Ureteroscopic Lithotripsy in the Reverse Trendelenburg Position for Upper Ureteral Stones
Condition: Ureterolithiasis; Ureter Stone; Ureter Calculi
MeSH terms: Ureteral Calculi; Ureterolithiasis; Calculi
Study type: Interventional

Summary: 
      This study investigated a previously unassessed operating position for ureteroscopic holmium
      laser lithotripsy in patients with upper ureteral stone. The reverse Trendelenburg position
      can reduce migration and improve the stone free rate (SFR). Moreover, less utilization of
      flexible ureteroscope and hospital stay in reverse Trendelenburg position can reduce the
      medical cost. Therefore, it can be safely used as an optional surgical method for the
      treatment of upper ureteral stones.
    

Detailed description: 
      With the rapid development of urological endoscopy technology, minimally invasive surgery has
      replaced open surgery in ureteral stones. The majority of upper ureteral stones are treated
      with endoscopic techniques. In the last 10 years, URSL (Ureteroscopic Lithotripsy) has
      surpassed SWL (Shock-wave lithotripsy) with its wide use [1]. While URSL was considered in
      the foreground according to SWL for proximal ureteral stones larger than 1 cm, today it is
      recommended with equal efficiency and safety with SWL for stones smaller than 1 cm [2].
      However, migration of stones to renal calyces is a common problem during ureteroscopic
      treatment of upper ureteral stones. Migration can be caused by many factors such as the
      momentum of the laser pulse, stone manipulation of the laser fiber, fluid irrigation pressure
      and the increase of ureteral dilatation. The degree of migration varies according to the
      impaction level of the stone and the location in the ureter [3].

      The migration of the stone to the renal pelvis and calyces increases the operation time and
      cost [4-6]. Recently published American Urological Association Guidelines reported that
      ureteroscopy of ureteral stones performed an average of 1.33 procedures per patient [7]. In
      order to prevent stone migration, tools have been developed that are used in the proximal of
      the stone or that interfere with the stone in the kidney after retreatment. Although these
      developed devices are effective, it has been determined that their additional use causes an
      additional cost of $ 278 per case as well as extending the operation time [8]. In addition,
      placing an anti-migration device in the ureter can restrict laser fiber manipulation.
      Ureterorenoscopes (Flexible URS) that can flex 270 degrees, which can be used to intervene in
      the stone after retraction into the kidney, have made a very serious improvement, but these
      devices are not yet available in all centers, especially in developing countries.

      There is an in-vitro study using polymer tubes that predict that the proximal ureter should
      stay higher than the distal ureter in order to prevent retrograde in proximal ureteral stones
      [9].
    

Intervention name(s): Ureteroscopic lithotripsy
Intervention type(s): Procedure
Intervention description(s): After combined spinal and epidural anesthesia, patients were subjected to low pressure perfusion; The semirigid ureteroscope was passed through the urethra to the bladder, after which both ureteral orifices were observed. A 0.035 "soft-tipped guidewire was sent through the ureter orifice and reached the renal pelvis. Subsequently, the patients were placed in the reverse trendelenburg position by leaning 10 ° or 20 ° with their head up and hips down or standard lithotomy position. The ureter stone was accessed with a semirigid ureteroscope. A 273 micron Holmium: yttrium-aluminum-garnet (Ho: YAG) laser was applied as an energy source set at 1.0 J and a speed of 8-10 Hz.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Upper ureteral stone; Ureteroscopic lithotripsy; Reverse Trendelenburg