Is semirigid ureteroscopy sufficient in the treatment of proximal ureteral stones? When is combined therapy with flexible ureteroscopy needed?

Abstract

The goals of this study were to examine cases of proximal ureteral stones in which semirigid or flexible ureteroscopes alone were insufficient for endoscopic treatment, requiring the combination of both. A total of 137 patients were retrospectively evaluated. Holmium laser was used as the energy source for stone fragmentation. Each operation was begun with a 6/7.5 Fr semirigid ureteroscope (URS), and continued with a 7.5 Fr flexible URS in those procedures that failed to reach the stone or push-up. Double J stents were inserted into those patients in whom the flexible URS failed. Shock wave lithotripsy (SWL) or a repeat ureteroscopy (after 2–4 weeks) was planned in those patients who were considered to be treated unsuccessfully. The demographic features of the patients, stone sizes, treatment outcomes, need for additional treatment, complications, and the results of the postoperative 1-month early follow-up were evaluated. The mean age of the patients (77 males and 60 females) was 38 ± 6.7 years old, the mean stone size was 12.3 ± 3.7 mm, and the number of patients with persistent hydronephrosis was 86 (62.8 %). A stone-free diagnosis was achieved in a total of 124 patients (90.5 %), using a semirigid URS in 80 patients and a flexible URS in 44 patients. Treatment using a flexible URS was administered in 38 patients (27.7 %) due to push-up, and in 6 patients (4.3 %) because of the failure to advance the semirigid URS into the ureter. The treatment failed in 13 patients (9.4 %) despite the use of both methods. Treatment using low-caliber semirigid ureteroscopy and a holmium laser is possible, regardless of the stone size, in female patients without hydronephrosis. However, the need for combined treatment with flexible ureteroscopy is increased in male patients with hydronephrosis.

How Effective Is Retrograde Semirigid and Flexible Ureteroscopic Lithotripsy for the Treatment of Large Ureteral Stones Equal of or Greater than 15 mm? Results from a Single Center

“…The decision regarding the use of antiretropulsed measures was made according to the preference of the surgeon and the estimated intraoperative risk of stone migration. This risk is higher for proximal stones located in a dilated ureter [7].…”

“…It was shown that f-URS and ureteral sheaths were valuable instruments for treating upper stones (Table 2) Discussion SR ureteroscopes with size less than 9 F are excellent instruments for endoscopy of the distal ureter [1]. When modern lithotripters are used fragmentation of lower ureteral stones is feasible in 90-100% of the cases [7]. Endoscopy of the upper tract only with the SR scope may be a challenging intervention, which fails in approximately 32% of patients.…”

“…Endoscopy of the upper tract only with the SR scope may be a challenging intervention, which fails in approximately 32% of patients. Mucosal edema, ureteral stenosis, steep angulation of the ureter, and a fixed urethra in males are some of the reasons of failure [4,6,7]. In such cases, f-URS may be used to approach and fragmentize centrally located stones [7,10].…”

“…Mucosal edema, ureteral stenosis, steep angulation of the ureter, and a fixed urethra in males are some of the reasons of failure [4,6,7]. In such cases, f-URS may be used to approach and fragmentize centrally located stones [7,10]. Furthermore, should a large stone is accidently retropulsed into the kidney f-URS can be continued to RIRS to avoid treatment failure.…”

“…However, treatment with semirigid (SR) scopes may be less effective in proximally located larger ureteral stones [4,5]. The flexible instruments have enhanced our capability to approach all the ureteral stones, but there is still debate regarding the results in large proximally located ones [6][7][8][9], Herein, we present and discuss the results and complications of retrograde ureteroscopic (URS) treatment of large ureteral stones performed in the urologic department of a district Hospital in Magnesia.…”