ESWL in situ or ureteroscopy for ureteric stones?

Summary

As documented by follow-up data on ureteric stones in 1259 ureteric units treated, ESWL in situ on advanced lithotriptors with stone location by ultrasonography and fluoroscopy was successful without any retrograde ureteric manipulation in 98% of stones in the upper, 71% in the iliac, and 84% in the distal ureter; 85% of the units were stone-free within 3 months: ancillary measures were needed in 11% and the stone-free state was reached after a median of 39 days. The results obtained with treatment after manipulation of the stone from the upper and mid-ureter by retrograde instrumentation were similar, but ancillary measures were needed in 20% of cases. Endoscopic management with rod-lens ureteroscopes was highly efficient in the distal and midureter, but involved a complication rate of about 11% and required general anaesthesia. In the upper ureter it was abandoned in favour of the two former methods. Endoscopic stone removal has been greatly facilitated by the development of ultrathin, semirigid ureteroscopes 6.2–9 F in diameter, as well as by laser and pneumatic lithotriptors that operate through their minute working ports. Of the stones impacted in 127 ureteric units, 97% were successfully managed at the first attempt, involving an overall complication rate of 6%. Although ESWL in situ without any instrumentation remains the primary treatment of choice for stones in the upper and distal ureter, primary ureteroscopy is again being employed more frequently for stones in the iliac ureter, which are more difficult to focus, and small stones in the distal ureter, as well as in patients unwilling to accept the prolonged time until the urinary tract becomes stone-free after ESWL. This resulted in an increase in the frequency of ureteroscopy as the primary treatment for ureteric stones from 9% in 1990 to 32% in 1991.