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COMMENTARY
Year : 2013  |  Volume : 5  |  Issue : 3  |  Page : 146-147  

Commentary on "Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position"


Department of Surgery and Urology, Azeezia Medical College, Meeyannoor, Kollam, India

Date of Web Publication29-Jul-2013

Correspondence Address:
Y M Fazil Marickar
Azeezia Medical College, Meeyannoor, Kollam - 691 537
India
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PMID: 24049374

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How to cite this article:
Fazil Marickar Y M. Commentary on "Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position". Urol Ann 2013;5:146-7

How to cite this URL:
Fazil Marickar Y M. Commentary on "Large impacted upper ureteral calculi: A comparative study between retrograde ureterolithotripsy and percutaneous antegrade ureterolithotripsy in the modified lateral position". Urol Ann [serial online] 2013 [cited 2020 Feb 17];5:146-7. Available from: http://www.urologyannals.com/text.asp?2013/5/3/146/115730

The treatment of large upper ureteric stones had primarily been open ureterolithotomy till recently as extracorporeal shock wave lithotripsy (ESWL), per cutaneous nephro lithotomy (PCNL) and uretero reno scopy (URS) became popular. Lithotripsy machines have made stone fragmentation perfect.

In many countries, several patients seeking treatment for ureteric stones are below the poverty line (BPL) and cannot afford the cost of newer modalities of treatment. Open surgery may be free in Government institutions and thus is available free of cost. Endoscopic instruments and competent endoscopists may not be available. Even though post-operative morbidity for open ureterolithotomy is high, there are long term advantages for open procedures.

We studied 300 ureteric stone patients who had different modes of stone retrieval [Table 1]. We followed up 100 patients each, of open ureterolithotomy, other modes of stone retrieval (ESWL, PCNL, and URS) and spontaneous passage with or without appropriate chemotherapy (medical management based on biochemical profile). Follow-up ranged from 3 years to 17 years (mean 6.7 years). The recurrence rate was 31% in the open surgery group, 63% in the ESWL/PCNL/URS group and 11% in the spontaneous passage group as detailed in [Table 2].
Table 1: Stone retrieval pattern in 300 ureteric stone patients

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Table 2: Stone recurrence rate among 300 ureteric stone patients with different retrieval patterns

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It is possible that the scattered fragments of stones following ESWL, PCNL, URS etc., get embedded in the sub urothelial plane and form a nidus for further stone formation.

In the light of all these facts, it may be surmised that modern treatments for ureteric stones are beneficial to patients, but the cost factor and feasibility of performing these in the peripheral centers are restrictive. For large upper ureteric stones, open surgery rates are high as recurrence is lesser in them. Recurrence rates may also have a relation to the prophylactic advice given. The patients treated in the stone clinic were given strict chemoprophylactic and dietetic advice accounting for lesser recurrence. The local scenario in my area of practice still has open ureterolithotomy procedures due to the financial constraints for the BPL patients. Several patients, who had endoscopic retrieval procedures, have come to the stone clinic only after occurrence of recurrence and hence the recurrence rate for these patients may be higher. The best option for stones in the upper one third would be an appropriate chemotherapy based on the metabolic status of the blood and 24 hour urine for stones less than or equal to 8 mm in diameter (not the length). This may be extended to larger stones in patients with history of repeated passage of stones. The composition of the stones passed or retrieved earlier will also help in deciding the course of action. Patients with uric acid stone passage and those with significant hyperuricemia and hyperuricosuria are best candidates for chemotherapy, even with bigger stones. CT scan may be of benefit in differentiating between uric acid stones and calcium oxalate monohydrate (COM) stones pre-operatively. If the stones are indeed recognized to be COM stones and of size more than 15 mm in the breadth (not length), it will be appropriate to do a PCNL rather than URS. URS in the upper one third of the ureter has a definite high chance of significant ureteric injury, ending up in recurrent urinary tract infection and stricture. I deal with lithoclast primarily, and the breakage levels are unacceptable for the upper ureteric level stones. The PCNL does pose a problem in cases where the ureteric catheter does not go beyond the stone. Needle insertion into the calyceal system will be very difficult if radiologically supported needle insertion is practiced.



 
 
    Tables

  [Table 1], [Table 2]



 

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