Proximal Ureteral Stones Research Articles

Tratamiento endourológico de la litiasis ureteral lumbar. ¿Qué aporta la ureterorrenoscopia flexible?

Introduction and objectivesCurrently, there are no established criteria regarding treatment for lumbar ureteral stones. The objective of this work is to present our results in the endourological treatment of this pathology, analyzing the variables associated with the use of the flexible ureterorenoscope. Material and methodsRetrospective review of 103 patients who underwent retrograde URS with semi-rigid or flexible ureterorenoscope. Proximal location: L2-L3. Medial location: L4-L5. Semirigid URS was the initial treatment, with conversion to flexible URS when it was required to complete the procedure. Success was defined as absence of residual fragments (6 weeks). Demographic, surgical, immediate postoperative variables, and those related to the stone, were analyzed. Their correlation with the use of the flexible ureterorenoscope was evaluated. ResultsMean age: 57.2 years (SD 15.6); there were 73 men (70.9%). Stone size: 8mm (range 4-30; IQR 4.5). Proximal location: 58 (56.3%). Previous JJ: 44.7%. Previous nephrostomy: 10.7%. Semirigid URS with conversion to flexible URS: 51 (49.5%). Impacted stones: 28.2%. Intraoperative complications: 2 (1.9%). Postoperative JJ: 84.5%. Immediate postoperative complications: 23 (22.3%) (Clavien-Dindo I-II: 91.3%). Postoperative ureteral stricture: 5.8%. Success: 88.4%. Residual fragments: 12 (11.7%). Spontaneous passage: 6 (50%). Greater performance of flexible URS in proximal ureteral stones (P=0.001) of more than 11mm (P=0.02) in univariate analysis, and in proximal stones [OR 3.5; 1.5-8.1; P=0.004] in multivariate analysis. ConclusionsEndourological treatment obtained a high success rate in our sample. Size greater than 11mm and proximal ureteral location in univariate and multivariate analysis, respectively, behaved as predictors of flexible URS.

The Effect of Shock Wave Lithotripsy on Male and Female Sexual Dysfunction in Patients with Proximal Ureteral Stones

Introduction: This study aims to investigate the effects of shock wave lithotripsy (SWL) treatment for proximal ureteral stones on the sexual functions of patients of both genders. Methods: In this prospective study, 30 female and 72 male patients who had received SWL treatment for proximal ureteral stones in our clinic between August 2019 and October 2020 were evaluated. CT, creatinine, urinary analysis, and culture were performed during the initial consultation for all patients. Information regarding the age, BMI, and stone burden of the patients was recorded. Male patients answered the International Index of Erectile Function-5 (IIEF-5) questionnaire, and female participants answered the Female Sexual Function Index (FSFI) 3 times: pre-procedural and post-procedural first and third month. CT was repeated on the first month, and any residues were noted. Results: The mean IIEF-5 scores of the male patients were 23.11 ± 8.11 prior to surgery, and it decreased to 19.74 ± 7.65 in the first month and 23.88 ± 9.23 in the third, p = 0.001. The mean FSFI scores of female patients were 18.2 ± 9.9, which decreased to 12.8 ± 6.12 in the first month and 17.8 ± 8.66 in the third, p = 0.001. Univariate analysis revealed that the patients’ age (male: p = 0.004 and female: p = 0.008) and BMI (male: p = 0.044 and female: p = 0.027) were related to the poorer scores for both genders. However, there were not any significant findings regarding stone burden (male: p = 0.054 and female: p = 0.078). Conclusions: The possibility of developing temporary sexual dysfunction should be taken into account for patients who are candidates for SWL treatment. As the patient’s age and BMI increase, SWL-related sexual dysfunction becomes more severe.

NEEDLE RENAL LIFTING TECHNIQUE IN MANAGEMENT OF COMPLICATED PROXIMAL URETERAL LITHOTRIPSY: A CASE REPORT

Objective: To described a needle renal lifting technique using an 18-gauge needle to adjunct ureterorenoscopy (URS) in the management of complicated proximal ureteral stones. Case(s) Presentation: A 46 years old man presented with right flank pain for 1 month. This patient was diagnosed with ureteral stone and ureteral kinking that prohibits access to the proximal side of the ureter. Due to difficult access to the proximal ureter, we perform a needle renal lifting technique which is initialized by puncturing the middle renal calyx with 18-gauge needle. Then, the proximal end of the needle was pushed to the caudal direction to move the kidney to the cephalic direction and straighten the kinked ureter. After that procedure, the URS sheat can easily enter the proximal ureter to the stone site. Discussion: The success rate of this procedure is based on the operator skills to access the calyx and perform URS simultaneously. Like a previous technique, needle renal lifting is effective only when the kidney is mobile. Conclusion: The needle renal lifting technique can be used to adjunct URS in the management of complicated ureteral stones which prohibited access to the proximal ureter. 

Percutaneous antegrade ureterolithotripsy for proximal ureteral stones: overview own experience use

Introduction. Currently, a large number of techniques are used in the treatment of patients with ureteral stones: extracorporeal shock-wave lithotripsy (ESWL), retrograde ureterolithotripsy (RULT), laparoscopic and retro-peritoneoscopic ureterolithotomy.Purpose of the study. To evaluate the possibilities and effectiveness of percutaneous antegrade ureterolithotripsy in the treatment of patients with proximal ureteral stones in comparison with transurethral contact ureterolithotripsy.Materials and methods. Twenty-eight patients with urolithiasis were treated, who underwent percutaneous antegrade ureterolithotripsy (PAULT) and 27 patients of the control group, who underwent RULT. All patients included in the study underwent a standard preoperative examination: complete blood count and urine analysis, bacteriological urine culture, biochemical tests, and X-ray research methods. Plain urography, renal ultrasound, computed tomography were used as imaging methods. The OLYMPUS URF-V3 8.4 Ch (Olympus Europa SE & Co. KG., Germany) video uretero-renoscope was used for PAULT in patients of the main group; lithotripsy was performed using thulium laser. The results of the study were subjected to statistical processing in order to determine the statistical significance of the differences between the data obtained. Quantitative variables were described using the arithmetic mean (M) and standard deviation (5). Qualitative variables were estimated by absolute and relative frequencies (percentages). The data were considered reliable at p values < 0.05.Results. The average time of surgical intervention in patients of the main group from the moment of placement of the ureteral catheter was 47 ± 12 min, with access without preliminary renal catheterization: 28 ± 4 min. Average time of surgical intervention in patients of the control group: 42.0 ± 10.7 minutes. The presented data indicate a significant (p < 0.05) greater cases' number of complete stone removal among patients of the main group compared with patients in the control group (74.0%).Conclusion. PAULT is preferred among choice treatment methods for patients with proximal ureteral large stones, for whom RULT and ESWL cannot be performed with a high level of “stone-free” rate and a minimum number of complications.

Retrospective Analysis of the Factors Affecting Intraoperative and Immediate Postoperative Complications of Retrograde Intrarenal Surgery Classified by the Clavien and Satava Grading Systems.

Background: To classify intraoperative and postoperative complications using the modified Clavien classification system (MCCS) and modified Satava classification system (SCS) and to evaluate the parameters associated with complications in patients undergoing retrograde intrarenal surgery (RIRS) for renal and proximal ureteral stones. Materials and Methods: We performed a retrospective analysis of 949 patients who underwent RIRS for renal stones and proximal ureteral stones at two institutions between March 2015 and June 2020. Intraoperative complications were assessed using the SCS, and postoperative complications were graded according to the MCCS. Univariate and multivariate analyses were undertaken to determine predictive factors affecting complication rates. Results: The median stone size was determined as 13 mm (range 10-20 mm). The stone-free rate was 83.6% after the first intervention. Reprocedure was applied to 89 of the patients with residual stones and the final stone-free rate was 94.4% after reprocedure. According to SCS, the number of intraoperative events and complication incidences was 153 (16.1%). MCCS revealed postoperative complications in 121 (12.8%) patients. Major complications were observed in 18 (1.9%) patients. The rate of complications was higher in patients with renal anomalies (9.9% vs 3.4%, p = 0.001). Stone location, stone size, stone burden, stone number, stone density, and residual fragments were determined to be associated with the development of complications (p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.002, and p < 0.001, respectively). In addition, the multivariate analysis revealed that only the presence of residual fragments was a significant predictor of complication development for the patients with Grade ≥3 complications according to MCCS (p = 0.032). However, significant predictors were stone burden (p < 0.001), stone density (p = 0.002), and fluoroscopy time (p < 0.001) for those with Grade ≥2b complications according to SCS. Conclusion: This study showed that abnormal kidney anatomy, operation time, stone burden, and residual fragments were reliable predictors of complication development during and after RIRS. Appropriate preoperative management should be planned according to these predictors to prevent intraoperative and postoperative complications.

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%).

FREQUENCY AND PREDICTORS OF ACCESS FAILURE IN PATIENTS UNDERGOING URETERORENOSCOPY FOR UPPER URINARY TRACT CALCULI

Objective: To determine the frequency and factors responsible for access failure during primary ureteroscopy (URS).&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Aga Khan University, Karachi Pakistan, from Jan to Jul 2019.&#x0D; Methodology: All patients undergoing Ureterorenoscopy for upper urinary tract urolithiasis were included. Ureterorenoscopy was performed with either semi rigid, rigid digital or fiber opticflexible ureterorenoscope as appropriate. Data was collected for demographics, history of stone passage, previous Ureterorenoscopy /double J stenting and history of stent placement. Preoperative imaging reviewed for stone location, size and number. Level of access failure (proximal/mid/distal ureter) was noted. Post-operative complications and need of ancillary procedure was noted.&#x0D; Results: We included 250 participants undergoing ureteroscopy for the upper urinary tract calculi. Mean age of the patients was 44.15 ± 13.76 years. Mean stone size was 9.12 ± 4.23mm. Overall access failure rate was found to be 8% (20/250), all required an ancillary procedure. None of the patients with previous history of endoscopic intervention or stone passage had access failure. On univariate and multivariate analysis only stone location was found to be significant factor predicting access failure.&#x0D; Conclusion: Failure to access is not uncommon during primary ureteroscopy. Access failure is more common in proximal ureteral stone and in patients with no previous episode of ureteral stones and procedure. Information from this study will help in counseling patients’ pre-operatively and may be a guide to urologists on pre stenting of selected patients at high risk of access failure.

A profile of laparoscopic ureterolithotomy: four years initial experience at Persahabatan Hospital, Jakarta, Indonesia

Introduction: The introduction of laparoscopy in the field of urology has advanced surgery into a minimally invasive era, achieving better perioperative outcomes and lower incidence of complications. This study reports on the profile of laparoscopic ureterolithotomy performed in Persahabatan Hospital, Jakarta.Method: This retrospective study examined laparoscopic procedures done during the years 2016-2019. Demographic characteristics, surgical duration, length of stay, perioperative parameters, and antibiotics prescribed were recorded.Result: A total of 30 cases were reported. The gender ratio was 2:1 (male to female), with a mean age of 54.2 ± 9.9. Twenty-two (73.3%) had proximal ureteric stone. Surgical duration and length of stay had means of 197.4 ± 46.1 minutes and 3.6 ± 1.1 days, respectively. The mean blood loss, preoperative and postoperative hematocrit was 40.5 ± 27.8 mL, 36.14% ± 5.73 and 35.76% ± 5.71, respectively. Mean preoperative and postoperative hemoglobin was 12.27 g/dL ± 1.84 and 12.12 g/dL ± 1.89, respectively. The mean postoperative pain VAS score was 2.1 ± 0.8. The most prescribed antibiotics for the procedure were cefoperazone (53.33%).Conclusion: Considerably short duration of operations and hospital stay comparable with other study findings were reported. This study can be applied as baseline data for further research.

Proximal ureteral access for symptomatic stone removal using ultrathin semirigid ureterorenoscope in preschool-age children: Is it possible?

Introduction and ObjectivesWe aimed to point out the ureteral access facility and obstruction removal efficiency of mini-URS in the use of proximal ureteral stone management in children under five-year-old. PatientsWe retrospectively reviewed the data of 26 children who underwent mini-URS-LL for obstructive stones in proximal ureter between January 2016 and August 2018. The effectiveness of the mini-URS-LL was assessed based on the feasibility, reliability, and success of the technique. ResultsMean age was 3 ± 1.3 years, and 11 (42.3%) patients were ≤2 years old, remaining 15 (57.7%) were aged 3−5 years. Mean stone size was 9.11 ± 3.02 mm. A stone-free status was obtained at the end of 31 ureteroscopic procedure in 24 (92.3%) patients. The mean age was found significantly higher in patients who had the procedure without pre-stenting than the others who did (P = .027). No perioperative complication was experienced. ConclusionIn preschool-age children, laser lithotripsy with mini-URS may be a safe technique in the hands with advanced endo-urological skills but it has low efficacy with higher rates of prestenting causing additional anesthesia sessions.

Safety and Efficacy of Flexible Ureterorenoscopy Surgery in Different Age Groups.

To comparatively investigate the efficacy, safety and complications of flexible ureterorenoscopy (f-URS) in the treatment of patients of different age groups (<60, 60-74 and ≥75 years) with proximal ureteral and kidney stones. Descriptive study. Department of Urology, HSU Izmir Bozyaka Training and Research Hospital, HSU Ankara Diskapi Training, Research Hospital, and Mustafa Kemal University Faculty of Medicine, between March 2014 and June 2020. Nine hundred and fifty-six patients, who underwent f-URS due to proximal ureteral and kidney stones, were divided into three age groups as <60 years (Group 1), 60-74 years (Group 2) and ≥75 year (Group 3). The patients' American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), anticoagulant use, stone-free rates and surgical and medical complication rates were examined for each group. There were 688 patients in Group 1, 230 in Group 2, and 38 in Group 3. A significant difference was observed between the age groups in terms of CCI and anticoagulant use (p<0.001 for both). The highest rate of medical complications was observed in Group 3 at 42.1%, followed by Group 2 at 17.8%, while the lowest rate was observed in Group 1 at 2.3% (p<0.001). As a result of the multivariate analysis, receiving anticoagulant treatment (p=0.002) and having a high CCI (p=0.005) were independent predictors of medical complication development. It was clearly demonstrated that f-URS could be used as a safe and effective alternative for the treatment of moderate-size kidney stones in all age groups. Key Words: Elderly, Geriatric patients, RIRS, Holmium laser lithotripsy, Urolithiasis, Safety, Efficacy.

P0297 - Percutaneous nephrolithotomy can reduce the incidence of sepsis compared with flexible ureteroscopy in treating solitary proximal ureteral stone patients with positive urine culture

P0297 - Percutaneous nephrolithotomy can reduce the incidence of sepsis compared with flexible ureteroscopy in treating solitary proximal ureteral stone patients with positive urine culture

Ureteroscopy-assisted puncture for ultrasonography-guided renal access significantly improves overall treatment outcomes in endoscopic combined intrarenal surgery.

To assess the impact and availability of ureteroscopy-assisted puncture for percutaneous renal access during ultrasonography-guided miniaturized (mini)-endoscopic combined intrarenal surgery for large volume renal and/or proximal ureteral stones. We conducted a multi-institutional retrospective cohort study for urolithiasis treatment. Data from a total of 313 patients who underwent mini-endoscopic combined intrarenal surgery to treat renal and/or ureteral stones between January 2016 and April 2020 were collected. We compared the outcomes between ultrasonography-guided mini-endoscopic combined intrarenal surgery with and without ureteroscopy-assisted puncture (ureteroscopy-assisted puncture(+) group [n=126] and ureteroscopy-assisted puncture(-) group [n=187] group, respectively). The primary outcome was requirement for additional surgical intervention. Secondary outcomes were stone-free rate, complications and total procedure, fluoroscopy, hospital stay, and postoperative ureteral stent placement durations. The ureteroscopy-assisted puncture(+) group had a lower additional surgical intervention rate and a higher stone-free rate immediately after and 3months after surgery than the ureteroscopy-assisted puncture(-) group (5.6% vs 19.7%, P<0.001; 82.5% vs 65.8%, P=0.001; 59.5% vs 44.6%, P=0.011). The median total procedure, fluoroscopy, and postoperative ureteral stent placement durations were 18min, 3min, and 5days shorter, respectively, in the ureteroscopy-assisted puncture(+) group. Multivariate analyses showed that ureteroscopy-assisted puncture was associated with a decreased risk of additional surgical intervention (odds ratio 0.31, P=0.011) and postoperative infection (odds ratio 0.34, P=0.003) and decreased total procedure (estimate=-11min; P=0.011), fluoroscopy (estimate=-3min; P=0.034), and postoperative ureteral stent placement (estimate=-8days; P=0.011) durations. Female patients and those with smaller stone volumes or without hydronephrosis were identified as ideal ureteroscopy-assisted puncture candidates. Ureteroscopy-assisted puncture during mini-endoscopic combined intrarenal surgery could provide favorable surgical outcomes, especially in female patients without collecting system obstruction.

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.

Acceso ureteral proximal para la eliminación de cálculos sintomáticos mediante ureterorrenoscopio semirrígido ultrafino en niños en edad preescolar: ¿es posible?

Introduction and objectivesWe aimed to point out the ureteral access facility and obstruction removal efficiency of mini-URS in the use of proximal ureteral stone management in children under five-year-old. PatientsWe retrospectively reviewed the data of 26 children who underwent mini-URS-LL for obstructive stones in proximal ureter between January 2016 and August 2018. The effectiveness of the mini-URS-LL was assessed based on the feasibility, reliability, and success of the technique. ResultsMean age was 3±1.3 years, and 11 (42.3%) patients were≤2 years old, remaining 15 (57.7%) were aged 3-5 years. Mean stone size was 9.11±3.02mm. A stone-free status was obtained at the end of 31 ureteroscopic procedure in 24 (92.3%) patients. The mean age was found significantly higher in patients who had the procedure without pre-stenting than the others who did (P=.027). No perioperative complication was experienced. ConclusionIn preschool-age children, laser lithotripsy with mini-URS may be a safe technique in the hands with advanced endo-urological skills but it has low efficacy with higher rates of prestenting causing additional anesthesia sessions.

Percutaneous Nephrolithotomy Can Reduce the Incidence of Sepsis Compared with Flexible Ureteroscopy in Treating Solitary Proximal Ureteral Stone Patients with Positive Urine Culture.

Background Sepsis is a potentially lethal complication for both flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PCNL). This study is aimed at comparing the sepsis rate after fURS and PCNL and the risk factors for sepsis in patients with solitary proximal ureteral stone. Methods We reviewed the data of patients with calculi between 10 mm to 20 mm who underwent fURS or PCNL surgery from Tongji Hospital's database. A total of 910 patients were eligible with 412 fURS cases and 498 PCNL cases. We used univariate analysis and multivariate logistic regression analysis to identify the risk factors for sepsis. Subgroup analysis was performed using logistic regression analysis. Results In the cohort, 27 (6.6%) and 19 (3.8%) patients developed sepsis after fURS and PCNL, respectively. Multivariate analysis shows that the risk factors for sepsis are fURS (OR = 3.160, P = 0.004), serum WBC ≥ 10,000 cells/μL (OR = 3.490, P = 0.008), albumin − globulin ratio < 1.2 (OR = 2.192, P = 0.029), positive urine culture (OR = 6.145, P < 0.001), and prolonged operation time (OR = 1.010, P = 0.046). Subgroup analysis was conducted using potential risk factors: stone size, serum WBC, urine culture, and albumin-globulin ratio (AGR). In subgroup of positive urine culture, patients were more likely to develop sepsis after fURS than PCNL. Conclusions PCNL may be a better choice than fURS to reduce postoperative sepsis, especially for patients with positive urine culture.

Fluoroless endourological surgery for high burden renal and proximal ureteric stones: A safe technique for experienced surgeons

ABSTRACT Objective: To describe the feasibility of treating proximal ureteric and renal stones using flexible ureteroscopy (fURS) or a double approach (mini-percutaneous nephrolithotomy [PCNL] + fURS) without any use of radiation. Patients and methods: We retrospectively reviewed the data of all patients operated by one surgeon for retrograde endoscopic removal of renal and ureteric lithiasis performed between June 2015 and January 2019 in our institution. Patients with anatomical complexities, high-burden stone disease (diameter >20 mm), and medical comorbidities (anti-platelet drug administration) were included in our study. Outcomes analysed included complication rate, stone-free rate (SFR, defined as no residual stone >1 mm), and repeat procedure rate. Results: In all, 183 consecutive URS for proximal ureteric and renal lithiasis were conducted. C-arm fluoroscope guidance was not required, not even in the complex cases. Simultaneous ultrasonography and fURS guidance was used in patients where the mini-PCNL approach was indicated. Lead aprons were not needed by the operating room staff in any of the operations. The SFR was 91.8% after the first procedure, with no Clavien–Dindo Grade III or IV complications. Conclusion: Our present series shows clearly that the fURS and mini-PCNL approach under fURS control is a feasible and safe technique for experienced surgeons. Patients had a high SFR and no technique-related complications, with no additional risk of X-ray exposure. However, a prospective study is required to test the reproducibility of this technique. Abbreviations: GMSV: Galdakao-modified supine Valdivia; ICRP: International Commission on Radiological Protection; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; OR: operating room; PCNL: percutaneous nephrolithotomy; SFR: stone-free rate; UAS: ureteric access sheath; (f)URS: (flexible) ureteroscopy; US: ultrasonography

Does extracorporeal shock wave lithotripsy before retrograde intrarenal surgery complicates the surgery for upper ureter stone? The results of the RIRSearch group.

To evaluate the effect of pre-RIRS ESWL on the efficiency and safety of RIRS in the treatment of proximal ureter stones. The patients in the study population were divided into two groups. Group-1 was composed of patients who had undergone ESWL for proximal ureter stones before RIRS and Group-2 was composed of patients who directly underwent RIRS without any prior ESWL. The clinical and demographic properties of the patients were analysed in the RIRSearch database. The operative outcomes, peroperative complications, postoperative complications, hospitalisation time and stone-free rates were compared between the groups. There were 56 patients in Group 1 and 95 patients in Group 2. The demographic and clinical properties were similar between the groups. The stone-free rates, peroperative complications and postoperative complications were also similar between the groups; however, the fluoroscopy time was significantly higher in Group 1 (P=.043). The cut-off duration of 10weeks between ESWL and RIRS had reasonable/favourable discriminating ability, with a 51% sensitivity and 88% specificity rate for stone-free status. Performing ESWL on the proximal ureter stones before RIRS did not change the efficacy and safety of RIRS. The time between the patient's last ESWL session and RIRS had a predictive value for stone-free status, but did not have any effect on complications.

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

BackgroundAntegrade 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.MethodsThis 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 s 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.ResultsA 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.ConclusionsDespite the heterogeneity of data and bias limitations, this latest evidence reflects real practice data, which may be useful for decision making.

Prediction of Proximal Ureteral Stones Clearance after Shock Wave Lithotripsy Using an Artificial Neural Network.

The cumulative effect of measurable parameters on proximal ureteral stone clearance followed by the shock wave lithotripsy was assessed via the application of an artificial neural network. From January 2015 to January 2020, 1182 patients with upper ureteral stone underwent extracorporeal shock wave lithotripsy (ESWL) with supine position. The corresponding significance of each variable inputted in this network was determined by means of Wilk's generalized likelihood ratio test. If the connection weight of a given variable can be set to zero while maximizing the accuracy of the network classification, the variable is not considered an important predictor of stone removal. A total of 1174 cases (excluding 8 cases) were randomly assigned into a training group (813 cases), testing group (270 cases), and keeping group (91 cases). We evaluated artificial neural network analysis to the stone clearance rate of the training group, with a predictive accuracy of 93.2% (482/517 cases). While the predictive accuracy of the stone clearance rate of the training group was 75.3% (223 cases/296 cases). The order of importance of independent variables was stone length > course (d) > patient's age > Stone Width > PH value. The neural network possess a huge prediction potential for the invalidation of ESWL.

‘Boxing in the corner’: A modified retrograde approach for the management of proximal ureteric stones of 1–2 cm

ABSTRACT Objectives: To study a modification to the conventional retrograde ureteroscopic approach for treating proximal ureteric stones of 1–2 cm; we intentionally push the stone from the proximal ureter into a favourable calyx then the flexible ureteroscope is used to fragment the trapped stone using laser lithotripsy (‘boxing in the corner’). Patients and methods: The study was conducted in a randomised prospective manner and included 100 patients who presented with a single proximal ureteric stone of 1–2 cm. We randomised the patients into two equal groups: Group A (50 patients) underwent the conventional retrograde technique (CRT) and Group B (50 patients) underwent the modified retrograde technique (MRT) with the primary intention of relocating the stone into a favourable calyx. Intended relocation of the proximal ureteric stone in the MRT group was achieved in a stepwise manner. All intraoperative parameters and postoperative outcomes were recorded and compared between the two groups. Results: There was no statistical significant difference in terms of the patients’ demographics and stone criteria between the two groups. The stone-free rate (SFR) was significantly higher in Group B (92%) compared to Group A (78%) (P = 0.049). Fluoroscopy time was significantly longer in Group B (P < 0.001), while operative time, lithotripsy time and hospital stay were comparable. There was no difference between the groups regarding complications. Conclusion: The MRT was found to be safe and more effective than the CRT for treating proximal ureteric stones of 1–2 cm, with a significantly higher SFR. Abbreviations CONSORT: Consolidated Standards of Reporting Trials; ESWL: extracorporeal shockwave lithotripsy; fURS: flexible ureteroscope; NCCT: non-contrast CT; SFR: stone-free rate; YAG: yttrium-aluminium-garnet