Ureteroscopy vs. SWL for Ureteral Stones

Amy E. Krambeck, MD

Associate Professor Department of Urology

Mayo Clinic, Rochester, MN

Improvements in Ureteroscopes

• Miniaturization of ureteroscopes • 4.8 Fr rigid • 5.9 Fr flexible

• No dilation

Flexibility Matters

• Active secondary deflection • 29 without vs. 61 with 2nd deflection1

• Greater flexibility = treatment success • 70% vs. 38%, p=0.003

1. Wendt-Nordahl G et al Urol Res 2011; 39: 185-8

Fragmentation and Retrieval Devices

• Holmium laser • Fragments all stones1

• Minimal tissue damage • Miniaturization of devices

• 100, 200 µm • Baskets > 1.3 Fr

• Baskets safer

1. Teichman JM et al Urology 1998; 53: 392-7 2. Kessler SS et al J Endourol 2008; 22: 1213-8

•Ureteral injury 3-6%1 Perforation <2%, Avulsion 0.06%2

•Stricture 1-2%1 Stricture 0-0.2%2 •UTI/sepsis 2-4%1 1. Preminger GM et al J Urol 2007; 178: 2418-34

2. Bader MJ et al Eur Urol 2012; E Pub ahead of print

Complications Comparison

Outcomes Favor Ureteroscopy

Stone Location SWL Ureteroscopy Distal Ureteral1 X >1 cm Proximal Ureteral1 X Multiple2 X Stricture2 X >1 cm Lower Pole3 X Infundibular stenosis2 X Calyceal Diverticulum2 X

1. Preminger GM, et al. J Urol 2007; 178: 2418-34 2. Campbell-Walsh Urology 10th edition 3. Pearle MS et al J Urol 2005; 173: 2005-9

Stone Location SWL Ureteroscopy Mid Ureteral1 Not significant X

< 1 cm Lower Pole3 X X <1 cm Proximal Ureteral X?

1. Preminger GM, et al. J Urol 2007; 178: 2418-34 2. Campbell-Walsh Urology 10th edition 3. Pearle MS et al J Urol 2005; 173: 2005-9

Points of Contention

Ureteroscopy vs. SWL

• 2011 Cochrane Review of 7 RCTS1 • 1205 patients • Various ureteroscopy and SWL techniques

1. Aboumarzouk OM et al Cochrane database syst rev 2011

2011 Review Results

• URS lower retreatment • RR 6.18 (CI 3.68-10.38)

• URS higher SF rate • RR 0.84 (CI 0.73-0.96)

• SWL higher emergency presentation rate • RR 2.33 (CI 1.12-4.84)

• URS more complications • RR 0.54 (CI 0.33-0.88) • Most unrelated to procedure

Aboumarzouk OM et al Cochrane database syst rev 2011

Current Era Comparison of URS & SWL

Proximal Ureter • URS 35% >SFR over SWL

• SWL - HM3 RR 1.35 • SWL – other RR 1.15

• URS less retreatment • Complications highest in SWL

–HM3

Distal Ureter • URS 55 % >SFR over SWL

(RR 1.55) • URS less retreatment (RR 0.14) • No difference in complications

• Meta-analysis of RCT using current technique • 216 studies only 13 adequate

Matlaga BR, et al. J Urol 2012; 188: 130-131

Advantages of Ureteroscopy • Pregnancy1,2

• Anticoagulation3 • SF 81.1% vs. 78.4%, p=0.772 • Complications 0 vs. 3% p=0.3140

• Similar findings in coagulopathies4

• Morbid Obesity • No difference in SF rates5,6

• Advanced age7 1. Semins MJ et al J Urol 2009; 81:139-43 2. Johnson EB et al J Urol 2012: pending 3. Turna B et al J Urol 2008;179:1415-9 4. Watterson JD et al J Urol 2002;168: 42 5. Andreoni et al J Endo 15 2001 6. Dash et al Urol 60 2002 7. Dhar NB et al J Urol 2004; 172: 2271

Conclusions • Ureteroscopy has seen improvements in

instrumentation and technique

• Biggest drawback is the ureteral stent

• Ureteroscopy has an overall higher stone free rate and lower retreatment rate than SWL