How to treat urinary stone disease without eswl? Development of endourology at urology department of university hospital centre zagreb

Mario Šunjara

Urology Department of University Hospital Centre Zagreb, Croatia

According to guidelines on urolithiasis approximately 90% of stones are candidates for ESWL and ESWL should be the first choice for most stones. However success rates of ESWL reported in literature are often unachievable in clinical practice. Availability of the machine and costs of a new one become very important and prohibitive factors for routine use of ESWL.

With failure of aged ESWL and continuous influx of patients with urinary stone disease a rapid switch to endoscopic methods was of utmost importance at our clinic. HoYAG laser and flexible ureterorenoscope were new and logical additions to endoscopic equipment already available and greatly increased indications for endoscopic treatment of urinary stones. In the period between June of 2010. and April of 2012. we performed in total 322 endoscopic procedures for stone removal: 223 with semirigide ureteroscope, 63 with flexible uretorerenoscope, 24 with percutaneous nephroscope and 12 with cystoscope. 297 (92%) of those procedures were carried out exclusively with HoYAG as a source of energy. We always chose laser first with exceptions being made in case of its unavailability.

Success rates of semirigide ureteroscopy were high, almost guaranteeing a „stone-free“ state with single procedure in patients with ureteral stones in distal in mid ureter and 85% in patients with proximal ureteral stones. Flexible renoscopy also showed very good results with far superior outcomes after initial 30 procedures clearly demonstrating „learning-curve“ effect.

Combined complications of all procedures were negligible. Almost all complications were Clavien grade I or II. There was no need for open surgery (either reconstructive or ablative) or blood transfusion. Rare Clavien III grade complications were those that required repeated endoscopic treatment either for residual fragments or displaced stents.

In conclusion we can say that endoscopic methods for stone removal are minimally invasive, offer very high „stone-free“ rates in a single procedure with very low complication rate. In our experience success rates of endoscopic methods are far superior to ESWL.