Which is the best option to treat large (>1.5 cm) midureteric calculi?
Before the 1980s, ureteric stones were managed by open ureterolithotomy. Since the introduction of shock-wave lithotripsy (SWL) and ureteroscopy, the use of an open surgical approach for the removal of ureteric stones has rapidly declined. Open surgery, which is currently being replicated by laparoscopic techniques, is generally indicated for failed endourologic procedures, particularly in centers that do not have flexible ureteroscopy or laser lithotripter, and in patients with larger stones. Considering this, we conducted a retrospective study to compare the different modalities for the management of midureteric calculi of more than 1.5 cm. Between August 2000 and July 2005, a total of 71 patients with large midureteric calculi (>1.5 cm in size) were treated with the three different modalities; SWL, ureteroscopic pneumatic lithotripsy (URS), and laparoscopic ureterolithotomy at AMAI Trust's Institute of Urology. Data were collected and all the patients were analyzed for stone-free rate, intraoperative and immediate postoperative complications, and the results were calculated. Stone clearance was 39.1% with SWL (group 1), 79.2% with ureteroscopic pneumatic lithotripsy (group 2), and 100% with the laparoscopic method (group 3), with a statistically significant difference between groups 1 and three and groups 1 and 2, but there was no statistical significance in groups 2 and three. However, hospital stay and hence morbidity was significantly greater in group 3, when compared to the other two groups. SWL gives the least clearance for large midureteric calculi. Statistically, URS and laparoscopic ureterolithotomy give equal results; hence, URS still remains the treatment of choice for the treatment of large midureteric calculi considering the low morbidity and acceptable stone-free rate of the procedure. Though laparoscopic ureterolithotomy can be considered as a treatment option, prospective, randomized trials are needed to confirm the efficacy of one modality of treatment over the other.