What is the optimal treatment for lower ureteral stones larger than 1cm?

Abstract

Purpose: To compare the treatment options for lower ureteral stones larger than 1 cm. Methods:The records of 449 patients with lower ureteral calculi larger than 1 cm were reviewed retrospectively. Of these patients 342 (76.1%) were treated with extracorporeal shock wave lithotripsy (ESWL) (group 1), 66 (14.7%) with pneumatic lithotripsy (PL) (group 2) and 128 (28.5%) with ureterolithotomy (group 3). Eighty-seven (19.5%) patients underwent any of the two treatment modalities because of unsuccessful primary treatment. Results:The overall stone-free rates were 32.4, 90.9 and 95.3% for ESWL, PL and ureterolithotomy, respectively. These values were 84.4% for primary PL and 96.7% for primary ureterolithotomy. The re-treatment rate (46.4%) and secondary procedures were much more frequent in the ESWL group. There was no difference in the complication rates of the three groups. Conclusions: Pneumatic lithotripsy with ureteroscopy seems to be an appropriate treatment for larger ureteral stones. While ESWL can be tried as a first treatment option because of its noninvasive nature, lower success and higher re-treatment rates limit its usefulness. Ureterolithotomy is still a reasonable alternative for these large or unfragmented stones.

In Situ Extracorporeal Shock-Wave Lithotripsy as a Primary Treatment for Ureteral Stones

“…Such studies support proponents of ESWL as a first choice treatment of ureteral calculi regardless the location, while saving URS as a first choice for distal obstructive calculi and those with difficult radiological study. 3,5,8,16 Although stones in the upper ureter might respond better to ESWL treatment than those in the lower ureter, the ultimate treatment results are comparable in both clinical settings. At an institution where ESWL and URS are equally available, ESWL is still a valid safe and simple non-invasive option of choice for most ureteral calculi at different levels.…”

“…These results compare favorably with other reports even for stones in the lower ureter. [2][3][4][5] The clinical outcome of ESWL treatment of radiolucent stones did not appear to differ from that of radioopaque ones. Intravenous contrast medium administration overcomes the problem of reduced visibility by indirectly depicting the localization of the stone.…”

The need for additional equipment after ESWL in ureteroscopic lithotripsy

“…[4,[6][7][8] ESWL üreter taşlarında yüksek başarı oranı ile kullanılmakla beraber erken dönemde %50 hastada taştan temizlenme sorunu yaşandığı ve bu hastalarda alternatif tedavi gereksinimi olabildiği de bilinmektedir. [5] Uzun dönemde ESWL'nin mukozaya adezyonu arttırıcı etkisinin olduğu da bilinmektedir.…”

“…Bunun tersine ESWL'de taşın lokalizasyonu yukarı çıktıkça başarı oranı artmaktadır. [3][4][5] Her iki yöntemden birinin birincil tedavide başarısız olduğu durumlarda diğeri alternatif veya tamamlayıcı tedavi olarak başarıyla kullanılabilmektedir. Ayrıca ESWL sonrası taş yolu gelişimi gibi nedenlerle de ÜRS ihtiyacı doğabilmektedir.…”

Diagnosis and therapy of acute ureteral colic

“…Dies geschieht jedoch auch hier auf Kosten der gösseren Invasivität und der damit verbundenen erhöhten Komplikationstrate [44]. Bei Steinen ≥ 10 mm ist die URS der ESWL noch deutlicher überlegen [45]. Komplikationen treten bei der URS in Abhängigkeit der Steinlokalisation und Erfahrung des Operateurs in 9-11% der Fälle auf, wobei eine Avulsion der Harnleiterschleimhaut am häufigsten ist.…”