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Common Urological Problems

Urinary Stone Disease Intervention

  • - General Urology - Common Urological Problems - Urinary Stone Disease
  • Jul 25, 2010
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Tags: | citric acid | computed tomography | dissolution agents | fluoroscopic imaging |

4. Postoperative care-
Patients should be encouraged to maintain an active ambulatory status to facilitate stone passage.  Gross hematuria should resolve during the first postoperative week.  Fluid intake should be encouraged.

Follow-up in approximately 2 weeks for discussion and evaluation of a KUB and renal ultrasonography will help assess success of fragmentation and passage of gravel.

Patients may return to work as soon as they feel comfortable in doing so.

Abdominal pain may be related to the shock waves.
Severe pain unresponsive to routine intravenous or oral medications should alert the physician for possible rare (0.66%)  perirenal hematomas.  In such a situation,  CT should then be undertaken to stage the injury.

The potential association of ESWL with the development of hypertension has not been substantiated.  Longterm data are still being collected.

Urinary Stone Disease

Urinary Stone Disease

Stone burden correlates with postoperative complications.  Steinstrasse (stone street)  or columnation of stone gravel in a ureter can be frustrating. It should be specifically ruled out when postoperative radiographs are evaluated.

Asymptomatic individuals can be followed up with serial KUBs and ultrasonography.  Severe pain or fever requires intervention.  Percutaneous nephrostomy drainage is usually uncomplicated owing to the associated hydronephrosis.  Decompressing   the   collecting   system allows for effective coaptation of the ureteral walls and encourages resolution of the problem. It is only in the rare patient that steinstrasse does not resolve with the procedures outlined;  such cases require retrograde endoscopic manipulations to relieve the obstructed stone fragments.

Usually one finds 1 or 2 relatively large fragments that are obstructing. With their removal the columnation of fragments resolves.

Patients with large renal pelvic calculi (>1.5 cm) have a stone-free rate at 3 months approximating 75%, in comparison with those with a similar stone in a lower calyx, which approximates only 50%. Patients with small renal pelvic stones (<1.5 cm) have approximately a 90% stone-free rate in comparison to those with similar stones in a middle calyx (approximately 75%) or lower calyx (approximately 70%). Lower calyceal stone-free rates are increased with a small stone burden, a short and wide infundibulum, and a nonacute infundibulo-pelvic angle. Overall, approximately 75%  of patients with renal calculi treated with ESWL become stone-free in 3 months. As stones increase in size, stone-free rates decrease, more so in the lower and middle calyces than in superior calyceal and renal pelvic locations.

E. URETEROSCOPIC STONE EXTRACTION
Ureteroscopic stone extraction is highly efficacious for lower ureteral calculi.  The use of small-caliber ureteroscopes and the advent of balloon dilation or ureteral access sheaths have increased stone-free rates dramatically.  Even relatively large-caliber endoscopes without balloon dilation are effective in lower ureteral stone retrieval. 

Stone-free rates range from 66%  to 100%  and are dependent on stone burden and location,  length of time the stone has been impacted, history of retroperitoneal surgery, and the experience of the operator. Complication rates range from 5% to 30%; the rates increase when manipulations venture into the proximal ureter. Ureteral stricture rates are <5%.

Postoperative vesicoureteral reflux is extremely rare. Calculi that measure <8 mm are frequently removed intact. Round wire stone baskets can be torqued to help entrap stone or stone fragments. Flat wire baskets should be used with caution;  if twisted,  they can develop sharp,  knifelike edges resulting in ureteral injury. Excessive force with any instrument in the ureter may result in ureteral injury.

A variety of lithotrites can be placed through an ureteroscope, including electrohydraulic, solid and hollow-core ultrasonic probes, a variety of laser systems, and pneumatic systems such as the Swiss lithoclast. 

Electrohydraulic lithotrites have power settings as high as 120 V that result in a cavitation bubble, followed by collapse of this bubble causing subsequent shock waves. Care should be taken to keep the tip of the electrode away from surrounding tissue and the tip of the endoscope. Ultrasonic lithotrites have a piezoceramic energy source that converts electrical energy into ultrasonic waves in the range of 25,000 Hz.  This vibratory action is effective in fragmenting calculi. Hollow probes can suction stone fragments and debris simultaneously. Laser systems are discussed elsewhere in this book.

The electromechanical impactors are similar to jackhammers with a movable piston-like tip that fragments calculi.




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