A Prospective Randomized Study of Large Proximal Ureteral Stones: Uretero-lithotripsy v/s Laparoscopy

Background Upper one third ureteric stones has plethora of treatment, choice being medical expulsive therapy, shock wave lithotripsy (SWL), ureteroscopy (URS), laparoscopic and open ureterolithotomy. With the advent of newer generation lithotripters, flexible ureteroscopes and miniature semi-rigid ureteroscopy, most of the upper ureteral stones can be managed with a minimally invasive approach. However, large ureteral stones are a challenge to minimally invasive techniques. The optimal management of large proximal ureteral stones (>15mm) is still to be defined. Method A total of 39 cases of large proximal ureteral stones (>15mm) were included in this prospective study. All patients were randomly divided in to two groups: Ureterolithotripsy with Pneumatic lithotripter (URS-P)-21 cases and Transperitoneal Laparoscopic Ureterolithotomy (LAP-TPUL)-18 cases. Results Mean stone size was 16.79±1.51and 17.14±1.96 in URS-P and TPUL respectively. The overall stone-free rate was 13/21(61.9%) for URS-P versus (17/18) 94.4% for TPUL. Auxiliary procedure rate was higher in URS-P than in TPUL (38% vs. 5.6% respectively). The complication rate was 22.2% in TPUL versus 23.8% in URS-P. Mean procedure time was higher in Lap-TPUL group as compared to URS group (84.07±16.80 vs 65.17±12.78 minutes). Hospital stay was 4.16±0.67 days in Lap TPUL group and 1.32±0.43 days in URS group (p<0.0001). Conclusion For large proximal ureteral stones of size greater than 15mm, Laparoscopic Ureterolithotomy has a greater stone clearance rate, lesser need for auxiliary procedure, less complication rate but higher procedure time and hospital stay as compared to URS. We strongly recommend Laparoscopic ureterolithotomy for large proximal ureteral stones.