A stone pushed back to the collecting system – long therapeutic path in centers with limited access to flexible instruments

INTRODUCTION: Availability of flexible ureteroscopes is still limited in many countries and centers. Under such circumstances treating small stones pushed from the ureter to the kidney that pose a risk of symptomatic recurrence is controversial as it may require a number of surgical procedures to remove. The aim of this study was to assess the type and number of procedures used to treat stones relocated from the ureter to the collecting system in a high volume urological center with limited access to flexible instruments. MATERIALS AND METHODS: Patients treated for ureteral stones in years 2013–2016 were retrospectively reviewed. All procedures performed after stone relocation were counted. Final stone status was determined by ultrasonography and radiography. RESULTS: Out of 75 patients with a stone relocated to the collecting system full follow-up was available for 66. In three patients (4%) the stone remained in the collecting system untreated. Seven patients (11%) passed their stones spontaneously. Active treatment was successful in 45 (68%), while it failed in 11 (17%) patients. Extracorporeal shock wave lithotripsy was used 132 times, semi-rigid ureteroscopy 21 times and percutaneous nephrolithotripsy 22 times – 175 procedures altogether (2.6 procedures/patient + accessory procedures such as JJ removal). Shockwave lithotripsy was effective in 7/41 patients, semi-rigid ureteroscopy in 18/21 and percutaneous nephrolithotripsy in 22/22 patients. CONCLUSIONS: Treating small stones relocated from the ureter to the collecting system in centers not equipped with flexible endoscopes is inefficient, time-consuming or too invasive. Cost-effectiveness analysis should follow this study to obtain evidence for public health payers to change their policies.