Abstract
The present report focuses on questions from the survey that concern the treatment of patients with ureteral calculi: Do you have access to the holmium laser for ureteroscopic stone treatment? (Answer choices, yes or no) Which treatment would you recommend for an uncomplicated patient with a symptomatic distal ureteral stone that was 4 (or 8 or 15) mm? (Answer choices, ureteroscopic stone removal, extracorporeal shock wave lithotripsy (SWL) or ureteral stent placement alone) Which treatment would you recommend for an uncomplicated patient with a symptomatic midureteral stone that was 4 (or 8 or 15) mm? (Same answer choices as question 2) Which treatment would you recommend for an uncomplicated patient with a symptomatic proximal ureteral stone that was 4 (or 8 or 15) mm? (Same answer choices as question 2)
The results are presented in Tables 1 to 7.
SWL = shockwave lithotripsy.
SWL = shockwave lithotripsy.
SWL = shockwave lithotripsy.
SWL = shockwave lithotripsy.
SWL = shockwave lithotripsy.
SWL = shockwave lithotripsy.
Many factors have influenced changes in the treatment choice for patients with ureteral calculi. These include the advent and wider availability of the holmium laser, improvements in endoscopes, and a growing dissatisfaction with the overall results achieved with SWL. As can be seen in Table 1, the holmium laser is available to almost all North American urologists, while in other areas of the world, many treating physicians do not have access to this laser.
Better fiberoptic instrumentation has also had a profound impact on the management of ureteral calculi. Smaller semirigid instruments and, more importantly, improved and more durable flexible ureteroscopes have given urologists the ability to effectively manage stones anywhere in the ureter, as well as in the kidney itself. Most urologists who train in the United States and Canada in the present era are very comfortable with flexible endoscopes, and in concert with the holmium laser, can achieve very high success rates with limited morbidity in managing almost any ureteral stone.
More limited availability of the Dornier HM3 lithotriptor has also led to an overall decrease in the effectiveness of SWL. In one study that compared patients with ureteral stones of varying sizes and locations who were treated by SWL or ureteroscopy, SWL was associated with an overall success rate of 64% (up to two treatments) vs 96% with ureteroscopy in a single treatment. 2 The efficiency quotient between the two treatments strongly favored ureteroscopy at 0.52 vs 0.39.
In the present report, North American urologists tended to favor ureteroscopy over SWL for the management of ureteral calculi to a greater degree than those respondents from other areas of the world. This was particularly true for patients with distal ureteral stones (Tables 2 and 5).
In a previous survey, urologists were asked about their treatment recommendations for patients with varying sized ureteral stones, as was done in the present report. 3 This older report primarily consisted of American urologists, so there was no geographic distribution of results, as in the present survey.
The most notable difference in the results of the two surveys is a strong trend toward ureteroscopy and away from SWL for the management of stones of all sizes throughout the ureter. For example, previously, fewer than 15% of urologists selected ureteroscopy for managing proximal ureteral stones of any size, 3 compared with 30% to 40% in the present report. For stones in the midureter, approximately 75% in the more recent survey chose ureteroscopy, compared with fewer than 50% in the older report. These findings are consistent with the overall trend in the management of ureteral calculi in which ureteroscopy is being used more commonly. This trend is likely to continue, because there is continued improvement in instrumentation and younger urologists who are more comfortable with flexible endoscopes move into practice.
Footnotes
Disclosure Statement
No competing financial interests exist.