Emerging Concepts in the Treatment of Ureteral Stones
Extracorporeal shock-wave lithotripsy (ESWL) has become the therapy of first choice in the treatment of most ureteral stones. Parameters for the selection of the optimal procedure (ESWL in situ, stone manipulation and consecutive ESWL, ureteroscopic or open surgical stone removal) have been recently established and proven in a larger series of patients. Controversy as to whether ESWL should be done in an “in situ” fashion or whether it should be preceded by ureteral stone manipulation, however, has persisted. In this regard, we basically have noticed a continental shift reflecting the peculiarities of different health systems in Europe and the USA. In the United States, most centers prefer stone manipulation by ureteral stents in a retrograde fashion. This is done in order to dislodge the stone from its confinement in the edematous stone bed. Ideally, the stone is repositioned into the renal collecting system, the natural expansion chamber. If this can not be accomplished, creation of an artificial expansion chamber by passing ureteral stents alongside the stone is attempted. At UCLA, a differentiated approach is utilized which is as follows: based on the radiographic appearance of an existing natural expansion chamber (gross ureteral dilatation above the stone, no complete obstruction), approximately 10% of stones above the iliac crest, and 25% of stones located in the pelvic window (for example, in the true pelvis) below the pelvic brim are eligible for in situ ESWL treatment. All other stones which do not qualify for in situ treatment still undergo ureteral stone manipulation utilizing stents. This approach has advantages over our previously-described combined approach in that it does not change the success rate (97%) and overall hospital stay (1.2 days), but it does save ureteral manipulation for approximately 30% of patients (Tables 1 and 2).
KeywordsUreteral Stone Ureteral Stents Expansion Chamber Pelvic Brim Distal Ureteral Stone
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