Genitourinary John
D. Barr,
MD
In Situ Review
J. Tegtmeyer,
#{149} Charles
calculi.
Two
hundred
fifty-four
calculi were successfully treated with lithotripsy and, when necessary, with additional postlithotripsy radiologic and urologic interventions. Seven (3%) calculi were not successfully fragmented. Nephrostomy was performed in 13 (5%) patients. Retrograde ureteral catheters were not found to enhance calculus fragmentation. In situ (97%)
lithotripsy
of ureteral
calculi
been shown to be feasible ternative to ureterolithotomy retrograde manipulation Index
terms:
Lithotripsy
82.81 #{149} Ureter, 82.1299
Radiology
#{149} Alan
D. Jenkins,
MD
Lithotripsy of Ureteral of 201 Cases’
The authors report 261 cases of single ureteral calculi treated with in situ lithotripsy after retrograde manipulations had failed. Previous reports have indicated that extracorporeal lithotripsy of impacted ureteral calculi has not been highly successful. Two hundred five of the calculi were located in the proximal ureter, above the sacroiliac joint; 27 were in the presacral ureter, overlying the bony pelvis; and 29 were in the juxtavesicular ureter, below the inferior border of the sacroiliac joint. Retrograde ureteral catheters were in place during lithotnipsy for 215
MD
interventional
.
has
as an alwhen has failed.
Ureter, calculi, procedure,
the advent significantly
treatment
of most
the
Calculi:
of lithotnipchanged
patients
with
urolithiasis (1-8), patients with unetemal calculi that cannot be manipulated back into the renal pelvis are not commonly thought to be promising candidates for this form of therapy. It has been shown that uretenal calculi are treated with relative ease
when
they
can
be manipulated
into the renal pelvis; sy of unetenal calculi been less successful the first six lithotripsy
United
States,
the
we review
lithotnip-
(9-12). As centers
one of in the
University
of Vim-
our
results
and
the
the
Departments
of Radiology
(J.D.B.,
three
different tracorporeal
techniques lithotnipsy.
ed manipulation nal
pelvis.
More treated the
METHODS
6,000 patients
have
extracorporeal
lithotripsy
University
Among 261
AND
than with
of Virginia
this
group
ureters
could
not
renal
pelvis
from this undergone
since
were
containing
be manipulated before
back
that
into
the
Excluded
who had procedures,
ipsilateral renal nephrostomy
at presentation,
with
calculi
group were patients ureteral diversion
additional percutaneous
at
1984.
lithotripsy.
had
with
percutaneous
were
excluded often
this
many
calculi, tubes
calculi
in
that
nephrostomy
Retrograde
performed
was
In
215
cx-
tion This
of intact method
the
(83%)
of the
without patients,
were
calculi was was reserved
ret-
in
place
to be
percutaneous
proximal
suc-
extrac-
not for
attempted. patients
joint
of the ureter,
inferior
and
in
(Fig
the
inferior
proximal
1). The
to the
of the
calculi
to 4.0 cm in greatest
205 ure-
joint; 27 the supesacroiliac
juxtavesicular
border
with
to the
sacroiliac between
borders
29 in
the
distal but
border presacral
and
joint;
ureter,
junction
superior in the
below
tubes
of
attempted
whom success could not be achieved relatively noninvasive means. The calculi were located as follows:
nor
dur-
into the me-
extraction
also
antegrade
teropelvic
ureter,
of the ranged
sacroiliac from
dimension,
0.2
with
to allow
us to determine
mean
invasive
procedure
ing the first the patients
three presacral calculi supine, we found that
shock pelvis calculi
waves well. were
did not penetrate the bony The remaining 24 presacra! treated with the patients
prone The
(13,14). calculi
would
lin, NJ). All patients were examined with plain radiography and excretory urography; retrograde urography and ultrasonography were performed when neces-
was
with
of the calculi
calculi
cessful,
in
be required. An HM3 lithotripter (Donnier Medical Systems, Marietta, Ga) was used to treat 257 calculi, while the remaining calculi were treated with a Lithostar unit (Siemens Medical Systems, Ise-
sary.
of the require
treatment
rograde ureteral catheters during lithotripsy. Although it is acknowledged
been
259 patients single
for
Ureteroscopic
success.
PATIENTS
how From
1. Calculi located in each illustrated uretcral segments
Figure
radio-
moved more than 2 cm in the ureter ing manipulations, or had ureteropelvic junction calculi. In particular, patients
I
JUXTAVESICULAR URETER
however,
logic and unologic interventions mequined after lithotripsy to successfully treat these patients.
place
C.J.T.) and Urology (A.D.J.), University of Vimginia Health Sciences Center, Charlottesville, VA 22908. From the 1988 RSNA annual meeting. Received January 24, 1989; revision mequested March 14; revision received July 31; accepted August 7. Address reprint requests to C.J.T. © RSNA, 1990 See also the editorial by Banner et al (pp 1214) in this issue.
PRESACRAL URETER
back
in situ
has,
PROXIMAL URETER
ginia has treated 261 single umetenal calculi in situ after retrograde manipulations had failed. In this article,
had had
1990; 174:103-108
LTHOUGH sy has
Radiology
ureteral
catheterization
in all patients
for attempt-
their
size
locations
of 0.95
cm
were in the
± 0.46.
grouped ureters.
After
a
treat-
with the
according The
to
number
of lithotripsy treatments given in each category, together with the number of calculi requiring radiologic or urologic intervention after lithotripsy, are shown 103
Table
1
of in Situ Lithotripsy
Results
of 261 Ureteral
Calculi No. of No. of Calculi Not Successfully Fragmented
Treatments
Location of Calculi
No. of Calculi
Proximal
ureter Prcsacmal ureter Juxtavesicular ureter
All locations Only one calculus
*
without
not
No. of Calculi Successfully Fragmented
forSuccess 1
2
3
176 18
22 5
3 2
3
0
1
8
30
5
7
54
205 27
201 25
1.0 0.5 0.9 ± 0.3
29 261
28
0.8 ± 0.4
254
successfully
fragmented
25
1.0 ± 0.5
received
more
than
one
219
lithotripsy
Table
A 1.4-cm
Post-
lithotnipsy Intervention
4 2
presacral
cystine
36 10
calculus
was
treated
five
times
2
Apparent
Fragmentation
Overall
Calculi Proximal
Findings
Overall, achieved
successful outcomes for 254 (97%) calculi,
nephmostomy was required to success in 13 (5%). Of the 261 treated with in situ lithotmip-
sy,
(97%)
were
successfully
mented. Only one lithotnipsy ment was required for 219 culi, two treatments were for 30, and three treatments quired for five to achieve fragmentation. Successful
ureter
a rate
of smaller
ureter
Juxtavesicular
All locations
radiographic
calculi
lithotnipsy
the
initial
treatment
ized
in Table
ened
to be well
fragment
dimension fragments
consid-
when
3 mm
could from
no
on more
in
be detectpartially
calculi 5 mm,
measured and from
fragmented
calculi,
5 mm
from poorly
3
on more.
urognaphy Of the
254
four tnipsy.
Of
tional passed
uretemal treat-
treatment,
the
23 17 50
6 2 16
59
12
149
36
20
None Inferior Adjacent Superior
3 0 4 20
2 0 3 10
1 0 0
0 0 1
4
6
Total
27
15
5
7
None Inferior
7 1
3 i
2 0
2 0
Adjacent Superior
2 19
2 i4
0 3
0 2
Total
29
20
5
4
28 18
9
9
Inferior
46 20
Adjacent
78
55
2 16
0 7
Superior
1i7
83
19
15
Total
261
184
46
31
after 14 (30%)
fragments
volume of In most cases,
fragments
cleaned
quickly, as shown with plain madiography, and excretory urography was not necessary. As our experience with patients who have undergone grown,
postlithotnipsy
we
have
excretory
culi
repeat with
one
lithopartial
lithotnipsy
required
addi-
lithotnipsy. Thirty-two patients the fragments and were me-
additional lithotnipsy for 15 of these. In the
of calculus
was delayed on a large fragments was present.
necessary. fragmented
46 calculi
when
104 #{149} Radiology
Poorly Fragmented
78
well-fnag-
lieved of their first lithotnipsy calculi appeared
that
Partially Fragmented
205
required
ments. To detect silent renal obstruction, excretory umogmaphy was employed
has
Well Fragmented
Total
apparently
calculi
and location of retrograde catheters during lithotripsy
lithotnipsy
Lithotripsy
Initial
Superior
is often not successfully
of these
mented
fragmentation
calculus
after
36 19 72
calculi, 184 (72%) appeared to be well fragmented on plain nadiographs aften one lithotripsy treatment. Only
The groups of calculi were also subdivided according to the presence
however,
Appearance
of
were
fragmented to less than
clearance
Treatment
on sole
fragmented
measuring
ed.
Lithotripsy
are character-
2. Calculi
greatest The
appearances
after
or Sole
7 0 6 7
culi.
The
No. of Calculi
Tip
None
cal-
Initial
of
None Inferior Adjacent
frag-
34 calculi meawas achieved,
to that
Presacral
treat(86%) calrequired were mesuccessful fragmenta-
tion of 33 (97%) of the suning 1.5 cm on larger
identical
ureter
were al-
though achieve calculi 254
Position Retrograde Catheter
of
RESULTS
after
of Calculi
Location
found
treatment.
Requiring
success.
in Table 1. A successful outcome was defined as radiographic evidence of calculus fragmentation and dispersion accompanied by resolution of clinical symptoms.
the
No. of Calculi
Mean Size (cm)
that
were
symptoms. treatment, poorly
apparently
After the 24 (9%) fragmented;
was required other nine calpoorly
fragmented, fragmentation was sufficient for passage of the debris. With additional time for fragment dispersion, calculi initially spond unsatisfactorily may subsequently fragmentation and
thought to meto lithotnipsy show greater dispersion on
delayed Of
situ
radiognaphs.
the uneteral
261 calculi
treated
lithotripsy,
with seven
in calculi
could not be successfully fragmented. Four of the treatments were failunes. Symptoms were relieved in the remaining analysis
three
patients.
Careful
of the radiographs and nonvisualization of the calculi at uretenoscopy revealed that the three calculi had been pushed through the uneteral wall into the netropenitoneurn during attempted retrograde manipulations. Poor dispersion of calculus fragments was noted after lithotmipsy. This outcome may have been due to the lack of a fluid-calculus in-
temface and the absence of an expansion space for fragment dispersion. Uneteral perforation with passage of calculi into the netnoperitoneum was well tolerated in these patients. No adverse found. parent
long-term Theme was, advantage
effects were however, no apto treating these
January
1990
eten tip inferior to the calculus on absence of a catheter during lithotnipsy would be less satisfactory for optimal calculus
fragmentation
than
place-
ment of the tip adjacent or superior to the calculus. Our results were, however,
nearly
groups.
identical
In the
former
of the 66 calculi were ed after one lithotnipsy
with
an average
± 782,
and
in the
group,
well fragmenttreatment,
of 2,056
138
two
46 (70%)
(71%)
shock
of the
waves
195
calcu-
ii in the latter group were well fragmented, with an average of 2,302 shock waves ± 626. The mean calculus sizes in each of the two groups (0.99 cm ± 0.48 and 0.94 cm ± 0.45, respectively) shock cantly sults b. Figure 2. Studies lus. (a) Intravenous struction secondary
catheter
in a 32-year-old woman with rena! colic and a history of a ureteral calcupye!ogram obtained before lithotripsy reveals high-grade ureteral obto a 4.0 X 1 .8-cm proximal uretcral calculus. (b) After treatment with
2,000 shock waves, the calculus appears moved by means of ureterolithotomy.
unchanged.
An intact
cystine
calculus
was later
me-
tips
calculi:
well
and
the
placed
18 (90%)
were
not
in the
Percutaneous
calcu2).
unchanged
waves
af-
at 18-26
lithotmipsy
was
kV.
not
thought to be feasible. After removal by means of uretenolithotomy, the calculus was found to be composed cystine. Cystine calculi have been found to be relatively resistant to fragmentation (12).
In two patients 0.6-cm proximal calculi
were
the calculi fragmented lithotmipsy tenolithotomy. and
other
could treated sitating
of
fragmented
after
treatment in each. were disappointed that had been inadequately and declined further in favor of traditional ureAdditional lithotnipsy
nonsungical
probably
have
these patients, unetemolithotomy.
In three patients, poor fragmentation
without
174 #{149} Number
manipu-
tenal
calculus
the first lithotnipsy treatment. subsequent lithotripsy treat-
was
neces-
cal-
poorly
fragmented.
statistically small number this manner
This
Retrograde
Catheter
and
catheters
lithotnipsy unetens
positioning
A
Use
ureteral
in place during (82%) of the 26i
were
in 215 treated. Pres-
of retrograde
cathetens were categorized into four groups: no catheter, catheter with the tip located inferior to but not in contact with the calculus, catheter with the tip adjacent to but not superior to the calculus, and catheter with the tip superior to the calculus. Table 2 characterizes these groups for each calculus location.
On the (9),
placement
basis
of experimental of the
to the
significant of calculi (P > .10).
were
result
was
not
due to the treated in
Interventions
retrograde
The number of radiologic logic interventions required lithotmipsy is shown in Table
fore
lithotmipsy
ureter
was
to attempt
fragmented
ments and uneteroscopic manipulation failed to clean the fragments. umetenolithotomy was subsequently performed.
Retrograde
unexpectedly of one 0.6-cm
calculus
after Four
ence
1
during
lation before lithotnipsy. The stnictune was successfully treated with balloon dilation through the nephnostomy tube placed to relieve obstruction.
interventions
successfully
culus in the proximal uneter and two 0.5-cm calculi in the presacral and juxtavesiculan uneters was noted after normally adequate lithotnipsy. Dcspite this, these patients had relief of symptoms shortly thereafter. The third patient later had recurrent colic, apparently secondary to an inflammatony umetemal stricture (Fig 3).
Volume
perforation
inferior
of nadiographs
In a patient with known cystinunia, a poorly visible 1.4-cm presacral ume-
with 1 .3-cm and unetemal calculi, the
poorly
one lithotripsy Both patients
analysis
confirmed that the calculi had been displaced into the peniuneteral metropenitoneal soft tissues. The proximal umetenal stricture in the third patient may have contributed to the uneteral
ureter
fragmented.
appeared
shock
Retrospective
litho-
had a 4.0 X 1.8-cm in the ureter (Fig
calculus
ten 2,000
with
proximal
adequately
One patient lus impacted
The
calculi
of
of 20 calculi
Postlithotnipsy three peniunetenal tripsy. Four calculi
number
waves used were not signifidifferent (P > .10). The best mewere actually achieved with the
data cath-
was
catheterized
retrograde
and umoafter 3. Be-
performed, at least
calculus
each once
ma-
nipulation. After lithotnipsy, 39 unetens were again catheterized to assist clearance of debris. In most cases, the catheters were maintained in place after treatments so repeat cathetenization was not necessary. Early in our clinical experience, ureteral meatotomy was performed in a number of patients to permit passage of calculus debris. Only one meatotomy was penformed in one patient in this study. Meatotomy has subsequently been found to be unnecessary in most cases and is now infrequently employed at our institution. Percutaneous nephnostomy was mequimed in 13 patients. In these patients, calculi were in the proximal ureter (n = 10) and the pnesacnal ureten (n = 3) (none were located in the juxtavesiculam ureter). Of the 34 patients with calculi larger than or equal to 1.5 cm, two (6%) required nephrostomy, and 1 1 (5%) of 227 patients with calculi smaller than 1.5 cm required nephrostomy. Postlithotmipsy interventions were required for 36 (18%) proximal, 10 (37%) presacral, and eight (28%) juxtavesiculan ureteral calculi. When compared with the proximal ureteral calculi, the increased frequencies of Radiology
#{149} 105
Table 3 Interventions
Required
after
Lithotnipsy
in 261 Ureters
Location
Urcteral
of
Percutaneous
Calculi Proximal
Nephrostomy
ureter
Presacraluretem Juxtavcsicular All
Cathetcri-
Meatot-
Ureter-
Waterpik
Waterpik
zation
omy
oscopy
interventions
required
for
3
1
26 (30)
0
2
7* (8)
1 0
1 0
8(13) 5
0
6
3t
13
4
2
39 (48)
1 i
4 12
both
and a combined and juxtavesiculan
Interventions
3 0
Note-Numbers in parentheses indicate the total number of procedures when multiple * Umeterolithotomy. n 3; balloon dilation of ureteral stricture, n 3 (four procedures); t Laser fragmentation, n 1; balloon dilation of ureteral stricture, n 1; ureterolithotomy,
sacral calculi of pmesacmal
All other
Antegrade
10
ureter
locations
Ureteral
Retrograde
procedures were laser fragmentation, n 1.
performed n
=
in one
kidney
0 10(11) or ureter.
1.
pne-
group calculi
were found to be significant (P < .02). When compared directly with proximal unetenal calculi, juxtavesiculam calculi did not require significantly more interventions (P > .10). The location of the calculi did not, how-
ever, significantly affect the requirement for nephmostomy (P > .10). The increased interventions required for presacmal and ju.xtavesicular calculi consisted
mainly
retrograde
of unetemoscopy
and
catheterization.
Follow-up Of the 254 successfully treated tens, 95 (37%) were free of calculus fragments at the time of discharge.
ure-
Long-term follow-up radiognaphs were available for 54 (34%) of the memaining 159 patients who were successfuily
treated
fragments
had
and
not
in whom
been
a.
b.
all
cleared
at
the time of discharge (Table 4). Obtaming a high follow-up percentage
has been difficult at our institution because of the large geographic distnibution
of our
luctance submit
We
patients
to follow-up
have
pliance
and
of asymptomatic found
me-
to
examinations.
that
is strongly
posttneatment
the
patients follow-up
corn-
linked
to both
complications
and
per-
sistent renal colic. Overall, follow-up madiographs were available for 149 (59%) of the 254 successfully treated uretenal calculi. Follow-up madiogmaphs were exammed to determine the shortest interval at which all fragments had cleaned or the longest interval at which fragments were known to persist. Of the 54 patients in whom follow-up nadiognaphs were available, 39 (72%) who were not clear of fragments at discharge were later shown to be free of fragments at an average of 9 weeks after lithotmipsy. Including the patients clean of fragments at discharge,
134
106 #{149} Radiology
(90%)
of the
149
une-
d.
C.
Figure after
3.
Studies
lithotripsy,
row),
thought
in a 63-year-old although
With
the
calculus
to be in the proximal
catheter lies close to but months later shows the stricture just superior to was performed through tern. The partially inflated
(d)
the
man
balloon
fully
with did
ureter,
renal not
colic
appear
is shown
whose
symptoms
fragmented.
before
lithotripsy.
(a)
initially A 0.6-cm
resolved calculus
A retrograde
(ar-
ureteral
not in contact with the calculus. (b) Retrograde study obtained 18 unchanged calculus (arrow) to be outside the ureter. A tight uretera! the calculus was causing recurrent symptoms. (c) Balloon dilation a nephrostomy tube placed to decompress the renal collecting sys6-mm balloon has a tight waist at the stricture. Arrow calculus. inflated,
the
stricture
disappears.
Arrow
calculus.
January
1990
tens successfully
treated and with follow-up results available proved to be completely free of fragments at some time after lithotnipsy. In the 149 successfully treated uretens with followup available, fragments were present in 15 (10%) at an average interval of 9 weeks after lithotripsy. A significantly reduced volume of calculus fragments (3 mm in diameter) were present in nearly all cases, with no evidence of obstruction, and the patients were asymptomatic. Although long-term follow-up madiographs were not available for 105 (41%) of the patients who were initially successfully treated, our extensive previous experience with lithotripsy of renal calculi has shown that most of these patients will remain asymptomatic and will eventually pass all calculus fragments (12). Initial calculus fragmentation was apparently successful in these patients, and they had no evidence of developing complications. Whether of renal on uretenal origin, calculus fragments in the ureter have similar characteristics. Patients with large quantities of calculus debris were not discharged until significant fragment clearance was noted on the patients had been thoroughly advised of the necessity of maintaining follow-up evaluations. Aggressive efforts were made to contact these patients if follow-up appointments were missed. Patients lost to long-term follow-up residual
had only calculus
small debris.
quantities
of
DISCUSSION Placement of a retrograde ureteral catheter adjacent to the calculus was not shown to improve the likelihood of successful in situ lithotnipsy of uretenal calculi in our series. Experimental data suggest that both a fluidcalculus interface and an expansion space for fragment dispersion are necessary for adequate fragmentation to occur and that these conditions do not exist for impacted uretenal calculi (9). Theoretically, the presence of a
Volume
174 #{149} Number
1
catheter adjacent to the unetenal calculus displaces the unetenal wall away from the calculus, creating both a fluid-calculus interface and an cxpansion space into which fragments may dispense. On the basis of these principles, placement of a catheter with its tip inferior to the calculus would not be expected to improve fragmentation. Our results revealed no significant difference in fnagmentation whether no catheters were placed on catheters were placed with their tips inferior, adjacent, on superior to the calculi. Our clinical results suggest that a minute fluid-calculus interface and space for fragment dispension are both present and adequate for calculus fragmentation, even for impacted uretenal calculi. A macroscopic expansion space was not found to be necessary. Although they have no effect on calculus fragmentation, retrograde unetenal catheters have frequently been used to successfully locate poorly visualized calculi during lithotnipsy, with contrast material being injected during the procedure. The presence of a retrograde uneteral catheter positioned with its tip superion to the calculus virtually eliminates the possibility of obstruction when the catheter is maintained in place after lithotripsy. Of the 261 solitary ureteral calculi in our series, 254 (97%) were satisfactorily fragmented in situ. This figure compares with success rates ranging from 62% (9) to 85% (iO) reported by other groups. Results from these groups do not, however, cleanly cxdude patients with calculi located at the ureteropelvic junction or patients with additional ipsilateral renal calculi. An average of 2,248 shock waves ± 655 were administered during the initial on sole lithotripsy treatment of the calculi in our series. We note that this number is significantly greater than the averages ranging from i,205 to 1,382 shock waves pen treatment reported by other groups (10,11,15). While renal parenchymal contu-
sion been tients
and hematoma formation have described in 0.7%-3.8% of paafter lithotnipsy of renal calculi (16), we did not note any apparent complications related to shock-wave
contusion of the ureter and sunrounding structures. This suggests that the ureter is more resistant to shock-wave injury than the kidney. The tightly focused shock waves employed by the Donnier HM3 lithotripter deliver only 50% of their peak pressure 2 cm from the axis of the tanget (17). As stated previously, calculi located in the unetenopelvic junction were excluded from our review, so that only calculi located within the true ureter, several centimeters from the renal panenchyma, were included. This explains the lack of shockwave-induced renal injuries in our series. In addition, evidence suggests that shock-wave-induced complications are not related to the number of shock waves delivered (16). Successful fragmentation was achieved for 201 (98%) of 205 pnoximal ureteral calculi, 25 (93%) of 27 presacral calculi, and 28 (97%) of 29 juxtavesiculan calculi. The slightly greaten success achieved with proximal and juxtavesicular ureteral calculi was not statistically significant (P> .10). After initial or sole lithotripsy treatment, 56% of the pnesacnal, 73% of the proximal, and 69% of the juxtavesicular ureteral calculi appeared well fragmented. Due to the relatively small number of pnesacral ureteral calculi treated, these differences were not shown to be statistically significant (P > .50). More than one lithotnipsy treatment was required for 30% of the presacral uneteral calculi, but only 12% of the proximal and 10% of the juxtavesiculan uretenal calculi required additional treatments. These differences were significant (P < .05). There was, however, no significant difference in the numben of shock waves used for the mitial or sole lithotnipsy treatment of calculi located in the three distinct ureteral segments (P > .iO).
Radiology
#{149} 107
More successful fragmentation of calculi treated after retrograde manipulation into the renal pelvis has been achieved at our own and other institutions. In our earlier clinical cxperience, 64 (98%) of 65 calculi of this type were successfully fragmented (i2). Our continuing experience has revealed an extremely low failure rate for calculi manipulated into the renal pelvis before lithotnipsy. Other groups have reported success rates ranging from 93% (10) to 100% (18) for this type of calculus. Placement of a percutaneous nephrostomy tube is the most significant required intervention from the viewpoints of both the patient and the physician. Nephrostomy was mequmred for successful treatment in 13 (5%) of the 261 patients in our series. This figure was not significantly greaten (P > .10) than one (1.5%) of 65 patients with calculi that we manipulated into the renal pelvis before lithotnipsy (12). Other groups have reported nephrostorny mates ranging from 5% (15) to 20% (19) for treatment of uneteral calculi, without distinction between calculi treated in situ versus successfully manipulated calculi. Once the nephrostorny tube has been placed, a variety of well-dcscnibed interventional nadiologic techniques are available to clean the calculus fragments (20). It was not necessary to resort to open surgical procedures in any of the patients in whom a nephnostomy tube was placed. In conclusion, successful in situ fragmentation was achieved for 254 (97%) of the 261 solitary uretemal calculi in our series. In the 149 successfully treated calculi with long-term follow-up available, 134 (90%) were
proved completely free of fragments. Our high success rate may be related to the greaten number of shock waves given each calculus than that reported by other groups. We have demonstrated the feasibility of in situ lithotnipsy for uretemal calculi that cannot be manipulated back into the renal pelvis. Although our success rate is slightly lower and our rate of required interventions is slightly higher, our results compare favorably with those achieved with calculi manipulated back into the menal pelvis. As the alternative to open unetenolithotomy, in situ lithotnipsy of uneteral calculi is clearly preferable when retrograde manipulation has failed. U
9.
Drach GW, Dretler 5, Fair W, et al. Report of the United States cooperative study of extracorporeal shock wave lithotripsy. J Urol 1986; 135:1127-1133. Mueller SC, Wilbert D, Thuemoff JW, A!ken P. Extracorporeal shock wave lithotripsy of ureteral stones: clinical experi-
ence and experimental 10.
1 1.
12.
13.
1.
Schmiedt
E, Chaussy
shock-wave
2.
CH.
lithotripsy
14.
E.xtracorporeal
(ESWL)
of kidney
and umeteric stones. mt Urol Nephmol 1984; 16:273-283. Chaussy CH, Brendel W, Schmiedt E. Extmacorporeally induced destruction of kidney stones by shock waves. Lancet 1980; Chaussy CH, Schmiedt E, Jocham D, Brendel W, Forssmann B, Walther V. First clinical experience with extracorporeally induced destruction of kidney stones by
4.
Chaussy
lithotripsy: of kidney
Kargem,
in the treatNew York:
1982. 18.
B, eds. Stones:
19.
kins,
clinical Baltimore:
1983;
Chaussy Schu!lem
porca!
7.
new aspects stone disease.
Chaussy CH, Schmiedt E, Jocham D. Nonsurgical treatment of renal calculi with shock waves. In: Roth RA, Finlayson urolithiasis.
6.
17.
waves.
wave ment 5.
cases.
J Umol 1982; 127:417-420. CH, ed. Extracorporeal shock
shock
Schmiedt
J, Brand! shock-wave
an 1984;
Williams
of & Wil-
461-476.
CH,
alternative
E, Jocham
20.
D,
H, Lied! B. Extracorlithotripsy (ESWL) for
treatment of urolithiasis. 23:59-66. Chaussy CH, Schmiedt shock wave lithotripsy stones:
management
Urology
ureter
or anomalous
a retrospective
J Urol
J Urol
kidney.
analysis
of 417
1988; 139:513-516.
Knapp PM, Kulb TB, Lingeman JE, et al. Extracorporeal shock wave lithotripsy-induced perirenal hematomas. J Urol 1988; 139:700-703. Coleman AJ, Saunders JE. Comparison of extracorporeal shock-wave lithotripters. In: Coptcoat MJ, Miller RA, Wickham JEA, eds. Lithotripsy II: textbook of second generation extracorpomeal lithotripsy. London: BDI, 1987; 121-131. Dretler SP, Keating MA, Riley J. An algorithm for the management of ureteral calcu!i. J Umol 1986; 136:1190-1193. Cochran ST. Extracorporeal shock wave lithotripsy: clinical results. Urol Radiol 1988; 10:46-47. Tegtmeyer CJ, Kellum CD, Jenkins A, et a!. Extracorpomea! shock wave lithotripsy: interventional radiologic solutions to associated
1984;
J Uro!
1988; 139:911-915. Jenkins AD. Domniem extracorporeal shock-wave lithotripsy for ureteral stones. Umol Clin North Am 1988; 15:377-384. Graff J, Pastor J, Funke PJ, et a!. Extracorpomeal shock wave !ithotripsy for uretera! stones:
16.
2:1265-1268.
3.
15.
findings.
1986; 133:831-834. Riehle RA, N#{227}s!und EB. Treatment of calculi in the upper ureter with extracorporeal shock wave lithotripsy. Surg Gynecol Obstet 1987; 164:1-8. Lingeman JE, Shirrell WL, Newman DM, et al. Management of upper ureteral calculi with extracorpomeal shock wave lithotripsy. J Urol 1987; i38:720-723. Kellum CD, Tegtmeyem CJ, Jenkins AD, et a!. The role of radiology in extracorporea! shock wave therapy. Radiology 1987; 165:431-438. Jenkins AD, Gillenwater JY. Extracorporeal shock wave lithotripsy in the prone position: treatment of stones in the distal
References
diol
108 #{149} Radiology
8.
problems.
Radiology
1986;
161:587-592. E. Extracorporeal (ESWL) for kidney to surgery?
Umol
Ra-
6:80-87.
January
1990