Therapeutic options for proximal ureter stone: extracorporeal shock wave lithotripsy versus semirigid ureterorenoscope with holmium:yttrium-aluminum-garnet laser lithotripsy.

OBJECTIVES: To compare the safety and cost-effectiveness of ureterorenoscopic holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy (URSL) with extracorporeal shock wave lithotripsy (ESWL) for proximal ureteral stones. METHODS: This investigation assessed 220 patients with upper ureteral stones. Those in the ESWL group were treated on an outpatient basis using the Medispec Econolith 2000 (Medispec, Germantown, MD) under intravenous sedation. URSL was performed with a 6/7.5F semirigid tapered ureterorenoscope and holmium:YAG laser under spinal anesthesia on an inpatient basis. A successful outcome was defined as the patient being stone free on radiography 1 month after treatment. The stone size, success rate, postoperative complications, and cost were evaluated in each group. RESULTS: A total of 220 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. The mean stone burden +/- SD was 58.7 +/- 3.1 mm2 in the ESWL group and 108.4 +/- 10.0 mm2 in the URSL group (P = 0.000). The accessibility of the semirigid ureterorenoscope for upper ureteral stones was 98.1% (101 of 103), and the stone-free rate achieved after one treatment was 83.2% (84 of 101). The initial stone-free rate of in situ ESWL was 63.9% (76 of 119). Significantly, the initial stone-free rate of the URSL group was superior to that of the ESWL group (P = 0.001). The average cost in the URSL group appeared to be lower than that in the ESWL group (P = 0.000). CONCLUSIONS: The results of this study have demonstrated that URSL achieved excellent results for upper ureter calculi. In terms of cost and effectiveness, this procedure should be the first-line therapy for proximal ureter stones.

Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal ureteral stones.

PURPOSE: Management of large impacted upper ureteral calculi remains challenging for urologists. These calculi are frequently associated with obstructive uropathy and deteriorated renal function. Extracorporeal shock wave lithotripsy (SWL) is the least invasive treatment but its success rate is decreased for large impacted upper ureteral calculi. According to the American Urological Association guidelines on ureteral stones published in 1997, the appropriateness of ureteroscopy decreases when stone size exceeds 1 cm. However, the application of advanced ureteroscopy and techniques has increased the success rate of treating proximal ureter calculi. In this study we compared the safety and efficacy of ureterorenoscopic holmium:YAG laser lithotripsy (URSL) with SWL for large impacted proximal ureteral stones. MATERIALS AND METHODS: This study evaluated 82 patients with large impacted upper ureteral stones. Two patients were excluded from study owing to conversion to open surgery. SWL and URSL were performed in 41 and 39 patients, respectively. Those in the SWL group were treated on an outpatient basis with Medispec Econolith 2000 (Medispec, Germantown, Maryland) under intravenous sedation. The URSL was performed with a 6/7.5Fr semirigid tapered ureterorenoscope and holmium:YAG laser with the patient under spinal anesthesia on an inpatient basis. Successful outcome was defined as the patient being stone-free on radiography 1 month after treatment. Stone size, success rate, postoperative complications and cost were analyzed in each group. RESULTS: A total of 80 patients were enrolled in this study. Hematuria and flank pain were the most common complaints in each group. Mean stone size +/- SD was 1.28 +/- 0.04 cm in the SWL group and 1.51 +/- 0.05 cm in URSL group (p = 0.0009). Accessibility of the semirigid ureterorenoscope for impacted upper ureteral stones was 95.1% (39 of 41) and the stone-free rate achieved after 1 sitting was 92% (36 of 39). The initial stone-free rate of in situ SWL was 61% (25 of 41). Notably, the initial stone-free rate in the URSL group was better than that of the SWL group (p = 0.003). The efficiency quotient was 0.53 for URSL and 0.59 for SWL. The average cost in the URSL group appears to be lower than in the SWL group. Both groups were free of major complications. CONCLUSIONS: This study demonstrated that URSL achieved excellent results for upper ureteral calculi greater than 1 cm. Thus, this procedure should be considered first line therapy for large proximal ureteral stones.