Objective To assess the ef®cacy and safety of the retrograde ureteropyeloscopic holmium laser for treating renal stones that are too large to treat with extracorporeal shock wave lithotripsy (ESWL). Patients and methods Thirty patients (22 men and eight women, mean age 43 years, range 18±62) with a renal stone burden of >2 cm were selected for laser treatment. The stones were in the renal pelvis in 16 patients, lower calyx in ®ve, middle calyx in two, upper calyx in one and multiple pelvic and calyceal in six. Lithotripsy was undertaken using a holmium laser through 550 mm and 200 mm laser ®bres passed through a semi-rigid ®bre-optic long ureteroscope or the actively de¯ectable¯exible ureteropyeloscope, respectively. Success was de®ned as total fragmentation of the stone to <2 mm in diameter and/or clear imaging on renal ultrasonography and plain ®lms within the 3-month follow-up. Patients in whom the treatment failed received either alternative therapy or complementary ESWL.Results Endoscopic access and complete stone fragmentation was achieved in 23 of the 30 patients (77%). The treatment failed in seven patients because of poor visualization, the initial presence of stones in, or migration of their large fragments to, an inaccessible calyx. There were no major intraoperative complications. Minor complications after treatment included haematuria that persisted for 2 days in one patient and high-grade fever in two patients; all were treated conservatively. Conclusion Large renal calculi that are not amenable to ESWL monotherapy can be safely and effectively treated with a retrograde endoscopic technique that seems to compete well with the more invasive percutaneous or open surgical manoeuvres.

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