EURURO Vol. 72 No. 5

Introduction

Optimal management of urinary tract stones located in the

proximal part of the ureter has been controversial for a long

period of time, with the clinical introduction of minimally

invasive treatment approaches making the decision-

making process more complex than ever

[1–3] .

Bringing

the patient(s) to a completely stone-free status with

limited or no morbidity is the ultimate goal, and to achieve

that, in addition to stone (size and location) and patient-

related factors (quality of life, length of hospital stay, and

analgesic requirement), the surgeon’s experience and the

availability of particular technologies are the crucial

factors that should be considered on an individual basis.

Among the available management alternatives, currently

both extracorporeal shock wave lithotripsy (SWL) and

ureteroscopy (URS) are the most commonly applied

procedures

[4,5] ,

with varying success and complication

rates reported in the literature.

Because of its noninvasive and practical nature, SWL has

been the preferred therapeutic option

[6–8]

, but its success

depends on the location of the treated stone(s), with greater

success in the management of proximal ureteral calculi. The

success rates tend to decrease for distal stones, while stones

treated in an emergency setting have a high success rate,

similar to those treated with delayed lithotripsy

[6– 12]

. However, the clinical introduction of URS has signifi-

cantly changed the treatment concepts for ureteral stones. As

a result of the accumulated experience and clinical use of

thinner and/or flexible instruments, nowadays the vast

majority of ureteral calculi can be treatedwith URS as well as

SWL

[3,13,14]

The advantage of the endoscopic approach is the adequate

and immediate decompression of the obstruction in one

session with significantly higher stone-free rates when

comparedwith SWL

[3,13,14]

. Concerning the complications,

traditionally, ureteroscopic techniques have been associated

with greater complication rates than SWL (9–11% vs 4%)

[13]

. However, the use of small-calibre, semirigid, and

flexible ureteroscopes combined with holmium:ytrrium-

aluminium-garnet (Ho:YAG) laser disintegration have im-

proved the stone-free rates and decreased the risk of severe

complications.

The objective of this review was to determine the

benefits and harms of URS compared with SWL in the

treatment of upper ureteric stones in children and adults.

Evidence acquisition

2.1.

Search strategy

We conducted a systematic review in accordance with the

Preferred Reporting Items for Systematic Reviews and

Meta-analyses statement

[15]

and the Cochrane Handbook

for Systematic Reviews of Interventions

[16]

. Medline,

Embase, and Cochrane controlled trials databases and

clinicaltrial.gov were searched between January 2000 and

November 2014 for all relevant, English-language publica-

tions. This search was supplemented by manually searching

the reference list of The European Association of Urology

(EAU) Guidelines on Urolithiasis and by discussion with

relevant trialists and organisations. The search strategy is

published elsewhere

[17] .

Following deduplication, two review authors (N.G. and

T.D.) independently screened the titles and abstracts of the

identified records for eligibility. The full text or abstract

from congress proceedings of all potentially eligible records

were retrieved and scrutinised independently by two

review authors using a standardised form, linking together

multiple records of the same study. In the case of any

incompletely reported data, study authors were contacted.

Any disagreements were resolved by discussion or by

consulting a third review author (S.D.).

2.2.

Types of study design included

All randomised controlled trails (RCTs) and quasi-random-

ised controlled trials (QRCTS) comparing any subtype or

variation of URS and SWL were included. Comparative

nonrandomised studies (NRSs) were excluded, unless they

had more than 10 patients per study arm. Noncomparative

studies (eg, single-arm case series) were excluded. Only

studies published from the year 2000 onwards were

included to reduce the influence of general changes in

medical procedures on the results. Furthermore, only

English language studies, either published in peer-reviewed

reported in 11 out of 22 studies. In eight studies, it was possible to report this as a Clavien-

Dindo Grade. Higher complication rates across all grades were reported for URS compared

with SWL. For intragroup (intra-SWL and intra-URS) comparative studies, 25 met the

inclusion criteria. These studies varied greatly in outcomes measured with data being

heterogeneous.

Conclusions:

Compared with SWL, URS was associated with a significantly greater SFR up to

4 wk but the difference was not significant at 3 mo in the included studies. URS was

associated with fewer retreatments and need for secondary procedures, but with a higher

need for adjunctive procedures, greater complication rates, and longer hospital stay.

Patient summary:

In this paper, the relative benefits and harms of the two most commonly

offered treatment options for urinary stones located in the upper ureter were reviewed. We

found that both treatments are safe and effective options that should be offered based on

individual patient circumstances and preferences.

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