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-

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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

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In situ lithotripsy of ureteral calculi: review of 261 cases.

The authors report 261 cases of single ureteral calculi treated with in situ lithotripsy after retrograde manipulations had failed. Previous reports h...
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