A Series Clinical Study Of Minimally Invasive Treatment Of Upper Urinary Tract Calculi

First section Extracorporeal Shock Wave Lithotripsy for upper urinary tract stonesChapter 1:Prediction of success rate after Extracorporeal Shock Wave Lithotripsy of upper urinary tract stonesBackground and Objective This study was performed to investigate the prognostic factors associated with the success rate of ESWL and develop a preoperative nomograms for predicting stone-free rate after ESWL.Methods Between January 2005 and December 2007,a total of 480 patients (334 men and 146 women;range 11-80 years;mean age 42.83±12.88 years)with radiopaque upper urinary stones were treated with extracorporeal shock wave lithotripsy with a Dornier Lithotripter S.All cases were identified by KUB/IVU or Type B ultrasonic.Patient age,sex,height,weight,body mass index,duration of disease,stone length,width,number,side,location,haematuria and ache were evaluated before extracorporeal shock wave lithotripsy,and treatment efficacies were evaluated at 3 months.Treatment success was defined as complete clearance of the stones with no residual fragments with a single extracorporeal shock wave lithotripsy session.The stone-free rate was correlated with stone features and patient characteristics using the chi square test and t-test.Factors found to be significant using the tests were further analyzed using multivariate regression analysis,which was performed using a logistic regression model. Results Using the chi square test and t-test,age,duration of disease, height,weight,stone length,width,number and location had a significant impact on the stone-free rate.Multivariate analysis excluded age,duration of disease, height,weight and stone width from the logistic regression model while the other factors,such as stone length,number and location maintained their statistically significant effect on success rate,indicating that they were independent predictors.A logistic regression model was developed using these variables and to estimate the probability of stone-free status after ESWL.The sensitivity of the model was 91.9%, the specificity 55.9%and the overall accuracy 81.0%.In these nomograms the stone-free probability was highest for solitary ureteral stones less than 5 mm in size (96.7%)and lowest for multiple lower caliceal stones greater than 20 mm(0%).Conclusions This study demonstrated that stone length,number and location are significant predictors of extracorporeal shock wave lithotripsy outcome.We have developed nomograms for predicting the stone-free rate of extracorporeal shock wave lithotripsy,which is useful for counseling patients with urolithiasis before surgery.Chapter 2:Analysis of the outcome of extracorporeal shock wave lithotripsy for renal calculiObjective To evaluate the factors affecting the efficacy of extracorporeal shock wave lithotripsy(ESWL)for renal calculi.Methods Between January,2004 and January,2007,316 patients(212 men and 104 women)with renal stone underwent ESWL.The correlations of the patients' age, gender,body mass index(BMI),disease course,pain,hematuria,stone size,location, side,number and hydronephrosis to the outcome of the treatment was analyzed.The treatment success was defined as complete clearance of the stones or residual stone fragments＜0.4 cm,and ESWL was considered unsuccessful with residual stones≥0.4 cm. Results The overall success rate was 75.3%(238/316)in these patients. Significant difference in stone clearance rates was observed in patients with stone size of 0.5-1.0 cm(90.3%,167/185),1.0-2.0 cm(69.6%,55/79),and＞2.0 cm(30.8%, 16/52)(P=0.000).The success rates differed significantly between cases of pelvic stones(83.1%,118/142)and those of caliceal stones(69.0%,120/174)(P=0.004). But in cases of caliceal stones,the success rates were comparable between cases with stones at the upper calyx(71.7%,43/60),middle calyx(68.9%,31/45),and lower calix(66.7%,46/69)(P=0.829).Patients with single stones had significantly higher success rate(82.9%,170/205)than those with multiple stones(61.3%,68/111)(P= 0.000).The patients' gender,age,disease course,pain,hematuria,stone side and hydronephrosis did not produce significant impact on the outcome of the treatment (P＞0.05).Conclusion Stone size,location and quantity are significant independent factors affecting the outcome of ESWL for renal stones.Second section Contrast with different minimally invasive methods for ureteral calculiChapter 3:Contrast with three minimally invasive methods for ureteral calculiObjective To compare the clinical efficacy and evaluate the experiment of management of ureteral stone by three minimally invasive methods(extracorporeal shock wave lithotripsy,ureteroscopic lithotripsy and percutaneous nephrolithotripsy).Method We retrospectively investigated 326 cases(194 males,132 females, 16～72 years)who underwent ESWL,URL and PCNL for ureteral stone from 2006 to 2007.Clinical data including stone free rate and complications were analyzed.Results Stone free rate was 78.5%(146/186),91.2(93/102)and 100%(38/38) respectively。In ESWL group,3 groups of different stone size[0.5-1.0 cm (90.8%,89/98),1.0-2.0 cm(69.3%,52/75),＞2.0 cm(30.8%,5/13)in diameter]were statistically significant(X~2=24.752,P=0.000);In URL group,nine cases were failure,in which three can't enter the ureter or approach the stone,five the stone were pushed back to kidney,and one had residual stones＞4 mm in diameter;In PCNL group,the percutaneous renal access was successfully established and immediate phaseⅠlithotripsy was performed in all patients,Severe complication did not occur during nephrolithotripsy.Conclusion The best indication of ESWL is the stone smaller than 10 mm in diameter;URL suits most ureteral stone,but successful entrance of uretersocop is a prerequisite and the upward pushing of the stone is a main reason for failure;PCNL is efficient and causes less complication,thus suitable for treatment of complex upper ureteral stone,especially for the cases that have failed ESWL or ureteroscopy.Chaptor 4:Contrast with extracorporeal shock wave lithotripsy,ureteroscopic lithotripsy,Percutaneous nephrolithotripsy and retroperitoneal laparoscopic ureterolithotomy for upper ureteral calculiObjective To compare the clinical efficacy and evaluate the experiment of management of upper ureteral stone by four minimally invasive methods (extracorporeal shock wave lithotripsy,ureteroscopic lithotripsy,percutaneous nephrolithotripsy and retroperitoneal laparoscopic ureterolithotomy).Method We retrospectively investigated 190 cases(104 males,86 females, 19～68 years)who underwent ESWL,URL,PCNL and retroperitoneal laparoscopy for upper ureteral stone from 2006 to 2007.Clinical data including stone free rate and complications were analyzed.Results Stone free rate was 84.9%(73/86),64%(16/25),100%(38/38)and 100 %(31/31)respectively。In ESWL group,3 groups of different stone size[0.5-1.0 cm (96.6%,56/58),l.0-2.0 cm(75.0%,15/20),＞2.0 cm(25.0%,2/8)in diameter]were statistically significant(X~2=29.686,P=0.000);In URL group,nine cases were failure,in which three can't enter the ureter or approach the stone,five the stone were pushed back to kidney,and one had residual stones＞4 mm in diameter;In PCNL group,the percutaneous renal access was successfully established and immediate phaseⅠlithotripsy was performed in all patients,Severe complication did not occur during nephrolithotripsy;In retroperitoneal laparoscopy group,all the cases underwent ureterolithotomy successfully,no ureteric stricture was found during follow-up.Conclusion The best indication of ESWL is the stone smaller than 10 mm in diameter;URL isn't the best selection for it's high probability of upward pushing of the stone;PCNL and retroperitoneal laparoscopic ureterolithotomy are efficient and cause less complication,thus suitable for treatment of complex upper ureteral stone.Third section A series study of percutaneous nephrolithotripsy with pneumatic and ultrasonic power under B-type ultrasound guidance for treatment of complex upper urinary tract calculiChapter 5:Percutaneous nephrolithotripsy with pneumatic and ultrasonic power under B-type ultrasound guidance for treatment of complex renal calculiObjective To evaluate the clinical efficacy and experiment of management of complex renal stone by PCNL with pneumatic and ultrasonic power under B-type ultrasound guidance.Method We retrospectively investigated 382 cases(218 males,164 females, 4～74 years)who underwent PCNL using the third generation Swiss LithoClast Master for complex renal stone from 2004 to 2007.Clinical data including operation time,stone free rate and complications were analyzed.Results The 24F percutaneous renal access was successfully established under B type ultrasound guidance in all patients besides one access was 12F,immediate phaseⅠlithotripsy was performed in 397 sides and delayed phaseⅡlithotripsy in 8 sides.23 cases underwent Simultaneous bilateral PCNL.Operation time ranged from 70 to 190 minutes,average time was(93±11)minutes,9 cases were supported by transfusion,severe complications did not occur during nephrolithotripsy.Stone free rate was 91.8%(372/405),residual stone fragment was found in 33 cases after delayed phaseⅡlithotripsy and 14 cases received adjuvant extracorporeal shock wave lithotripsy.Follow-up of 3 to 24 months for 146 cases showed good results and no recurrence.Conclusion PCNL with pneumatic and ultrasonic power under B type ultrasound guidance is efficient and causes less complication for complex renal stone, which may substitute most open operations.Chapter 6:Percutaneous nephrolithotripsy with pneumatic and ultrasonic power under B-type ultrasound guidance for treatment of complex upper ureteral calculiObjective To evaluate the clinical efficacy and experiment of management of complex upper ureteral stone by PCNL with pneumatic and ultrasonic power under B-type ultrasound guidance.Method We retrospectively investigated 68 cases(36 males,32 females,19～70 years)who underwent PCNL using the third generation Swiss LithoClast Master for complex upper ureteral stone from 2004 to 2007.Clinical data including operation time,stone free rate and complications were analyzed.Results The 24F percutaneous renal access was successfully established under B type ultrasound guidance and immediate phaseⅠlithotripsy was performed in all patients.Average operation time was 65 minutes and arerage hospitalization duration was 5 days after operation.Severe complication did not occur during nephrolithotripsy. Stone free rate was 100%.Follow-up of 3 to 36 months for 46 cases showed good results and no recurrence.Conclusion PCNL with pneumatic and ultrasonic power under B type ultrasound guidance is efficient and causes less complication,thus suitable for treatment of complex upper ureteral stone,especially for the cases that have failed ESWL or ureteroscopy.Chapter 7:Experience of 48 cases of simultaneous bilateral percutaneous nephrolithotomyObjective To evaluate the safety and efficacy of simultaneous bilateral percutaneous nephrolithotomy(SBPCNL)for bilateral renal or upper ureter calculus.Methods We retrospectively investigated 48 cases(26 males,22 females,24～57 years)who underwent SBPCNL with pneumatic and ultrasonic power for bilateral renal or upper ureter calculus from June 2004 to August 2007.Clinical data including operation time,blood loss,transfusion rates,length of hospital stay,stone free rate and complications were analyzed.Results The percutaneous renal access was successfully established under B type ultrasound guidance in all patients,the average operation time was(105±18) minutes(range 80-190 minutes).The average drop in hemoglobin was 21 g/L(range 5-54 g/L),with 5 patients(13%)requiring blood transfusion.In 87%of patients,a single stage was performed on both sides,while 13%required two stages on one side. A single tract was on both sides utilized in 91.7%,while 8.3%of the patients required two tracts on one side.None required two tracts on both sides or more than one stage on both sides.The stone-clearance rate was 87.5%.The average hospital stay was 6.5 days.Severe complications did not occur.Conclusion SBPCNL is safe and effective for bilateral renal or upper ureter calculus,but patients with a large stone burden or bad renal function should not be selected for SBPCNL.Chapter 8:Some Criteria for Assessment of Staged or Synchronous Bilateral Percutaneous NephrolithotomyObjective To determine the validity of some criteria that could guide in the decision of staged or synchronous bilateral percutaneous nephrolithotripsy.Methods Patients with an indication for bilateral PCNL were enrolled in this study from January 2008 to December 2008.the criteria to stop the operation at the end of the initial side were:operative time was＞180 min,the hemoglobin level was＜10g/dL or the decrease was＞3 g/dL,the systolic arterial pressure was＜90 mm Hg or the decrease was＞30mmHg,the arterial oxygen saturation was＜95%,the arterial blood pH was＜7.35,,the blood sodium was＜128 umol/L,or the patient was intolerant.The success and complication rates were compared in patients who underwent synchronous bilateral percutaneous nephrolithotomy(group 1)and those for whom the procedure was stopped after the initial side and underwent staged bilateral percutaneous nephrolithotomy after 3 to 6 weeks(group 2).Results Of 60 planned simultaneous bilateral PCNLs,9 were stopped after the initial side,with the cause being prolonged operative time in 4,the hemoglobin level was＜100g/dL or the decrease was＞30 g/dL in 3,the systolic arterial pressure was＜90 mm Hg or the decrease was＞30mmHg in 2,the arterial oxygen saturation was＜95%or the arterial blood pH was＜7.35 in 2,and the patient was intolerant in 3. Differences in patient and stone characteristics,such as patient gender,age,BMI, preoperation hemoglobin level,the total hemoglobin decrease,from which side begin operation,stone number and second side stone burden,and overall success(The stone-clearance rate was 87.3%in group 1 and 88.9%in group 2)and complication rates were insignificant.Transfusion,postoperative urinary infection,and prolonged urine drainage rates were similar,but differences in the first side stone burden,total stone burden,the first side operation time and total operation time were significant. And the total hospitalization time was significantly longer in group 2.Conclusions Despite the best of intentions,about 15%of anticipated simultaneous bilateral PCNL cases might be changed to staged bilateral PCNL.Our criteria seem reasonable and can be considered in the decision of staged or synchronous bilateral percutaneous nephrolithotomy,because similar success and complication rates were obtained with two groups according to them.