Ureteroscopic fragmentation followed by extracorporeal shock wave lithotripsy: a treatment alternative for selected large or staghorn calculi.

Ureterorenoscopic fragmentation followed by extracorporeal shock wave lithotripsy (ESWL) is proposed as an addition to the alternatives of percutaneous nephrostolithotomy alone or with ESWL, or ESWL monotherapy for treatment of large (greater than 500 mm.2) or staghorn calculi. Six patients who failed percutaneous tube placement and 2 additional patients, all of whom had fragile-appearing, large volume (greater than 500 mm.2) renal calculi, were treated by primary ureteroscopy with semirigid or flexible instruments, fragmentation of the stone with the pulsed dye laser, ureteral stenting and subsequent ESWL. There were 2 instances of acute pyelonephritis and 2 of steinstrasse. A total of 2.76 procedures was performed per patient and the average anesthesia time was 160 minutes (excluding ESWL). Median hospitalization was 3.5 days (average 7.5). Of the 8 patients 7 became stone-free. One patient has sterile urine and a residual fragment smaller than 5 mm. All patients have been followed for 1 year and there have been no recurrences. The properly selected patient for ureterorenoscopic fragmentation followed by ESWL is one with a fragile calculus of moderate volume without strictured infundibula or significantly dilated calices.