457 Vol.

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No. 2
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Spring 2012
| UROLOGY JOURNAL
2
nd
Department of Urol-
ogy, Sisli Etfal Training
and Research Hospital,
Istanbul, Turkey
Orhan Tanriverdi, Mesrur Selcuk Silay, Mustafa Kadihasanoglu, Mustafa Aydin, Muammer
Kendirci, Cengiz Miroglu
Revisiting the Predictive Factors for Intra-Op-
erative Complications of Rigid Ureteroscopy
A 15-Year Experience
Corresponding Author:
Mesrur Selcuk Silay, MD
Sisli Etfal Egitim ve Ara-
stirma Hastanesi, 2. Uroloji
Klinigi, 34360, Istanbul,
Turkey
Tel: +90 212 231 2209
Fax: +90 212 233 9876
E-mail: selcuksilay@gmail.
com
Received August 2011
Accepted October 2011
Endourology and Stone Disease
Purpose: To revise the predictive factors for intra-operative complications of rigid
ureteroscopy in the treatment of ureteral calculi.
Materials and Methods: During a 15-year period (1993 to 2008), a total oI 1496
consecutive patients who had undergone 1660 ureteroscopy procedures were retro-
spectively reviewed. After exclusion of the cases for diagnostic purposes, diseases
other than ureteral calculi, and repeated ureteroscopy procedures, 1189 patients were
left as the study population. Those patients were then divided into two groups based
on the presence oI the complications: complicationpositive (group 1, n 57) and
complicationnegative (group 2, n 1132). Both groups were statistically compared
regarding patients age and gender, stone surface area, lateralization and localization
of the stone, impaction of the stone, type of the ureteroscope, necessity of ureteral
orifce dilation, and use oI a catheter during and aIter the procedure. Furthermore, the
effect of leaving the fragmented stones in situ small enough to pass spontaneously
(break`n`leave) on occurring oI the complications has been investigated.
Results: The complication rate was recorded as 4.7. Success rate aIter a single in-
tervention was 86.3, whereas increased to 94.1 aIter ancillary procedures. Stone
surface area, lateralization, and type of lithotripter used were comparable between
the groups, but impacted stones and the stones located at the upper ureters were as-
sociated with signifcantly increased complication rates. Furthermore, signifcantly
less complication has been observed in cases where we performed breaknleave.
Furthermore, multivariate analysis revealed that stone impaction and failure to ad-
here to the breaknleave principle were the independent predictors of occurring
of the complications.
Conclusion: Ureteroscopy is safe and effective in the treatment of ureteral calculi.
Careful attention for the patients having a potential for occurrence of the complica-
tions and selection of the techniques are of importance for reducing untoward events.
Keywords: ureteroscopy, complications, retrospective studies, ureteral calculi, lith-
otripsy
458
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Endourology and Stone Disease
INTRODUCTION
T
echnical advances in the design of uretero-
scopes have encouraged urologists for the
compact use oI ureteroscopy (URS) either
for the treatment of ureteral calculi or for some
diagnostic approaches. Continuously, evolving
fberoptic visualization, refnements in fexibility,
downsizing oI the devices, use oI fuoroscopy, var-
ious baskets and stents, and improvements in the
ability of stone fragmentation have broadened the
indications of URS and upgraded this procedure
almost as the frst-line treatment choice Ior every
location of the collecting system of the urinary
tract. The competitions among URS, extracorpore-
al shock wave lithotripsy (SWL), retrograde intra-
renal surgery, and percutaneous nephrolithotomy
(PNL) Ior the urinary tract calculi have been the
subject of numerous publications in the last dec-
ade, maintaining the debate among urologists.
(1-3)
Unfortunately, surgical misadventures may still
occur, some of which have lasting consequences.
The nature of the ureteroscopic complications is
well-known, but the predictive factors are still a
question that has yet to be clearly elucidated. Care-
ful attention to the selection of the instruments and
techniques are of importance for reducing unto-
ward events related to ureteroscopic procedures.
Furthermore, the ultimate technologies are still not
available in the majority of the urological centers
in developing countries that make rigid or semi-
rigid URS the best cost-effective option for the
urologists. Frankly, patients having a potential for
occurrence of the complications should be well-
discriminated and addressed to different treatment
modalities, such as SWL, PNL, laparoscopy, or
multimodal approaches. Our aim is to report the
predictive factors related to the occurrence of intra-
operative complications during URS procedures in
the treatment of ureteral calculi.
MATERIALS AND METHODS
During a 15-year period (1993 to 2008), a total
oI 1496 consecutive patients who had undergone
1660 URS procedures were retrospectively ana-
lyzed. After exclusion of the cases for diagnostic
purposes, diseases other than ureteral calculi, and
repeated URS procedures, 1189 patients were left
as the study population.
Analysis was focused on intra-operative compli-
cations and possible predictive factors. The study
population was divided into two groups based on
the presence of the complications: Complication
positive (group 1, n 57) and complicationnega-
tive (group 2, n 1132). Recorded intra-operative
complications were mucosal injury, mucosal ever-
sion, ureteral perforation, ureteral avulsion, he-
maturia, and rupture of the basket catheter inside
the ureter (Table 1). Although the adverse events,
such as push-back of the stone towards the kidney
were included in the analysis of the risk factors
for the complications, they were primarily de-
fned as treatment Iailures and not considered as
a complication of the procedure.
(4)
Mucosal injury
was defned as any mucosal tears or Ialse-route
without the perforation of the ureter. The presence
of visible periureteral fatty tissue and/or contrast
extravasation was considered as evidence of com-
plete ureteral perforation. Hematuria was usually
minor and occurred in most of the patients, but was
only considered as a complication when caused a
diIfculty in the visibility and necessitated the ter-
mination of the procedure.
(5)
Comparative parameters were as follows: pa-
tients age and gender, stone surface area, later-
alization and localization of the stone, impaction
of the stone, type of the ureteroscope, necessity of
ureteral orifce dilation, and use oI a catheter dur-
ing and after the procedure. Furthermore, push-
back of the stone and adhering to the breaknleave
policy were also evaluated for whether they have
an impact on occurring of the complications.
Stones located below the pelvic brim were called
as distal or lower and above the pelvic brim were
called as proximal or upper. Breaknleave policy
459 Vol. 9
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Intra-Operative Complications of Ureteroscopy | Tanriverdi et al
was defned as Iragmentation oI the stone small
enough (_ 3 mm) to pass spontaneously, which
was named by our department previously.
(6)
Stone
impaction was defned as the stones causing com-
plete ureteral obstruction on excretory urography,
causing obstructive anuria, or present at the same
site for more than 3 months, or documented to be
impacted in the operative details.
Hospital charts, operative notes, and available
videos of URS procedures were reviewed in or-
der to determine the stone-free status with the
detailed evaluation of radiographic images. Di-
mension of stones were calculated from the radi-
ographic images pre-operatively. Treatment suc-
cess was defned as stone-Iree status aIter a single
intervention. Overall stone-Iree rate was defned
as stone-free status after multimodal intervention
in 3 months. Stone-free status was determined ei-
ther by direct visualization of the involved ureter
or by radiographic follow-up imaging.
If possible, extracted calculi were sent for analy-
sis and additional medical therapy was provided
for recurrent urolithiasis. Patients with positive
urine cultures were treated according to the cul-
ture results at least for 3 days prior to the pro-
cedure. Antibiotic prophylaxis (third-generation
cephalosporin) has been applied Ior all patients
on the day of surgery.
After obtaining signed informed consent, URS
was performed under regional or general anes-
thesia. The patients were placed in the lithotomy
position on an endoscopy table allowing the use
oI fuoroscopy when necessary. Semi-rigid URS
(Circon-Acmi: length 41.5 cm, distal diameter
6.9F) or rigid URS (WolI: length 42 cm, distal di-
ameter 8F) was used depending on the indication
of the procedure, patients characteristics, avail-
ability, and individual surgeon preference.
To minimize heat loss during the operation, 0.9%
NaCl warmed to 37C was used as an irrigant.
Routine cystoscopy and ureteral dilation were not
used and the safety guidewire was inserted under
direct vision. The ureteroscope was passed along
the urethra, then through the ureteral orifce un-
der video monitoring. A 0.035/0.038-inch stand-
ard soIt guidewire, a 4F ureteral catheter, or only
controlled hydrodilation was used to traverse the
intramural ureter.
An electrohydraulic lithotripter was used in the
frst 38 procedures and replaced with pneumatic
lithotripter for the remaining cases. A tempo-
rary postoperative 4F ureteral catheter or 4.6 or
4.8F, 10-to-28 cm double-J (DJ) stent was placed
in some patients to avoid ureteral damage or in
whom were considered for SWL treatment. The
decision of stenting was made according to the
duration of the procedure and the degree of vis-
ible ureteral trauma at the end of the procedure.
Complications were treated with stents, percu-
taneous nephrostomy, or open surgical repair
according to the severity or patients condition.
Patients were discharged within 24 hours unless
complications or comorbidity demanded pro-
longed hospitalization. In patients in whom URS
was not possible due to inability to advance the
ureteroscope into the ureter, a ureteric stent was
placed and URS was performed a few days later
(re-URS).
Univariate analyses, including Chi-Square and
Students t test, were performed to detect any
signifcant association between each oI the vari-
ables (NCSS 2007). Multivariate stepwise logis-
tic regression analysis was used to determine the
predictive factors affecting intra-operative com-
plications. The values were provided as mean
standard deviation (SD). A P value of less than
.05 was considered statistically signifcant.
RESULTS
Mean age oI the patients was 44.89 + 16.37 years
(range, 2 to 90 years) and comparable between
the groups 1 and 2 (46.75 + 14.78 and 44.50 +
13.89 years, respectively, P .363). No statisti-
cal difference was found regarding the male-to-
460
|
Iemale ratio between the groups (63.20/36.80
and 64.50/35.50, respectively, P .831).
The groups were comparable regarding the
lateralization oI the URS (43.90/56.10 and
46.10/53.90 right/leIt, respectively, P .744).
No signifcant diIIerence was Iound with respect
to stone surIace areas (72.04 + 47.38 and 82.95 +
87.05 mm, respectively, P .757). Upper loca-
tion of the ureteral stones was found to be a signif-
icant predictor in occurring of the complications
in the univariate analysis (P .047; Table 2). The
complication rate was 4.7 Ior all the procedures.
The type of the ureteroscope used did not exhibit
any impact on the complication rates (P .537).
Of the intra-operative complications, 51 out of 57
(89.4) were successIully managed by placement
of a DJ catheter, whereas remaining 6 procedures
required open surgery. The reasons for open sur-
gical approach in these cases were ureteral perfo-
ration (n 2), rupture oI the tip oI the basket (n
2), and complete ureteral avulsion (n 2).
The stone-free rate after a single ureteroscopic
intervention (treatment success) was reported as
86.30%. The push-back of the ureteral stone to-
wards the kidney occurred in 99 (8.30) oI the
procedures and was mostly encountered in the
upper ureter (59.50). These patients were di-
rected to SWL for further treatment. Furthermore,
25 (2.10) patients had undergone re-URS due to
the inability in advancing the ureteroscope in the
frst procedure (treatment Iailure). AIter second-
ary procedures, including re-URS, SWL, PNL,
and open surgery, the overall stone-free rate was
recorded as 94.10 at 3 months.
Pneumatic lithotripsy was the most commonly
used method Ior stone Iragmentation (96.81)
Iollowed by electrohydraulic lithotripsy (3.19).
Of the patients who had stones, the breaknleave
policy was perIormed in 19.30 and 48.30 oI
the patients in the groups 1 and 2, respectively
(P .0001). This Iactor was Iound to be a sig-
nifcant predictor Ior occurring oI the complica-
tions in univariate analysis. Another predictor in
the univariate analysis was the impaction of the
stone, which was Iound to be signifcantly high-
er in group 1 compared to group 2 (17.50 and
5.60%, respectively, P .0001).
Balloon dilation oI the ureteral orifce was per-
formed in only 16 out of 1189 URSs when the
ureteroscope could not be advanced. There was
no signifcant diIIerence again with respect to
ureteral orifce dilation (P .680). Ureteral ac-
cess catheters were used in 47.77 oI all proce-
dures to facilitate the advance of the ureteroscope,
whereas hydrodilation oI the ureteral orifce by a
hand-held irrigation pump was enough for ure-
teral access in the rest of the cases. There was
no statistically signifcant diIIerence between the
groups with regards to the rate of using an access
catheter (P .109).
In multivariate stepwise logistic regression analy-
sis, the independent predictive factors associated
with complications were also evaluated (Table 3).
The impaction of the stone was found to be the in-
dependent factor for increased complication rates.
Furthermore, deeming the stones small enough to
pass spontaneously (break`n`leave) was Iound to
be the other predictor decreasing the complica-
tion rates.
DISCUSSION
Evaluation oI our fndings revealed comparable
Table 1. Classifcation of complications.
Intra-operative Complications n (%)
Mucosal ln[ury 30 (52.6)
Hematuria 9 (15.7)
Ureteral perforation l3 (22.8)
Ureteral avulsion 2 (3.5)
Mucosal eversion 1 (1.7)
Rupture of the basket catheter 2 (3.5)
Total number 57 (100)
Endourology and Stone Disease
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complication rates (4.7) with other published
studies.
(7,8)
Success rate aIter the frst procedure
was 86.3, and overall stone-Iree rate was 94.1
with the auxiliary procedures. In univariate analy-
sis, upper location of the stones, stone impaction,
and disrespect to the breaknleave policy were
Iound to be the signifcant Iactors increasing the
complication rates. Presence of stone impaction
and the breaknleave policy remained independ-
ent predictors at multivariate analyses.
In the last quarter oI the 20
th
century, with the
development of small diameter endoscopes and
modifcations in the techniques, URS has become
a widely accepted modality in the treatment of
ureteral calculi. Therefore, URS has been a saf-
er and more eIfcacious modality with growing
worldwide experience.
(9)
However, complications
may still occur and the predictive factors should
be clearly elucidated to understand the nature of
the complications.
(7)
In this study, mucosal injury was the most fre-
quently encountered complication (52.60),
which was treated with stent placement and re-
solved with no further consequences. Parallel to
our results, mucosal injury was the most common
intra-operative complication over other compli-
cations reported up to 62 in the published se-
ries.
(7,10)
Ureteral perforation was second most
common complication in our group. Of 13 ure-
teral perforations, while 11 were treated with DJ
stent placement, 2 cases required immediate open
surgery due to guidewire slippage and failed DJ
placement. Stone extraction and repair of the
damaged segment of the ureter were successfully
perIormed in those cases. In other 2 cases, open
surgery was required due to the rupture of the
tip of the basket catheter inside the ureter, which
were both successfully managed with open sur-
gery.
The most tragic complication, however, was the
complete ureteral avulsion in two cases. One of
them had multiple ureteral stones in the proximal
ureter and the other one had proximally located
stone with acute kinkings in the mid-ureter. The
proximally located stones were fragmented suc-
cessfully, but with the unbalanced downward
Table 2. Univariate analysis of risk factors for occurring of the complications.
Categorical factor Group 1 (n = 57) Group 2 (n = 1132) P
Age (mean SD)*, y 46.75 l4.78 44.50 l3.89 .363
Gender (male), % 63.20 64.50 .83l
Stone surface area (mean SD), mm 72.04 47.38 82.95 87.05 .757
Lateralization, %
Right 43.90 46.10 .744
Upper 47.40 31.70 .047
Type of ureteroscope (Wolf ), % 66.70 73.20 .537
Ureteral access catheter, % 63.20 47.00 .109
Postoperative ureteral catheter, % 56.10 45.30 .263
Stone impaction, % 17.50 5.60 .0001
Balloon dilation of the ureteral orifce, % 1.75 1.32 .680
Push-back, % 7.01 8.39 .650
Breaknleave, % 19.30 48.30 .0001
*SD indicates standard deviation.
Intra-Operative Complications of Ureteroscopy | Tanriverdi et al
462
|
traction of the ureteroscope, the whole ureter
came out in both cases. Primary anastomosis was
tried initially, but after a period of follow-up with
the ancillary procedures, including ileal neoureter
placement, unfortunately both cases had under-
gone nephrectomy. In a comprehensive review
of endoscopic ureteral injuries, complete ureter-
al avulsion has been reported in 17 out of 5117
(0.3) procedures in one study.
(11)
Furthermore,
nephrectomy has also been reported as one of the
most worrisome complications of URS in other
published series.
(5,7)
Another technical factor to consider is the success
rate of the procedures. The reported overall stone-
free rate of URS for ureteral stones is remarkably
high ranging between 85% and 100%.
(12,13)
Our
data demonstrated comparable results with the
literature, ranging from 86.3% with initial URS
to 94.1 with auxiliary procedures at 3 months.
Taking the main goal of ureteroscopic lithotripsy
as rendering the patient stone-free without any
complication either during or after URS into ac-
count, all procedures were classifed into two
groups according to the presence of complica-
tions. Both groups were statistically evaluated for
all possible Iactors that might infuence the fnal
outcome.
In univariate analysis, the frst Iactor aIIecting
the complications was stone location. The stones
located in the upper portion of the ureters were
tended to be complicated. Although some re-
searchers did not fnd an association between the
stone location and complication, in those studies,
the number of the procedures was either low, or
statistical evaluation was not possible for the in-
dependent prediction.
(14,15)
However, some other
reports showed that proximal location of the stone
was the predictor for complications using multi-
variate analyses.
(7,12)
In the light oI our fndings,
which are also supported by the published series,
as for the initial treatment, it would be wiser to
refer the patients with proximally located stones
to SWL treatment.
After multivariate analysis of all factors, two in-
dependent predictors of complications have been
identifed (Table 3). The frst predictor was stone
impaction. The edema at the impaction site may
easily result in false route and mucosal injury. As
outlined by some researchers, the risk for perfora-
tion might be increased in impacted stones.
(7)
We
Iound similar fndings and 5 out oI 13 (38.4) ure-
teral perforations had impacted stones in the ureter.
El-Nahas and coworkers also found that stone im-
paction was the independent predictor for the unfa-
vorable results similar to our series.
(12)
Finally, adhering to the breaknleave policy was
found to be the other predictor for decreasing the
complication rates. The idea for breaknleave is
that if the left fragments of the stone are small
enough to pass down spontaneously (_ 3 mm), the
procedure should be terminated without any other
maneuvers. The effort of continuing the fragmen-
tation and/or using a Iorceps to pull the insignif-
cant fragments down may cause damage to the
ureter and prolong the procedure. We found that
in the procedures in which breaknleave were
Table 3. Multivariate analysis of risk factors for occurring of the complications.
Independent factor B* Exp (B) 95% Confdence Interval P
Stone impaction -2.164 0.115 0.036 to 0.365 .0001
Disrespect to breaknleave 1.959 7.089 l.584 to l.733 .01
Localization (upper) -2.892 0.055 0.003 to 0.925 .692
` Pegresslon coemclent
Relative risk
Endourology and Stone Disease
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not performed, the patient has almost seven times
higher risk of having a complication. To the best
oI our knowledge, our study is the frst to analyze
this factor statistically as a possible predictor of
complications.
Some limitations of our study must be taken into
account. One oI them was insuIfcient data oI the
long-term follow-up period. This is because our
center is a referral for many hospitals in our re-
gion and thus many patients were followed up
elsewhere after the procedure. Therefore, the
main focus of our study was the prediction of
intra-operative complications. Another drawback
of our study might be the lack of the use of a la-
ser energy source, which may decrease the rate of
push-back ratios, particularly for the proximally
located stones. Although laser lithotripsy with
fexible ureteroscopes is an eIIective method with
limited complications, because of its high cost
it may not be available in many urology depart-
ments like ours.
(8)
Recently, we were equipped
with laser system and due to limited number of
cases, these patients have not been included into
the present study.
CONCLUSION
Ureteroscopy is a safe and highly effective pro-
cedure for the treatment of ureteral calculi. Com-
plications are rare and generally can be managed
with the placement of a ureteral catheter or with
minimally-invasive treatments. Stones located
at the upper ureters were associated with signif-
cantly increased complication rates. Furthermore,
multivariate analysis revealed that stone impac-
tion and failure to adhere to the breaknleave
principle were the independent predictors of oc-
curring of the complications. Frankly, careful at-
tention for the patients having a potential for oc-
currence of the complications and selection of the
techniques are of importance for reducing unto-
ward events.
CONFLICT OF INTEREST
None declared.
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Endourology and Stone Disease