Endourology Endourology Endourology

Benign Prostatic Hyperplasia

Introduction

Benign prostatic hyperplasia (BPH), often called simply “prostate enlargement” is a common condition in men of middle and advanced age. Studies demonstrates that the pathological process can start already between the ages of 30 and 40 years old and, finally, approximately 90% of elderly men suffer from BPH at the age of 80. Therefore, this condition increases with age resulting in a gradual progression and often leading to a worsening in micturition that can affect the quality of life.

Symptoms of BPH can develop gradually. They include:

  • Frequency or frequent urination. It is one of the most common and bothers most of the patients. When it occurs at night is called nocturia.
  • Reduction of the urine flow (force of urination). Typically, the patients observe that the urine flows near to the body so that, sometimes, the urination results in wetting their shoes. It is particularly troublesome because many men with BPH are forced to urinate sitting down in the basin in an attempt to avoid wetting themselves.
  • Urgency or urgent urination. Many patients complain that they have an urgent desire to urinate that cannot be held and, sometimes, on the way to the toilet they may also lose some urine.
    The emergence of the so-called teardrop bladder is usually a result of reduction of the urine flow. In healthy individuals the urination can be voluntary stopped without any loss of urine, thus remaining dry. On the contrary with a BPH, urination may continue for a few seconds forming drops of urine despite the will of the person to control the process.
  • Urinary hesitation. Many patients describe struggling over the toilet to start urination that comes only after a long wait. Other patients use the sound of running water, for example opening the tap, in order to relax and urinate. Sometimes they complain pain and can see also some blood colouring the urine.
  • Feeling of incomplete emptying of the bladder. Many people feel that after urination their bladder is not empty and there is residual urine in it.
  • Acute urinary retention. It is a dangerous and dramatic symptom of hyperplasia, resulting in an inability to void despite the full bladder. The patient feels great discomfort and pain in the lower abdomen. The condition requires immediate treatment by a medical specialist with the placement into the bladder of a transurethral catheter or a suprapubic drainage of urine.

BPH can be treated either conservatively or surgically. In most patients the initial treatment proceeds conservatively with the administration of drugs. Surgical treatment follows when the conservative treatment fails. Only the urologist is able to set the appropriate “indication” for each case.
The surgery includes the excision, or rather, the removal of the obstructive central part of the prostate (the prostatic adenoma) and it is called prostatectomy.

With this purpose, our department offers 3 different techniques to the patient: transurethral resection of the prostate (TURP), laser treatment and laparoscopic simple prostatectomy.

The photoselective vaporization of the prostate (PVP) with greenlight laser or the vapo-resection with thulium laser are recently advanced methods of prostatectomy for the treatment of BPH. Similarly to TURP, these endoscopic methods does not require any skin incision and the introduction of the tools is done through the urethra.The difference is in the removal of the prostatic adenoma with a different type of energy using a laser.

An important advantage of this method is the increased potential for intraoperative hemostasis, which is useful especially in patients receiving anticoagulant therapy with an increased risk for bleeding. In addition, the inserted catheter can be removed on the first day after the surgery.

The TURP is the current gold standard for the treatment of medium size (up to 80g) prostate. This endoscopic procedure is performed by the use of a special tool called resectoscope under control vision and inserted through the urethra till the prostate that can be resected. The surgery is performed under general or spinal anesthesia. Urinary catheter is placed after the surgery and removed on 2-3 day postoperatively. Normally the patients can be discharged from the hospital and return home after approximately 3-4 days.

Apart from the symptoms, there are significant risks, not always visible, that can seriously jeopardize the health of unsuspecting men. It should be emphasized that the disease is not dangerous at its early stages. Nevertheless, its final evolution can include serious complications.

The obstruction caused by the prostatic hyperplasia prevents urine to find a natural way out, so there is always an amount of urine remaining into the bladder. This “trapped” urine is the source of many problems such as the formation of bladder stones.

Moreover, serious complications such as hydronephrosis, pyelonephritis, and eventually renal failure are also possible. The term hydronephrosis describes the pathological dilatation of the kidney that “swells” due to its inability to expel urine over the prostatic obstruction. This creates a vicious circle in the urinary system. The stagnant urine can become infected and ultimately cause a renal infection called pyelonephritis. Eventually, kidney failure is the most unfortunate but rare condition of the benign prostatic hyperplasia.

Close collaboration with a urologist is necessary in order to early diagnose and treat prostatic hyperplasia, avoiding the above complications.

Laparoscopic simple prostatectomy is an advanced approach for bigger size prostates. It replaces open prostatectomy surgery which has represented the basis for the surgical treatment of BPH for decades. In the case of laparoscopic simple prostatectomy, the surgical incision in the lower part of the abdomen of the patient (unlike open prostatectomy) is avoided: surgery is performed using laparoscopic instruments placed through small 5-10mm incisions.

In the end, one of the incisions is enlarged (about 5cm) in order to get out the removed prostatic tissue. During the surgery a bladder catheter is placed. Usually after 5 days, the catheter is removed and the patient returns back home.

The method has significant advantages compared to the open prostatectomy in terms of blood loss, post-operative pain and mobilization of the patient. It should be noted that this method is indicated to patients with very large prostates in which the performance of the transurethral methods is difficult or impossible.

As for any surgical procedure, there is a possibility of adverse situations after prostatectomy.

In some cases, sudden bleeding may appear even after discharge of the patent. If the bleeding does not stop immediate, the consultation with the treating doctor or a urologist is required. However, the patient should avoid to panic. Usually such bleeding can be controlled conservatively or with the insertion of urethral catheter. In rare cases surgical coagulation of the bleeding vessel may be required.

Another complication is the infection of the urinary tract. It can result in painful urination, sometimes fever and infection of the testicles. Also in this case the patient should contact the treating urologist to receive the appropriate treatment, usually pharmacological.

Some patients (up to 30%) may experience urinary incontinence in the early postoperative period; however, the incidence of late incontinence that persists for more than 6 months is only 0.5%–1% of crucial importance is the question of sexual potency after prostatectomy for BPH.

The answer is that the surgery does not affect the potency unless the patient has erectile dysfunction preoperatively. Nevertheless, it should be emphasized that there is the possibility not to see the sperm with the ejaculation: this is associated with the release of the sperm in the bladder where it is mixed with the urine. In short, the sperm comes out together with the urine. This situation is called “retrograde ejaculation” and there is no reason to believe that the operation has not succeeded.

Urolithiasis (Extracorporeal Shock Wave Lithotripsy)

Introduction

Patients that are not successfully treated with ESWL may be treated by rigid and/ or flexible Ureteroscopy or Percutaneous Nephrolithotripsy.


Our protocol for ESWL is to thoroughly examine the patient before the session with proper imaging, and to obtain a negative urine culture. If there are signs of collecting system distention (hydronephrosis), placing a pigtail before ESWL is considered, as with stones ≈ 2cm. Patients receive analgesia throughout the session to maximize their comfort. Since the beginning of our experience with ESWL, in March 2006 we have treated a large number of patients of Western periphery of Greece and Peloponnese. More than 5.000 sessions have been performed until today.
Extracorporeal shock wave lithotripsy (ESWL) was introduced in 1980, as an alternative, minimally invasive method of urinary stone fragmentation. Early devices required the patient to stay immersed in a water bath in order to obtain better energy transfer to the patient.

Later on, as the technology developed, this was not required, and patients lie comfortably on a bed and the shock generating head is coupled to the patient through a gel filled cushion.

Following the European Urological Association Guidelines, our indications for

  • Stones
  • Proximal ureter
  • Mid ureter
  • Distal stones
  • Occasionally for ureteral stones in all locations >10mm, with a higher probability of retreatment or progression to URS / PCNL

Urolithiasis (Renal Stones)

Introduction

Urinary stones are known since the ancient times and represent one of the main issues in urological practice. The patients with small renal stones are generally asymptomatic or mildly symptomatic unless they pass to the ureters and cause renal colic. The asymptomatic course of the disease can lead to the formation of the bigger renal stones. The latter can lead to the reduction of the affected kidney function and repeated upper urinary tract infections. Therefore, a timely diagnosis and treatment of renal stones is very important to avoid further complications of the disease.

Abdominal ultrasound is the initial imaging tool for the diagnosis of ureteral stones. It could provide information regarding the stone location, stone size and anatomical changes of the kidneys. Plain radiography of kidney, ureter and bladder may provide additional information about stone parameters. Currently, computer tomography with remains the gold standard imaging tool for proper diagnosis of renal calculi. In some cases, contrast enhanced computer tomography (with administration of intravenous contrast regimen) can be used for better depiction of the urinary system.

Important parameters in the management of ureteral stones are the size, number of stones and their composition. The elimination of controlled risk factors and behavioral changes are the initial general recommendations for patients harboring renal stones. Depending on the composition of the stone, oral treatment can be administered for dissolution of the stone. Depending on the size of the stone different minimally invasive procedures are indicated for the treatment of renal stones. Currently open surgeries are performed in only 1-2% of all renal stone cases.

Extracorporeal shock wave lithotripsy

Exytracorporeal shock wave lithotripsy is a method of choice for the treatment of 1-2cm renal stone. But the success of the method depends on many factors including the size, location, composition and hardness of the stone. In addition, in important role predicting the outcomes is the patient’s body mass (i.e obesity). During extracorporeal lithotripsy, the patient lies on a device called Lithotripter. Fluoroscopy is used to identify and target the stone. The shock waves are generated outside the body and directed to the target (in this case stone). The latter leads to the fragmentation of the stone. Thereafter, the fragments are expelled with the urine. The procedure usually does not require any anesthesia. The duration of the procedure is 45-60 minutes. Patients can then go home if no side effects are observed. During the first post-procedural hours patients can have some minor discomfort or bloody urine (hematuria). Serious complications (such as renal trauma) are extremely rare after shock wave lithotripsy and are usually treated conservatively.

Flexible ureteroscopy

Flexible ureteroscopy is another treatment modality for renal stones of 1-2cm size in diameter. This procedure is especially preferred for stones localized in lower calyx. This method is performed by the introduction of a tool called ureteroscope through the urethra and bladder into the ureter. The stone is identified and fragmented or dusted using a laser lithotripsy device. Current lasers allow fragmentation of stones with any composition. The generated fragments are removed by using a special endoscopic basket. In most of the cases stents are placed in the ureters in the end of the surgeries allowing easier passage of the stone fragments. The use of flexible ureteroscope allows to reach renal stone in any localization. The use of ureteroscope by an experienced urologist gives solutions to many problems with minimal burden to the health of the patient. The patient is usually dismissed from the hospital the next day after the surgery. If a ureteral stent is placed during the surgery patients are advised to return in 3-4 weeks for its. The removal procedure is done under local anesthesia, lasts about 5 minutes and is not painful.The main postoperative complications of ureteroscopy are hematuria and urinary tract infection leading to prolonged hospitalization. Symptoms such as urinary frequency, minor hematuria or minor discomfort during urination in postoperative period are generally associated with ureteral stents and pass when the stents are removed.

Percutaneous lithotripsy

Percutaneous nephrolithotripsy is the preferred treatment modality for renal stones > 2cm. The procedure is fast and is associated with the best stone clearance results. This method is performed by percutaneous puncture of the kidney under fluoroscopic guidance, introduction of special endoscopic wires and placement of a special sheath that provides a channel between the skin and kidneys. Through this channel a tool called nephroscope is introduced, the stone is recognized and disintegrated by the use of ultrasonic lithotripter. The fragments are removed with the aid of an endoscopic forceps.The above instruments method provide solution to renal calculi with minimal burden on the health of the patient and treat successfully even large stones that occupy the entire cavity of the kidney drainage (staghorn stones). Renal stones that have failed conservative or extracorporeal lithotripsy treatment have also indication for percutaneous nephrolithotripsy. The patient is dismissed from the hospital on the fourth day after the surgery. A nephrostomy tube remains in place for the above time period and removed the day of discharge. The removal process takes 1 minute and is not painful. The procedure is associated with a number of complications which in experienced-hands are rare. Complications that might be encountered are bleeding, pneumothorax and infection leading to prolonged hospitalization. Most of the complications are managed conservatively only 1% of patients requiring any additional intervention.

Urolithiasis (Ureteral Stones)

Introduction

Urinary stones are known since the ancient times and represent one of the main issues in urological practice. The stones formed in the kidneys can pass to the ureter at any time causing renal colic. The ureteral stones lead to the disturbance of urine flow from the kidney to the bladder resulting in dilation of the renal collecting system. Depending on the location of the stone in the ureter and level of obstruction it is characterized by strong pain in the projection of affected kidney, ureter and bladder. It can be associated with frequent and painful urination, nausea and vomiting, and in some cases with fever.

Abdominal ultrasound is the initial imaging tool for the diagnosis of ureteral stones. It could provide information regarding the stone location, stone size and presence of kidney obstruction. Plain radiography of kidney, ureter and bladder may provide additional information about stone parameters. Currently, computer tomography with remains the gold standard imaging tool for proper diagnosis of ureteral calculi. In some cases, contrast enhanced computer tomography (with administration of intravenous contrast regimen) can be used for better depiction of the urinary system.

Important parameters in the management of ureteral stones are the size, number of stones and their composition. Stones measuring up to 6mm in diameter are frequently expelled automatically. Medication can also accelerate the elimination of ureteral stones and can be administered to patients without contraindications. Depending on the composition of the stone, oral treatment can be administered for dissolution of the stone. In cases of bigger ureteral stones or failure of conservative therapy the following minimally invasive approaches can considered:

Extracorporeal shock wave lithotripsy

The majority of patients have an indication for extracorporeal lithotripsy. But the success of the method depends on many factors including the size, location, composition and hardness of the stone. In addition, in important role predicting the outcomes is the patient’s body mass (i.e obesity). During extracorporeal lithotripsy, the patient lies on a device called Lithotripter. Fluoroscopy is used to identify and target the stone. The shock waves are generated outside the body and directed to the target (in this case stone). The latter leads to the fragmentation of the stone. Thereafter, the fragments are expelled with the urine. The procedure usually does not require any anesthesia. The duration of the procedure is 45-60 minutes. Patients can then go home if no side effects are observed. During the first post-procedural hours patients can have some minor discomfort or bloody urine (hematuria). Serious complications are extremely rare after shock wave lithotripsy.

Endoscopic lithotripsy

This method is performed by the introduction of a tool called ureteroscope through the urethra and bladder into the ureter. The stone is identified and fragmented or dusted using a laser lithotripsy device.The generated fragments are removed by using a special endoscopic basket. In most of the cases stents are placed in the ureters in the end of the surgeries allowing easier passage of the stone fragments. It is worth noting that there are two types ureteroscopes depending on the flexibility of the instrument. These types include the rigid and flexible ureteroscopes. The flexible ureteroscope can also be used to treat kidney stones. The use of ureteroscope by an experienced urologist gives solutions to many problems with minimal burden to the health of the patient. Stones that have failed conservative or extracorporeal lithotripsy treatment are prime indications for endoscopic lithotripsy. Practically, stone in any location (and kidney stone) may be treated with this method. The patient is usually dismissed from the hospital the next day after the surgery. If a ureteral stent is placed during the surgery patients are advised to return in 3-4 weeks for its. The removal procedure is done under local anesthesia, lasts about 5 minutes and is not painful.The main postoperative complications of ureteroscopyare hematuria and urinary tract infection leading to prolonged hospitalization. Symptoms such as urinary frequency, minor hematuria or minor discomfort during urination in postoperative period are generally associated with ureteral stents and pass when the stents are removed.

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Benign Prostatic Hyperplasia

Introduction

Benign prostatic hyperplasia (BPH), often called simply “prostate enlargement” is a common condition in men of middle and advanced age. Studies demonstrates that the pathological process can start already between the ages of 30 and 40 years old and, finally, approximately 90% of elderly men suffer from BPH at the age of 80. Therefore, this condition increases with age resulting in a gradual progression and often leading to a worsening in micturition that can affect the quality of life.

Symptoms of BPH can develop gradually. They include:

  • Frequency or frequent urination. It is one of the most common and bothers most of the patients. When it occurs at night is called nocturia.
  • Reduction of the urine flow (force of urination). Typically, the patients observe that the urine flows near to the body so that, sometimes, the urination results in wetting their shoes. It is particularly troublesome because many men with BPH are forced to urinate sitting down in the basin in an attempt to avoid wetting themselves.
  • Urgency or urgent urination. Many patients complain that they have an urgent desire to urinate that cannot be held and, sometimes, on the way to the toilet they may also lose some urine.
    The emergence of the so-called teardrop bladder is usually a result of reduction of the urine flow. In healthy individuals the urination can be voluntary stopped without any loss of urine, thus remaining dry. On the contrary with a BPH, urination may continue for a few seconds forming drops of urine despite the will of the person to control the process.
  • Urinary hesitation. Many patients describe struggling over the toilet to start urination that comes only after a long wait. Other patients use the sound of running water, for example opening the tap, in order to relax and urinate. Sometimes they complain pain and can see also some blood colouring the urine.
  • Feeling of incomplete emptying of the bladder. Many people feel that after urination their bladder is not empty and there is residual urine in it.
  • Acute urinary retention. It is a dangerous and dramatic symptom of hyperplasia, resulting in an inability to void despite the full bladder. The patient feels great discomfort and pain in the lower abdomen. The condition requires immediate treatment by a medical specialist with the placement into the bladder of a transurethral catheter or a suprapubic drainage of urine.

BPH can be treated either conservatively or surgically. In most patients the initial treatment proceeds conservatively with the administration of drugs. Surgical treatment follows when the conservative treatment fails. Only the urologist is able to set the appropriate “indication” for each case.
The surgery includes the excision, or rather, the removal of the obstructive central part of the prostate (the prostatic adenoma) and it is called prostatectomy.

With this purpose, our department offers 3 different techniques to the patient: transurethral resection of the prostate (TURP), laser treatment and laparoscopic simple prostatectomy.

The photoselective vaporization of the prostate (PVP) with greenlight laser or the vapo-resection with thulium laser are recently advanced methods of prostatectomy for the treatment of BPH. Similarly to TURP, these endoscopic methods does not require any skin incision and the introduction of the tools is done through the urethra.The difference is in the removal of the prostatic adenoma with a different type of energy using a laser.

An important advantage of this method is the increased potential for intraoperative hemostasis, which is useful especially in patients receiving anticoagulant therapy with an increased risk for bleeding. In addition, the inserted catheter can be removed on the first day after the surgery.

The TURP is the current gold standard for the treatment of medium size (up to 80g) prostate. This endoscopic procedure is performed by the use of a special tool called resectoscope under control vision and inserted through the urethra till the prostate that can be resected. The surgery is performed under general or spinal anesthesia. Urinary catheter is placed after the surgery and removed on 2-3 day postoperatively. Normally the patients can be discharged from the hospital and return home after approximately 3-4 days.

Apart from the symptoms, there are significant risks, not always visible, that can seriously jeopardize the health of unsuspecting men. It should be emphasized that the disease is not dangerous at its early stages. Nevertheless, its final evolution can include serious complications.

The obstruction caused by the prostatic hyperplasia prevents urine to find a natural way out, so there is always an amount of urine remaining into the bladder. This “trapped” urine is the source of many problems such as the formation of bladder stones.

Moreover, serious complications such as hydronephrosis, pyelonephritis, and eventually renal failure are also possible. The term hydronephrosis describes the pathological dilatation of the kidney that “swells” due to its inability to expel urine over the prostatic obstruction. This creates a vicious circle in the urinary system. The stagnant urine can become infected and ultimately cause a renal infection called pyelonephritis. Eventually, kidney failure is the most unfortunate but rare condition of the benign prostatic hyperplasia.

Close collaboration with a urologist is necessary in order to early diagnose and treat prostatic hyperplasia, avoiding the above complications.

As for any surgical procedure, there is a possibility of adverse situations after prostatectomy.

In some cases, sudden bleeding may appear even after discharge of the patent. If the bleeding does not stop immediate, the consultation with the treating doctor or a urologist is required. However, the patient should avoid to panic. Usually such bleeding can be controlled conservatively or with the insertion of urethral catheter. In rare cases surgical coagulation of the bleeding vessel may be required.

Another complication is the infection of the urinary tract. It can result in painful urination, sometimes fever and infection of the testicles. Also in this case the patient should contact the treating urologist to receive the appropriate treatment, usually pharmacological.

Some patients (up to 30%) may experience urinary incontinence in the early postoperative period; however, the incidence of late incontinence that persists for more than 6 months is only 0.5%–1% of crucial importance is the question of sexual potency after prostatectomy for BPH.

Urolithiasis (Extracorporeal Shock Wave Lithotripsy)

Introduction

Patients that are not successfully treated with ESWL may be treated by rigid and/ or flexible Ureteroscopy or Percutaneous Nephrolithotripsy.

Our protocol for ESWL is to thoroughly examine the patient before the session with proper imaging, and to obtain a negative urine culture. If there are signs of collecting system distention (hydronephrosis), placing a pigtail before ESWL is considered, as with stones ≈ 2cm. Patients receive analgesia throughout the session to maximize their comfort. Since the beginning of our experience with ESWL, in March 2006 we have treated a large number of patients of Western periphery of Greece and Peloponnese. More than 5.000 sessions have been performed until today.
Extracorporeal shock wave lithotripsy (ESWL) was introduced in 1980, as an alternative, minimally invasive method of urinary stone fragmentation. Early devices required the patient to stay immersed in a water bath in order to obtain better energy transfer to the patient.

Later on, as the technology developed, this was not required, and patients lie comfortably on a bed and the shock generating head is coupled to the patient through a gel filled cushion.

Following the European Urological Association Guidelines, our indications for

  • Stones
  • Proximal ureter
  • Mid ureter
  • Distal stones
  • Occasionally for ureteral stones in all locations >10mm, with a higher probability of retreatment or progression to URS / PCNL

Urolithiasis (Renal Stones)

Introduction

Urinary stones are known since the ancient times and represent one of the main issues in urological practice. The patients with small renal stones are generally asymptomatic or mildly symptomatic unless they pass to the ureters and cause renal colic. The asymptomatic course of the disease can lead to the formation of the bigger renal stones. The latter can lead to the reduction of the affected kidney function and repeated upper urinary tract infections. Therefore, a timely diagnosis and treatment of renal stones is very important to avoid further complications of the disease.

Abdominal ultrasound is the initial imaging tool for the diagnosis of ureteral stones. It could provide information regarding the stone location, stone size and anatomical changes of the kidneys. Plain radiography of kidney, ureter and bladder may provide additional information about stone parameters. Currently, computer tomography with remains the gold standard imaging tool for proper diagnosis of renal calculi. In some cases, contrast enhanced computer tomography (with administration of intravenous contrast regimen) can be used for better depiction of the urinary system.

Important parameters in the management of ureteral stones are the size, number of stones and their composition. The elimination of controlled risk factors and behavioral changes are the initial general recommendations for patients harboring renal stones. Depending on the composition of the stone, oral treatment can be administered for dissolution of the stone. Depending on the size of the stone different minimally invasive procedures are indicated for the treatment of renal stones. Currently open surgeries are performed in only 1-2% of all renal stone cases.

Extracorporeal shock wave lithotripsy

Exytracorporeal shock wave lithotripsy is a method of choice for the treatment of 1-2cm renal stone. But the success of the method depends on many factors including the size, location, composition and hardness of the stone. In addition, in important role predicting the outcomes is the patient’s body mass (i.e obesity). During extracorporeal lithotripsy, the patient lies on a device called Lithotripter. Fluoroscopy is used to identify and target the stone. The shock waves are generated outside the body and directed to the target (in this case stone). The latter leads to the fragmentation of the stone. Thereafter, the fragments are expelled with the urine. The procedure usually does not require any anesthesia. The duration of the procedure is 45-60 minutes. Patients can then go home if no side effects are observed. During the first post-procedural hours patients can have some minor discomfort or bloody urine (hematuria). Serious complications (such as renal trauma) are extremely rare after shock wave lithotripsy and are usually treated conservatively.

Flexible ureteroscopy

Flexible ureteroscopy is another treatment modality for renal stones of 1-2cm size in diameter. This procedure is especially preferred for stones localized in lower calyx. This method is performed by the introduction of a tool called ureteroscope through the urethra and bladder into the ureter. The stone is identified and fragmented or dusted using a laser lithotripsy device. Current lasers allow fragmentation of stones with any composition. The generated fragments are removed by using a special endoscopic basket. In most of the cases stents are placed in the ureters in the end of the surgeries allowing easier passage of the stone fragments. The use of flexible ureteroscope allows to reach renal stone in any localization. The use of ureteroscope by an experienced urologist gives solutions to many problems with minimal burden to the health of the patient. The patient is usually dismissed from the hospital the next day after the surgery. If a ureteral stent is placed during the surgery patients are advised to return in 3-4 weeks for its. The removal procedure is done under local anesthesia, lasts about 5 minutes and is not painful.The main postoperative complications of ureteroscopy are hematuria and urinary tract infection leading to prolonged hospitalization. Symptoms such as urinary frequency, minor hematuria or minor discomfort during urination in postoperative period are generally associated with ureteral stents and pass when the stents are removed.

Percutaneous lithotripsy

Percutaneous nephrolithotripsy is the preferred treatment modality for renal stones > 2cm. The procedure is fast and is associated with the best stone clearance results. This method is performed by percutaneous puncture of the kidney under fluoroscopic guidance, introduction of special endoscopic wires and placement of a special sheath that provides a channel between the skin and kidneys. Through this channel a tool called nephroscope is introduced, the stone is recognized and disintegrated by the use of ultrasonic lithotripter. The fragments are removed with the aid of an endoscopic forceps.The above instruments method provide solution to renal calculi with minimal burden on the health of the patient and treat successfully even large stones that occupy the entire cavity of the kidney drainage (staghorn stones). Renal stones that have failed conservative or extracorporeal lithotripsy treatment have also indication for percutaneous nephrolithotripsy. The patient is dismissed from the hospital on the fourth day after the surgery. A nephrostomy tube remains in place for the above time period and removed the day of discharge. The removal process takes 1 minute and is not painful. The procedure is associated with a number of complications which in experienced-hands are rare. Complications that might be encountered are bleeding, pneumothorax and infection leading to prolonged hospitalization. Most of the complications are managed conservatively only 1% of patients requiring any additional intervention.

Urolithiasis (Ureteral Stones)

Introduction

Urinary stones are known since the ancient times and represent one of the main issues in urological practice. The stones formed in the kidneys can pass to the ureter at any time causing renal colic. The ureteral stones lead to the disturbance of urine flow from the kidney to the bladder resulting in dilation of the renal collecting system. Depending on the location of the stone in the ureter and level of obstruction it is characterized by strong pain in the projection of affected kidney, ureter and bladder. It can be associated with frequent and painful urination, nausea and vomiting, and in some cases with fever.

Abdominal ultrasound is the initial imaging tool for the diagnosis of ureteral stones. It could provide information regarding the stone location, stone size and presence of kidney obstruction. Plain radiography of kidney, ureter and bladder may provide additional information about stone parameters. Currently, computer tomography with remains the gold standard imaging tool for proper diagnosis of ureteral calculi. In some cases, contrast enhanced computer tomography (with administration of intravenous contrast regimen) can be used for better depiction of the urinary system.

Important parameters in the management of ureteral stones are the size, number of stones and their composition. Stones measuring up to 6mm in diameter are frequently expelled automatically. Medication can also accelerate the elimination of ureteral stones and can be administered to patients without contraindications. Depending on the composition of the stone, oral treatment can be administered for dissolution of the stone. In cases of bigger ureteral stones or failure of conservative therapy the following minimally invasive approaches can considered:

Extracorporeal shock wave lithotripsy

The majority of patients have an indication for extracorporeal lithotripsy. But the success of the method depends on many factors including the size, location, composition and hardness of the stone. In addition, in important role predicting the outcomes is the patient’s body mass (i.e obesity). During extracorporeal lithotripsy, the patient lies on a device called Lithotripter. Fluoroscopy is used to identify and target the stone. The shock waves are generated outside the body and directed to the target (in this case stone). The latter leads to the fragmentation of the stone. Thereafter, the fragments are expelled with the urine. The procedure usually does not require any anesthesia. The duration of the procedure is 45-60 minutes. Patients can then go home if no side effects are observed. During the first post-procedural hours patients can have some minor discomfort or bloody urine (hematuria). Serious complications are extremely rare after shock wave lithotripsy.

Endoscopic lithotripsy

This method is performed by the introduction of a tool called ureteroscope through the urethra and bladder into the ureter. The stone is identified and fragmented or dusted using a laser lithotripsy device.The generated fragments are removed by using a special endoscopic basket. In most of the cases stents are placed in the ureters in the end of the surgeries allowing easier passage of the stone fragments. It is worth noting that there are two types ureteroscopes depending on the flexibility of the instrument. These types include the rigid and flexible ureteroscopes. The flexible ureteroscope can also be used to treat kidney stones. The use of ureteroscope by an experienced urologist gives solutions to many problems with minimal burden to the health of the patient. Stones that have failed conservative or extracorporeal lithotripsy treatment are prime indications for endoscopic lithotripsy. Practically, stone in any location (and kidney stone) may be treated with this method. The patient is usually dismissed from the hospital the next day after the surgery. If a ureteral stent is placed during the surgery patients are advised to return in 3-4 weeks for its. The removal procedure is done under local anesthesia, lasts about 5 minutes and is not painful.The main postoperative complications of ureteroscopyare hematuria and urinary tract infection leading to prolonged hospitalization. Symptoms such as urinary frequency, minor hematuria or minor discomfort during urination in postoperative period are generally associated with ureteral stents and pass when the stents are removed.

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