Eritrsh Journalo/C‘rologq’(1987),59, 137-141 0 1987 British Journal of Urology

Ureteric Stone Surgery in Practice

M. C. BISHOP, W. T. LAWRENCE and R. J. LEMBERGER

Urology Unit, City Hospital, Nottingharn

Summary-From 1983 to 1986 140 patients underwent surgery for ureteric calculus. In approximately 30% “blind” basket extraction was considered appropriate and continued to be effective. Increasing expertise with the rigid ureterorenoscope led to a considerable reduction in open ureterolithotomy ( 15% in 1985-86), the majority following failed ureteroscopic extraction.

of attempts respectively. Electrohydraulic and ultrasonic lithotripsy were used in 12 patients to reduce large impacted calculi. The commonest complication of ureteroscopic stone surgery was perforation; this occurred in 14% of cases, though it was usually trivial and near the vesicoureteric junction. Perforations higher in the ureter tended to follow endoscopic lithotripsy and were often associated with urinary extravasation. Extra-ureteric stone fragments were also occasionally observed in such cases. There were no serious sequelae, although the in-patient stay was prolonged beyond the 48 h customary for uncomplicated extraction.

The results suggest that ureteroscopic stone extraction, which can be conveniently introduced into urological practice, should become a standard endoscopic procedure.

In the same year both “blind” basket extraction and ureteroscopy were successful in 82 and 86%

The removal of ureteric calculi with the rigid ureterorenoscope is an established endourological technique (Bush et al., 1982; Perez-Castro and Martinez-Pineiro, 1982). However, the risk of complications and prolonged operating times have discouraged busy surgeons from adopting this technique (Keating et al., 1986). The corollary is that ureteroscopy should be reserved for centres with special expertise and spare operating time. This report concerns the increasing use of the rigid ureterorenoscope in urological practice.

Patients and Methods

From March 1983 to 1986, 140 patients underwent 169 operations for the removal of ureteric calculi in the Nottingham City Hospital (Table 1). They formed approximately 50% of the total number of patients operated on for upper urinary tract calculi from a catchment population of approximately

Read atthe Combined Meeting ofthe British Association of Urological Surgeons and the Canadian Urological Association in London, June 1986

Table 1 Calculi 1983-1986

Surgical Treatment of Upper Urinary Tract

Procedures

Renal (140 patients) Percutaneous 125 Open surgery 40

(pyelo/nephrolithotomy) (nephrectomy)

Ureteric (1 40 patients) Open ureterolithotomy 39 “Blind” basket meatotomy 51 Ureteroscopic extraction 73

Renal and ureteric calculi 7

400,000. During the 3-year period, approximately 70% were dealt with by endourological techniques. Ten patients had multiple calculi, usually in the ureter and pelvicaliceal system or in both ureters (three patients). Ureteric calculi were removed by :

(a) Open surgery. (b) “Blind” extraction (without fluoroscopic con-

trol) using a basket extractor of standard type

137

138 BRITISH JOURNAL OF UROLOGY

(Dormia) or of the Pfister-Schwartz pattern. In a few patients the calculus was released by incising the roof of the ureteric meatus with electrocautery or with the internal urethrotome (Sachse).

(c) Ureteroscopy.

The Wolf 1 1.5 F straight pattern instrument was used. Graded flexible Teflon dilators were used to dilate the ureteric orifice and the distal 5 cm of the ureter. They were sometimes inserted over a guide wire. The instrument was then introduced under direct vision. A stone basket was passed through the instrument channel and opened ahead of the end of the telescope to determine the direction and straighten corrugations in the ureteric wall. The calculus was extracted with the basket. Stone forceps were not used. Where necessary the calculus was reduced by electrohydraulic lithotripsy (EHL) using a 5 F coaxial electrode (10 patients) or by ultrasonic disintegration using the standard ureteric sonotrode (twopatients) (Bushetaf., 1982; Huffman et al., 1983). “Blind” basket extraction was used for small calculi (< 7 mm) situated below the pelvic brim. Ureteroscopy was used for all other calculi and where “blind” basket extraction had failed. The procedure was always covered with parenteral broad spectrum antibiotics. In patients with severe obstruction and infection the kidney was decom- pressed by prior percutaneous nephrostomy. Most patients had a post-operative IVU at 3 months.

Results

The results of surgery for ureteric calculi were assessed annually for 3 consecutive years. The proportion of patients undergoing open surgery decreased progressively (Fig. 1, Table 2). Similar proportions of patients underwent “blind” basket extraction and meatotomy. In the first 2 years many of the open operations were elective, whereas in the last year they usually followed a failed attempt at ureteroscopic extraction. By the last of the three periods (1985-86) the rate of success had increased to approximately 80% for both basket and ureter- oscopic extraction. Four patients who had had failed attempts at basket extraction were subse- quently successfully treated by ureteroscopy. If spontaneous calculus extrusion and success from repeat endoscopic removal (after a first unsuccessful attempt) are included, the success rate for ureter- oscopy was 86%.

Success rates were lower for stones in the upper ureter (9 of 19 patients: 48%). However, 10 of 14

n =35

012 34 70

m

D20

m LLLLLL u3

1983 -84

n-50

1984 -85

n =55

1985-86

Fig. 1 Final operations for ureteric calculus performed an- nually between 1983 and 1986. O=open ureterolithotomy. D = Dormia basket extraction or meatotomy. U = ureteroscopic extraction.

patients (7 1 %) had stone removal from the so-called “no man’s land” in the middle third of the ureter. In one patient the calculus was pushed into the renal pelvis and extracted percutaneously. In several other patients an open procedure could have been similarly avoided if facilities for percutaneous surgery had been immediately available. In three other patients stones were extracted by the ureter- oscope from the renal pelvis. In the majority, lack

URETERIC STONE SURGERY IN PRACTICE 139

Table 2 Results of Surgical Treatment of Ureteric Calculi 1983- 1986

% Success

Operations immediate Dela-yeti

1983-1984 35patients (Total=38) Open 12 L

FD FU

0 DR S

0 S

Dormia 22 Success

Ureteroscopic 4 Success

1984-1 985 50 patients (Total = 65) Open 19 L

F D FU

0 S

0 UR S

Dormia 13 Success

Ureteroscopic 33 Success

1985-1986 55patients (Total=66) Open 8 L

Dormia 22 Success FU

U

Ureteroscopic 36 Success 0 UR D S

9 2 1

12 2 1 I 2 1 1

5 1

13 9 1 3

13 13

1 6

3 5

18 4

28 5 1 1 1

55 90

50 15

69 92

39 58

82

18 86

L = Listed/elective D = Dormia/meatotomy U = Ureteroscopy procedure 0 =Open ureterolithotomy

S = Spontaneous expulsion of stone after prior

F = Failed R = Repeat

of success with the ureteroscope was due to failure to reach the calculus through inability to negotiate the points of natural constriction in the ureter. In a much smaller proportion the stone could be reached but not engaged in the basket. Between 1985 and 1986 the success rate improved, with EHL allowing fragmentation of larger calculi. In the previous year, stone reduction was achieved in two cases with the ultrasonic probe (Table 3).

Operating time for “blind” basket extraction was approximately 15 min and for simple ureteroscopic extraction it was approximately 30 min. The dura-

Table 3 Results of Procedures for Calculus Reduction

Result Complication

Electrohydraulic lithotripsy

Middle third 6 Perforation 2

Lower third 2 Temporary

Upper third 2 0 2

Successful

dilatation 1 Ileus 1

Ultrasound Upper third 2 Successful Temporary

dilatation 1

0 =Open ureterolithotomy

tion was invariably longer (40-90 min) for tech- niques involving stone reduction before extraction. The duration of post-operative in-patient care was 24 to 48 h for virtually every patient undergoing basket or ureteroscopic extraction. The maximum duration for patients who suffered complications not requiring open surgery was 8 days. The mean duration of post-operative stay for open ureterolith- otomy was 9 days (range 7-21).

Complications (Table 4) Most perforations were trivial ; they occurred near the ureteric orifice and were usually caused by the tip of the flexible Teflon dilators. With increasing experience it was possible to direct the ureteroscope beak away from the mouth of the false passage which was usually lateral and inferior to the true lumen. In five patients the ureter was perforated in the upper two-thirds. In two of these cases it was associated with the use of EHL (Table 3) and in neither was the perforation recognised at the time of surgery. One such patient in whom extravasation was demonstrated in an early post-operative IVU (Fig. 2) suffered prolonged ileus, though he was discharged 8 days post-operatively.

In several patients fragments of calculus were identified outside the line of the ureter, after

Table 4 tion

Complications of Ureteroscopic Stone Extrac-

Perforation 10 near/at VUJ 6 above pelvic brim 4

Stenosis near externalised stone fragment 1 Stenosis at VUJ 1 Temporary dilatation of ureter 3 VU reflux 1 Urinary infection 3 Thromboembolic (DVT/PE) 2

140 BRITISH JOURNAL OF UROLOGY

Fig. 2 Ureteric perforation. Post-operative IVU 24 h after ureteroscopic extraction and EHL of calculus in left mid-ureter.

extraction and EHL. In one patient, dilatation of the upper tract above the extra-ureteric stone suggested obstruction, though this was discounted by antegrade pyelography and pressure flow meas- urements (Figs 3 and 4). With one exception, post- operative IVU at 3 months showed normal ureteric calibre. In three patients urography performed earlier showed dilatation up to the site of lithotripsy and extraction.

Severe recurrent urinary infection with multi- resistant organisms occurred in three patients. Parenteral antibiotic treatment was required but was successful in eradicating it.

Two patients suffered symptomatic complica- tions at the lower end of the ureter. In one, stenosis was identified 6 weeks after ureteroscopy and reimplantation was required. A second patient has recurrent mild loin pain, possibly due to vesicoure- teric reflux. Both patients with thrombo-embolic complications had undergone open ureterolitho- tomy after failed ureteroscopy . There were no complications from “blind” basket extraction and ureteric meatotomy.

Fig. 3 Post-operative IVU. Questionable residual fragment in upper third of right ureter after EHL.

Discussion Same patient as Fig. 3. Nephrostogram on right kidney

The results indicate a rising success rate for with double pigtail stent in siru showing extra-ureteric calculus endoscopic stone extraction from the ureter, corn-

Fig. 4

fragment.

URETERIC STONE SURGERY IN PRACTICE 141

parable with the experience in other units and a corresponding reduction in open surgery (Ford et al., 1984; Tolley and Buist, 1986). The considerable impact of the introduction of the ureteroscope was delayed by a learning period which seems invariable (Keating et al., 1986). More open surgery could have been avoided, particularly with upper third calculi, by a policy of “push-pull” or “push-bang’’ after deliberate retrograde delivery of the calculus into the renal pelvis followed by percutaneous nephrolithotomy or shockwave lithotripsy (Keating et al., 1986). Such facilities could not be arranged at short notice. Ureteroscopic stone extraction has been achieved in an acceptable operating time which is shorter than reported elsewhere (Ford et al., 1984; Keating et al., 1986).

In several other units ureteroscopic extraction has been used for many lower ureteric calculi which presently have been dealt with by “blind” basket extraction. We feel that this is still a safe and effective procedure which ;Is more quickly accom- plished than ureteroscopy and should be used for many calculi as first choice (Furlow and Bucchiere, 1976; O’Flynn, 1980). The present results seem to emphasise that it is prudent to regard the two techniques as complementary.

The complication rate for ureteroscopy is similar to that reported elsewhere. Ureteric perforation generally has no sequelae, assuming that one can discount stenosis occurring as a late complication despite normal urography at 3 months. EHL is a useful adjunct for the larger impacted ureteric stone, though it is prone to cause perforation which must be recognised at the time of surgery. Stone fragments can also be expelled into the periureteric

tissues. In such cases there seem to be no deleterious consequences in terms of delayed healing of the fistula or periureteric abscess or fibrosis.

Acknowledgements We thank Mr M. Dunn and Mr C. P. Bates for their cheerful assistance and Mrs Hilda Burton for typing the manuscript.

References Bush,[. M.,Guinan,D.and Lanners,J.(1982). Uceterorenoscopy.

L’rol. Clin. North Am., 9, 131-136. Ford, T. F., Payne, S. R. and Wickham, J. E. A. (1984) The

impact of transurethral ureteroscopy on the management of ureteric calculi. Br. J . Urol., 56, 602-603.

Furlow, W. L. and Bucchiere, J. J. (1976). The surgical fate of ureteral calculi: review of the Mayo Clinic experience. J . Lirul., 116, 559-562.

Huffman, J. L., Bagley, D. H., Schoenberg, H. W. and Lyon, E. S. (1 983). Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J . Urul., 130, 31-33.

Keating, M. A., Heney, N. M., Young, H. H., Kerr, W. S., O’Leary, M. P. and Dretler, S. P. (1986). Ureteroscopy: the initial experience. J . Urol., 135,689-693.

OFlynn, J. D. (1980). The treatment of ureteric stones. Report on I120 patients. Br. J . Urol., 52,436-438.

Perez-Castro, E. E. and Martinez-Pineiro, J. A. (1982). Ureteral and renal endoscopy. A new approach. Eur. U F O ~ . , 8, 117-120.

Tolley, D. A. and Buist, T. A. S. (1986). Endoscopic management of upper urinary tract stones. Ann. R. Cull. Surg. Engl., 68,70- 72.

The Authors M C. Bishop, MD, MRCP, FRCS, Consultant Urologist. W . T. Lawrence, FRCS, Senior Registrar. R . J Lemberger, FRCS, Consultant Urologist.

Requests for reprints to: M. C. Bishop. Department of Urology, City Hospital, Hucknall Road, Nottingham N G 5 IPB.