0022-534 7/90/1432-0273$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 143, February
Printed in U.S.A.
LASER URETEROLITHOTRIPSY WITH COMBINED RIGID AND FLEXIBLE URETERORENOSCOPY EIJI HIGASHIHARA, SHIGEO HORIE, TAKUMI TAKEUCHI, SHUJI KAMEYAMA, YASUYUKI ASAKAGE, YOSHIO HOSAKA, YUKIO HONMA, SHIGERU MINOWADA AND YOSHIO ASO From the Department of Urology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
ABSTRACT
Because the pulsed dye laser can be transmitted through a thin, flexible quartz fiber a small caliber ureteroscope and flexible ureterorenoscope are applicable. Therefore, the use of a rigid or flexible ureterorenoscope was combined with laser lithotripsy to treat upper urinary tract calculi. All 14 ureteral stones below the pelvic brim were removed successfully with a rigid 7.2F (outer diameter) ureteroscope and 14 of 16 stones above the pelvic brim were removed with a flexible ureterorenoscope. Laser monotherapy was effective in 24 cases and the complementary use of forceps or electrohydraulic lithotripsy was required in 4. Two stones were lost from the visual field during endoscopic manipulation. There was no complication requiring surgical correction. The combined use of these instruments is highly successful and safe for the treatment of upper urinary tract calculi. (J. Ural., 143: 273-274, 1990) Watson and associates 1- 3 introduced the pulsed dye laser for stone fragmentation and its clinical efficacy has been established by Dretler4 •5 and Coptcoat6 and their associates. Dretler and associates initially used a 9.5F ureteroscope. Later, Dretler developed a 7.2F in diameter device and achieved good clinical results. 7 The laser beam can be transmitted through a thin, flexible quartz fiber and it can be used with a flexible ureterorenoscope. Therefore, we combined the use of rigid and flexible ureterorenoscopy with laser lithotripsy for upper urinary tract stones.
flexible ureterorenoscope the quartz fiber was encased in the polyethylene tube when the working channel was passed. The tip of the quartz fiber was placed in contact with the surface of the calculus and laser pulses were delivered at a repetition rate of 10 Hz. under direct vision with a video monitoring system until the stone was reduced to spontaneously passable fragments of less than 1 to 2 mm. in diameter. The power of the laser emission was set at 40 mJ. and increased to 50 mJ. when stone fragmentation was not sufficient. When stone fragmentation was not achieved with laser lithotripsy adjuvant electrohydraulic lithotripsy was performed.
MATERIALS AND METHODS
Patients with ureteral stones were selected for laser treatment if the stone had been impacted for more than 1 month or required retrograde ureteral manipulation before extracorporeal shock wave lithotripsy (ESWL*). The flush lamp MDL-1 excited dye laser,t emitting a wavelength of 504 nm. was used. A 7.2F rigid ureteroscope 7 was selected for stones below the pelvic brim. If the stone was pushed up to the upper ureter or renal pelvis during manipulation with a rigid ureteroscope or if it was primarily above the pelvic brim a 10.8F flexible ureterorenoscope:j: was used. The patients were placed in the lithotomy position under spinal or epidural anesthesia. For insertion of the rigid ureteroscope a hydrophilic polymer-coated guide wire was inserted retrograde into the ureter. The lubricating characteristic of the polymer facilitated the guide wire bypassing the calculus. The 7.2F ureteroscope had 2 working channels 0.028 inch in diameter that allowed for smooth manipulation of a 0.025 inch guide wire and a 0.25 mm. laser quartz fiber with saline irrigation. The rigid ureteroscope was passed per urethram through the outer cystoscopy sheath and advanced up to the calculus over the guide wire without ureteral dilation. When the stone was in view the guide wire was replaced with the laser quartz fiber. The method to insert the flexible ureterorenoscope has been described previously. 8 - 10 When a calculus was visualized the guide wire was replaced with the laser quartz fiber. To avoid penetration of the quartz fiber tip into the luminal wall of the Accepted for publication August 16, 1989. Supported in part by funds of Japanese Ministry of Education. * Dornier Medical Systems, Inc., Marietta, Georgia. t Candela, Wayland, Massachusetts. t Olympus, Tokyo, Japan.
RESULTS
From May to December 1988, 30 patients underwent transurethral laser fragmentation of ureteral calculi (fig. 1). The calculi ranged from 5 X 3 to 20 X 11 mm. (mean 11.6 ± 4.1 x 6.8 ± 2.4 mm. standard deviation) on a plain film of the kidneys,
!Patients Male Female Total
20 10 30
Age Age Age
lStone
l
18,--...,60 (38.2±12.7) 22,--...,65 (47.0±11.4) 18,--...,65 (40.9±12.8)
Position
I
.................. 5~{{ __
UPJ Upper Ureter ...... ··· 12- Mid Ureter · · · · · · · · · 4--..__ Lower Ureter·········
r--=-
--1,l-J.-'~
9~=:===-
FIG. 1. Characteristics of patients. UPJ, ureteropelvic junction 273
'i
!1
274
HIGASHIHARA AND ASSOCIATES
ureters and bladder. The duration of impaction was 1 to 13 months, mean 4.9 ± 2.9 months. In 14 patients with mid or lower ureteral calculi the 7.2F ureteroscope was used and the flexible device was applied in another 16 with upper ureteral or ureteropelvic junction stones (fig. 2). Visualization of stones. Stone visualization was successful in 28 patients. In 2 patients (1 with a ureteropelvic junction stone and 1 with an upper ureteral calculus) the stones were pushed back to the renal pelvis and visualization became difficult due to bleeding. These 2 patients eventually were treated with ESWL and became free of stones. In 4 patients the stone was disintegrated successfully under direct vision despite retrograde migration to the renal calix. Stone disintegration. Of the 28 calculi that were treated under direct vision 24 were fragmented via laser monotherapy. The 2 calculi that were fragmented only partially by the laser required electrohydraulic lithotripsy or forceps removal. The other 2 stones were not fragmented at all by the laser and required electrohydraulic lithotripsy. The composition of these 4 stones was calcium oxalate monohydrate (more than 90%) in 3, and a mixture of calcium oxalate and calcium phosphate in 1. The number of laser pulses ranged from 236 to 4,120 (mean 1,394 ± 1,242) at 40 mJ. in the 24 patients treated by the laser alone. The duration of ureteroscopy and stone fragmentation was 16 to 135 minutes (mean 38 ± 20 minutes). Complications. In 1 patient with a 12 X 4 mm. mid ureteral stone ureteral perforation was noted after successful disintegration of the calculus and a Double-J* stent was left indwelling for 2 weeks. No ureteral stenosis was noted on excretory urograms obtained 1 month after removal of the stent. The perforation was caused by the rigid ureteroscope and there was no mucosal injury due to laser irradiation. Postoperative pyrexia of more than 38C was encountered in 5 patients who were treated with antibiotics without any infectious complication. DISCUSSION
Transurethral retrograde manipulation is required for ESWL of ureteral stones that are impacted or below the iliac crest. Ureteral stones should be pushed back into the urinary collecting system via a ureteral catheter or Double-J stents should be used extensively to improve the results free of stones after ESWL of ureteral calculi. 11 - 13 Our experience shows that ureteral calculi are fragmented with a high stone eradication rate (28 of 30 patients, or 93%) without complications by means of retrograde manipulation solely.
.._
UPJ
L2
.l!l
~ :::,
.5 Q)
> Ql
..J
L3
• •*
.. .
*
**
I
I
L4
0
lleoSacral
0
8
Lower
0 0 0 0
80
Q)
C
0 (Jl
....
• • •
• • • •
6
8
0
0
0
10 12 14 16 18 20 longitudinal Size of Stone
22 mm
FIG. 2. Results of laser lithotripsy of ureteral calculi. Asterisk indicates that stone migrated into renal pelvis where it was successfully fragmented. All patients eventually became free of stones. 0, treated with 7.2F ureteroscope. •, treated with flexible ureterorenoscope. D, failed endoscopy and eventually required ESWL. UPJ, ureteropelvic junction.
* Medical Engineering Corp., New York, New York.
Pre-ESWL retrograde manipulation alone might be sufficient to remove ureteral calculi. ESWL can be applied if the stone migrates upward and endoscopic fragmentation becomes difficult. In addition, urologists who do not have access to ESWL can treat ureteral calculi by almost the same procedure with a Double-J stent if a laser lithotriptor and appropriate ureteroscopes are available. These methods are more economical than ESWL. The pulsed dye laser is transmitted through a thin and flexible quartz fiber, 1 • 2 which facilitates use of a flexible ureterorenoscope as well as a small caliber rigid ureteroscope. The small caliber rigid device is maneuvered easily and does not require ureteral dilation in most cases. 7 However, it is difficult and dangerous to treat upper ureteral calculi with a rigid ureteroscope. Fragmentation of upper ureteral stones with a rigid ureteroscope is poor. 14' 15 The major advantage of the flexible ureterorenoscope is in the treatment of upper ureteral calculi. Electrohydraulic lithotripsy also is applicable for flexible ureteroscopy. However, it induces tissue injury when fired near the ureteral wall. The flush-lamp pulsed dye laser causes minimal tissue injury,3 which is an important advantage to fragment impacted stones. Our flexible ultrasound lithotriptor is limited by the size and flexibility of the lithotrite compared to the laser lithotriptor. 10 The benefits of combined flexible and small caliber rigid ureteroscopy in conjunction with the laser lithotriptor can be appreciated, since this procedure is highly successful and safe for the treatment of ureteral stones and it can be done during the same retrograde manipulation to reposition the stone that usually is required before ESWL. REFERENCES
1. Watson, G. M. and Wickham, J. E. A.: Initial experience with a pulsed dye laser for ureteric calculi. Lancet, 1: 1357, 1986. 2. Watson, G., Murray, S., Dretler, S. P. and Parrish, J. A.: The pulsed dye laser for fragmenting urinary calculi. J. Urol., 138: 195, 1987. 3. Watson, G., Murray, S., Dretler, S. P. and Parrish, J. A.: An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter. J. Urol., 138: 199, 1987. 4. Dretler, S. P., Watson, G., Parrish, J. A. and Murray, S.: Pulsed dye laser fragmentation of ureteral calculi: initial clinical experience. J. Urol., 137: 386, 1987. 5. Dretler, S. P.: Laser photofragmentation ofureteral calculi: analysis of 75 cases. J. Endourol., 1: 9, 1987. 6. Coptcoat, M. J., Ison, K. T., Watson, G. and Wickham, J.E. A.: Lasertripsy for ureteric stones in 120 cases: lessons learned. Brit. J. Urol., 61: 487, 1988. 7. Dretler, S. P.: Techniques of laser lithotripsy. J. Endourol., 2: 123, 1988. 8. Aso, Y., Ohtawara, Y., Fukuta, K., Sudoko, H., Nakano, M., Ushiyama, T., Ohta, N., Suzuki, K. and Tajima, A.: Operative fiberoptic nephroureteroscopy: removal of upper ureteral and renal calculi. J. Urol., 137: 629, 1987. 9. Aso, Y., Takayasu, H., Ohta, N. and Tajima, A.: Flexible ureterorenoscopy. Urol. Clin. N. Amer., 15: 329, 1988. 10. Higashihara, E. and Aso, Y.: Flexible ultrasonic lithotriptor and fiberoptic ureterorenoscope: a new approach to ureteral calculi. J. Urol., 142: 40, 1989. 11. Mueller, S. C., Wilbert, D., Thueroff, J. W. and Alken, P.: Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J. Urol., 135: 831, 1986. 12. Puppo, P., Bottino, P., Germinale, F., Caviglia, C., Ricciotti, G. and Giuliani, L.: Techniques and results of extracorporeal shock wave lithotripsy in the ureter. J. Endourol., 2: 1, 1988. 13. Fuchs, G. J., Chaussy, C. G. and Stenz!, A.: Current management concepts in the treatment of ureteral stones. J. Endourol., 2: 117, 1988. 14. Netto, N. R., Jr., Lemos, G. C. and Claro, J. F. A.: Methodology for endoscopic treatment of ureteral calculi. J. Urol., 135: 909, 1986. 15. Schultz, A., Kristensen, J. K., Bilde, T. and Eldrup, J.: Ureteroscopy: results and complications. J. Urol., 137: 865, 1987.
Vol. 143, February
Printed in U.S.A.
LASER URETEROLITHOTRIPSY WITH COMBINED RIGID AND FLEXIBLE URETERORENOSCOPY EIJI HIGASHIHARA, SHIGEO HORIE, TAKUMI TAKEUCHI, SHUJI KAMEYAMA, YASUYUKI ASAKAGE, YOSHIO HOSAKA, YUKIO HONMA, SHIGERU MINOWADA AND YOSHIO ASO From the Department of Urology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
ABSTRACT
Because the pulsed dye laser can be transmitted through a thin, flexible quartz fiber a small caliber ureteroscope and flexible ureterorenoscope are applicable. Therefore, the use of a rigid or flexible ureterorenoscope was combined with laser lithotripsy to treat upper urinary tract calculi. All 14 ureteral stones below the pelvic brim were removed successfully with a rigid 7.2F (outer diameter) ureteroscope and 14 of 16 stones above the pelvic brim were removed with a flexible ureterorenoscope. Laser monotherapy was effective in 24 cases and the complementary use of forceps or electrohydraulic lithotripsy was required in 4. Two stones were lost from the visual field during endoscopic manipulation. There was no complication requiring surgical correction. The combined use of these instruments is highly successful and safe for the treatment of upper urinary tract calculi. (J. Ural., 143: 273-274, 1990) Watson and associates 1- 3 introduced the pulsed dye laser for stone fragmentation and its clinical efficacy has been established by Dretler4 •5 and Coptcoat6 and their associates. Dretler and associates initially used a 9.5F ureteroscope. Later, Dretler developed a 7.2F in diameter device and achieved good clinical results. 7 The laser beam can be transmitted through a thin, flexible quartz fiber and it can be used with a flexible ureterorenoscope. Therefore, we combined the use of rigid and flexible ureterorenoscopy with laser lithotripsy for upper urinary tract stones.
flexible ureterorenoscope the quartz fiber was encased in the polyethylene tube when the working channel was passed. The tip of the quartz fiber was placed in contact with the surface of the calculus and laser pulses were delivered at a repetition rate of 10 Hz. under direct vision with a video monitoring system until the stone was reduced to spontaneously passable fragments of less than 1 to 2 mm. in diameter. The power of the laser emission was set at 40 mJ. and increased to 50 mJ. when stone fragmentation was not sufficient. When stone fragmentation was not achieved with laser lithotripsy adjuvant electrohydraulic lithotripsy was performed.
MATERIALS AND METHODS
Patients with ureteral stones were selected for laser treatment if the stone had been impacted for more than 1 month or required retrograde ureteral manipulation before extracorporeal shock wave lithotripsy (ESWL*). The flush lamp MDL-1 excited dye laser,t emitting a wavelength of 504 nm. was used. A 7.2F rigid ureteroscope 7 was selected for stones below the pelvic brim. If the stone was pushed up to the upper ureter or renal pelvis during manipulation with a rigid ureteroscope or if it was primarily above the pelvic brim a 10.8F flexible ureterorenoscope:j: was used. The patients were placed in the lithotomy position under spinal or epidural anesthesia. For insertion of the rigid ureteroscope a hydrophilic polymer-coated guide wire was inserted retrograde into the ureter. The lubricating characteristic of the polymer facilitated the guide wire bypassing the calculus. The 7.2F ureteroscope had 2 working channels 0.028 inch in diameter that allowed for smooth manipulation of a 0.025 inch guide wire and a 0.25 mm. laser quartz fiber with saline irrigation. The rigid ureteroscope was passed per urethram through the outer cystoscopy sheath and advanced up to the calculus over the guide wire without ureteral dilation. When the stone was in view the guide wire was replaced with the laser quartz fiber. The method to insert the flexible ureterorenoscope has been described previously. 8 - 10 When a calculus was visualized the guide wire was replaced with the laser quartz fiber. To avoid penetration of the quartz fiber tip into the luminal wall of the Accepted for publication August 16, 1989. Supported in part by funds of Japanese Ministry of Education. * Dornier Medical Systems, Inc., Marietta, Georgia. t Candela, Wayland, Massachusetts. t Olympus, Tokyo, Japan.
RESULTS
From May to December 1988, 30 patients underwent transurethral laser fragmentation of ureteral calculi (fig. 1). The calculi ranged from 5 X 3 to 20 X 11 mm. (mean 11.6 ± 4.1 x 6.8 ± 2.4 mm. standard deviation) on a plain film of the kidneys,
!Patients Male Female Total
20 10 30
Age Age Age
lStone
l
18,--...,60 (38.2±12.7) 22,--...,65 (47.0±11.4) 18,--...,65 (40.9±12.8)
Position
I
.................. 5~{{ __
UPJ Upper Ureter ...... ··· 12- Mid Ureter · · · · · · · · · 4--..__ Lower Ureter·········
r--=-
--1,l-J.-'~
9~=:===-
FIG. 1. Characteristics of patients. UPJ, ureteropelvic junction 273
'i
!1
274
HIGASHIHARA AND ASSOCIATES
ureters and bladder. The duration of impaction was 1 to 13 months, mean 4.9 ± 2.9 months. In 14 patients with mid or lower ureteral calculi the 7.2F ureteroscope was used and the flexible device was applied in another 16 with upper ureteral or ureteropelvic junction stones (fig. 2). Visualization of stones. Stone visualization was successful in 28 patients. In 2 patients (1 with a ureteropelvic junction stone and 1 with an upper ureteral calculus) the stones were pushed back to the renal pelvis and visualization became difficult due to bleeding. These 2 patients eventually were treated with ESWL and became free of stones. In 4 patients the stone was disintegrated successfully under direct vision despite retrograde migration to the renal calix. Stone disintegration. Of the 28 calculi that were treated under direct vision 24 were fragmented via laser monotherapy. The 2 calculi that were fragmented only partially by the laser required electrohydraulic lithotripsy or forceps removal. The other 2 stones were not fragmented at all by the laser and required electrohydraulic lithotripsy. The composition of these 4 stones was calcium oxalate monohydrate (more than 90%) in 3, and a mixture of calcium oxalate and calcium phosphate in 1. The number of laser pulses ranged from 236 to 4,120 (mean 1,394 ± 1,242) at 40 mJ. in the 24 patients treated by the laser alone. The duration of ureteroscopy and stone fragmentation was 16 to 135 minutes (mean 38 ± 20 minutes). Complications. In 1 patient with a 12 X 4 mm. mid ureteral stone ureteral perforation was noted after successful disintegration of the calculus and a Double-J* stent was left indwelling for 2 weeks. No ureteral stenosis was noted on excretory urograms obtained 1 month after removal of the stent. The perforation was caused by the rigid ureteroscope and there was no mucosal injury due to laser irradiation. Postoperative pyrexia of more than 38C was encountered in 5 patients who were treated with antibiotics without any infectious complication. DISCUSSION
Transurethral retrograde manipulation is required for ESWL of ureteral stones that are impacted or below the iliac crest. Ureteral stones should be pushed back into the urinary collecting system via a ureteral catheter or Double-J stents should be used extensively to improve the results free of stones after ESWL of ureteral calculi. 11 - 13 Our experience shows that ureteral calculi are fragmented with a high stone eradication rate (28 of 30 patients, or 93%) without complications by means of retrograde manipulation solely.
.._
UPJ
L2
.l!l
~ :::,
.5 Q)
> Ql
..J
L3
• •*
.. .
*
**
I
I
L4
0
lleoSacral
0
8
Lower
0 0 0 0
80
Q)
C
0 (Jl
....
• • •
• • • •
6
8
0
0
0
10 12 14 16 18 20 longitudinal Size of Stone
22 mm
FIG. 2. Results of laser lithotripsy of ureteral calculi. Asterisk indicates that stone migrated into renal pelvis where it was successfully fragmented. All patients eventually became free of stones. 0, treated with 7.2F ureteroscope. •, treated with flexible ureterorenoscope. D, failed endoscopy and eventually required ESWL. UPJ, ureteropelvic junction.
* Medical Engineering Corp., New York, New York.
Pre-ESWL retrograde manipulation alone might be sufficient to remove ureteral calculi. ESWL can be applied if the stone migrates upward and endoscopic fragmentation becomes difficult. In addition, urologists who do not have access to ESWL can treat ureteral calculi by almost the same procedure with a Double-J stent if a laser lithotriptor and appropriate ureteroscopes are available. These methods are more economical than ESWL. The pulsed dye laser is transmitted through a thin and flexible quartz fiber, 1 • 2 which facilitates use of a flexible ureterorenoscope as well as a small caliber rigid ureteroscope. The small caliber rigid device is maneuvered easily and does not require ureteral dilation in most cases. 7 However, it is difficult and dangerous to treat upper ureteral calculi with a rigid ureteroscope. Fragmentation of upper ureteral stones with a rigid ureteroscope is poor. 14' 15 The major advantage of the flexible ureterorenoscope is in the treatment of upper ureteral calculi. Electrohydraulic lithotripsy also is applicable for flexible ureteroscopy. However, it induces tissue injury when fired near the ureteral wall. The flush-lamp pulsed dye laser causes minimal tissue injury,3 which is an important advantage to fragment impacted stones. Our flexible ultrasound lithotriptor is limited by the size and flexibility of the lithotrite compared to the laser lithotriptor. 10 The benefits of combined flexible and small caliber rigid ureteroscopy in conjunction with the laser lithotriptor can be appreciated, since this procedure is highly successful and safe for the treatment of ureteral stones and it can be done during the same retrograde manipulation to reposition the stone that usually is required before ESWL. REFERENCES
1. Watson, G. M. and Wickham, J. E. A.: Initial experience with a pulsed dye laser for ureteric calculi. Lancet, 1: 1357, 1986. 2. Watson, G., Murray, S., Dretler, S. P. and Parrish, J. A.: The pulsed dye laser for fragmenting urinary calculi. J. Urol., 138: 195, 1987. 3. Watson, G., Murray, S., Dretler, S. P. and Parrish, J. A.: An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter. J. Urol., 138: 199, 1987. 4. Dretler, S. P., Watson, G., Parrish, J. A. and Murray, S.: Pulsed dye laser fragmentation of ureteral calculi: initial clinical experience. J. Urol., 137: 386, 1987. 5. Dretler, S. P.: Laser photofragmentation ofureteral calculi: analysis of 75 cases. J. Endourol., 1: 9, 1987. 6. Coptcoat, M. J., Ison, K. T., Watson, G. and Wickham, J.E. A.: Lasertripsy for ureteric stones in 120 cases: lessons learned. Brit. J. Urol., 61: 487, 1988. 7. Dretler, S. P.: Techniques of laser lithotripsy. J. Endourol., 2: 123, 1988. 8. Aso, Y., Ohtawara, Y., Fukuta, K., Sudoko, H., Nakano, M., Ushiyama, T., Ohta, N., Suzuki, K. and Tajima, A.: Operative fiberoptic nephroureteroscopy: removal of upper ureteral and renal calculi. J. Urol., 137: 629, 1987. 9. Aso, Y., Takayasu, H., Ohta, N. and Tajima, A.: Flexible ureterorenoscopy. Urol. Clin. N. Amer., 15: 329, 1988. 10. Higashihara, E. and Aso, Y.: Flexible ultrasonic lithotriptor and fiberoptic ureterorenoscope: a new approach to ureteral calculi. J. Urol., 142: 40, 1989. 11. Mueller, S. C., Wilbert, D., Thueroff, J. W. and Alken, P.: Extracorporeal shock wave lithotripsy of ureteral stones: clinical experience and experimental findings. J. Urol., 135: 831, 1986. 12. Puppo, P., Bottino, P., Germinale, F., Caviglia, C., Ricciotti, G. and Giuliani, L.: Techniques and results of extracorporeal shock wave lithotripsy in the ureter. J. Endourol., 2: 1, 1988. 13. Fuchs, G. J., Chaussy, C. G. and Stenz!, A.: Current management concepts in the treatment of ureteral stones. J. Endourol., 2: 117, 1988. 14. Netto, N. R., Jr., Lemos, G. C. and Claro, J. F. A.: Methodology for endoscopic treatment of ureteral calculi. J. Urol., 135: 909, 1986. 15. Schultz, A., Kristensen, J. K., Bilde, T. and Eldrup, J.: Ureteroscopy: results and complications. J. Urol., 137: 865, 1987.
