Large impacted upper ureteral calculi: a comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position

ABSTRACT

The treatment for patients with large impacted proximal ureteral stone remains controversial, especially at institutions with limited resources. The aim of this study is to compare and to evaluate the outcome and complications of two main treatment procedures for impacted proximal ureteral calculi, retrograde ureterolithotripsy [URS], and percutaneous antegrade ureterolithotripsy [Perc-URS]. Our inclusion criteria were solitary, radiopaque calculi, >15 mm in size in a functioning renal unit. Only those patients in whom the attempt at passing a guidewire or catheter beyond the calculus failed were included in this study. Between January 2007 and July 2011, a total of 52 patients [13 women and 39 men] with large impacted upper-ureteral calculi >15 mm and meeting the inclusion criteria were selected. Of these, Perc-URS was done in 22 patients [group 1] while retrograde ureteroscopy was performed in 30 patients [group 2]. We analyzed operative time, incidence of complications during and after surgery, the number of postoperative recovery days, median total costs associated per patient per procedure, and the stone-free rate immediately after 5 days and after 1 month. Bivariate analysis used the Student t-test and the Mann-Whitney test to compare two means and Chi-square and Fisher's exact tests to compare two percentages. The significance level was set at 0.05. The mean age was 42.3 years [range 22-69]. The mean stone sizes [mm] were 34 +/- 1.2 and 29.3 +/- 1.8 mm in group 1 and 2, respectively. In the Perc-URS group, 21 patients [95.45%] had complete calculus clearance through a single tract in one session of percutaneous surgery, whereas in the URS group, only 20 patients [66.7%] had complete stone clearance [P = 0.007]. The mean operative time was higher in the Perc-URS group compared to group 2 [66.5 +/- 21.7 vs. 52.13 +/- 17.3 min, respectively; P = 0.013]. Complications encountered in group 1 included transient postoperative fever [2 pts] and simple urine outflow [2 pts]. Ten patients [33%] of group 2 experienced failure Migration to the kidney [3 pts], ureteral perforation [2 pts], tortuosity of the ureter [2 pts], and epithelial polyps [2 patients]. Group 1 patients had an average visual analog [VAS] pain score of 47 mm compared with 31 mm in group 2 patients. The mean hospital stay [days] in group 1 was higher than the group 2 [2.27 +/- 0.8 vs. 1.67 +/- 0.6, respectively; P = 0.01]. The mean analgesia requirement for group 1 [paracetamol chlorhydrate + codeine 12 +/- 3 g] was significantly more compared with group B [6.8 +/- 2 g] [P < 0.01]. The difference in average blood loss between the two groups was not statistically significant. Total costs was slightly higher in group 1 but the difference was not statistically significant between the two groups [15000 vs. 13400 MDH respectively; P > 0.05]. After 1 month, the stone free-rate remained higher in group 1 [95.5% vs. 66.7%, respectively; P = 0.012]. In our series, Perc-URS is a safe and efficient treatment option for proximal ureteral stone, especially when the stone size is superior to 15 mm with the presence of moderate or severe hydronephrosis.