|Year : 2013 | Volume
| Issue : 1 | Page : 52-55
Ureteroscopic lithotripsy as day care procedure: Our early experience in Regional Institute of Medical Sciences
Somarendra Khumukcham, Sandeep Gupta, Bijit Lodh, Sholay Meitei Kangjam, Kaku Singh Akoijam, Rajendra Singh Sinam
Department of Urology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||17-Aug-2013|
Department of Urology, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to report the outcome of ureteroscopic lithotripsy (URSL) under local anesthesia (LA) as a day care procedure in patients with lower ureteric calculus. Materials and Methods: Patients with lower ureteric calculus attending urology out patient department, Regional Institute of Medical Sciences (RIMS) Hospital during August 2011 to February 2012 underwent URSL under LA-analgesia as day care procedure. The results are analyzed on aspects of perioperative pain, completion of procedure, stone clearance, hospital stay, complications and patient compliance. Institutional ethical clearance and written informed consent for the procedure taken from all patients for the study. Results: A total of 30 patients with lower ureteric calculus size ranging from 8 to 15 mm underwent URSL with Double J stenting under local anesthesia in RIMS urology operation theatre. Twenty four patients completed the procedure in single session, five required two sessions (four with ureteric stricture DJ stent kept for passive dilation and one patient had edematous non visualized ureteric orifice) and another patient converted to open ureterolithotomy due to hard stone resistant to our pneumatic energy. None of the patients required hospital stay following the procedure except for two patients for IV antibiotics. Visual analog scale was mild in 15 patients, moderate in 10 and severe in five patients. Dysuria with transient hematuria was the most common complication; all were managed conservatively on OPD basis. Overall patient compliance for this procedure was excellent. Conclusion: Ureteric colic is a urological emergency in terms of the severe pain experienced by the patient. In view of the long waiting period for routine OT, fear of obstructive uropathy with urosepsis and consequent decrease in renal function, the initiative of URSL as a day care procedure started in our department and our early experience of this procedure in carefully selected patients is having encouraging results.
Keywords: Day care surgery, Local anesthesia, Ureteroscopic lithotripsy or Ureterorenoscopic lithotripsy
|How to cite this article:|
Khumukcham S, Gupta S, Lodh B, Kangjam SM, Akoijam KS, Sinam RS. Ureteroscopic lithotripsy as day care procedure: Our early experience in Regional Institute of Medical Sciences. J Med Soc 2013;27:52-5
|How to cite this URL:|
Khumukcham S, Gupta S, Lodh B, Kangjam SM, Akoijam KS, Sinam RS. Ureteroscopic lithotripsy as day care procedure: Our early experience in Regional Institute of Medical Sciences. J Med Soc [serial online] 2013 [cited 2021 Mar 8];27:52-5. Available from: https://www.jmedsoc.org/text.asp?2013/27/1/52/116646
| Introduction|| |
Urinary stone disease is a major health problem that concerns millions of patients worldwide affecting 2-3% 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. ,
Most of the ureteric stones pass spontaneously and do not require intervention. Spontaneous passage depends on the stone size, shape, location, and associated ureteral edema, which is likely to depend on the length of time that a stone has not progressed. Ureteral calculi less than 5 mm in size have a 77% chance of spontaneous passage. In contrast, calculi more than 5 mm have a lesser than 46% chance of spontaneous passage. The vast majority of stones that pass do so within a six weeks period after the onset of symptoms. Ureteral calculi discovered in the distal ureter at the time of presentation have 71% chance of spontaneous passage, in contrast to 22% in case of proximal ureter. 
Ureteroscopic lithotripsy (URSL) has been usually performed under general anesthesia or spinal anesthesia. URSL under local anesthesia (henceforth, local URSL) is not usually performed, 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 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 URSL was comparable to that under general or spinal anesthesia. ,,,
Here, we report our early results of URSL under local anesthesia (LA) as a day care procedure in Department of Urology, Regional Institute of Medical Sciences (RIMS) hospital on aspects of per operative pain, completion of procedure, stone clearance, hospital stay, complications and patient compliance.
| Materials and Methods|| |
Between August 2011 and February 2012, 30 patients with mid and lower ureteric stones who attended the Urology clinic, Department of Urology RIMS Hospital Imphal underwent URSL under LA. Institutional ethical clearance and written informed consent for the procedure taken from all patients for the study.
Our aim of the study were to evaluate the effectiveness of URSL under local anesthesia in terms of stone clearance rates after this procedure in male versus females and also in the mid versus lower ureter and measure the pain perception and tolerability of the patients. We also aimed to assess the intra-operative and immediate post-operative complications and record the number of patients requiring post procedure hospital admission.
Our inclusion criteria were patients aged above 20 years of either sex having ureteric calculi in the lower and mid ureter size ranging from 0.8 cm to 1.5 cm.
We excluded younger patient (< 20 years), larger calculi (> 1.5 cm in length), those in the upper ureter and patients with co-morbid conditions such as uncontrolled Diabetes Mellitus, Hypertension, Bronchial Asthma, and uncontrolled coagulopathy. Febrile patients with or without positive urine culture were also excluded. Patients with ankylosis who are not able to maintain lithotomy position were also excluded.
The entire patients were worked up for prerequisite sterile urine culture, complete blood count, bleeding time, clotting time, viral profile and necessary imaging - Intra Venous Urogram. Informed consent was taken before the procedure about the nature of the procedure, the need for hospital admission and further treatment procedures if any.
All patients were prepared with an intravenous access line, intravenous antibiotics (Amino glycosides) and intramuscular analgesic injection (inj. Diclofenac) given 15 min prior to the procedure and topical lignocaine jelly instillation per urethra for 5 min. Blood pressure, electrocardiogram and Pulse oxymeter recording carried out throughout the procedure.
All procedures were performed by different urology residents. Our standard procedure of ureteroscopic procedure starts with a cystourethroscopy, guide wire insertion (terumo) beyond the stone if possible, ureteroscopy and visualization of stone. Ureteroscopy is done with a semi rigid, offset, tapered ureteroscope (6-7.5 Fr) Karl Storz, Germany) and lithotripsy is carried out using pneumatic intracorporeal lithotripter. Retrieval of fragments is not mandatory in all the patients but DJ Stent was inserted in all patients. If uretero vesical junction is not negotiable, Double J stenting is done and called for another session after 1 week. Patient is discharged with oral antibiotics for 5 days oral analgesics for 3 days and oral tamsulosin for 10 days. Follow-up advised to come after 2 weeks with X-ray kidney ureter bladder and Double J stent removed after 3 weeks. Patients were encouraged to view the procedure on screen. Anatomy and different steps were also explained to patients during the procedures. After each procedure, patients were asked to grade the discomfort/pain level experienced during the procedure using a 10 point linear visual analog scale.
Accordingly, all the procedures were recorded on various aspects of perioperative pain, completion of procedure, stone clearance (for mid versus lower ureteric and also male versus female patients), hospital stay, complications and patient compliance.
| Results|| |
The overall success rate in our series of local URSL was 97% (29/30).The age ranged from 20 to 70 years including 17 males and 13 females. The stone size ranges from 8 mm to 15 mm. In 17 patients, the stone were in the lower ureter or UVJ and in the remaining 13 patients it was in the mid ureter. The average duration of the procedure was 30 mins (15-45 mins). Twenty four patients (80%) required a single session although five patients (17%) competed the procedure in two sessions. One patient required conversion into open procedure.
In mid ureteric stones nine patients (70%) completed the procedure in one session while four patients (30%) required two sessions. In case of lower ureteric stones 15 patients (88%) required only single session and two patients (12%) completed with the second session; thus the overall success rate was 97% (29 out of 30). Among male patients, 12 patients (70%) completed successfully in the first session and five in second sessions. In females, out of the 13 patients, 12 patients (92%) required only first session.
The visual analog scale record of perioperative pain was mild (0-3) in 15 patients (50%), moderate (4-7) in 10 patients (33%) and severe (8-10) in five patients (17%).Two patients required post-operative admissions and were managed conservatively. The most common complication was dysuria recorded in 15 patients followed by transient hematuria in three patients and urosepsis in two patients. All these patients were managed conservatively.
The success rate in our present series was 97% and this was comparable to other series i.e., Kim et al. with 93%, Abdel-Razzak et al. with 88%, Yalcinskava et al. with 83% and Taylor et al. with 98% success rates respectively.
| Discussions|| |
With the miniaturization of the ureteroscope and use of small caliber intracorporeal lithotripsy devices, the complication and pain associated with ureteroscopy have decreased with time.  Several reports have shown the effectiveness of local URSL. ,,
In order to establish as a treatment modality local URSL must be able to reproduce the results of URSL under that of general or spinal anesthesia. The pain associated with the local ureteroscopic lithotripsy must also be tolerable and at least similar to that with the urologic procedures that are usually performed under local anesthesia such as cystoscopy. 
Review of published series from the last decade on treatment with ureteroscopy using a variety of ureteroscopes and intracorporeal lithotripsy devices reveals success rates ranging from 86% to 100%. , Rittenberg et al. were the first to report on 30 selected patients who were treated by URSL under local anesthesia and sedoanalgesia.  Yalcinkaya et al. reported a success rate of 83% in their experience with local URSL.  A similar success rate (88%) was reported by Abdel-Razzak et al. Kim et al. reviewed a large series of 200 patients with a success rate of 93%.  Taylor et al. also recorded a very high success rate of 98% in their series of day care ureteroscopy. 
In our experience, the overall calculi-free rate of local URSL was 97%, which is consistent with the success rates in other reported series of URSL under general or spinal anesthesia.
To summarize the advantages of local URSL are many which include patient discharged on the same day, no post-operative admission, minimal patient morbidity, minimal investment low cost and no waiting in the list of routine operation theatre. There are also certain disadvantages to this kind of procedure like it is not always applicable to all the ureteric calculus, chances of stone retropulsion, not suitable for uncooperative and apprehensive patient with the low pain threshold, risk of injury to patient, risk of instrument damage, etc. Some authors even recommend conservative management of ureteric stones<7 mm diameter to be safe. 
Ureteroscopy is a suitable procedure for an out-patient setting and under local anesthesia. Various series suggest that day- care ureteroscopy is effective and safe in view of careful patient selection, smooth instrumentation, adequate instruments, carried out by trained urologists, acceptable duration of operative time, good stone clearance rate, no serious complications, relatively pain free with zero admission rate. However, in India as in many other Asian centers, this practice has not been widely adopted. One of the reasons is the logistical problem of having the equipment readily available in an out-patient center. The infrastructure of service and staffing required is also major limitations. Furthermore, the physician or the patient may be reluctant to undertake the procedure on an out-patient basis. This study was formulated to highlight the success of local URSL in the treatment of mid and lower ureteric stones.
| Conclusions|| |
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 treatment of choice for ureteric (especially mid and lower) stones.
Based on these new concepts and our findings, we 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.
| References|| |
|1.||Romero V, Akpinar H, Assimos DG. Kidney stones: A global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010;12:e86-96. |
|2.||Papadoukakis S, Stolzenburg J, Truss MC. Treatment strategies of ureteral stones. EAU-EBU Update Series 2006;4:184-90. |
|3.||Matlaga BR, Lingeman JE. Surgical management of upper urinary tract calculi. In: Alan JW, Kavoussi LR, Alan WP, Novick AC, Craig AP, editors. Campbell Walsh Urology 10 ed. Vol. 2. Philadelphia: Elsevier Saunders; 2012. p.1375-6. |
|4.||Park HK, Paick SH, Oh SJ, Kim HH. Ureteroscopic lithotripsy under local anaesthesia: Analysis of the effectiveness and patient tolerability. Eur Urol 2004;45:670-3. |
|5.||Yalcinkaya F, Topaloglu H, Ozmen E, Unal S. Is general anesthesia necessary for URS in women? Int Urol Nephrol 1996;28:153-6. |
|6.||Abdel-Razzak O, Bagley DH. The 6.9 F semirigid ureteroscope in clinical use. Urology 1993;41:45-8. |
|7.||Bierkens AF, Hendrikx AJ, De La Rosette JJ, Stultiens GN, Beerlage HP, Arends AJ, et al. Treatment of mid and lower ureteric calculi: Extracorporeal shock-wave lithotripsy vs. laser ureteroscopy. A comparison of costs, morbidity and effectiveness. Br J Urol 1998; 81:31-5. |
|8.||Kupeli B, Biri H, Isen K, Onaran M, Alkibay T, Karaoglan U, et al. Treatment of ureteral calculi: Comparison of extracorporeal shock wave lithotripsy and endourologic alternatives. Eur Urol 1998; 34:474-9. |
|9.||Turk TM, Jenkins AD. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi. J Urol 1999;161:45-6. |
|10.||Rittenberg MH, Ellis DJ, Bagley DH. Ureteroscopy under local anesthesia. Urology 1987;3:475-8. |
|11.||Blute ML, Segura JW, Patterson DE. Ureteroscopy. J Urol 1988;139:510-2. |
|12.||Dretler SP, Cho G. Semirigid ureteroscopy: A new genre. J Urol 1989;141:1314-18. |
|13.||Vogeli TA, Mellin HE, Hopf B, Ackermann R. Ureteroscopy under local anaesthesia with and without intravenous analgesia. Br J Urol1993;72:161-4. |
|14.||Irving SO, Calleja R, Lee F, Ballock KN, Wraight P, Doble A. Is conservative management of ureteric calculi of > 4 mm is safe? BJU Int 2000;85:637-40. |
|15.||Taylor AL, Oakley N, Das S, Parys BT. Day case ureteroscopy: An observational study. BJU Int 2002;89:181-5. |