Intracorporeal treatment of urolithiasis is characterized by continuous technological evolution. In this review we present updated data upon the use of ureteroscopy for the management of urolithiasis. Novel digital flexible ureteroscopes are used in clinical practice. Ureteroscopic working tools are revolutionized resulting in safer and more efficient procedures. Special categories of stone patients such as pregnant women, children and patients on anticoagulation medication can now undergo uneventful ureteroscopy. Routine insertion of stents and access sheaths as well as bilateral ureteroscopy is still a controversial issue. Future perspectives include smaller and better instruments to visualize and treat a stone, while robotic ureteroscopy is becoming a fascinating reality.Key words: evolution, indications, technique, ureteroscopy.
IntroductionSince its first description over 20 years ago, ureteroscopic surgery (URS) has progressed from an awkward diagnostic procedure with limited visualization to a precise, complex surgical intervention allowing access to the entire collecting system. 1 Current practice patterns in the management of upper urinary tract stones reveal that fellowshiptrained endourologists, academic urologists, and urologists in practice for less than 5 years are more likely to utilize URS and/or percutaneous nephrolithotomy (PCNL) and less likely to utilize extracorporeal shock wave lithotripsy (SWL).2 Herein, we review the relevant literature, published in Medline-indexed journals since 2008, upon the ureteroscopic treatment of urolithiasis (Table 1).
Stone location Renal stonesFlexible URS is indicated in treating renal stones less than 15 mm that do not respond to SWL and is an attractive option for treating renal and ureteral stones in the same patient in a single session.3 Stone size larger than 15 mm is associated with single-session treatment failure for stone-free status. 4 In the vast majority, cases of flexible URS for unilateral renal stones can be performed as outpatient procedures. In a study of 51 patients with 161 renal stones (mean stone size of 6.6 mm), the overall stone-free rate after one and two procedures was 64.7% and 92.2%, respectively.5 In 97.6% of the cases the operation was performed on an outpatient basis.Perlmutter et al. studied whether stone location affects the stone-free rates of flexible URS. 6 A total of 86 renal stones were treated and the stone-free rates were 100% for upper pole stones, 95.8% for middle pole and 90.9% for lower pole stones (P = 0.338). Lower pole stones may not be easily accessed and fragmented because of acute infundibular angles and reduced deflection of ureteroscopes. This can be overcome by relocating lower pole stones into a more favorable location before fragmentation. A prospective randomized trial comparing SWL (32 patients) and URS (35 patients) for lower pole caliceal stones of 1 cm or less, demonstrated a statistically significant difference in stonefree rates in favor of URS.7 However, SWL was associated with greater pa...
