Current Management Concepts in the Treatment of Ureteral Stones

Abstract

Since ureteral stones have been included in the range of stones routinely treated by ESWL, controversy as to whether ESWL should be done in situ or whether it should be preceded by stone manipulation has occurred. In this regard, we have noticed a continental division, reflecting the peculiarities of the differences in health care systems in Europe and the United States. In the U.S., most physicians prefer retrograde manipulation to reposition the stone into the renal collecting system with or without the use of ureteral stents to bypass the stone and to create an artificial expansion chamber. At UCLA, we pursue a differentiated approach. Based on the radiographic appearance of natural expansion chamber, approximately 10% of stones above the iliac crest and 40% of stones in the pelvic window are eligible for ESWL in situ treatment. All other stones undergo manipulation utilizing stents and extensive ureteral lubrication. This differential approach has advantages in that it does not change our success rate (97%) and overall hospital stay (1.2 days), but it does avoid ureteral manipulation for approximately 30% of patients. Stones that cannot be manipulated, cases of failed ESWL treatment, and persistent Steinstrasse are treated with ureteroscopy.