Percutaneous antegrade management of large proximal ureteral stones using non-papillary puncture

Objective:To evaluate the feasibility and the safety of medial non-papillary percutaneous nephrolithotomy(npPCNL)for the management of large proximal ureteral stones.Methods:We evaluated prospectively collected data of 37 patients with large proximal ureteral stones more than 1.5 cm in diameter treated by prone npPCNL.Depending on stone size,in-toto stone removal or lithotripsy using the Lithoclast®Trilogy(EMS Medical,Nyon,Switzerland)was performed.Perioperative parameters including operative time(from start of puncture to the skin suturing),stone extraction time(from the first insertion of the nephroscope to the extraction of all stone fragments),and the stone-free rate were evaluated.Results:Twenty-one males and 16 females underwent npPCNL for the management of large upper ureteral calculi.The median age and stone size of treated patients were 58(interquartile range[IQR]:51-69)years and 19.3(IQR:18.0-22.0)mm,respectively.The median operative time and stone extraction time were 25(IQR:21-29)min and 8(IQR:7-10)min,respectively.One case(2.7%)of postoperative bleeding and two cases(5.4%)of prolonged fever were managed conservatively.The stone-free rate at a 1-month follow-up was 94.6%.Conclusion:The npPCNL provides a straight route to the ureteropelvic junction and proximal ureter.Approaching from a dilated portion of the ureter under low irrigation pressure with larger diameter instruments results in effective and safe stone extraction within a few minutes.

Use of a modified ureteral access sheath in semi-rigid ureteroscopy to treat large upper ureteral stones is associated with high stone free rates

Objective:To examine differences in outcomes of semi-rigid ureteroscopy(URS)with or without a modified-ureteral-access-sheath(mUAS)to treat large upper ureteral stones.Methods:Patients with single,radio-opaque large upper ureteral stone(≥10 mm)treated using semi-rigid URS between August 2013 and October 2016 were retrospectively evaluated.The stone-free status was determined from Kidney-ureter-bladder(KUB)X-ray films taken on postoperative Day 1 and after 1 month.Results:Of 103 patients meeting inclusion criteria,43(41.75%)and 60(58.25%)were treated with semi-rigid URS with and without mUAS,respectively.The immediate stone-free rate(SFR)for the mUAS group was significantly higher than the non-mUAS group(40[93.0%]vs.46[76.7%];p=0.033).The SFR at 1 month was also high for patients treated using mUAS,but not statistically different from patients not treated with mUAS(41[95.3%]mUAS vs.51[85.0%]non-mUAS;p=0.115).Auxiliary procedure rates were significantly lower for mUAS patients compared to non-mUAS patients(2[4.7%]vs.14[23.3%];p=0.01).There were no significant differences in surgical duration and hospital stays,and the overall complication rates were statistically similar for mUAS patients compared to non-mUAS patients(1[2.3%]vs.3[5.0%];p=0.638).

Extracorporeal Shock Wave Lithotripsy Treatment for Renal and Ureteral Stones in Duhok City

The present study reports the results of extracorporeal shock-wave lithotripsy treatment for renal and ureteral stones in Duhok city. The data were collected from the center of breakdown kidney stones in Duhok hospital. There were a total of 40 patients (25 males and 15 females) aged from 20 to 60 years old. The patients harboring (23 renal and 17 ureteral) stones of size ranged from 7.5 to 20 mm. Almost stones are of average size 9 mm and composed of uric acid, calcium and cystine stones. The study has been carried out by taking into consideration the parameters (type, sizes, composition and location of stone as well as region and ages of patients, also power, number of shock wave and sessions). The results show that the stones size increases according to increasing ages of patients (male and female) for uric acid ureter stone and calcium (renal, ureter) stones. Also (renal, ureter) stone size for patients aged from 20 to 30 years old increases from the minimum value for phosphate to maximum value for cystine stones, while for patients aged from 40 to 60 years old, the minimum size is obtained for calcium oxalate and the maximum size for calcium only. On the other hand, for uric acid stones of average size 9 mm, number of shock wave and sessions as well as the power required to breakdown the stones decrease nearly exponentially according to enhancing patients’ ages. At the same time, it's found that for adult patients (20 - 30 years old), number of sessions and the power of shock wave decrease also according to increasing size of calcium and cystine stones. Contrary to that, for the same ages and renal, uretral cysteine stones number of shock wave needed to breakdown large stones will be increased.

Primary squamous cell carcinoma with sarcomatoid differentiation of the kidney associated with ureteral stone obstruction: A case report

BACKGROUND Primary squamous cell carcinoma(SCC)with sarcomatoid differentiation of the kidney was rarely reported.This disease is usually related to renal stones,and due to a lack of symptoms and radiological features,patients usually attend the hospital with late stage disease.CASE SUMMARY A 54-years-old female presented with left flank pain and an abdominal mass for 6 mo.Imaging studies revealed that the left kidney was enlarged and massive hydronephrosis was present.A stone was seen in the ureteropelvic junction.The patient subsequently underwent left radical nephrectomy,and histopathological examination of the mass revealed a poorly differentiated renal SCC with sarcomatoid differentiation.After primary surgery,the patient received four cycles of tirelizumab.Four months later,the patient developed adrenal,lymph,and uterine appendage metastases.CONCLUSION SCC of the kidney has a poor prognosis,and should be considered in patients with a renal mass,long-standing urinary calculi and massive hydronephrosis.

Mechanism of therapeutic effects of Huangbo on ureteral stones based on network pharmacology

Objective:To analyze the effective chemical components and action targets of Phellodendron chinense,and to study the mechanism of Phellodendron chinense in treating ureteral stones.Methods:Search the potential chemical active substances of Phellodendron chinense and target proteins acting on the human body through the TCMSP database,and use the genomic annotation database platform(Genecards)to predict the target of ureteral stones,and use the uniprot database Query the corresponding gene names,build a network diagram of"drug-disease-target"with the help of Cytoscape(3.7.2)software,build a protein interaction network through the String database platform,and then use the Bioconductor platform and R language GO Enrichment analysis and KEGG enrichment analysis.Results:Through screening,a total of 36 effective chemical constituents of Phellodendron chinense,8 key chemical constituents related to ureteral calculi,and 20 common targets of Phellodendron-ureteral calculi were obtained.The core genes of PPI were FOS,CXCL8,IL6,SERPINE1,VEGFA,EGF,NOS3,SPP1,CCL2,CCND1,EGFR,HMOX1,IL10,CDKN1A,CRP;obtained 36 GO biological processes,and 14 KEGG related signaling pathways,including HIF-1 signaling pathway,FoxO signaling pathway,EGFR tyrosine kinase inhibitor resistance,endocrine resistance,viral protein interaction with cytokines and cytokine receptors,calcium signaling pathway,p53 signaling pathway,ErbB signaling pathway,MAPK signaling pathway,Ras signaling pathway.Conclusion:Phellodendron can achieve the effect of treating ureteral calculi through multiple targets and multiple ways,which provides a theoretical basis for the future extraction of effective components to treat ureteral calculi.

Comparison of combined laparoscopic ureterolithotomy and flexible ureteroscopy with percutaneous nephrolithotomy for removing large impacted upper ureteral stones with concurrent renal stones

Objectives:The present study compared the safety and efficacy of combined laparoscopic ureterolithotomy(LU)and flexible ureteroscopy with percutaneous nephrolithotomy(PCNL)for removing large impacted upper ureteral stones with concurrent renal stones.Methods:This study included 52 patients who underwent combined LU and retrograde flexible ureteroscopy for removing renal stones(group A)or PCNL(group B)for removing large upper impacted ureteral stones and concurrent renal stones at our department from January 2014 to December 2016.Patient demographics,stone characteristics,and procedure-related parameters including stone-free rate,operation time,hospital stay after surgery,mean decrease in hemoglobin levels,visual analog scale(VAS)score,auxiliary procedure rate,and complication rate were compared between groups A and B.Results:Results of this study showed that both procedures were effective for removing large impacted upper ureteral stones with concurrent renal stones.The stone-free rate after a single procedure was 95.7%in group A and 89.7%in group B(p?0.62).The operation time was longer in group A than in group B(112.2±23.3 min versus 96.2±16.4 min,p?0.006).However,no significant difference was observed between the two groups with respect to the length of hospital stay after the surgery(5 days versus 6 days,p?0.06).The decrease in hemoglobin levels was significantly higher in group B than in group A(0.64±0.36 g/dL versus1.44±0.65 g/dL,p<0.0001).The mean VAS scores obtained at 24 hours(2.91±1.08 versus 5.10±1.01,p<0.0001)and 48 hours after the surgery(1.09±0.73 versus 2.28±0.96,p<0.0001)were significantly higher for group B than for group A.Moreover,the auxiliary procedure rate was higher in group B than in group A(6.9%versus 0%).Conclusion:These results indicate that both combined LU and flexible ureteroscopy and PCNL are suitable for removing large impacted upper ureteral stones with concurrent renal stones and are associated with a high rate of patients being stone free afterwards.Despite the longer operation time,the combined laparoscopic and endourological procedure may be associated with less postoperative pain and fewer major complications.However,the choice of treatment depends on the preferences of surgeons and patients.

Prospective observational study on the prognosis of ureteral lesions caused by impacted stones via dual-energy spectral computed tomography

Objective Ureteral lesions caused by impacted ureteral stones are likely to result in postoperative ureteral stricture.On this basis,the study aimed to investigate if dual-energy spectral computed tomography can predict ureteral hardening caused by impacted stones and to explore the relationship between different types of ureteral lesions and the risk of ureteral stricture.Methods This prospective study collected data of 93 patients with impacted stones from hospital automation system during January 2018 to October 2019.They underwent an abdominal scan on a dual-energy spectral computed tomography.During surgery,the operator used ureteroscopy to identify ureteral lesions,which were classified into four categories:edema,polyps,pallor,and hardening.Seven months later,90 patients were reviewed for the degree of hydronephrosis.Results Endoscopic observations revealed 38(41%)cases of ureteral edema,20(22%)cases of polyps,13(14%)cases of pallor,and 22(24%)cases of hardening.There were significant differences in hydronephrosis,the period of impaction,the calcium concentration of the ureter,and the slope of the spectral Hounsfield unit curve between the four groups.After that,we evaluated the factors associated with ureteral hardening and found that the calcium concentration of the ureter and hydronephrosis remained independent predictors of ureteral hardening.Receiver operating characteristic curve analysis showed that 5.3 mg/cm^(3)calcium concentration of the ureter is an optimal cut-off value to predict ureteral hardening.The result of follow-up showed that 80 patients had complete remission of hydronephrosis,with a complete remission rate of 61.9%(13/21)in the hardening group and 97.1%(67/69)in the non-hardening group(p<0.001).Conclusion Calcium concentration of the ureter is an independent predictor of ureteral hardening.Patients with ureteral hardening have more severe hydronephrosis after ureteroscopic lithotripsy.When the calcium concentration of the ureter is less than 5.3 mg/cm^(3),ureteral lesions should be actively treated.

Ureteroscopic lithotripsy using holmium laser for 187 patients with proximal ureteral stones

Background Improving the success rate of ureteroscopic lithotripsy for proximal ureteral stones is the hot issue in this field. Here we reported our experience on the treatment of proximal ureteral stones.Methods From 2005 to 2010, 187 consecutive patients with proximal ureteral stones who underwent ureteroscopic lithotripsy were enrolled. The initial 52 patients treated by semi-rigid ureteroscope alone were classified as group 1. The subsequent 135 patients treated by semi-rigid ureteroscope with the aid of stone basket and flexible ureteroscope were classified as group 2.Results In group 1, the overall stone-free rate was 67.3%. By a single procedure of ureteroscopic lithotripsy using a semi-rigid instrument, patients with ureteral stones below the 4th lumbar vertebra level achieved 91.7% stone-free rate, which was only 50% in patients with stones above the 4th lumbar vertebra level. Conversion to open surgery occurred in two patients since ureteral perforation was observed. In group 2, the stone-free rate achieved 93.2% with the aid of an N-Trap basket, which was significantly higher than that of patients without the aid of the basket （51.6%）. Flexible ureteroscope was subsequently used in patients with fragment migration, thus making the overall success rate in group 2 increases to 97.0%.Conclusions Ureteroscopic lithotripsy is a safe and efficacious treatment for proximal ureteral stones. A single procedure of ureteroscopic lithotripsy using semi-rigid ureteroscope could achieve a satisfactory stone-free rate in patients with proximal ureteral stones below the 4th lumbar vertebra level. However, patients with ureteral stones above the 4th lumbar vertebra level experienced higher stone-migration rate, which would decrease the success rate. Fortunately, the stone-free state could possibly be achieved with the aid of an N-trap basket and flexible ureteroscope.

Comparison of tamsulosin with extracorporeal shock wave lithotripsy in treating distal ureteral stones

Background Tamsulosin, an alpha-1 receptor antagonist, has been demonstrated effective in promoting distal ureteral stone passage and in reducing pain associated with stone expulsion. This study aimed to evaluate the effect of tamsulosin in comparison with nifedipine and extracorporeal shock wave lithotripsy （ESWL） on the expulsion rate of distal ureteral stones at different sizes. Methods We assigned 314 patients to three categories： Ⅰ, the stone with maximal diameter of 4.0-5.9 mm; Ⅱ, 6.0-7.9 mm, and Ⅲ, 8.0-9.9 mm. Patients in each category were randomly subdivided into three treatment subgroups： group A （nifedipine group）, group B （tamsulosin group）, and group C （ESWL group）. Stone-free rate and the dose of analgesics were recorded weekly during the 4-week follow-up period. Results Three hundred and three patients completed the study. The results showed that nifedipine and tamsulosin treatments promoted a small （4-8 mm, categories Ⅰ and Ⅱ） stone expulsive rate that was comparable with ESWL treatment. Nonetheless, when the stone diameter was 8.0-9.9 mm, ESWL showed a greater stone free rate than nifedipine and tamsulosin treatments; no significant difference existed between the latter two therapies. Although the ESWL treatment group required the least analgesics, tamsulosin treatments required less pain medication than nifedipine （P 〈0.05）. Conclusions Tamsulosin treatment is recommended for patients with the stone diameter smaller than 8 mm because of its feasibility, effectiveness and safety. ESWL is more appropriate than tamsulosin therapy for the patients whose stones are larger than 8 mm.

The effect of perirenal fat stranding on infectious complications after ureterorenoscopy in patients with ureteral calculi

Objective:Perirenal fat stranding(PFS)is linear areas of soft-tissue attenuation in the perirenal space on non-contrast computed tomography.The present study aimed to investigate whether PFS is associated with infectious complications after ureterorenoscopy(URS)in patients with ureteral calculi in any location.Methods:The data of 602 patients with ureteral stones who underwent URS were analyzed retrospectively.The patients were divided into two groups as Group 1(PFS not detected)and Group 2(PFS detected).Gender,and age of patients,size,side,and location of the stone,operation time,double-J stent insertion status,perioperative ureter injury,postoperative infection after URS and related complications,and duration of hospital stay were compared.Results:While PFS was not detected in 530 patients,PFS was detected in 72 patients.The mean age,male/female ratio,side and localization of the stones,operation time,and perioperative insertion of the double-J after lithotripsy were statistically similar(p>0.05).The median stone diameter was smaller in Group 2(9 mm vs.8 mm)(p=0.033).Fever was observed in 30 and 38 patients in Group 1 and Group 2,respectively(p=0.0001).Urinary tract infection was detected in 24 and 27 patients in Group 1 and Group 2,respectively(p=0.0001).The urosepsis did not occur in any patients in Group 1,whereas 8(11.1%)patients in Group 2 experienced urosepsis(p=0.0001).Conclusion:According to the results of the present study,patients with ureteral stones accompanied by PFS are much more prone to ureteral injuries and infectious complications such as urinary tract infection,fever,and sepsis after URS.

Can Computerized Hounsfield Unit Estimation Be Used as Predictor for Ureteric Stone Localization by Fluoroscopy during Extra Corporal Shock Wave Lithotripsy and Ureteroscopy?

Current minimally invasive interventions for ureteric stones involve either ESWL or Ureteroscopy and stone localization is mandatory for successful treatment in both. Objectives: To avoid doing KUB radiograph before ESWL routinely by correlating the stone attenuation value on CT KUB with stone visualization at fluoroscopy. Methods: This is a prospective cross sectional hospital based, Multicentric study carried out on 1010 patients with ureteric stones in Sudan from August 2014 to March 2016. Results: Mean stone density in HU was 704.45 ± 300 (SD) ranging (81 - 1873) HU. All of the stones were localized using fluoroscopy and only 26.5% of them were not seen under fluoroscopy. I.V contrast was used mostly, and also mainly in the upper ureter. More than 80% of the application of contrast through the ureteric catheter was in the lower ureteric stones. 91.2% of patients with stone density ≤ 400 HU failed to appear at fluoroscopy and therefore 400 HU attenuation value can be used as a cut-off level to request doing KUB before ESWL and Ureteroscopy. Conclusion: the ureteric stones with density ≤400 HU the likelihood of being non-visualized at fluoroscopy is 91.2% therefore if the stone has ≤400 HU at CT KUB it is mandatory to do KUB before treatment above that it is most likely to be seen at fluoroscopy and no need to request KUB for them before ESWL or URS. 1) Inclusion Criteria: All patients diagnosed by CT scan to have ureteric stones for ESWL or Ureteroscopy. 2) Exclusion Criteria: Patients for whom treatment of ureteric stone by ESWL or ureteroscopy is not indicated like severe infection or poor kidney function where nephrectomy is needed.