Therapeutic options in lithiasis of the lumbar ureter

Introduction: In the past 25 years, the treatment of lithiasis of the lumbar ureter has evolved from ureterolithotomy to extracorporeal shockwave lithotripsy and/or endoscopic lithotripsy. Our objective has been to analyse the results of extracorporeal lithotripsy and endoscopic surgery in lithiasis of the lumbar ureter. Materials and Methods: We have analysed 734 single calculi of the lumbar ureter treated during the decade 1990-2000, excluding patients with lithiasis in other locations in order to avoid bias in the assessment of the results. Extracorporeal shockwave lithotripsy (ESWL) was carried out using a Siemens Lithostar, urinary diversion with a double pigtail ureteric catheter or percutaneous nephrostomy, semi-rigid ureteroscopy and electrokinetic contact lithotripsy. The patient were divided into six groups. We assessed complete and partial success, the fragmentation index, and complications, analysing the results using a test for the comparison of proportions. Results: In group A, non-obstructive lithiasis treated by in situ ESWL, complete success was achieved in 95.5%. In group B, obstructed lithiasis treated by in situ ESWL, 93.15%. In group C, obstructive lithiasis treated with a double pigtail catheter and ESWL, 81.11%. In group D, obstructive lithiasis treated with percutaneous nephrostomy and ESWL, 93.75%. In group E, ureteric lithiasis <1 cm, treated by retrograde displacement to the renal cavities and ESWL, 82.3%. In group F, lithiasis of the lumbar ureter treated by ureteroscopy, 91%. Conclusions: The primary therapeutic option for the treatment lithiasis of the lumbar ureter, in the absence of criteria for urinary diversion, is in situ ESWL. We consider the criteria for urinary diversion prior to ESWL to be severe obstruction, obstruction associated with urinary tract infection, and obstruction caused by a proximal ureteric calculus adjacent to the inferior renal pole. Ureteroscopy and/or contact lithotripsy is the technique of choice in lithiasis of the lumbar ureter resistant to ESWL due to non-fragmentation or to the persistence of impacted fragments. Ureteroscopy may be the first choice of therapy in obstructive lithiasis, substituting urinary diversion plus ESWL. (C) 2003 Elsevier Science B.V. All rights reserved.