title: Impacted upper-ureteral calculi >1 cm: blind access and totally tubeless percutaneous antegrade removal or retrograde approach?
abstract: OBJECTIVE
  To compare blind access and totally tubeless percutaneous antegrade removal and pneumatic transurethral ureterolithotripsy for the management of impacted upper-ureteral calculi >1 cm.
  
  
  METHODS
  Seventy patients (41 male, 29 female) with impacted upper-ureteral calculi >1 cm were selected in randomized order for pneumatic transurethral ureterolithotripsy (35 patients) or blind access and totally tubeless percutaneous nephrolithotomy (PCNL) (35 patients). Ultrasonography and intravenous urography were performed for all patients before surgery. After operation, plain films and ultrasonography were done.
  
  
  RESULTS
  In the PCNL group, blind access was achieved from the lumbar notch area in all 35 patients, but in 3 patients, the exposure was not optimal for approaching the ureteropelvic junction (UPJ). So we injected contrast material into the collecting system, and, under fluoroscopic control, another access was achieved. In 33 patients (94.3%), intact removal of the stones was performed. In the other two patients, we fragmented the stones with the Swiss Lithoclast by an antegrade approach. The success rate thus was 100%. The mean operative time was 38 minutes (range 25-48 minutes). In the transurethral lithotripsy group, 12 stones (34.2%) migrated upward to the pelvis of kidney, and 5 stones (14.2%) fragmented incompletely. In these cases, a double- J stent was inserted, and SWL was performed. In follow-up, plain films and ultrasonography showed complete clearance in these patients. Eighteen calculi (51.4%) fragmented completely with the Lithoclast. The mean operative time in this group was 34 minutes (range 20-58 minutes).
  
  
  CONCLUSIONS
  In the presence of moderate to severe hydronephrosis, blind access and totally tubeless PCNL is an effective option for large, impacted upper-ureteral calculi. Flexible ureteroscopy with laser lithotripsy is expensive and not readily available. Pneumatic transurethral ureterolithotripsy has a back-pressure effect and pushes back the calculi to the kidney. Thus, this procedure does not have satisfactory results in the management of these calculi.
authors.affiliation: Department of Urology, Shohada-e-Tajrish Hospital and Urology and Nephrology Research Center, Shaheed Beheshti University of Medical Sciences, Tehran, Iran.
authors.forename: Hossein
authors.initials: H
authors.lastname: Karami
authors.forename: Amir Haji Mohammad Mehdi
authors.initials: AH
authors.lastname: Arbab
authors.forename: Seyed Jalil
authors.initials: SJ
authors.lastname: Hosseini
authors.forename: Mohammad Reza
authors.initials: MR
authors.lastname: Razzaghi
authors.forename: Navid Reza
authors.initials: NR
authors.lastname: Simaei
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D005471:Fluoroscopy; D006801:Humans; D006869:Hydronephrosis / Q000150:complications; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000379:methods*; D014514:Ureteral Calculi / Q000628:therapy*; D020709:Ureteroscopes