May PC et al, 2018: The Morbidity of Ureteral Strictures in Patients with Prior Ureteroscopic Stone Surgery: Multi-Institutional Outcomes.
May PC, Hsi RS, Tran HH, Stoller M, Chew BH, Chi T, Usawachintachit M, Duty BD, Gore JL, Harper JD.
Department of Urology, University of Washington, Seattle, Washington.
Department of Urology, University of California, San Francisco, San Francisco, California.
Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Department of Urologic Sciences, University of British Columbia, Vancouver, Canada .
Department of Urology, Oregon Health and Science University, Portland, Oregon.
Purpose Nephrolithiasis is an increasingly common ailment in the United States. Ureteroscopic management has supplanted shockwave lithotripsy as the most common treatment of upper tract stone disease. Ureteral stricture is a rare but serious complication of stone disease and its management. The impact of new technologies and more widespread ureteroscopic management on stricture rates is unknown. We describe our experience in managing strictures incurred following ureteroscopy for upper tract stone disease. Materials and methods Records for patients managed at 4 tertiary care centers between December 2006 and October 2015 with the diagnosis of ureteral stricture following ureteroscopy for upper tract stone disease were retrospectively reviewed. Study outcomes included number and type (endoscopic, reconstructive, or nephrectomy) of procedures required to manage stricture. Results Thirty-eight patients with 40 ureteral strictures following URS for upper tract stone disease were identified. Thirty-five percent of patients had hydronephrosis or known stone impaction at the time of initial URS, and 20% of cases had known ureteral perforation at the time of initial URS. After stricture diagnosis, the mean number of procedures requiring sedation or general anesthesia performed for stricture management was 3.3 ± 1.8 (range 1-10). Eleven strictures (27.5%) were successfully managed with endoscopic techniques alone, 37.5% underwent reconstruction, 10% had a chronic stent/nephrostomy, and 10 (25%) required nephrectomy. Conclusions The surgical morbidity of ureteral strictures incurred following ureteroscopy for stone disease can be severe, with a low success rate of endoscopic management and a high procedural burden that may lead to nephrectomy. Further studies that assess specific technical risk factors for ureteral stricture following URS are needed.
J Endourol. 2018 Jan 12. doi: 10.1089/end.2017.0657. [Epub ahead of print]
This report is not directly associated with SWL but shows the complexity of strictures as a complication to URS. The frequency of strictures in the presented material is not given, but literature data show that URS might result in stricture formation in up to 4% of the patients.
Although the occurrence of strictures after URS is relatively low, the development of a stricture might require a series of demanding surgical procedures. From the article the following information can be extracted:
Chronic diversion 10%
Endoscopic solution 28%
These notations give support to the use of non-invasive treatment of ureteral stones.
Impaction of stone fragments in the ureter is occasionally seen following SWL, but stricture complications in patients treated with SWL are sparsely reported in the literature and my own experience, from thousands of patients in whom SWL had been used for removal of ureteral stones, is that stricture is not a common problem and probably seen at frequencies much lower than that following URS.