The management of ureteric stones

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The earliest observations that acoustic shockwaves could fragment brittle materials were made in the 1950s. The first experience of treating renal calculi in humans using extracorporeal shockwave lithotripsy (SWL) was reported in 19801 and by 1983 the first commercially-produced lithotriptor was available, the Dornier HM-3. Its use quickly became wide-spread and it revolutionised themanagement of urinary stone disease from what had previously been entirely surgical to what has become almost exclusively minimally invasive. Although stone fragmentation rates were impressive, treatment with the HM-3 required general anaesthesia. The development of second-generation lithotriptors allowed local anaesthetic treatment but at the cost of less efficient stone fragmentation. Outcomes of treatment with the most contemporary fourth generation lithotriptors approach those of the HM-3, but as an out-patient procedure with oral or intravenous analgesia.2 Today, approximately 80% of all upper tract urinary stone disease is treated with SWL. This topic has been a perennial discussion point amongst urologists; although the latest guidelines have suggested that the stone-free rates for ureteroscopy are higher than with extracorporeal shockwave lithotripsy (ESWL), it is well recognised that the evidence base is weak with many of the studies being retrospective, with precious few randomised clinical trials. This controversy is well argued on both sides by the two sets of authors who are eminent in the field of ureteric stone treatment. However, for the practicing urologist, the decision-making process is not always so straightforward and the decision to intervene must be based not only on the clinical situation faced by the patient, but also by the level of resource available locally. The EAU Guidelines (2008) suggest that 98% of stones 15 mm); (ii) impacted stones; (iii) unfavourable anatomy; and (iv) those in whom two sessions of ESWL have failed to achieve successful fragmentation (T Knoll et al. EAU Update Series 3, 2005). In these scenarios, intervention in the form of ureteroscopy is to be preferred, whilst, in the mid-ureter, the options are equal given the issues in respect of locally available resources and expertise. In the distal ureter, traditionally ureteroscopy is the modality of choice due to the ease of access, high stone-free rates and minimum of complications.