Hypothesis / aims of study
Treating upper ureteric stones (UUS) poses significant challenges in developing countries due to the high costs and limited access to Extracorporeal Shock Wave Lithotripsy (ESWL) and Flexible Ureteroscopy (URS), which are the standard treatment options. This study aims to assess the effectiveness and complications associated with using semi-rigid ureteroscopy (URS) as an alternative approach for UUS management.
Study design, materials and methods
A total of 202 patients (115 males, 56.9%; 87 females, 43.1%) with a mean age of 45.3 years (range: 20–76) underwent primary ureteroscopy. Among these, 185 (91.6%) had single stones, 7 (3.3%) had bilateral stones, and 10 (5%) were diagnosed with steinstrasse stones. The average stone size was 1.6 mm (ranging from 1.2 mm to 2.0 mm). In all cases, a ureteric stent was placed postoperatively.
Results
Of the 202 treated stones, 185 (92.1%) were successfully cleared in a single session. Seventeen patients (8.4%) required an additional procedure for complete stone removal. In 6 cases (3%), stone migration occurred, while 2 patients (1%) experienced difficulty with ureteral access. Minor complications included mucosal injury in 39 cases (19.3%) and false passage in 37 cases (18.3%), though these did not interfere with the surgical process or stone fragmentation. No major complications, such as avulsion or perforation, were recorded.
Interpretation of results
The study demonstrates that semi-rigid ureteroscopy (URS) is a highly effective and safe alternative for treating upper ureteral stones (UUS) in resource-limited settings. Below is a detailed interpretation of the findings:
1. Success Rate and Efficacy
92.1% of cases achieved complete stone clearance in a single session, which is comparable to or even better than some reported success rates of ESWL and flexible URS in similar settings.
8.4% of cases required a second procedure, indicating that while semi-rigid URS is effective, some patients (possibly those with larger or more complex stones) may need additional intervention.
2. Complications and Safety Profile
Stone Migration (3%): This is a relatively low percentage, suggesting that semi-rigid URS, despite its limited flexibility, remains effective in controlling stone displacement. However, this complication can still prolong treatment and necessitate further procedures.
Difficulty in Ureteral Access (1%): A minimal number of cases faced access challenges, indicating that patient selection and preoperative imaging are important to predict possible anatomical difficulties.
Mucosal Injury (19.3%) and False Passage Formation (18.3%): While these complications were relatively common, they did not interfere with stone removal, suggesting they were minor and manageable.
Absence of Major Complications (Perforation or Avulsion): The lack of severe complications supports the safety of the procedure when performed by skilled urologists.
3. Clinical Implications
Cost-Effective Alternative: Given the financial and technological constraints in developing countries, semi-rigid URS provides a reliable and cost-effective alternative to ESWL and flexible URS.
Training and Experience Matter: The incidence of mucosal injury and false passages highlights the need for proper surgical training and refined technique to further minimize complications.
Potential Limitations: Although effective, semi-rigid URS might be less suitable for very proximal or large stones, which may still require flexible URS or ESWL in some cases.
Conclusion
The results suggest that semi-rigid URS is a highly successful, low-risk, and feasible treatment option for UUS, especially in settings with limited access to advanced urological technologies. Future studies could compare long-term outcomes, patient recovery times, and cost-effectiveness against ESWL and flexible URS to further validate these findings.