Original Paper

Urologia Internationalis

Received: August 20, 2014 Accepted after revision: September 16, 2014 Published online: January 29, 2015

Urol Int 2015;94:205–209 DOI: 10.1159/000368374

Comparison of Ureteroscopic Laser Lithotripsy with Laparoscopic Ureterolithotomy for Large Proximal and Mid-Ureter Stones Onur Kaygısız Burhan Coşkun Hakan Kılıçarslan Yakup Kordan Hakan Vuruşkan Gökhun Özmerdiven İsmet Yavaşcaoğlu 

Abstract Objectives: To compare the effectiveness and complications of ureteroscopic laser lithotripsy with laparoscopic ureter laparoscopic ureterolithotomy in mid- or proximal portion of large ureteral stones. Material and Methods: We reviewed patients with large (>15 mm) ureteral stone and those who underwent ureteroscopic laser lithotripsy (URS group) or laparoscopic ureterolithotomy (LU group). The first attempt was considered successful in patients who had residual fragments smaller than 2 mm and no conversion of the primary procedure to another. Results: Sixty patients (URS group 29, LU group 31) met inclusion criteria. FURS was used as an adjunctive procedure in one patient for URS group and in two patients for LU group in the same season. LU had a higher success rate and the first-day stone-free rate when compared with URS. Number of procedures was also significantly higher in URS group. There was no difference in stone-free rates at the first and third months, and length of hospitalization and operation were higher in the LU group. Only two patients in the LU group and one patient in the URS group had major complications. Conclusions: Laparoscopy is an effective option of large proximal and mid-ureter stone treatment; however, URS provides similar stone-free rates at three months as a minimal invasive procedure. © 2015 S. Karger AG, Basel

© 2015 S. Karger AG, Basel 0042–1138/15/0942–0205$39.50/0 E-Mail [email protected] www.karger.com/uin


Urolithiasis is a common disease of the urinary system, and it constitutes an important part of urology practice [1]. Ureteral calculus is more symptomatic and prone to deterioration of renal function when compared to kidney stones. Indications for active treatment of ureteral stones include large calculi with low spontaneous passage, persistent pain, obstruction, or renal failure [2]. Extracorporeal shock-wave lithotripsy (SWL) and ureterorenoscopy (URS) are the first choices for active treatment of ureteral calculi. Necessity of open or laparoscopic procedures is limited with the evolution of modern lithotripsy and ureteroscopy. URS has been found to be more effective than SWL for ureteral calculi that are bigger than 10-mm in diameter with success rates of more than 80%. URS success rates are decreased in mid- or upper-ureter stones [2]. Currently, laparoscopic ureterolithotomy is indicated for large impacted stones when other minimal invasive procedures fail. Stone clearance rates of large (>1.5 cm) mid-ureteral stones were reported as 39% for SWL, 79% for ureteroscopic pneumatic lithotripsy, and 100% for laparoscopic ureterolithotomy [3]. Improvements in medical technology increased the success rate of ureteroscopic lithotripsy. Laser lithotripsy has better stone-free rates and lower complications rates than pneumatic lithotripsy for upperureteral stones [4]. Furthermore, laser lithotripsy has advantages over pneumatic lithotripsy with low-retrograde migration of ureteral calculi [5] and flexible ureterorenoOnur Kaygısız Department of Urology, Faculty of Medicine Uludağ University TR–16059 Görükle/Bursa (Turkey) E-Mail onurkygsz @ yahoo.com

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Key Words Endourology · Laparoscopy · Laser · Ureteral Calculus · Ureteroscopy

Materials and Methods We reviewed medical records of patients who underwent surgery for the upper and mid portion of ureteral stones between April 2004 and May 2014 in a single center. Patients with a radiopaque stone larger than 15 mm in diameter and who underwent laparoscopic ureterolithotomy (LU) or ureteroscopic laser lithotripsy were included in this study. Exclusion criteria were ureteral stricture due to malignant disease, nonfunctional renal unit, distal ureteral calculi, previous ipsilateral ureter operation history, loss of follow-up, and acute renal deficiency. Patient demographics, stone location, stone size on the X-ray kidney, ureter and bladder (X-ray KUB), and perioperative data were recorded. The stone size was measured according to its largest dimension on X-ray KUB. Patients were categorized into two groups according to primary treatment procedure: URS group and LU group. Patients with an unsuccessful attempt of URS and subsequent utilization of LU at the session were included in both groups. Impacted ureteral stones in the URS group were defined as stones attached to the ureteral wall. Both LU and URS were performed under general anesthesia. URS Procedure In this procedure, 7.5- or 8.5-F semi-rigid ureterorenoscopy (R. WolfTM) was used for URS and flexible URS (Karl Storz Flex-X 2TM) was used secondarily when necessary. After a guide wire was inserted into the ureter under a fluoroscopic image, the semirigid double lumen 7.5- or 8.5-F ureterorenoscopy was passed into the ureter. Ureterorenoscopy was forwarded to the stone localization with visual and fluoroscopic images. Stone fragmentation was performed with holmium laser lithotripsy. The stones that were less than 2 mm in size were fragmented. Small fragments were left for spontaneous passage. A double-J stent was inserted at the end of the operation and was removed after 4 weeks. Retroperitoneoscopic (15 renal unit) or transperitoneoscopic (16 renal unit) ureterolithotomy was performed in the LU group. Retroperitoneal Approach The patient was placed in the full flank position. A 2-cm muscle-splitting incision was performed below the 11th rib at the Petit triangle. A balloon trocar system was used to expand the pararenal space. A 10-mm camera port was inserted and after pneumoretroperitoneum was provided with a pressure of 12 mm Hg. Other trocars (10 mm, 10 mm, and 5 mm) were inserted under direct vision. After opening the Gerota’s fascia, ureter and following stone


Urol Int 2015;94:205–209 DOI: 10.1159/000368374

was identified. In the upper side of the stone, the ureter was controlled by a vascular tape. A longitudinal ureterotomy was made directly over the stone by utilizing a laparoscopic scalpel (cold knife) or scissors. The stone is extracted with grasping forceps. After double-J stent insertion, the ureterotomy incision was closed with 4/0 polyglycolic acid sutures. A hemovac drain was placed to retroperitoneal space. Transperitoneal Approach The patient was placed in the full flank position. Veress needle was inserted in 1/3 lateral part of lines extending from anterior superior iliac spine to umbilicus. After pneumoperitoneum was established, the camera port was inserted at the intersection of mid-clavicular line and umbilical line. The other trocar (10, 10, 5 mm) was placed under laparoscopic vision. After colon was mobilized, the preparation of ureter and stone removal procedures were similar to those used in the retroperitoneal access. A 4.7-F ureteral double-J stent was inserted at the end of the operation for all patients, and the stents were removed at 4 weeks after the operation for stone-free patients. Complications were recorded according to the modified Clavien classification. The stone-free rate after the first attempt was assessed with Xray KUB on the first postoperative day. The first attempt was considered successful in patients who had residual fragments smaller than 2 mm and no conversion of the primary procedure to another. Stone status was assessed with physical examination, urinalysis, Xray KUB, and urinary ultrasound. When there was any suspicion, non-contrast computed tomography was used to assess the stone status. The stone status was evaluated one day after the DJ stent was removed. Patients on whom secondary treatment was applied for residual fragment were evaluated at three months later after the last procedure. Statistical analysis was performed with the SPSS version 22 (SPSS Inc., Chicago, Ill., USA) software. The Shapiro-Wilk test was used to test the normality of variables. The normally distributed variables are presented as mean ± standard deviation and were compared with Student’s t-test. The non-normally distributed variables were presented as median (minimum-maximum) and were compared with Mann-Whitney U test. Data for nominal variables. The Mann-Whitney U test was used for nonparametric continuous data. Nominal data were presented as number and percentage and were compared by Fisher’s Exact test. p less than 0.05 was considered statistically significant.


Sixty patients met inclusion criteria. The URS group consisted of 29 patients, and the LU group consisted of 31 patients. The mean age was 46.5 ± 14.8. Forty (66.7%) patients were male and 20 (33.3%) were female. Ureter calculi were localized at the right side in 23 (38.3%) patients and at the left side in 37 (61.7%) patients. There were no differences between groups according to age, gender, body mass index (BMI), and stone side (table 1). The calculi was located in the mid-ureter in 21 (38.5%) and in the upper Kaygısız/Coşkun/Kılıçarslan/Kordan/ Vuruşkan/Özmerdiven/Yavaşcaoğlu

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scopy (FURS) could reach the migrated stones in the same season. Thus, higher stone-free rates and lower complications can be expected for upper-ureteral stones where laser lithotripsy and flexible ureterorenoscopy are available. In this study, we aim at comparing the complications and effectiveness of ureteroscopic laser lithotripsy with laparoscopic ureter laparoscopic ureterolithotomy in the mid- or proximal portion of ureteral stones that are more than 15 mm when the FURS is available.

Table 1. Patients’ demographics and stone parameters

Mean age, yeara Genderb Female Male BMI, kg/m2c Stone diameter, mmc Stone localizationb Upper ureter Mid ureter Stone sideb Right Left

URS group (n = 29)

LU group (n = 31)





11 (37.9%) 18 (62.1%) 27.30 (16.51–36.85) 15 (15–25)

9 (29.0%) 22 (71.0%) 27.46 (21.08–47.45) 20 (15–30)


15 (51.7%) 14 (48.3%)

24 (77.4%) 7 (22.6%)


12 (41.4%) 17 (58.6%)

11 (35.5%) 21 (64.5%)


0.407 0.005

a Normally distributed variables; b nominal variables; c not-normally distributed variables; n% = percentage in group.

tween the upper- and mid-ureter stones after the primary procedure (73.3, 85.7%, respectively, p  = 0.651), first month (80%, 100%, respectively, p = 0.224), and 3 months after the last procedure (93.3, 100%, respectively, p = 1). The success rates after primary procedure were also found to be similar (60.0, 71.4%, respectively, p = 0.70).

URS Procedures URS procedures were converted to laparoscopy in three (10.3%) patients, percutaneous nephrolithotomy (PNL) in one (3.4%) patient because of ureteral kinking and obstruction due to ureteral edema. There were 7 impacted stones in the URS group. Ureteral stones were pushed back into the kidney in 7 patients. FURS with laser lithotripsy was used in one patient in the same season, and stone-free status was provided. Then, 3- to 5-mm residual stones were passaged spontaneously at the first-month control visit in further three patients. An additional URS procedure was performed for one patient. SWL was recommended to 3 patients. One patient did not want to proceed with the procedure, and the other two patients had a total of 5 SWL sessions. The success rate was 65.5% (19 patients); the stone-free was 79.3% (23 patients) after the first operative day, 89.7% (26 patients) at postoperative first month, and 96.6% (28 patients) at postoperative third month. These parameters and number of procedures were similar for impacted and non-impacted stones. The stone size were similar for successful and unsuccessful groups (p = 0.701). There was no significant difference with regard to stone-free rates be-

Laparoscopic Procedures The stone size, localization, and side were similar according to retroperitoneoscopic (15 renal units) and transperitoneoscopic (16 renal units) approaches. The laparoscopic approach was indicated in three patients with a history of unsuccessful URS attempt, and it was carried out in three patients at the same season of URS. Other patients underwent LU, primarily due to an impacted stone, which was bigger than 15 mm and was located in the same position on two consecutive KUB for at least 1 month. Laparoscopy procedure converted to open surgery in one patient due to tissue adhesions (3.1%). FURS was used as an adjunctive procedure in two patients with migration of ureteral stones to the kidney. These stones were removed from the renal unit with a basket catheter. The success rate was 96.77% (30 patients) after the primary procedure and 100% (31 patients) at postoperative month one and three. Although laparoscopic ureterolithotomy had a higher stone-free rate after the primary procedure (p = 0.009), there was no difference in stone-free rates between LU and URS at the first and third months after the procedure (p = 0.107, p = 0.483, respectively) (table 2). Conversion

Laparoscopy versus URS in Large Upper- and Mid-Ureter Stones

Urol Int 2015;94:205–209 DOI: 10.1159/000368374


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ureter in 39 (61.5%). In the LU group, upper-ureter calculi were higher than those in the URS group. However, this was not statistically significant (p = 0.058) (table 1). The stone size was significantly larger in the LU group (p = 0.005) (table 1).

Table 2. Comparison of two groups with respect to the operation and hospitalization parameters

Operation time (min)a Hospitalization time (day)a Number of proceduresa Success rate after first attemptb Stone free rate at first dayb Stone free rate at first monthb Stone free rate 3 months after last procedureb


62.50 (30–120) 2 (1–7) 1.31±0.71 1 (1–4) 65.5% 79.3% 89.7% 96.6%

142.50 (45–330) 4 (2–28) 1.03±0.180 1 (1–2) 96.8% 100% 100% 100%

1.5cm) midureteric calculi? J Laparoendosc Adv Surg Tech A 2009;19:501–504. 4 Bapat SS, Pai KV, Purnapatre SS, Yadav PB, Padye AS: Comparison of holmium laser and pneumatic lithotripsy in managing upper-ureteral stones. J Endourol 2007;21:1425–1427. 5 Jeon SS, Hyun JH, Lee KS: A comparison of Holmium: YAG laser with Lithoclast lithotripsy in ureteral calculi fragmentation. Int J Urol 2005;12:544–547. 6 Lopes Neto AC, Korkes F, Silva JL 2nd, Amarante RD, Mattos MH, Tobias-Machado M, Pompeo AC: Prospective randomized study of treatment of large proximal ureteral stones: extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy. J Urol 2012;187:164–168.

Comparison of ureteroscopic laser lithotripsy with laparoscopic ureterolithotomy for large proximal and mid-ureter stones.

To compare the effectiveness and complications of ureteroscopic laser lithotripsy with laparoscopic ureter laparoscopic ureterolithotomy in mid- or pr...
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