What is the role of retrograde ureteroscopy in the management of large renal calculi?☆

Summary 

Background and purpose

The management of large renal calculi has traditionally been with percutaneous nephrolithotomy (PCNL) or occasionally extracorporeal shock wave lithotripsy (ESWL). We present our experience of ureteroscopic treatment of large renal calculi in patients where PCNL/ESWL were contraindicated, refused or failed.

Patients and methods

Data from 30 patients with intra-renal calculi ≥20mm was prospectively entered onto a database and analysed. Patients were treated with rigid and flexible ureteroscopy (URS) using holmium laser or lithoclast (pneumatic) lithotripsy.

Results

Mean stone size was 2.8cm (range 2.0–6.0cm). The most common indications were ESWL failure (40%), anatomical reasons (20%), patient choice (10%) and failed PCNL access (7%). Stone clearance (no fragments >3mm on follow-up imaging) was observed after one URS treatment alone in 30% of patients and a further 27% with a post-operative session of ESWL. Two URS sessions alone were used in 23% of patients, with a single patient needing two URS and post-operative ESWL. Three URS sessions plus ESWL was used in 7% of patients. Three patients (10%) required PCNL. Median operative time was 60min. Complications were minimal: four patients had urinary tract infection, one failed trial without catheter, one atrial fibrillation, and one stent migration.

Conclusion

Where PCNL is not favoured for any reason, patients with a large stone burden can be safely and effectively managed with retrograde URS, either with the intention of stone clearance or de-bulking prior to ESWL.

Keywords: Renal calculi, Laser therapy, Lithotripsy, Ureteroscopy