Clinical Papers © 1990 S. Karger AG, Basel 0302-2838/90/0174-0269Î2.75/0

Eur Urol 1990;17:269-272

Is Routine Dilation of the Ureter Necessary for Ureteroscopy?

1608061

Nelson Rodrigues Netto, Jr., Gustavo Caserta Lemos, Carlos Arturo Levi D’Ancona, Osamu Ikari, Ubirajara Ferreira, Joaquim Francisco de Almeida Claro Hospital Israelita Albert Einstein and Division of Urology, University of Campinas Medical Center, Säo Paulo, Brazil

Key Words. Ureter • Ureteroscopy • Endourology ■ Dilation • Ureterovesical junction • Calculi ■ Lithotripsy Abstract. The results of transurethral ureteroscopic stone removal in 144 patients were reviewed. Patients were treated by two different techniques according to the dilation of the ureterovesical junction before the introduction of the ureteroscope. Group 1 was represented by 71 patients submitted to ureteral dilation and in group 2 there were 73 patients treated without ureteral dilation. There was only one failure in introducing the instrument without ureteral dilation. In patients submitted to transurethral ureteroscopy with previous ureteral dilation, the success of uretero­ scopic stone removal was 91.6% and complications occurred in 6.9%, and, in the cases not submitted to ureteral dilation, the success rate was 99.4% and the complication rate 4.1 %. The success rate achieved in removing upper third stones was 100.0% middle third 90.5% and lower third stones 95.6%. Of the 144 patients treated, 8 (5.5%) had ureteral injury, but only 1 (0.6%) needed open surgery. We do not believe that ureteral dilation prevents complica­ tions or improves the results of ureteroscopic lithotripsy.

Ureteral calculi occur frequently and their treatment remains a major problem to urologists. Extracorporeal shock wave lithotripsy (ESWL) has dramatically changed the management of renal calculi, but questions still exist concerning its application to treat ureteral stones [1]. Transurethral ureteroscopic extraction and fragmen­ tation are the preferred methods for the removal of mid and lower ureteral calculi [2, 3]. After the introduction of the rigid ureteroscope in our clinic, ureterolithotomy was no longer performed. However, the procedure is invasive and it is likely that, as it is performed more generally, there will be more complications. Our reports compare the value of previous ureteral dilation with regard to surgical facilitation and prevention of operatory complications. All procedures were performed by three different members of our department over the last 3 years.

Patients and Methods From January 1984 to December 1987, the records of 144 patients with ureteral calculi treated by a transurethral approach were studied for evidence of operative complications or later mor­ bidity, with regard to the dilation of the ureterovesical junction. Forty-five patients treated before 1984 were not included in this study because they represented the learning period. The indications for ureteroscopy and stone retrieval are similar to those for open ureteral surgery. The technique of ureteroscopy and stone removal was reported previously [4, 5], Dilation was performed over a guide wire with plastic dilators of up to 14 French. The nondilating pro­ cedure is shown in figures 1 and 2. The first 71 ureters were rou­ tinely dilated. It was decided that the following 73 ureters would not be dilated, unless there was a failure in the introduction of the instrument. Therefore, there was only one ureter which needed dila­ tion in this group and it was evaluated in the other group. Epidural anesthesia plus sedation and a fluoroscopy unit were used in all cases. Preoperatively, each patient had an excretory urogram (IVP), complete blood count, blood urea nitrogen, creatinine, glucose, uri­ nalysis with culture and sensitivity, and other tests as indicated by the medical history. Each patient received prophylactic cephalo­ sporins or amnioglycosides. The patients were assigned to 1 of 3 Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 10:52:04 AM

Introduction

Rodrigues Netto/Caserta Lemos/Levi D’Ancona/Ikari/Ferreira/Francisco de Almeida Claro

270

Fig. 1. Two guide wires in place open the ureteral meatus.

C^3 's

groups according to the location of the calculi. Patient data, stone characteristics and technique utilized for stone removal are shown in table 1. Besides the preoperative tests, postoperative follow-up included a metabolic profile and IVP or renal ultrasonography 6 months up to 1 year after surgery. Fisher’s exact probability tests were used. The criteria for statis­ tical significance were set at p = 0.05 for all comparisons.

Results

The results were considered to be successful or unsuc­ cessful according to the outcome of stone removal. The success rate was not significantly different with or without dilation of the ureter regardless of the posi­ tion of the stone (table 2). Overall, 137 of 144 stones

(95.1 %) were removed successfully. Of the calculi local­ ized in the mid ureter, 1 could not be engaged and another could not be extracted. There were 5 failures in the lower ureter. Two stones were displaced out of ureter and, in another patient, the ureter was perforated and an intramural stone could not be removed. In 1 patient the calculus was not found, but the stone passed sponta­ neously after unsuccessful ureteroscopy. Only one failure was submitted to surgical ureterolithotomy (1 of 144, 0.6%). The mean hospitalization after uncomplicated ureterolithotripsy was 3 days. Late complications of transurethral ureteroscopy with regard to ureteral dilation are given in table 3. There were no deaths and no serious cardiovascular accidents. The data presented do not show a statistically significant difference between the groups (p > 0.05).

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éo-

Fig. 2. The ureteroscope is in­ troduced over one of the guide wires. A rotation of 180°, turning down the tip of the instrument, fa­ cilitates the insertion into the orif­ ice and intramural ureter.

Is Routine Dilation of the Ureter Necessary for Ureteroscopy?

271

Table 1. Patient data, stone characteristics and surgery technique Not dilated

Total

71

73

144

Age, years Range Mean Sex Male Female

17-42 40

18-71 46

40 31

41 32

81 63

Position Upper Mid Lower

7 14 51

3 7 62

21

Stone size Length Width

Upper Mid Lower

*

range median range medial

0.6-1.2

0.7-1.2

1.0

1.0

0.3-1.0 0.7

0.4-0.9

37 37 4

47 5

Mean follow-up, months

25

20

21

Not dilated

Total

7/7 (100%) 12/14 (85.7%) 47/51 (92.1%)

3/3 (100%) 7/7 (100%) 61/62 (98.3%)

10/10(100%) 19/21 (90.5%) 108/113 (95.6%)

66/72 (91.6%)*

71/72 (99.4%)*

137/144 (95.1 %)

p = 0.12 (NS).

10 113

Table 3. Late complications of transurethral ureteroscopy ac­ cording to ureteral dilation

Perforation Bleeding Pain Stenosis

1.0

Technique Ultrasound Basket Both

Dilated

58 84 9

Of the 144 patients treated, 8 (5.6%) had ureteral injury but only 1 (0.6%) needed an open operation. There were 2 open surgeries, 1 case due to unsuccessful stone removal and another due to complication during surgery (1.3%).

Discussion

In the past, endoscopic treatment of ureteral calculi was considered under certain restrictions according to the size and the site of the stone, as well as to the urinary infection. Before the introduction of ultrasound disinte­ gration in the treatment of ureteral stones, the indica­ tions for surgical ureterolithotomy were more restricted [4]. The increasing success and low morbidity of ureteroscopic removal of ureteral stones are particularly en­ couraging in view of the drawbacks of other approaches [5], Nowadays, the extracorporeal shock wave lithotriptor can successfully treat stones in all locations [7], How­ ever, the results of the treatment of lower ureteral stones

Dilated

Not dilated

Total

2(1) 3

2(1) 4

0

0 1 1 1

5(1)

3

8(1)

0

1 1

In parentheses are the complications requiring open surgery, p = 0.41 (NS).

with ESWL were not uniformly successful [1,8], Besides, morbidity may also occur [9], Therefore, ureteroscopy will persist as an important technique in the treatment of ureteral stones [6], Questions arose because of the need to dilate the ure­ ter to perform the procedure. Several publications stressed the influence of previous dilation of the ureter in the success rate of stone retrieval [6]. Clinical and exper­ imental studies show that dilation does not damage the ureter [5]. Sometimes the ureteroscope cannot be passed through the orifice and intramural ureter because of unsuccessful attempts to dilate a narrow ureter [10]. Occasionally the failure to introduce the instrument and to progress into the ureter results from the dilator or guide being caught in the mucosa of the intramural ure­ ter. This is particularly frequent when someone has impacted calculi in the intramural ureter surrounded by intense edema. If a mucosal lesion or false passage is created at this level, further dilation or ureteroscopy becomes difficult or impossible. This was seen in 1 patient who had to be submitted to open surgery to remove the stone. The introductory maneuvers are very Downloaded by: University of Exeter 144.173.6.94 - 5/5/2020 10:52:04 AM

Number of patients

Dilated

Table 2. Overall success of ureteral removal according to the stone location and ureteral dilation

Rodrigues Netto/Caserta Lemos/Levi D’Ancona/Ikari/Ferreira/Francisco de Almeida Claro

difficult in some men with an enlarged prostate, which predisposes to ureteral damage and failure to remove the stone. Schultz et al. [ 10] reported trapping of the ureter to occur in approximately 10% of the patients and the ureteroscope could not be inserted [10]. In the present series this was always successful. The ureteroscope was introduced without dilation in all but 1 patient (1 of 73, 1.3%) in the group not submitted to ureteral dilation. Injury of the lower ureter during ureteroscopy, which required ureteroneocystostomy, has already been re­ ported [8, 11, 12]. To avoid this kind of lesion, it is advisable to pass the ureteroscope over or alongside a guide wire which enables the control of the position of the instrument throughout the procedure. An open sur­ gery rate of 0.6% for retrieval of ureteral stones reflects the efficacy of the treatment even for more difficult cases. Several techniques for ureteral dilation have been used and discussed in detail previously [13-15]. Balloon dilation may be less traumatizing; however, the high costs have limited our experience very much. Our late results clearly show that ureteral dilation is not needed to prevent ureteral damage. We observed no significant difference in the group submitted to ureteral dilation, 6.9% (5 of 72) ureteral lesions compared to 4.1 % (3 of 72) in the group without dilation. Some pub­ lications report frequent perforation of the ureter after dilation with coaxial catheters [16]. Perhaps balloon dilation would have given less complications than plastic dilation, but as dilation was not needed routinely, per­ haps this was significantly less traumatizing than all other techniques. In essence, we advocate the introduction of the urete­ roscope without dilating the orifice and the intramural ureter, since this does not facilitate the insertion of the ureteroscope nor does it protect against potential injury to the ureter.

Acknowledgments Statistical analysis was performed by Dr. Neil F. Novo and Iara Giuliano.

References 1 Jenkins, A.D.: ESWL treatment of ureteral calculi (abstract 315). J. Urol. 135: 62A (1986). 2 Huffman, J.L.; Bagley, D.H.; Schoenberg, H.W.; Lyon E.S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J. Urol. 130: 31 (1983). 3 Green D.F.; Lytton, B.: Early experience with direct vision electrohydraulic lithotripsy of ureteral calculi. J. Urol. 133: 767 (1985). 4 Rodrigues Netto, N., Jr.; Lemos, G.C.; Claro, J.F.A.: Methodol­ ogy for endoscopic treatment of ureteral calculi. J. Urol. 135: 909 (1986). 5 Rutner, A.B.: Ureteral balloon dilatation and stone basketing. Urology 23: suppl. 5, p. 44 (1984). 6 Weinberg, J.J.; Ansong, K.; Smith, A.D.: Complications of ure­ teroscopy in relation to experience: report of survey and author experience. J. Urol. 137: 384 (1987). 7 Gillenwater, J.Y.: Complications of ureteroscopy in relation to experience: report of survey an author experience. J. Urol 137: 384 (1987). 8 Lytton, B.; Weiss, R.M.; Green, D.F.: Complications of ureteral endoscopy. J. Urol. 137: 649 (1987). 9 Hardy, M.R.; McLeod, D.G.: Silent renal obstruction with severe functional loss after extracorporeal shock wave lithotrip­ sy: a report of 2 cases. J. Urol. 137: 91 (1987). 10 Schultz, A.; Kristensen, J.K.; Bilde, T.; Eldrup, J.: Ureteroscopy: results and complications. J. Urol. 137: 865 (1987). 11 Carter, S.St.C.; Cox, R.; Wickham, J.E.A.: Complications associ­ ated with ureteroscopy. Br. J. Urol. 58: 625 (1986). 12 Chang, R.; Marshall, F.F.: Management of ureteroscopy injuries. J. Urol. 137: 1132 (1987). 13 Lyon, E.S.; Banno, J.J.; Schoenberg, H.W.: Transurethral urete­ roscopy in men using juvenile cystoscopy equipment. J. Urol. 122: 152 (1979). 14 Bagley, D.H.: Dilation of ureterovesical junction and ureter; in Huffman, Bagley, Lyon, Ureteroscopy, chapt. 5, p. 51 (Saunders, Philadelphia 1988). 15 Blute, M.L.; Segura, J.W.; Patterson, D.E.: Ureteroscopy. J. Urol. 139: 510(1988). 16 Newman, R.C.; Hunter, P.T.; Hawkins, I.F.; Finlayson, B.: The ureteral access system: a review of immediate results in 43 cases. J. Urol. 137: 380 (1987).

Nelson Rodrigues Netto, Jr., MD R. Augusta 2347 3 and. 01413 Säo Paulo (Brazil)

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272

Is routine dilation of the ureter necessary for ureteroscopy?

The results of transurethral ureteroscopic stone removal in 144 patients were reviewed. Patients were treated by two different techniques according to...
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