Percutaneous Nephrolithotomy Versus Ureteroscopic Lithotomy for Large (>15 mm) Impacted Upper Ureteral Stones in Different Locations: Is the Upper Border of the Fourth Lumbar Vertebra a Good Indication for Choice of Management Method?

Abstract

To determine whether treatment of patients with large (>15 mm) impacted upper ureteral stones depended on stone location, we prospectively evaluated the therapeutic outcomes, complications, safety, and effectiveness of percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotomy (URSL) in patients with stones higher and lower than the upper border of the fourth lumbar vertebra. Of the 174 patients analyzed, 83 (47.7%) underwent PCNL and 91 (52.3%) underwent URSL; all patients were followed up 1 month later and every 6 months for 18 months. Mean operation time (108.76±19.36 vs. 63.56±16.38 minutes, p<0.05) and postoperative hospital stay (2.49±1.23 vs. 5.36±1.98 days, p<0.05) were significantly longer in the PCNL than in the URSL group. The overall stone-free rates after 1 month were 96.4% and 75.8%, respectively, differing significantly for stones higher (97.8% vs. 57.5%, p<0.05) but not lower (94.7% vs. 90.2%) than the upper border of the fourth lumbar vertebra. The stone-retropulsion rate of URSL differed significantly for stones higher and lower than the upper border of the 4th lumbar vertebra (47.5% vs. 9.8%, p<0.05). Postprocedural complication rates were comparable in the URSL and PCNL groups, although the rate of auxiliary or salvage procedures was higher in the URSL group. The efficiency quotients (EQ) for PCNL and URSL were 0.93 and 0.59, respectively, with EQs in the URSL group differing significantly for stones higher and lower than the upper border of the fourth lumbar vertebra (0.40 vs. 0.82, p<0.05). Our findings indicate that treatment of impacted upper ureteral stones is dependent on stone location relative to the upper border of the fourth lumbar vertebra. URSL is unsuitable for stones at a higher location, whereas URSL and PCNL were equally effective for stones at a lower location.

Treatment of ureterolithiasis with the use of percutaneous antegrade ureterolithotripsy

“…These conclusions have been noted by previous researchers [7][8][9][10]. However, a number of authors believe that with large ureteral calculi the frequency of urethral injury and the percentage of ureteric stricture development in the antegrade approach are higher than in retrograde ureteroscopy [9,10]. To prevent these complications they recommend using a smaller caliber ureteroscope and avoiding the ureteral mucosal damage during lithotripsy, which is achieved using a flexible ureteroscope that usually has a smaller caliber than a rigid or semi-rigid ureteroscope, and using an ureteroscope with a casing can reduce friction between the mucosa ureter and ureteroscope.…”

“…And the use of the nephroscope tube allows for large fragments of calculi evacuation that significantly reduces the time of operation. These conclusions have been noted by previous researchers [7][8][9][10]. However, a number of authors believe that with large ureteral calculi the frequency of urethral injury and the percentage of ureteric stricture development in the antegrade approach are higher than in retrograde ureteroscopy [9,10].…”

“…However, in certain circumstances the retrograde ureteroscopy (RURS) is not successful due to anatomical and functional individual characteristics of the upper urinary tract (anatomical narrowness and pathological tortuosity of the ureter) that makes it difficult to access to the middle and upper parts of the ureter. Large (more than 1.0 cm) or impacted calculi of the proximal ureteral parts result in decrease of the method effectiveness and increase the percentage of intraoperative complications, including proximal migration of both the calculus and its fragments into the renal cavity system [10].…”

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 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%.…”