TREATMENT TACTICS FOR PATIENTS WITH LARGE PROXIMAL URETERAL STONES
Authors: Kochetov A.G. , Martov A.G. , Sidorov O.V. , Pavlov D.V. , Dubrovskih S.A. , Plechanova O.A. , Kasaikin A.V. 
Published: July 2024

Background. A retrospective analysis of surgical treatment of patients with large proximal ureteral stones for the period from January 2018 to December 2022 was carried out. A total of 275 patients were included in the study, 246 (89.4%) men and 29 (10.5 %) women, The average age was 42.7±3.5 years. The inclusion criteria were the stone size ≥10 mm, the average size was 12.7±0.8 cm, the localization of the stone was above the intersection of the ureter with the iliac vessels. The patients were divided into groups according to the performed method of surgical treatment: remote lithotripsy (ESWL-ureterolithotripsy) in 75 patients, percutaneous (antegrade) lithotripsy in 38 patients and transurethral lithotripsy in 128 patients. Simultaneous percutaneous percutaneous nephrolithotripsy (PNLT) and transurethral ureterolithotripsy were performed in 14 patients and percutaneous (antegrade) flexible ureterolithotripsy through previously formed percutaneous accesses was performed in 20 patients. The density of stones subjected to ESWL was significantly lower than in groups with other methods of treatment p≤0.001. Percutaneous methods of treatment were used for larger stones (p<0.05). The SFR index was achieved with ESWL in 60 (80 %) and was maximally expressed with endoscopic and percutaneous methods of treatment. Antegrade flexible ureterolithotripsy was achieved in 19 (95 %) patients in the group. Simultaneous percutaneous and retrograde interventions were successful in 12 (85.7 %) patients, which is comparable to the effectiveness of PLT — 32 (84,2 %) patients. Intraoperative complications were noted in 2 (2.6 %) patients in the ESWL group (subcapsular hematoma) and in 17 (8.5 %) cases in the endoscopic and percutaneous treatment groups. Postoperative complications were associated with exacerbation of pyelonephritis in 18 (6.5 %) patients and were managed by the conservative measures. Aim. To evaluate the effectiveness of the main methods of treatment for large proximal ureteral stones. Materials and Methods. The results of the performed surgical treatment of patients with large stones of the proximal ureter in one of the Urological Departments of the Urological Center of the National Medical Research Center for High Medical Technologies named after A.A. Vishnevsky for the period from January 2018 to December 2022 were analyzed. A total of 275 patients were included in the study Results. The key indicator of the effectiveness of surgical intervention in large stones of the proximal ureter is the stonefree rate (SFR), which was achieved with ESWL-ureterolithotripsy in 60 (80 %) patients and the maximum in the group of antegrade flexible ureterolithotripsy in 19 (95 %) patients. Conclusions. Percutaneous and transurethral endoscopic methods of treatment demonstrate the greatest effectiveness of removing large stones of the proximal ureter. ESWL-ureterolithotripsy as a first-line method can be considered provided that the kidney function on the side of the stone is preserved and there are no clinical manifestations of obstructive pyelonephritis activity. ESWL-ureterolithotripsy is successful with a stone density of up to 1000-1100 HU.