Comparison of Flexible Ureterorenoscopy and Laparoscopic Ureterolithotomy Methods for Proximal Ureteric Stones Greater Than 10 mm Idris Kivanc Cavildak,1 Ismail Nalbant,2* Can Tuygun,2 Ufuk Ozturk,2 Hasan Nedim Goksel Goktug,2 Hasan Bakirtas,3 Muhammed Abdurrahim Imamoglu4 Purpose: To examine the outcomes and compare the effectiveness of laparoscopic ureterolithotomy and flexible ureterorenoscopy (FURS) in patients with proximal ureteral stones larger than 10 mm in diameter. Materials and Methods: In total, 150 patients who underwent laparoscopic ureterolithotomy and FURS because of ureteral stones in our urology clinic from January 2010 to June 2015 were retrospectively analyzed. The patients were divided into 2 groups: 70 patients who underwent laparoscopic ureterolithotomy (Group 1) and 80 patients who underwent FURS (Group 2). Success rates and complications were compared. Results: The success rates were 95.7% and 90.0% in Groups 1 and 2, respectively; there was no statistically sig- nificant difference between the groups. No statistically or clinically significant complications occurred in either group. Conclusion: Laparoscopic ureterolithotomy and FURS are both effective and reliable for the treatment of proxi- mal ureteral stones. However, considering the shorter operation and hospitalization times and the management of situations that require secondary interventions, we suggest that FURS, as a minimally invasive method, may be the first choice in the treatment of proximal ureteral stones. Keywords: ureteral calculi; surgery; laparoscopy; adverse effects; lithotripsy; postoperative complications; ureter- olithiasis; treatment outcome; ureteroscopy; methods. INTRODUCTION Ureteral stones are seen in approximately 15% of the population and are responsible for 20% of cases of urolithiasis.(1) The aim of treatment of ureteral stones is to achieve complete stone removal with minimal mor- bidity. Standard treatment methods for upper ureteral stones include extracorporeal shock wave lithotripsy (SWL), ureterorenoscopy (URS), ureterolithotomy, and antegrade percutaneous nephrolithotomy. Although the rates of laparoscopic treatment for large and impacted ureteral stones seem to have decreased with the devel- opment of flexible URS (FURS) and fine-tipped laser lithotripsy, laparoscopy still has high success rates in the treatment of ureteral stones that cannot be treated by SWL and endoscopic methods.(2) In this study, we examined the outcomes and compared the effectiveness of laparoscopic ureterolithotomy and FURS in patients with proximal ureteral stones larger than 10 mm in di- ameter. MATERIALS AND METHODS After obtaining approval from the local ethics commit- tee at our hospital, the medical files of 150 patients who underwent laparoscopic ureterolithotomy and FURS because of ureteral stones in our urology clinic from January 2010 to June 2015 were retrospectively analyz- ed. The patients were divided into 2 groups: 70 patients who underwent laparoscopic ureterolithotomy (Group 1) and 80 patients who underwent FURS (Group 2). Patients with proximal ureteral stones larger than 1 cm in diameter were included in the study. Patients with a solitary kidney, ureteropelvic junction obstruction, pelvic kidney abnormalities, non-opaque and multiple stones, and a history of open or percutaneous surgery or SWL were excluded. Preoperatively, all patients underwent a complete blood count, serum urea and creatinine measurement, bleed- ing and coagulation profile analysis, urinalysis and urine culture, intravenous urography, and computed to- ENDOUROLOGY AND STONE DISEASES Endourology and Stone Diseases 2484 1 Department of Urology, 29 Mayis State Hospital, Ankara 06450, Turkey. 2 Department of Urology, Diskapi Training and Research Hospital, Ankara 06110, Turkey. 3 Department of Urology, Special Memorial Hospital, Ankara 06450, Turkey. 4 Department of Urology, Medical Faculty, Bozok University, Yozgat 66000, Turkey. *Correspondence: Dişkapi Training and Research Hospital, Clinics of Urology, Irfan Bastug Street, Diskapi/Altindag/An- kara, Turkey. Tel: +90 312 5962000. Fax: +90 312 3186690. E-mail: nalbant60@yahoo.com. Received August 2015 & December 2015 Vol 13 No 01 January-February 2016 2485 mography without contrast, if needed. The success rates and complications in Groups 1 and 2 were compared. Residual stones and stone-free rates were evaluated by urinary tract radiography and ultra- sonography 4 to 6 weeks after surgery. Cases involving detection of small fragments (< 4 mm) and the absence of stones were considered successful. Cases involving symptomatic and/or residual fragments greater than 4 mm or stone clearance achieved with an auxiliary pro- cedure were deemed technique failures. Double J (DJ) ureteral stents in the stone-free patients were removed 2 weeks after FURS. We first compared the success rates of the procedures and then compare the hospitalization and operation times and complication rates. Three trocars (10–12 mm) were used for laparoscop- ic ureterolithotomy. The initial port was placed by the open method at the junction of the 12th rib and posterior axillary line. In the open method, a 1.5 cm incision was made in the fascia of the external oblique muscle. The retroperitoneal space was accessed by puncturing the fascia of the transversus abdominis muscle with a blunt clamp. First, an 800-mL space was created with a finger and then with a balloon dissector while the peritoneum was shifted medially at the same time. The second port was placed 1 cm anterior to the 11th rib. The third port was placed at the anterior axillary line, 2 cm superior and 2 cm medial to the spina iliaca anterior superior. After expansion of the retroperitoneum and opening of Gerota’s fascia, the ureter was identified over the psoas muscle. Protuberance of the stone was noted, and the stone was grasped with a Babcock clamp. After stabi- lization of the stone, the ureter was incised vertically with a wedge-tipped endoscopic scalpel. The stone was extracted with right-angle forceps. It was placed in an endobag, and a 26 cm antegrade DJ ureteral catheter was inserted. The ureteral incision was closed using 4/0 Vicryl suture. A Hemovac drainage catheter was placed in the periureteric area near the second port site. The DJ catheter was left in place for 7 days.(3) In the FURS procedure, a 9.5- to 11.5 French (F) ac- cess sheath (Elit Flex, Ankara, Turkey) was placed in all patients in the lithotomy position. Standard retro- grade FURS was applied with a 7.5 F flexible ureter- oscope (Flex X2; Karl Storz GmbH, Tuttlingen, Ger- many). Stone fragmentation was achieved using a 4- to 30 W holmium laser (Medilas H20; Dornier Med-Tech GmbH, Wessling, Germany) with 200- or 365 µm laser fibers at 5 to 10 Hz and 0.2- to 3.0 joule (J) intervals. The fragments were collected in a 1.9 F basket (Zero Tip; Boston Scientific, Marlborough, MA, USA) and sent for stone analysis. Residual stones were checked on postoperative day 1 with X-rays and ultrasonogra- phy, and the stone-free status was confirmed on X-ray, ultrasonography, and non-contrast computed tomogra- phy 2 weeks after surgery.(4) Treatment of Large Proximal Ureteral Stones-Cavildak et al. Parameters Group 1 (n = 70) Group 2 (n = 80) P Value Median age, years (range) 49 (20-70) 46 (16-76 ) . 459 Gender, n (%) . 781 Male 32 (45.71) 44 (55) Female 38 (54.28) 36 (45) Side, n (%) . 624 Right 33 (47.14) 31 (38.75) Left 37 (52.85) 49 (61.25) Median BMI, kg/m2 (range) 25.77 (23.63-30.42) 25.87 (23.18-29.15) . 894 Table 1. Demographic and clinical characteristics of study participants. Abbreviation: BMI, Body Mass Index. Variables Group 1 (n = 70) Group 2 (n = 80) P Value Median stone diameter, mm (range) 17 (14-30) 15.5 (10-20) .074 Median hospitalization time, days (range) 3 (2 - 13) 1 ( 0.5 - 3) < .001 Median operational time, min (range) 80 (40-150) 45 (35-85) .001 Stone-free rate, n (%) 67 ( 95.7) 75 (93.75) .081 Table 2. Operation parameters. Statistical Analysis The Statistical Package for the Social Science (SPSS Inc, Chicago, Illinois, USA) version 15.0 was used for statistical analysis of the data. Numerical variables are expressed as mean ± standard deviation. Because there were two groups, the significance of differences in medians was tested with the Mann–Whitney U test. Nominal variables were tested with Pearson’s χ2 test or Fisher’s exact test. P values of < .05 were considered to indicate statistical significance. RESULTS Demographic characteristics of the patients (Table 1) and stone sizes (Table 2) were similar in both groups. The mean operation time in Groups 1 and 2 was 80.71 ± 2.90 and 49.18 ± 1.39 min, respectively, and the mean hospitalization time in Groups 1 and 2 was 3.08 ± 0.17 and 1.19 ± 0.06 days, respectively. The operation time and hospitalization time were shorter in Group 2, and the differences were statistically significant (Table 2). The grade of hydronephrosis was similar between the two groups (Table 3). In Group 1, the surgical procedure was ended laparo- scopically in 67 of 70 (95.7%) patients. We returned to open surgery after incision of the ureter laparoscopical- ly in three patients. We could not perform percutaneous nephrolithotomy or FURS because of gonadal vein in- jury in one patient and the possibility of extravasation and failure to provide clear vision in two. Although the patients were stone-free after the open procedure, these cases were considered unsuccessful. In Group 2, 75 of 80 patients (93.75%) became stone- free, and the fluoroscopy time was 22.09 ± 4.21 s. Stone fragments migrated into the lower calices in five patients, and because FURS was not able to reach the lower calix, these patients needed SWL postoperative- ly to obtain complete stone clearance. These five cases were considered FURS failures. In three patients, we could not reach the proximal ureter using a flexible ure- terorenoscope because of stricture of the distal ureter; thus, we placed a DJ catheter. Two weeks later, these patients were treated with FURS. FURS after place- ment of DJ was described as a part of the procedure, so these three cases were considered FURS successes. There was no significant difference in success rates be- tween the groups (Table 2). No statistically significant differences were observed in the total number of complications or grade of com- plications by the Clavien classification (Table 4). We observed no renal failure or increased creatinine levels in any patient in the preoperative or postoperative pe- riod. We placed a percutaneous nephrostomy tube on postoperative day 7 in one patient in Group 1 because of prolonged urine extravasation, although a DJ stent was placed intraoperatively. The patient was discharged on postoperative day 13 after the leakage stopped, and no clinical pathology was observed. A postoperative fever was detected in three patients in Group 2, but the fe- ver resolved with conservative treatment. These three patients were discharged successfully. No preoperative stone analysis was performed in these patients. We did perform postoperative stone analyses of 17 patients in Group 1 and found calcium oxalate in 9 patients, cal- cium phosphate in 6, and struvite in 2. Postoperative stone analysis of 13 patients in Group 2 revealed cal- cium oxalate in 8 patients and calcium phosphate in 5. We recommended specific suggestions for patients with stone analyses and general suggestions for the patients without analyses. DISCUSSION While some ureteral stones may pass readily through the urinary tract, some require surgical procedures to provide a stone-free status. The location and size of the stone, presence of hydronephrosis, and initial renal function play important roles in determining the type of surgery. When these factors are taken into consid- eration, treatment options include medical treatment, SWL, URS, antegrade URS, and laparoscopic and open ureterolithotomy. Success of SWL for proximal ureteral stones ranges from 57% to 96%.(5-7) It is generally considered a first- line therapy because it has no need for anesthesia or surgical intervention and is a noninvasive outpatient Endourology and Stone Diseases 2486 Hydronephrosis Group 1 (n = 70) Group 2 (n = 80) P Value Grade 0 1 (1.42) 6 (7.5) Grade 1 29 (41.42) 36 (45) .550 Grade 2 31 (44.28) 32 (40) Grade 3 9 (12.85) 6 (7.5) * Data are presented as n (%). Table 3. Grade of hydronephrosis in patients.* Treatment of Large Proximal Ureteral Stones-Cavildak et al. Vol 13 No 01 January-February 2016 2487 procedure. However, SWL may be insufficient for large stones and hard stones, such as cystine and calcium ox- alate, and it has a risk of renal parenchymal damage. Thus, alternative treatment methods are needed for some patients.(8) For these reasons, minimally invasive methods, such as laparoscopic approaches and FURS, are taking the place of SWL. Recently, based on developments in URS and lithotrip- sy, FURS with holmium-YAG laser lithotripsy is be- coming preferred to a semi-rigid URS with lithotripsy in the endoscopic treatment of ureteral stones. FURS can reach migrated stones because of its high mobili- ty. However, it may not be possible to perform FURS or place a ureteral access sheath because of stricturing of the ureteral orifice. Thus, secondary procedures may still be needed.(9,10) In the present study, eight patients required additional interventions. The stone-free rate for URS in proximal ureteral stones larger than 1 cm ranges from 77% to 85%.(11,12) In their series of 58 patients with this type of stone, Potis and colleagues(13) reported a stone-free rate of 84%. Chen and colleagues(14) reported a stone-free rate of 84% for proximal ureteral stones of > 2 cm. In our study, the success rate of FURS was 90%, consistent with the cur- rent literature. Prabhakar and colleagues(15) performed FURS in their series of 30 patients. They reported a mean stone di- ameter of 25 mm, a mean hospitalization time of 1 day, and a mean operational time of 92 min. In their series of 100 patients, Hatipoğlu and colleagues(16) reported a mean stone diameter of 15.26 mm, a mean hospitaliza- tion time of 1.3 days, and a mean operational time of 52.72 min. In the present study of 80 patients, we found a mean stone diameter of 15.8 mm, a mean hospitaliza- tion time of 1.19 days, and a mean operational time of 49.1 min, consistent with the current literature. FURS has some minor complications, such as hema- turia, fever, and ureteral laceration, with rates ranging from 0% to 35%.(17,18) The most common postoperative complication is fever at a rate of 1.8%.(19) In the present study, postoperative fever occurred in three patients, and the complication rate was 3.75%. FURS is per- formed under direct vision, and the device has a thin, flexible nature; thus, major complications are rare. Se- rious complications include ureteral stricture and ure- teral avulsion. No major complications occurred in this study. The first application of laparoscopic surgery in stone disease is ureterolithotomy. European urology guide- lines state that laparoscopic ureterolithotomy has high- er success rates than SWL or URS if performed with correct indications, such as the presence of large and impacted ureteral stones that cannot be treated by endo- scopic methods or SWL.(2) Laparoscopic ureterolithot- omy may be performed via transperitoneal or retroperi- toneal techniques. In both, the subsequent procedure is similar once the ureter is reached. The most important difference is that to reach the transperitoneal space, mo- bilization of the colon is required, which can lead to significant injuries and morbidity. The most important advantages of retroperitoneal laparoscopic ureterolitho- tomy are the direct access to retroperitoneal organs, less frequent abdominal contamination and infection due to urinary leakage, and the absence of peritoneal irritation. (20) Thus, we prefer a retroperitoneal approach in all of our cases. The success rate for laparoscopic ureterolithotomy is > 90%.(21,22) The largest series of laparoscopic ureter- olithotomies (123 cases) reported a stone-free rate of 96.7%.(23) Only one patient in this series required open surgery due to migration of the stone. The stone-free rate was 96% among 24 patients in the series by Bayar Table 4. Complication rates according to Clavien classification. Clavien Complication Grade Group1 (n = 70), no Group 2 (n = 80), no P Value 1 0 3 (fever) 2 0 0 .491 3a 1( percutaneous nephrostomy) 5 (SWL) 3b 3 ( open operation) 0 Total, n (%) 4 (5.71) 8 (10) .334 Abbreviation: SWL, extracorporeal shock wave lithotripsy. Treatment of Large Proximal Ureteral Stones-Cavildak et al. and colleagues(24) In the present study, the success rate was 95.7%. In their series of eight patients, Demirkesen and col- leagues(25) reported a mean stone diameter of 17 mm, a mean hospitalization time of 3.25 days, and a mean operational time of 150 min. In their series of 24 pa- tients, Bayer and colleagues(24) reported a mean stone diameter of 15 to 20 mm and a mean hospitalization time of 3.4 days. In their series of 101 patients, Gaur and colleagues(26) reported a mean stone diameter of 16 mm, a mean hospitalization time of 3.5 days, and a mean operational time of 79 min. The present study showed similar results. The complication rate of laparoscopic ureterolithotomy is low; even in the study with the highest reported rate of 17.6%, the most common cause was ureteral urinary leakage.(27) In the present study, the urinary leakage rate was 1.4%, and the leakage was treated by percutaneous nephrostomy. To prevent the development of ureteral stenosis, another complication, it is important to protect the blood supply of the incised portion of the ureter dur- ing the operation. Nouira and colleagues(28) reviewed the literature and reported a ureteral stenosis rate of 2.5%. In the present study, we found no complications that could be attributed to ureteral stenosis. Overall, we found that the FURS and laparoscopic uret- erolithotomy had similar success rates for the treatment of proximal ureteral stones. Open surgery seems to be the only way to manage complications when endoscop- ic procedures are not sufficient for laparoscopic uret- erolithotomy. However, the management of complica- tions in FURS can be less invasive than laparoscopy. CONCLUSIONS Laparoscopic ureterolithotomy and FURS are both ef- fective and reliable in the treatment of proximal ureteral stones. However, when considering the short operation- al and hospitalization times and the management of sit- uations that require secondary interventions, we suggest that FURS, as a minimally invasive method, may be the first choice in the treatment of proximal ureteral stones. CONFLICT OF INTEREST None declared. REFERENCES 1. Dellabella M, Milanese G, Muzzonigro G. 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