Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9 Comparison of dusting method and fragmentation method in Laser lithotripsy approach for upper ureteric stone: Case reference study

Mohammed Ridha Joodi A.Jalo1* 1. Department of Surgery, College of Medicine ,University of Babylon, Hilla, Iraq *Corresponding author: E-mail: [email protected] (Jalo) Phone number: 009647809113938

*Corresponding author

Dr. Mohammed RidhaJoodi A.Jalo Department of Surgery, College of Medicine, University of Babylon, Hilla, Iraq. E-mail: [email protected] Phone number: 009647809113938

Abstract

Background: Electively, renal calculi can be surgically approached in a number of ways. Extracorporeal shockwave lithotripsy (ESWL) may be indicated to handle calculi anywhere in the urinary tract; however, it is principally indicated for upper ureter kidney stones. Ureteroscopy with laser lithotripsy may be indicated to treat calculi endoscopically and it is preferred was for ureteral calculi in the distal ureter.

Objectives:: The current study was aiming at assessing the effect of laser frequency and energy power setting on outcome in the management of upper ureteric stones by semi-rigid ureteroscopy.

Patients and methods: The current case reference study has been conducted in the urology department in Al-Hilla Teaching Hospital, From June the 2nd 2015 to June the 2nd 2017. The study included 46 patients with upper ureteric stones, 28 men and 18 women with an age range of 17 to 80 years. Patients were categorized into two categories. The first category, the dusting method group, included 26 patients (26 ureteric stones) who were managed using URS with laser setting (high frequency, low pulse energy and fixed irrigation system); whereas, the second group, the fragmentation method group, included 20 patients (24 ureteric stones: 4 patients having bilateral ureteric stones) who were managed using URS with laser setting (low frequency, high pulse energy and fixed irrigation system).

Results: Mean operative time was lower significantly in group 2 in comparison with group 1, 40.85 ±5.34 minutes versus 50.40 ±3.21 minutes, respectively (P = 0.042). Stone freedom from single session was comparable in both groups, 21 (80.8 %) versus 17 (70.8 %), respectively (P = 0.411). The rate of double j stent was greater significantly in group 2 in comparison to group 1, 18 (75.0 %) versus 12 (46.2 %), respectively (P = 0.032). There was insignificant variation in the rate intra-operative complications between both groups (P> 0.05), in addition to lack of significant variation in the rate of early post-operative complications (P> 0.05).

Conclusion: High-frequency, low pulse energy settings are more favorable for fine fragmentation (dusting) of stones especially in impacted ureteric stones, with minimal trauma to the mucosa, less retropulsion, less intra and post-operative complicationand more operative time. On other hand low-frequency, high- pulse energy settings are more effective for stone fragmentation, less operative time, more retropulsion and mucosal damage.

Keywords: Dusting, fragmentation, Laser lithotripsy, upper ureteric stone.

How to cite this article: Jalo MRJA (2020): Comparison of dusting method and fragmentation method in laserlithotripsy approach for upper ureteric stone: Case reference study, Ann Trop Med & Public Health; 23(S9): SP23928. DOI: http://doi.org/10.36295/ASRO.2020.23928

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928

Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9 Introduction

Abdominal pain, groin pain and flank pain in addition to hematuria are frequently caused by renal stones(1- 3). Urinary tract calculi are common so that every one in 11 individual is going to have the disease at some point in his lifetime. The disease is more frequently encountered in men more than women with an approximate ratio of 2:1(2, 4, 5). The main two reasons associated with stone formation are increase in the amount of stone forming molecules such as cystine, calcium, xanthine, uric acid and phosphate or reduction in overall urine volume. Others reasons such as increased urine acidity and low urinary citrate content have been also implicated in causation of renal calculi (6, 7). The usual form of clinical presentation in association with renal stone is the severe acute pain with typical referral to emergency department with agony. Single attack of renal stone is not a cause of renal impairment; however, renal tubular epithelium is going to be severely affected with recurrent episodes of renal stones (8- 10). Crystallization of urine solutes is the main phenomenon in association with formation of renal calculi. This phenomenon may accompany low urine volume, anatomic abnormalities leading to urinary stasis, urinary tract infections, dietary elements (e.g., high sodium or high oxalate), medications, systemic acidosis, or rarely genetic predisposition including cystinuria(11- 14). Indeed, the most frequent reason behind renal stone is inadequate hydration with subsequent low renal volume (15, 16).

Proper evaluation of kidney stone includes adequate history, physical examination, general urine examination and imaging methodsincluding as “x-ray, ultrasound and computed tomography”(17-19).Treatment modalities are diverse and depend on many factors. Medical intervention is reversed for small size stone, often less than 5 mm, with expulsive therapy including alfuzosin, nifedipine or tamsulosin because in 90 % of cases such stones are going pass with no need for surgical intervention. Aggressive antibiotic therapy will be considered in cases of evident urinary tract infection(20- 22).

Electively, renal calculi can be surgically approached in a number of ways. Extracorporeal shockwave lithotripsy (ESWL) may be indicated to handle calculi anywhere in the urinary tract; however, it is principally indicated for upper ureter kidney stones(23). Ureteroscopy with laser lithotripsy may be indicated to treat calculi endoscopically and it is preferred was for ureteral calculi in the distal ureter(24-27). For large stones, a size bigger than 2 cm, located in the renal pelvis, percutaneous nephrolithotomy may be preferred(28).

The current study aims to assessthe effect of laser frequency and energy power setting on outcome in the management of upper ureteric stones by semi-rigid ureteroscopy.

Patients and Methods

The current case reference study has been conducted in the urology department in Al-Hilla Teaching Hospital, From June the 2nd 2015 to June the 2nd 2017. The study included 46 patients with upper ureteric stones, 28 men and 18 women with an age range of 17 to 80 years, provided that included patients were not responding to conservative treatment or having an evidence of infection or sustained colic. Uremic patients, those who were unfit for general anesthesia, pregnant ladies, patients with systemic disease and those with pyonephrosis were not included. Patients were categorized into two categories. The first category, the dusting method group, included 26 patients (26 ureteric stones) who were managed using URS with laser setting (high frequency, low pulse energy and fixed irrigation system); whereas, the second group, the Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928

Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9 fragmentation method group, included 20 patients (24 ureteric stones: 4 patients having bilateral ureteric stones) who were managed using URS with laser setting (low frequency, high pulse energy and fixed irrigation system).Patients’ assessment included history taking, thorough physical examination, biochemical and radiological investigations. Stone size assessment was based on largest diameter according to abdominal ultrasound or CT-scan report.

Patients were anesthetized by spinal or general anesthesia. Each patient was given a single dose of ceftriaxone at time of aesthesia induction. Foley catheter was left for 24 hours postoperatively. Antibiotics were continued for 2 days through parenteral route and 5 to 7 days orally. Standard ureteroscopy with laser lithotripsy was carried out using: The Holmium YAG laser lithotripsy system (calculase II - KARL STORZ-) which operates at a wavelength of 2100 nm and its power was (20) watt; a 600 μ m quartz end fiber; 8 Fr& 9.5 Fr. KARL STORZ semi rigid ureteroscope with 4 & 5 Fr. Working channel respectively; A 0.035- inch (Polytetrafluoroethylene –PTFE-) coated guide wire; Camera and video system; Continuous flow irrigation system (uromate E.A.S.I -KARL STORZ) using standard URS setting,(pressure 90 mmHg & flow 150 ml/min). Ureteric stent was used in case of prolonged procedures (> 60 minutes), large residual stone burden, evident ureteral edema/trauma, ureteric stricture that required dilatation, ureteric perforation, solitary kidney and bilateral stones. The main outcomes at the end of the study were stone freedom and complication rates.

The study was approved based on formal ethical approval provided by the institutional committee responsible for ethical considerations, in addition, a verbal consent was obtained for all patients participating in this study. Data was then transformed into an SPSS (IBM, Chicago, USA, version 23) in order to be statistically analyzed. “Quantitative data were expressed as mean, standard deviation” and range, whereas, “qualitative data were expressed as number and percentage”. Chi-square test was used to evaluate for differences in proportions between both categories. The level of significance was considered at P ≤ 0.05.

Results

The current study included 46 individuals with an average age of 46.08±16.61 years and an age range of 17-80 years. The study enrolled 28 (60.9 %) men and 18 (39.1 %) women, as shown in table 1.The stone characteristics are shown in table 2. The total number of stones was 50 because 4 patients had bilateral ureteric stones. The mean size of stones was 15.8 ±3.14 mm and it ranged from 12 to 25 mm; the majority of them were between 11 to 15 mm. In most of the cases the stone was found on the left side followed by right side and some patients had stones on both sides, 24 (52.2 %), 18 (39.1 %) and 4 (8.7 %), respectively, as shown in Table 2.

The outcome was shown in Table 3. “Mean operative time was significantly less” in group 2 in comparison with group 1, 40.85 ±5.34 minutes versus 50.40 ±3.21 minutes, respectively (P = 0.042). Stone freedom from single session was comparable in both groups, 21 (80.8 %) versus 17 (70.8 %), respectively (P = 0.411). The rate of double j stent was “significantly higher” in group 2 in comparison to group 1, 18 (75.0 %) versus 12 (46.2 %), respectively (P = 0.032). There was insignificant variation in the rate intra-operative complications between both groups (P> 0.05), in addition to lack of significant variation in the rate of early post-operative complications (P> 0.05), as shown in table 3.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928

Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9

Table 1: Characteristics of patients enrolled in the present study

Characteristic Result

Number of cases 46

Age (years)

Mean ±SD 46.08±16.61

Range 17-80

Gender

Male, n (%) 28 (60.9 %)

Female, n (%) 18 (39.1 %) n: number of cases; SD: standard deviation

Table 2: Stone characteristics

Characteristic Result

Number of stones 50 Size (mm)

11-15 mm, n (%) 30 (60.0 %) † 16-20 mm, n (%) 16 (32.0 %) † > 20 mm, n (%) 4 (8.0 %) † Range 12-25 Mean ±SD 15.8 ±3.14 Site

Right, n (%) 18 (39.1 %) ¥ Left, n (%) 24 (52.2 %) ¥ Bilateral, n (%) 4 (8.7 %) ¥ n: number of cases; SD: standard deviation; †: percentage was calculated out of total stone number; ¥: percentage was calculated out of total patients’ number.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928

Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9

Table 3: Outcome

Group 1( Dusting method) Group 2 (Fragmentation method) Outcome Number of cases = 26 Number of case = 20 P Number of stones = 26 Number of stones = 24 Operation time (minutes) 50.40 ±3.21 40.85 ±5.34 0.042 €*

Stone freedom from single session 21 (80.8 %) † 17 (70.8 %) † 0.411 £

Need for double J stent 12 (46.2 %) † 18 (75.0 %) † 0.038 £*

Intra-operative complications

Simple mucosal injury, n (%) 6 (23.1 %) † 11 (45.8 %) † 0.090 £

Migration, n (%) 2 (7.7 %) † 5 (20.8 %) † 0.352 Y

Perforation, n (%) 1 (3.8 %) † 1 (4.2 %) † 1.000 Y

Access failure (stricture), n (%) 1 (3.8 %) † 1 (4.2 %) † 1.000 Y

Early post-operative complications

Transient hematuria, n (%) 4 (15.4 %) ¥ 8 (40.0 %) ¥ 0.059 £

Flank pain, n (%) 4 (15.4 %) ¥ 6 (30.0 %) ¥ 0.406 Y

Fever, n (%) 1 (3.8 %) ¥ 2 (10.0 %) ¥ 1.000 Y Data were expressed as mean ±standard deviation or number (%);†: percentage was calculated out of total stone number; ¥: percentage was calculated out of total patients’ number; €: Independent samples t-test; £: Chi-square test; Y: Yates correction for continuity; *: Significant at P ≤ 0.05

Discussion

The gold standard technique for “endoscopic lithotripsy of stones in the upper tract” is the Ho: YAG laser lithotripsy (29) with a successful fragmentation rate of 90-100%(30). Variables, such as pulse energy, pulse width and pulse frequency,aid the surgeon to selectvarious combinations which have particular effects on fragmentation of stone during URS lithotripsy. “Contact laser lithotripsy” can be carried out using dusting or fragmentationsettings (31). Patients in our study ages range from 17-80 years with a mean age of 46.08±16.61 years. Male to Female ratio in our study was 1.55:1 which was comparable to other studies in which male to female ratio was 2: 1 and reflect that men are affected two times more frequently than women(32). Experimentally, they found low-frequency high-pulse energy settings are more ablative than high-frequency low– pulse energy settings despite similar total power levels(33).However, High power “(pulse energy) levels and short pulses width increase the risk of retropulsion” and mucosal damage(29, 34).

The findings of Kortenberg and Traxer: “High-frequency, low power” settings are more favorable for fine fragmentation of stones -especially in impacted ureteric stone- which yieldsfiner stone pieces (dusting effect) than high

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928

Jalo (2020): Case study of upper ureteric stone May 2020 Vol. 23 Issue 9 power. Another benefit of “low power” is minimal trauma to mucosa, but its increase operative time and may be not efficient for hard stones(35).So in our study we focus on these parameters in laser setting, trying to achieve a better result with minimal complication.The current study provided evidence that better results accompany dust method in line with previous reports (29, 34, 35).

Regarding intra operative complication we get less stone migration (7.6% Vs 20.8%), and less mucosal injury (23.1% Vs 45.8%) in group I and group II respectively.Also we get less post-operative complication in group I than group II like (Transient hematuria, Flank pain, fever).The risk of perforation from laser energy is minimal, because the “depth of thermal injury” is only 0.5 to 1 mm(36).Ureteric perforations in our patients were due to ureteroscopic manipulation and guide wire equally. Perforations rate in our study was (3.8% Vs 4.1%) in group I and group II respectively which was approximately the same rates that observed in other studies concerning laser lithotripsy which ranged from 2.6%-6 %(32, 37).Ureteral stenting is the best management of perforation(32, 37).

Our result of successful stone fragmentation was (80.7% Vs 70.8%) in group 1 and group 2 respectively, that percentage from single session only.This mean by using dusting method, high percentage of stone freedom can be achieved. The difference was not significant between 2 groups, larger sample may be needed to achieve a better and clearer results. In comparison to ESWL, the success rate of ESWL for upper ureteral stones reported by Iraqi study was 70 %(38). In the current study, DJ insertion was (46.2% VS 75%) in group 1 and group 2 respectively. DJ stenting in dusting groupwas mostly due to long operative time, while in fragmentation group DJ stenting was mostly due to simple mucosal injury caused by high energy power of laser in addition to the cases with bilateral stones.

Conclusion “High-frequency”, low pulse energy settings are more favorable for “fine fragmentation (dusting)” of stones especially in impacted ureteric stones, with minimal trauma to the mucosa, less retropulsion, less intra and post-operative complicationand more operative time. On other hand low-frequency, high- pulse energy settings are more effective for stone fragmentation, less operative time, more retropulsion and mucosal damage. Conflict of interest

There has been no conflict of interest of any kind with the author of this work.

Ethical Approval

All the variable information consents of the patients and control groups were taken after explaining the purpose of the study to the patients, Those who refused to participate in the study were excluded. The study was formally approved the research plan by the ethical committee board at the Babylon health directorate.

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.23928