الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
Over the past two decades, major technological advances have been introduced to the management of urolithiasis[12, 17-19]. URS in particular was subjected to multiple refinements and advancements which led to higher success rates and lower complications rate in treatment of ureteral calculi at any location [12, 17-19].
Ureteric stricture is a late serious complication of URS that was reported in literature in highly variable rates from 0.2 to 24%[17, 20-26]. The literature shows obvious controversy regarding risk factors of post-URS stricture. The majority of studies that investigated post-URS stricture were retrospective including relatively small number of patients (<78)[23, 25, 26, 28]. Further, the short follow up period (3 months or less) in some studies may not reflect the actual incidence and risk factors of ureteral stricture[26, 29, 30].
Moreover, the published studies shows large heterogeneity in their design and the used tools which may explain the high variability in results [22, 23, 25, 26, 31]. An example of this variability is the association between intraoperative ureteral perforation and the development of stricture. Perforation was a significant predictor of stricture in some studies [22, 25, 26], while it was not in others [23, 28, 229].
After addressing points of debate and criticism in literature, this study was performed prospectively with relatively large number of patients (251) and long-term follow-up period (12 months). Aim of the study was mainly to reportthe incidence and detect risk factors of post-URS stricture.
Target population was the patients undergoing transurethral ureteroscopy for treatment of ureteric stones. Detailed surgical history and clinical examination, pelvi-abdominal U/S, plain KUB, NCCT-UT, urine analysis, routine pre-operative laboratory investigations and surgical fitness were done for all cases. Urine culture was done in case of pyuria and UTI was treated pre-operatively with antibiotics selected according to sensitivity pattern.
During the period from May 2015 to August 2016, 251 patients with a total of 304 ureteral stones, who met the inclusion criteria, underwent 263 ureteroscopic procedures at Urology and Nephrology center at Assiut university Hospital. The mean age was 43.45 years.The mean total stone burden was 12.8 mm. Bilateral URS was done in 12 cases. URS for multiple ipsilateral ureteral stones was done in 34 (12.9%) procedures. URS for treatment of impacted stones was done in 49 (18.6%) procedures. Diameter of ureteroscope was either 8.5-11.5 Fr. (200 procedures, 76%) or 6-7.5 Fr (63 procedures, 24%). The mean operative time was 54.77 minutes.
Initial and final stone-free rates (SFR) were 83.3% and 100% respectively. Bivariate analysis of pre and intra-operative variables with SFR revealed that significantly lower SFR were found in each of the following situations:
1. Upper stone location.
2. Larger stone burdens.
3. Procedures where Dormia basket was not utilized.
4. Procedures where Lithotripsy was not done.
5. The use of Double-J stent.
6. Longer duration of stent.
In current study, the overall complications rate was 28.1%. A total of 104 (71 intraoperative, 29 early PO and 4 late PO) complications were encountered in 74 procedures. Fortunately, open conversion or termination of procedure due to IO complications didn’t take place in any procedure. There were 61 out of 263 (23.2%) procedures where intraoperative complications occurred. This rate is within the same range of overall intraoperative complications in literature (3 -38%) [16, 17, 31, 192, 224, 226, 232-235, 262-265].
Bivariate analysis of pre, intra and post – operative variables revealed that significantly higher incidence of IO complications was found in each of the following situations:
1. Right – sided stone(s).
2. Larger stone burden.
3. Impacted stone(s).
4. Longer operative time
5. Double-J stent insertion.
6. Longer duration of stent.
Multivariable analysis using logistic regression test revealed that only impacted stones and longer duration of stent had significant association with IO complications.
Stricture occurred after 4/263 (1.5%) procedures. It was suspected by development of hydronephrosis on U/S and documented by CTU, diuretic renogram and later on Retrogradepyelography (RPG). Three procedures were associated with pre-operative HN. Stones were located at lower 1/3 of ureter in 2 cases, middle 1/3 in one case and upper 1/3 in another. Stones were impacted in 3 cases. The 8.5/11.5 Fr.ureteroscope was used in all these 4 procedures. Active ureteral dilatation was done in 3 procedures. None of these procedures were associated with IO perforation. Three procedures were JJ-stented. Three of these procedures were associated with PO ipsilateral loin pain (i.e. there was a single case of silent obstruction).Stricture occurred at the same level in 3 cases only while the fourth case that had the stone at middle 1/3 developed stricture at upper 1/3. No significant association between stricture and any of variablescould be revealed and this can be largely explained by the few number of stricture cases.
To conclude, the incidence of post-URS ureteral stricture in our experience is low. In general URS is considered a safe and effective procedure for treatment of ureteral stones in all locations.