USE OF STONE BRUSH FOR TREATMENT OF IMPACTED STONES IN ASSOCIATION WITH EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY MARC A. RUBENSTEIN, M.D. D O N A L D M. NORRIS, M.D. From the Parkside Kidney Stone Center, Park Ridge, and the Striteh School of Medicine, Loyola University, Maywood, Illinois
ABSTRA C T--A new device is described which enhances the treatment o] impacted stones i ciation with the extracorporeal shock-wave lithotripsy. This technique may result in d e c r ~ / ~ number o] shocks and increased efficiency, as well as, enhance outpatient treatment,
The treatment of impacted ureteral stones utilizing extracorporeal shock-wave lithotripsy has become common in urologic practice in recent years. However, the success rate with impacted stones is less than with stones which have been moved into the kidney, or in some cases, in which a catheter has been passed proximal to the stone. It is generally believed that the presence of fluid around the stone allows the ability for the stone to expand and for shock-waves to strike the core of the stone. * In response to these problems, we have devised a stone brush~ which addresses several of these problems and is quite simple to use (Fig. 1). Material and Methods In treating ureteral calculi, it is frequently helpful to have a ureteral catheter near the stone to help in localization of the calculi. Not infrequently, on one of the two fluoroscopic cameras, the stone will overlie the spine and make it otherwise difficult to localize. The stone brush utilizes a 5F PVC end-hole ureteral catheter which is passed eystoscopically to the *Riehl RA, Fair WR, and Vaughan D: Extracorporeal shock wave lithotripsy for upper urinary tract calculi, JAMA 225: 20432048 (1986). SManufactured by Van-Tcc, Inc., Spencer, Indiana.
154
FIGURE 1.
Sheathwith brush.
area of the impacted stone. Inside the is a 0.038 inch wire with a brush fitte~ end of the wire and a soft filiform tip t the end of the brush. The brush is simi urinary cytology brush, but is somewh~ and slightly longer. The entire appa: passed up with the wire entirely enclose catheter. The patient is then moved to the tr~ room where the stone is localized with 1: fluoroscopy in standard fashion. After mately 400-500 shocks have been deli~ the stone, the wire, which is sufficiently extend safely outside the tub, is adva~ the catheter under fluoroscopic guida nc area of the stone. An attempt is then I pass the brush beyond the impacted sto the initial shock treatment. In most c~ have found that the catheter will now t; ily. The soft filiform tip makes perfor':~
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ly unlikely, and also allows t around the stone. In those have not been able to sue[iform beyond the stone, we 7cave treatment and make pass beyond the stone. Once messfully beyond the stone, o contact with the stone and fragments whieh have alup, exposing new area of the wave. This proeedure is re500 shocks until there is no aing. ay stone fragments as they number of shocks necessary eted calculi are deereased. Ld that when the fragments throughout, this completely etion whieh may be present :o discharge patients directly er to home, with no stenting necessary in most eases. Je does not work with every have found it to be highly 2ases.
he stone brush to be effective ne is not actually impacted. tes which are small may not kidney where they would be e. Also, stones which are raer treated in the ureter. In ne brush works even better. Case Report
percutaneous nephrostomy tube was plaeed on the right side, and the patient was given appropriate antibioties. After she stabilized and bec a m e afebrile, a n e p h r o s t o g r a m was performed. This revealed a radiolucent stone in the distal right ureter (Fig. 2A). Attempts at ureteroseopy were unsuccessful due to spasm of the distal ureter; therefore, the patient was scheduled for extraeorporeal shock-wave lithotripsy. A nephrostogram was done with the patient in the tub (Fig. 2B). Through the nephrostomy tube, the ureteral stone brush was passed down to the area of the stone. The brush was left just superior to the stone, and a total of 500 shocks were delivered. Subsequently the stone was brushed w i t h the ureteral stone f r a g m e n t brush A total of 1,500 shocks were given at 22 KV to the stone with brushing of the fragments done at intervals of 500 shocks. By the end of the 1,500 shocks, another nephrostogram was done with the patient still in the tub (Fig. 2C). This revealed the absence of any further fragments and immediate flow of dye into the bladder. The nephrostomy tube was removed the following morning, and the patient was diseharged. Conclusion A new technique has been developed for the treatment of ureteral stones via extraeorporeal shock-wave lithotripsy which involves the use of a new stone fragment brush. This device is highly effective and adds little extra time to the procedure.
ii:!!:IAsixty-three-year-old white w o m a n was adii!~ted with urosepsis. An intravenous pyelo!~ggrnshowed poor visualization of the right eol:~i~ing system a n d h y d r o n e p h r o s i s . A
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FEBRUARY 1990
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VOLUME XXXV, NUMBER 2
Suite G-04
1875 Dempster Street Park Ridge, Illinois 60068 (DR, RUBENSTEIN)
155
ABSTRA C T--A new device is described which enhances the treatment o] impacted stones i ciation with the extracorporeal shock-wave lithotripsy. This technique may result in d e c r ~ / ~ number o] shocks and increased efficiency, as well as, enhance outpatient treatment,
The treatment of impacted ureteral stones utilizing extracorporeal shock-wave lithotripsy has become common in urologic practice in recent years. However, the success rate with impacted stones is less than with stones which have been moved into the kidney, or in some cases, in which a catheter has been passed proximal to the stone. It is generally believed that the presence of fluid around the stone allows the ability for the stone to expand and for shock-waves to strike the core of the stone. * In response to these problems, we have devised a stone brush~ which addresses several of these problems and is quite simple to use (Fig. 1). Material and Methods In treating ureteral calculi, it is frequently helpful to have a ureteral catheter near the stone to help in localization of the calculi. Not infrequently, on one of the two fluoroscopic cameras, the stone will overlie the spine and make it otherwise difficult to localize. The stone brush utilizes a 5F PVC end-hole ureteral catheter which is passed eystoscopically to the *Riehl RA, Fair WR, and Vaughan D: Extracorporeal shock wave lithotripsy for upper urinary tract calculi, JAMA 225: 20432048 (1986). SManufactured by Van-Tcc, Inc., Spencer, Indiana.
154
FIGURE 1.
Sheathwith brush.
area of the impacted stone. Inside the is a 0.038 inch wire with a brush fitte~ end of the wire and a soft filiform tip t the end of the brush. The brush is simi urinary cytology brush, but is somewh~ and slightly longer. The entire appa: passed up with the wire entirely enclose catheter. The patient is then moved to the tr~ room where the stone is localized with 1: fluoroscopy in standard fashion. After mately 400-500 shocks have been deli~ the stone, the wire, which is sufficiently extend safely outside the tub, is adva~ the catheter under fluoroscopic guida nc area of the stone. An attempt is then I pass the brush beyond the impacted sto the initial shock treatment. In most c~ have found that the catheter will now t; ily. The soft filiform tip makes perfor':~
UROLOGY
FEBRUARY1 9 9 0
VOLUMEXXXV, N
ly unlikely, and also allows t around the stone. In those have not been able to sue[iform beyond the stone, we 7cave treatment and make pass beyond the stone. Once messfully beyond the stone, o contact with the stone and fragments whieh have alup, exposing new area of the wave. This proeedure is re500 shocks until there is no aing. ay stone fragments as they number of shocks necessary eted calculi are deereased. Ld that when the fragments throughout, this completely etion whieh may be present :o discharge patients directly er to home, with no stenting necessary in most eases. Je does not work with every have found it to be highly 2ases.
he stone brush to be effective ne is not actually impacted. tes which are small may not kidney where they would be e. Also, stones which are raer treated in the ureter. In ne brush works even better. Case Report
percutaneous nephrostomy tube was plaeed on the right side, and the patient was given appropriate antibioties. After she stabilized and bec a m e afebrile, a n e p h r o s t o g r a m was performed. This revealed a radiolucent stone in the distal right ureter (Fig. 2A). Attempts at ureteroseopy were unsuccessful due to spasm of the distal ureter; therefore, the patient was scheduled for extraeorporeal shock-wave lithotripsy. A nephrostogram was done with the patient in the tub (Fig. 2B). Through the nephrostomy tube, the ureteral stone brush was passed down to the area of the stone. The brush was left just superior to the stone, and a total of 500 shocks were delivered. Subsequently the stone was brushed w i t h the ureteral stone f r a g m e n t brush A total of 1,500 shocks were given at 22 KV to the stone with brushing of the fragments done at intervals of 500 shocks. By the end of the 1,500 shocks, another nephrostogram was done with the patient still in the tub (Fig. 2C). This revealed the absence of any further fragments and immediate flow of dye into the bladder. The nephrostomy tube was removed the following morning, and the patient was diseharged. Conclusion A new technique has been developed for the treatment of ureteral stones via extraeorporeal shock-wave lithotripsy which involves the use of a new stone fragment brush. This device is highly effective and adds little extra time to the procedure.
ii:!!:IAsixty-three-year-old white w o m a n was adii!~ted with urosepsis. An intravenous pyelo!~ggrnshowed poor visualization of the right eol:~i~ing system a n d h y d r o n e p h r o s i s . A
/
FEBRUARY 1990
/
VOLUME XXXV, NUMBER 2
Suite G-04
1875 Dempster Street Park Ridge, Illinois 60068 (DR, RUBENSTEIN)
155
