LETTER TO EDITOR I read with great interest the recently published article entitled “Ureteroscopy: The first line treatment for distal lo-cated ureteral stones smaller than 10 mm” by Kirac M et al.(1) This article highlights the superiority of ureteroscopy (URS) over observation, and medical expulsion therapy (MET) with tamsulosin in managing distal ureteric stone smaller than 10 mm. In my opinion this is inappropriate comparison as URS is in the group of minimally invasive urology procedures, whereas the latter two are in non-invasive treatment method group. Thus, the complications of these two groups of treatment option (minimally invasive vs. non-invasive) will be obviously different. All the possi- ble complications should also be considered before deciding which is the best choice of treatment for any patient. On top of that, cost effective and availability of the services should also be considered. The most common comparison in many of the published literatures was between URS and extracorporeal shock wave lithotripsy (SWL). These two procedures have almost equal risk of complication as well as cost.(2,3) Besides that, in this paper there was no clear definition for stone expulsion time in URS group. Based on the presented result, the expulsion time was obviously short (1.95 ± 2.2 days). Most likely the authors calculated stone expulsion time in URS group starting from post-operative period onwards. Whereas for the other two groups the expulsion time was calculated starting from the stone first diagnosed (in which usually medication started). In my opinion, similar starting point should be used to give better comparison of stone expulsion time between all 3 groups. Thus, the stone expulsive time in URS group will be calculated starting from stone being diagnosed until post-operative imaging shows stone free. This will include pre-operative waiting period. In busy center with high work load the operation waiting list may up to a few months. Thus, the finding of this paper not applicable for all urology center. The URS with simultaneous stone extraction or stone fragmentation was being an efficacious single session treatment. However it comes with complication and some limitation. Thus, the final therapeutic decision should be individualized in each patient. Mohd Nazli Kamarulzaman Department of Surgery, Kulliyyah of Medicine, International Islamic University Malaysia (IIUM) Kuantan, Malaysia. REFERENCES 1. Kiraç M, Atkin MS, Biri H, Deniz N. “Ureteroscopy: The first line treatment for distal located ureteral stones smaller than 10 mm. Urol J. 2014;10:1028-34. 2. Lingeman JE1, McAteer JA, Gnessin E, Evan AP. Shockwave lithotripsy: Advance in technology and tech- nique. Nat Rev Urol. 2009;6:660-70. 3. Papadoukakis S, Stolzenburg JU, Truss MC. Treatment Strategies of Ureteral Stones. Eur Urol. 2006:184–190. EAU–EBU update series 4. Letter to Editor 1914 I took your letter about my published article entitled “Ureteroscopy: the first-line treatment for distallylocated ureteral stones smaller than 10 mm”. Firstly, thanks for your worthy opinion and criticisms about our article. According to the literature, there are different treatment options including, observation, medical expulsive therapy (MET), ureteroscopy (URS) and extracorporeal shock wave lithotripsy (SWL) in distally located ureteral stones.(1,2) In our study, it was investigated which treatment options were effective for distal ureteral stones. You may think that the comparison of an invasive method (URS) and a non-invasive method (MET or observation) may be un- reasonable. But this comparison is reasonable both theoretically and statistically. On the other hand, currently, URS has become a widely used technique and very low complication rate for treatment of distal ureteral stones. In my opin- ion, now, URS can be considered as a non-invasive technique. According to European Association of Urology (EAU) guidelines, if there is indication of active stone removal, URS is the first choice for treatment of distal ureteral stones.(3) In our study, the stone expulsion time was calculated since the time of URS. Yes, you are right. It must be calculated since the stone diagnosis. We did not include the patients who has long time waiting period before the surgery in the study. We had to specify this situation in our paper but we did not. Recently, in most urology centers, URS has been selected as the first choice for the treatment distal ureteral stones because of technical and instrumental development. This study introduces our clinical results. Our results must be exactly confirmed by other clinical results. Mustafa Kirac Endourology Department of Koru Hospital, Ankara, Turkey. REFERENCES 1. Perez Castro E, Osther PJ, Jinga V, et al. Differences in Ureteroscopic Stone Treatment and Outcomes for Distal, Mid-, Proximal, or Multiple Ureteral Locations: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study. Eur Urol. 2014;66:102-9. 2. Yencilek F, Sarica K, Erturhan S, Yagci F, Erbagci A Treatment of ureteral calculi with semirigid ureteros- copy: where should we stop? Urol Int. 2010;84:260-4. 3. Türk C, Knoll T, Petrik A, Sarica K, Seitz C, Straub M. Guidelines on Urolithiasis, European Association of Urology. 2011. Available at http://www.uroweb.org/guidelines/online-guidelines. RESPONSE BY AUTHOR Vol 11. No 05 Sept-Oct 2014 1915