Minimally Invasive Surgical Ureterolithotomy Versus Ureteroscopic Lithotripsy for Large Ureteric Stones: A Systematic Review and Meta-analysis of the Literature.

CONTEXT: The management of large ureteric stones represents a technical and clinical challenge. OBJECTIVE: To investigate the safety and efficacy of minimally invasive surgical ureterolithotomy (MISU) in comparison with ureteroscopic lithotripsy (URS) for the treatment of large ureteric stones. EVIDENCE ACQUISITION: The Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines were followed for the conduction of the study, which was registered in the PROSPERO database. Search string was "(laparoscop* OR retroperito* OR robot*) AND ureterolitho*"; database scope included PubMed, SCOPUS, Cochrane, and EMBASE. Primary end points were the stone-free (SFR) and complications rates. Secondary end points included operative time and hospital stay. Subgroup analyses were performed for stones 1-2 and >2cm, as well as different lithotripters and ureteroscopes. Meta-analysis and forest-plot diagrams were performed with the RevMan 5.3.5 software. EVIDENCE SYNTHESIS: After screening 673 publications, seven randomized controlled trials were eligible to be included in the meta-analysis. A total of 778 patients were pooled after the elimination of the dropouts. No robotic cohorts were found. Only upper ureteral stones were treated in the included studies. The SFR at discharge and 3 mo was higher with MISU with odds ratios of 6.30 (95% confidence interval [CI]: 3.05, 13.01; I2=0%) and 5.34 (95% CI: 2.41, 8.81; I2=0%), respectively. The most common complications for MISU and URS were conversion to open surgery and stone migration to the renal pelvis, respectively. Favorable results in terms of operative time were observed in the case of URS with a mean difference of 29.5min (95% CI: 14.74, 44.26; I2=98%). Hospitalization time was favorable in the case of URS with a mean difference of 2.08 days (95% CI: 0.96, 3.20; I2=99%). CONCLUSIONS: This meta-analysis showed a significantly higher SFR at discharge and 3 mo for MISU in comparison with URS when upper ureteral stones were treated. Operative and hospitalization time favored URS over MISU. PATIENT SUMMARY: The current study investigated the literature on the minimally invasive management of large ureteric stones. The available evidence shows that both ureteroscopic lithotripsy and minimally invasive surgical ureterolithotomy could be considered for the treatment of these stones with similar results. The selection of the approach should be based on the advantages and disadvantages of each technique.