Tanta University

Faculty of Medicine
Tanta Urology Department

Flexible Ureteroscopic Laser Lithotripsy

versus
Extracorporeal Shock Wave Lithotripsy

in management of large proximal ureteral stone

Kyrillos Medhat Maher Iskandar M.B., B. CH + Resident of

Urology
 Supervisors
 
Prof. Dr.
Ayman Ahmed Hassan
Professor of urology
Faculty of Medicine – Tanta University

Prof. Dr.
Mohamed Abo El-enen Ghalwash
Professor of Urology
Faculty of Medicine, Tanta University

Dr. Tarek Ahmed Gammel

Lecturer of urology
Faculty of Medicine, Tanta University
 AIM
OF PATIENTS
INTRO and RESULTS CONCLUSION
THE
METHODS
WORK

Introduction
Flexible Ureteroscopic Laser Lithotripsy vs Extracorporeal Shock Wave Lithotripsy
in management of large proximal ureteral stone
• Ureteral stones account for 33-54% of urinary stones,
they are commonly associated with obstruction that
may lead to irreversible damage of renal parenchyma,
so proper management should be considered.

• Multiple lines of treatment can be used: open or

laproscopic ureterolithotomy, extracorporeal shock
wave lithotripsy and endourological procedures.
• In 1980 was the first to report the clinical application of
shock wave lithotripsy in the management of urinary
stones.

• With the several advances in the shock wave generators;

from the Dual-head, the tandem-pulse and wide-focus low
pressure lithotripters, till the advances in stone locatization
and imaging, ESWL has been recommended as a
successful line of treatment for upper ureteric stone.
• In the era of endourology, with the advantage of small-
caliber flexible ureteroscopes and holmium laser
lithotripsy, the treatment of upper ureteric stones has
shifted towards ureteroscopy with success rates
approaching 95% but with documented complication rate.

• Due to the parallel advancement in technologies in both

fields, ESWL and FURS is one of the debated
controversies in urology.
 AIM
OF PATIENTS
INTRO and RESULTS CONCLUSION
THE
METHODS
WORK

Aim of the work

Flexible Ureteroscopic Laser Lithotripsy vs Extracorporeal Shock Wave Lithotripsy
in management of large proximal ureteral stone
 The aim is to compare
the success and complication rates
of flexible ureteroscopic laser lithotripsy and
extracorporeal shock wave lithotripsy

for management of patients with large upper

ureteral calculi up to 2 cm.
 AIM
OF PATIENTS
INTRO and RESULTS CONCLUSION
THE
METHODS
WORK

Patients and methods

Flexible Ureteroscopic Laser Lithotripsy vs Extracorporeal Shock Wave Lithotripsy

in management of large proximal ureteral stone
This prospective randomized comparative study included 30
patients admitted to Tanta Urology Department suffer from
proximal ureteral stones up to 2 cm.
Patients were divided into 2 groups by Even–odd
randomization:
• Group A : 15 patients underwent holmium laser
lithotripsy using flexible ureteroscopy (KARL STORZ 8
Fr., Germany).
• Group B : 15 patients underwent extracorporeal shock
wave lithotripsy (Dornier Compact Delta II lithotripter,
Germany).
Inclusion criteria:

• Adult patient.
• Solitary proximal ureteric stone.
• Radioopaque stones.
• Stone size up to 2 cm.
Exclusion criteria:

• Stones larger than 2 cm or smaller than 0.5 cm.

• Radiolucent stones.
• Multiple upper ureteral stones.
• Children.
• Active Urinary tract infection.
• Bleeding disorders.
• Distal ureteric obstruction.
• Renal insufficiency.
• Pregnancy.
• Morbid obesity.
Preoperative Evaluation:

All patients were preoperatively evaluated by

• Complete history taking.
• General and local examination.
• Routine laboratory investigations.
• Plain urinary tract film and spiral non contrast CT
scan were done for all patients.
Group A : FURS group

• Under general anesthesia, the patient was positioned in the

lithotomy position.
• Visualizing cystoscopy with the semi-rigid cystosope
(KARL STORZ 22 Fr., Germany) is performed and
insertion of 2 wires (Teflon coated 0.035 inch or non-
hydrophilic guidewire) under fluoroscopy through the UO
till the renal pelvis.
• A ureteral access sheath was inserted over the guidewire,
then admission of flexible ureteroscopy (KARL STORZ 8
Fr., Germany) up to the ureter under fluoroscopy, while
using control-pump syringe technique for proper
irrigation.
• A 200-µm holmium-YAG laser fiber was used. The
settings for (VersaPulse PowerSuite 100W, Lumenis)
adjusted on 0.6 J pulse energy at a rate of 6 to 8 Hz. The
pulse energy can be raised up to 0.8 J or 1.0 J and the
frequency up to 20 Hz for best fragmentation.
• The stone basket (Zero Tip Nitinol Stone Basket 3F.,
Boston Scientific, USA) used in extraction of stone
gravels.
• Double J 6F. stent was inserted in most cases for 1 month
and the patients are discharged after 48 hours, unless
presence of any post-operative complications.
Group B : ESWL group

• The patient was placed in the supine position on the

machine (Dornier Compact Delta II, Germany).

• Local infiltration anesthesia with 10 cm Lidocaine diluted

in 10 cm saline is given subcutaneously in the area of
drum contact, with application of a thin layer of K-Y jelly
after filling the drum with the fluid automatically.
• the stone is localized by fluoroscopy in two axes in
anteroposterior and in oblique axe.

• The number of shock waves used average of 3000 shock

at a rate of (70-90) shock per minute, then the intensity
gradually increased till reaching the full power of machine
or until the stone was completely fragmanted.
• Fine localization of the stone site in the focus was done
fluoroscopically every 5 minutes in both axes.

• The patients are discharged at the same day of treatment.

Postoperative Evaluation:

the patients will be evaluated after 4 weeks by plain urinary

tract film and spiral non contrast CT scan if indicated.

Both groups were compared for:

• Procedure time.
• Retreatment rate.
• Complication rate.
• Stone free rate.
• Secondary procedure rate.
 AIM
OF PATIENTS
INTRO and RESULTS CONCLUSION
THE
METHODS
WORK

Results
Flexible Ureteroscopic Laser Lithotripsy vs Extracorporeal Shock Wave Lithotripsy
in management of large proximal ureteral stone
Demographic & Preoperative data:
Variable FURS - 15 patients ESWL - 15 patients p
Gender, N (%)     1.000
Males 11 (73.3) 10 (66.7)  
Females 4 (26.7) 5 (33.3)  
Age, N (%)     0.691
Range 30-54 28-54  
Mean ± SD 39.80 ± 8.65 41.07 ± 8.62  
BMI     0.867
Range 23-30 23-30  
Mean ± SD 26.60 ± 1.96 26.73 ± 2.34  
Side of stone, N (%)     0.713

Right 8 (53.3) 9 (60)  

Left 7 (46.7) 6 (40)  
Size     0.830
Range 0.60-1.80 0.50-2.0  
Mean ± SD 1.31 ± 0.36 1.27 ± 0.48  
• Patients' demographic and pretreatment
characteristics are summarized, where there was no
significant difference between the two treatment
modalities.
 1- Procedure time:

Comparison between the two studied groups according to procedure time.

Lithotripsy
Extracorporeal shock wave
Procedure time (min.) Flexible ureteroscopic laser t p
(n = 15)
(n = 15)
Min. – Max. 60.0 – 90.0 35.0 – 55.0
Mean ± SD. 72.07 ± 9.20 43.53 ± 6.30 9.911* <0.001*
Median 70.0 40.0

There was statistical significant difference as regard the

 
.procedure time
 

 
 1- Procedure time:

Comparison between the two studied groups stone size ≥1.5 cm according to
procedure time.
Lithotripsy (stone size ≥1.5)
Procedure time (min.) Flexible ureteroscopic laser Extracorporeal shock wave t p
(n = 5) (n = 6)
Min. – Max. 80.0 – 90.0 40.0 – 55.0
Mean ± SD. 83.40 ± 4.22 47.0 ± 5.76 11.709* <0.001*
Median 82.0 45.0

There was statistical significant difference as regard the

  .procedure time with stone size ≥1.5 cm
 

 
 2- Retreatment rate:

Comparison between the two studied groups according to retreatment rate.

Lithotripsy
Flexible ureteroscopic laser Extracorporeal shock wave
FE
p
  (n = 15) (n = 15)

  No. % No. %
0 0.0 6** 40
 

Retreatment rate
0.016 *

 
There was statistical significant difference as regard the
 
.retreatment rate
 
 2- Retreatment rate:

Comparison between the two studied groups stone size ≥1.5 cm according to
retreatment rate.

Lithotripsy (stone size ≥1.5)

Flexible ureteroscopic laser Extracorporeal shock wave
FE
p
  (n = 5) (n = 6)

  .No % .No %
0 0.0 5** 83.3
 

Retreatment rate
0.015
*

There was statistical significant difference as regard the

  . retreatment rate with stone size ≥1.5 cm
 

 
 3- Complication rate:

Comparison between the two studied groups according to complication rate.

(the Clavien-Dindo classification).

Lithotripsy

Complication rate Flexible ureteroscopic laser Extracorporeal schock wave

(n = 15) (n = 15)
(The clavien–dindo c2 MC
p
classification)
No. % No. %

GI 1 6.7 2 13.3

  GII 3 20.0 1 6.7 1.640 0.836

 
GIII 1 6.7 1 6.7
 
 3- Complication rate:

Comparison between the two studied groups according to complication rate.

(the Clavien-Dindo classification).

  There was no statistical significant difference as regard the

 
.complication rate
 
 3- Complication rate:

Comparison between the two studied groups stone size ≥1.5 cm according to
complication rate.
(the Clavien-Dindo classification).

Lithotripsy (stone size ≥1.5)

Complication rate Flexible ureteroscopic laser Extracorporeal schock wave

(n = 5) (n = 6)
The clavien–(
c2 MC
p
dindo
)classification
.No % .No %

GI 0 0.0 1 16.7
 
GII 1 20.0 1 16.7 2.203 1.000
 
GIII 0 0.0 1 16.7
 
 3- Complication rate:

Comparison between the two studied groups stone size ≥1.5 cm according to
complication rate.
(the Clavien-Dindo classification).

There was no statistical significant difference as regard the

  .complication rate with stone size ≥1.5 cm
 

 
 4- Stone Free rate and secondary procedure:

Comparison between the two studied groups according to stone free rate and
secondary procedure.

Lithotripsy

Extracorporeal schock wave

Flexible ureteroscopic laser
  c2 p
(n = 15)
(n = 15)

No. % No. %

Stone free rate 13 86.7 7 46.7 5.400* 0.020*

Secondary procedure 2 13.3 2 13.3 0 FE

p=1.000

  .There was statistical significant difference as regard the stone free rate
.There
 
was no statistical significant difference as regard the secondary procedure

 
 4- Stone Free rate and secondary procedure:

Comparison between the two studied groups stone size ≥1.5 cm according to stone
free rate and secondary procedure.

Lithotripsy (stone size ≥1.5)

Flexible ureteroscopic laser Extracorporeal schock wave

  FE
p
(n = 5) (n = 6)

No. % No. %
Stone free rate 4 80.0 1 16.7 0.080
Secondary procedure 1 20.0 1 16.7 1.000

There
 
was no statistical significant difference as regard the stone free rate and
.the secondary procedure with stone size ≥1.5 cm
 

 
 AIM
OF PATIENTS
INTRO and RESULTS CONCLUSION
THE
METHODS
WORK

Conclusion
Flexible Ureteroscopic Laser Lithotripsy vs Extracorporeal Shock Wave Lithotripsy
in management of large proximal ureteral stone
• Prediction of success or failure of both modalities
affected by many factors as stone size, Hounsfield
unit, degree of hydronephrosis, stone impaction and
equipment availability.

• In our study we concluded that both FURS with laser

lithotripsy and ESWL have no statistically
significant difference as regard complication rate
and secondary procedure rate in patients with
stones from 0.5 to 2 cm.
• Otherwise FURS with laser lithotripsy has a
significant result as a lower retreatment rate and
higher stone free rate, but longer procedure time
when it compared with ESWL session which is
considered as a less invasive and outpatient
procedure.

• Data analysis for stones equal or more than 1.5 cm

showed almost the same with significant lower
retreatment rate and longer procedure time for
flexible laser lithotripsy group.
 So, flexible laser lithotripsy is recommended as
a treatment modality for proximal ureteric stones
of 0.5-2 cm with higher stone free rate and lower
retreatment rate.

Shock wave lithotripsy can be considered as a

reasonable noninvasive modality in patients with
smaller stones less than 1 cm.