Objectives: Our study aims at
researching the operative outcomes after using Flexible ureteroscopy (F.URS)
versus rigid ureteroscopy (R.URS) lithotripsy for the management of patients
with symptomatic proximal ureteric stones (PUS).
and Methods: The
(390) patients aged between 18 and 67 who underwent URS (F. vs. R.) for upper
ureteric stones (From June 2017 to June 2018) at Prince Hussein
Urology Center were found eligible to be enclosed during this
retrospective study. Patients were divided into two equal groups with regard to
the number of examined patients, (F.URS); the number of patients for group-1
was 195, (R.URS); the number of patients for group-2 was 195 as well. A number
of chosen "Demographic characteristics" and "stones sizes"
were collected at baseline; in addition to that, the categorical data were
analyzed by SPSS version / 24. The Follow up period was estimated for at least
3 months. The Operative time was also calculated; the intraoperative and the
post-operative complications were expressed by the "Clavien-Dindo"
It was found
that of the total number of the 390 patients, no statistical significant
differences at baseline were found regarding ages, gender, stone sizes,
laterality and opacity of the stones when both groups' results were compared:
(the stone sizes P value was estimated at 0.36), (the laterality P value was
estimated at 0.14) and (the opacity P value was estimated at 0.98). The mean
operative time was shorter in the (R.URS) group in comparison to the (F.URS)
group (40.9± 16.4, 52±13.81, P= 0.018). The (F.URS) group
had a higher proportion for the stone clearance rate (P =0.007); the
Perioperative complication rate was not statistically different (P= > 0.05).
time was less in (R.URS) and the stone clearance rate was considerably higher
in (F.URS). Therefore, it was concluded that (R.URS) was less successful in the
stone clearance rate, and hence should be used only as a second option as
regards F.URS which must be used as the first viable option.
Keywords: ureteroscopy, flexible, rigid, lithotripsy,
of the most common types or sorts of urinary calculi could be the ureteral
calculus; what makes this type most projecting is the manifestations of
hematuria and renal colic; this sort of stone
become and proved to be the reason for the deterioration of renal function;
this is due to two main causes: obstructive uropathy and progressive
stones are divided into three types in line with their location within the
ureter; proximal (upper), mid and distal (lower) ureteric stones (2).
The Management of the upper ureteric stones includes medical intervention
through the use of extracorporeal shock wave lithotripsy (ESWL) which will
provide potential advantages when compared with different procedures in stones
less than 1 cm in size; the second preferred option, particularly in stones
more than 1 cm in size is ureteroscopy (Flexible, Semi vs. Rigid URS) which
involves percutaneous nephrolithotomy (PCNL); taking into consideration that
there is rarely any need for surgical open intervention or laparoscopic surgery
the well-preferred technique by specialists for removal of mid and distal
ureteric stones is the URS, which mainly uses a rigid, semi-rigid, or flexible
endoscope, improved ureteroscopes techniques and sizes have increased the
employment of this modality for stone disintegration. Additionally, the ESWL
can be used for the management of those stones; however, in case ESWL has
become unsuccessful, or in the event that there have been factors precluding
lithotripsies such as: pregnancy, coagulopathy, or morbid obesity, the
employment of ureteroscopy becomes helpful (4). Besides that, the
comparison between the ESWL and the URS for ureteric stones has resulted in a
lower stone-free rate in the ESWL group (5, 6).
the one hand, the success rate of stone clearance by the URS is more or less
(95-100%) for distal ureteric stones; it was (90-95%) as well for mid ureteric
calculi; however, it was (70-100%) for upper ureteric calculi (7).
the other hand, the use of the URS as a procedure itself is not without
complications; based of clinical observation, there are a number of minor
complication involved such as: (flank pain, dysuria, hematuria, “pushed back”
stone, fever, urinary tract infection, and residual stones) ; however, there
are also some major complications present such as: (stricture, perforation, and
avulsion). Regardless of that, these complications have significantly been
utterly weakened by the use of the flexible URS apart from the rigid URS
primarily in proximal ureteric stones; yet, concerning the distal ureteric
stones; the rigid URS remains in favor for being the most flexible one on
account of easier stone manipulation and larger working channel as well for
better irrigating flow and visualization (8).
comparison between the flexible and the rigid URS (F. URS vs. R. URS) in
reference to the upper ureteric stones will be discussed in this study
according to the results that will be shown in the results section. We
hypothesized there are no significant differences between (F.URS) and (R.URS)
in operative outcomes which include (stone clearance rate, operative time,
intra-and post-operative complications).
Materials and Methods
medical files of the (390) patients (200 males and 190 females) with
symptomatic proximal ureteric stones were found eligible to be enclosed during
this quasi-experimental retrospective study from June 2017 to June 2018. These
patients underwent URS (F. vs. R.) in Prince Hussein Urology Center at the
Royal Medical Services of Jordan. These patients were divided into two teams
respectively; group-1 (F. URS) which included (195) patients and group-2 (R.
URS) which included the same number of patients (195).
location of the stone was determined by the distance between the ureteropelvic
junction and also the higher border of the sacroiliac joint. The exclusion
criteria were: impaired renal functions,
coagulopathy, pregnant, associated urinary tract pathology, and multiple
were diagnosed according to their records by detailed history and physical
examination, laboratory results; (complete blood count, kidney function tests,
urine analysis, and culture) and radiology investigations; (kidney, ureter and
bladder X-ray (KUB) and non-contrast renal computed tomography CT).
URSs were done in a lithotomy position after scrubbing all patients who were
given general or spinal anesthesia. The third-generation cephalosporins
(ceftriaxone 1 gr intravenous single dose) were given also to all patients
before all operations. Then, a diagnostic cystoscopy was done by a 17Fr
cystoscope that was used for retrograde pyelogram by retrograde angiocatheter
5Fr which facilitated the insertion of a 0.038 floppy-tipped hydrophilic guide
wire through its lumen under the monitoring of fluoroscopy. After discharging
the cystoscope and the angiocatheter, R. URS size 8 Fr (Karl Storz) or F. URS
7.5 Fr (Karl Storz) was inserted alongside the guide wire, then, after the
visualization of the stone, the process of the disintegration of the stones was
completed by a pneumatic lithotripter (R. URS) or a 230-micron holmium laser
fiber at an energy level of 0.6-1.2 J and at a rate of 10Hz for both ( R. and
F. URS) beside the using of URS forceps to extract the fragments of stones
which were more than 2 mm in size. If the stone was pushed back to the kidney
and all manipulations have failed or any major complication may have occurred
during the process, then, double j catheter (DJC) size 5-7 Fr was inserted
inserted then follow up by (KUB or CT) to decide for alternative management
URS was done by the same steps that mentioned in R. URS technique till the
discharging of the cystoscope and the angiocatheter, then a Flexible ureteral
access catheter was used for insertion of a second 0.038 inch guidewire over
which a ureteral access sheath was introduced, then F. URS was inserted to the ureter to disintegrate
the stones by using 230-micron holmium laser fiber at an energy level of
0.6-0.8 J and at a rate 10-25Hz. Residual fragments < 2mm were left in place
and DJC was inserted for complicated procedures.
Follow up of the patients once the procedures was done by KUB was done
instantly post operations then, another follow up was made by nonenhanced renal
CT three months later.
(minor complications from grade 1 to 2) such as: hematuria, fever, urinary
tract infection and renal colic ;( major complications from grade 3 to 5) such
as: the ureteral perforation, avulsion, stricture, and even patient death) have
all been assessed with reference to the Clavien-Dindo classification of
surgical complications (9).
Categorical data have been expressed in percentages, quantitative data have
been expressed in mean ± SD; moreover, Normality has been assessed by
Kolmogorov–Smirnov test; in addition, the equality of variances was tested
by the Levene's test. An independent t-test was used for groups’ differences in
scale outcome, the Chi-square was used for proportional differences, the alpha
level (P-value) set at 0.05 was considered statistically significant, and a
study power of 80% with medium effect size and SPSS version 24 was used to
committee approval was granted from our Royal Medical Services institution for
the publication of this study.
total number of patients was 390 divided into two groups; every group contains
195 patients. Their age range was from 18 to 67 years; group-1 (18-62 years),
group-2 (20-67 years). The information that was collected from the patients’
files was retrospectively analyzed; we have arrived at a number of conclusions
and the subsequent results were found:
the number of male patients is two hundred, while the number of females
patients is one hundred ninety; the right side ureteral stones were 183,
whereas the left side stones were 207; the stones sizes were from 0.7 to 1.7 cm
(group1 0.7-1.4 cm vs. group2 0.9-1.7 cm); The stone opacity was radiopaque in
a number of 357 patients and radiolucent in the remaining 33 patients
respectively for the total number of patients. Detailed results with
percentages regarding the total number of patients, mean± SD and significant
P-value < 0.05 for each group were presented in Table I (Demographic
I: The Demographic data of the patients.
of the patients
age (year)± SD
M-F (N*/ %)
size (mean± SD) cm
of the stones
opacity (N/ %)
II, we have a tendency to place the
categorical data of the patients concerning every group in relation to: success
rate of stone clearance, operative time and perioperative complications
(intraoperative and postoperative) from grade-2 such as: hematuria
("43" patients in group-1 vs. "61" patients in group2),
fever ("11" patients in group-1 and "13" in group-2), urinary
tract infection ("2" patients in group-1 vs. "1" patient in
group-2) and renal colic ("5" patients in group-1 and "7"
patients in group-2) ; concerning grade
3b such as: the ureteral stricture ("1" patient in group-1 vs.
"1" patient in group-2); with regard to perforation ("0"
patients in group-1 and "2" patients in group-2). They were presented
by mean± SD and P-value considered statistically significant < 0.05.
II: The Categorical data of the patients.
according to the number of patients for each group
clearance rate (N/ %*)
rate (N\ %)
time/ minutes (mean± SD)
the above mentioned results, we have a tendency to notice that F.URS took an
extended operative time for the management of the proximal ureteric stones and
a higher success rate for stone clearance, whereas there have been no
significant variations between both techniques (F. vs. R.URS) regarding the
perioperative complication rate. Consequently, to increase the stone free rate,
using the F.URS is highly preferable and advisable.
MA et al. reported that the F.URS is a favorable option for the treatment of
the upper ureteric stones due to a higher stone free rate that supports our
analysis (10). Additionally,
Galal EM and colleagues suggested that because the R.URS is less successful for
the treatment of proximal ureteric stones, it should be used cautiously with
the availability of the F.URS (11).
the one hand and due to the high cost and the less availability of the F.URS in
some centers, semi or R. URS can be an acceptable alternative option for the
clearance of upper ureteric stones despite the less success rate than the
F.URS, Kotb YM et al. and Yuskel OH et al. (12, 13).
the other hand, Alkan E and colleagues recommended the employment of the
F.URS as a primary option of treatment
of the upper ureteric stones because of the less complication rate, while there
was no statistical distinction within the effectuality between each teams of
the study, that within the contrary of our results (14).
R et al. and other literature reported that F.URS has become the more effective
and safer treatment selection of the whole upper urinary tract stones, however,
the stone clearance rate decreases once the size of stone becomes larger
associates also noted that the size of the upper ureteric stone plays a role in
the operative time, and both procedures (F. vs. R. URS) can be carried out in
outpatient department (17).
Therefore, R. or semi rigid URS with holmium YAG laser
can be used as a day case operation for upper ureteric stones, but patients
should be informed about the slightly high risks with this technique (18).
to avoid additional ESWL, combination of both techniques after the proximal
ureteric stone had been pushed to the kidney could be efficacious (19).
R.URS has a shorter operative time when compared to the F.URS and fewer
effective rates regarding stone clearance rates, while in different variables
such as: the complication rate and patients vs. the stone characteristics,
there have been no significant variations. This makes the F.URS as the most
popular and viable possibility and option for the management of the upper
ureteric stones due to the higher stone free rate which decreases the
requirement for one more endoscopic session or alternative surgical treatments.
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