Stetsyshyn: Analysis of Postoperative Complications In Urethrolithiasis Treatment Using Intracorporeal Ultrasonic Lithotripsy



Problem statement and analysis of the recent research

In modern urology, more and more focused on the minimally invasive procedure, ureteroscopy has a leading position as a method of diagnosis and treatment of many diseases, especially urolithiasis. This procedure was first described in the late 1970s (Lyon et al.), complications of ureteroscopy were also described for the first time then (5). Large number of studies on the structure and frequency of complications with the complication rate ranging from 8% to 16% was published [3, 4, 5].

Transurethral ureterolithotripsy is the method of choice for the treatment of calculi in the lower and middle third of the ureter [1-4]. In addition to the therapeutic benefits, contact ureterolithotripsy may be accompanied by a number of slight or severe complications ranging from dull back pain to the ureter perforation, avulsion and sepsis [5, 6]. In recent decades, the number and severity of these complications has significantly decreased due to the extensive use of semi-rigid and flexible ureteroscopes and the accumulation of urologists’ experience in terms of this operation performance [1, 2, 7]. Despite this, ureteroscopy is still the most common cause of the ureter injury. Therefore, surgeons should be aware of the potential complications and therapeutic strategies if they appear.

The objective of the research

This research is devoted to the structure, frequency and etiology of postoperative complications encountered during the treatment of ureteral calculi with the use of semi-rigid ureteroscope and ultrasonic lithotripsy.

Materials and methods

Patients with complications in the postoperative period were examined. During the examination all patients underwent urinalysis, complete blood count with the number of cellular elements, urea and creatinine levels determination, bacteriological urine culture (if necessary) with the determination of antibiotic sensitivity. Ultrasonography of the urinary tract was performed for preliminary diagnosis. Computed tomography was performed in order to specify the location and size of ureteral calculi as well as to measure the calculus density in Hounsfield units. Separately, an analysis was performed in the group of patients without such complications, but the procedure was unsuccessful, as for some reason the calculus (or its clinically significant fragments) remained after the operation in the lumen of the upper urinary tract, that is, “stone-free” status was not achieved.

In the process of the complications analysis, the patients’ demographic data, size and location of calculi, the operation time, and its effectiveness in terms of “stone-free” status achievement were studied.

All patients underwent intraoperative prevention of bacterial complications with the use of ceftriaxone or fluoroquinolones. All operations were performed under epidural or spinal anesthesia in a position for lithotomy. Semi-rigid ureteroscopy was started with an introduction of 8.5 8 Fr uretheroscope into the bladder, opening verification, guide introduction into it. Calculi were fragmented by leading ultrasonic lithotripter probe to them. Dormia basket was used to fix the calculus. The fragments were removed with forceps for ureteroscopy. JJ stents were used according to indications. Routinely, permanent catheter was retained in patients draining the urinary bladder during the day.

After anesthesia, the normalization of patient’s general medical condition, ultrasonography and X-ray control of the stent position and “stone-free” status, monitoring of laboratory parameters, the patients were discharged for outpatient treatment. The reasons for the prolonged patients’ stay in the hospital were uncontrolled pain syndrome, hematuria, dysuria, and the development of early postoperative complications.

Patients were followed up after discharge over time for 1, 4 and 8 weeks, and according to indications – up to the elimination of complications. During each visit the complaints were examined, physical examination was performed. Laboratory examination of patients was conducted according to the indications, ultrasound examination of the urinary system was performed. Traditional X-ray examination of the urinary tract and / or CT was performed at suspicion on residual fragments. Residual fragments of size less than 2 mm were considered clinically insignificant, in case of the absence of any clinical symptoms including infection and obstruction. JJ-stents were removed in 2-4 weeks after surgery.

If hematuria persisted >6 hours and discontinued independently in 48 hours, the patient was considered to have “transient hematuria”. Hematuria wjich remained for more than 48 hours was considered to be “persistent hematuria”.

All complications were distributed according to the degree of their severity in accordance with MCCS classification. Each complication was evaluated separately in a patient with more than one complication.

287 postoperative complications of varying severity were observed in 204 patients included into the research.

Results of the research and their discussion

Postoperative complications in the treatment of urethrolithiasis using contact ureterolithotripsy with the use of an ultrasonic lithotripter were analyzed. Table 1 provides the data including general characteristic of this group of patients.

Table 1.

General characteristics of patients with postoperative complications in case of ureteroscopic treatment of ureteral calculi

Parameter Average / absolute value Interval
Age, years 46.25±2.12 19-78
Sex, %
Male 155 (57.6)
Female 114 (42.4)
Disease side, %
Left 153 (56.9)
Right 116 (43.1)
Calculus size, cm 1.31±0.03 0.6-2
Calculi density, Hounsfield units 1047.60±18.78 506-1567
The number of calculi, %
Single 253 (95.1%)
2 and more 16 (4.9%)
Calculi location, %
Upper third, % 108 (40.1%)
Middle third, % 56 (20.8%)
Lower third, % 105 (39.0%)
Prescription of disease , days 8.28±0.24 1-15
Duration of the operation, minutes 49.01±1.16 14-82
Duration of stay in a hospital after the operation, days 22.67±0.26 15-30
Procedure effectiveness ( “stone-free” status), % 181 (63.1%)
Total complications 269

The average age of patients with postoperative complications during urethrolithiasis treatment constituted 46.25 ± 2.12 years, moreover, this index ranged from 19 to 78 years. There were more men than women as well as in the group with intraoperative complications: 155 (57.6%) and 114 (42.4%) respectively. Left ureteral calculi were detected in 153 (56.9%) patients and right ureteral calculi were observed in 116 (43.1%).

Average size of calculus constituted 1.31 ± 0.03 cm in case of range of values 0.6 to 2 cm in the group with postoperative complications in the treatment of ureteral calculi. Calculi density ranged from 50 to 1567 Hounsfield units, an average value amounted 1047.60 ± 18.78 Hounsfield units.

Calculi were single in the vast majority of patients, namely in 253 cases (95.1%) and 2 and more ureteral calculi were detected in 16 (4.9%) patients.

In the group of patients with postoperative complications calculi were localized in the upper third of the ureter in 108 (39.0%) patients, in the middle third in 65 (20.8%) patients and in the lower third in 144 (39.0%) patients. The prescription of disease in this group of patients constituted 8.28 ± 0.24 days ranging from 1 to 15 days. Operation lasted 14 to 82 minutes, 49.01 ± 1.16 min on average, in patients with postoperative complications. The duration of postoperative morbidity fluctuated in the range of 22.67 ± 0.24 days in the patients of this group. “Stone-free” status was achieved in 181 patients with postoperative complications, i.e. ureterolithotripsy effectiveness in this group constituted 63.1%.

The next stage of the research was univariate analysis of early postoperative complications in the course of endoscopic treatment of ureteral calculi with the use of contact ultrasonic lithotripsy. For this purpose, we analyzed groups of patients with early and late postoperative complications separately. The aim of the analysis was to find the dependence on the basic parameters such as the duration of the disease, the size of the calculus, its location in the ureter, the calculus density.

Analyzing the distribution of complications depending on the calculus size we observed the following features presented in Table 2.

Table 2.

Distribution of early postoperative complications depending on the size of the calculus

Complication type Severity Calculus size, cm Total
0.6-0.9 1-1.4 Over 1.5
Hyperthermia G2 12 (6.7%) 18 (10.1%) 32 (17.9%) 62 (34.6%)
Persistent hematuria G1 17 (9.5%) 15 (8.4%) 24 (13.4%) 56 (31.3%)
Renal colic G2 13 (7.3%) 25 (14.0%) 23 (12.8%) 61 (34.1%)
Total 42 (23.5%) 58 (32.4%) 79 (44.1%) 179 (100.0%)

Early postoperative complications in case of ureterolithotripsy were observed in 179 patients. They were not severe. The severity of complications was not higher than G2, thus complications were not life-threatening and required only medical correction. Early postoperative complications occurred in 42 (23.5%) patients with the calculus less than 1 cm in size. Moreover, hyperthermia over 38º C was observed in 12 (6.7%) of them, persistent hematuria during 3-5 days was detected in 17 (9.5%) patients after the surgery, renal colic was observed in 13 (7.3%) patients.

Early postoperative complications were observed in 58 (32.4%) patients with the calculus from 1 to 1.4 cm in size. Hyperthermia occurred in 18 (10.1%) of them, persistent hematuria was detected in 15 (8.4%) patients, and renal colic was found in 25 (14.0%) patients.

Complications occurred in 79 (44.1%) patients with the largest size of the calculi, namely 1.5 cm or more. In the structure of complications hyperthermia was observed more often, namely in 32 (17.9%) patients. Persistent hematuria and renal colic were detected less often, in 24 (13.4%) and 23 (12.8%) patients respectively.

Subsequently, the relationship between the frequency of early postoperative complications and calculus localization in different parts of the ureter was analyzed. The analysis data are provided in Table 3.

Table 3.

Distribution of early postoperative complications depending on the localization of ureteral calculi

Complication type Severity Calculus localization in the ureter Total
lower 1/3 middle 1/3 upper 1/3
Hyperthermia G2 35 (19.6%) 7 (3.9%) 22 (12.3%) 62 (34.6%)
Persistent hematuria G1 16 (8.9%) 5 (2.8%) 28 (15.6%) 46 (25.7%)
Renal colic G2 28 (15.6%) 27 (15.1%) 11 (6.1%) 61 (34.1%)
Total 79 (44.1%) 39 (21.8%) 61 (34.1%) 179 (100.0%)

According to the data in the table, calculi were localized in the lower 1/3 of the ureter in 70 (44.1%) of patients with early postoperative complications. At the same time, hyperthermic syndrome associated with exacerbation of the inflammatory process in the kidney was noted in 39 (19.6%) patients. The early postoperative period was complicated by persistent hematuria in 16 (89%) patients with this calculi localization and by renal colic in 28 (15.6%) patients.

The group of patients with calculi localization in the middle third of the ureter included 29 (16.2%) persons. Hyperthermia was observed in 5 (2.8%) patients, persistent hematuria was detected in 2 (1.1%) patients, and renal colic complicated the early postoperative period in 22 (12.3%) patients.

Early postoperative complications were observed in 61 (34.1%) patients with calculi localization in the upper third of the ureter. 22 (12.3%) patients suffered from hyperthermic syndrome, persistent hematuria as postoperative complication was observed in 28 (15.6%) patients, renal colic was noted in 11 (6.1%) patients.

Such parameter as calculus density could also undoubtedly affect the presence and nature of early postoperative complications. Data of the analysis concerning these calculus features are provided in Table 4.

Table 4.

The relationship between early ureterolithotripsy complications and calculi density

Complications type Severity Calculus density, Hounsfield units Total
500-1,000 1000-1,500 Over 1,500
Hyperthermia G2 19 (10.6%) 31 (17.3%) 12 (6.7%) 62 (34.6%)
Persistent hematuria G1 25 (14.0%) 24 (13.4%) 7 (3.9%) 56 (31.3%)
Renal colic G2 20 (11.2%) 23 (12.8%) 18 (10.1%) 61 (34.1%)
Total 64 (35.8%) 78 (43.6%) 37 (20.7%) 179 (100.0%)

According to the Table 4, early postoperative complications were observed in 64 (35.8%) patients in case of calculus density from 500 to 1000 Hounsfield units. Among them 19 (10.6%) patients suffered from hyperthermic syndrome, early postoperative period was complicated by persistent hematuria in 24 (13.4%) cases, and renal colic was observed in 20 (11.2%) patients.

Early postoperative complications were detected in 78 (43.6%) patients in case of more high calculus density, namely from 1000 to 1500 Hounsfield units. Hyperthermic syndrome was detected in 31 (17.3%) patients, persistent hematuria was observed in 24 (13.4%) patients, postoperative renal colic had to be stopped in 23 (12.8%) patients.

Early postoperative complications were observed in 37 (20.7%) patients with calculus density over 1,500 Hounsfield units. Among them 12 (6.7%) patients suffered from hyperthermic syndrome, persistent hematuria was observed in 7 (3.9%) cases, renal colic was detected in 18 (10.1%) patients.

Thus, we can state that univariate analysis of the early postoperative complications causes cannot identify the key factors influencing their occurrence. In this regard, we also had to apply bivariate analysis to identify factors affecting the development of early postoperative complications in the treatment of urethrolithiasis with the use of contact ultrasound ureterolithotripsy. Results of the analysis as the relationship of early postoperative complications with calculus size and density are represented in Figure 1.

Fig. 1.

Interrelation of early postoperative complications with the size and density of the calculus

gmj-23-gmj.2016.3.15-g1.jpg

According to the diagram, complications were most often observed in case of the highest calculus density, namely over 1,500 Hounsfield units and the least the size up to 1 cm. Thus, in the group with intraoperative complications only 6 (14.3%) out of 42 patients with calculus size up to 1 cm had calculus density less than 1,000 Hounsfield units. Early postoperative complications were noted in 24 (28.6%) patients with calculus density from 1,000 to 1,500 Hounsfield units. However, early postoperative complications were detected in 24 (57.1%) patients with calculus density over than Hounsfield 1,500 units.

Early postoperative complications were observed in 58 patients with large calculus size from 1 to 1.5 cm; moreover, those complications were less dependent on the calculus density. Calculi with density up to 1,000 Hounsfield units were observed in 27 (46.6%) of them. 26 (44.8%) complications were detected in patients with calculi of these sizes and density of 1,000-1,500 Hounsfield units. Only five (8.6%) complications were observed in case of calculi density more than 1,500 Hounsfield units.

Intraoperative complications also did not depend on calculi density in 79 patients with the largest calculi sizes, namely more than 1.5 cm. 31 (39.2%) complications were noted in case of density up to 1,000 Hounsfield units. Complications were observed in 40 (50.6%) patients with calculi density of 1,000-1,500 Hounsfield units. Complications were detected only in 8 (10.1%) cases in patients with large calculi and a density over 1,500 Hounsfield units.

Thus, in the course of bivariate analysis of early postoperative complications causes, clear dependence of intraoperative complications development was detected in patients with calculi size of up to 1 cm and 1-1.4 cm of its density. Intraoperative complications were observed in 60% of patients with calculi of 1 cm and 50% of patients with calculi up to 1.5 cm in case of calculi density over 1,500 Hounsfield units. In case of calculi size of 1.5 cm and more, intraoperative complications occurred regardless of calculi density.

Subsequently, the dependence of early postoperative complications on calculi size and localization was observed. The results of this analysis are presented in Figure 2.

Fig. 2.

Interrelation of early postoperative complications with the size and localization of the calculus

gmj-23-gmj.2016.3.15-g2.jpg

The conducted analysis demonstrated that early postoperative complications in patients with calculi size up to 1 cm occurred most often when the calculus was located in the upper third of the ureter. Complications were noted in 25 (59.5%) out of 42 patients with calculi up to 1 cm in size with localization in the upper third of the ureter. In the middle third of the ureter the calculi were localized in 8 (19.0%) cases in patients with early postoperative complications. In the lower third of the ureter the calculi were localized 9 (21.4%) patients.

Ureterolithotripsy of the calculi ranging from 1 to 1.5 cm in size was previously performed in 58 patients with early postoperative complications. Calculi were located in the upper third of the ureter in 14 (24.1%) patients, in the middle third in 15 (25.9%) patients and in the lower third of the ureter in the majority of patients, namely in 29 (50.0%) cases.

Calculi over 1.5 cm were found in 79 patients. Calculi were located in the upper third of the ureter in 22 (27.8%) patients, in the middle third in 16 (20.3%) patients. Calculi were located in the lower third of the ureter in more than half of the patients, namely, in 79 (51.9%) cases.

Thus, it may be concluded that early postoperative complications were noted mainly when the calculus was located in the upper third of the ureter (i.e. more than half of all complications) in patients with early postoperative complications in the treatment of urethrolithiasis using ultrasonic ureterolithotripsy with calculi size up to 1 cm.

The next stage of the research was the analysis concerning the relationship of early postoperative complications with the density and localization of the calculus. The results of this analysis are presented in Figure 3.

Fig. 3.

Interrelation of early postoperative complications with the density and localization of the calculus

gmj-23-gmj.2016.3.15-g3.jpg

Studying this relationship, the following was noted. Early postoperative complications were most often observed in case of calculus localization in the lower third of the ureter in patients with calculi density up to 1,000 Hounsfield units: 34 (53.1%) cases out of 69 patients. Less than half of the complications occurred in the upper and middle third of the ureter, namely 21 (32.8%) and 9 (14.1%), respectively.

In case of calculi density from 1,000 to 1,500 Hounsfield units the complication rate was distributed nearly in equal parts: 26 (33.3%), 23(29.5%) and 29 (37.2%) cases with localization in the upper, middle and lower third of the ureter.

In patients with the highest calculi density over 1,500 Hounsfield units the greatest number of complications was observed in case of their localization in the upper and lower third of the ureter, in 14 (37.8%) and 16 (43.2%) cases respectively. Early postoperative complications were observed with a frequency of 7 (18.9%) cases in case of calculi location in the middle third of the ureter.

Analysis was also conducted to determine late postoperative complications causes. For this purpose we conducted univariate analysis of the main factors which could affect the development of complications during ureterolithotripsy in this group.

The data concerning the distribution of late postoperative complications depending on calculi size are provided in Table 5.

Table 5.

Distribution of late postoperative complications depending on calculi size

Complication type Severity Calculus size, cm Total
0.6-0.9 1-1.4 Over 1.5
Transient reflux G1 28 (31.1%) 23 (25.6%) 27 (30.0%) 78 (86.7%)
Ureterostenosis Grade 3b 2 (2.2%) 5 (5.6%) 5 (5.6%) 12 (13.3%)
Total 30 (33.3%) 28 (31.1%) 32 (35.6%) 90 (100.0%)

Thus, according to the Table 5, late postoperative complications were observed in 30 (33.3%) out of 90 patients with calculi size up to 1 cm. Among them transient vesicoureteral reflux occurred in 28 (31.1%) patients. More severe complication, namely ureterostenosis was detected in 2 (2.2%) patients. Transient reflux was found in 23 (25.6%) patients with calculi size from 1 to 1.4 cm, and ureterostenosis was observed in 5 (5.6%) patients. Approximately the same number of complications, namely a total of 32 (35.6%) cases was observed in patients with ureteral calculi size over 1.5 cm. Among them 27 (30.0%) had transient reflux, and therapeutic measures concerning ureterostenosis were to be taken in 5 (5.6%) cases.

Analyzing the data on the dependence of late complications on the calculi localization in different parts of the ureter, some features were noted. They are provided in Table 6.

Table 6.

Distribution of late postoperative complications depending on the calculi localization

Complication type Severity Calculus localization Total
upper 1/3 middle 1/3 lower 1/3
Transient reflux G1 25 (27.8%) 14 (15.6%) 39 (43.3%) 78 (86.7%)
Ureterostenosis Grade 3b 4 (4.4%) 3 (3.3%) 5 (5.6%) 12 (13.3%)
Total 29 (32.2%) 17 (18.9%) 44 (48.9%) 90 (100.0%)

According to the Table 6, late postoperative complications were observed in 29 (32.2%) patients with calculi localization in the upper third of the ureter. Among them 25 (27.8%) patients had transient reflux, and ureterostenosis was observed in 4 (4.4%) cases. Complications were detected in 17 (18.9%) patients with calculi localization in the middle third of the ureter. Among them vesicoureteral reflux was observed in 14 (15.6%) patients and ureterostenosis was noted in 3 (3.3%) cases. In case of calculi localization in the lower parts of the ureter late postoperative complications were noted in about half of all patients in this group, namely in 44 (48.9%) out of 90 patients. Transient reflux was detected in 39 (43.3%) patients and ureterostenosis was observed in 5 (5.6%) cases.

The relationship between the late postoperative complications and calculi density was also analyzed (Table 7).

Table 7.

Distribution of late postoperative complications depending on the calculi density

Complication type Severity Calculi density, Hounsfield units Total
Up to 1,000 1,000-1,500 Over 1,5
Transient reflux G1 23 (25.6%) 29 (32.2%) 26 (28.9%) 78 (86.7%)
Ureterostenosis Grade 3b 3 (3.3%) 5 (5.6%) 4 (4.4%) 12 (13.3%)
Total 26(28.9%) 34(37.8%) 30 (33.3%) 90 (100.0%)

Thus, we observed that late complications occurred in 26 (28.9%) patients out of 90 with calculi density up to 1,000 Hounsfield units. Among them transient vesicoureteral reflux was detected in 23 (25.6%) patients and ureterostenosis was observed in 3 (3.3%) cases.

Late postoperative complications were detected in 34 (37.8%) patients with calculi density from 1,000 to 1,500 Hounsfield units. Namely, transient vesicoureteral reflux was noted in 29 (32.2%) patients and ureterostenosis was found in 5 patients. Complications were observed in one third of patients, namely in 30 (33.3%) cases in case of calculi density over 1,500 units. Among them transient reflux was observed in 26 (28.9%) patients and ureterostenosis was detected in 4 (4.4%) cases.

Thus, we also cannot identify precise causes of late postoperative complications using univariate analysis. For this purpose, bivariate analysis of the relationship between complications and different calculi properties was conducted.

Analysis results of the relationship between late complications on the one hand and calculus size and density on the other are presented in Figure 4.

Fig. 4.

Interrelation of late postoperative complications with the size and density of the calculus

gmj-23-gmj.2016.3.15-g4.jpg

According to the conducted analysis the following features were noted. Calculi density was less than 1,000 Hounsfield units in 3 (10.0%) out of 30 patients with calculi up to 1 cm in size. Later complications developed in 13 (43.3%) patients with such calculi size in case of calculus density of 1,000-1,500 Hounsfield units and in 14 (46.7%) patients with calculi density over 1,500 Hounsfield units.

Late postoperative complications developed in 28 cases in patients with ureteral calculi from 1 to 1.5 cm in size. Among them 4 (14.3%) patients had calculi with density up to 1,000 Hounsfield units; calculi density of 1,000-1,500 Hounsfield units was observed in 11 (39.3%) cases; calculi density of 1,500 Hounsfield units and more was noted in 13 (46.4%) patients. Complications were observed in 32 patients with calculi size of 1.5 cm and more. Among them calculus density was less than 1,000 Hounsfield units in 19 (59.4%) patients. Calculus density was 1,000-1,500 Hounsfield units in 10 (31.3%) patients with late postoperative complications. Calculus density of 1,500 Hounsfield units and over was observed in 3 (9.4%) cases.

Thus, distinct dependence of complications on calculus density was observed in case of late postoperative complications in patients with calculus size up to 1 cm. This dependence is neutralized with an increase in calculi size, and complications can occur at any calculus density.

We also analyzed the occurrence of late postoperative complications depending on the size and localization of the calculus in different parts of the ureter. The results of the analysis are presented in Figure 5. We noted that out of 30 patients with ureteral stones smaller than 1 cm late postoperative complications were observed in 17 (56.7%) of them with the localization of the calculus in the upper third of the ureter. Complications were observed in 7 (23.3%) patients with calculus in the middle third of the ureter and in 6 (20.0%) patients with calculus in the lower third of the ureter.

Fig. 5.

Interrelation of late postoperative complications with the size and localization of the calculus

gmj-23-gmj.2016.3.15-g5.jpg

At the same time, in case of calculi size of 1-1.4 cm, postoperative complications were found in 7 (25.0%) patients with calculi in the upper third of the ureter, in 6 (21.4%) patients with calculi in the middle third of the ureter, and in 15 (53.6%) patients with calculi in the lower third of the ureter out of total 28 patients. The same trend concerning the incidence of postoperative complications occurred in 32 patients with ureteral calculi of 1.5 cm or more in size. Complications occurred in 5 (15.6%) patients with calculi localization in the upper third of the ureter, in 4 (21.4%) patients with calculi in the middle third of the ureter and in 23 (53.6%) cases with calculi in the lower third of the ureter.

Thus, the conclusion may be drawn that the likelihood of late postoperative complications development does not depend on the calculus size in case of calculus localization in the upper and middle thirds. Complications occur much more frequently in case of calculus size of 1 cm or more with calculus localization in the lower third of the ureter.

The relationship of late postoperative complications with the localization of calculi of varying density was also analyzed. The results are presented in Figure 6. 26 patients had calculus density of up to 1,000 Hounsfield units. Among them the calculus was located in the upper third in 10 (38.5%) patients, in the middle third in 6 (23.1%) patients and in the lower third in 10 (38.5%) cases. Calculi density from 1,000 to 1,500 Hounsfield units was observed 34 patients. Among them the calculus was located in the upper third in 11 (32.4%) patients, in the middle third in 5 (23.1%) cases and in the lower third in 18 (52.9%) patients. In case of the highest calculus density of 1,500 Hounsfield units, the calculus was located in the upper third in 8 (26.7%) out of 30 patients, in the middle third in 6 (20.0%) cases and in the lower third of the ureter in 16 (53.3%) patients.

Fig. 6.

Interrelation of late postoperative complications with the density and localization of the calculus

gmj-23-gmj.2016.3.15-g6.jpg

It should be noted that the likelihood of late postoperative complications development increases with the calculus density of 1,000 Hounsfield units and more regardless of the calculus localization.

Conclusions

Thus, it is not always possible to avoid a considerable number of failure, intra- and postoperative complications even with the use of modern ureteroscopes with a minimum diameter, a sufficient overview of the surgical field, the application of ultrasonic contact lithotripter for calculus disintegration in patients with multiple ureteral calculi.

Taking into account the high risk of failure and complications, intracorporeal ureterolithotripsy in patients with complicated ureteral calculi, a differentiated approach to the use of devices for the disintegration of the concretion, or other types of surgery to treat multiple ureteral calculi should be used in this group of patients.

The main reserve for increase in the effectiveness of endoscopic treatment of complicated ureteral calculi should be the use of other methods of intracorporeal lithotripsy allowing application of more energy to the calculus for disintegration of the calculus, being at the same time more secure in terms of the development of various kinds of complications.

Prospects for further research

Study of ultrasonic contact lithotripsy possibilities has significant prospects in the treatment of urethrolithiasis. However, the so-called “multiple calculi” in patients increase the risk of complications when using this type of treatment making it necessary to study further the development of an algorithm to treat these patients.

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