This is a prospective study aiming at the assessment of safety and efficacy of ureteroscopy (URS) and laser lithotripsy (LL) with dusting technique (low energy high frequency) in the management of upper urinary tract stones in sixty patients done at The Urology Department, during the period between July 2017 and February 2018. (Hospital name is blinded for peer review.)
Symptomatic single or multiple UUT stones (mid- and upper ureter, pelvic and calyceal stones), less than 3 cm in maximum diameter in both genders, were included with exclusion of stone size > 3 cm, coagulation disorders, and active UTIs. All patients were evaluated by history taking, physical examination, history of previous stone disease, and associated medical diseases. Patient physical status (PS) was categorized according to American Society of Anesthesiologists.
Mid-stream urine analysis, urine culture, serum creatinine, CBC, coagulation profile, and serum electrolyte were done.
All patients underwent non-contrast spiral CT (NCSCT) to detect stone site, size, number, hounsfield unit (HFU), and degree of hydroureteronephrosis (HUN).
The semirigid long ureteroscope made by Karl Storz (Tuttlingen, Germany) with size of 12 Fr, length of 43 cm, distal tip of 9 Fr, 6-degree lens, and 6 Fr, central channel was used.
Flex- × 2 flexible ureteroscope made by Karl Storz (Tuttlingen, Germany) is 7.5 Fr in mid shaft, 6.7 Fr at tip, 65 cm in length, and 3.6 Fr working channel. Field of view is 90-degree.
Laser (LISA laser products-OHG, Katzenberg, landau, Germany). The generator had the following specifications: fiber rate 5–20 Hz, power 30-W, energy 0.5–2.7 J, and wavelength 2.1 micron.
The Laser fiber used was Flexi Fib with an optical core diameter 272 micron, an outer diameter 420 microns and main bend radius 15 mm made by LISA Laser product (Katzenberg, landau, Germany).
Patients with infected urine were treated preoperatively by the appropriate antibiotics according to urine culture and sensitivity. Prophylactic parenteral antibiotics were given with induction of anesthesia in the form of 3rd-generation cephalosporin. Antibiotic treatment was usually continued during the first 24 h postoperatively.
Patients were then maintained on oral antibiotics for 5 days postoperatively.
Patients were placed in the dorsal lithotomy position with abducted contralateral leg under general or spinal anesthesia.
Under fluoroscopic monitoring, a guidewire was placed till the kidney; the lower ureter was dilated using sequential Teflon dilators. A ureteral access sheath was used to facilitate easy passage of flexible ureteroscope. The ureteroscope was then introduced alongside the guide wire until the stone was seen; if flexible URS is planned, it is passed carefully over a second guidewire under fluoroscopic imaging. Stone dusting is done using the Ho: YAG laser that is set to low energy and high frequency (0.5 J & 20 Hz). After completion of stone fragmentation, the ureter was inspected for any evidence of trauma. A ureteric catheter was inserted at the end of the procedure for a period of 24 h. If ureteric injury was suspected or residual stones, a DJ stent was placed to be removed after 4 weeks.
Postoperative care and follow-up:
Patients were observed for 24 h postoperatively for loin or abdominal pain, fever, or hematuria. Analgesics (NSAIDs) and/or narcotics were given. Patients with renal impairment were discharged after laboratory and clinical stabilization. On the next day, the ureteric catheter was removed, and antibiotic treatment was continued for 5 days after discharge.
Postoperative complications were classified according to Clavien–Dindo grading of surgical complications (Dindo et al., 2004). Operative and fluoroscopy time in minutes, endoscopy utilized, total energy delivered, type of stent, hospitalization time in days, complications and their grade, and stone-free status as recorded by NCSCT after 4 weeks were reported. Patients were defined as stone-free if there is no evidence of residual fragments > 4 mm in size .