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Retrograde, antegrade, and laparoscopic approaches for the management of large, proximal ureteral stones: a randomized clinical trial.

BACKGROUND AND PURPOSE
Multiple procedures have been introduced for the management of urinary stones in the upper ureter. In this randomized clinical trial, we compared three surgical options in this regard.


PATIENTS AND METHODS
From September 2004 to May 2006, we enrolled in the study 150 patients with upper ureteral stones who were referred to our center. We included patients with a stone size >or= 1.5 cm in the greatest diameter. Using the random table, patients were divided into three 50-patient groups by treatment: Group A, retrograde ureteroscopic lithotripsy using a semirigid ureteroscope; group B, transperitoneal laparoscopic ureterolithotomy; and group C, percutaneous nephrolithotripsy. All procedures were performed in a training program.


RESULTS
The stone-free rates for patients in groups A, B, and C, at discharge and 3 weeks later, were 56%, 88% and 64% and 76%, 90% and 86%, respectively. Conversion to open surgery and repeated laparoscopy was necessary for two and one patients in group B. Urinary leakage continued more than 3 days in eight (16%) and nine (18%) patients in groups B and C after operation, respectively (P = 0.7).


CONCLUSIONS
Although the success rate of ureteroscopy was not significantly lower than the two other options, the complications seen with this technique were negligible. Consequently, the procedure of choice for large proximal ureteral stones seems to depend on surgeon expertise and availability of equipment.