A Multicenter, Randomized, Controlled Trial of Transureteral and Shock Wave Lithotripsy—Which is the Best Minimally Invasive Modality to Treat Distal Ureteral Calculi in Children?

Complication rate after pediatric shock wave lithotripsy according to Clavien-Dindo grading system: results from a systematic review and meta-analysis of the existing literature

PURPOSE

Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children.

METHODS

MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data.

RESULTS

Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1].

CONCLUSION

SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications.

Complication rate after pediatric shock wave lithotripsy according to Clavien-Dindo grading system: results from a systematic review and meta-analysis of the existing literature

PURPOSE

Shockwave lithotripsy (SWL) is a minimally invasive technique utilized for renal and ureteric stones in children. Despite being considered safe, certain complications have been recorded. We performed this systematic review and meta-analysis to provide a pooled analysis of Clavien-Dindo graded complications after SWL in children.

METHODS

MEDLINE/PubMed, Scopus and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, were screened from inception to 12/02/2022 by two authors independently. Only randomized controlled trials providing Clavien-Dindo classification or relevant clinical information were considered eligible. Overall complications were calculated using the aggregate number of each complication divided by the total number of patients in studies with data.

RESULTS

Pooled analysis revealed that from children treated with SWL, 27.7% [95% CI 13.1-49.4] suffered Clavien I complications, 4.9% [95% CI 3.1-7.6] Clavien II complications, 2.7% [95% CI 1.6-4.7] Clavien III complications, 2.3% [95% CI 1.3-4] Clavien IV complications, while no Clavien V complications were recorded. In total, 28.1% [95% CI 15.6-45.3] of children suffered minor complications (Clavien-Dindo I-II), while 3% [95% CI 1.8-5] major complications (Clavien-Dindo III-V). Pooled analysis revealed that 10.7% [95% CI 3.2-30.1] of patients suffered macroscopic hematuria, 7.3% [95% CI 2.1-22.7] pain, 5.5% [95% CI 3.3-9] steinstrasse, 5.3% [95% CI 3-9.3] fever, 2.2% [95% CI 0.8-5.6] sepsis, 1.1% [95% CI 0.3-3.7] urinoma, 1% [95% CI 0.4-2.7] symptomatic hematoma and 1% [95% CI 0.3-2.7] asymptomatic hematoma. Need for re-treatment was 42.6% [95% CI 31.4-54.7] and need for auxiliary procedures was 11.8% [95% CI 8.5-16.1].

CONCLUSION

SWL is an irreplaceable tool for treating urolithiasis in children. Although a minimally invasive technique, parents and children should be adequately informed about the risk of minor/major complications.

Scoping review of recent evidence on the management of pediatric urolithiasis: summary of meta-analyses, systematic reviews and relevant randomized controlled trials

This scoping review aimed to evaluate and summarize the recent 10 year pediatric urolithiasis literature with a particular focus on systematic reviews, randomized-controlled trials (RCT) and meta-analysis. The systematic literature search performed on September 1, 2021, restricted to the recent 10 years, focused on pediatric urolithiasis that are RCTs, meta-analysis and systematic reviews. The summarized literature included etiology, diagnostics, medical and surgical management. GRADE criteria are used to evaluate and standardize the reporting of evidence quality. A total of 33 relevant articles were included. The recent high-level studies included topics of genetic and diet association with pediatric stone formation, diagnostic assessment, medical management intervention including medical dissolution and expulsion therapy. The study extended to include the efficacy and safety of extracorporeal lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery. However, evidence quality was ranked "very-low" or "low". Based on the GRADE criteria downgrading of the quality level was due to heterogeneity and low precision. A majority of the RCTs were categorized as having a "high" to "uncertain" risk of bias. The relevant RCTs, meta-analyses and systematic reviews within the past decade are of low quality. Consequently, the research provided no clear evidence-based recommendations for managing pediatric urolithiasis. More rigorous research and high-quality studies are needed to determine the best practices.

Reprint - Medical and surgical interventions for the treatment of urinary stones in children: A Cochrane Review

INTRODUCTION

We performed systematic review to assess the effects of different medical and surgical management of urinary stones in children.

METHODS

We performed a comprehensive search using multiple databases (MEDLINE, EMBASE, Cochrane Register of Controlled Trials), trials registries (World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov), and abstract proceedings of major urological and pediatric urology meetings, with no restrictions on the language of publication or publication status, up until December 2017. We included all randomized controlled trials (RCTs) and quasi-RCTs. Two review authors independently assessed the eligibility of studies for inclusion, extracted data, and assessed risk of bias in accordance with the Cochrane "Risk of bias" tool. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to GRADE.

RESULTS

We included 14 studies with a total of 978 randomized participants in our review, informing seven comparisons with shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy (regardless of the type of lithotripsy), open stone surgery, and medical expulsive therapy. There was very low quality of evidence in the most comparisons with regards to the effectiveness and adverse events for the treatment of pediatric upper renal tract stone disease.

CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children. There is a critical need for better-quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of percutaneous nephrolithotripsy on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Medical and surgical interventions for the treatment of urinary stones in children

BACKGROUND

Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction.

OBJECTIVES

To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures.

AUTHORS' CONCLUSIONS

Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

Laser Application in Iran Urology: A Narrative Review

The usage of laser in medicine is not recent, and its history in urology goes back to 40 years ago. For the last 2 decades, common uses of laser have been treatments of subjects with urolithiasis, bladder tumors, benign prostatic enlargement, lesions of the genitalia and urinary tract strictures. To evaluate laser application in urology in Iran, we reviewed all of the Iranian literature on the topic. This study was designed to retrieve all studies on laser application in urology in Iran, regardless of publication status or language, covering years 1990-2017. Twenty-six articles were identified: 12 about urolithiasis, 8 about benign prostatic hyperplasia (BPH), 2 case reports, 1 paper about prostate cancer, 1 on female urethral stricture, 1 review and 1 basic sciences study. We conclude that the use of this technology has not yet found its position in Iran, especially in the field of urology. The main causes for it are the difficult accessibility and disturb of laser devices and its accessories, as well as the lack of adequate knowledge of the medical community about this modality.

[TRANSURETHRAL URETEROLITHOTRIPSY FOR UPPER URINARY TRACT STONE IN SMALL CHILDREN WEIGHNING AROUND 10KG]

Management strategy for upper urinary tract calculi in small children is still a matter controversial. We report successful management of ureteral stone with transurethral ureterolithotripsy (TUL) in 2 boys weighing around 10 kg. Case 1: A 2-year-old boy (78 cm in height, 9.6 kg in weight), who received hydrocortisone and fludrocortisone for the treatment of 21-hydroxylase deficiency, was referred to our hospital with a right 9-mm lower ureteral stone. For TUL, a 7.5 Fr rigid cystoscope was introduced into the ureter directly after dilation of the ureteral orifice. By using Holmium:YAG laser for lithotripsy, complete stone evacuation was achieved. Stone analysis showed the composition of calcium phosphate and calcium oxalate. Case 2: A 1-year-old boy (80 cm in height, 10.5 kg in weight) with neurofibromatosis type 1 was referred to our hospital with a left 7.5-mm ureteral stone at the ureteropelvic junction. TUL was performed using a 4.5 F rigid ureteroscope and Holmium:YAG laser. No residual stone was identified. Stone analysis showed the composition of calcium oxalate. TUL is a safe and feasible option for small children, even in boys weighing approximately 10 kg.

Non-compliance with randomised allocation and missing outcome data in randomised controlled trials evaluating surgical interventions: a systematic review

Background

Randomised controlled trials are widely acknowledged as the gold standard in medical research although their validity can be undermined by non-compliance with the randomly allocated treatment and missing data. Due to the nature of the intervention, surgical trials face particular threat to compliance and data collection. For example, ineligibility for the intervention may only become apparent once the operation has commenced. It is unclear how such cases are reported and handled.

Objective

The objective was to assess non-compliance and missing data in reports of trials of surgical interventions.

Methods

Searches for reports of trials involving at least one surgical procedure and published in 2010 were carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE^®). Data on missing data, non-compliance and methods of handling missing data were extracted from full texts. Descriptive data analyses were carried out on the data.

Results

Forty-five (55 %) studies reported non-compliance with treatment allocation and 52 (63 %) reported primary outcome missing data. The median levels of non-compliance and missing data were 2 % [IQR (0, 5), range (0–29)] and 6 % [IQR (0, 15), range (0–57)], respectively. Fifty-two (63 %) studies analysed as randomised, 17 (21 %) analysed per protocol and 3 (4 %) analysed as treated. Complete case analysis was the most common method used to deal with missing data, 35/52 (67 %).

Conclusions

The reporting of non-compliance to allocation and the handling of missing data were typically suboptimal. There is still room for improvement on the use of the CONSORT statement particularly in accounting for study participants. Transparency in reporting would facilitate evidence synthesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1364-9) contains supplementary material, which is available to authorized users.

A comparison of antegrade percutaneous and laparoscopic approaches in the treatment of proximal ureteral stones

Purpose. To compare the effectiveness and safety of retroperitoneal laparoscopic ureterolithotomy (RLU) and percutaneous antegrade ureteroscopy (PAU) in which we use semirigid ureteroscopy in the treatment of proximal ureteral stones. Methods. Fifty-eight patients with large, impacted stones who had a history of failed shock wave lithotripsy (SWL) and, retrograde ureterorenoscopy (URS) were included in the study between April 2007 and April 2014. Thirty-seven PAU and twenty-one RLU procedures were applied. Stone-free rates, operation times, duration of hospital stay, and follow-up duration were analyzed. Results. Overall stone-free rate was 100% for both groups. There was no significant difference between both groups with respect to postoperative duration of hospital stay and urinary leakage of more than 2 days. PAU group had a greater amount of blood loss (mean hemoglobin drops for PAU group and RLU group were 1.6 ± 1.1 g/dL versus 0.5 ± 0.3 g/dL, resp.; P = 0.022). RLU group had longer operation time (for PAU group and RLU group 80.1 ± 44.6 min versus 102.1 ± 45.5 min, resp.; P = 0.039). Conclusions. Both PAU and RLU appear to be comparable in the treatment of proximal ureteral stones when the history is notable for a failed retrograde approach or SWL. The decision should be based on surgical expertise and availability of surgical equipment.

[Ureteroscopy: is it the best?]

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

Prospective randomized study of treatment of large proximal ureteral stones: extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy

PURPOSE

The best treatment modalities for large proximal ureteral stones are controversial, and include extracorporeal shock wave lithotripsy, ureterolithotripsy, percutaneous nephrolithotripsy, laparoscopic ureterolithotomy and open surgery. To the best of our knowledge extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy and laparoscopic ureterolithotomy have not been previously compared for the treatment of large proximal ureteral stones. Therefore, we compared these modalities for the treatment of large proximal ureteral stones.

MATERIALS AND METHODS

A total of 48 patients with large proximal ureteral stones (greater than 1 cm) were prospectively randomized and enrolled in the study at a single institution between 2008 and 2010. Eligible patients were assigned to extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy or laparoscopic ureterolithotomy.

RESULTS

Extracorporeal shock wave lithotripsy had a 35.7% success rate, semirigid ureterolithotripsy 62.5% and laparoscopic ureterolithotomy 93.3%. Stone-free rates showed a statistically significant difference among the groups (p = 0.005). Patients treated with laparoscopic ureterolithotomy vs semirigid ureterolithotripsy vs extracorporeal shock wave lithotripsy required fewer treatment sessions (mean ± SD 1.9 ± 0.3 vs 2.2 ± 0.6 vs 2.9 ± 1.4, p = 0.027). Neither major nor long-term complications were observed.

CONCLUSIONS

Proximal ureteral stone treatment requires multiple procedures until complete stone-free status is achieved. Laparoscopic ureterolithotomy is associated with higher success rates and fewer surgical procedures, but with more postoperative pain, longer procedures and a longer hospital stay. Although it is associated with the highest success rates for large proximal ureteral calculi, laparoscopic ureterolithotomy remains a salvage, second line procedure, and it seems more advantageous than open ureterolithotomy. At less well equipped centers, where semirigid ureterolithotripsy or extracorporeal shock wave lithotripsy is not available, it remains a good treatment option.