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URSL with Lithotripsy

  • Posted on- Apr 16, 2018
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A urinary stone disease is a very big health problem that concerns millions of patients worldwide and is affecting more than 3-5% of the human population with a high recurrence rate of almost 50%.


Ureteric colic is a urological emergency in terms of the severe pain experienced by the patient. They occur most commonly in men aged between 30 years and 60 years.


Ureteroscopic lithotripsy (URSL) has been generally performed under general anesthesia or spinal anesthesia.


Ureteroscopic lithotripsy (URSL) not usually performed under local anesthesia, which is largely due to a fear of the risk of ureteral injury caused by painful jerky movement by the patient or of the patient complaining of pain during the procedure. Thus, local Ureteroscopic lithotripsy (URSL) is still in its infancy.


However, with the improvement of technology which has decreased the caliber of the Ureteroscope and other accessories, there is much progress in the management of ureteral calculi. Recent reports showed that the success rate of local Ureteroscopic lithotripsy (URSL) was comparable to that under general or spinal anesthesia.


This is the endoscopic treatment of ureter stones using a mini-scope. Under general anesthesia and fluoroscopic X-ray guidance, a rigid or flexible Ureteroscope is passed up the ureter via the urethra.


The stone is broken into smaller pieces with the Holmium laser. These tiny stone pieces will pass out on their own. A container can be used to store the stone or extract the broken pieces. This surgery takes 30 minutes on average and can be done in a day under general anesthesia.


Usually, a double-J (DJ) stent can be needed and will be inserted after the procedure if there is an injury to the ureter wall or if there is prior gross hydronephrosis of the kidney from an impacted stone. The success rate for stones lodged in the lower ureter is near 100%.


For the stones lodged at the mid- to the upper ureter, there is a chance they may float up into the kidney. If a flexible Ureteroscope is used, this may not be the issue as the scope can flex backwards within the kidney calyces to find the stone.


However, if only the rigid Ureteroscope is available, then the floated-up stone cannot be treated and a DJ stent is inserted for subsequent ESWL.


The advantage of URS over ESWL is that even hard stones can be broken and the ureter opening can be dilated to facilitate subsequent stone passage. However, URS is a more expensive and more invasive way of breaking ureter stones.

 

Complications include:

  • Bloody urine - This should clear in a few days.
  • Infection, this occurs postoperatively and is due to bacteria released when the stone is broken. This can be minimized by giving antibiotics prior to the surgery.
  • Perforation of the ureter - If this happens, it results in urine leak and pain. A DJ stent will need to be inserted to prevent further urine leak and avoid a late stricture
  • Stone migration - Because pressurized water is used to access the ureter and visualize the stone, the pressure may accidentally push the stone up beyond the reach of the Ureteroscope.


Desired outcomes:

  • no ureter injury
  • complete stone breakage


Recent advances in endourology and utilization of shock wave physics in urological stone disease have changed the management of urolithiasis altogether.


With the emergence of fine Ureteroscopes, intracorporeal lithotripsy with ureterorenoscopy has emerged as the treatment of choice for ureteric (especially mid and lower) stones.


Based on these new concepts and the findings, doctors suggest that URSL as day care procedure is safe and effective in a carefully selected group of patients with good antibiotic prophylaxis and analgesic protocols.


Furthermore, incorporation of sedoanalgesia technique and better instruments would improve our patient care to a new level.


The reduction in the treatment cost and early return to work among the patient also would be tremendous and need to be documented in a larger study.

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