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Access To Lower Pole Renal Stones During Ureteroscopy With Laser Lithotripsy
Christopher Hoover, MD, Jessica E. Kreshover, MD, MS, Richard K. Babayan, MD, David S. Wang, MD.
Boston University Medical Center, Boston, MA, USA.

Background: Ureteroscopy has become an increasingly more common modality for treatment of nephrolithiasis. Optimal treatment modality for lower pole stones however, has remained debatable. With improvements in surgical equipment, use of ureteroscopy for lower pole stones has become more common. We sought to identify the incidence of ability to access radiographically diagnosed lower pole stones via ureteroscopic approach and further to attempt to characterize the difficulty with access and treatment success rate.
Methods: A retrospective chart review was performed on all ureteroscopies performed by a single surgeon from August 2003 to May 2008 for renal and ureteral stones. Renal units were examined separately to include bilateral cases. Only renal units with CT diagnosed lower pole stones were included. Renal units were excluded for procedures performed for encrusted stents. Operative notes were examined to determine whether lower pole was accessed, if access was described as “difficult”, and whether stone was directly visualized. Post operative imaging was noted for presence or absence of fragments >2mm to characterize treatment success. Quantitative analysis was performed.
Results: A total of 113 ureteroscopy cases for lower pole stones were identified. In one hundred seven (94.7%) cases the lower pole was accessed despite 31.9% being described as very difficult to access. In 92.9% of the cases, the stone was directly visualized in the lower pole. Cases were divided into two cohorts: preoperative stone size of ≤ 10mm and stone size 11-20mm. Patients are routinely followed with KUB and renal ultrasound at six weeks post-operatively. Overall treatment success rate was 64.4%. For stone size 11-20mm, 11 of 24 patients (45.8%) had no fragments visualized. For stone size 10mm and less, 48 of 69 patients (70.0%) had no residual stone seen. Of the 21 patients in this subset with stones remaining, 11 (52.4%) had noted inability to completely access the lower pole during ureteroscopy. The remaining cases had residual stone fragments as a function of aberrant anatomy or submucosal location.
Conclusions: With improvement in ureteroscopic equipment, lower pole ureteroscopy has become more common. Despite access frequently being difficult, the lower pole is able to be accessed for stone treatment almost 93% of the time and has success in stone treatment and clearance.


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