title: Staged retrograde endoscopic lithotripsy as alternative to PCNL in select patients with large renal calculi.
abstract: OBJECTIVE
  Percutaneous nephrolithotomy (PCNL) is currently the gold standard for management of large renal calculi. PCNL is associated, however, with a higher complication rate, degree of risk, and longer recovery period compared with ureteroscopy. In a selected group of patients who were not ideal candidates for PCNL because of extenuating health factors, a staged retrograde endoscopic approach was used to manage upper urinary tract calculi.
  
  
  METHODS
  We conducted a retrospective review of 23 patients (selected because of comorbidities, obesity, anatomy, and previous treatment failure as poor candidates for PCNL) who underwent staged retrograde endoscopic lithotripsy to manage upper urinary tract calculi. Lithotripsy was based on the application of small-diameter fiberoptic ureteroscopes and the holmium laser. Successful therapy was defined as total fragmentation of stone burden on repeated imaging. Data were analyzed using descriptive statistics.
  
  
  RESULTS
  Of the 468 patients who underwent ureteroscopy at our institution from 2003 to 2006, 23 patients (52% men, 57.70 +/- 11.44 years of age) were treated with retrograde endoscopic procedures for upper urinary tract calculi (52.2% lower pole). Stone burden at the initial procedure was 2.13 +/- 2.34 stones with a total linear length of 30.91 +/- 14.28 mm and an estimated total stone volume of 12,040.78 +/- 11101.54 cc (median value, 7,234.00 cc). There were no intraoperative complications; three patients were admitted postoperatively for observation. Ten 43.5%) patients (progressed to second-stage procedures (34.6 +/- 10.8 days apart). After repeated imaging, 73.9% of patients were stone free (88% lower pole), and 8.7% progressed to further intervention. Total linear stone length <4 cm and estimated calculus volume > or =15,000 cc predicted treatment failure (40%, 42.9%).
  
  
  CONCLUSIONS
  Percutaneous methods of managing renal stones have an increased rate of complications compared with ureteroscopy. In patients with complex medical histories, upper urinary tract calculi <4 cm can be safely and effectively managed using a staged retrograde endoscopic approach.
authors.affiliation: Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA. dricchiuti@yahoo.com
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ricchiuti
authors.forename: Marc C
authors.initials: MC
authors.lastname: Smaldone
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Jacobs
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Smaldone
authors.forename: Stephen V
authors.initials: SV
authors.lastname: Jackman
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Averch
mesh_terms: D004867:Equipment Design; D005260:Female; D005336:Fiber Optic Technology; D006801:Humans; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D020709:Ureteroscopes; D018666:Ureteroscopy / Q000379:methods*; D052878:Urolithiasis / Q000175:diagnosis / Q000628:therapy*