STONE DISEASE

Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: a randomized clinical trial
Basiri A, Simforoosh N, Ziaee A, Shayaninasab H, Moghaddam SM, Zare S
Urology and Nephrology Research Center, Tehran, Iran
J Endourol. 2008; 22: 2677-80

• Background and Purpose: Multiple procedures have been introduced for the management of urinary stones in the upper ureter. In this randomized clinical trial, we compared three surgical options in this regard.
• Patients and Methods: From September 2004 to May 2006, we enrolled in the study 150 patients with upper ureteral stones who were referred to our center. We included patients with a stone size ≥ 1.5 cm in the greatest diameter. Using the random table, patients were divided into three 50-patient groups by treatment: Group A, retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; group B, transperitoneal laparoscopic ureterolithotomy; and group C, percutaneous nephrolithotripsy. All procedures were performed in a training program.
• Results: The stone-free rates for patients in groups A, B, and C, at discharge and 3 weeks later, were 56%, 88% and 64% and 76%, 90% and 86%, respectively. Conversion to open surgery and repeated laparoscopy was necessary for two and one patients in group B. Urinary leakage continued more than 3 days in eight (16%) and nine (18%) patients in groups B and C after operation, respectively (P = 0.7).
• Conclusions: Although the success rate of ureteroscopy was not significantly lower than the two other options, the complications seen with this technique were negligible. Consequently, the procedure of choice for large proximal ureteral stones seems to depend on surgeon expertise and availability of equipment.
  
  
• Editorial Comment
  The authors are to be commended for conducting a randomized prospective study of a difficult clinical situation. Indeed, it is note-worthy that they were able to recruit 150 patients with > 1.5 cm proximal ureteral calculi in less than 2 years. Similarly, it is a challenge to consent patients to be randomized to procedures that vary greatly in the degree of invasiveness and risk.
  The authors concluded that ureteroscopy is a reasonable first alternative as the severity of potential complications is lower than the other procedures tested. Indeed, patients would tend to agree with this assessment, and if given the alternative of shockwave lithotripsy (not tested in the current study due to concerns of efficacy) would often select SWL over more effective procedures.
  The study is somewhat limited by the choice of technology. The authors did not utilize flexible endoscopy - either flexible ureteroscopy as an adjunct to the ureteroscopic approach, or flexible cystoscopy/ureteroscopy as an adjunct to the antegrade percutaneous approach. One would anticipate that these modalities would significantly improve the initial post-procedural stone-free rates. Pneumatic lithotripsy has been demonstrated to lead to greater stone migration and larger stone fragments. Intraoperative ultrasound may have facilitated identification of the “missed stone” in the laparoscopic group.
  The authors did not stratify results based on the severity of hydronephrosis - it is our practice to consider the antegrade approach if we anticipate that the severity of hydronephrosis will preclude manipulation of the flexible ureteroscope for stone retrieval. The authors report a high secondary procedure rate in all groups in this study (10-20%); underscoring the challenge of the large ureteral calculus. Most importantly, it tempers the enthusiasm of prior reports of laparoscopic ureterolithotomy.
  In summary, the addition of a flexible ureteroscope and decreased reliance on pneumatic lithotripsy may have placed ureteroscopy more solidly as the front-runner for large proximal ureteral stones.

Dr. Manoj Monga
Professor, Department of Urology
University of Minnesota
Edina, Minnesota, USA
E-mail: endourol@yahoo.com