Withdraw of the Ureteroscope Causes Fragmented Ureter Stones to Disperse
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doi: 10.1590/S1677-5538.IBJU.2013.05.21

Onder Canguven, Mustafa Boz, Mustafa Bulbul, Ahmet Selimoglu, Selami Albayrak

Urology II Clinics, Kartal Teaching and Research Hospital, Istanbul, Turkey


Introduction: Ureteroscopy has improved from the first use of ureteroscope in the 1970’s. Although the success rate increased in the last years, (1) new treatment techniques are being developed for impacted and large proximal ureter stones (2). Pneumatic lithotripsy has high efficiency with low complication rates (2). However, in case of steinstrasse and large (> 1 cm) ureter stones, fragmented small stones may obstruct insertion of a ureteroscope after initial lithotripsy. In order to triumph over this issue, multiple ureteroscopic passages and manipulations needed for extraction of these small stones by forceps or basket catheters. The overall incidence of stricture was found upto 14.2% when the fragments were removed with a grasping forceps or a basket (3). We present our technique to disperse small fragmented stones in order to contact non-fragmented rest stone.
Materials and Methods: Ureteral lithotripsy was performed with an 8-9.8F semirigid ureteroscope using a pneumatic lithotripter (Swiss LithoClast, EMS, Nyon, Switzerland). The stone was fragmented into small pieces as small as 2-3 mm. by pneumatic lithotripter. Eventually, these fragmented stones interfered with vision and the lithotripter to get in touch with the rest stone. After fragmenting distal part of the large stone, the ureteroscope was pulled back out of ureter. While pulling back, the operating channel was closed and irrigation fluid was flowing in order not to decrease pressure behind the stones. Simultaneously, a person tilted the operating table to about 30º in reverse Trendelenburg position. When the ureteroscope was out of ureteral orifice, the operating channel was opened and irrigation fluid was stopped. This maneuver aided decreasing pressure in the bladder more rapidly in addition to feeding tube. Stone dust and antegrade fluid flow were easily seen out of the ureteral orifice. Ureteroscope was re-inserted after 30-60 seconds. While reaching the rest of the stone, small stone dust was seen at first. Bigger stones were approximately 3-5 cm distal to the original place of the stone. When the non-fragmented rest stone appeared, there were no blocking fragmented stones. Insertion of the ureteroscope was easy and we could go on with the lithotripsy procedure.
Conclusions: In comparison to standard position, tilting and rapid decrease in pressure by pulling back the ureteroscope made gravity and negative pressure more effective.


  1. Gunlusoy B, Degirmenci T, Arslan M, Kozacioglu Z, Nergiz N, Minareci S, et al.: Ureteroscopic pneumatic lithotripsy: is the location of the stone important in decision making? Analysis of 1296 patients. J Endourol. 2008; 22: 291-4.
  2. Dellabella M, Milanese G, d'Anzeo G, Muzzonigro G: Rapid, economical treatment of large impacted calculi in the proximal ureter with ballistic ureteral lithotripsy and occlusive, percutaneous balloon catheter: the high pressure irrigation technique. J Urol. 2007; 178(3 Pt 1): 929-33; discussion 933-4.
  3. Brito AH, Mitre AI, Srougi M: Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi. Int Braz J Urol. 2006; 32: 295-9.


Available at: www.brazjurol.com.br/videos/september_october_2013/Canguven_756_757video.htm

Int Braz J Urol. 2013; 39 (Video #13): 756-7

Submitted for publication:
March 20, 2013


Accepted after revision:
June 15, 2013

Correspondence address:
Dr. Onder Canguven
Sakacı sokak 34 5 Yildiz apt.
Kozyatagi, Kadikoy, Istanbul 34738, Turkey
Fax: + 90 216 352-0083
E-mail: ocanguven@yahoo.com


Editorial Comment


            In the present video, the authors describe a technique to promote small ureteral stone fragment expulsion using a combination of pressure gradient and patient re-positioning (i.e. reverse trendelenburg) at time of ureteroscopic stone pneumatic lithotripsy. Although this video does not highlight a truly novel technologic advancement in ureteral stone management, the authors detail technical considerations that can not only optimize stone fragment expulsion but similarly improve surgical proficiency. As we embark in a new era of medical and surgical care in which where we are judged not only on surgical outcomes as healthcare providers but as well on our optimized utilization of surgical resources, such original technical novelties are to be commended and encouraged.



Philippe E. Spiess, MD
Associate Professor, Department of GU Oncology
Moffitt Cancer Center
Video Section Editor, International Brazilian Journal of Urology
E-mail: philippe.spiess@moffitt.org