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At our institution ureteroscopy is more efficacious than ESWL for the treatment of distal ureteral calculi.

Dietary acid or alkali loading was given to rats by providing 150 mM NH4Cl or 150 mM NaHCO3 in place of drinking water for 6 days; control animals received 150 mM NaCl. After 6 days, the citrate clearance was 0.04 +/- 0.01 ml/min (mean +/- SE) in the acid-loaded group, 0.9 +/- 0.1 ml/min in the control group, and 2.5 +/- 0.2 ml/min in the alkali-loaded group. At the end of the experiment, the rats were killed, and the Na+ gradient-dependent (Nao+ greater than Nai+) citrate uptake (pmol/mg protein) was measured in brush border membrane (BBM) vesicles prepared from each group. At 0.3 min, the [14C]citrate uptake was 198 +/- 8 pmol/mg protein (mean +/- SE) in the acid-loaded group, 94 +/- 16 pmol/mg protein in the control group, and 94 +/- 13 pmol/mg protein in the alkali-loaded group. The rate of Na+-independent (NaCl in medium replaced by KCl) [14C]-citrate uptake by BBM vesicles was the same for acid-loaded, control, and alkali-loaded animals. Thus, the increased capacity of the proximal tubular BBM to transport citrate from the tubular lumen into the cell interior may be an important factor that contributes to decreased urinary citrate in the presence of metabolic acidosis induced by chronic dietary acid loading.

A total of 15 patients underwent ESWL using the Dornier HM3 lithotriptor with the patient in the prone position. The stones were in the distal ureter over the sacroiliac joint in 10 patients, 8 of whom had undergone unsuccessful ureteroscopic manipulation. Two patients had horseshoe kidneys with stones that were too anterior to permit accurate targeting with the patient in the standard supine position. One patient had a solitary stone in a pelvic kidney and 1 had an obstructing ureteropelvic junction stone in a crossed ectopic kidney. The final patient had a reconstructed lower urinary tract with a stone at 1 of the ureterointestinal anastomoses. Excellent pulverization was achieved in all patients after only 1 prone ESWL treatment. One patient required temporary percutaneous nephrostomy after ESWL and 1 may require retrograde manipulation of fragments at the ureterovesical junction. No patient had melena, and other than temporary ileus in 1 patient who had concurrent supine ESWL of renal calculi, no gastrointestinal complications were seen. All but 1 patient were free of stones 1 month after prone ESWL. Prone ESWL prevents blockage of shock wave energy by the bony pelvis, because the shock waves enter anteriorly and exit posteriorly. ESWL with the patient in the prone position is a safe and effective treatment of calculi in the distal ureter or anomalous kidney.