Minimally invasive surgical treatment for large impacted upper ureteral stones: Ureteroscopic lithotripsy or percutaneous nephrolithotomy?

Abstract

Introduction:The management of patients with large impacted upper ureteral stones is difficult; there is no standard treatment. We compared the outcomes of percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (UL) to treat large (≥1.5 cm), impacted, upper ureteral stones. Methods: In total, 86 patients with large impacted upper ureteral stones were included in this study. Of these patients 41 underwent UL and 45 underwent PCNL. The inclusion criteria were: longest diameter of stone ≥1.5 cm, the localization of stone between the lower border of L4 spine and ureteropelvic junction and impacted stone. Results: In the UL group, we were unable to reach the stone in 3 patients because of ureteral stricture and edema despite balloon dilation. Of these 3 patients, we were unable to optimally visualize the stone in 2 patients due to bleeding and mucosal injury following balloon dilation. The stricture was too firm and could not be passed in the third patient. Also in the UL group, 15 patients had stones or big fragments which migrated into the renal collecting system. In the PCNL group, 21 patients had concurrent renal stones <1 cm and stones were successfully removed in all patients. No statistically significant difference was found between groups in terms of operation time. Mean hospital stay was significantly shorter in the UL group. Success rates were 82.3% in the UL group and 97.6% in the PCNL group (p = 0.001). Conclusion:The recent study confirms that PCNL is a safe and effective minimally invasive procedure with acceptable complication rates in the treatment of patients with large, impacted upper ureteral stones.

Ureteroscopic Lithotripsy versus Laparoscopic Ureterolithotomy or Percutaneous Nephrolithotomy in the Management of Large Proximal Ureteral Stones: A Systematic Review and Meta-Analysis

“…Table 1 provides a description of the 14 studies. Of the 14 included studies, 7 compared URS with LU [1,9,12] , 4 compared URS with PCNL [10,13,18,19], and 3 compared URS with LU or PCNL [6,8,11] . Among these 7 studies that compared URS with LU, 3 studies used the retrograde intrarenal surgery (RIRS) technique in the URS group comparing with LU [2,12,20] .…”

“…The remaining 8 were non-RCTs. The methodological quality of included studies was relatively high for 6 of the nonrandomized studies [2,6,10,13,18,19] , and low for 1 [20] ( Table 1 ). For all of 7 RCTs, every RCT could achieve 3 or more items in the Cochrane Collaboration's tool for assessing the risk of bias respectively (online suppl.…”

“…The mean size of stones ranged from 12 to 23 mm. Ten trials reported the presence of complications [2,7,[10][11][12][13][18][19][20][21] . The complication rate ranged from 4.1 to 33.8%.…”

“…Seven trials were RCTs [1, 7-9, 11, 12, 21] of which 6 were retrospective control studies [2,6,11,[18][19][20] and 1 was a prospective control study [13] . The remaining 8 were non-RCTs.…”

Treatment strategies for large impacted upper ureteral stones

“…1 An impacted stone was defined as a stone that did not allow any passage on contrast graphies, stayed at the same localization for more than one month, and resulted in dilation in the collecting system. In some publications, an impacted stone is defined as a stone that cannot be bypassed either by a wire or a catheter.…”