10 mg or triflupromazine 10 mg was used. One hundred and forty-four of 220 patients (65%) needed an analgesic and 75 (34%) a tranquilizer; of these, 67 (31 %) had a combination of both. Prophylactic antibiotics were not used routinely.



U reteral calcu lu s


No obstruction

No infection





Antibiotics and/or D J, PCN, UK

No obstruction

No infection


D J, PCN, UK / /



ESWL has proven to be effective for stented ureteral stones [6, 7], It is argued that the decreased efficacy of ESWL for ureteric stones is due to a lack of adequate expansion chamber around the stone [8], Therefore, inva­ sive techniques to dislodge, fragment and extract the ure­ teral calculus are given first priority [9], Impacted radiodense stones at any level of the ureter exceeding 1.5 cm unstentable by definition - should even be treated by ure­ terolithotomy [8], Conversely, ESWL is considered as an alternative only after failure of invasive standard tech­ niques [10]. According to some reports, invasive procedures de­ spite all their complications and risks are preferred to noninvasive techniques, although the ‘positive’ results of all invasive procedures vary between 60 and 95% [11, 12], At this point, it should be reemphasized that ‘endoscopically successful' does not mean immediate stone clear­ ance. In detail, the success rate decreases in the mid- and upper ureter to 60-70%; in the lower ureter the success rate varied from 80 to 95% [11]. Thus, the majority of ureteral stones may be successfully managed using endo­ scopic techniques; however, results are related to stone size, location and experience of the urologist. In our study, after ESWL in situ 95% of the stones were desintegrated. These techniques have been accompanied in up to 35% by minor complications like hematuria, fever, mild ureteral trauma and proximal stent migration, in addition major complications (8%) like ureteral perforation, avul­ sion, necrosis, stricture and ureteral-valve insufficiency


ESW L in situ

Contrast filling of the fistula or i.v. urogramm



▼ i.v.urogramm


Fig. 1. Algorithm for the first line treatment of ureteral calculi.

after dilatation when rigid LISL is used are encountered [ 11]. Among the latter, ureteral perforation is the most common complication and has been reported to occur in up to 28% of all procedures [3, 11], Furthermore, 3 or 4 h - in general anesthesia - are not unusual for successful fragmentation of a large impacted calculus [13], which does not mean stone clearance. Contrary to these programs, our complication rate using ESWL first is very low with no severe aftermaths and corresponds to similar studies [14-18], In addition, the amount of invasive measures has been lowered to 29.5%. Our results are comparable to those mentioned above and show the same fragmentation rate as other authors in first ESWL session and a similar rate of repeti­ tion of unsuccessful ESWL [1, 14, 15]. In all sections of the ureter, in situ ESWL is easily feasible; the fragmenta­ tion rate, repetition and frequency of auxiliary methods being minimally worse in the mid-ureter after the first ses­ sion: 78% in the mid-ureter to 88% in the upper and 82% in the lower ureter. SW energy is independent of the local­


Downloaded by: Univ. of California Santa Barbara - 3/5/2018 10:44:25 AM

tional procedures. No fragmentation at all occurred in I 1 patients (5%) to whom we applied the following proce­ dures: ureterolithotomy (4). LISL (4), and disintegration with an ultrasound probe (3). In 7 of these 11 cases exten­ sive obesity was thought to be responsible for the ESWL failure. Severe complications did not occur. Colicky pain or arrhythmias in 24 cases (11%) had no serious conse­ quences. The outset of pain during ESWL led us to double the analgesic medication under ECG control. In the pres­ ence of arrhythmia we continued the ESWL with reduced energy until the disappearance of arrhythmia and trig­ gered the SW application by the R peak of the ECG. A dilatation of the pyelon due to ESWL of the ureter persist­ ing on hospital discharge disappeared as proven by ultra­ sound in our outpatient clinic 4 weeks after hospital dis­ charge.

isation of the stone but depends on its physicochemical structure [8], No general anesthesia - as is required in invasive ure­ teral manipulations or surgical techniques - is necessary. 35% of the patients did not require any anesthesia at all during ESWL. The remaining 65% could be managed with sedoanalgesia only to ensure motoric sedation dur­ ing the session in agreement with other studies using the Lithostar [14], The hospitalization time of our patients was relatively long. It was partly due to the number of complicated stones with severe obstruction (> EII), colic, fever or urosepsis in nearly one third of all cases of our patients causing a delay of stone treatment in 21 %. Also, the length of hospital stay was influenced by the request of the referring urologist preferring stone clearance or disin­

tegration of the calculi with a maximum size of 5 mm for spontaneous clearance before getting the patient back. In essence, the optimal treatment of stone is debatable. In all sections of the ureter, including the upper and lower ureter, noninvasive in situ ESWL deserves first priority provided the stone is exactly positionable on the focal point (fig. 1). Furthermore, it does not require general anesthesia. Stone clearance is in the same range as in patients having had invasive procedures (including rigid L1SL) first. Flexible LISL is an attractive procedure although it requires general anesthesia and stone debris are left behind. A randomized trial should be helpful to further define the proper treatment of ureteral calculi. Presently, most of the ureteral stones can be managed by noninvasive technique.

1 Ikemoto S. Sugimoto T. Yamamoto K. ct al: Comparison of transurethral ureteroscopy and extracorporal shock wave lithotripsy for treat­ ment of ureteral calculi. Eur Urol 1988:14: 178-180. 2 Liong ML, dayman R, Gittes R, ct al: Treat­ ment options proximal ureteral urolithiasis: Review and recommendations. J Urol 1989: 141:504-509. 3 Miller K, Fuchs G, Rassweiler J, et al: Treat­ ment of ureteral stone disease: The role of ESWL and endourology. World J Urol 1985;3: 53-57. 4 Wilbert D, Voges G, Müller S: ESWL des Harnleitersteins - Klinische Ergebnisse mit der lokalen Stosswellenlithotripsie. Urologe 1987; 26:317-321. 5 Emmett JL: Urinary stases: The obstructive uropathies, atony and neuromuscular dysfunc­ tion of the urinary tract: in Emmett JL (ed): Clinical Urography. Philadelphia, Saunders, 1964.

6 Lingemann JE. Shippcll WL. Ncwmann DM, et al: Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. J Urol 1987;138:720-723. 7 Preminger GM, Kettelhut S, Elkins SL. ct al: Ureteral stenting during ESWL: Help or hin­ drance? J Urol 1989:142:32-36. 8 Morgenthaler A, Bridge SS, Drcttler SP, et al: Management of the impacted ureteral calculus. J Urol 1990;143:263-266. 9 Drettler SP, Renting MA, Riley J, et al: An algorithm for management of ureteral calculi. J Urol 1986;136:1190-1193. 10 Evens RJ, Wingfield DD, Morollo BA. et al: Ureteral stone manipulation before extracor­ poreal shock wave lithotripsy. J Urol 1988; 139: 33-36. 11 Spirnak JP, Resnick MJ: Percutaneous Man­ agement; in Resnick MJ. Pak ChYC(eds): Uro­ lithiasis. Philadelphia, Saunders. 1990, 1st ed, chap 15, pp 279-319. 12 Spirnak JP. Resnick MJ: Ureteroscopy; in Rcsnick MJ, Pak ChYC (eds): Urolithiasis. Phila­ delphia, Saunders, 1990, 1st ed. chap 15, pp 253-278.

13 Seeger AR. Ritterberg MH, et al: Ureteropyeloscopic removal of ureteral calculi. J Urol 1988; 139:1180-1183. 14 El-Damanhoury H. Schärfe Th, Rüth J. et al: ESWL of urinary calculi: Experience in treat­ ment of 3,278 patients using the Siemens Li­ thostar and Lithostar Plus. J Urol 1991 ; 145: 484-488. 15 Puppo P, Bottino P, Germinale F, et al: Extra­ corporeal shock wave lithotripsy in the prone position for stones situated anteriorly. Eur Urol 1988:15:113-117. 16 Tiselius HG. Petterson B. Anderson A, et al: Extracorporeal shock wave lithotripsy of stones in the mid ureter. J Urol 1989;141:280-282. 17 Bauer E, Baur H, Schneider W. ct al: ESWL management of ureteral calculi without anes­ thesia: An alternative to invasive procedures. Eur Urol 1989;16:405-409. 18 Chaussy C, Schmiedt E, Jocham D. et al: Extra­ korporale Stosswellenlithotripsie. Beginn einer Umstrukturierung in der Behandlung des Harnsteinleidens? Urologe A 1984;23:25-29.



ESWL of Stones in the Mid-Ureter

Downloaded by: Univ. of California Santa Barbara - 3/5/2018 10:44:25 AM


ESWL of stones in the mid-ureter.

Two hundred and twenty patients with a ureteric calculus were treated by in situ ESWL; in 60 of these the stone was located in the mid-ureter. Treatme...
608KB Sizes 0 Downloads 0 Views