A Prospective Randomized Comparison Between Laparoscopic Ureterolithotomy and Semirigid Ureteroscopy for Upper Ureteral Stones >2 cm: A Single-Center Experience

Flexible ureteroscopic treatment of kidney stones: How do the new laser systems change our concepts?

Objective

Flexible ureteroscopy (fURS) has become a widely accepted and effective technique for treating kidney stones. With the development of new laser systems, the fURS approach has evolved significantly. This literature review aims to examine the current state of knowledge on fURS treatment of kidney stones, with a particular focus on the impact of the latest laser technologies on clinical outcomes and patient safety.

Methods

We conducted a search of the PubMed/PMC, Web of Science Core Collection, Scopus, Embase (Ovid), and Cochrane Databases for all randomized controlled trial articles on laser lithotripsy in September 2023 without time restriction.

Results

We found a total of 22 relevant pieces of literature. Holmium laser has been used for intracavitary laser lithotripsy for nearly 30 years and has become the golden standard for the treatment of urinary stones. However, the existing holmium laser cannot completely powder the stone, and the retropulsion of the stone after the laser emission and the thermal damage to the tissue have caused many problems for clinicians. The introduction of thulium fiber laser and Moses technology brings highly efficient dusting lithotripsy effect through laser innovation, limiting pulse energy and broadening pulse frequency.

Conclusion

While the holmium:yttrium-aluminum-garnet laser remains the primary choice for endoscopic laser lithotripsy, recent technological advancements hint at a potential new gold standard. Parameter range, retropulsion effect, laser fiber adaptability, and overall system performance demand comprehensive attention. The ablation efficacy of high-pulse-frequency devices relies on precise targeting, which may pose practical challenges.

2022 Recommendations of The AFU Lithiasis Committee: Open surgery and laparoscopy

Only few hundred interventions are performed in France each year to remove upper urinary tract stones using a laparoscopic/robotic transperitoneal or retroperitoneal approach. These interventions are proposed to patients with large (>20mm) and complex stones, sometimes after failure of endoscopic techniques or in the presence of malformations that can be treated at the same time. The major interest of these interventions is the possibility to remove the whole stone without prior fragmentation. Some anatomical situations can increase the technical difficulty, particularly the presence of an intrarenal pelvis and the presence of pelvic and periureteral adhesions. The reported complications are essentially urinary fistula and ureteral stenosis, the risks of which are reduced by the use of double J stenting. As struvite stones are more friable, their whole removal is more difficult and may lead to dispersion of fragments, particularly during laparoscopy. Conventional open surgery has a higher stone-free rate, but comes with a greater kidney function loss. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU Guidelines on urolithiasis. 2022) and their adaptability to the French context.

Clinical application of flexible ureteroscopic sheath with controllable intraluminal pressure in treating ureteral stones

Objective

The purpose of the study was to assess the clinical efficacy and safety of a combined perfusion suction platform with pressure feedback control function and an ureteroscopic suction sheath that can measure the ureteropelvic pressure in implementing lithotripsies.

Methods

Fifty-two patients who underwent lithotripsy under intelligent monitoring of ureteral intraluminal pressure from June 2016 to January 2018 were retrospectively recruited. The inclusion standard was stone diameter >1.5 cm but <2.5 cm. After the 12/14 Fr suction sheath was placed, manometer interface and suction interface of the sheath were connected to the platform via the pressure sensor and suction tube, respectively. The ureteroscope was connected to the platform perfusion pump, and the crushed stones were aspirated out under negative pressure.

Results

According to the location of the stone, 21 (40.4%) cases were classified as upper ureteral stones, 19 (36.5%) were midureteral stones, and 12 (23.1%) were lower ureteral stones. Forty-seven patients underwent successful primary sheath placement and lithotripsy with a mean operative time of 34.5 (standard deviation 18.3) min. Retrograde stone migration did not occur. There were eight patients with hematuria postoperatively. Serious complication was 1.9% with one case of ureteral perforation. Stone clearance was 95.7% at Day 1-2 postoperatively, and 100% at Day 30 postoperatively.

Conclusion

Ureteroscopic lithotripsy with intelligent pressure control using our device improved the efficiency of the lithotripsy and rate of stone clearance. The safety of the operation can be ensured. It is worth popularization and application in clinical practice.

Comparison of laparoscopic ureterolithotomy and retrograde lithotripsy in the treatment of proximal ureteral stones

The current approach in the surgical treatment of ureteral calculi involves the use of endourological procedures such as retrograde ureteroscopy with lithotripsy or percutaneous antegrade lithotripsy in the proximal ureter. Ureterolithotomy as a treatment method is of an auxiliary nature and is used when endourological intervention is impossible or in case of intraoperative collisions during access conversion. However, there are several comparative studies on lithotripsy and lithotomy.

The aim. Comparative analysis of the outcomes of laparoscopic lithotomy and retrograde lithotripsy in the surgical treatment of proximal ureteral calculi, as well as the search for predictors of prolonged disability.

Materials and methods. A prospective randomized multicenter study included 53 patients with an established diagnosis of ureterolithiasis who were treated in the period 2018–2021 in urological hospitals in Irkutsk. All patients were divided into two comparison groups: Lithotomy group (group 1; n = 30) and Lithotripsy group (group 2; n = 23).

Results. When analyzing the results of the study, it was found that the level of complications of class II–III according to Clavien – Dindo was statistically comparable in both groups (p > 0.05). However, in absolute and relative terms, the prevalence of this indicator was noted during retrograde ureterolithotripsy. According to hard endpoints (reoperation, presence of residual stones or migration during the operation), 29 (96.6 %) patients of group 1 and 17 (73.4 %) patients of group 2 (p = 0.514) were successfully operated on.

Conclusion. Laparoscopic ureterolithotomy may be offered to patients with large proximal ureteral stones as an alternative treatment option with better residual stone freedom but generally similar overall outcomes and complication rates.

Comprehensive endoscopic management of impacted ureteral stones: Literature review and expert opinions

Treatment of urolithiasis, a benign disease, requires high efficacy and safety. Endoscopic treatment of impacted ureteral stones remains a challenging procedure for urologists, despite recent remarkable advances in surgical technology in treatment of urolithiasis. The success rate of endoscopic treatment in patients with impacted stones is reported to be lower than that in patients with nonimpacted stones. Moreover, the presence of stone impaction is associated with high rates of intraoperative and postoperative complications. The best management for patients with impacted ureteral stones should therefore be devised based on the latest knowledge and techniques. The present review focuses on the preoperative prediction of stone impaction, the safest and most effective endoscopic surgical procedures, and the most appropriate management for postoperative ureteral strictures. We overview comprehensive endoscopic management for impacted ureteral stones based on literature review and expert opinions.

Comparison of efficacy and safety of various management options for large upper ureteric stones a systematic review and network meta-analysis

To compare the safety and efficacy of various surgical modalities to manage large (> 1 cm) upper ureter stones. Systematic literature search was conducted to include all randomized studies comparing various treatment options for large (> 1 cm) upper ureteric stones. This review included 13 randomized studies with 1871 patients. Laparoscopic ureterolithotomy (LUL) and percutaneous nephrolithotomy (PNL) were superior to ureteroscopy (URS) and shockwave lithotripsy (SWL) for stone-free rates and need for auxiliary treatments. LUL and PNL were equally effective for stone-free rates and the need for auxiliary treatments. According to SUCRA values for stone-free rates and the need for auxiliary treatments, LUL was the best, followed by PNL. For the duration of surgery, there was no significant difference among all the techniques on network analyses, and SWL was the best according to SUCRA values. Length of hospital stay was significantly shorter for URS than LUL and PNL from network analysis, but there was no significant difference for the rest of the comparisons. Overall complications were similar in all the groups. According to the CINeMa approach, the confidence rating ranged from “very low” to “moderate” for various comparisons. LUL followed by PNL is the most efficacious treatment modality for upper ureteric stones compared to SWL and URS in terms of stone-free rates. However, due to the poor quality of included studies, further high-quality randomized studies are needed.

Laparoscopic ureterolithotomy for large proximal ureteric stones: Surgical technique, outcomes and literature review

INTRODUCTION

We evaluated the efficacy and safety of laparoscopic ureterolithotomy (LPU) for the treatment of large proximal ureteric stone.

METHODS

A retrospective multicenter analysis for patients with solitary impacted proximal ureteric stone ≥15 mm who underwent LPU from 2016 to 2019 was performed. Primary outcome was to estimate the stone-free rate (SFR). SFR was defined as absence of residual stones on postoperative computed tomography scan. Secondary outcome was to assess the perioperative outcomes, as well as to review literature data of randomized controlled trials and meta-analyses comparing LPU to other treatment options.

RESULTS

Forty-four patients were included in our study. Mean stone size was 22.9 ± 5.8 mm and median follow-up was 14 months. Three patients had previous abdominal surgery, one patient had severe degree of scoliosis and six patients failed primary therapy. All stones were extracted successfully (SFR = 100%) without need of auxiliary treatments. Mean operative time and estimated blood loss were 86.6 ± 14.1 minutes. and 11.9 ± 14.7 mL, respectively. No intraoperative complications or conversion to open surgery were reported. No major postoperative complications (≥grade 3) were reported. Mean length of hospital stay was 2 ± 0.8 days.

CONCLUSIONS

For treatment of large ureteric stones, our study showed that LPU achieves 100% stone-free status. When performed by well-trained laparoscopic surgeons, it is safe and has no major perioperative complications. According to our results and literature data, when counseling patients with large impacted proximal ureteral stones, LPU should be advised as the procedure that has the higher SFR, lower auxiliary treatments, and comparable complication rates to other treatments.

Efficacy and safety of various surgical treatments for proximal ureteral stone ≥10mm: A systematic review and network meta-analysis

Purpose

Various surgical options are available for large proximal ureteral stones, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URSL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LU). However, the best option remains controversial. Therefore, we conducted a network meta-analysis comparing various surgical treatments for proximal ureteral stones ≥10mm to address current research deficiencies.

Materials and methods

We searched PubMed, Ovid, Scopus (up to June 2019), as well as citation lists to identify eligible comparative studies. All clinical studies including patients comparing surgical treatments for proximal ureteral stones ≥10mm were included. A standard network meta-analysis was performed with Stata SE 14 (Stata Corp, College Station, TX, USA) software to generate comparative statistics. The quality was assessed with level of evidence according to the Oxford Centre for Evidence-based Medicine and risk of bias with the Cochrane Collaboration’s Review Manager (RevMan) 5.3 software.

Results

A total of 25 studies including 2.888 patients were included in this network meta-analysis. Network meta-analyses indicated that LU and PCNL had better stone-free rates and auxiliary procedures. PCNL could result in major complications and severe bleeding. In initial stone-free rate, final stone-free rate, and auxiliary procedures results, SUCRA ranking was: LU> PCNL> URSL> ESWL. In Clavien Dindo score ≥3 complications, SUCRA ranking was: LU> ESWL> URSL> PCNL. In fever, SUCRA ranking was: ESWL> LU> URSL> PCNL. In transfusion, SUCRA ranking was: LU> URSL> ESWL> PCNL. In Cluster analysis, LU had the highest advantages and acceptable side effects. Considering the traumatic nature of PCNL, it should not be an option over URSL. ESWL had the lowest advantages.

Conclusions

LU have the potential to be considered as the first treatment choice of proximal ureteral stone ≥10mm.

Optimal management of large proximal ureteral stones (>10 mm): A systematic review and meta-analysis of 12 randomized controlled trials

OBJECTIVES

To develop an evidence base to guide clinicians treating adults with large proximal ureteral stones (LPUS) greater than 10 mm.

METHODS

A systematic search of PubMed, EMBASE, and Cochrane Library was conducted to identify randomized controlled trials (RCT) concerning different LPUS management techniques including laparoscopic ureterolithotomy (LU), percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URL) up until March 2020. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement when searching and determining inclusion. All included articles were quality assessed and the data analyses were conducted with Review Manager (5.3).

RESULTS

12 RCTs involving 1416 patients met our eligibility criteria and were analyzed. Of these participants, 44.6% (n = 632) underwent URL, 25.5% (n = 361) PCNL, and 29.9% (n = 423) LU. Pooled analysis revealed that URL had a significantly lower stone-free rate (SFR) compared to PCNL and LU (both with p < 0.05). URL had a significantly higher ureteral injury rate compared to LU (Relative risk (RR) = 5.27, 95% confidence interval (CI) 1.52 to 18.22, p = 0.009) and PCNL (RR = 4.11, 95% CI 1.03 to 16.34, p = 0.04). However, no significant differences were found between PCNL and LU in terms of SFR or overall complications, both with p > 0.05. URL initially costs less than PCNL (Weighted mean difference (WMD) -597.35US$, 95% CI -823.10 to -371.60, p < 0.00001), but being less effective creates greater demand for repeat or ancillary treatments compared to LU (RR 15.65, 95% CI 2.11-116.12, p = 0.007) and PCNL (RR 8.86; 95% CI 3.19-24.60; p < 0.00001).

CONCLUSIONS

Both PCNL and LU appear more effective and safer than URL for LPUS; although, LU has higher risk of urine leakage and is more likely incur trauma which requires additional support. However, caution must be taken because this recommendation is based upon a very limited number of clinical studies, and even fewer comparing flexible ureteroscopic technologies. Further prospective real-world studies or RCTs comparing flexible URL, LU and PCNL are required, as well as an in depth analysis of the hidden costs involved in unsuccessful URL treatments.

Stone clearance times with mini-percutaneous nephrolithotomy: Comparison of a 1.5 mm ballistic/ultrasonic mini-probe vs. laser

INTRODUCTION

A limitation of mini-percutaneous nephrolithotomy (mPCNL) is the narrow working channel of mini-nephroscopes, typically restricting instrumentation to 5 French (F) or smaller. We evaluated the efficacy of the 1.5 mm Swiss LithoClast ^® Trilogy (Trilogy) rigid probe and compared the results to consecutive cases performed with a 30 W Holmium:YAG (Ho:YAG) laser.

METHODS

A retrospective review of 30 consecutive mPCNL cases using the Trilogy and 30 W Holmium laser was performed. A 12 F MIPS nephroscope with a 16.5 F access sheath and 6.7 F working channel was used for all mPCNL cases. The Trilogy was used with a disposable 1.5 mm × 440 mm probe with dual ultrasonic and ballistic energy. The Ho:YAG laser was used with a 550 micron fibre and a maximum of 30 W. Stone clearance time (SCT) was defined by the total time interval between activation of the lithotripter until insertion of the nephrostomy tube and measured in mm²/minutes. SCT included time for fragment retrieval, equipment adjustments, and rigid and flexible nephroscopy during and after lithotripsy.

RESULTS

Eleven cases using a 1.5 mm Trilogy probe and 16 cases using a Ho:YAG laser met final inclusion criteria. Three cases using the Trilogy were excluded from final analysis due to conversion to alternative energy sources - two of those were upsized to standard PCNL and one was converted to laser. Mean stone diameter and density in the final Trilogy cohort was 26.7 mm and 1193 Hounsfield units (HU). Mean diameter and density in the laser cohort was 25.2 mm and 1049 HU. The mean stone area clearance time for Trilogy was 4.7±1.8 mm²/minute vs. 3.4±0.7 mm²/minute with Ho:YAG laser (p=0.21). For hard stones, defined as density >1000 HU, the Trilogy averaged 3.7±1.6 mm²/minutes, while the laser averaged 3.1±1.3 mm²/minutes (p=0.786). For soft stones, defined as <1000 HU, the Trilogy averaged 8.9±1.0 mm²/minutes compared to the Ho:YAG, which averaged 3.6±1.8mm²/minutes (p=0.019). No device-related complications occurred in either cohort.

CONCLUSIONS

The 1.5 mm mPCNL Trilogy probe was comparable to 30 W Ho:YAG laser for clearing hard stones. The Trilogy performed better than laser on soft stones with a HU density <1000 HU.

Stone-free rate after semirigid ureteroscopy with holmium laser lithotripsy versus laparoscopic ureterolithotomy for upper ureteral calculi: a multicenter study

Background

Different treatment options were used to treat upper ureteral calculi. The aim of our study is to compare the stone-free rate and postoperative outcomes between semirigid ureteroscope with holmium laser lithotripsy and laparoscopic ureterolithotomy for the management of large solitary upper ureteral stones. Sixty-seven patients with a solitary upper ureteral stone who had LU or semirigid ureteroscopy in the period between January 2014 and March 2017 were included in our study. Out of the sixty-seven patients, 37 patients had semirigid ureteroscopy and holmium laser lithotripsy (Group A) and 30 patients had laparoscopic ureterolithotomy (Group B). Both groups were compared regarding operative time, intraoperative complications, need for auxiliary procedures, hospital stays, postoperative complications and stone-free rate.

Results

The mean stone size was 1.84 ± 0.12 cm in Group A and 1.79 ± 0.17 cm in Group B, P value = 0.2. The mean operative time was 61.5 ± 3.5 min in Group A and 63 ± 4.2 min in Group B, P value = 0.13. Stone migration was recorded in five cases (14%) in Group A while no cases in Group B had stone migration. Flexible ureteroscope was used as an auxiliary measure in five patients (14%) in Group A at the same session. No auxiliary measures were used in the LU group.

Conclusion

The stone-free rates after semirigid URS and laser lithotripsy are comparable to those following LU, especially when flexible URS is used to manage migrating stone fragments at the same session.

A Novel Semirigid Ureterorenoscope with Vacuum Suctioning System for Management of Single Proximal Ureteral and Renal Pelvic Stones: An Initial Experience

INTRODUCTION

A novel semirigid ureterorenoscope, named the Sotn ureterorenoscope, was designed with a vacuum suction system. The present study aimed to evaluate the feasibility and safety of using the Sotn ureterorenoscope to manage single proximal ureteral or renal pelvic stones.

PATIENTS AND METHODS

Data were retrospectively collected from consecutive patients treated with a Sotn ureterorenoscope between February 2010 and August 2015 at Sun Yat-sen Memorial Hospital of Sun Yat-sen University and Jiangmen Wuyi Traditional Chinese Medicine Hospital in China. The primary outcome was the primary stone-free rate (SFR) in 1 month. The secondary outcomes were the final SFR and the perioperative complication rate.

RESULTS

A total of 386 patients were evaluated, including 240 males and 146 females. The median (interquartile range [IR]) age was 50 (40-59) years. There were 96 and 290 stones located in the renal pelvis and proximal ureter, respectively. The median (IR) operative time and console time for all patients were 40 (30-70) and 20 (12-38) minutes, respectively. The primary overall SFR was 86.5%, whereas the SFRs for stones with a diameter of ≤1, 1 to 2, and 2 to 3 cm were 95.7%, 86.9%, and 69.0%, respectively. Complications occurred in 90 patients (23.3%); these complications were classified as Clavien-Dindo grades 1 to 2 (minor) in 79 (20.5%) patients, and grades 3 to 4 (major) in 11 (2.8%).

CONCLUSIONS

The novel semirigid Sotn ureterorenoscope featuring a vacuum suction system is effective and safe for managing proximal ureteral and renal pelvic stones.

Laparoscopic ureterolithotomy versus ureteroscopic laser lithotripsy for large proximal ureteral stones: a systematic review and meta-analysis

INTRODUCTION

To review current studies and conduct a meta-analysis on the topic of laparoscopic ureterolithotomy (LU) versus ureteroscopic lithotripsy (URSL) with holmium laser for large proximal ureteral stones.

EVIDENCE ACQUISITION

A systematic research of PubMed, Ovid, Scopus (up to March 2019), and citation lists was performed to identify eligible comparative studies. All studies comparing LU versus URSL with holmium laser in proximal ureteral stones were included. Statistical analyses were performed using the Cochrane Collaboration's Review Manager (RevMan) 5.3 software.

EVIDENCE SYNTHESIS

Overall, seven studies were included in analysis involving 884 patients (LU 387; URSL 497). Our meta-analysis showed that LU group had bigger stone size than URSL group (WMD 0.19 cm; P=0.001). LU group was associated with longer operative time (WMD 36.29 min; P<0.001), and length of hospital stay (WMD 1.24 d; P=0.04). However, LU group showed better initial stone-free rate (OR 11.03; P<0.001), and final stone-free rate (OR 22.37; P<0.001). There were no significant differences in all complications (RR 1.06; P=0.76). While, LU group had fewer Clavien Dindo score ≥3 complications (RR 0.21; P=0.002), fewer ureteral stricture (RR 0.26; P=0.04), and lower need of auxiliary procedures (RR 0.09; P<0.001) compared with URSL group.

CONCLUSIONS

LU could provide a higher stone-free rate and fewer severe complications compared with URSL with holmium laser for large proximal ureteral stones. More importantly, LU could also reduce the postoperative ureteral stricture rate.

Laparoscopic Ureterolithotomy vs Ureteroscopic Lithotripsy for Large Ureteral Stones

Background and Objectives:

The purpose of this study was to compare two methods (transperitoneal laparoscopic ureterolithotomy [TLU] and a combination of ureteroscopic lithotripsy [UL] with retrograde intrarenal surgery [RIRS]) designed for the treatment of large proximal ureteral calculi so that their associated complications and stone-free rates could be assessed.

Methods:

A total of 100 patients from three different hospitals who were diagnosed with large upper ureteral stones (≥15 mm) were treated via TLU (n = 48) or UL-RIRS (n = 52). They were treated between March 2012 and May 2014. The study compared the complications, success rate, patient characteristics, and the operation time between the two groups.

Results:

The immediate stone clearance rate after a single session was higher in the TLU group than in the UL-RIRS group (100% vs 73.1%, P = .005). However, there was no significant difference in the stone-free rates between the two groups three months after the last procedure was performed (100% vs 96.1%, P = .655). Regarding patients with a history of early-failure extracorporeal shock-wave lithotripsy, there was no significant difference in the stone-free rate between the two groups three months after the last procedure (100% vs 94.4%, P > .05). Further, overall complication rates between the groups were not statistically different (P = .261).

Conclusion:

This study demonstrates that TLU is an effective and safe procedure to treat large impacted upper ureteral stones. When compared to UL-RIRS, TLU showed equivalent efficacy and safety, though there were failed first-line treatments.

Robotic Management of Urolithiasis in the Pediatric Population

A variety of surgical techniques exist for the management of urolithiasis. Minimally invasive techniques have replaced open surgery in the last few decades. For complex stone management, robotic-assisted laparoscopic surgery (RALS) has emerged as a safe and feasible alternative in adults. The literature for RALS for urolithiasis (RALS-UL) in the pediatric population is scarce. Herein, we present a review of the literature in both adult and pediatric patients as well as our experience using RALS-UL at our institutions. Special attention is given to the synchronous management of urolithiasis when surgery is performed for other conditions such as ureteropelvic junction obstruction (UPJO), and a supplemental video is provided.

Laparoscopic and robotic surgery for stone disease

Treatment for stone disease has evolved drastically during the past 3-4 decades. Ureteroscopy, percutaneous nephrolithotomy along with SWL, provides the means to treat practically all urinary tract stones with minimal invasion to the patients. However, for complex stone case scenarios where open surgery is being considered, a less invasive and better tolerated option such as laparoscopy (robot assisted or not) can be performed. The present manuscript reviews role of laparoscopic and robotic surgery in treating urinary tract stones.

Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta - analysis of randomized controlled trials

Introduction:

To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone.

Materials and methods:

A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria.

Results:

Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = −31.26 min; 95%CI −46.88 to −15.64; p<0.0001) and length of hospital stay (WMD = −1.48 days; 95%CI −2.78 to −0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications – Clavien ≥3 – (OR = 1.79; 95%CI 0.59-5.42; p=0.30). LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001).

Conclusions:

Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.

The usefulness of flexible cystoscopy for preventing double-J stent malposition after laparoscopic ureterolithotomy

Background

The aim of this study was to evaluate the role of flexible cystoscopy in preventing malpositioning of the ureteral stent after laparoscopic ureterolithotomy in male patients.

Methods

From April 2009 to June 2015, 97 male patients with stones >1.8 cm in the upper ureter underwent intracorporeal double-J stenting of the ureter after laparoscopic ureterolithotomy performed by four different surgeons. In the last 50 patients who underwent laparoscopic ureterolithotomy flexible cystoscopy was performed through the urethral route to confirm the position of the double-J stent, while in the first 47 correct positioning of the stent was confirmed through postoperative KUB. The demographic data and perioperative outcomes were reviewed retrospectively. Penalized logistic regression analysis was used to evaluate the effects of flexible cystoscopy.

Results

Upward malpositioning of the ureteral stent was found in 9 of the 47 (19.1%) patients who underwent surgery without flexible cystoscopy. Among the 50 most recent patients who underwent surgery with flexible cystoscopy through the urethral route, upward malpositioning was observed in 10 (20%) patients. The factors preventing upward malpositioning of the double-J catheter in multivariate analysis were surgeon (p = 0.039) and use of flexible cystoscopy (p = 0.008).

Conclusion

Flexible cystoscopy is a simple, safe, quick, and effective method to identify and correct malpositioning of double-J stents, especially in male patients.

Trial registration

This study was registered with ClinicalTrials.gov Registry on May 11, 2017 (retrospective registration) with a trial registration number of NCT03150446.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-017-0232-4) contains supplementary material, which is available to authorized users.

Minimally Invasive Surgical Ureterolithotomy Versus Ureteroscopic Lithotripsy for Large Ureteric Stones: A Systematic Review and Meta-analysis of the Literature

CONTEXT

The management of large ureteric stones represents a technical and clinical challenge.

OBJECTIVE

To investigate the safety and efficacy of minimally invasive surgical ureterolithotomy (MISU) in comparison with ureteroscopic lithotripsy (URS) for the treatment of large ureteric stones.

EVIDENCE ACQUISITION

The Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines were followed for the conduction of the study, which was registered in the PROSPERO database. Search string was "(laparoscop* OR retroperito* OR robot*) AND ureterolitho*"; database scope included PubMed, SCOPUS, Cochrane, and EMBASE. Primary end points were the stone-free (SFR) and complications rates. Secondary end points included operative time and hospital stay. Subgroup analyses were performed for stones 1-2 and >2cm, as well as different lithotripters and ureteroscopes. Meta-analysis and forest-plot diagrams were performed with the RevMan 5.3.5 software.

EVIDENCE SYNTHESIS

After screening 673 publications, seven randomized controlled trials were eligible to be included in the meta-analysis. A total of 778 patients were pooled after the elimination of the dropouts. No robotic cohorts were found. Only upper ureteral stones were treated in the included studies. The SFR at discharge and 3 mo was higher with MISU with odds ratios of 6.30 (95% confidence interval [CI]: 3.05, 13.01; I²=0%) and 5.34 (95% CI: 2.41, 8.81; I²=0%), respectively. The most common complications for MISU and URS were conversion to open surgery and stone migration to the renal pelvis, respectively. Favorable results in terms of operative time were observed in the case of URS with a mean difference of 29.5min (95% CI: 14.74, 44.26; I²=98%). Hospitalization time was favorable in the case of URS with a mean difference of 2.08 days (95% CI: 0.96, 3.20; I²=99%).

CONCLUSIONS

This meta-analysis showed a significantly higher SFR at discharge and 3 mo for MISU in comparison with URS when upper ureteral stones were treated. Operative and hospitalization time favored URS over MISU.

PATIENT SUMMARY

The current study investigated the literature on the minimally invasive management of large ureteric stones. The available evidence shows that both ureteroscopic lithotripsy and minimally invasive surgical ureterolithotomy could be considered for the treatment of these stones with similar results. The selection of the approach should be based on the advantages and disadvantages of each technique.

Retroperitoneal laparoscopic ureterolithotomy in comparison with ureteroscopic lithotripsy in the management of impacted upper ureteral stones larger than 12 mm

OBJECTIVE

To compare the results of ureteroscopic lithotripsy (URSL) with retroperitoneal laparoscopic ureterolithotomy (RPLU) as two minimally invasive techniques in the management of proximal ureteral stones larger than 12 mm.

PATIENTS AND METHODS

From January 2009 to October 2013, patients with impacted unilateral upper ureteral stones larger than 12 mm were enrolled including 182 males and 93 females with a medium age of 40 years (22-72 years). Patients were randomized to receive URSL (139 cases) with semirigid ureteroscope or RPLU (136 cases).

RESULTS

Stone size was similar in RPLU and URSL groups (13.8 ± 1.9 vs 13.6 ± 1.4 mm, P = 0.312). Operating time and hospitalizing days in URSL group were significantly shorter than those in RPLU group (P < 0.001), whereas stone clearance rate was significantly higher in RPLU group (97.1 vs 89.9 %, P = 0.017). Ureteral strictures happened higher in URSL group (5 patients, 3.6 %) than RPLU group (2 patients, 1.5 %) with no statistical significance, while the strictures requiring surgical intervention were significantly higher in URSL group (4 cases) (2.9 vs 0 %, P = 0.046).

CONCLUSION

RPLU could provide better stone clearance rate than semirigid URSL for upper ureteral impacted stones larger than 12 mm. It may also reduce the chance of surgical intervention for postoperative ureteral stricture.