"Everything comes down to patient selection and location of the stones," says one urologist.
Urology Times® reached out to 3 urologists (selected randomly) and asked them each the following question: Do you prefer dusting or basketing when removing kidney/ureteral stones?
“I like a combination. Dusting creates less risk of injuring the ureter, reducing fragment size, so they don’t get stuck. It’s nice to have pieces for analysis so you can determine composition and figure out what to do in terms of prevention. Also, information is power, and most patients want to know the type of stone they have. Often, I dust as much as I can, basketing a small fragment to analyze. Fragments left after dusting sometimes aren’t always large enough to grab. Dusting is easier because it allows those fragments to pass without damage to the ureter.
Location makes a difference, however, especially if you have a larger stone up in the renal pelvis. Those are more amenable to dusting because no one wants to make a lot of trips up and down the ureter removing fragments. Dust them as small as possible and let that debris pass spontaneously.
Lower ureteral stones are easier to remove at times. I really don’t have to dust them as much to achieve a stone free status. Higher in the renal pelvis, dusting expedites the procedure because you don’t have to take the scope in and out as many times.
Everything comes down to patient selection and location of the stones. If it’s a smaller stone in the lower ureter, basketing it and pulling it out may be quicker than dusting it.”
T. Casey McCullough, DO, MBA, FACOS
Johns Creek, Georgia
“I’m doing a lot more dusting. I do a hybrid, but because we have a new-generation laser, the dusting really changed and became a lot faster.
I work in 2 hospitals. Last year, we got a new holmium at one, then we got a thulium laser at the other. They’re both much faster than what I had before. They use much higher frequencies to dust. They’re also a lot more efficient.
With lasers, sometimes, you would still have quite large fragments. With newer lasers, they turn everything to dust, and often, there’s nothing left.
I’ll still do a hybrid at times. If it’s a distal stone, I’ll out basket it because then I know for sure it’s completely out. If I have a ureteral access sheath, I’ll basket, easily removing everything.
You can reliably basket everything; then, you’re guaranteed to have 100% stone clearance rate. With an access sheath, you can go in and out of the kidney easily and get everything out.
I try to leave a fragment for stone analysis if I can, but I recently had a case with this new laser where I dusted, put a basket in, and nothing came out. I wasn’t able to get a stone analysis, but we can always do a 24-hour urine, so it’s not a terrible loss.”
Roger Yau, MD
Matthews, North Carolina
“I prefer dusting. With basketing, stones can still get stuck or create tears in the ureter, whereas if you dust the stone, you can blow the pieces out more gently.
We probably all do some sort of combination, dusting the stone down until it’s an appropriate size where there won’t be tugging and pulling, and you can basket it through the ureter without scraping the sides.
The location of the stone also helps determine the technique choice. If it’s small and up in the kidney, you may basket it and know you’ve gotten it, whereas if the stone is already stuck in the ureter, you know you’ll have to laser it before basketing.
There are potential problems relying on just 1 method. Just dusting risks leaving microparticles that can form a new stone, and it’s a bit more time-consuming, whereas with the basket, it’s gone. But you have to ensure you can get through the entire ureter without pulling or scraping if you’re just basketing.
A significant influence from my residency, while I was a second year, my attending basketed a stone and pulled so hard he pulled the ureter down—which is probably why I’m not a fan of basketing.
Although it’s nice to have a sample to determine the stone’s composition, patients can make different stones every time, depending on what’s going into their urine. Mrs. Jones may have too much oxalate, whereas Mrs. Smith may lack citrate. So although the composition is important, doing the 24-hour urine test to advise the patient on dietary measures is really more important. So I don’t always treat the patient on a basketed sample anyway.”
Jennifer Linehan, MD
Santa Monica, California