# Abstract

 

## Objective: To compare the safety and effectiveness of flexible ureteroscopy (F-URS) with transperitoneal laparoscopic ureterolithotomy (TPLU) in cases of obstructive pyelonephritis secondary to large proximal ureteral stones. 

## Methods: A series of 42 patients presenting with obstructive pyelonephritis due to proximal ureteral stones larger than 1.5 cm were included from April 2006 to February 2015 in this comparative study. After drainage of pyonephrosis and resolution of sepsis, 22 patients treated with TPLU (Group I), and 20 patients were treated with F-URS (Group II). Preoperative patient and stone characteristics, procedure-related parameters and clinical outcomes were assessed for each group. 

## Results: It was seen that both methods were effective in the treatment of large proximal ureteral stones. However TPLU provided a higher stone- free rate (100% vs 80%. p=0.043) and lower retreatment rate. There was no difference between the groups for the operative time and complication rate. On the other hand, patients treated with F-URS had less postoperative pain (p=0.008), a shorter hospital stay (p\<0.001) and a faster return to daily activities (p\<0.001). 

## Conclusions: The results of our study show that both F-URS and TPLU are safe and effective surgical procedures for treatment of large proximal ureteral stones after controlling obstructive pyelonephritis. However, TPLU has a higher stone-free rate with comparable operating time and complication rate as compared to F-URS. On the other hand F-URS has the advantages of less postoperative pain, shorter hospital stay and faster return to daily activities. # RESULTS 

## Patient and Stone Characteristics The present study included 26 (61.9%) men and 16 (38.1%) women. Group I consisted of 22, and group II consisted of 20 patients. There was no significant difference between the groups of patients for age, gender, stone size, stone density and stone site; however, there was a significant difference for body mass index (BMI). The mean BMI were 25.9±2.3 kg/m ^2^ and 27.8±1.3 kg/m ^2^ in group I and II, respectively (p=0.002). The patient demographics and stone characteristics of the groups are shown in [Table-I](#) . ::::table-wrap

::: caption
Patient and stone characteristics.
:::

```
                        *TPLU Group (Group I)*   *F-URS Group (Group II)*   *p value*
```

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No. patients (%) 22 20\
Male / Female 14 / 8 12 / 8\
Mean age±sd, years 47.3±10.0 49.0±8.7 0.556
Mean stone size±sd, mm 19.9±3.2 19.6±2.6 0.698
Mean BMI, kg/m ^2^ 25.9±2.3 27.8±1.3 0.002 [\*](#)
Stone side (right/left) 12 / 10 10 / 10 1
Mean stone density (HU) 1000.0±293.9 1184.65± 144.2 0.013 [\*](#)

Significant at 0.05 level.:::: 

## Operative Findings The mean operation time was 74.1±12.2 minutes and 78.1±6.4 minutes in group I and II, respectively (p=0.192). The stone-free rate was 100% in Group I, and 80% in Group II after a single procedure (p=0.043). The retreatment rate was significantly higher in group II than group I (20% vs 0%, respectively). Any of the patients in either group did not have bleeding requiring blood transfusion and the mean blood loss was 58.8 mL in Group I. Intraoperative findings of the patients are summarized in [Table-II](#) . ::::table-wrap
::: caption
Comparison of intraoperative and postoperative data.
:::

```
                                *TPLU Group (Group I)*   *F-URS Group (Group II)*   *p value*
```

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Mean operation time, min    74.1±12.2    78±6.4 0.192
Stone-free rate    100%    80% 0.043 [\*](#)
Re-treatment rate    0%    20%\
Mean hospital stay, days    4.2±1.2    2.1±1.1 0.001 [\*](#)
Return to normal activity, days    13.3±1.7    9.0±1.6 0.001 [\*](#)
*VAS score*\
Day 0    6.4±1.3    5.1±1.6 \<0.008 [\*](#)
Day 1    4.3±1.0    3.6±1.2 0.093
Complications    5 (22.7%)    7 (35%) 0.591
*Grade I*\
Mucosal injury    -    1\
Stent related dyscomfort    2    2\
Ileus    3    1\
*Grade II*\
Ureteral perforation    -    1\
Fever    -    2

Significant at 0.05 level:::: 

## Postoperative Findings and Complications The mean hospital stay was 4.2±1.2 days in the TPLU group and 2.1±1.1 days in F-URS group (p\<0.001). The mean VAS score obtained 6 hours after surgery was 6.4±1.3 in TPLU versus 5.1±1.6 in F-URS (p=0.008) and on the first postoperative day mean VAS was 4.3±1.0 in TPLU versus 3.6±1.2 for F-URS2 (p=0.093). Time to return daily routine activities was 13.3±1.7 days in Group I, and 9.0±1.6 days in Group II (p\<0.001). The complications were classified according to modified Clavien classification system, and are presented in [Table-II](#) . No major complications such as septic shock or death were reported in either treatment group. The overall complication rate was 22.7% in Group I, and 35% in Group II. This difference of complications between two groups was not statistically significant (p=0.591).


Extracted trial result:
Outcome: Postoperative pain (continuous)
Intervention: Transperitoneal laparoscopic ureterolithotomy
Comparator: Flexible ureteroscopy
Intervention group size: 22
Intervention mean: 4.3
Intervention standard deviation: 1
Comparator group size: 20
Comparator mean: 3.6
Comparator standard deviation: 1.2