Clinical observation of different minimally invasive surgeries for the treatment of impacted upper ureteral calculi

A Comparative Analysis between Flexible Ureteroscopic Lithotripsy and Tubeless Percutaneous Nephrolithotomy in the Treatment of >15 mm Non-Obstructing Proximal Ureteral Stones

BACKGROUND

The proper surgical modality for large non-obstructing proximal ureteral stones is disputed. We compare effectiveness and safety of flexible ureteroscopic lithotripsy (FURL) and tubeless percutaneous nephrolithotomy (TPNL) in treatment of upper ureteral stones larger than 1.5 cm.

METHODS

We reviewed the medical records of patients who performed FURL or TPNL for upper ureteral stones between June 2016 and November 2018. Comparative analysis was conducted regarding demographic parameters, stone free rate, postoperative pain and complications.

RESULTS

This study included 58 patients treated with FURL and 60 patients treated with TPNL owing to upper ureteral stones larger than 1.5 cm. Stone size was similar in the FURL and TPNL groups (17.6 ± 2.6 vs. 18.0 ± 2.1 mm, p = 0.194). The overall 3-month stone clearance rate was 95.8% for FURL versus 96.0% for TPNL (p = 0.575). There was no difference between the FURL and TPNL groups for hospital stay (p = 0.280) and postoperative complications. On the other hand, patients treated with FURL had longer operative time (p = 0.012) and less postoperative pain (p = 0.008).

CONCLUSIONS

Both surgical techniques were considered feasible and effective surgical procedures in the treatment of large upper ureteral stones.

Medial deviation of the ureter is a new sign that could predict stone impaction: a pilot study

OBJECTIVE

To assess the value medial deviation of the ureter at site of ureteric stone as a sign of ureteric stone impaction.

PATIENTS AND METHODS

All cases with medial deviation of the ureter at site of ureteric stones in our department over 4 years were enrolled in this pilot study. All cases were diagnosed with KUB and non-contrast CT (NCCT). Radiological and ureteroscopic findings were recorded.

RESULTS

A total of 32 patients with a single impacted stone in the proximal and middle third of the ureter were included in the study. Medial deviation of the ureter at the site of the stone was detected in the upper third of the ureter in 24 (75%) cases and in the middle third in 8 (25%) cases. There were mucosal polyps and mucosal erythema (inflammatory changes) seen by ureteroscopy in all cases (100%). Ureteroscopy was successfully completed with stone fragmentation in 23 (71.8%) patients: 8 of them needed ureteric catheter and 15 required JJ stent insertion. Failure of ureteroscopy with insertion of JJ stent was done in 5 (15.6%) patients. Removal of the stent and ureteroscopy was done after 4 weeks.

CONCLUSION

We conclude from this study that medial deviation of the ureter is a new reliable radiological sign of ureteric stone impaction.

Comparative study between antegrade flexible ureteroscopy and reterograde intrarenal surgery in the management of impacted upper ureteric stones 1.5 cm or larger

OBJECTIVE

To prospectively investigate the safety and efficacy of antegrade flexible ureteroscopy (FURS) with the following criteria (supine, ultrasonic guided puncture through lower calyx with 14 fr tract, tubeless) versus retrograde intrarenal surgery (RIRS) in the management of large impacted upper ureteric stones ≥ 1.5 cm.

PATIENTS AND METHODS

This study recruited 61 patients with single large impacted upper ureteric stone of ≥ 1.5 cm. The patients were randomly allocated to two groups. Group A, included 31 patients who treated by antegrade FURS, all patients were put in supine modified galadako Valdivia position and the renal access is reached by ultrasonic guided puncture through the lower calyx with dilatation upto 14 fr to insert ureteric access sheath and all cases were tubless with JJ stent insertion. Group B, included 30 patients who were treated by RIRS with JJ stent insertion. Stone fragmentation was done by holmium laser in both group.

RESULTS

Group A was significantly associated with higher proportion of SFR (90.3%) compared to Group B (70%) (p = 0.046). Group B was significantly associated with shorter operative time and fluoroscopy time in comparison with Group A (p < 0.001). No significant differences were found between studied groups regarding bleeding (p = 0.238). Urosepsis showed significantly higher proportion associated with retrograde approach when compared to antegrade approach (p = 0.024).

CONCLUSION

This study showed that antegrade FURS is safe and more effective than RIRS for the management of large impacted upper ureteric stones ≥ 1.5 cm.

Percutaneous nephrolithotomy versus retrograde intrarenal surgery for treatment of renal stones in adults

BACKGROUND

Kidney stones (also called renal stones) can be a source of pain, obstruction, and infection. Depending on size, location, composition, and other patient factors, the treatment of kidney stones can involve observation, shock wave lithotripsy, retrograde intrarenal surgery (RIRS; i.e. ureteroscopic approaches), percutaneous nephrolithotomy (PCNL), or a combination of these approaches.

OBJECTIVES

To assess the effects of percutaneous nephrolithotomy (PCNL) versus retrograde intrarenal surgery (RIRS) for the treatment of renal stones in adults.

SEARCH METHODS

We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Scopus, and two trials registries up to 23 March 2023. We applied no restrictions on publication language or status.

SELECTION CRITERIA

We included randomized controlled trials that evaluated PCNL (grouped by access size in French gauge [Fr] into three groups: ≥ 24 Fr [standard PCNL], 15-23 Fr [mini-PCNL and minimally invasive PCNL], and < 15 Fr [ultra-mini-, mini-micro-, super-mini-, and micro-PCNL]) versus RIRS.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data from the included studies. Our primary outcomes were stone-free rate, major complications, and need for secondary interventions. Our main secondary outcomes were unplanned medical visits to emergency/urgent care or outpatient clinic, length of hospital stay, ureteral stricture or injury, and quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using GRADE criteria. We adopted a minimally contextualized approach with predefined thresholds for minimal clinically important differences (MCIDs).

MAIN RESULTS

We included 42 trials assessing the effects of PCNL versus RIRS in 4571 randomized participants. Twenty-two studies were published as full-text articles, and 20 were published as abstract proceedings. The average size of stones ranged from 10.1 mm to 39.1 mm. Most studies did not report sources of funding or conflicts of interest. The main results for the most important outcomes are summarized below. Stone-free rate PCNL compared with RIRS may improve stone-free rates (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.08 to 1.18; I2 = 71%; 39 studies, 4088 participants; low-certainty evidence). Based on 770 participants per 1000 being stone-free with RIRS, this corresponds to 100 more (62 more to 139 more) stone-free participants per 1000 with PCNL (an absolute difference of 10%, where the predefined MCID was 5%). Major complications PCNL compared with RIRS probably has little or no effect on major complications (RR 0.86, 95% CI 0.59 to 1.25; I2 = 15%; 34 studies, 3649 participants; moderate-certainty evidence). Based on 31 complications in the RIRS group, this corresponds to six fewer (13 fewer to six more) major complications per 1000 with PCNL (an absolute difference of 0.6%, where the predefined MCID was 2%). Need for secondary interventions PCNL compared with RIRS may reduce the need for secondary interventions (RR 0.31, 95% CI 0.17 to 0.55; I2 = 61%; 21 studies, 2005 participants; low-certainty evidence). Based on 222 secondary interventions in the RIRS group, this corresponds to 153 fewer (185 fewer to 100 fewer) secondary interventions per 1000 with PCNL (an absolute difference of 15.3%, where the predefined MCID was 5%). Unplanned medical visits No studies reported unplanned medical visits. Length of hospital stay PCNL compared with RIRS may extend length of hospital stay (mean difference 1.04 days more, 95% CI 0.27 more to 1.81 more; I2 = 100%; 26 studies, 2804 participants; low-certainty evidence). This effect size is greater than the predefined MCID of one day. Ureteral stricture or injury PCNL compared with RIRS may have little or no effect on the occurrence of ureteral strictures (RR 0.93, 95% CI 0.39 to 2.21; I2 = 0%; 13 studies, 1574 participants; low-certainty evidence). Based on 14 ureteral strictures in the RIRS group, this corresponds to one fewer (nine fewer to 17 more) ureteral strictures per 1000 with PCNL (an absolute difference of 0.1%, where the predefined MCID was 2%). Quality of life No studies reported quality of life.

AUTHORS' CONCLUSIONS

Based on a large body of evidence from 42 trials, we found that PCNL compared with RIRS may improve stone-free rates and may reduce the need for secondary interventions, but probably has little or no effect on major complications. PCNL compared with RIRS may have little or no effect on ureteral stricture rates and may increase length of hospital stay. We found no evidence on unplanned medical visits or participant quality of life. Because of the considerable shortcomings of the included trials, the evidence for most outcomes was of low certainty. Access size for PCNL was less than 24 Fr in most studies that provided this information. We expect the findings of this review to be helpful for shared decision-making about management choices for individuals with renal stones.

The association between ureteral wall thickness and need for additional procedures after primary ureteroscopy in patients with ureteral stones above the iliac crest

PURPOSE

To examine the parameters affecting the need for additional procedures in the primary ureteroscopy treatment in patients with ureteral stones above the iliac crest level.

METHODS

Seventy-one patients were included in the study who were ≥ 18 years old and had undergone ureteroscopy (URS) for ureteral stones above the iliac crest level between 2018-2020 and had a non-contrast-enhanced abdominal computed tomography before the procedures were included in the study. Patients and stone characteristics were prospectively collected. The results were evaluated six weeks after URS. The absence of any residual fragment was thought to indicate stone-free status. The patients with failure were referred for the additional procedures.

RESULTS

The median patient age was 51 years [interquartile range (IQR): 18-66]. The median transverse stone diameter was 9.5 mm (IQR: 7.1-11.4), and the median ureteral wall thickness (UWT) was 5.8 mm (IQR: 4.3-6.5). In the univariate analysis, UWT (p < 0.001), presence of multiple stones (p = 0.008), and stone length (p = 0.022) affected stone-free status. The multivariate analysis revealed UWT as the only independent factor affecting the need for additional procedures after URS (p = 0.028). In the receiver operating characteristic curve analysis, the best threshold value for UWT according to the outcomes was identified as 5.8 mm.

CONCLUSION

Ureteral wall thickness was the only independent parameter determining the need for additional procedures and affecting the treatment outcomes after the URS procedure.

Comparison of Transperitoneal and Retroperitoneal Laparoscopic Ureterolithotomy: A Meta-Analysis

<b><i>Purpose:</i></b> The aim of this study was to evaluate the efficacy and safety of transperitoneal and retroperitoneal laparoscopic ureterolithotomy (TLU and RLU). <b><i>Materials and Methods:</i></b> We undertook a literature search PubMed, Embase, and the Cochrane Library. Search date will range from inception to January 1, 2020. The final article results will be analyzed using StataSE 12 software. This meta-analysis was reported according to PRISMA guidelines, and a protocol was registered in PROSPERO (CRD42020160906). <b><i>Results:</i></b> Eleven articles eventually met the requirements, involving a total of 609 patients. The final result shows the operative time (Std. Mean Difference [SMD] = 0.58; 95% CI 0.36–0.80; <i>p</i> &#x3c; 0.01), hospital stay (SMD = 0.26; 95% CI 0.02–0.49; <i>p</i> = 0.031), and the complication of paralytic ileus (risk difference = 0.11; 95% CI 0.05–0.17; <i>p</i> &#x3c; 0.01) are significant difference between TLU and RLU, and TLU are higher or longer. <b><i>Conclusions:</i></b> Our meta-analysis suggests that if there are no other constraints, it is better to choose RLU. And more clinical trial data are needed to confirm this conclusion.

Laparoscopic ureterolithotomy for large proximal ureteric stones: Surgical technique, outcomes and literature review

INTRODUCTION

We evaluated the efficacy and safety of laparoscopic ureterolithotomy (LPU) for the treatment of large proximal ureteric stone.

METHODS

A retrospective multicenter analysis for patients with solitary impacted proximal ureteric stone ≥15 mm who underwent LPU from 2016 to 2019 was performed. Primary outcome was to estimate the stone-free rate (SFR). SFR was defined as absence of residual stones on postoperative computed tomography scan. Secondary outcome was to assess the perioperative outcomes, as well as to review literature data of randomized controlled trials and meta-analyses comparing LPU to other treatment options.

RESULTS

Forty-four patients were included in our study. Mean stone size was 22.9 ± 5.8 mm and median follow-up was 14 months. Three patients had previous abdominal surgery, one patient had severe degree of scoliosis and six patients failed primary therapy. All stones were extracted successfully (SFR = 100%) without need of auxiliary treatments. Mean operative time and estimated blood loss were 86.6 ± 14.1 minutes. and 11.9 ± 14.7 mL, respectively. No intraoperative complications or conversion to open surgery were reported. No major postoperative complications (≥grade 3) were reported. Mean length of hospital stay was 2 ± 0.8 days.

CONCLUSIONS

For treatment of large ureteric stones, our study showed that LPU achieves 100% stone-free status. When performed by well-trained laparoscopic surgeons, it is safe and has no major perioperative complications. According to our results and literature data, when counseling patients with large impacted proximal ureteral stones, LPU should be advised as the procedure that has the higher SFR, lower auxiliary treatments, and comparable complication rates to other treatments.

Comparison of antegrade and retrograde ureterolithotripsy for proximal ureteral stones: a systematic review and meta-analysis

Background

Antegrade percutaneous ureterolithotripsy (URSL) could be a treatment option for large and/or impacted proximal ureteral stones, which are difficult to treat. To review the current approach and treatment outcomes and to compare the efficacy of retrograde and antegrade URSL for large proximal ureteral stones, we evaluated the unique perspectives of both surgical modalities.

Methods

This systematic literature review and meta-analysis was performed in July 2020. Articles on human studies and treatment of ureteral stones with URSL were extracted from the PubMed, MEDLINE, Embase, Cochrane Library, Scopus, and the Japan Medical Abstracts Society databases without any language restrictions. The risks of bias for randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) were assessed using the Cochrane risk of tool and the Risk of Bias in Non-randomized Studies- of Interventions tool, respectively.

Results

A total of 10 studies, including seven RCTs and three non-RCTs, were selected for the analysis; 433 and 420 cases underwent retrograde and antegrade URSL, respectively. The stone-free rate (SFR) was significantly higher in antegrade URSL than in retrograde URSL (SFR ratio: 1.17, 95% CI: 1.12-1.22; P<0.001), while the hospital stay was significantly longer in antegrade URSL than in retrograde URSL (standardized mean difference: 2.56, 95% CI: 0.67-4.46; P=0.008). There were no significant differences in the operation time and the overall complication rate between the two approaches.

Conclusions

Despite the heterogeneity of data and bias limitations, this latest evidence reflects real practice data, which may be useful for decision making.

Antegrade mini-percutaneous flexible ureteroscopy versus retrograde ureteroscopy for treating impacted proximal ureteric stones of 1-2 cm: A prospective randomised study

Objectives

To prospectively assess the safety and effectiveness of antegrade mini-percutaneous (miniperc) ureteroscopy (URS) and compare it with the conventional retrograde URS (RURS) approach in treating impacted proximal ureteric stones of 1–2 cm.

Patients and methods

The study included 60 patients admitted to the Department of Urology, Alexandria Main University Hospital, presenting with impacted proximal ureteric stones of 1–2 cm. Patients were randomly divided into two groups: Group A, were treated with RURS using a semi-rigid or flexible ureteroscope to access the stone; and Group B, were treated by antegrade miniperc URS, were a 14-F renal tract was obtained to pass a ureteric access sheath, then a flexible ureteroscope was used going downwards to the stone. Holmium laser was used for stone fragmentation. A JJ stent was inserted in all cases. Follow-up with non-contrast computed tomography was performed after 2 weeks.

Results

Both groups were comparable in terms of patient demographics and stone criteria. The stone-free rate was significantly higher in Group B (83.3%) compared to Group A (60%). The mean (SD) operative time was significantly shorter in Group A vs Group B, at 64.7 (±17.7) vs 112.0 (±15.3) min; while the mean lithotripsy time was comparable between the groups. The mean radiation exposure time was significantly less in Group A (11 s) compared to Group B (200 s). Both groups where comparable concerning minor complications, with no major complications.

Conclusion

Antegrade miniperc flexible URS is safe and more effective than RURS for treating large impacted proximal ureteric stones.

Abbreviations

ESWL: extracorporeal shockwave lithotripsy; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; miniperc: mini-percutaneous; PCNL: percutaneous nephrolithotomy; PCS: pelvi-calyceal system; SFR: stone-free rate; (R)URS: (retrograde) ureteroscopy

Optimal management of large proximal ureteral stones (>10 mm): A systematic review and meta-analysis of 12 randomized controlled trials

OBJECTIVES

To develop an evidence base to guide clinicians treating adults with large proximal ureteral stones (LPUS) greater than 10 mm.

METHODS

A systematic search of PubMed, EMBASE, and Cochrane Library was conducted to identify randomized controlled trials (RCT) concerning different LPUS management techniques including laparoscopic ureterolithotomy (LU), percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URL) up until March 2020. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement when searching and determining inclusion. All included articles were quality assessed and the data analyses were conducted with Review Manager (5.3).

RESULTS

12 RCTs involving 1416 patients met our eligibility criteria and were analyzed. Of these participants, 44.6% (n = 632) underwent URL, 25.5% (n = 361) PCNL, and 29.9% (n = 423) LU. Pooled analysis revealed that URL had a significantly lower stone-free rate (SFR) compared to PCNL and LU (both with p < 0.05). URL had a significantly higher ureteral injury rate compared to LU (Relative risk (RR) = 5.27, 95% confidence interval (CI) 1.52 to 18.22, p = 0.009) and PCNL (RR = 4.11, 95% CI 1.03 to 16.34, p = 0.04). However, no significant differences were found between PCNL and LU in terms of SFR or overall complications, both with p > 0.05. URL initially costs less than PCNL (Weighted mean difference (WMD) -597.35US$, 95% CI -823.10 to -371.60, p < 0.00001), but being less effective creates greater demand for repeat or ancillary treatments compared to LU (RR 15.65, 95% CI 2.11-116.12, p = 0.007) and PCNL (RR 8.86; 95% CI 3.19-24.60; p < 0.00001).

CONCLUSIONS

Both PCNL and LU appear more effective and safer than URL for LPUS; although, LU has higher risk of urine leakage and is more likely incur trauma which requires additional support. However, caution must be taken because this recommendation is based upon a very limited number of clinical studies, and even fewer comparing flexible ureteroscopic technologies. Further prospective real-world studies or RCTs comparing flexible URL, LU and PCNL are required, as well as an in depth analysis of the hidden costs involved in unsuccessful URL treatments.

Laparoscopic ureterolithotomy versus ureteroscopic laser lithotripsy for large proximal ureteral stones: a systematic review and meta-analysis

INTRODUCTION

To review current studies and conduct a meta-analysis on the topic of laparoscopic ureterolithotomy (LU) versus ureteroscopic lithotripsy (URSL) with holmium laser for large proximal ureteral stones.

EVIDENCE ACQUISITION

A systematic research of PubMed, Ovid, Scopus (up to March 2019), and citation lists was performed to identify eligible comparative studies. All studies comparing LU versus URSL with holmium laser in proximal ureteral stones were included. Statistical analyses were performed using the Cochrane Collaboration's Review Manager (RevMan) 5.3 software.

EVIDENCE SYNTHESIS

Overall, seven studies were included in analysis involving 884 patients (LU 387; URSL 497). Our meta-analysis showed that LU group had bigger stone size than URSL group (WMD 0.19 cm; P=0.001). LU group was associated with longer operative time (WMD 36.29 min; P<0.001), and length of hospital stay (WMD 1.24 d; P=0.04). However, LU group showed better initial stone-free rate (OR 11.03; P<0.001), and final stone-free rate (OR 22.37; P<0.001). There were no significant differences in all complications (RR 1.06; P=0.76). While, LU group had fewer Clavien Dindo score ≥3 complications (RR 0.21; P=0.002), fewer ureteral stricture (RR 0.26; P=0.04), and lower need of auxiliary procedures (RR 0.09; P<0.001) compared with URSL group.

CONCLUSIONS

LU could provide a higher stone-free rate and fewer severe complications compared with URSL with holmium laser for large proximal ureteral stones. More importantly, LU could also reduce the postoperative ureteral stricture rate.

Systematic review and cumulative analysis of the managements for proximal impacted ureteral stones

PURPOSE

To compare the efficacy and safety of different treatment options for the management of proximal impacted ureteral stones (PIUS).

METHODS

A systematic literature search using Pubmed, Medline, Embase and Cochrane Library was conducted to obtain studies concerning different managements for PIUS up to Jan 2018. Summary odds ratios (ORs), standard mean differences (SMDs) or weighted mean differences with their 95% confidence intervals (CIs) were calculated to compare the efficacy and safety of all included treatment methods, registered in PROSPERO under number CRD42018092745.

RESULTS

A total of 15 comparative studies with 1780 patients were included. Meta-analyses of final stone-free rate (SFR) favored percutaneous nephrolithotomy (PCNL) over ureteroscopic lithotripsy (URL) (OR 10.35; 95% CI 5.26-20.35; P < 0.00001), laparoscopic ureterolithotomy over URL (OR 0.11; 95% CI 0.05-0.25; P < 0.00001) and URL over extracorporeal shockwave lithotripsy (OR 0.47; 95% CI 0.28-0.77; P = 0.003). As to complications, PCNL had a significantly higher blood transfusion rate (OR 7.47; 95% CI 1.3-42.85; P = 0.02) and a lower ureteral injury rate (OR 0.15; 95% CI 0.04-0.52; P = 0.003) compared with URL. It also shared a significantly lower stone-retropulsion rate (OR 0.03; 95% CI 0.01-0.15; P < 0.0001) and higher treatment costs (SMD = 2.71; 95% CI 0.71-4.70; P = 0.008) than URL.

CONCLUSIONS

Our meta-analysis suggested that PCNL might be the best option for PIUS owing to its higher successful rate. Complications such as hemorrhage could be decreased by the application on mini-PCNL.

Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta - analysis of randomized controlled trials

Introduction:

To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone.

Materials and methods:

A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

Results:

Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = −31.26 min; 95%CI −46.88 to −15.64; p<0.0001) and length of hospital stay (WMD = −1.48 days; 95%CI −2.78 to −0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications – Clavien ≥3 – (OR = 1.79; 95%CI 0.59-5.42; p=0.30). LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001).

Conclusions:

Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.

Comparison of the efficacy and safety of URSL, RPLU, and MPCNL for treatment of large upper impacted ureteral stones: a randomized controlled trial

Background

There are three minimally invasive methods for the management of large upper impacted ureteral stones: mini-percutaneous nephrolithotomy (MPCNL), transurethral ureteroscope lithotripsy (URSL), and retroperitoneal laparoscopic ureterolithotomy (RPLU). This study aimed to compare MPCNL, URSL, and RPLU, and to evaluate which one is the best choice for large upper impacted ureteral stones.

Methods

Between January 2012 and December 2015, at the Department of Urology, Huai’an First People’s Hospital, 150 consecutively enrolled patients with a large upper impacted ureteral stone (>15 mm) were included. The patients were randomly divided (1:1:1) into the MPCNL, URSL, and RPLU groups. The primary endpoint was success of stone removal measured 1 month postoperatively and the secondary endpoints were intraoperative and postoperative parameters and complications.

Results

Fifteen patients needed auxiliary ESWL after URSL, and 3 patients after MPCNL, but none after RPLU. The stone clearance rate was 96% (48/50) in the MPCNL group and 72% (33/46) in the URSL group. In the RPLU group the stones were completely removed and the stone clearance rate was 100% (48/48) (P = 0.021 vs. URSL; P = 0.083 vs. MPCNL). Operation-related complications were similar among the three groups (all P > 0.05). Hospital stay was shorter in the URSL group compared with MPCNL (P = 0.003). Operation time was the shortest with URSL and the longest with MPCNL (all P < 0.05).

Conclusions

MPCNL and RPUL are more suitable for upper ureteral impacted stones of >15 mm. URSL could be considered if the patient is not suitable for general anesthesia, or the patient requests transurethral uretroscopic surgery.

Trial registration

This study was registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR-INR-17011507; Registration date: 2017–5-22).

Retrospective comparative study of rigid and flexible ureteroscopy for treatment of proximal ureteral stones

BACKGROUND

We analyzed the outcome and complications of rigid (R-URS) and flexible (F-URS) ureteroscopic lithotripsy for treatment of proximal ureteric stone (PUS).

SUBJECTS AND METHODS

Retrospective data of 135 patients (93 males and 42 females) submitted to R-URS and F-URS for treatment of PUS in the period between July 2013 and January 2015 were investigated. (R-URS, group 1) was performed in 72 patients while 63 patients underwent (F-URS, group 2).We compared the 2 groups for success, stone characteristics, operative time, intraoperative and postoperative complications.

RESULTS

The overall stone free rate (SFRs) was 49/72 (68%) in group 1 and 57/63 (91%) patients in group 2, (P=0.005). The operative time was shorter in group 1 in comparison to group 2 with statistically significant difference (P=0.005). There was not any statistically significant difference between 2 groups in complication rate (P=0.2). Conclusıon: Both R-URS and F-URS could be a feasible option for treatment of PUS. R-URS is less successful for treatment of PUS and should be used cautiously and with availability of F-URS.

The usefulness of flexible cystoscopy for preventing double-J stent malposition after laparoscopic ureterolithotomy

Background

The aim of this study was to evaluate the role of flexible cystoscopy in preventing malpositioning of the ureteral stent after laparoscopic ureterolithotomy in male patients.

Methods

From April 2009 to June 2015, 97 male patients with stones >1.8 cm in the upper ureter underwent intracorporeal double-J stenting of the ureter after laparoscopic ureterolithotomy performed by four different surgeons. In the last 50 patients who underwent laparoscopic ureterolithotomy flexible cystoscopy was performed through the urethral route to confirm the position of the double-J stent, while in the first 47 correct positioning of the stent was confirmed through postoperative KUB. The demographic data and perioperative outcomes were reviewed retrospectively. Penalized logistic regression analysis was used to evaluate the effects of flexible cystoscopy.

Results

Upward malpositioning of the ureteral stent was found in 9 of the 47 (19.1%) patients who underwent surgery without flexible cystoscopy. Among the 50 most recent patients who underwent surgery with flexible cystoscopy through the urethral route, upward malpositioning was observed in 10 (20%) patients. The factors preventing upward malpositioning of the double-J catheter in multivariate analysis were surgeon (p = 0.039) and use of flexible cystoscopy (p = 0.008).

Conclusion

Flexible cystoscopy is a simple, safe, quick, and effective method to identify and correct malpositioning of double-J stents, especially in male patients.

Trial registration

This study was registered with ClinicalTrials.gov Registry on May 11, 2017 (retrospective registration) with a trial registration number of NCT03150446.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0232-4) contains supplementary material, which is available to authorized users.

Rigid ureteroscopic lithotripsy versus percutaneous nephrolithotomy for large proximal ureteral stones: A meta-analysis

Object

To compare the safety and efficacy of rigid ureteroscopic lithotripsy (rigid URSL) and percutaneous nephrolithotomy (PCNL) in treating large proximal ureteral stones.

Methods

A systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science databases was performed to find out relevant studies. After literature screening according to the predetermined inclusion and exclusion criteria, data of eligible studies was extracted and then a meta-analysis was conducted via RevMan 5.3 software.

Results

Five randomized controlled trials (RCTs), one prospective and four retrospective cohort studies involving 837 patients were included. Patients underwent rigid URSL were associated with shorter operation time (WMD, -23.66min; 95%CI, −45.00 to -2.32; p = 0.03), shorter hospital stay (WMD, -2.76d; 95%CI, −3.51 to −2.02; p< 0.00001), lower 3rd-day (RR, 0.73; 95%CI, 0.66 to 0.82; p < 0.00001) and 1st-month (RR, 0.82; 95%CI, 0.77 to 0.87; p < 0.00001) stone-free rate, higher risk of conversion to other surgical procedures (RR, 4.28; 95%CI, 1.93 to 9.46; p = 0.0003), higher incidence of migration (RR, 28.49; 95%CI, 9.12 to 89.00; p < 0.00001) and ureteral perforation (RR, 6.06; 95%CI, 1.80 to 20.44; p = 0.004), lower risk of fever (RR, 0.64; 95%CI, 0.42 to 0.97; p = 0.04), transfusion (RR, 0.19; 95%CI, 0.04 to 0.85; p = 0.03) and hematuria (RR, 0.38; 95%CI, 0.25 to 0.57; p < 0.0001). No significant difference was observed in terms of incidence of embolization, pain and ureterostenosis. When cohort studies or studies in which flexible ureteroscopy was used as an intraoperative auxiliary procedure were excluded, we both found that most of the results kept stable.

Conclusions

Both PCNL and rigid URSL are safe for patients with large proximal ureteral stones while PCNL is more effective in stone clearance.

Minimally invasive percutaneous nephrolithotomy improves stone-free rates for impacted proximal ureteral stones: A systematic review and meta-analysis

Background

Urinary stones are common medical disorders and the treatment of impacted proximal ureteral stones (IPUS) is still a challenge for urologists. The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MI-PCNL) and ureteroscopic lithotripsy (URL) in the treatment of IPUS via a meta-analysis.

Methods

We collected studies using PubMed, Embase, and Cochrane Library from 1978 to November 2016 and analyzed them using Stata 12.0 and RevMan 5.3. Odds ratios (ORs) and standard mean difference (SMD) were calculated for binary and continuous variables respectively, accompanied with 95% confidence intervals (CIs). All study procedures followed the PRISMA guidelines.

Results

Five prospective studies were included in our meta-analysis, with 242 MI-PCNL and 256 URL cases. MI-PCNL was associated with a longer postoperative hospital stay than URL (SMD, 3.14; 95% CI, 1.27 to 5.55). However, no significant difference was observed in operative time (SMD, -0.38; 95% CI, -3.15 to 2.38). In addition, MI-PCNL had higher initial (OR, 11.12; 95% CI, 5.56 to 22.24) and overall stone-free rates (OR, 8.70; 95% CI, 3.23 to 23.45) than URL, along with lower possibilities of surgical conversion (OR, 0.11; 95% CI, 0.03 to 0.49) and postoperative shock wave lithotripsy (OR, 0.06; 95% CI, 0.02 to 0.18). Regarding complications, no significant differences were observed between MI-PCNL and URL (OR, 1.39; 95% CI, 0.93 to 2.10), except for hematuria (OR, 4.80; 95% CI, 1.45 to 15.94).

Conclusions

MI-PCNL is optimal and should be considered as the preferred treatment method for IPUS, as it has better efficacy and a safety profile similar to that of URL. However, further high quality studies with larger sample size are required in future.

Comparison of laparoscopic stone surgery and percutaneous nephrolithotomy in the management of large upper urinary stones: a meta-analysis

For the treatment of large upper urinary stones percutaneous nephrolithotomy (PCNL) is generally considered the first choice, and Laparoscopic Stone Surgery (LSS) is an alternative. We aim to compare the efficiency and safety of PCNL with LSS, as far as the management of large upper urinary stones is concerned. A systematic search from Pubmed, Web of Science, Wiley Online Library and Elsevier was performed up to August 1, 2015 for the relevant published studies. After data extraction and quality assessment, meta-analysis was performed using the RevMan 5.3 software. 15 eligible trials evaluating LSS vs. PCNL were identified including 6 prospective and 9 retrospective studies with 473 patients undergoing LSS and 523 patients undergoing PCNL. Although LSS led to longer operative time (p = 0.01) and higher open conversion rate (p = 0.02), patients might benefit from significantly fewer overall complications (p = 0.03), especially lower bleeding rate (p = 0.02), smaller drop in hemoglobin level (p < 0.001), less need of blood transfusion (p = 0.01). The stone free rate was also higher for LSS compared with PCNL (p < 0.001) with less secondary/complementary procedure (p = 0.006). There was no significant difference in other demographic parameters between the two groups. Our data suggests that LSS turns out to be a safe and feasible alternative to PCNL for large upper urinary stones with less bleeding and higher stone free rate. Because of the inherent limitations of the included studies, further large sample prospective, multi-centric studies and randomized control trials should be undertaken to confirm our findings.

Flexible Ureteroscopy Can Be More Efficacious in the Treatment of Proximal Ureteral Stones in Select Patients

Purpose. We aimed to compare and evaluate the outcomes and complications of two endoscopic treatment procedures, semirigid ureteroscopy (SR-URS) and flexible ureteroscopy (F-URS), in the treatment of proximal ureteral stones (PUS). Methods. SR-URS (group 1) was done on 68 patients whereas 64 patients underwent F-URS (group 2) for the treatment of PUS. Success rate was defined as the absence of stone fragments or presence of asymptomatic insignificant residual fragments < 2 mm. Outcomes and complications were recorded. Results. The differences were statistically not significant in age, gender, body mass index (BMI), and stone characteristics between groups. Mean ureteral stone size was 9.1 ± 0.4 mm and 8.9 ± 0.5 mm for groups 1 and 2. Mean operative time was 34.1 ± 1.5 min and 49.4 ± 2.3 min for groups 1 and 2 (p = 0.001). SFRs were 76.5% and 87.5% for groups 1 and 2 (p = 0.078). Two major complications (ureteral avulsion and ureteral rupture) occurred in group 1. Conclusion. F-URS is safer and less invasive than SR-URS in patients with PUS. There is no statistically significant difference in the efficacy of either technique. Nonetheless we recommend F-URS in the management of PUS as a first-line treatment option in select cases of proximal ureteral calculi.