Ureteroscopy preferred to ESWL for proximal stones

San Antonio-Ureteroscopy is associated with significantly better outcomes than extracorporeal shock wave lithotripsy (ESWL) for the treatment of proximal ureteral stones, according to the results of a prospective randomized study undertaken by urologists at the University of Innsbruck, Austria. The researchers now recommend the ureteroscopic approach as first-line treatment for proximal stones, they said at the 2005 AUA annual meeting here.

The trial randomized 40 patients with radiodense ureteral stones proximal to the bony pelvis that had not passed spontaneously within 3 weeks or that required earlier intervention because of recurrent colicky pain or upper urinary tract obstruction. Compared with ESWL, ureteroscopy was associated with a significantly shorter time to achieve a stone-free state (5 days vs. 14 days) along with a higher stone-free state at 3 weeks (90% vs. 60%).

"Stone-free rates ranging from 60% to 90% have been reported for both techniques, and each has its own proponents. To our knowledge, however, ESWL and ureteroscopy have not been compared for the treatment of proximal ureteral calculi in a prospective randomized study," said co-author Richard Neururer, MD, a urologist specializing in stones and endourology at the University of Innsbruck.

Comparing methods, outcomes

The study was conducted between November 2002 and July 2004, and the randomization resulted in treatment groups that were similar in mean age, gender distribution, and stone size.

Patients in both groups ranged in age from 20 to 78 years (mean age, 47 years). Mean stone size in both groups was 8.0 mm (range, 5 mm to 16 mm) and 8.5 mm (range, 4 mm to 5 mm), respectively, and the overall numbers of men and women were approximately equal.

ESWL was performed using the Litho Diagnost M lithotriptor (Philips Medical Systems) with fluoroscopic guidance for calculi localization and with the patient under sedoanalgesia. Ureteroscopy was performed with a 6.5F semirigid ureteroscope under general or epidural anesthesia using a basket or forceps for stone extraction (six patients) or a holmium laser for disintegration (14 patients). In all cases, a double pigtail catheter was placed and fluoroscopy was performed at the end of the procedure to identify whether the ureter was stone-free.

Maximum operating time was similar for ureteroscopy and ESWL (69 minutes vs. 63 minutes), but ureteroscopy was associated with a shorter mean operating time compared with ESWL (38 minutes vs. 52 minutes). Mean fluoroscopy time was also shorter for ureteroscopy than for ESWL (0.9 minutes versus 2.1 minutes). However, patients who underwent ureteroscopy needed to have a stent in place for an average of 7 days after surgery (range, 2 days to 15 days).

Radiographic follow-up was performed on postoperative day 1, then weekly thereafter for 6 weeks to evaluate the stone-free state. If stones recurred or if the calculi failed to pass by postoperative day 43, ureteroscopic stone removal was performed.

In the ureteroscopy group, 18 patients achieved a stone-free state within 15 days after the procedure, while only two patients (10%) needed re-treatment for failure to pass stones.

In the ESWL group, 14 patients became stone-free, but the time to achieve a stone-free state ranged from 1 to 43 days (mean, 14 days), and six patients (30%) needed re-treatment for failure to pass stones.

Both treatments were associated with a good safety profile, the researchers said.