Original Article URETERIC STONES: ISSUES and CONTROVERSIES GETTMAN and SEGURA

Management of ureteric stones: issues and controversies

MATTHEW T. GETTMAN and JOSEPH W. SEGURA
Department of Urology, Mayo Clinic, Rochester, Minnesota, USA

KEYWORDS ureteroscopy, shockwave lithotripsy, surgical treatment, ureteric calculus

INTRODUCTION In the last 20 years, the management of ureteric stones has radically changed [1]; currently most ureteric stones are successfully managed with shockwave lithotripsy (SWL) or ureteroscopy. Technological advances and innovation by physicians have improved the endourological treatment of ureteric stones. Regardless of the location of the ureteric stone, access and denitive treatment is commonly achieved with a minimal risk of complications. Despite the denite success of endourological stone treatment, ongoing questions about optimum management remain debated among urologists. Herein we discuss the current issues and controversies surrounding the management of ureteric stones

passage in 2998% of stones of <5 mm diameter above the iliac vessels, and 7198% of stones of <5 mm diameter below the iliac vessels. For stones of 510 mm diameter, spontaneous passage occurred in 1053% of proximal calculi and 2553% of distal calculi. In a multivariate analysis of risk factors associated with spontaneous ureteric stone passage, Miller and Kane [2] found that smaller, more distal stones on the right side were more likely to spontaneously pass and require fewer surgical interventions. In a recent report by Coll et al. [3] spontaneous ureteric stone passage rates, regardless of size, were 48%, 60%, 75% and 79% for stones in the proximal, middle and distal ureter or at the vesico-ureteric junction, respectively. Adjuvant pharmacological intervention during conservative therapy, in addition to routine analgesics, has also been used in an attempt to facilitate spontaneous stone passage, but the impact of these interventions remains incompletely evaluated. In a randomized, double-blind, placebo-controlled study, Borghi et al. [4] evaluated the role of nifedipine and methyl prednisolone on spontaneous stone passage, noting a signicant increase in spontaneous stone passage among patients in the treated group. In a related study involving deazacort and nifedipine, Porpiglia et al. [5] reported not only a greater incidence of stone passage but also less time to stone passage and decreased analgesic requirements among treated patients. In a study evaluating standard analgesics plus steroids, nifedipine and trimethoprim/sulfamethoxazole, Cooper et al. [6] reported that treated patients had a higher spontaneous stone passage rate, fewer days off work and fewer emergency-room visits. While benet appears possible with adjuvant medical therapies, possible side-effects related to calcium-channel blockers (i.e. hypotension, palpitations) or other potential medical therapies remain a concern. Furthermore, additional evaluation is recommended before medical adjuncts to conservative observation alone become widely practised. The choice of therapy for urgent decompression of the collecting system in the

presence of an obstructing ureteric stone and infection has also been controversial. For patients with no overt signs of sepsis, we have favoured urgent decompression of the collecting system with an external ureteric catheter. In this manner, urine output can be directly measured and the ureter easily irrigated. Others recommend urgent decompression of the collecting system with a percutaneous nephrostomy tube or internalized stent. Among 42 patients randomized to external ureteric catheter or percutaneous nephrostomy, Pearle et al. [7] reported equivalent success for either method but twice the cost for retrograde stent placement. In another prospective randomized study [8], a percutaneous nephrostomy was better than an internal stent. Especially among males and juveniles, the overall quality of life was signicantly reduced by the internal stent. DEFINITIVE THERAPY When conservative therapy fails or is contraindicated, the choice of specic treatment can be inuenced by stone size, location, composition, previous stone history, habitus, patient and surgeon preference, and previous surgical treatments. To guide treatment selection, recommendations based on clinical outcome data have been devised for ureteric stones located above or below the pelvic brim [1]. Importantly, guidelines have not supported the superiority of one treatment option over another. Thus, selecting the treatment remains controversial for distal and proximal stones. However, at present, some treatment choices have become less appealing. For the most part, open ureteric stone surgery has become obsolete, and laparoscopic ureterolithotomy has been described as an effective alternative to open ureterolithotomy [9,10]. Although laparoscopic ureterolithotomy has been used as a rst-line treatment of ureterolithiasis in some institutions, the technique is used predominantly in the USA as a salvage therapy. Last, the use of percutaneous ureterolithotomy, reserved predominantly for managing large, impacted proximal ureteric stones is also used less commonly today for 85

INTERVENTION CONSERVATIVE THERAPY As denitive management of ureteric calculi has become easier, more successful and associated with fewer complications, enthusiasm for the conservative management of symptomatic ureteric stones has dwindled. Nonetheless, many symptomatic patients will spontaneously pass a ureteric stone with no intervention [13]. As such, we think that a trial of conservative therapy should be considered for many patients with symptomatic ureteric stones. Conservative therapy is contraindicated for ureteric calculi in the presence of urinary infection, complete ureteric obstruction, signicant symptoms prompting several ofce visits, or for patients with specic occupational requirements (i.e. a pilot). Stone size and initial stone location inuence the likelihood of spontaneous stone passage and guide treatment recommendations. Segura et al. [1] reported spontaneous

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ureteric stones, given the advances in other endourological techniques.

DISTAL URETERIC STONES The choice of treatment for distal ureteric stones remains one of the most heavily debated subjects in urology. This issue has been evaluated in many retrospective studies comparing ureteroscopy to Shock Wave Lithotripsy (SWL). Among the retrospective series, success rates are in general higher with ureteroscopy than with SWL [1115]. Nonetheless, some groups recommend SWL as rst-line therapy as it is less invasive, despite SWL being associated with inferior stone-free rates [14,15]. Prospective randomized trials have also evaluated the optimum treatment of distal ureteric stones [16,17]. Peschel et al. [16] reported a complete ureteroscopic stone-free rate (40 patients) and 90% SWL stone-free rate on a Dornier MFL5000 lithotripter (40 patients). For stones of < 5 or >5 mm in diameter, the SWL stonefree rates were 95% and 85%, respectively. No complications were noted in either group, but the procedure was faster for ureteroscopy. In addition, all patients were satised with ureteroscopy, but only 85% after SWL. Based on these results, ureteroscopic stone extraction was recommended as the rst-line therapy for distal stones. Pearle et al. [17] prospectively randomized 32 patients with distal stones (diameter < 1.5 cm) to ureteroscopy or SWL on a HM3 lithotripter; both treatments cleared the stones completely. As SWL was associated with fewer perioperative complications, less postoperative discomfort, and greater overall patient satisfaction, the group recommended SWL with a HM3 lithotripter as rst-line treatment for distal stones. We think that current technical and practical issues make ureteroscopy the favoured treatment for distal stones. On a practical basis, the lower ureter can be accessed almost all the time with a semi-rigid or exible instrument. Compared with SWL increasingly applied using higher-generation lithotripters, ureteroscopy is associated with higher stonefree rates and fewer secondary interventions (Table 1)[1146] and Table 2 [11,12,1517,27, 28,32,45,4759]. Most importantly, patients typically can have a successful outcome after just one surgical procedure. For example, in series published between 1996 and 2003 the need for a second treatment was reported in 86

3.5% of patients (Table 1). In addition, the effectiveness of intracorporeal lithotripsy with the Ho:YAG laser can make treatment of all stones a reality in the distal ureter, regardless of composition or burden. For series using Ho:YAG laser lithotripsy, ureteroscopic success rates for distal stones are 93100% [17,2325,2931,33,34]. Ureteroscopy has also become less invasive and the risk of complications is lower with modern instruments. Among series published between 1996 and 2003, the overall incidence of ureteroscopic complications for distal stone manipulation was 7% (Table 1). Furthermore, the incidence of ureteric stricture was <2% and the incidence of ureteric perforation < 4% in recent studies [17,2325,2931,33,34]. Also, most patients undergoing ureteroscopy are currently treated as outpatients and the overall cost of intervention is less than that reported for SWL or more invasive stone therapies [60]. Finally, characteristics of the Ho:YAG laser have made ureteroscopic stone treatment of distal stones a reality among patients with uncorrected bleeding diatheses or during pregnancy [61,62].

and the auxiliary procedure rate 9.4%. However, in 21 ureteroscopy series for proximal ureteric stones published between 1995 and 2003, the overall stone-free rates was 82% and the second-procedure rate 10% (Table 1). The overall ureteroscopy complication rate decreased to 6.6% when treating proximal ureteric stones (Table 1). Furthermore, among ve recent series, the incidence of ureteric perforation and stricture was 2% and < 1%, respectively [24,25,37,40,45]. At present, studies comparing SWL with ureteroscopy provide an insight into therapeutic trends. Grasso et al. [35] compared the efcacy of ureteroscopy (27 patients) to SWL on a Siemens Lithostar lithotripter (27 patients) for large proximal stones. Stone-free rates of 62% and 97% were achieved for SWL and ureteroscopy, respectively. Combined re-treatment and auxiliary treatment rates were signicantly higher for SWL (37% vs 3.7%), and treatment costs were higher and postoperative visits more common after SWL. Lam et al. [45] recently compared SWL with Ho:YAG lithotripsy in 67 patients with proximal ureteric stones. Among stones of > 1.0 cm diameter, the initial stone-free rate was 93% for ureteroscopy and 50% with SWL using a Dornier DoLi 50 lithotripter. For stones of < 1.0 cm diameter, the initial stone-free rates were 100% and 80% for ureteroscopy and SWL, respectively. The authors recommended SWL as rst-line therapy for stones of <1.0 cm diameter and ureteroscopy for those >1.0 cm in diameter. While current data may suggest superiority for ureteroscopic treatment of proximal stones, several issues deserve comment. First, despite the technological advances, ureteroscopy remains much more challenging than SWL in the proximal ureter. Also, the type of lithotripter used can have a major effect on success rates. While we concur that treatments for proximal ureteric stones are developing, we still favour SWL as rst-line therapy for most proximal ureteric stones of < 1.0 cm diameter. Based on recent outcome data, ureteroscopy appears favourable as salvage therapy for stones of <1 cm diameter. For stones larger than this in the proximal ureter, we tend to favour ureteroscopy or possibly percutaneous ureterolithotomy as alternatives to SWL, especially if a Dornier HM3 lithotripter were not available. In addition, ureteroscopy and percutaneous

PROXIMAL URETERIC STONES Since the advent of endourology, proximal ureteric stones have classically been managed with SWL. Historically, ureteroscopy has remained less widely accepted and more controversial than SWL for proximal ureteric stones. Initially, ureteroscope design did not particularly facilitate stone treatment in the proximal ureter. Furthermore, early ureteroscopic success rates for proximal ureteric stones were suboptimal when compared to other treatments [1]. Also, from a technical standpoint, ureteroscopy was considered much more difcult than SWL. Concurrent with the development of Ho:YAG laser and potentially with the replacement of the Dornier HM3 lithotripter with secondand third-generation machines, interest in the ureteroscopic treatment of proximal ureteric stones has increased. Contemporary reports show comparable success rates for endourological treatments of proximal ureteric stones (Tables 1 and 2). Among 11 SWL series published between 1998 and 2003 using second- or third-generation lithotripters, the overall stone-free rate was 75% (Table 2). Nonetheless, among patients in these reports the re-treatment rate was 30%

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TABLE 1 The treatment of distal (series with > 30 patients) and proximal (series with > 15 patients) ureteric stones with ureteroscopy N patients 68 156 322 430 80 134 66 48 102 34 40 34 96 220 40 228 32 103 69 115 430 237 176 3260 27 40 43 39 17 18 51 84 114 62 40 22 20 32 29 29 81 194 81 24 32 1079 Size (F) of ureteroscope 6 6.5 11.5 9.512 7.2 711.5 7.911.5 6.98.5 7.5 8.59.5 6.59.5 69.8 7.59.5 78 7.59.5 11.5 6.911.5 6.9 6.5/7 6F9.5 8 6.9, 9.5, 11.5 6F11.5 4.814 6.9F, 7.5 6.5 6.9 6.913 611.5 8.5F, 9.5 6.98.5 <8 7.5 78 NR 4.89.5 8.5 69.5 69.8 6.97.5 6.9F, 7.5 7.510.5 7.5 7, 8 611.5 4.813 Method of stone removal Intact Alexandrite laser Intact EHL, USL, PL Pulsed dye PL Intact, PL Alexandrite laser Ho:YAG Intact, Ho:YAG Intact, PL Intact, EHL, PL, Ho:YAG Intact, Pulsed dye laser EHL, PL Intact, EHL USL, EHL Alexandrite, Ho:YAG, EHL Intact, Ho:YAG Intact, Ho:YAG Ho:YAG, EHL Intact, PL Ho:YAG, EHL Intact, Ho:YAG, EHL Stone-free rate, % (n/N) 97 (66/68) 94.5 (148/156) 98.1 (316/322) 91.9 (395/430) 99 (79/80) 89.5 (120/134) 86.4 (57/66) 94 (45/48) 93 (95/102) 94 (32/34) 100 (40/40) 100 (34/34) 95 (93/96) 99.6 (219/220) 97 (39/40) 92 (219/238) 100 (29/29) 96 (99/103) 99 (68/69) 99.1 (90/91) 96 (413/430) 98 (232/237) 95.1 (77/81) 95 (3005/3148) 96 (26/27) 68 (27/40) 84 (36/43) 99 (38/39) (13/17) (14/18) 69 (35/51) 97 (82/84) 88 (77/114) 99 (61/62) 80 (32/40) 100 (22/22) 85 (17/20) 81 (26/32) 97 (28/29) 90 (26/29) 78 (63/81) 97 (188/194) 97 (30/31) 100 (24/24) 72 (23/32) 82 (888/1079) Complications, % (n/N) 0 (0/68) 0 (0/156) 4.3 (14/322) 12.6 (54/430) 0 (0/80) 2.2 (3/134) 0 (0/40) 0 (0/34) 5.2 (5/96) 2.5 (6/238) 25 (8/32) 14 (14/103) 13 (60/69) 6.1 (7/115) 4.2 (18/430) 4 (24/598) 7 (213/2945) 5 (1/40) 9 (4/43) 5 (2/40) 1 (2/150) 10 (2/20) 25 (22/87) 0 (0/29) 0 (0/29) 17 (14/81) 4 (7/194) 0 (0/81) 0 (0/24) 6.6 (54/818) Secondary procedures, % (n/N) 0 (0/68) 5 (8/156) 0 (0/322) 7 (6/80) 6.0 (8/134) 5 (5/102) 6 (2/34) 0 (0/40) 0 (0/34) 3.1 (3/96) 6.3 (14/220) 4.2 (10/238) 0 (0/32) 4 (4/103) 1 (1/69) 1.7 (2/115) 0 (0/430) 6 (38/598) 3.5 (101/2871) 4 (1/27) 28 (11/40) 14 (6/43) 3 (1/39) (1/18) 11 (12/114) 26 (16/62) 15 (6/40) 7 (10/150) 45 (9/20) 3 (1/29) 10 (3/29) 9 (7/81) 6 (12/194) 3 (1/31) 0 (0/24) 10 (97/941)

Ref Distal [18] [19] [20] [11] [21] [13] [15] [22] [23] [24] [16] [25] [12] [26] [27] [28] [17] [29] [30] [31] [32] [33] [34] Total Proximal [35] [19] [36] [37] [38] [24] [22] [39] [23] [26] [40] [41] [42] [43] [25] [44] [29] [33] [45] [46] [34] Total

Pulsed dye, EHL Alexandrite laser EHL EHL, Ho:YAG, Pulsed dye Intact, EHL, USL, Ho:YAG Alexandrite laser Pulsed dye, EHL, Ho:YAG Ho:YAG EHL, PL Ho:YAG Ho:YAG USL, PL EHL, Pulsed dye Intact, EHL, PL, Ho:YAG Ho:YAG, EHL Intact, Ho:YAG Ho:YAG, EHL Ho:YAG, Intact PL Ho:YAG, EHL

USL, ultrasonic lithotripsy; EHL, electrohydraulic lithotripsy; PL, pneumatic lithotripsy.

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TABLE 2 Results of SWL for distal and proximal (series with > 25 patients) ureteric calculi using the Dornier HM3 or higher-generation lithotripters No. of patients 312 27 44 32 518 933 726 131 37 395 91 40 182 639 524 546 57 165 102 3635 386 478 46 48 958 458 38 83 397 1071 130 67 746 74 74 44 3182 Stone-free rate, % (n/N) 81 (199/245) 96 (26/27) 78 (35/44) 91 (29/32) 97 (502/518) 91 (791/866) 42 (306/726) 92 (120/131) 59 (22/37) 99 (391/395) 73 (66/91) 90 (36/40) 54 (99/182) 91 (581/639) 87 (455/524) 86 (469/546) 74 (42/57) 99 (163/165) 83.3 (85/102) 78 (2835/3635) 77 (211/273) 73 (243/333) 96 (44/46) 94 (45/48) 78 (543/700) 61 (279/458) 76 (29/38) 90 (84/93) 84.3 (334/397) 70 (749/1071) 83.8 (108/130) 69 (38/55) 83 (619/746) 85 (63/74) 80 (59/74) 81.8 (36/44) 75 (2398/3180) Re-treatment, % (n/N) 4 (14/312) 3 (2/65) 0 (0/32) 9 (46/518) 6.6 (62/927) 11 (15/131) 6 (23/368) 15 (14/91) 0 (0/40) 46 (83/182) 17.2 (110/639) 13.7 (71/524) 23 (125/546) 30 (17/37) 7 (11/165) 30 (31/102) 18 (500/2825) 5 (19/386) 4 (18/478) 2 (1/46) 0 (0/48) 4 (38/958) 31 (123/397) 30 (321/1071) 60 (78/130) 22.8 (170/746) 50 (37/74) 30 (22/74) 30 (13/44) 30 (764/2536) Aux procedure % (n/N) 6 (4/65) 4 (20/518) 4.1 (24/583) 41 (15/37) 1 (4/368) 7 (6/91) 10 (4/40) 12.8 (67/524) 6.5 (35/546) 26 (14/57) 2.4 (4/165) 16.7 (17/102) 10.2 (166/1630 8 (21/273) 2 (5/333) 4 (26/606) 24 (9/38) 9 (8/93) 10.7 (14/130) 13 (7/55) 6.5 (48/746) 12 (9/74) 20 (15/74) 19 (8/44) 9.4 (118/1254) Ureteric catheter % (n/N) 79 (246/312) 0 (0/27) 16 (5/32) 28 (145/518) 45 (396/889) 16 (6/37) 19 (34/182) 11.6 (74/639) 0 (0/524) 0 (0/57) 0 (0/165) 0 (0/102) 6.6 (114/1706) 100 (273/273) 0 (0/478) 0 (0/46) 0 (0/48) 32 (273/845) 0 (0/458) 39 (15/38) 0 (0/93) 11.6 (46/397) 19 (203/1071) 0 (0/130) 39 (29/74) 0 (0/74) 0 (0/44) 12 (293/2379) % Outpatients 94 All All 72.5 All All All All 72.5 Complication rate, % (n/N) 5 (16/312) 0 (0/27) 9 (3/32) 0 (0/518) 2 (19/889) 5 (36/726) 4 (17/395) 0 (0/91) 0 (0/40) 0 (0/639) 0 (0/524) 0 (0/57) 0 (0/165) 1 (1/102) 2 (54/2739) 3.9 (18/458) 0 (0/93) 0 (0/397) 16 (21/130) 0 (0/67) 0 (0/74) 0 (0/44) 3 (39/1263)

Ref [47] [48] [12] [17] [49] Subtotal [11] [15] [27] [28] [12] [16] [50] [51] [32] [52] [53] [54] [55] Subtotal Proximal [56]* [56] [57] [57] Subtotal [11] [27] [58] [51] [50] [59] [45] [52] [53] [60] [55] Subtotal

Lithotripter Dornier HM3 Dornier HM3 Dornier HM3 Dornier HM3 Dornier HM3 Lithostar MPL9000 Modulith, Compact Lithostar MFL5000 MFL5000 MFL5000 Modulith SL-20 Lithostar Modulith Compact Lithostar EDAP LT-02

Dornier HM3 Dornier HM3 Dornier HM3 Dornier HM3 Lithostar Modulith, Compact MFL5000 Modulith MFL5000 Lithostar DoLi 50 Modulith Compact MFL5000 EDAP LT02

*stent bypass; pushback SWL; in situ SWL.

ureterolithotomy appear advantageous for large, impacted proximal ureteric stones and for treating morbidly obese patients who are not candidates for SWL.

controversies about treatment have developed. URETEROSCOPY Deciding on ureteroscopic instrumentation was simple when the endourological arsenal was limited, but at present specic decisions on ureteroscopes, lithotrites, guidewires, baskets, access sheaths and stents must be evaluated for each patient. The size of ureteroscope remains an important treatment

TECHNICAL ISSUES Technological advances have improved the management of ureteric stones, but as the endourological options have expanded, 88

consideration. While a larger ureteroscope improves visualization and can increase the chance of intact stone extraction, the larger instrument typically necessitates active intramural ureteric dilatation and a potential risk of more serious complications. With the introduction of the Ho:YAG laser, the benet realized with the larger ureteroscopes is somewhat decreased, given the increased efcacy of intracorporeal lithotripsy. On the other hand, using a smaller ureteroscope can result in many trips through the ureter to

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retrieve stone fragments, unless the stone is fragmented entirely to dust. With modern endoscopy the availability of stone baskets has also increased. While we favour the use of a at wire basket for stone extraction, threepronged graspers and tipless baskets at times provide a denite advantage during stone extraction, especially in the passively dilated ureter. With the advent of smaller ureteroscopes, many studies have evaluated the need to place a stent after uncomplicated ureteroscopy. Stents have routinely been placed after ureteroscopy to minimize the risk of ank pain secondary to ureteric oedema, facilitate the passage of residual stone fragments and decrease risk of ureteric stricture. However, the presence of a ureteric stent is associated with an adverse affect on quality of life and the risk of stent-related complications. Indeed, using a recently validated symptom questionnaire on ureteric stents, urinary symptoms and pain associated with stents reduced the quality of life in up to 80% of patients [63]. Retrospective, prospective unrandomized, and prospective randomized studies have found uncomplicated ureteroscopy to be safe with no ureteric stent [31,6471]. For most of the reported series, selection criteria for stent-less ureteroscopy remain an important consideration. For example, in most prospective, randomized trials the decision to omit a stent was predominantly for patients with small distal stones that could be adequately fragmented or removed with no ureteric dilatation or signicant ureteric trauma [31,6668]. For patients meeting these type of inclusion criteria, many patientrelated benets were realized, including less postoperative pain, urinary symptoms, operative time and procedural costs [31,6770]. Using less stringent inclusion criteria (no limitations on stone burden, ureteric location, degree of obstruction), Cheung et al. [71] recently reported similar patient-related benets for ureteric stones treated with uncomplicated ureteroscopy. The practice of stent-less ureteroscopy in other clinical scenarios remains poorly understood. Hollenbeck et al. [72] retrospectively reviewed the records of 219 patients (including renal and ureteric stones) who had stent-less ureteroscopy. Overall, an 18% incidence of postoperative complications was correlated with univariate factors, e.g. renal pelvic stone location, bilaterality, lithotripsy, history of urolithiasis, diabetes mellitus, recent/

recurrent infections, or longer operative times with or without lithotripsy or ureteric dilatation. To date, studies have shown that routine stenting for all patients after ureteroscopy is unnecessary. However, we think that the ultimate extent to which ureteric stenting can be omitted will probably be determined by a lack of adverse intraoperative events and common sense. The use of ureteric access sheaths represents another treatment consideration during ureteroscopy. Such sheaths were initially introduced to aid difcult access to the ureter. At present a new generation of access sheaths has been introduced that can dilate the ureter and possibly facilitate ureteroscope placement. Kourambas et al. [73] compared perioperative data for 59 patients (62 ureteroscopic procedures) undergoing ureteroscopy with (30) or without (32) a ureteric access sheath. They reported a greater incidence of postoperative symptoms for patients who required balloon ureteric vs access sheath dilatation alone. Interestingly, the use of a ureteric access sheath decreased the operative time and costs among the study patients. Given the large diameter of the access sheaths (1016 F), one concern has been the safety of the devices in the ureter. At the short-term follow-up, Delvecchio et al. [74] reported that the new access sheaths were safe; among 62 patients included in the review there was a 1.4% incidence of stricture, but the authors postulated that this complication was unrelated to the access sheath. In our experience, ureteric access sheaths have also facilitated intrarenal and proximal ureteric ureteroscopy. Additional reports on the efcacy of sheaths and longterm complication rates are currently lacking, but all early indications suggest that this is an important adjunct to the ureteroscopic management of proximal ureteric and intrarenal stones.

commonly used today (Table 2). We think that this machine is the single most important factor for effective, single-session stone treatment. However, for a variety of reasons the gold standard Dornier HM3 has been replaced with higher generation lithotripters. For example, the high energy level secondary to the large focal area at F2 requires that essentially all patients have a general anaesthetic for the procedure. While HM3 lithotripsy has been used elsewhere with patients under deep sedation or regional anaesthesia, with favourable results, our anaesthesiologists feel more comfortable with general anaesthesia, given the constraints imposed by the water tub. At least on paper, the higher generation lithotripters have the potential that more patients are treated using intravenous sedation. In reality, the inability of patients to tolerate or cooperate during treatment has also resulted in the need for general anaesthesia with these machines [75]. Physical constraints for the HM3 (i.e. control unit, uoroscopy units, ceiling-mounted gantry, and water tub) also decreased the appeal of this lithotripter. Second- and thirdgeneration lithotripters are favourable in this regard as they occupy less space and often can be used for other endourological procedures. Furthermore, as the success rates with the HM3 and higher-generation machines are ultimately comparable, and the treatment is thought to be less invasive, interest in the higher-generation machines has developed despite the rate of retreatment and ancillary treatments being greater with the newer lithotripters (Table 2). Stone targeting remains another important treatment consideration during SWL; compared with the Dornier HM3, stone targeting is much more important (and often cumbersome) with second- and thirdgeneration lithotripters. Radiographic imaging is often better for the higher generation machines. However, given the reduced margin for positioning error with these machines, this imaging advantage is critically important for successful treatment. Eichel et al. [75] reviewed their initial and most recent clinical experience with the Dornier U/50 lithotripter, noting that with increased experience in stone targeting, optimized pressure for the water balloon coupling device, and with increased use of general anaesthesia, the success rates were signicantly better. These types of treatment 89

SWL The type of lithotripter used remains the most important treatment issue for SWL; it has become increasingly clear that the original lithotripter, the Dornier HM3, remains the most effective machine. For example, at our institution we continue to perform all lithotripsy using an unmodied Dornier HM3; this can be associated with signicantly higher success rates and lower re-treatment rates than the newer, less powerful machines

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factors should be optimized early, as the best attempt at attaining a successful treatment with higher-generation lithotripters appears to occur with the initial treatment. For instance, Singh et al. [58] recently reported that stone fragmentation at initial treatment, power index and stone size were the most important variables for SWL of proximal ureteric calculi. Pace et al. [50] also noted a decreasing success rate for repeat SWL after initially treating ureteric stones with a Dornier MFL 5000 lithotripter. After one treatment the success rate was 68% but by the third procedure (i.e. second re-treatment), the success rate had decreased to 31%. The group suggested that SWL failures may be better treated with ureteroscopy. Patient positioning should also be considered when targeting a stone during SWL. A prone position can often be benecial when treating stones in the distal ureter or stones in horseshoe or pelvic kidneys with SWL. However, most groups would recommend treating proximal ureteric stones with the patient supine. Indeed, Goktas et al. [76] recently reported, in a prospective randomized trial, the benet of treating proximal ureteric stones with the patients supine. The use of ureteric stents has also remained a controversial issue for SWL. In two previous prospective randomized trials, stent use did not signicantly improve stone-free rates [77,78]. While this issue appears to be more applicable to larger renal stones (>2 cm diameter), Chandhoke et al. [79] recently compared the outcomes of the Dornier HM3 lithotripter for renal and proximal ureteric stones, with or without a multi-length stent. While stone-free rates were comparable among treatment arms, stent use signicantly decreased the re-hospitalization rate and resulted in fewer emergency room visits. On the other hand, stent use was associated with signicantly more irritative voiding symptoms. While we have not routinely used stents after lithotripsy with the Dornier HM3, but it seems important to consider stents for patients with larger volume stones and solitary kidneys, especially when using a second- or third-generation lithotripter. In the light of the recent advances in ureteroscopy, the safety of SWL has remained a concern. The controversial impact of SWL on renal function, haematoma formation and hypertension is less of a concern when using 90

SWL for ureteric stones, but the effect of lithotripsy on the reproductive organs remains a greater concern when treating distal ureteric stones [8083]. MartinezPortillo et al. [83] recently evaluated the effect of SWL for distal stones vs proximal stones on semen quality; the quality remained the same after SWL for proximal stones, but there was a transient deterioration in semen quality among men undergoing SWL for distal stones. However, by 12 weeks the semen quality had returned to pretreatment values. The issue of semen quality, haematospermia and impact of SWL on the female reproductive tract remains controversial [84,85]. As signicant clinical data are lacking, this issue should be addressed with reproductive-aged patients before considering SWL for distal stones. Furthermore, patients concerned about this potential risk may be better treated with ureteroscopy.

CONCLUSIONS The current status of ureteric stone surgery represents a true milestone in urology. Currently, most patients with straightforward ureteric stones can be denitively managed with ureteroscopy or SWL. For salvage treatment or for stones not amenable to these primary treatments, second-line endoscopic treatment (i.e. percutaneous ureterolithotomy or laparoscopic ureterolithotomy) also provide the patient with an effective minimally invasive treatment option. The coexistence of many effective treatments for managing ureteric calculi has created controversy. With increased innovation, technological advances and careful outcome research, the impact of these treatment concerns will probably diminish and the treatment of ureteric calculi improved.

REFERENCES FOLLOW-UP 1 The radiographic follow-up after treatment of ureteric stones remains controversial. For radio-opaque stones, a plain radiograph can usually identify the presence of larger residual stone fragments, but cannot detect smaller radio-opaque fragments, radiolucent fragments, ureteric obstruction or strictures. Excretory urography (EXU) not only better detects residual stone fragments, but also detects the presence of ureteric obstruction. Unfortunately, EXU is associated with more cost and radiation exposure, and is not indicated for patients with renal insufciency. While some investigators recommend followup EXU after all stone procedures, others have recommended less involved surveillance. Recently, Cheung et al. [59] evaluated the role of plain radiographs and ultrasonography for the follow-up after ureteric stone lithotripsy, noting that this combination was effective for screening after lithotripsy and saved up to 74% of patients the need for EXU. Weizer et al. [86] reported a 12.3% (30 patients) postoperative obstruction rate among 241 patients undergoing ureteroscopic stone manipulation. Of these 30 patients, silent obstruction was present in seven. These studies stress the importance of more than just plain radiographs for the radiographic follow-up after ureteric stone treatment. However, the complexity of radiological follow-up (EXU vs CT vs plain lm with ultrasonography) should be tailored to the characteristics of the patient. Segura JW, Preminger GM, Assimos DG et al. Ureteral stones clinical guidelines panel summary report on the management of ureteral calculi. J Urol 1997; 158: 191521 Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol 1999; 162: 68890 Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR 2002; 178: 1013 Borghi L, Meschi T, Amato F et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double blind, placebo controlled study. J Urol 1994; 152: 1095 8 Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deazacort in the management of distal ureteral stones. Urology 2000; 56: 57982 Cooper J, Stack GM, Cooper TP. Intensive medical management of ureteral calculi. Urology 2000; 56: 5758 Pearle MS, Pierce HL, Miller GL et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 1998; 160: 12604 Mokhmalji H, Braun PN, Martinez Portillo FJ et al. Percutaneous

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Friedrichs R, Loening SA. Quality of semen after extracorporeal shock wave lithotripsy for lower ureteral stones. J Urol 1996; 155: 12813 86 Weizer AZ, Auge BK, Silverstein AD et al. Routine postoperative imaging is important after ureteroscopic stone manipulation. J Urol 2002; 168: 4650 Correspondence: J.W. Segura, Department of Urology, Mayo Clinic Rochester, 200 First Street, SW Rochester, MN 55901, USA. e-mail: segura.joseph@mayo.edu Abbreviations: SWL, shockwave lithotripsy; EXU, excretory urography.

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