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Objectives: Extracorporeal shock wave lithotripsy is a minimally invasive therapeutic option for the treatment of renal-ureteral lithiasis. The aim of this study was to analyze the results and complications of shock wave extracorporeal lithotripsy treatment with the Dornier Gemini® Generator EMSE 220f-XXP device in patients with renal and ureteral lithiasis., Material and Methods: Retrospective study including 377 patients with renal or ureteral lithiasis with indication for treatment with extracorporeal shock wave lithotripsy. The following variables were analyzed, age, sex, body mass index, lithiasis size, lithiasis location, presence of urinary diversion, number of lithotripsy sessions, number of shock waves, fluoroscopy time, wave energy, applied focal energy coefficient, efficiency coefficient, lithiasic fragmentation, lithiasic clearance, residual lithiasis, presence of lithiasis and complications. The results were analyzed with SPSS 17.0 considering statistical significance p≤0.05., Results: Of the 377 patients, 213 were men and 164 women, with a mean age of 51.28 ± 12.77 years. The mean size of the stones in maximum diameter was 11.77 ± 6.13 mm. Lithiasis fragmentation occurred in 81.9% of cases, with a percentage of residual lithiasis after the first session of 58.7% and a total or partial expulsion rate of lithiasis fragments of 68.3%, with global success at the end of sessions of lithotripsy of 69.8%. The overall Efficiency Ratio was 0.42, higher in upper calyx 0.51 and lower in medium calyx 0.35, with significant differences (p<0.05). The only differences were found in relation to the success of lithotripsy treatment (75% versus 64.6%, p=0.02), according to lithiasis size (≤10 mm maximum diameter in comparison to >10 mm). In patients with a DJ catheter there is a higher percentage of residual lithiasis (p=0.006)., Conclusions: Treatment with extracorporeal lithotripsy in small lithiasis and in well-selected patients obtains good results with a low rate of complications regardless of sex and body mass index.

Objective: To analyse the efficiency of extracorporeal shockwave lithotripsy (ESWL) vs retrograde ureteroscopy and holmium:YAG laser lithotripsy, as ESWL is successful in 67-90% of cases but endoscopic lithotripsy with pneumatic lithotrites or lasers is successful in 90-96% of distal ureteric calculi, and holmium:YAG lithotripsy is effective in proximal ureteric calculi., Patients and Methods: From April 2006 to April 2008 we assessed 164 patients undergoing ureteric lithiasis in two homogeneous groups: group A included 83 treated with retrograde ureteroscopy and holmium:YAG endoscopic lithotripsy, and group B, 81 treated by ESWL. For laser lithotripsy we used 2071 mJ pulses at 3-6 Hz, with a mean of 1105 pulses and 2.5 kJ of total energy. ESWL was carried out using 37.5-87.5 mJ shock waves, a mean of 3650 shock waves and 187.6 J, with a radioscopy time of 1-4 min. The results were assessed after 3 weeks with plain films and ultrasonography, or urography. The efficiency of each procedure was assessed by calculating the relative risk, and results compared using the chi-square or Student's t-test. The efficiency quotient (EQ) was determined for both procedures, and the focal applied energy quotient (FAEQ) used to assess ESWL., Results: The overall success rate for retrograde ureteroscopy and laser lithotripsy was 96.4% (80/83 patients), with an EQ of 0.52; a JJ catheter was placed in 67 patients. The success rate for the first ESWL session was 48%, and after repeat ESWL was 64% (52/81 patients), giving an EQ of 0.39. For successful treatments the FAEQ was 9.22, vs 6.47 for the failures (P < 0.005). There was a significant difference (P < 0.001) favouring laser lithotripsy, with an absolute benefit of 46% (95% confidence interval 33.8-57.9%), and number needed to treat of 2 (2-3), but no significant differences for lumbar ureteric calculi., Conclusions: Endoscopic lithotripsy with the holmium laser is more effective than ESWL, but for lumbar ureteric calculi ESWL is therapeutically recommended as it is less invasive.

Introduction: In the past 25 years, the treatment of lithiasis of the lumbar ureter has evolved from ureterolithotomy to extracorporeal shockwave lithotripsy and/or endoscopic lithotripsy. Our objective has been to analyse the results of extracorporeal lithotripsy and endoscopic surgery in lithiasis of the lumbar ureter., Materials and Methods: We have analysed 734 single calculi of the lumbar ureter treated during the decade 1990-2000, excluding patients with lithiasis in other locations in order to avoid bias in the assessment of the results. Extracorporeal shockwave lithotripsy (ESWL) was carried out using a Siemens Lithostar, urinary diversion with a double pigtail ureteric catheter or percutaneous nephrostomy, semi-rigid ureteroscopy and electrokinetic contact lithotripsy. The patient were divided into six groups. We assessed complete and partial success, the fragmentation index, and complications, analysing the results using a test for the comparison of proportions., Results: In group A, non-obstructive lithiasis treated by in situ ESWL, complete success was achieved in 95.5%. In group B, obstructed lithiasis treated by in situ ESWL, 93.15%. In group C, obstructive lithiasis treated with a double pigtail catheter and ESWL, 81.11%. In group D, obstructive lithiasis treated with percutaneous nephrostomy and ESWL, 93.75%. In group E, ureteric lithiasis <1cm, treated by retrograde displacement to the renal cavities and ESWL, 82.3%. In group F, lithiasis of the lumbar ureter treated by ureteroscopy, 91%., Conclusions: The primary therapeutic option for the treatment lithiasis of the lumbar ureter, in the absence of criteria for urinary diversion, is in situ ESWL. We consider the criteria for urinary diversion prior to ESWL to be severe obstruction, obstruction associated with urinary tract infection, and obstruction caused by a proximal ureteric calculus adjacent to the inferior renal pole. Ureteroscopy and/or contact lithotripsy is the technique of choice in lithiasis of the lumbar ureter resistant to ESWL due to non-fragmentation or to the persistence of impacted fragments. Ureteroscopy may be the first choice of therapy in obstructive lithiasis, substituting urinary diversion plus ESWL.

Objectives: To evaluate the efficacy of JJ catheter as urinary diversion in the treatment of lumbar ureteral lithiasis by ESWL., Methods: Results obtained in our ESWL unit between january 1990 and October 2000 are compared. 680 cases of lithiasis are divided into 5 groups for analysis: Group A: Lumbar ureter non obstructive lithiasis. 200 cases. Group B: Lumbar ureter obstructive lithiasis without urinary diversion. 307 cases. Group C: Lumbar ureter obstructive lithiasis with JJ catheter. 90 cases. Group D: Lumbar ureter lithiasis with percutaneous nephrostomy. 32 cases. Group E: Lumbar ureter lithiasis pushed up to renal cavities by JJ catheter. 51 cases., Results: Groups are compared for stone size, number of ESWL sessions and average number of shock waves. Repeated ESWL, complications and success rates are also analyzed. Statistical analysis of these results and its comparison by 2 proportion comparison tests show that groups B and C are homogeneous in size. We analyze these groups for complete success rate, partial success, and fragmentation index; it is derived from this analysis that Group C maintains the same level of fragmentation but not fragment expulsion, being this due to the only difference between groups B and C, which is the JJ catheter., Conclusions: In our series JJ catheter makes fragment expulsion difficult after treatment of the lumbar ureter lithiasis although it minimises the incidence of renal colic, the most frequent post-ESWL complication.

Objective: To present the results achieved in the treatment of 1802 distal ureteral stones treated at the Lithotripsy Unit of the San Cecilio University Hospital over the last 10 years (1990-2000)., Methods: Stones were treated by extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy (URS). ESWL was the initial treatment in 81% of the cases (1460 calculi) and URS in the remaining 19% (342 stones). URS was performed for complication or failed ESWL (102 stones) and ESWL was performed for failed URS, basically due to stone migration (24 stones). Ureterolithotomy was required on 7 occasions. Sedation-analgesia with fentanyl and midazolam was routinely used in URS. Sedation was required in only 55% of the ESWL procedures., Results: Elective ESWL resolved 93% of the cases, a percentage which is similar to that achieved with URS as first treatment. The ESWL retreatment rate was 1.3. URS was successful in 98% of the cases of failed ESWL., Conclusions: There are two treatment modalities for stones in the distal ureter: ESWL and URS. We advocate the use of outpatient URS with sedation preferably in the female patient, impacted stones, obstructive uropathy, stones larger than 2 cm and radiotransparent stones.

Shock-wave extracorporeal lithotripsy (SWEL) is admittedly the choice method for most ureteral calculi (UC). Treatment of 1.674 UC was carried out with a Lithostar (Siemens). Endourologic support manoeuvres (ESM) were used in 11.7% patients. To determine their statistical influence on treatment's result variables such as site, size, calculus density, obstruction and functionality of the renal unit, as well as presence of ureteral malformation, were analyzed. With an average of 1.3 sessions (9100 waves) success rate was 91.8% cases. Only the variables of size, obstruction and function showed statistical significance, thus identifying through a multistep logistic regression test the subgroup of calculi less likely to succeed (calculi > 1 cm2, with severe uropathy and functional annulment or delay). Complication were rare (7.5%) and minimally relevant. We conclude than SWEL is the first choice treatment for UC regardless the location. Ureteroscopy (UR) should be considered as the first option particularly in distal (iliopelvic ureter), obstructive calculi and those of difficult radiological study.

The treatment of ureteral lithiasis has undergone a revolution since the arrival of new techniques offering different therapeutical choices for which time is gradually elucidating the indications for each of the new procedures; although, to a large extent, a degree of controversy still persists. This paper reviews the different methods for ureteral lithiasis; spontaneous ejection and medical treatment, surgery, early endoscopic manoeuvres, backward and forward urethroscopy and, finally, extracorporeal lithority. This therapeutical experience in 3 series of ureteral lithiasis addressed with different criteria are revised together with 182 obstructive calculi of the lumbar ureter. We believe that grading the ureteral calculi according to their anatomical and functional features improves the results, since improved adjustment can be achieved for the indications of the various methods. Also it is noted that support endourology for extracorporeal lithotrity does not improve the results of treatment in lumbar calculi under 2 cm, and therefore our current approach is towards "in situ" treatment without complementary manoeuvres. Finally we show the therapeutic algorithm we are following actually to manage ureteral litiasis.

Presentation of our experience on 1000 cases of ureteral lithiasis treated over the last five years with ESWL, ureteroscopy and ureterolitotomy, distributed in three series of 396, 265 and 339 cases respectively. In the first series (396 cases), lumbar ureter calculi were treated with ESWL (dornier HM3) and iliopelvian calculi with ureteroscopy. In the second series (265 cases), all calculi were treated with ESWL (Siemens Lithostar). The third series was in turn subdivided in three groups: in the first group, comprising simple ureteral calculi, 'in situ' ESWL was performed; in the second group, of lumbar ureter complex calculi, ESWL was performed assisted by simple endourological techniques; ureteroscopy was performed in the third group, iliopelvian ureter complex calculi. Calculi characteristics (site, size, consistency and number), excretory tract and renal function, designated as CEP/LTS-X were assessed. These parameters allow us to grade ureteral lithiasis in Types I, II and III. A comparative study of the results in the three series was made reaching an overall conclusion that simple or Type I ureteral lithiasis can be treated with 'in situ' ESWL as first choice; in Type II or lumbar ureter complex lithiasis, 'in situ' ESWL is insufficient and other endoeurological support techniques are required, while in Type III, iliopelvian ureter complex lithiasis, ureteroscopy should be recommended.

Currently, most calculi can be treated with shockwave extracorporeal lithotrity regardless their location within the urinary apparatus or their physico-chemical features. In order to optimize results only medical criteria for patient's selection should be taken into account. Certain type of calculi can obstruct adequate radioscopic viewing by not allowing correct centring for shockwave emission. The problem can be overcome by using echography or other contrast procedures. Of a total 514 patients treated in our Unit with ESWL, execution of contrast procedures was necessary in 18 cases (3.5%) in order to allow adequate viewing of the calculi. Calculi in 10 patients were midly radiopacque, uric acid in 4, and bone-superimposed in the remaining 4. This technical manoeuvre allowed in all cases a good centring of the calculi. After a two months follow-up. lithiasis is absent in 15 patients and only 2 present expellable lithiatic fragments. It can therefore be concluded that the use of contrast procedures, both through i.v. or a catheter, is a simple, safe and well tolerated procedure allowing convenient viewing of those calculi, also followed by good results after ESWL treatment.