title: Combined electrohydraulic and holmium: YAG laser ureteroscopic nephrolithotripsy of large (>2 cm) renal calculi.
abstract: Percutaneous nephrolithotripsy (PCL) is a standard treatment for renal calculi >2 cm. Modern flexible ureteroscopes and accessories employing the complementary effects of electrohydraulic lithotripsy (EHL) and Ho:YAG laser lithotrites can treat these renal calculi in a minimally invasive fashion with similar or superior results.
  
  
  OBJECTIVE
  To assess the safety and efficacy of ureteroscopic nephrolithotripsy monotherapy for the management of >2 cm renal calculi in the community setting.
  
  
  METHODS
  Fifty nine patients with 63 renal calculi ranging from 20 to 97 mm (mean 44 mm) in length and 175 to 3300 mm2 (mean 728 mm2) area underwent staged ureteroscopic nephrolithotripsy monotherapy. Obesity (BMI > 30) was present in 54% and 19% were morbidly obese (BMI > 40). An infectious etiology was present in 49% and hard stone components in 89%. All patients presented with hematuria, pain, and/or recurrent urinary tract infection (UTI). Lithotripsy was performed with a single deflection flexible ureteroscope and predominantly EHL. Laser drilling was employed (n = 6) to weaken very hard stones prior to EHL. Low intrarenal pressure was maintained by continuous bladder drainage and placement of a stiff safety wire. Visibility was maintained using manual pulsatile irrigation.
  
  
  RESULTS
  All patients were rendered pain and infection-free. No patient required a blood transfusion and there was no change in serum creatinine. Mobile stone-free status was achieved in 60/63 (95%) with a mean of 1.7 nephrolithotripsy stages and 0.38 secondary or ancillary procedures. Outpatient management was sufficient for 121/131 (92%) of the procedures. Operative time averaged 46 min/stage and 79 min/calculus. Complications included endotoxic shock (3), fever (5), ureteral fragments requiring treatment (11), delayed extubation (2), delayed pneumonia (1), and urinary retention (1).
  
  
  CONCLUSIONS
  Staged ureteroscopic nephrolithotripsy of large renal calculi is feasible with low morbidity and stone clearance rates that compare favorably with PCL. It has largely replaced PCL at this institution.
authors.affiliation: Department of Urology, University of Hawaii John A. Burns School of Medicine, Kaiser Medical Center, 3288 Moanalua Road, Honolulu, HI 96819, USA.
authors.forename: Albert J
authors.initials: AJ
authors.lastname: Mariani