Laparoscopic Ureterolithotomy vs Ureteroscopic Lithotripsy for Large Ureteral Stones

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.

Laparoscopic Ureterolithotomy and Single-Use Digital Flexible Ureteroscope For Unilateral Large Ureteral Stone and Small Renal Stone

BACKGROUND The removal of concurrent ureteral and renal stones within a single procedure has always been a challenge for urological surgeons. The incorporation of single-use digital flexible ureteroscopes into laparoscopic ureterolithotomy procedures has demonstrated effective removal of concurrent stones with a good clearance rate and decreased risk of bleeding and trauma. We report the successful removal of a unilateral upper ureteral stone and a smaller renal stone with this procedure. CASE REPORT A 60-year-old man visited the outpatient clinic with an ultrasonography report that revealed a large proximal ureteral stone with moderate hydronephrosis, accompanied by bilateral renal stones and prostatic hyperplasia. He had been experiencing urinary urgency for a year and was determined to undergo lithotomy. Due to his longstanding history of coronary artery disease and myocardial ischemia, the urologists decided that concurrent stone removal within an operation would be the best treatment. A preoperative computed tomography urogram measured the left ureteral and renal stones to be 2.0×0.8 cm and 0.6 cm, respectively. Both stones were successfully removed by laparoscopic ureterolithotomy using a single-use digital flexible ureteroscope. The patient had an uneventful recovery and remained well 1 month post-operation. CONCLUSIONS The application of single-use digital flexible ureteroscopes for laparoscopic ureterolithotomy has demonstrated safety, efficiency, and cost-effectiveness. The authors believe that it is a safe alternative for the removal of concurrent ureteral and renal stones, especially in patients with multiple comorbidities.

Reverse Trendelenburg Lithotomy with Certain Inclination Angles Reduces Stone Retropulsion during Ureteroscopic Lithotripsy for Proximal Ureteral Stone

The objective of this study is to investigate how different inclination angles of reverse Trendelenburg lithotomy affect stone retropulsion and stone-free rates during ureteroscopic lithotripsy for proximal ureteral stones. Patients with proximal ureteral stones undergoing ureteroscopic lithotripsy in our institution between January 2019 and December 2020 were included according to predefined criteria. The rigid ureteroscope and Holmium: YAG laser were utilized to perform lithotripsy, and a stone basket was used to keep the stone in place and to avoid retropulsion. Before initiating lithotripsy, the upper part of the patient’s body was tilted up to establish a reverse Trendelenburg posture with appropriate inclination angles. To quantify the stone-free rate, computed tomography was used to evaluate the residual stones in the kidney one month following surgery. Patients’ clinical data were obtained retrospectively, including age, gender, the largest diameter of stone, stone density on computed tomography, and the distance between stone and ureteral pelvic junction, etc. Patients were divided into four groups based on the inclination angles of reverse Trendelenburg lithotomy: 0°, 10°, 20°, and 30°. The chi-square test was used to compare stone retropulsion and stone-free rates between groups. To discover possible determinants of the stone-free rate, logistic regression analyses were used. There were 189 patients that qualified. There were no differences in clinical characteristics between groups (p > 0.05). Multiple comparisons between groups revealed that the 20° and 30° groups had less retropulsion and a greater stone-free rate than the 0° and 10° groups (p < 0.05), whereas there were no significant differences in stone retropulsion or stone-free rates between the 20° and 30° groups or between the 0° and 10° groups (p > 0.05). The inclination angles as well as distance between the stone and ureteral pelvic junction were identified by using logistic regression analyses as the related factors for the stone-free rate. According to our results, the appropriate inclination angles of reverse Trendelenburg lithotomy during ureteroscopic lithotripsy for proximal ureteral stones would help preclude stone retropulsion and increase the stone-free rate.

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.

Comparison of the effects of retroperitoneoscopic ureterolithotomy and ureteroscopic lithotripsy in the treatment of upper ureteral calculi

ABSTRACT

This study compares the efficacy of retroperitoneoscopic ureterolithotomy (RPUL) and ureteroscopic lithotripsy (URL) in the treatment of upper ureteral calculi.The clinical data of 150 patients with upper ureteral calculi who underwent RPUL and 136 patients who underwent URL between January 2014 and October 2019 were retrospectively analyzed. The operation time, postoperative hospital stay, operation success rate, stone clearance rate, and surgical complications were evaluated between the two groups.For the RPUL and URL groups, respectively, the average operation time was 74.5 ± 24.6 minutes and 54.5 ± 13.2 minutes; the postoperative hospital stay was 5.8 ± 1.4 days and 3.2 ± 1.2 days; the operation success rate was 96.0% (144/150) and 85.3% (116/136); the incidence rate of complications was 3.5% (5/144) and 17.5% (18/103); and the stone clearance rate was 100% (144/144) and 88.8% (103/116), which were all statistically significant (P < .05).Both RPUL and URL had the advantages of low trauma and fast recovery rate for patients with upper ureteral calculi. However, patients who underwent RPUL showed higher success and fewer complication rate. RPUL might be a safe and effective laparoscopic method for the treatment of patients with upper ureteral calculi.

The reasons of unsatisfactory results of extracorporeal shock wave lithotripsy in patients with ureterolithiasis

The article dedicate to the problem of failure of extracorporeal shockwave lithotripsy in patients with ureterolithiasis and reveal the changes which appear in the ureter in the location of the stone.The aim. Analysis of the results of treatment in patients, suffering ureteric stones, using the ureterolithotripsy procedure after failure extracorporeal shockwave lithotripsy. Materials and methods. In 137 patients with ureteric stones, whom ureterolithotripsy procedure after failure extracorporeal shockwave lithotripsy was conducted, the symptoms of the disease, the diagnostic methods value, efficacy of surgical treatment and reasons of the failure of previous method of treatment were analyzed. Results. In 135 patients endoscopic removal of stones has been succeeded, in 2 patients because of total obliteration of the ureter, uretero-ureteral anastomosis has been performed. If the symptoms, with are characteristic of ureterolithiasis, persists up to one week stones don’t cause significant macroscopic changes to the ureter wall. If the stone persists in the ureter longer than a week we identified local appearing of oedema. Long–term (more than two months) ureteric stone persistence increase the risk of intramucosal “ingrowth” of the calculi greatly. Conclusion. The URS and ESWL are high effective and minimal invasive methods of surgical intervention for patients with ureterolithiasis, guaranteeing high level of postoperative “stone free rate”. Prolongation of the stone insertion time in the ureter causes the ureteric wall changes, complicating performance of minimal invasive interventions (ureterolithotripsy and extracorporeal shock–wave lithotripsy) and reduce its efficacy.

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.

Efficacy and safety of various surgical treatments for proximal ureteral stone ≥10mm: A systematic review and network meta-analysis

Purpose

Various surgical options are available for large proximal ureteral stones, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LU). However, the best option remains controversial. Therefore, we conducted a network meta-analysis comparing various surgical treatments for proximal ureteral stones ≥10mm to address current research deficiencies.

Materials and methods

We searched PubMed, Ovid, Scopus (up to June 2019), as well as citation lists to identify eligible comparative studies. All clinical studies including patients comparing surgical treatments for proximal ureteral stones ≥10mm were included. A standard network meta-analysis was performed with Stata SE 14 (Stata Corp, College Station, TX, USA) software to generate comparative statistics. The quality was assessed with level of evidence according to the Oxford Centre for Evidence-based Medicine and risk of bias with the Cochrane Collaboration’s Review Manager (RevMan) 5.3 software.

Results

A total of 25 studies including 2.888 patients were included in this network meta-analysis. Network meta-analyses indicated that LU and PCNL had better stone-free rates and auxiliary procedures. PCNL could result in major complications and severe bleeding. In initial stone-free rate, final stone-free rate, and auxiliary procedures results, SUCRA ranking was: LU> PCNL> URSL> ESWL. In Clavien Dindo score ≥3 complications, SUCRA ranking was: LU> ESWL> URSL> PCNL. In fever, SUCRA ranking was: ESWL> LU> URSL> PCNL. In transfusion, SUCRA ranking was: LU> URSL> ESWL> PCNL. In Cluster analysis, LU had the highest advantages and acceptable side effects. Considering the traumatic nature of PCNL, it should not be an option over URSL. ESWL had the lowest advantages.

Conclusions

LU have the potential to be considered as the first treatment choice of proximal ureteral stone ≥10mm.

Comparative evaluation of retrograde intrarenal surgery, antegrade ureterorenoscopy and laparoscopic ureterolithotomy in the treatment of impacted proximal ureteral stones larger than 1.5 cm

INTRODUCTION

The aim of this article was to compare retrograde intrarenal surgery (RIRS), antegrade ureterorenoscopy (URS), and laparoscopic ureterolithotomy (LU) for impacted proximal ureter stones larger than 1.5 cm in terms of operative data, success, complications, auxiliary treatment rates, and visual analog scale (VAS) scores.

MATERIAL AND METHODS

Medical records of patients undergoing RIRS, antegrade URS, or LU were retrospectively reviewed. After exclusion criteria, 122 patients were included in advanced analyses. Patients were divided into 3 groups as RIRS (n = 43), antegrade URS (n = 38) and LU (n = 41).

RESULTS

Operation time was shortest in the antegrade URS and hospitalization time was shortest in the RIRS group (p <0.001 and p <0.001, respectively). VAS scores were lowest in the RIRS group and highest in the LU group (p <0.001). Success (complete stone clearance) rates were 83.7%, 97.4%, and 97.5% in the RIRS, antegrade URS, and LU groups, respectively (p <0.001). Auxiliary treatment rates in the RIRS, antegrade URS, and LU groups were 19.1%, 2.6%, and 4.7%, respectively (p <0.001). Although there was no significant difference in terms of general complication rates, grade II complication rate (blood transfusion) was significantly higher in the antegrade URS group and grade IVb complication rate (urosepsis) was higher in the RIRS group according to the modified Clavien-Dindo classification system (p = 0.007 and p = 0.02, respectively).

CONCLUSIONS

Antegrade URS or LU are more logical options than RIRS for the treatment of large impacted proximal ureter stones. Between antegrade URS or LU, antegrade URS seems to be a more reasonable option due to its less invasive nature.

Surgical management of urinary stone

Urolithiasis is a common urological disease that causes a significant deterioration in patients’ life quality due to severe pain and frequent recurrence. With increases in the incidence of urolithiasis, different treatment methods have been developed. Although urolithiasis is still managed in Korea with extracorporeal shock wave lithotripsy, the development of minimally invasive techniques and endoscopy instruments has led to increased surgery. Prior to the introduction of endoscopy, urolithiasis surgery was performed as open procedures such as ureterolithotomy, pyelolithotomy, and nephrolithotomy. However, most recent stone surgeries are performed using endoscopy with comparable outcomes and fewer complications. Laparoscopic or robot-assisted laparoscopic surgeries are performed in exceptional cases. Since urolithiasis can be found in various urinary organs, such as the kidney, ureter, bladder, and even the urethra, the approach, method, and availability of endoscopy will vary depending on the stoneʼs size and location. Understanding the types and characteristics of each surgical method will determine the appropriate procedure for each patient and improve the surgical outcomes.

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.