188 EPITOMES-UROLOGY

reservoir used, the method of antireflux protection and the the upper urinary tract and the ability to visualize and obtain a
continence mechanism. Such names as Kock, Camey, Mainz biopsy of peripheral collecting system lesions and extract or
and Mitrofanoff have been used to identify some of the more disintegrate calyceal stones. Significant complication rates
commonly done procedures. for those with experience have decreased to about 4% with
The Kock pouch is the most desirable continent diversion less than 1 % of those cases requiring an open surgical proce-
because the pressure within the created reservoir remains dure. As with any new technique, a learning curve exists, and
extremely low, even with volumes of as much as 1,000 ml, complication rates will diminish and success rates increase as
and there are no pressure spikes from bowel smooth muscle a surgeon gains experience.
contraction (a frequent cause of incontinence in other types of Transurethral ureteroscopic procedures (diagnostic and
continent diversions). Intussuscepted small bowel afferent therapeutic) have become standard clinical practice and have
and efferent one-way nipple valves prevent urine reflux to the saved many patients the morbidity of open surgical proce-
kidneys and urine leaking from the pouch. If these valves are dures to accomplish the same goal. JEFFRY L. HUFFMAN, MD
not competent, revision may be necessary, though revision Los Angeles
rates are decreasing as technical innovations are perfected. REFERENCES
For those patients whose general condition and prognosis Biester R, Gillenwater JY: Complications following ureteroscopy. J Urol 1986;
permit them to consider the aesthetic and body image advan- 136:380-382
Huffman JL, Bagley DH, Lyon ES (Eds): Ureteroscopy. Philadelphia, WB Saun-
tages of a continent urinary diversion, the Kock pouch ap- ders, 1987
pears to be an attractive alternative. Huffman JL, Bagley DH, Lyon ES, et al: Endoscopic diagnosis and treatment of
STUART D. BOYD, MD upper tract urothelial tumors. Cancer 1985 Mar; 55:1422-1428
Los Angeles Stackl W, Marberger M: Late sequelae of the management of ureteral calculi with
REFERENCES the ureterorenoscope. J Urol 1986; 136:386-389
Boyd SD, Skinner DG, Lieskovsky G: The continent ileal reservoir (Kock
pouch). Semin Urol 1987 Feb; 5:15-27
Kock NG, Nilson AE, Nilsson LO, et al: Urinary diversion via a continent ileal
Integrated Management of Urinary Stone
reservoir: Clinical results in 12 patients. J Urol 1982 Sep; 128:469-475 Disease
Olsson CA: Continent urinary diversion (Editorial). Semin Urol 1987 Feb; 5:1-2
THE SIMPLICITY, efficacy and relative lack of morbidity of
extracorporeal shock-wave lithotripsy (ESWL) in destroying
Ureterorenoscopy kidney and ureteral stones have revolutionized "surgical"
TRANSURETHRAL ENDOSCOPY of the upper urinary tract has treatment methods since it was first introduced in 1980. Urol-
become a routine part of most urologic practices. The tech- ogists now simply place patients in the treatment machine,
nical advances of increasingly smaller rigid and flexible endo- aim the shock wave via the sighting cross hairs and destroy
scopes with high-resolution lenses and channels sufficient for the stone in less than 50 minutes. Efficacy? More than 80% of
irrigation and the passage of diagnostic and therapeutic in- patients are stone-free within three months, and fewer than
struments have opened the door of nonincisional access to the 30% have any significant pain while passing the fragments.
upper urinary tract. It is obvious that the therapeutic options Perirenal hematoma, the worst complication noted to date,
offered by direct visualization have had the greatest clinical occurs in 1 of every 400 patients. There are very few other
impact. The options include stone extraction, catheter or stent complications of significance. Hence, it is clear that ESWL
passage and removal of foreign bodies. functions remarkably well.
Rigid transurethral ureteroscopy is done with instruments The success of this procedure and other relatively nonin-
varying between 8.5 and 12.5 French. Following dilation of vasive stone-removal techniques (percutaneous nephrosto-
the ureterovesical junction, the ureteroscope is passed lithotomy and transurethral ureteroscopic lithotripsy) have
through the ureteral orifice and up the ureter under direct permitted the elimination of most stones without an open
vision to the point of interest. Success rates for passage are surgical procedure.
above 95 %, with failures due to anatomic limitations (ureteral Each of these procedures has specific areas of strength
angulation or fixation). The successful extraction of ureteral where its use is preferable. ESWL is most effective for renal
stones has improved dramatically. Initially only 60% of stones, but can be used for ureteral stones above the sacroiliac
stones could be removed ureteroscopically, but now stones in joint if there is enough fluid around them to transmit the shock
the lower ureter can be removed in more than 90% of pa- wave and permit fragmentation, or if they can be pushed back
tients, and those in the upper ureter can be considered for up into the kidney for disintegration. Percutaneous nephrosto-
removal. Ureteroscopic stone extraction or disintegration lithotomy is used to debulk staghorn stones, to remove those
complements other forms of nonsurgical stone removal. poorly fragmented by ESWL because of hardness (cystine)
Stones below the rim of the bony pelvis cannot routinely be and to eliminate stones in poorly draining calyces (dependent,
treated with current extracorporeal shock-wave lithotriptors or with narrow infundibulae). Transurethral ureteroscopic
or percutaneous methods. But this region, the most common lithotripsy is addressed in another of this series of epitomes.
site for ureteral stones to lodge, is ideally located for uretero- Does this mean we need not worry about preventing renal
scopic access. When a stone is large or resists extraction, stone disease? Hardly! Even with these new treatment
transureteroscopic lithotripsy (stone fragmentation) by ultra- methods, there can be renal compromise from the stone, from
sonic electrohydraulic or pulsed-dye laser can be done. the treatment or from complications of either, and it is certain
Flexible ureteroscopes, available for 25 years, have fi- that a kidney will occasionally be irrevocably damaged.
nally been perfected to a clinically useful state. Those that are In view of this, it is important that we prevent recurrences
not actively deflectable simply follow the ureter and thus are whenever possible. Nearly 80 % of patients with stones have a
useful more for diagnostic than therapeutic indications. The definite metabolic abnormality that can be identified and
deflectable flexible ureteroscope just now becoming commer- treated. Diseases such as hyperabsorption or renal leak hyper-
cially available promises more frequently successful access to calciuria, hypomagnesiumuria, hypocitruria and so forth re-