ureteroscopy vs. swl for ureteral stones · campbell-walsh urology 10. th. edition 3. pearle ms et...

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