ORIGINAL ARTICLE

Ureteroscopic Pneumatic versus Extracorporeal Shock Wave

Lithotripsy for Lower Ureteral Stones
Muhammad Islam and Asif Malik

ABSTRACT
Objective: To compare the efficacy of ureteroscopic pneumatic lithotripsy (URS) and extracorporeal shock wave lithotripsy
(ESWL) in the treatment of lower ureteric stones in terms of stone-free rates.
Study Design: Randomized trial.
Place and Duration of Study: Department of Urology, Government Institute of Kidney Diseases and Transplant,
Hayatabad, Peshawar, from September 2010 to March 2011.
Methodology: Patients (n=136) presented with lower ureteric stones and fulfilling the inclusion criteria for the study were
included. They were divided equally into two groups. Division of patients was done by lottery method. Patients in group A
were treated with ureteroscopic pneumatic lithotripsy (URS) as compared to those in group B, who were dealt with
extracorporeal shock wave lithotripsy (ESWL).
Results: There were 46 males (67.6%) and 22 females (32.3%) with a ratio of 2.1:1 in group A as compared to 50 males
(72%) and 18 females (26.4%) with a ratio of 2.8:1 in group B. Mean age was 35.2 9.5 years in group A and 35.4 9.2
years in group B. The mean stone size in group A was 12.8 3.7 (range 5 - 25 mm) and 12.82 3.5 (range 5 - 25 mm)
in group B. Mean hospital stay in group A was 2.07 0.6, while patients in group B were all day-cases. The statistical
difference was significant in terms of repeat procedure, auxiliary procedure postoperative analgesia and stone free status
at 3 months (p=0.043, 0.020, 0.000, 0.001) respectively, while it was not significant in respect of complications of
procedure (p=0.753).
Conclusion: URS proved more effective than ESWL for the treatment of ureteric calculi. However, ESWL performed as
an outpatient procedure showed fewer complications.
Key words:

Ureteral calculi. Ureteroscopic pneumatic lithotripsy. Extracorporeal shock wave lithotripsy.

INTRODUCTION
A varying degree of obstruction of the lower ureter due
to urinary lithiasis has been explained by the size of the
calculus, ureteral oedema and degree of impaction.
Most of the cases with urinary lithiasis present with
colicky pain although they may sometimes remain
asymptomatic and identified only on routine assessment.1 During the last two decades there has been a
rapid development in the various endourological
instruments for manipulation and retrieval of these
stones.2 Advances in the design of the ureteroscopes
and ongoing developments in shock wave lithotripsy
have greatly influenced the management of ureteric
stones.3,4 Advances in intracorporeal lithotripsy have
also facilitated fragmentation of ureteric stones with
pneumatic lithotripsy as one these types. It is less-costly
and simple to manage as compared to laser, ultrasonic
and electrohydraulic lithotripsy. Even for larger stones it
is a safe and highly efficacious procedure particularly in
Department of Urology, Government Institute of Kidney
Diseases (IKD) and Transplants, Hayatabad, Peshawar.
Correspondence: Dr. Muhammad Islam, Gulberg No. 3,
Chairmain Colony, Peshawar.
E-mail: drislammercy@yahoo.com
Received June 23, 2011; accepted April 12, 2012.
444

the distal ureter.5 The improved technology in extracorporeal shock wave lithotripsy (ESWL) has also facilitated the management of ureteric stones, particularly the
smaller stones.6 ESWL and ureteroscopic pneumatic
lithotripsy (URS) are currently accepted modalities of
treatments for distal ureteral calculi.7,8 However, despite
the definite success of endourological stone treatment,
ongoing questions about optimum management remain
debated among urologists.
This comparative study was therefore, done with the aim
to compare the relative efficacy of URS and ESWL in
treating stones in the lower ureter.

METHODOLOGY
This study was performed in the Department of Urology,
Institute of Kidney Diseases, Hayatabad, Peshawar,
from September 2010 to March 2011.
Inclusion criteria were ureteric stones size less than 25
mm, not passed spontaneously within 3 weeks, located
in lower ureter occurring in adult patient with age above
18 years. Exclusion criteria were patients with solitary
kidney, renal insufficiency with creatinine more than 3
mg/dl, ipsilateral ureteric stricture, active renal tract
infection, failure to apply Swiss Lithoclast, transplanted
kidney, morbid obesity, pregnancy, previous surgery for

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (7): 444-447

Lithotripsy for lower ureteral stones

ureteric stones, coagulation disorders and patients with

the co-existent renal stone and post-ESWL Steinstrasse.
Patients with symptoms of ureteric colic registered in
OPD were followed by detailed history and thorough
examination. On establishment of diagnosis of lower
ureteric stone by X-ray KUB, intravenous urography
(IVU) and ultrasonography, they were included in the
study after explaining merits and demerits of both
treatment options and fully informed written consents
were taken. Patients were allocated to either group A or
B by lottery method. Group A was treated with
ureteroscopic pneumatic lithotripsy and group B was
treated with ESWL. The first group were admitted and
surgery was done the next day, while the patients in
group B were treated as outpatients on day care basis.
ESWL was performed using the MODULITH SLX-F2
(STORZ, Switzerland). All patients were put in prone
position and the calculi were localized with fluoroscopy
for the radiopaque stones and ultrasound guidance was
used for radiolucent stones for focusing. All patients
were given analgesics and the level of shock wave
energy was progressively stepped up taking into
consideration patients' comfort and level of pain till
fragmentation of stones within the ease of the patient.
URS was performed with semi rigid 8 Fr. KorlStorz
Ureteroscope. The stones were disintegrated with
pneumatic lithotripsy by using Swiss Lithoclast.
Placement of ureteral stent was left at the discretion of
the operating surgeon. All patients had prophylactic
antibiotics. After completion of the procedure, at-hand
fluoroscopy was performed to know the stone-free
status of the ureter.
Patients in each of the two groups were followed-up to
assess the efficacy and complication of the two
procedures. Complete stone clearance was assessed at
3 months follow-up. The follow-up schedule was same
for both groups of patients i.e.; 2 weeks, 6 weeks and 3
months interval. Complete examination and investigation were performed at follow-up visits, X-ray KUB and
ultrasound. All the data were recorded in a prestructured proforma. The efficiency quotient for each
treatment modality was calculated using the formula:
Stone free (%) x 100 / (100 + retreatment rate (%) + rate of
auxiliary procedure (%).

Descriptive statistics for data were computed using

Statistical Package for Social Sciences (SPSS) version
10. Frequency and percentage were calculated for
categorical variables like gender, outcome, and modality
of treatment and complication. Mean + S.D. were
calculated for continuous variables like age, stone size
and hospital stay. Chi-square test was used to compare
the outcome in both the groups. P-value < 0.05 was
considered significant.

RESULTS
A total of 136 patients were included in this study. None
of the patients in both the groups was dropped from
follow-up protocol of the study. In each group, 68
patients were treated. Group A patients were treated
with URS and comprised of 46 males (67.6%) and 22
females (32.3%) with a male to female ratio of 2.1:1. The
second group (Group B) was treated with ESWL also
comprised of 68 patients with 50 males (73.5%) and 18
females (26.5%), with a ratio of 2.8:1. The mean age in
group A was 35.3 9.5 (range 18-65) years while in
group B, the mean age was 35.4 9.2 (range 18-65)
years.
The mean stone size in group A was 12.8 3.7 (range
5 - 25 mm) and in group B it was 12.82 3.5 (range
5 - 25 mm). Patients in group A were admitted via outpatients. In this group, all patients were given general
anaesthesia. Almost all these patients needed less
frequent visits for follow-up than ESWL. After URS and
intracorporeal pneumatic lithotripsy (ICL), double J stent
was put in 22 patients for 2 - 3 weeks due to difficultly in
dealing with the stones with resultant ureteral wall
oedema. Repeat URS was required in 5 patients (7.3%)
after 4 weeks.
Open surgery was done in 2 patients (2.9%) in group B
due to the pressure of 25 mm hard non-breakable
stones and complete uterine procedentia as well.
Proximal migration of calculi to the kidney occurred in 2
patients (2.9%), who were later on treated with ESWL.
Mean hospital stay in URS was 2.1 0.6 days. Four
patients (5.9%) had urinary tract infection and 2
patients (2.9%) had ureteric perforation that received
stents for 6 weeks. During the follow-up period, no
ureteric stricture were documented as evaluated by
history, examination, imaging (IVP) and retrograde
evaluation under fluoroscope and URS. Oral and
parenteral pain medication was given to 62 patients
(92%) of URS as compared to 49 patients (72%) of
ESWL. In group A, 64 patients (92.6%) were completely
free of stones at 3 months duration. Efficiency quotient
at 3 months was 81.8.
Patients in group B were treated with ESWL. Patients
(n = 68) who received this treatment modality had mean
stone size of 12.8 3.7 mm (range 5 - 25 mm). In this
group, all patients received oral or parenteral analgesia
with no general anaesthesia. All patients in this group
had treatment as an outpatient procedure, but all
patients needed frequent follow-up visits. Only 5 patients
(7.4%) required pre-ESWL double pigtail stents for
persistent ureteric colic who were not responding to
conservative treatment. A total of 68 patients required
87 sessions of lithotripsy with average number of
3500 shock waves at 7 - 9 Kv. Overall stone free status
at 3 months was 73% (n:50). No major complications
were documented, though 5 patients (7.4%) developed

Journal of the College of Physicians and Surgeons Pakistan 2012, Vol. 22 (7): 444-447

445

Muhammad Islam and Asif Malik

infection. In a total of 68 patients, 13 patients (19.1%)

required more than one session of ESWL for
disintegration. In these 13 patients, one patient had post
ESWL broken double pigtail stent in ureter, 12 patients
(17.6%) were treated by URS and ICL. Ureterolithotomy
was done for one case (1.5%) with a hard 25 mm stone.
The efficiency quotient for this treatment modality at 3
months was 53.2.
Data for the various variables of outcome among the
patients in the two groups and their statistical
significance are given in Table I. Except for the
complications observed in the two groups of patients,
the remaining variable had a significantly different effect
on the outcome.
Table I: Outcome variables with significance in the two groups.
Group

Repeat procedure
Auxiliary procedure
Complications
Postoperative
analgesia

p-value

Outcome

Outcome

Chi-square test

Yes

No

Yes

05

63

13

No
55

(97.4%)

(92.6%)

(19.1%)

(80.9%)

04

64

13

55

(5.9%)

(94.1%)

(19.1%)

(80.9%)

06

62

05

63

(8.8%)

(91.2%)

(7.4%)

(92.6%)

64

04

48

20

(94.1%)

(5.9%)

(70.6%)

(29.4%)

0.043
0.020

64

04

50

18

(94.1%)

(5.9%)

(73.5%)

(26.5%)

In comparison to ureteroscopic lithotripsy, the stone-free

rate of different studies at 3 months for distal ureteral
stones was more than 90%.21 The present results are
also comparable to national and international studies i.e.
92.6% stone free rate at 3 months with efficiency
quotient of 81.8 while the patient who offered ESWL the
stone free rate at 3 months was 73.5% with efficiency
quotient of 53. An important disadvantage of URS is that
the procedure has to perform under general or spinal
anaesthesia; in ESWL simple analgesia is sufficient.
Whereas, ESWL had minimal invasiveness but had
more risk of treatment failure as compared to URS.

0.753

CONCLUSION

0.000

Ureteroscopic intracorporeal pneumatic lithotripsy is

superior to ESWL in terms of stones free rate for distal
ureteral stones but needs expertise to avoid complications.

Free of stone at
3 months

Since 1980, ESWL had been applied extensively in the

treatment of ureteral calculi.9 It is a non-invasive
procedure that can be performed without anaesthesia.
Delakas and colleagues found an increased failure rate
of ESWL with more severe obstruction.17 Other studies
showed the success rate for distal ureteric stones that
ranged between 53% and 84%.18,19 Hafez and
colleagues showed the stone free rate at 3 months after
the last treatment session as 79.2%.20 Their results of
ESWL matched with the present results i.e. 73.50% with
efficiency quotient of 53.

0.001

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