Selection Of Minimally Invasive Surgical Treatment Of Ureteral Calculi

BACKGROUND:Ureteral calculus is one of the common diseases in the urologic disease, which is accounted for33%to54%of urinary calculi. Most of ureteral calculi may be induced by renal calculus, and primary ureteral calculus is infrequent. In the past several decades, the treatment for ureteral calculus has changed from the previous surgical operation to the current minimally invasive therapic methods, such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic lithotripsy (URL), percutaneous nephrolithotomy (PCNL) and laparoscopic ureterolithotomy (LUL). We should choose the most suitable treatment according to different patients.OBJECTIVE:The study summarized the minimally invasive methods for the treatment of ureteral calculi and assessed the efficacy and safety of the three kinds of techniques, such as URL, PCNL and LUL. Moreover, the operation skill, matters needing attention in the operation and influencing factor of the three methods were investigated in the study.PATIENTS AND METHODS:In the study,129patients with ureteral calculi were retrospectively reviewed, who were treated in the three methods in our hospital from January2010to December2011. All of the patients were examined by B-mode ultrasonography, plain film of kidney ureter bladder (KUB) and CT. The operative time, hospital stay, hospitalization costs and cure rate of the three methods were analyzed and compared.URL:Under the continuous epidural anesthesia, patients were lithotomy position. F8/9.8ureteroscope was inserted into the ureter, and the calculi were shattered by Holmium Laser or Pneumatic lithotripsy. Double-J stent and urethral catheter were placed after the operation. The Double-J stent was removed one month after the operation.MPCNL:Under the general anesthesia, patients were lithotomy position firstly and the ureter with calculi was intubated with ureteral stent tube. Then, patients were contralateral prone bits and the upper or middle renal calyx was piqured under the conduction of B-mode ultrasonography. F8/9.8ureteroscope was placed to explore the calculi. Then nephroscope was placed to shatter the calculi by Ultrasonic or Pneumatic lithotripsy. Double-J stent, kidney fistula and urethral catheter were placed after the operation. The kidney fistula was removed one week after the operation, and the Double-J stent was removed one month after the operation.RLU:Under the general anesthesia, patients were contralateral prone bits. The ureter was cut and the calculi were removed after the pneumoperitoneum was established. The ureter was sutured after the Double-J stent was placed, and then we also place the peritoneal drainage tube under the lower pole of kidney. The peritoneal drainage tube and Double-J stent were removed two weeks and two months after the operation respectively.RESULTS:86patients were treated by the method of URL, and the diameter of calculi ranged from0,6cm to3.0cm with the average of1.04±0.36cm. Another four patients were transferred to PCNL or LUL because of ureteral stricture or polyps. With the method of URL, the clearance was97.67%(84/86) one month later and the complication rate was1.16%(1/86).29patients were treated by the method of PCNL with two patients transferred from URL, and the diameter of calculi ranged from0.8cm to2.5cm with the average of1.44±0.33cm. With the method of PCNL, the clearance was100%(29/29) one month later, and the complication rate was10.34%(3/29).14patients were treated by the method of LUL with two patients transferred from URL, and the diameter of calculi ranged from0.8cm to2.1cm with the average of1.73±0.62cm. With the method of LUL, the clearance was100%(14/14) one month later, and the complication rate was7.14%(1/14).Compared to the URL, the PCNL had longer operative time, longer hospital stay and higher hospitalization costs, and the LUL had longer hospital stay, and significant differences were observed. There was no significant difference between URL and LUL in the operative time and hospitalization costs. Moreover, no significant difference was observed in the complication rate after the operation and the clearance of calculi one month later after the operation among groups.CONCLUSIONS:All of the three methods were effective and safe operation for the treatment of ureteral calculi. Compared to the URL, the PCNL and LUL have higher clearance of calculi, but no significant difference was observed. Thereby, URL could be the first choice for minimally invasive treatment of ureteral calculi. If the stones are large and located in the proximal end of ureter, or hydronephrosis and dilatation of proximal ureter is obvious because of urinary tract obstruction, or stones return into the renal pelvis in the operation, we should select PCNL or LUL.