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Stone Management
Retrograde Ureteroscopy in Upper Urinary Tract Lithiasis
Petrisor Geavlete, Dragos Georgescu, Razvan Multescu and Bogdan Geavlete
Department of Urology, Saint John Emergency Clinical Hospital, Bucharest
Abstract
A major dilemma for the modern urologist is to choose the optimal treatment mode for upper urinary tract lithiasis. Recently, semi-rigid and
flexible ureteroscopes have undergone modifications that extended the indications and improved success rates while keeping morbidity
relatively low. Some parameters must be taken into consideration when choosing a specific therapeutic alternative, such as stone size,
location and composition, as well as associated morbidities. Ureteroscopy is the first therapeutic choice for distal, middle and large or
multiple proximal ureteral stones. By enabling access to the entire pyelocaliceal system and using modern intracorporeal lithotripsy devices,
flexible ureteroscopy has become a viable alternative for the treatment of pyelocaliceal stones, with reduced potential associated morbidity
in comparison with percutaneous surgery. Indications for the retrograde ureteroscopic approach for pyelocaliceal diverticulae are limited to
symptomatic cases not larger than 1.5cm in size, especially those in an anterior position that are difficult to treat percutaneously.
Keywords
Holmium:yttrium–aluminium–garnet (Ho:YAG), lithotripsy, pyelocaliceal diverticulum, stone size, upper urinary tract lithiasis, ureteroscopy
Disclosure: The authors have no conflicts of interest to declare.
Received: 3 November 2008 Accepted: 22 February 2009
Correspondence: Petrisor Geavlete, Department of Urology, Saint John Emergency Clinical Hospital, Vitan-Barzesti 13, Sector 4, 042122 Bucharest, Romania.
E: geavlete@gmail.com
Complete extraction of the calculi with minimal morbidity is the goal of (AUA/EAU) reach a consensus regarding the treatment indications for
surgical treatment in upper urinary tract lithiasis. Technological progress ureteral lithiasis, individualised for the ‘index patient’ as well as for
has essentially modified the treatment of this pathology. Until the 1980s those with particular characteristics. Some parameters must be taken
open surgical ureterolithotomy and basket stone extraction under into consideration when choosing a specific therapeutic alternative,
fluoroscopic control represented the only therapeutic options. The such as stone size, location and composition, as well as associated
development of minimally invasive treatment alternatives for urinary morbidities.
3
In terms of stone size, spontaneous elimination under
lithiasis was closely correlated with the technological evolution in medical treatment of calculi smaller than 10mm can be considered the
different areas, such as fibre optics, imaging and shock-wave lithotripsy first-line therapeutic option. These patients must be monitored
(SWL) and ultrasonic, electrohydraulic and laser lithotripters. Due to this periodically, and active stone removal is recommended in cases of
progress, modern treatment techniques including ureteroscopic persistent obstruction, renal colic impervious to medical treatment and
extraction, percutaneous nephrolithotomy and SWL were developed. the absence of calculi progression. For stones larger than 10mm, the
first-line treatment is interventional; both SWL and ureteroscopy
Modern Indications represent viable options. Currently, patients must be given the
Choosing the optimal treatment mode is the essential element in opportunity to make a well-informed choice between these two
the therapeutic approach to ureteral calculi. The major dilemma for the alternatives. Additionally, surgical experience, the technical equipment
modern urologist is choosing between the most used treatment available and the cost-effectiveness of the procedure should be
modalities, i.e. SWL and ureteroscopy. Although the initial experience evaluated before making a therapeutic decision. Recent data suggest a
concerning rigid ureteroscopy led to favourable results as far as distal change of preference from SWL to ureteroscopy due to technological
ureteral lithiasis was concerned, the success rate for middle and progress and increasing surgical experience.
5
proximal ureteral calculi is not as impressive. In the last few years, semi-
rigid and flexible ureteroscopes have undergone modifications that According to the EAU/AUA consensus, although the success rates of
improved success rates while keeping morbidity relatively low.
1,2
This SWL and ureteroscopy for proximal ureteral calculi are relatively equal
progress increased the efficiency of the retrograde endoscopic (82 and 81%, respectively), there are differences related to stone size.
approach regardless of stone location. Therefore, the success rate Therefore, in calculi smaller than 10mm, SWL has superior success rates
of this procedure in cases of ureteral lithiasis varies between 81 (90 versus 80%), while in larger stones ureteroscopy represents the
and 95%,
3
with a complication rate lower than 5%.
4
In 2007, the more efficient method (79 versus 68%).
3
Consequently, SWL is
re-evaluation of the data available from recent meta-analyses helped recommended for single small stones, and ureteroscopy for large or
the American Urological Association/European Association of Urology multiple calculi. The improved efficiency of the ureteroscopic approach
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