THE TREATMENT OF URETERIC STONES

by

C/Associate Professor Chng Hong Chee,

MBBS, MMed(Surgery), FRACS, FAMS,

Senior Consultant Surgeon & Urologist,

Chief of Surgery,

Toa Payoh Hospital, Singapore 1129.

Ureteric colic is one of the most common causes of abdominal pain seen today.

The initial investigations for the confirmation of the diagnosis include urine for microscopy, a plain Xray Abdomen (KUB) and subsequently an intravenous urogram.

Once the diagnosis is reached, relief of pain is necessary. Traditionally, pethidine or morphine is required. Recently, Tramal or injection Voltaren has been used. The pain relief is withheld until reasonable concensus with regard to diagnosis is reached.

The classical indications for intervention are well known & include the following:

* Presence of infection

* Presence of obstruction

* Persistent colic with no advancement of the stone

* A stone more than 0.5 cm in diameter

The classical indications have recently been modified because of the advent of new technology & the high expectations of today's patients.

These include:

* Surgery

* Percutaneous surgery

* Ureteroscopy with Electrohydraulic lithotripsy(EHL), Ultrasound lithotripsy,

Laserlithotripsy, Electro-mechanical Impactor lithotripsy, & Lithoclast lithotripsy.

* ESWL

* Spontaneous passage

There has been a shift away from the classical operation of ureterolithotomy. This has been due mainly to the prolonged hospitalisation of at least 10 days & being laid off from work for approximately 3 weeks. It is regarded as being too invasive.

On the other hand , the non-invasive method of treatment of ureteric calculi by ESWL has met with some problems. The role of ESWL in the management of renal calculi is well known. Its use in the treatment of ureteric stones is perhaps less well defined. Experience worldwide has shown difficulty in fragmentation especially with impacted calculi.

Presently the state of the art is such that ureteroscopy with fragmentation by laser or EHL

is the method of choice for lower as well as proximal ureteric stones. It has an especially useful role for impacted ureteric stones. These methods are technological breakthroughs, being safe & effective. Laser causes disintegration of ureteric stones without injury to tissues whilst EHL is equally effective & safe if not applied directly to the ureter. It has to be used in conjunction with a small calibre rigid ureteroscope which renders dilatation of the ureteric orifice unnecessary. Dilatation with its complications is necessary in conventional ureteroscopy. In our experience, we have had over 95% of success & with minimal & insignificant complications with these new innovative techniques.