EURURO Vol. 72 No. 5

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equivalent in one study , improved SFRs at 3 mo were
observed when furosemide was administered alongside
SWL therapy in another study (86.6% vs 58.8%).
However, p values were not provided in either study.
3.16.5. SWL in patients with hydronephrosis versus SWL in patients
without hydronephrosis
Two studies looked at the effect of SWL on patients with and
without hydronephrosis due to UUS . There was no
significant difference found in SFR at 3 mo between these
two groups in neither study, although one showed a
significant ( p < 0.01) longer time to complete stone
clearance in patients with hydronephrosis.
3.16.6. SWL prone versus SWL supine
Two studies addressed the effect of patient positioning on
treatment outcomes with SWL . In one study, there
was no significant difference in the achieved SFR at 2 wk
whereas in the other study, these rates were improved
by treating the patient prone rather than supine (90.6% vs
88.3%, p < 0.05) .
3.16.7. SWL 60–80 s/min versus SWL 120 s/min
Three studies looked at whether the administered shock
rate affected SFRs In all studies, SFRs were higher
when shock waves were administered at a slower rate,
reaching a statistically significant difference (p < 0.05) in
one study . One study showed that the mean number of
SWL sessions required was reduced in patients undergoing
fast SWL (p = 0.021) The other study showed that
duration of procedure was significantly reduced in patients
undergoing fast SWL compared to slow SWL (p < 0.001)
A similar result was reported in one study but no
p-value was reported.
3.16.8. SWL with and without stenting
One study looked at the effect of prestenting on SFRs with
SWL . In this study, high SFRs were seen in both
treatment groups; 86.7% in the nonstented group and 90% in
the stented group, and there was no statistically significant
difference in the achieved SFRs.
3.16.9. SWL under sedation versus under general anaesthesia
One study looked at SFRs in patients undergoing SWL under
sedation, versus under general anaesthesia Stone-free
rates at 3 mo were higher in those treated under a general
anaesthesia (80% compared with 50%), but no p value was
given.
3.16.10. SWL using different lithotriptors
Three studies examined different types of SWL lithotriptors
for UUS The first study showed no
difference (88% vs 92%, p = 0.245) in SFR between electro-
hydraulic (EH) and electromagnetic lithotriptors in treating
UUS. The second study compared an EH, electromag-
netic, and a piezoelectric lithotripter to each other in
treating urinary stones. The EH lithotriptor was suggested
in a multivariate analysis to have a better SFR and lower
retreatment rate, although p-values for UUS were not
provided. Finally, a third study compared an EH model
(HM3) to a more modern EH (LithoTron) model lithotripter
in a small matched pair analysis. No significant differences
were found (p = 0.08).
3.16.11. URS with and without methods for preventing retrograde
stone migration
Two studies looked at stone-free rates with ureteroscopic
treatment using different methods for preventing retro-
grade stone migration during the procedure. The first, a RCT,
looked at URS with and without a backstop device . SFRs
were high in both groups (93.9% with backstop device
compared to 87.8% without, p-value = 0.7). The second, a
QRCT, looked at URS with and without lubrication jelly
instilled proximal of the stone SFRs were high in both
groups (93.7% with jelly compared with 83.3% without,
p = 0.384).
4. Discussion
4.1. Implications for clinical practice
Our systematic review demonstrates that URS and SWL are
both safe and effective in the treatment of proximal ureteric
stones. The key observation of this study, that short-term
SFR are better with URS compared with SWL, is perhaps
unsurprising given the advantages of direct stone visuali-
sation that this technique confers, enabling more accurate
delivery of the chosen stone fragmentation modality onto
the stone, combined with the ability to actively retrieve
stones and/or fragments using baskets and forceps after
stone fragmentation.
Historically, the success rates associated with uretero-
scopic treatment of proximal ureteral stones were subopti-
mal compared with the results of other treatment
modalities. In general, the low success rates were attribut-
able to the inability to reach the stone, inability to fragment
the stone, or cephalad stone migration during treatment.
Technological advances such as introduction and down-
sizing of the flexible ureteroscopes and the development of
Ho:YAG laser have greatly improved interest and efficacy of
ureteroscopy for proximal ureteral stone treatment. The
advent of new technology is inevitably correlated with
changes in the treatment of proximal ureteral stones as
suggested in International Urological Guidelines over the
last 20 yr. In the 1990s, the recommended first-line therapy
for stones with a diameter <1.0 cm in the proximal ureter
was SWL. Ureteroscopy or more invasive PCNL was
recommended for salvage treatment or if SWL was contra-
indicated. For stones >1 cm in the proximal ureter, SWL,
URS, or PCNL was recommended as first-line treatment
The 2007 EAU/American Urological Association Guide-
lines for the management of ureteral calculi indicated that
besides SWL, URS should be considered for stones 10 mm
located in the proximal ureter. When stones of this diameter
were stratified by stone location, median SFR remained
superior for URS over SWL at all locations. In regards to 10-
mm proximal ureteral stones, SFR for URS reached 85%
compared with 66.5% for SWL. However, for stones
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