Elsevier

Urology

Volume 65, Issue 6, June 2005, Pages 1075-1079
Urology

Adult urology
Therapeutic options for proximal ureter stone: Extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium: Yttrium-aluminum-garnet laser lithotripsy

https://doi.org/10.1016/j.urology.2004.12.026Get rights and content

Abstract

Objectives

To compare the safety and cost-effectiveness of ureterorenoscopic holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy (URSL) with extracorporeal shock wave lithotripsy (ESWL) for proximal ureteral stones.

Methods

This investigation assessed 220 patients with upper ureteral stones. Those in the ESWL group were treated on an outpatient basis using the Medispec Econolith 2000 (Medispec, Germantown, Md) under intravenous sedation. URSL was performed with a 6/7.5F semirigid tapered ureterorenoscope and holmium:YAG laser under spinal anesthesia on an inpatient basis. A successful outcome was defined as the patient being stone free on radiography 1 month after treatment. The stone size, success rate, postoperative complications, and cost were evaluated in each group.

Results

A total of 220 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. The mean stone burden ± SD was 58.7 ± 3.1 mm2 in the ESWL group and 108.4 ± 10.0 mm2 in the URSL group (P = 0.000). The accessibility of the semirigid ureterorenoscope for upper ureteral stones was 98.1% (101 of 103), and the stone-free rate achieved after one treatment was 83.2% (84 of 101). The initial stone-free rate of in situ ESWL was 63.9% (76 of 119). Significantly, the initial stone-free rate of the URSL group was superior to that of the ESWL group (P = 0.001). The average cost in the URSL group appeared to be lower than that in the ESWL group (P = 0.000).

Conclusions

The results of this study have demonstrated that URSL achieved excellent results for upper ureter calculi. In terms of cost and effectiveness, this procedure should be the first-line therapy for proximal ureter stones.

Section snippets

Material and methods

From January 2002 to December 2003, 222 consecutive patients with a single, primary, upper ureteral stone were enrolled in this investigation. ESWL and URSL were offered to all the patients. Ureterolithotomy was regarded as the salvage treatment. The benefits, drawbacks, and side effects of each technique were thoroughly described to the patients. The method was determined according to patient choice after the patient provided informed consent. In the case of treatment failure after first-line

Results

Ureteroscopy was chosen as the primary procedure in 58 patients with calculi 1 cm or greater. URSL was possible in 56 patients and failed in the remaining 2 patients owing to a tortuous ureter. Of the 56 patients, 10 exhibited epithelial polyp formation and polypectomy or polyp ablation was performed during laser lithotripsy. Double-J stents were inserted in 45 patients owing to the large stone burden, polypectomy (n = 10), stricture (n = 5), or mucosa edema (n = 5), facilitating stone passage

Comment

With the development of advanced instruments and techniques, minimally invasive surgical procedures have gradually replaced open surgery for treating upper ureter stones. ESWL is the least invasive technique for treating ureteral stones and can be done as an ambulatory procedure. ESWL has a high success rate of 85% to 96% for small nonobstructive upper ureteral stones when the calculi is pushed back or a double-J stent is placed temporarily.4 However, ESWL has a low success rate for large

Conclusions

Miniaturized ureterorenoscopes and improved laser lithotriptors facilitate effective and safe retrograde treatment of urinary tract calculi, regardless of stone size and location. The results of this study have demonstrated that URSL is the favored endourologic treatment for patients with upper ureter calculi with dimensions exceeding 1 cm. Considering the stone-free rate and cost together, URSL should remain the recommended first-line treatment for proximal ureter calculi smaller than 1 cm,

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