Large Impacted Proximal Ureteral Stones Research Articles

Propensity score matched comparison of transperitoneal laparoscopic ureterolithotomy and percutaneous nephrolithotomy for management of large impacted proximal ureteral stones with long-term follow-up.

Impacted proximal ureteral stones (IPUS) present challenging clinical scenarios due to their persistent nature and associated complications. While ureterorenoscopy (URS) lithotripsy is recommended as the primary treatment, controversies exist regarding the optimal management of such stones. In this retrospective analysis, we compared the operative outcomes and long-term results of transperitoneal laparoscopic ureterolithotomy (LU) and percutaneous nephrolithotomy (PCNL) for IPUS larger than 15mm. Propensity score matching (PSM) was employed to mitigate potential selection biases. Following PSM, 83 patients in each cohort exhibited comparable baseline characteristics. LU demonstrated a superior surgical success rate (100% vs. 96.4%, p = 0.244) and significantly lower perioperative hemoglobin decline (0.6 ± 0.4g/dL vs. 1.5 ± 0.7g/dL, p = 0.036) compared to PCNL. Additionally, LU exhibited a higher stone-free rate after 2 months (100% vs. 91.6%, p = 0.043), but a longer duration of catheterization (7.4 ± 1.2 days vs. 3.5 ± 2.2 days vs., p = 0.011). Conversely, PCNL was associated with a higher incidence of total complications (21.7% vs. 9.6%, p = 0.033) and stone recurrence during a mean period of 40-month follow-up (20.5% vs. 8.4%, p = 0.027). Transperitoneal LU and PCNL represent effective interventions for managing IPUS exceeding 15mm. Notably, LU emerges as a preferable option over PCNL, offering superior stone clearance rates, reduced perioperative complications, and lower recurrence rates.

Safety and efficacy of ureteroscopy for the treatment of large impacted proximal ureteralstones

Introduction and objective: Management of large impacted proximal ureteral stones is often challenging due to the presence of mucosal edema, inflammation and angulations of the ureter. Improvements in ureteroscopic technology increased the efficacy and safety of ureteroscopy (URS) as a first-line treatment in large impacted stones in the proximal ureter. The objective of this retrospective study is to evaluate the efficacy and safety of URS for the management of impacted proximal ureteral stones ≥ 10 mm. Material and methods: The medical records of 700 patients with ureteral stones, who underwent ureteroscopy and intracorporeal lithotripsy between January 2016 and Аpril 2024 were retrospectively reviewed. 179 patients had impacted stones ≥ 10 mm located in the proximal ureter – 125 (70%) were stones sized 10÷15 mm and 54 (30%) – stones ≥ 15 mm. URS was performed with 8.6 or 6.4Fr semirigid ureteroscope and Holmium laser. Flexible URS was performed in cases with tortuous ureter or stone retropulsion. Data on patients‘ preoperative characterstics, stone-free rates, operating times, intra- and postoperative complications were analyzed. Results: Patients’mean age was 54.1±12.3 years and mean stone size – 14.7±.4.8 mm. 30 % of the patients had previous unsuccessful shock- wave lithotripsy of the stone. Mean operative time was 45.1±15.7 min min and overall success rate – 85.3%. 66.2% of patients were treated with semirigid URS and 33.8% – with flexible URS. On subgroup analysis patients with stones 10÷15 mm and patients with stones ≥ 15 mm had similar preoperative characteristics. Success rate after a single procedure was higher and operating times significantly shorter in the subgroup of stones sized 10÷15 mm (87.1% vs 71.3%, p=0.159 and 41.3±12.9 vs 53.3±21.3 min, p=0.040,respectively). There were no statistically significant differences between the two subgroups in intraoperative stent JJ placement (34.1% vs 50.0%, p=0.400), stone retropulsion (21.3% vs 23.1%, p=0.847) and overall postoperative complications rate (9.3% vs 0%, p=0.161). Conclusion: The results of this study suggest that URS is a safe and effective treatment for management of patients with large impacted proximal ureteral stones. Larger stone size was a predictor of lower success rate after a single procedure.

Comparison of minimally invasive percutaneous nephrolithotomy and ureteroscopy in the management of impacted proximal ureteral stones

Introduction and objective: Management of large impacted proximal ureteral stones is often challenging due to the presence of mucosal edema, inflammation and angulations of the ureter and other factors which impede stone access, visibility and lithotripsy and can lead to different types of complications. The objective of our study is to compare the efficacy and safety of minimally invasive percutaneous nephrolithotripsy (mini-PCNL) and ureteroscopy (URS) in the treatment of impacted proximal ureteral stones. Material and methods: The medical records of 345 patients with impacted proximal ureteral stones 10-20 mm, treated between January 2016 – November 2022 were retrospectively reviewed. 178 patients (51.6%) underwent mini-PCNL, and 167 (48.4%) – URS. Data on patients’ preoperative characteristics, stone-free rates, operating times, intra- and postoperative complications were compared. Results: Patients’ preoperative characteristics were comparable between the two groups, except for mean stone surface and stone size, which were significantly higher in the mini-PCNL group (respectively, 137.87±44.32mm2 vs 80.94±29.66mm2, p=0.000; and 15.03±2.43 vs 12.02±2.22mm, p=0.000). The stone free rate after single procedure was 94.9% for mini-PCNL and 89,3% in the URS group (p=0,116). Four patients (2.3%) in the mini-PCNL group had significant hemorrhage necessitating selective renovasography and angioembolization of AV fistula. 21 (12.5%) patients had stones showing upward migration during the URS procedure and 3 (1.8%) had partial perforation of the ureteral wall. Hemoglobin drop was significantly higher in mini-PNL group (13.58±12.79g/l vs 4.69±5.72g/l, p=0,000). Mean operative time was significantly longer in the URS group, despite the smaller size of the stones (respectively, 41.41±13.62min vs. 30.67±10.34min, p=0,000). There were statistically significant difference of the necessity of auxiliary procedures in the URS group (respectively, 78 patients (46,4%) vs 6 patients (3.6%), p=0.000). Conclusions: For an impacted, proximal ureteral stone mini-PNL had better stone-free rates, shorter operative time and low percentage of auxiliary procedure and hospitalizations. However, URS had the advantages of less invasiveness procedure and shorter postoperative hospital stay.

Efficacy and safety of retrograde ureteroscopy for the treatment of impacted proximal ureteral stones larger than 10 mm

Introduction and objective: Optimal management of large impacted proximal ureteral stones remains controversial. Retrograde ureteroscopy in these cases may be challenging due to the presence of mucosal edema and inflammation, tortuousity and unusual angulations of the ureter. The objective of this study is to evaluate the efficacy and safety of retrograde ureteroscopy (URS) for the treatment of impacted proximal ureteral stones larger than 10 mm. Material and methods: A prospectively collected database of 143 patients, who underwent retrograde ureteroscopy for impacted proximal ureteral stones ≥ 10 mm between January 2016 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates, complications and auxiliary procedures was analyzed. Results: Patients’ mean age was 54.2±13.4 years, and male-to-female ratio – 67.8%/32.2%. Mean stone length was 14.2±5.4 mm and mean stone width – 9.6±2.9 mm. 26 (18.2%) patients were on preoperative anticoagulation therapy, which could not be discontinued. 26 patients (18.2%) had preoperative drainage with ureteral stent JJ, and 7 (4.9%) – with percutaneous nephrostomy. Stone-free rate after single procedure was 88.8%. Mean operative time was 44.2±15.4 min. There were no cases of failed endoscopic access to the stone. Flexible ureteroscopy was performed in 34 (23.8%) cases. Postoperative drainage was ureteral stent JJ in 71 (49.7%) patients and ureteral catheter for 24 h – in 33 (23.1%). Most common postoperative complications were fever in 5 (3.5%) and postoperative renal colic – in 5 (3.5%) patients. 8 patients (5.6%) underwent SWL for treatment of residual fragments and 2 (1.4%) – retrograde intrarenal surgery. Conclusions: The results from this study demonstrate that retrograde ureteroscopy is an effective and safe treatment modality for impacted proximal ureteral stones ≥ 10 mm. Its high stone-free rate and low complication rate make retrograde URS a suitable first-line treatment for anticoagulated patients with impacted proximal ureteral stones, who are at increased risk of complications from the antegrade approach

Ultrasound-Guided Mini Percutaneous Nephrolithotomy with Suction Sheath.

The mini percutaneous nephrolithotomy (PCNL) is a mainstay in the treatment of kidney calculi, particularly in case of >2 cm kidney stones, large lower pole stones, large impacted proximal ureteral stones, and residual stones after failed extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. An accurate renal access represents a fundamental part of the procedure, modalities to guide the percutaneous tract preparation include ultrasound, fluoroscopy, or their combination. Both ultrasound and fluoroscopy offer several advantages and some limitations. The combined utilization of ultrasound and fluoroscopy is less adopted nowadays; however, this strategy has its merits particularly in cases where the puncture can be problematic with one imaging modality alone. Ultrasound can easily identify the posterior renal calix and surrounding visceral structures, although some situations such as obese patients, undilated collecting system or complex stones may represent a challenge. Intracaliceal blood clots and air may reflect ultrasound, reducing significantly the image quality. Therefore, the assessment of the intrarenal anatomy, the stone identification, and the ability of guiding the needle during access may decrease significantly, particularly in cases with complex stones, when multiple tracts are required. In these cases, fluoroscopy could determine the relationship between the angle and depth of the puncture needle and the target calices by rotating the C-arm to help the needle puncture and tract dilation. Therefore, the benefits of dual guidance would be beneficial during PCNL. In addition to an improved accuracy of puncture and dilation, the combined approach improves the detection of residual stones, facilitating the achievement of a stone-free state. Herein we describe our experience with this technique, describing surgical steps and troubleshooting tips of mini-PCNL in the accompanying video. Further high-quality studies are needed to demonstrate the advantages of combined utilization of ultrasound and fluoroscopy during PCNL and its optimal indications.

The Surgical Technique of Mini Percutaneous Nephrolithotomy.

The mini percutaneous nephrolithotomy (mini-PCNL) has become a versatile tool to remove kidney stones >2 cm, lower pole stones >1 cm, renal stones previously unresponsive to shockwave therapy or inaccessible by ureteroscopy (within a caliceal diverticulum), stones within complex urinary tracts (urinary diversions, transplanted kidney, and horseshoe kidneys), and large impacted proximal ureteral stones. After positioning in either the supine or prone position, a cystoscopy is performed to place an open-ended catheter, occlusion balloon, or Accordian device into the collecting system. A foley catheter is placed in the bladder. An ultrasound with a curvilinear probe is used to survey the kidney and guide access into the collecting system with an 18 g percutaneous needle. Once access is obtained, a small 0.5 cm skin incision is made and the percutaneous tract is dilated over a wire. A 16.5F metallic or self-dilating suctioning access sheath is positioned with fluoroscopic guidance. A 12F rigid mini-PCNL nephroscope is used to evaluate the collecting system. Once a calculus is observed, options for stone fragmentation include a lithotripter with ultrasonic and ballistic energy, or laser lithotripsy using holmium or thulium laser fibers. Flexible ureteroscopy can be considered to ensure clearance of the collecting system. A 6F ureteral stent can be placed in either a retrograde or antegrade approach for drainage. The tract is sealed using Surgiflo hemostatic matrix with thrombin. Guidelines for postoperative care and troubleshooting techniques for mini-PCNL are reviewed along with the surgical steps in the accompanying video (Supplementary Video S1). There are few randomized trials comparing mini-PCNL with standard PCNL and ureteroscopy. There is some evidence to suggest a difference in transfusion rates comparing mini- and standard PCNL, as well as differences in stone-free rates when comparing mini-PCNL with ureteroscopy for the treatment of lower pole stones.

The Role of Antegrade Ureterolithotripsy in the Treatment of Large Impacted Proximal Ureteral Stones

The objective: optimization of approaches to the choice of endoscopic ureterolithorpsy method in the presence of large stones of the proximal ureter. Materials and methods. For the period 2017–2020 y. the study included 136 patients with large stones of the proximal ureter, who were performed one of two methods of ureterolithotripsy: rULT (group I) or m-aULT (group II). In group I 73 (53,7%) patients were operated, in group II – 63 (46,3%) patients. The age of patients ranged from 18 to 81 years, the average age was 52,7 years (54±10,5). The age of patients in group II ranged from 25 to 77 (63±10,5) years; the size of a concrement from 10 to 20 (14±3,5 mm). In group I, the age of patients ranged from 18 to 91 (63,5±10 years); the size of a concrement from 7 to 20 (12±5,5 mm). Results. The average time of m-AULT was 58,5±15,4 min, while the status of stone free was achieved in all 100% of patients. The operation ended with the installation of nephrostomy drainage in 11 (17,5%) cases, nephrostomy drainage and internal ureteral JJ-stent – in 33 (52,4%), in 19 (30,2%) cases – tubeless drainage method with the installation of ureteral stent. And the total percentage of stenting in staghorn stones of the proximal ureter, after lithotripsy and litholapaxy was 82,6% (52 patients). RULT surgery in 92% (67 patients) of cases ended with drainage of the kidney by JJ-stent, in 6 (8%) patients the operation ended without drainage. Conclusions. Analyzing the results, it was noted that the antegrade approach is a safe and effective method of treatment for proximal ureterolithiasis in the group with large stones of the proximal ureter, where the effectiveness of RULT (SFR up to 86,3±3,9%) is significantly inferior to AULT, and minimizing the size of instruments m-aULT) reduces the number and degree of complications associated with the size of the coiled tract, while providing a high level of SFR (96,8±4,4%).

Comparison of mini-percutaneous nephrolithotomy and retroperitoneal laparoscopic ureterolithotomy for treatment of impacted proximal ureteral stones greater than 15 mm.

Background:The optimal treatment for large impacted proximal ureteral stones remains controversial. The aim of this study was to evaluate the efficacy, safety, and potential complications of mini-percutaneous nephrolithotomy (MPCNL) and retroperitoneal laparoscopic ureterolithotomy (RPLU) in the treatment of impacted proximal ureteral stones with size greater than 15 mm.Methods:A total of 268 patients with impacted proximal ureteral stones greater than 15 mm who received MPCNL or RPLU procedures were enrolled consecutively between January 2014 and January 2019. Data on surgical outcomes and complications were collected and analyzed.Results:Demographic and ureteral stone characteristics found between these two groups were not significantly different. The surgical success rate (139/142, 97.9% vs. 121/126, 96.0%, P = 0.595) and stone-free rate after 1 month (139/142, 97.9% vs. 119/126, 94.4%, P = 0.245) of RPLU group were marginally higher than that of the MPCNL group, but there was no significant difference. There was no significant difference in the drop of hemoglobin between the two groups (0.8 ± 0.6 vs. 0.4 ± 0. 2 g/dL, P = 0.621). The mean operative time (68.2 ± 12.5 vs. 87.2 ± 16.8 min, P = 0.041), post-operative analgesics usage (2/121, 1.7% vs. 13/139, 9.4%, P = 0.017), length of hospital stay after surgery (2.2 ± 0.6 vs. 4.8 ± 0.9 days, P < 0.001), double J stent time (3.2 ± 0.5 vs. 3.9 ± 0.8 days, P = 0.027), time of catheterization (1.1 ± 0.3 vs. 3.5 ± 0.5 days, P < 0.001), and time of drainage tube (2.3 ± 0.3 vs. 4.6 ± 0.6 days, P < 0.001) of MPCNL group were significantly shorter than that of the RPLU group. The complication rate was similar between the two groups (20/121, 16.5% vs. 31/139, 22.3%, P = 0.242).Conclusions:MPCNL and RPLU have similar surgical success and stone clearance in treating impacted proximal ureteral stones greater than 15 mm, while patients undergoing MPCNL had a lower post-operative pain rate and a faster recovery.

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

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

Safety and efficacy of mini-percutaneous nephrolithotomy in the treatment of large impacted proximal ureteral stones

Background: To evaluate the efficacy and safety of Mini-Percutaneous Nephrolithotomy (PCNL) in the treatment of large (≥15mm) impacted proximal ureteral stones.Methods: This was a prospective observational study and was conducted in the Postgraduate Department of Surgery, Govt. Medical College, Srinagar. A total of 60 patients were included in this study.Results: The mean age (in years) of patients was 38.5±9.31 and range 22-58, the male female ratio was 40:20, the disease laterality (right: left) was 48:12, the mean stone size (in mms) was 17.6±2.11. All the patients were having hydronephrotic kidneys, however, all the renal units were functional. The mean operative time (in minutes) was 62±9.62. The overall success rate was 96.7% after one month of follow-up the stone free rate was 96.7% while as the stone free rate on discharge was 86.7%. The mean hospital stays (in days) was 2.8±1.08. The overall complication rate in this study was 15 patients (25%) which include post-operative fever in 5 patients (8.33%), prolonged hematuria in 4 patients (6.67%), residual stone/disease after 4weeks of follow-up was seen in 2 patients (3.33%) and in 4 patients (6.67%) thoracic complication was seen. However, no ureteral injury, hollow visceral or pelvic perforation was noted. The post-operative analgesic requirement was 100±40.45mgs of Inj. Tramadol. The need of auxiliary procedures was required in 3.3% of patients.Conclusions: Mini-PCNL is both safe as well as an effective therapy for large impacted proximal ureteral stones with a higher success, stone clearance rate and with acceptable complications.

Safety and efficacy of Mini-Percutaneous Nephrolithotomy in the treatment of large impacted Proximal Ureteral Stones

The management of large, impacted upper ureteric calculi remains challenging for urologists. Various treatment options include extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopic lithotripsy (URSL), percutaneous nephrolithotripsy (PCNL), laparoscopic and open ureterolithotomy. ESWL has poor overall success rate in the treatment of large stones with a significant possibility of residual fragments.

REASONS AND TREATMENT FOR URETERAL AVULSION

From 2010 to 2016 years we obsreved 8 patients with ureteral avulsion after endoscopic surgeries. All patients were men, their age ranged from 50 to 71 years. In all patients the ureter was damaged during ureteroscopy with lithotripsy and lithoextraction. Of the 8 patients, two had proximal ureteral avulsion between upper and middle thirds, four had ureteral avulsion 4 cm away from the pyeloureteral junction , two had had complete pyeloureteral junction avulsion. In 7 cases trauma of ureter occured at other hospitals. These patients were underwent revision of retroperitoneal space and drain for kidney by nephrostomy (6) and ureterocutaneostomy (1). One case occurred at our department and this patient was underwent laparoscopic nephrectomy with autotransplantation. The patient with ureterocutaneostomy was treated by nephrovesical bypass. In 6 patients with extended ureteral strictures we performed ileoureteroplasty. Results of reconstructive surgeries and nephrovesical bypass were successful in all patients. No intra- and postoperative complications. Mean operative time during uleoureteroplasty was 180 min, laparoscopic nephrectomy with autotransplantation – 210 min, nephrovesical bypass – 110 min. Ureteral avulsion often associated with ureterosopy in patients with large impacted proximal ureteral stones. In most cases after these injuries were diagnosed extended ureteral stricture that requires performing for autotransplantation or ileoureteroplasty.

047 - Percutaneous nephrostomy insertion followed by laser ureterolithotripsy versus immediate laser ureterolithotripsy for the management of large impacted proximal ureteral stones

047 - Percutaneous nephrostomy insertion followed by laser ureterolithotripsy versus immediate laser ureterolithotripsy for the management of large impacted proximal ureteral stones

Experience of Mini-Percutaneous Nephrolithotomy in the Treatment of Large Impacted Proximal Ureteral Stones

Objectives: To evaluate the efficacy and safety of mini- percutaneous nephrolithotomy (PCNL) in the treatment of large impacted proximal ureteral stones. Methods: We retrospectively reviewed the outcomes of 163 patients who underwent mini-PCNL between January 2006 and August 2010. Mean age was 48.6 years and mean stone size was 18.4 mm. Hydronephrosis and/or hydroureterosis appeared in all patients. In the prone position, percutaneous access (16-Fr sheath) was established by placement of an access needle into the intended calyx under fluoroscopic guidance or combined with ultrasound guidance for complete obstruction by stones while the contrast agent cannot transit. Pneumatic or ultrasonic probes were used throughout ureterorenoscopy for lithotripsy. The ureteral stents and nephrostomy tube were placed at the end of the procedure. Mean drop in hemoglobin, operative time, success rate, hospital stay, and complications were assessed. Results: Mini-PCNL operations were performed successfully in all patients. Mean operation time was 37 min. Mean postoperative hospital stay was 3.6 days. All cases were followed up for 6-20 months. No major complications like hemorrhage, perforation or organic injury were noted during the operation or postoperatively. The stone-free rate in all patients was 95.7%. Calculus had no recurrence during the follow-up period. Hydronephrosis and hydroureterosis disappeared or were relieved. Conclusions: Mini-PCNL is a safe and effective therapy for large impacted proximal ureteral stones.

Treatment of large impacted proximal ureteral stones: randomized comparison of minimally invasive percutaneous antegrade ureterolithotripsy versus retrograde ureterolithotripsy

To provide appropriate evidence for treatment planning of patients with an impacted proximal ureteral stones ≥1.5 cm in size, by analyzing the therapeutic outcomes for those undergoing minimally invasive percutaneous antegrade ureterolithotripsy and retrograde ureterolithotripsy. From September 2010 to November 2011, eligible patients with impacted proximal ureteral stones ≥1.5 cm in size referred to our institute were considered for this study. The closed envelope method was used to randomize the enrolled patients to mini-PCNL (30) or retrograde ureterolithotripsy (29). The efficiency quotient (EQ) was calculated to specifically address the efficiency for both the techniques. All preoperative and postoperative data for both groups were recorded. The initial stone-free rate was 93.3% in the mini-PCNL group and 41.4% in the URSL group (p < 0.001). However, the overall stone-free rate at the 1-month follow-up visit after initial treatment was 100% in the mini-PCNL group and 89.7% in the URSL group (p = 0.07). The EQs for the mini-PCNL and URSL groups were 0.83 and 0.50, respectively. Our study shows that mini-PCNL removal of large impacted proximal ureteral calculi can achieve higher stone-free rates and safe.

Treatment of Large Impacted Proximal Ureteral Stones: Randomized Comparison of Percutaneous Antegrade Ureterolithotripsy versus Retrograde Ureterolithotripsy

We compared the safety and efficacy of percutaneous antegrade ureterolithotripsy with retrograde ureterolithotripsy for large impacted proximal ureter stones in a prospective randomized manner. A total of 91 patients with large impacted proximal ureteral stones, defined as stones >1 cm in size located between the ureteropelvic junction and the lower border of the fourth lumbar vertebra, were prospectively randomized for antegrade (44) or retrograde (47) ureterolithotripsy. Failure of the procedure (conversion to an open procedure), intraoperative and postoperative morbidity, operative time, hospital stay, stone clearance at discharge home, and follow-up were analyzed in each group. The main complications were bleeding (2.3%; 1 of 43) for the antegrade procedure and ureteral injury (2.3%; 1 of 44) for the retrograde procedure. Percutaneous antegrade ureterolithotripsy was associated with longer operative times (75.4+/-11.8 v 30.6+/-7.8 minutes; P<0.001), longer hospital stay (6.3+/-0.5 v 2.1+/-0.4 days; P<0.001), and a longer interval to return to normal activities (7.8+/-0.7 v 2.7+/-0.6 days; P<0.001). Nevertheless, the percutaneous antegrade procedure had a higher stone-free rate both at discharge home (95.3% v 79.5%; P=0.027), and 1 month post-procedure (100% v 86.4%; P=0.026). Percutaneous antegrade ureterolithotripsy is a valuable treatment modality for impacted proximal ureteral calculi larger than 1 cm, and achieves higher stone-free rates than those of retrograde ureteroscopy with holmium:YAG laser lithotripsy. The drawbacks of the antegrade procedure are longer operative time and hospital stay.

Percutaneous Nephrostomy for Removal of Large Impacted Upper Ureteral Stones

The treatment for patients with large impacted proximal ureteral stone remains controversial. Extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy are the most popular treatment options due to their minimal invasive nature. However, percutaneous nephroscopic ureterolithotripsy is still important. Between June 2004 and March 2006, a total of 24 patients under went percutaneous antegrade nephrostomy for the removal of large impacted proximal ureteral stones of size > 15 mm. Combined ultrasonic and pneumatic lithotripters were used for the stone fragmentation. Twenty-three (95.8%) of the 24 patients were stone-free after one session of surgery. The mean operation time was 125.4 +/- 49.5 minutes (range, 45-170 minutes) and the mean postoperative hospital stay was 4.7 +/- 2.0 days (range, 4-12 days). Among the 24 patients, six experienced transient postoperative fever that could be controlled with appropriate antibiotics and supportive treatment, and two had blood loss requiring blood transfusion. We suggest that percutaneous nephroscopic ureterolithotripsy is a safe and efficient treatment option for the removal of large impacted proximal ureteral stones.

MP-19.03: Retroperitoneoscopy for treatment of ureteral stones

Recent advances in ureteroscopic management of ureteral stones with laser lithotripsy and in situ extracorporeal shockwave has made open surgery infrequent. But patients with large impacted proximal ureteral stones still may be a challenge for urologists. Laparoscopic technique has opened up a therapeutic option for the management of such cases.