title: Combined ureterorenoscopy and shockwave lithotripsy for large renal stone burden: an alternative to percutaneous nephrolithotomy?
abstract: OBJECTIVE
  To investigate the feasibility and initial outcomes of a combination of ureterorenoscopy (URS) using holmium laser lithotripsy and extracorporeal shockwave lithotripsy (SWL) in a single outpatient session for the treatment of large renal stone burdens in patients refusing or unsuitable for percutaneous nephrolithotomy (PCNL).
  
  
  METHODS
  Fourteen patients with a mean age of 52.7 years (range 34-81 years) having a mean stone burden of 847 mm2 (range 58 mm2-1850 mm2) were treated with combined URS laser lithotripsy and SWL as an alternative to PCNL. The SWL (mean 2800 shockwaves) was performed using the Storz Modulith SL-X, and flexible URS with holmium laser lithotripsy was performed either during or following SWL.
  
  
  RESULTS
  Ninety-three percent of the patients (13/14) were treated successfully on an outpatient basis. Two patients were rendered stone free after the initial procedure alone (14%). Overall, including secondary outpatient treatment with a second session of URS alone (N = 7) URS and SWL (N = 1), SWL (N = 1), or oral alkalinization therapy (N = 1), the stone-free rate was 76.9% (10/13). One patient was excluded secondary to death from unrelated causes after the initial procedure, and the success rate (residual fragments <4 mm) was 84.6% (11/13). The two treatment failures included one patient who required a third URS procedure and one patient who developed urosepsis necessitating nephrostomy-tube placement who underwent subsequent PCNL.
  
  
  CONCLUSIONS
  In comparison with traditional approaches using PCNL and second-look nephroscopy, single-session combined URS and SWL with a second outpatient procedure may offer equivalent results with decreased morbidity in carefully selected patients.
authors.affiliation: Department of Urology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York 10461, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Hafron
authors.forename: James D
authors.initials: JD
authors.lastname: Fogarty
authors.forename: Judd
authors.initials: J
authors.lastname: Boczko
authors.forename: David M
authors.initials: DM
authors.lastname: Hoenig
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007669:Kidney Calculi / Q000628:therapy*; D017602:Lithotripsy, Laser / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous; D018579:Patient Selection; D019233:Retreatment; D016896:Treatment Outcome; D018666:Ureteroscopy / Q000379:methods*