الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
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Abstract
The goal of treating ureteral calculi is to achieve complete stone clearance with minimal morbidity for the patient. The optimal choice of treatment depends on various factors, including stone size, composition and location, clinical patient factors, equipment availability and surgeon capability. Recent prospective trials suggest that ureteroscopy provides certain advantages over ESWL for distal ureteral calculi [88]. Nevertheless, several surgical options are available for proximal ureteral calculi.
Advances in ureteroscope design, newer methods of intracorporeal stone fragmentation, laparoscopic techniques and ongoing developments in ESWL have resulted in changes with regard to the use of treatment modalities for ureteral stones [89]. After the establishment of the AUA ureteral stone guidelines , there were a few reports describing management options for ureteral stones [89, 90]. However, these reports did not specifically address treatment options for proximal ureteral calculi. We reviewed minimally invasive treatment options, some controversial techniques and outcomes for the contemporary management of proximal ureteral calculi. The focus was specifically on ESWL and ureteroscopy. ESWL is the least invasive treatment for calculi of the upper urinary tract and it is recommended as first line therapy [91]. However, ESWL has a variable success rate for large upper ureteral calculi [92]. Development of the small flexible ureterorenoscope combined with advancements in intracorporeal lithotriptors have increased the success rate for managing upper ureteral calculi. However, flexible ureteroscopes are expensive and technique dependent. Moreover, the current trend in surgery is toward minimally invasive procedures. Based on this analysis we provided recommendations for treating proximal ureter stones.After addressing points of debate and criticism in literature, we performed a prospective study with relatively large number of patients and long-term follow-up period. Aim of the study is mainly to compare between ESWL and URS as the main treatment options for large proximal ureteral calculi.Our target population was the patients undergoing either ESWL or URS for the management of large proximal ureteral calculi.Detailed surgical history and clinical examination, US, plain KUB, MSCT KUB without contrast, urine analysis, routine preoperative laboratory investigations and surgical fitness were done for all cases. Urine culture was done in case of pyuria and UTI was treated preoperatively with antibiotics selected according to sensitivity pattern.
During the period between May 2016 and May 2018, 60 patients who met the inclusion criteria, underwent ESWL and URS at Assiut Urology and Nephrology Hospital with 30 patients undergoing ESWL and 30 patients undergoing URS.Complete stone clearance occurred in 20(66.7%) of the 30 patients undergoing ESWL and in 24(80%) of the 30 patients undergoing URS indicating no significant difference in overall stone clearance between both groups. However, the ESWL cases needed longer time, more number of sessions, and acorrdingly needed more money than URS cases and also the number of sessions in ESWL cases was affected by several factors such as skin to stone distance, stone density, and stone size which was not the case with URS cases.The time needed for complete stone clearance was 77.17 +/- 28.96 minutes for ESWL cases compared to 46.37 +/- 7.28 minutes for URS casesWe also identified in our study 3 cut-off points for ESWL cases above which The case will mostly need more than 1 session (Skin to stone distance more than 8.8 cm, stone size more than 1.1 cm, and stone density more than 1100 HU). At the same time, the number of sessions in URS cases was not affected by skin stone distance, stone size or stone density.After all, we recommended URS over ESWL for management of large proximal ureteral stones whenever the surgical skills, and the efficient equipment are available as a safe, cost-effective and rapid modality for management of large proximal ureteral calculi especially in patients with skin to stone distance more than 8.8 cm, stone size more than 1.1 com or stone density more than 1100 HU.