We reviewed our records in the period between January 2014 and March 2017; sixty-seven patients with solitary upper ureteral stone who had LU or semirigid ureteroscopy and holmium laser lithotripsy were included in our study. All procedures in the four centers were performed by well-trained surgeons with equivalent surgical experiences.
The mean stone size was 1.82 ± 0.15 cm (range 1.5:2 cm). All stones were located at the upper ureteral segment. Out of 67 patients, 37 patients had semirigid ureteroscopy and holmium laser lithotripsy (Group A) and 30 patients had laparoscopic ureterolithotomy. We excluded patients with stones smaller than 1.5 cm and bigger than 2 cm, previous open abdominal surgery, bleeding disorders, current UTI, respiratory illness, pregnancy, patients with one functioning kidney, fever > 37.2 and leukocytosis > 12.000 per microliter.
All patients were subjected to history taking and clinical examination, urinalysis and urine culture, renal function test, liver function test, coagulation profile, serum calcium, serum phosphate and serum uric acid, 24H urinalysis for calcium, phosphate and uric acid, renal ultrasound, KUB and noncontrast CT scan.
In Group A, all patients received general anesthesia. Cystoscopy and retrograde pyelogram were performed first, and then 6/7.5 semirigid ureteroscope was introduced through the ureteric orifice. Using follow-the-wire technique, a sensor guide wire was introduced till the level of the stone [10]. Under direct vision, the sensor guide wire was advanced to pass the stone all the way up to the kidney. Semirigid ureteroscope allowed steadiness during stone manipulation and subsequently allowed controlled movement to pass the wire beyond the stone without pushing the stone back to the kidney. Through the whole procedure, the fluid irrigation force was limited to a degree sufficient to see the stone without any pushing force (Fig. 1).
Semirigid ureteroscope allowed passing the edema below the stone that may present in some cases and subsequently passing the guide wire under direct vision up to the kidney. The ureteroscope was withdrawn and re-introduced all the way to the stone. Holmium laser was used with setting of 0.5 J/20 Hz, and laser fiber size 270 was introduced through the scope. Laser dusting technique was used to minimize stone retropulsion. In case of stone migration to the kidney, flexible ureterorenoscopy with holmium laser lithotripsy was used for stone disintegration. A ureteral stent was left at the end of the procedure and was removed after 2 weeks (Fig. 2).
Group B included patients who underwent laparoscopic ureterolithotomy. All patients received general anesthesia, and the patient was placed in lithotomy position. Diagnostic cystoscopy and retrograde pyelogram at the side of the stone were performed followed by introduction of sensor wire up to the lower border of the stone. Open-end ureteral catheter was introduced over the wire till the lower end of the stone. After that, the patient was repositioned into the modified flank position, 10 mm camera port was placed through the umbilicus and 10 mm port was placed midway between the umbilicus and anterior superior iliac spine. A 5 mm port was placed at the lumber region on the mid-clavicular line. A 5 mm harmonic shear [Ethicon Endo-Surgery (Johnson & Johnson) GEN 11] was used to dissect and reflect the colon.
The ureter was identified, stone was located and a vertical ureterotomy over the stone was performed to extract the stone. A stone grasper was used to deliver the stone through the ureterotomy. The sensor wire was advanced up to the kidney. A 4/0 Vicryl suture was used to close the ureterotomy. A small drain was introduced through the 10 mm port. The patient was then repositioned in lithotomy position, and a ureteral stent was then loaded over the wire. A Foley catheter was placed at the end of the procedure and was removed in POD 1.
Stone-free status was defined as absence of residual stones or the presence of residual stone fragments ≤ 4 mm in size on X-ray KUB performed up to 1 month after surgery [11].
Ureteral stents were removed after 2 weeks. In both groups, stones were sent for stone analysis. Postoperative follow-up included KUB/CT at 2 weeks postoperatively for both groups before ureteral stent removal to confirm stone clearance and absence of large residual stone fragments. (Fragment > 4 mm was considered residual stone.)
The need for any auxiliary measures either during the same session or at a different session was recorded in both groups.
