Bres-Niewada E et al, 2018: A stone pushed back to the collecting system - long therapeutic path in centers with limited access to flexible instruments.
Bres-Niewada E, Dybowski B, Zapała P, Poletajew S, Miązek-Zapała N, Michałek I, Radziszewski P.
Medical University of Warsaw, Department of Urology, Warsaw, Poland.
Introduction: Availability of flexible ureteroscopes is still limited in many countries and centers. Under such circumstances treating small stones pushed from the ureter to the kidney that pose a risk of symptomatic recurrence is controversial as it may require a number of surgical procedures to remove. The aim of this study was to assess the type and number of procedures used to treat stones relocated from the ureter to the collecting system in a high volume urological center with limited access to flexible instruments.
Materials and methods: Patients treated for ureteral stones in years 2013-2016 were retrospectively reviewed. All procedures performed after stone relocation were counted. Final stone status was determined by ultrasonography and radiography.
Results: Out of 75 patients with a stone relocated to the collecting system full follow-up was available for 66. In three patients (4%) the stone remained in the collecting system untreated. Seven patients (11%) passed their stones spontaneously. Active treatment was successful in 45 (68%), while it failed in 11 (17%) patients. Extracorporeal shock wave lithotripsy was used 132 times, semi-rigid ureteroscopy 21 times and percutaneous nephrolithotripsy 22 times - 175 procedures altogether (2.6 procedures/patient + accessory procedures such as JJ removal). Shockwave lithotripsy was effective in 7/41 patients, semi-rigid ureteroscopy in 18/21 and percutaneous nephrolithotripsy in 22/22 patients.
Conclusions: Treating small stones relocated from the ureter to the collecting system in centers not equipped with flexible endoscopes is inefficient, time-consuming or too invasive. Cost-effectiveness analysis should follow this study to obtain evidence for public health payers to change their policies.
Cent European J Urol. 2018;71(2):186-189. doi: 10.5173/ceju.2018.1716. Epub 2018 Jun 12. FREE ARTICLE
The authors of this report seem to be convinced that ureteral stones only can be removed with flexible ureteroscopy. This is a first line method in accordance with recommendations in several guideline documents.
Active push-back of stones from the ureter to the kidney was the standard procedure during the early days of SWL when the technique for treating stones in the ureter was insufficiently developed and ureteroscopes were not commonly available. We subsequently learnt, however, that it was much better to use SWL for in-situ treatment of ureteral stones at all levels. The reason is that following disintegration, stone fragments in the ureter can pass much more efficiently than fragments in the kidney.
Inasmuch as the authors obviously have access to an efficient lithotripter my recommendation is to use SWL for treating stones in the ureter instead of flexible ureteroscopy.
The reasons why SWL was disregarded is unknown and the authors only assumed that the reasons were general recommendations to avoid SWL in case of high BMI, long STS distance, hard and large stones. But we do not know if this was the reason. In this regard it is of note that such limits of SWL can be exceeded with the advantage of treating the patients non-invasively.
Bottom-line is that if flexible ureteroscopy is not available for removal of ureteral stones (and also if it is), use SWL as first line treatment! Then you will find that it is possible to manage a lot of patients with ureteral stones without access to flexible ureteroscopes.