JOURNAL OF ENDOUROLOGY

Volume 22, Number 9, September 2008

© Mary Ann Liebert, Inc.
Pp. 1845–1846
DOI: 10.1089/end.2008.9793

Flexible Ureteroscopy Is the Ideal Choice to Manage

a 1.5 cm Diameter Lower-Pole Stone

Michael Y.C. Wong, M.D.

Introduction free status was achieved at 3 months in 95% of lower-pole

stones smaller than 2 cm in diameter. The stone-free rate was

T ECHNOLOGY AND TECHNIQUE ADVANCEMENTS have dramat-

ically increased the therapeutic potential of retrograde
intrarenal surgery (RIRS) using the ureteroscope (URS). To-
only 45% for stones larger than 2 cm, but with a second look,
the stone-free rate increased to 82%, producing an overall
stone-free rate of 91%.
day, small volume, nonstaghorn stones can be effectively Two RIRS failures were caused by infundibular strictures.
managed with the URS with good outcomes without the The investigators found that the most significant predictor
need for percutanous nephrolithotomy (PCNL). for failure was long lower-pole infundibular length. All these
In general, present indications for ureteroscopy include patients were treated as outpatients, because there were no
patients whose shockwave lithotripsy (SWL) treatment incisions or need for a nephrostomy tube. Thus, the investi-
failed, those with stones smaller than 2 cm in diameter, pa- gators concluded that RIRS is a safe and effective surgical
tients with concomitant ureteral and renal stones, patients treatment for patients with lower-pole stones.
with a need for complete stone removal (such as pilots), and Kourambas and Preminger6 similarly showed that RIRS is
patients with bleeding disorders.1 Overall success rates in a a reasonable alternative to SWL and PCNL. They studied 34
single session are approximately 86%. Even higher success patients with 36 renal units between 1998 and 1999; stones
rates are expected after a second-look procedure. Reported in 26 units were fragmented with routine in-situ laser
complications are very low.1 For a 1.5-cm lower-pole stone, lithotripsy, while 10 units had stone displacement with a niti-
RIRS would be an ideal option if expertise is available. nol basket and fragmentation. The overall stone-free rate was
85% at 3 months.
Management At the University of Michigan School of Medicine, Hol-
lenbeck and colleagues7 conducted a prospective study in
Technical considerations for a successful outcome with
2001, recruiting 60 patients with lower-pole stones smaller
ureteroscopy for a 1.5-cm lower-pole stone include:
than 2 cm. The objective of the study was to demonstrate the
safety and efficacy of RIRS for lower-pole stones. The in-
1. Use of an access sheath to facilitate multiple entries into
vestigators reported a stone-free rate of 79% at 1 month; sub-
the upper tracts and to keep intrarenal pelvic pressure to
sequent re-treatment achieved an overall stone-free rate of
the minimum, thus decreasing the risk of sepsis.2
88%.
2. Use of smaller nitinol baskets to help facilitate greater flex-
The latest review in 2006 by Preminger8 compared SWL,
ibility of the URS as it reaches into the lower pole.
PCNL, and RIRS in the management of lower-pole stones.
3. Placement of a lower-pole stone into the upper pole at the
This review highlighted the common difficulty in accessing
beginning of the procedure before the start of laser
lower-pole stones, especially when holmium laser is used.
lithotripsy to facilitate stone removal.3
Lower-pole stones smaller than 2 cm can be managed pri-
4. At the start of procedure, urine samples for culture rou-
marily with RIRS, especially in patients who are obese; have
tinely obtained from the renal pelvis. This will facilitate
a bleeding diathesis; have stones resistant to SWL; with com-
choice of antibiotics in the event of a postoperative fever;
plicated renal anatomy; or as a salvage procedure after failed
preoperative bladder cultures do not correlate with renal
SWL, using either direct holmium laser fragmentation or by
pelvic cultures in 55% of cases.4
first displacing the stone into a less dependent position with
the aid of a nitinol basket. At 3 months, 85% of patients were
Discussion
stone free. This reinforced the advantage of RIRS in its ap-
Grasso and Ficazzola5 from New York University School plication for patients with higher surgical challenge or risks;
of Medicine evaluated the management of 90 lower-pole it achieves almost similar stone-free rates as percutaneous
stones with RIRS.5 After a single procedure, complete stone- treatment.

Singapore Urology and Fertility Centre, Singapore

1845
1846 WONG

Conclusion 5. Grasso M, Ficazzola M. Retrograde ureteropyeloscopy for

lower pole caliceal calculi. J Urol 1999;162:1904–1908.
With the current state of the art URS and endourologic ac- 6. Kaorumbas J, Delvecchio FC, Munver R, Preminger GM. Niti-
cessories, RIRS is the first-line option to remove a 1.5 cm nol stone retrieval-assisted ureteroscopic management of
lower-pole stone rather than PCNL. lower pole renal calculi. Urology 2000;56:935–939.
The advantage that URS has over PCNL is that there is no 7. Hollenbeck BK, Schuster TG, Faerber GJ, Wolf JS. Flexible
incision, and it is an outpatient procedure. In addition, there ureteroscopy in conjunction with in situ lithotripsy for lower
are excellent outcomes, with low morbidity, and there is no pole calculi. Urology 2001;58:859–863.
need for a nephrostomy tube. PCNL should only be reserved 8. Preminger GM. Management of lower pole renal calculi:
for patients in whom RIRS fails and/or in situations where Shock wave lithotripsy versus percutanous nephrolithotomy
the lower-pole anatomy is extremely unfavorable. versus flexible ureteroscopy. Urol Res 2006;34:108–111.
Address reprint requests to:
References
Michael Y.C. Wong, M.D.
1. Fuchs et al. Retrograde intrarenal surgery for calculus dis- Singapore Urology and Fertility Centre
ease: New minimally invasive treatment approach. J En- # 10-09 Mount Elizabeth Medical Centre
dourol 1990;4:337–345. Singapore
2. Auge BK, Pietrow PK, Lallas CD, Raj GV, Santa-Cruz RW,
Preminger et al. Ureteral access sheath provides protection E-mail: drmichaelwong@singaporeurology.com
against elevated renal pressures during routine flexible
ureteroscopic stone manipulation. J Endourol 2004;18:33–36.
3. Auge BK, Dahm P, Wu NZ, Preminger GM. Ureteroscopic Abbreviations Used
management of lower-pole renal calculi: Technique of calcu-
lus displacement. J Endourol 2001;15:835–838. PCNL  percutaneous nephrolithotomy
4. Margel D, Ehrlich Y, Brown N, Lask D, Livne PM, Lifshitz RIRS  retrograde intrarenal surgery
DA. Clinical implication of routine stone culture in percu- SWL  shockwave lithotripsy
tanous nephrolithotripsy—a prospective study. Urology URS  ureteroscope
2006;67:26–29.