Upper urinary tract calculi that are too large to treat with extracorporeal shock wave lithotripsy are most commonly cleared with percutaneous endoscopic techniques. In a select group of patients who were poor candidates for percutaneous nephrostolithotomy we used retrograde endoscopic lithotripsy, and define the safety and efficacy of this modality in treating large, noninfectious stone burdens (2 cm. or greater).
A total of 51 patients with 66 large (2 cm. or greater) upper urinary tract stones were chosen for retrograde ureteroscopic surgery. Many of these patients had co-morbid conditions that precluded or complicated standard percutaneous treatment. Lithotripsy was based on the application of small diameter fiberoptic ureteroscopes and the holmium laser lithotriptor. Specifically, the 200 micro. laser fiber was used when lower pole renal access was required. Successful therapy was defined as total fragmentation of a stone burden with creation of fine sand and 2 mm. or smaller debris. Second look endoscopy was commonly performed in select patients with large branched calculi or stone burdens in excess of 3 cm. to rule out and treat large residual fragments.
Of 51 patients 48 were treated solely in a retrograde ureteroscopic manner and in 3 either failure of lower pole access or infectious material encountered on initial endoscopy led to conversion to more standard percutaneous techniques. In 34 of 45 renal (76%), and 20 of 21 ureteral (95%) complete ureteroscopic fragmentation of the respective stone burden was accomplished after a single session. Second look endoscopy defined significant residual fragments requiring additional endoscopic lithotripsy in 8 of 15 large renal (53%) and 1 of 3 complex ureteral stone burdens. Success, that is complete pulverization of the stone burden to fine dust and small 2 mm. fragments, increased to 41 of 45 renal (91%) and all 21 ureteral calculi after these second look procedures. One patient required a third session to treat completely an exceptionally large (6 cm.) renal stone burden composed of pure cystine, thus increasing the overall success rate for renal calculi to 93%. Six-month followup data were available for 25 patients with large calculi treated ureteroscopically, of whom 15 (60%) had completely clear imaging, 6 (24%) had small lower pole debris that was decreasing on serial imaging and 4 (16%) had new stone growth which was, in part, related either to uncorrectable metabolic disorders or chronic renal scarring and urinary stasis. There were no intraoperative complications. Three postoperative complications included pyelonephritis in 1 patient, prostatic bleeding in 1 on anticoagulant therapy and a cerebral vascular accident 24 hours after the procedure in 1 with severe vascular disease.
Large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.