Retrograde,Antegrade,and Laparoscopic Approaches to the Management of Large Upper Ureteral Stones After Shockwave Lithotripsy Failure: A Four-Year Retrospective Study

Abstract

Purpose:

We compare the success rate and complications of retrograde ureteroscopy, laparoscopic ureterolithotomy, and percutaneous nephrolithotomy for the management of large upper ureteral stones.

Patients and Methods:

We retrospectively analyzed data from 73 patients with large (≥1 cm) upper ureteral stones at two institutions from January 2010 to May 2013. Twenty-two patients underwent retrograde ureteroscopy (group ULS), 30 patients underwent percutaneous nephrolithotripsy (group PCNL), and 21 patients underwent laparoscopic ureterolithotomy (group LS) for removal of upper ureteral stones. CT, intravenous urography, and ultrasound were performed 1 week and 1 month after surgical removal.

Results:

There were no significant differences in age, sex, or stone size among the three groups. Mean estimated blood loss and mean hospital stay showed a statistically significant difference among the three groups. Success rates in the PCNL, LS, and ULS groups were 100%, 90.5%, and 77.3%, respectively. The procedures of two patients in group LS were converted to open surgery because of the inability to find the ureteral stone in one patient and an adhesion too difficult to dissect in the other. The procedures of two patients in the ULS group were converted to LS, and those of three patients were converted to PCNL because of severe edema impaction at the site of the stone, a sharply angulated ureter obstruction, upward migration of the stone (seven patients), and intraoperative complications (two patients).

Conclusions:

Percutaneous antegrade nephrolithotomy is a safe and effective minimally invasive treatment for patients with large upper ureteral stones that has several advantages over retrograde ureteroscopy and laparoscopic ureterolithotomy. Thus, percutaneous antegrade nephrolithotomy is recommended as a safe and good treatment option for large upper ureteral stones. A combined procedure (e.g., ureteral push-back and percutaneous removal) can be considered in some patients.

Introduction

There are multiple approaches to the treatment of patients with upper ureteral stones. Extracorporeal shockwave lithotripsy (SWL), ureterorenoscopy (URS), percutaneous nephrolithotomy (PCNL), laparoscopic ureterolithotomy, and open ureterolithotomy each has advantages and disadvantages.

Although SWL is minimally invasive and can be performed as an outpatient procedure, disadvantages include a high re-treatment rate, long treatment time, and inability to dissect a large or impacted stone.¹ URS is recommended as first-line treatment for upper ureteral stones. Flexible ureteroscopy with laser lithotripsy has a high surgical success rate, but this procedure necessitates special devices that are not available in all hospitals.² PCNL is considered mainly for patients with a large stone burden and proximal ureteral stones.³

Laparoscopic ureterolithotomy can be used after first-line treatment has failed or is expected to fail. This approach may be a worthwhile alternative to open surgery,⁴ because the role of open ureterolithotomy declined rapidly amid the advent of minimally invasive surgery.⁵

Thus, the approach of choice to upper ureteral stones appears to depend on urologist expertise and type of device available. To the best of our knowledge, semirigid ureterolithotripsy, PCNL, and laparoscopic ureterolithotomy have not been compared for the mangement of large upper ureteral stones. Therefore, in the current study, we retrospectively analyzed data from 73 patients with large upper ureteral stones after SWL failure and compared each method's rate of success and complications.

Patients and Methods

We retrospectively analyzed data from 73 patients with large (≥1 cm) upper ureteral stones at two institutions from January 2010 to May 2013. Twenty-two patients underwent retrograde ureteroscopy (group ULS), 30 underwent PCNL (group PCNL), and 21 underwent laparoscopic ureterolithotomy (group LS) for removal of upper ureteral stones.

All patients had undergone SWL without success. Preoperatively, we performed a kidney function test, urinary analysis to detect urinary tract infections, CT, intravenous urography (IVU), and ultrasonography.

We performed ureteroscopy in patients in the lithotomy position under epidural anesthesia with a 8/9.8F Wolf semirigid ureteroscope using a pneumatic lithotripter (Swiss pneumatic LithoClast^® with 0.8 mm probes). A 4F ureteral catheter was placed into the ureteral orifice through the ureteroscope and, under the guidance of the catheter, the ureteroscope was inserted directly into the stone location. Intermittent low-pressure irrigation was used to obtain a clear operative visual field. After breaking up or removing the stone, a 6/7F ureteral stent was typically left in place for 4 to 6 weeks.

For percutaneous nephrolithotripsy, all procedures were performed under continuous epidural anesthesia. Guided by ultrasonography, we achieved access through the middle or upper calix with the patient in the prone position. Tract dilation was serially performed using a fascial dilator from 8F to 24F, and a matched peel-away sheath was placed. The stones were then fragmented with ultrasound or a pneumatic lithotripter through a 20.8F rigid nephroscope. After stone dissolution or removal, or both, a 6/7F Double-J catheter was typically left in place for 4 to 6 weeks, and a 16F nephrostomy tube was inserted into the collection system for 3 or 4 days after surgery.

For laparoscopy, we used the transperitoneal or retroperitoneal approach, according to surgeon preference. Under general anesthesia, the patient was placed in a flank position at a slanted angle of 60 or 90 degrees. After insertion of trocars, we exposed the ureter. We localized the stone and performed a ureterotomy with scissors. Stone removal was performed using a grasper or sharp dissector. After a 6/7F ureteral stent insertion, ureteral repair was performed using a 4-0 polyglactin suture. A drain was placed near the ureter. The drain (<50 mL) was removed 3 or 4 days after surgery, and ureteral stents were removed 4 to 6 weeks after surgery.

IVU and ultrasonography were performed 1 week and 1 month after surgery. Patients with a stone smaller than 4 mm in diameter were considered stone free. If there were residual fragments, those patients were treated by SWL again. The chi-square test or the Fisher exact test was used to compare stone-free percentages among the three groups. Medians were compared using the nonparametric two-sample median test. All analyses were performed using SAS software (SAS Institute, Cary, NC).

Results

There were no significant differences in age, sex, or stone size among the three groups. In group LS, the mean operative time was longer than in groups ULS and PCNL, mean estimated blood loss was greater than in group ULS, and mean hospital stay was longer than in groups ULS and PCNL (Table 1).

Table 1.

Comparison of Different Variable Among the Three Groups

	Group ULS	Group PCNL	Group PLS	P value
Case (n)	22	30	21
Age	49.6±7.1	51.9±8.4	50.2±4.3	>0.05
Male (%)	14 (63.3%)	18 (60%)	12 (57.1%)	>0.05
Female (%)	8 (46.7%)	12 (40%)	9 (42.9%)	>0.05
Left (%)	12 (54.5%)	17 (56.7%)	12 (57.1%)	>0.05
Right (%)	10 (45.5%)	13 (43.3%)	9 (42.9%)	>0.05
Mean stone size (mm)	1.2±0.8	1.4±0.7	1.5±0.7	>0.05
Mean HU CT attenuation	1173±293.6	1296±285.7	1237±152.8	>0.05
Mean operative time (min)	51.6±15.7^*	62.2±18.3^*	93.7±21.6^*	0.038^*
Mean estimated blood loss (mL)	11.4±0.8^*	21.6±5.8	25.8±3.6^*	0.041^*
Mean postoperative hospital stay (days)	3.2±0.9^*	4.4±1.2^*	6.1±1.7^*	0.047^*
Success rate	17 (77.3%)^*	30 (100%)	19 (90.5%)	0.028^*

P<0.05.

Group ULS underwent retrograde ureteroscopy; group PCNL underwent percutaneous nephrolithotomy; group LS underwent laparoscopic ureterolithotomy.

In group PCNL, the mean operative time was shorter than in group LS but longer than in group ULS, although the difference was not statistically significant. Mean estimated blood loss was more in group PCNL than in group ULS, and the mean hospital time was shorter than in group PLS and longer than in group ULS, although the difference was not statistically significant.

Success rates in groups PCNL, PLS, and ULS were 100%, 90.5%, and 77.3%, respectively. The procedures of two patients in group LS were converted to open surgery because of the inability to find the ureteral stone in one patient and an adhesion too difficult to dissect in the other. The procedures of two patients in group ULS were converted to LS, and those of three patients were converted to PCNL because of a severe edema impaction at the site of stone, a sharply angulated ureter obstruction, upward migration of the stone (seven patients), and intraoperative complications (two patients). In group LS, no persistent urinary leakage (>96 hours) occurred in any patient. No long-term (1–24 months, mean 14.8 months) complications were observed in any of the three groups.

Discussion

Currently, surgical approaches to the treatment of patients with upper ureteral stones include SWL, retrograde ureteroscopy, PCNL, and laparoscopic and open ureterolithotomy. No study had identified the most appropriate treatment for patients with large upper ureteral stones. In this study, we retrospectively analyzed the data from the last 4 years on management of large upper ureteral stones using retrograde ureteroscopy, laparoscopic ureterolithotomy, and PCNL.

The results showed that, in group ULS, mean operative time, mean estimated blood loss, and mean hospital stay were the best of the three groups, confirming that retrograde ureteroscopy is a safe minimally invasive procedure. The success rate was only 77.3%, however. The procedures of five (22.7%) patients in group ULS were converted to PCNL or laparoscopic ureterolithotomy.

Some studies have demonstrated that successful procedures and stone-free rates were more than 90% with retrograde ureteroscopy.⁶ Special devices, however, are needed for the management of upper ureteral stones (e.g., flexible ureteroscope, laser lithotripter).⁷ In developing countries, these special devices are not available in most hospitals. Furthermore, retrograde ureteroscopy could result in upward stone migration to the renal pelvis. The rate of upward migration is associated with pneumatic lithotripsy.⁸

In our study, the success and stone-free rate of retrograde ureteroscopy was only 77.3%. The procedures of five patients in group ULS were converted to PCNL or laparoscopic ureterolithotomy. Flexible nephroscopes and laser lithotripters, however, were not available in our hospital. In addition, surgeries on the patients whose proc edures were converted from ureteroscopy to the other two treatment methods were successful (e.g., they were treated with a combined procedure of ureteral push-back and percutaneous removal).

Our study has some important findings. Our results showed that, in group PCNL, mean operative time was better than in group LS. Moreover, the success rate in group PCNL was better than in groups ULS or LS. No patient needed a procedure conversion to another approach, confirming that PCNL is also an effective minimally invasive procedure.

Percutaneous antegrade nephrolithotomy appears to be a favorable approach to management of upper ureteral calculi. Some studies have reported on percutaneous antegrade ureteroscopic lithotripsy.⁹ Percutaneous nephrostomy has had a major impact on the management of obstructing ureteral calculi.¹⁰ Furthermore, PCNL can treat multiple kidney stones simultaneously,¹¹ although it is associated with significant complications such as uncontrolled hemorrhage, urinary leakage, and sepsis.¹²

In our study, the results showed that, of the three groups, mean operative time, mean estimated blood loss, and mean hospital stay were greatest in group LS. The procedures of two patients in group LS were converted to open surgery because of the inability to find the ureteral stone in one patient and an adhesion too severe to dissect in the other. Some studies have shown that laparoscopic ureterolithotomy is associated with a higher success rate and fewer surgical procedures than SWL and ureterolithotripsy, but with more postoperative pain, longer procedure, and longer hospital stay.¹³ On the other hand, laparoscopic ureterolithotomy is not effective for removal of multiple kidney stones at the same time, so we suggest it as a second-line procedure for removal of large upper ureteral stones.

With development of SWL and ureteroscopy, laparoscopic ureterolithotomy is not a first-line management option for uncomplicated ureteral stones. While the isolation of the ureter is not difficult, ureteral suturing is still a technical challenge for young urologists learning laparoscopy.¹⁴ Laparoscopic ureterolithotomy can be considered in patients with large stones in whom ureteroscopy failed or is expected to fail.¹⁵

The major drawback of our study is the lack of randomization. Another potential drawback is that different surgeons performed the different surgeries, so our comparison is not very precise. We did not intend to identify the gold standard approach to the management of upper ureteral stones, however; rather, we wanted to identify the most appropriate approach for different patients.

The groups we studied were similar in all aspects. Stone analysis was not available in our hospital, so we could not analyze whether the stone analysis results affected the success rate. As we know, however, unlike SWL, the success rates of URS, PCNL, and laparoscopic ureterolithotomy have no obvious correlation with stone analysis. Moreover, the stone density on CT was similar among all three groups.

Conclusion

Our study confirms that PCNL is a safe and effective minimally invasive procedure for treating patients with large upper ureteral stones. It is more advantageous than retrograde ureteroscopy and laparoscopic ureterolithotomy. Thus, PCNL is recommended as a safe and good treatment option for large upper ureteral stones. A combined procedure (e.g., ureteral push-back and percutaneous removal) can also be considered in some patients.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

Kreshover

, Dickstein

, Rowe

, et al. Predictors for negative ureteroscopy in the management of upper urinary tract stone disease. Urology, 2011; 78:748–752.

, Cheng

, Zhang

, et al. Retrograde ureteroscopic treatment for upper ureteral stones: A 5-year retrospective study. J Endourol, 2010; 24:1753–1757.

Yencilek

, Sarica

, Erturhan

, et al. Treatment of ureteral calculi with semirigid ureteroscopy: Where should we stop?. Urol Int, 2010; 84:260–264.

Leonardo

, Simone

, Rocco

, et al. Laparoscopic ureterolithotomy: Minimally invasive second line treatment. Int Urol Nephrol, 2011; 43:651–654.

Lee

, Han

, Kim

, et al. Laparoendoscopic single-site ureterolithotomy for upper ureteral stone disease: The first 30 cases in a multicenter study. J Endourol, 2011; 25:1293–1298.

Geavlete

, Georgescu

, Nita

, et al. Complications of 2735 retrograde semirigid ureteroscopy procedures: A single-center experience. J Endourol, 2006; 20:179–185.

Elganainy

, Hameed

, Elgammal

, et al. Experience with impacted upper ureteral stones: Should we abandon using semirigid ureteroscopes and pneumatic lithoclast?. Int Arch Med, 2009; 2:13.

Tunc

, Kupeli

, Senocak

, et al. Pneumatic lithotripsy for large ureteral stones: Is it the first line treatment?. Int Urol Nephrol, 2007; 39:759–764.

Zhong

, Zeng

, Wu

, et al. Minimally invasive percutaneous nephrolithotomy with multiple mini tracts in a single session in treating staghorn calculi. Urol Res, 2011; 39:117–122.

10.

Zilberman

, Lipkin

, de la Rosette

, et al. Tubeless percutaneous nephrolithotomy—the new standard of care?. J Urol, 2010; 184:1261–1266.

11.

Kumar

, Sandeep , Ganesamoni

, Mandal

. Efficacy and outcome of percutaneous nephrolithotomy in patients with calculus nephropathy. Urol Res, 2011; 39:111–115.

12.

Michel

, Trojan

, Rassweiler

. Complications in percutaneous nephrolithotomy. Eur Urol, 2007; 51:899–906.

13.

Lopes Neto

, Korkes

, Silva JL 2nd, et al. Prospective randomized study of treatment of large proximal ureteral stones: Extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy. J Urol, 2012; 187:164–168.

14.

Kijvikai

, Patcharatrakul

. Laparoscopic ureterolithotomy: Its role and some controversial technical considerations. Int J Urol, 2006; 13:206–210.

15.

Basiri

, Simforoosh

, Ziaee

, et al. Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: A randomized clinical trial. J Endourol, 2008; 22:2677–2680.