international Urology and Nephrology 24 (6), pp. 603--606 (1992)
Lasertripsy in the Treatment of Ureteral Lithiasis R. G. SERRATE,J. PRATS,R. REGUt~, G. RIUS Department of Urology, CILSA, Sagrada Familia Clinic, Barcelona, Spain (Accepted April 4, 1992)
We submit our experience with laser treatment for ureteral lithiasis. We used the laser Candela MDL 2000 for the treatment of 62 lithiases (40 at the pelvic ureter, 16 at the iliac ureter and 6 at the lumbar ureter) in 58 patients. A semi-rigid Dretler or Gautier multiscope were used. Of the 62 calculi complete fragmentation was not achieved in 4 and they were ascended to the renal pelvis for subsequent ESWL. In 51% of the patients the ureteral catheter was left for 24 hours, and a double-J stent was used in two cases. Complications: 2 simple perforations of the ureter that were solved by means of a double-J stent; occasionally petechiae on the ureteral wall and two cases of rupture of the laser fibre tip that was easily removed with a forceps.
Introduction
Recent developments achieved in the field of physics have made it possible to use pulsed colour red laser devices for the destruction of ureteral calculi [2, 9, 10] that is not possible to achieve with conventional continuous lasers [5, 11 ]. The ability of those new laser systems to emit fast and short light pulses, coupled with the small fibre diameter ( - 3 2 0 #n), led to the generation of energy power that emits shock waves, which, in contact with the calculus, brings about its fragmentation, and the whole process is completely atraumatic for the ureteral wall [8]. The possibility, on the other hand, of using small diameter fibres has led to the creation of a set of ureteroscopy tools which have a far smaller diameter and are more easily adapted to each individual situation, thereby enhancing the efficacy of endoscopic manoeuvers and decreasing its risks.
Material and methods
In our Lithiasis Center we have used the coloured and pulsed Candela laser M D L 2000, multipurpose (urology, biliary tract and vascular problems), with a maximum energy output of 140 mJ. F r o m April 1989 to March 1991, 58 patients (62 calculi) suffering from ureteral, non-ejectable lithiasis, with obvious clinical symptoms and overlying VSP, Utrecht Akad$miai Kiad6, Budapest
604
Serrate et al. : Lasertripsy
Table 1 Localization of calculi No. of calculi
Ureter
Pelvic Middle Lumbar
40 16 6
dilation were treated with lasertripsy. The localization of calculi is shown in Table 1. All patients had peridural anaesthesia followed by ureteroscopy performed with a semi-rigid Dretler miniscope, 7.2 French; a Gautier multiscope, 8,5 French, was used for larger calculi that had been sitting there for a longer time (impactation), because that device lets a larger amount of fluid go through and, on the other hand, a Dormia catheter can also be used to remove the lithiasic fragments that lend themselves more easily to be taken out. Fluid perfusion was performed by means of a Ureteromat pump. The laser fibre had 320 microns in diameter, a mean power of 90-100 mJ and an exposure time of 1.4 microseconds. No patient required ureteral dilatation. The mean URS time was 35 min and 3 min of laser use. All patients have been controlled with a plain kidney X-ray and ultrasonography, three months after the treatment was completed.
Results
The mean number of waves applied was 320, at an average power o f 100 mJ and 5'10 Hz. The physical and chemical composition of the calculi and the fragments was studied by infrared spectrometry (Table 2). Table 2 Composition of calculi Composition
Oxalate dihydrate Mixed oxalate Oxalate monohydrate Struvite Uric acid Miscellaneous (cysteine mixed) lnternati6~ Urology and Nephrolooy 24, 1992
No. of calculi
28 12 9 7 4 2
Serrate et aL : Lasertripsy
605
Complete fragmentation was achieved in all patients, except for 4 calculi (3 oxalate monohydrate and 1 uric acid), which were disimpacted and ascended to the pelvis; this treatment was supplemented with extracorporeal lithotripsy. In no case was ultrasound lithotripsy necessary.When the calculus was large and generated a high number of fragments, these were removed by means of a Dormia catheter. In 51% of the patients the catheter was left for 24 hours and in two patients a double-J catheter was used, with subsequent radiological and echographic controls. Mean hospital stay was 1-2 days. Complications were due to ureteroscopy in two cases: simple perforations of the ureter occurred that only required a double-J catheter. The laser device produced small petechiae on the wall of the ureter and in 2 cases we saw intraureteral rupture of the laser fibre tip that was easily removed with forceps. Open surgery was not required in any case. The patients were treated with prophylactic antibiotics. The use of ureteral catheters and the removal of the fragment with a Dormia catheter were efficient measures to prevent a nephritic cholic.
Discussion The use of ESWL [1] and ureteroscopy [6] for the treatment of ureteral lithiasis have brought about a radical change in the management of this pathology. Like many other authors [3, 4, 7], we believe that ESWL is still, as a rule, the technique of choice for the treatment of ureteral lithiasis. We are using a Dornier MH3 modified lithotriptor and an MPL 9000. By means of fluoroscopic control excellent results are achieved in the treatment of this pathology with the use of lithotripsy. However, there are many instances, such as the characteristics of the calculus (site, composition), impactation, women in child-bearing age and a potential ovarian injury with ESWL, failure of other techniques, etc., which make it necessary to use the ureteroscope in order to achieve the proper fragmentation of calculi, and this entails a number of iatrogenic risks. The possibility to use the pulsed light Candela laser with its high fragmentation efficiency [3, 4, 7, 10] and the possibility to adapt it to smaller calibre and/or semi-flexible ureteroscopy tools, make lasertripsy an extremely helpful adjuvant to ESWL in the treatment of ureteral lithiasis. In our series we have not seen ureteral injuries, except for some highly localized petechiae, as already mentioned by Ruiz Marcell~in et al. [7], without functional repercussions of the pathway. We have seen damage due to endoscopic manoeuvering, two cases of minimal ureteral perforation, solved with double-J stent.
Conclusion We believe that the use of the Candela pulsed laser is an efficient help in the treatment of ureteral lithiasis; it decreases the risk of complications of ureteroscopy and the need for open surgery. International Urology and Nephrology 24, 1992
606
Serrate et aL : Lasertripsy
We think that this laser technology should be available in all centers performing lithotripsy since it is an excellent therapeutic complement to ESWL.
References 1. Chaussy, C., Brendel, W., Schmiedt, E. : Extracorporeally induced destruction of kidney stone by shock waves. Lancet, 13, 1265 (1980). 2. Dretler, S. P., Watson, G. M., Parrish, J. : Pulsed dye laser fragmentation of ureteral calculi. Initial experience. J. UroL, 137, 386 (1987). 3. Gautier, J. R., Leandri, P., Roissignol, G. : Pulsed Dye Laser in the treatment of 325 calculi of the urinary tract. Eur. Urol., 18, 6 (1990). 4. Miller, K., Fuchs, G., Rassweiler, J.: Treatment of ureteral stone disease: The role of ESWL and endourology. Worm J. Urol., 3, 53 (1985). 5. Mulvaney, W. P., Beck, C. W. : Laser beam in urology. J. Urol., 99, 112 (1968). 6. Perez Castro Ellendt, E., Martinez Pifieiro, J. A. : Ureteroscopia transuretral. Arch. Esp. Urol., 33, 445 (1980). 7. Ruiz Marcellfin, F. J. : Ibarz Servio, L., Ram6n Dalmau, M. : Lasertripsia en el tratamiento de la litiasis ureteral. Acta tYroL Esp., 13, 444 (1990). 8. Watson, G. M., Murray, S., Dretler, S. P. : An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter. Z Urol., 138, 199 (1987). 9. Watson, G. M., Murray, S., Dretler, S. P. : The pulsed dye laser for fragmenting urinary calculi. J. Urol., 135, 195 (1987). 10. Watson, G. M., Wickham, J. E. A. : Initial experience with a pulsed dye laser fragmentation of ureteral calculi. Lancet, June 14, 1357 0986). I1. Watson, G. M., Wickham, J. E. A., Mills, T. N. : Laser fragmentation of renal calculi. Br. J. Urol., 55 613 (1983).
International Urology and Nephrology 24, 1992
Lasertripsy in the Treatment of Ureteral Lithiasis R. G. SERRATE,J. PRATS,R. REGUt~, G. RIUS Department of Urology, CILSA, Sagrada Familia Clinic, Barcelona, Spain (Accepted April 4, 1992)
We submit our experience with laser treatment for ureteral lithiasis. We used the laser Candela MDL 2000 for the treatment of 62 lithiases (40 at the pelvic ureter, 16 at the iliac ureter and 6 at the lumbar ureter) in 58 patients. A semi-rigid Dretler or Gautier multiscope were used. Of the 62 calculi complete fragmentation was not achieved in 4 and they were ascended to the renal pelvis for subsequent ESWL. In 51% of the patients the ureteral catheter was left for 24 hours, and a double-J stent was used in two cases. Complications: 2 simple perforations of the ureter that were solved by means of a double-J stent; occasionally petechiae on the ureteral wall and two cases of rupture of the laser fibre tip that was easily removed with a forceps.
Introduction
Recent developments achieved in the field of physics have made it possible to use pulsed colour red laser devices for the destruction of ureteral calculi [2, 9, 10] that is not possible to achieve with conventional continuous lasers [5, 11 ]. The ability of those new laser systems to emit fast and short light pulses, coupled with the small fibre diameter ( - 3 2 0 #n), led to the generation of energy power that emits shock waves, which, in contact with the calculus, brings about its fragmentation, and the whole process is completely atraumatic for the ureteral wall [8]. The possibility, on the other hand, of using small diameter fibres has led to the creation of a set of ureteroscopy tools which have a far smaller diameter and are more easily adapted to each individual situation, thereby enhancing the efficacy of endoscopic manoeuvers and decreasing its risks.
Material and methods
In our Lithiasis Center we have used the coloured and pulsed Candela laser M D L 2000, multipurpose (urology, biliary tract and vascular problems), with a maximum energy output of 140 mJ. F r o m April 1989 to March 1991, 58 patients (62 calculi) suffering from ureteral, non-ejectable lithiasis, with obvious clinical symptoms and overlying VSP, Utrecht Akad$miai Kiad6, Budapest
604
Serrate et al. : Lasertripsy
Table 1 Localization of calculi No. of calculi
Ureter
Pelvic Middle Lumbar
40 16 6
dilation were treated with lasertripsy. The localization of calculi is shown in Table 1. All patients had peridural anaesthesia followed by ureteroscopy performed with a semi-rigid Dretler miniscope, 7.2 French; a Gautier multiscope, 8,5 French, was used for larger calculi that had been sitting there for a longer time (impactation), because that device lets a larger amount of fluid go through and, on the other hand, a Dormia catheter can also be used to remove the lithiasic fragments that lend themselves more easily to be taken out. Fluid perfusion was performed by means of a Ureteromat pump. The laser fibre had 320 microns in diameter, a mean power of 90-100 mJ and an exposure time of 1.4 microseconds. No patient required ureteral dilatation. The mean URS time was 35 min and 3 min of laser use. All patients have been controlled with a plain kidney X-ray and ultrasonography, three months after the treatment was completed.
Results
The mean number of waves applied was 320, at an average power o f 100 mJ and 5'10 Hz. The physical and chemical composition of the calculi and the fragments was studied by infrared spectrometry (Table 2). Table 2 Composition of calculi Composition
Oxalate dihydrate Mixed oxalate Oxalate monohydrate Struvite Uric acid Miscellaneous (cysteine mixed) lnternati6~ Urology and Nephrolooy 24, 1992
No. of calculi
28 12 9 7 4 2
Serrate et aL : Lasertripsy
605
Complete fragmentation was achieved in all patients, except for 4 calculi (3 oxalate monohydrate and 1 uric acid), which were disimpacted and ascended to the pelvis; this treatment was supplemented with extracorporeal lithotripsy. In no case was ultrasound lithotripsy necessary.When the calculus was large and generated a high number of fragments, these were removed by means of a Dormia catheter. In 51% of the patients the catheter was left for 24 hours and in two patients a double-J catheter was used, with subsequent radiological and echographic controls. Mean hospital stay was 1-2 days. Complications were due to ureteroscopy in two cases: simple perforations of the ureter occurred that only required a double-J catheter. The laser device produced small petechiae on the wall of the ureter and in 2 cases we saw intraureteral rupture of the laser fibre tip that was easily removed with forceps. Open surgery was not required in any case. The patients were treated with prophylactic antibiotics. The use of ureteral catheters and the removal of the fragment with a Dormia catheter were efficient measures to prevent a nephritic cholic.
Discussion The use of ESWL [1] and ureteroscopy [6] for the treatment of ureteral lithiasis have brought about a radical change in the management of this pathology. Like many other authors [3, 4, 7], we believe that ESWL is still, as a rule, the technique of choice for the treatment of ureteral lithiasis. We are using a Dornier MH3 modified lithotriptor and an MPL 9000. By means of fluoroscopic control excellent results are achieved in the treatment of this pathology with the use of lithotripsy. However, there are many instances, such as the characteristics of the calculus (site, composition), impactation, women in child-bearing age and a potential ovarian injury with ESWL, failure of other techniques, etc., which make it necessary to use the ureteroscope in order to achieve the proper fragmentation of calculi, and this entails a number of iatrogenic risks. The possibility to use the pulsed light Candela laser with its high fragmentation efficiency [3, 4, 7, 10] and the possibility to adapt it to smaller calibre and/or semi-flexible ureteroscopy tools, make lasertripsy an extremely helpful adjuvant to ESWL in the treatment of ureteral lithiasis. In our series we have not seen ureteral injuries, except for some highly localized petechiae, as already mentioned by Ruiz Marcell~in et al. [7], without functional repercussions of the pathway. We have seen damage due to endoscopic manoeuvering, two cases of minimal ureteral perforation, solved with double-J stent.
Conclusion We believe that the use of the Candela pulsed laser is an efficient help in the treatment of ureteral lithiasis; it decreases the risk of complications of ureteroscopy and the need for open surgery. International Urology and Nephrology 24, 1992
606
Serrate et aL : Lasertripsy
We think that this laser technology should be available in all centers performing lithotripsy since it is an excellent therapeutic complement to ESWL.
References 1. Chaussy, C., Brendel, W., Schmiedt, E. : Extracorporeally induced destruction of kidney stone by shock waves. Lancet, 13, 1265 (1980). 2. Dretler, S. P., Watson, G. M., Parrish, J. : Pulsed dye laser fragmentation of ureteral calculi. Initial experience. J. UroL, 137, 386 (1987). 3. Gautier, J. R., Leandri, P., Roissignol, G. : Pulsed Dye Laser in the treatment of 325 calculi of the urinary tract. Eur. Urol., 18, 6 (1990). 4. Miller, K., Fuchs, G., Rassweiler, J.: Treatment of ureteral stone disease: The role of ESWL and endourology. Worm J. Urol., 3, 53 (1985). 5. Mulvaney, W. P., Beck, C. W. : Laser beam in urology. J. Urol., 99, 112 (1968). 6. Perez Castro Ellendt, E., Martinez Pifieiro, J. A. : Ureteroscopia transuretral. Arch. Esp. Urol., 33, 445 (1980). 7. Ruiz Marcellfin, F. J. : Ibarz Servio, L., Ram6n Dalmau, M. : Lasertripsia en el tratamiento de la litiasis ureteral. Acta tYroL Esp., 13, 444 (1990). 8. Watson, G. M., Murray, S., Dretler, S. P. : An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter. Z Urol., 138, 199 (1987). 9. Watson, G. M., Murray, S., Dretler, S. P. : The pulsed dye laser for fragmenting urinary calculi. J. Urol., 135, 195 (1987). 10. Watson, G. M., Wickham, J. E. A. : Initial experience with a pulsed dye laser fragmentation of ureteral calculi. Lancet, June 14, 1357 0986). I1. Watson, G. M., Wickham, J. E. A., Mills, T. N. : Laser fragmentation of renal calculi. Br. J. Urol., 55 613 (1983).
International Urology and Nephrology 24, 1992
